770 West Broad Street
Columbus, OH 43222
614-752-1164
John R. Kasich, Governor

www.drc.ohio.gov

TO:

Barry Goodrich, Warden
Lake Erie Correctional Institution

FROM:

Jayne Haverfield, Prison Audit Administrator
Bureau of Internal Audits and Standards Compliance

SUBJECT:

2012 Full Internal Management Audit Report

DATE:

September 25, 2012

Gary C. Mohr, Director

I am enclosing a copy of the Internal Management Audit Report for the Lake Erie Correctional Institution
following your full internal management audit on September 18-20, 2012. There were a total of forty-seven
(47) standards found in non-compliance during the audit which will require a plan of action from your
institution unless you wish to appeal any of the non-compliance findings.
During a final review of the audit standards found in non-compliance, there was one ACA Non-mandatory
standard and one Ohio Standard that were reviewed as compliant. This has changed your audit scores slightly
for those two areas.
Responses to non-compliance should be forwarded to this office on the approved format located on the BIASC
intranet site and must be received no later than October 9, 2012. Following the receipt of the plans of action,
the documents will be discussed with the appropriate Deputy Director/designee, if necessary, and Michelle
Burrows, South Region Prison Audit Administrator will conduct a reinspection. You will be notified in
advance of the reinspection review.
I appreciate the support and cooperation of you and your staff during the audit. If you have any questions
regarding this report, please feel free to contact this office.

CC:

Gary Mohr, Director
Stephen Huffman, Assistant Director
Linda Janes, Chief of Staff
Ed Voorhies, Region Director, Office of Prisons
Annette Chambers, Office of Administration
Kelly Sanders, Office of Administration
Andrew Albright, Chief, Bureau of Internal Audits and Standards Compliance
Michelle Burrows, Prison Audit Administrator, BIASC

OHIO DEPARTMENT OF REHABILITATION AND CORRECTION
Lake Erie Correctional Institution
Conneaut, Ohio
September 18-20, 2012
Full Internal Management Audit
Audit Chairperson – Jayne Haverfield, Prison Audit Administrator
I.

General Administration, Physical Plant – Safety – Personnel – Employee Safety
Steve Olds – Safety and Health Coordinator
Brian Smith – Safety and Health Coordinator
Correction Reception Center
Ross Correctional Institution
Leon Hill – Labor Relations Officer
London Correctional Institution

II.

III.

Security and Operations
Barb King – Deputy Warden
Lorain Correctional Institution

Dan Lipperman – Assistant HCA (Sept. 18)
Belmont Correctional Institution

Robert Morgan - Captain
Marion Correctional Institution

Joe Dina - Lieutenant
Ohio State Penitentiary

Fiscal, Food Service, Information Technology, Correctional Industries
Kathy Cole – Administrative Assistant
Belmont Correctional Institution
Pam Callahan – External Auditor (Ohio Standard Chapter 14)
Office of Administration

IV.

Inmate Programs & Special Services
Laura Solnick – Unit Management Administrator
Lorain Correctional Institution

Kent Litzenberger – Principal
Belmont Correctional Institution

Martha Jerew – Victim Coordinator
Office of Victim Services
V.

Medical & Mental Health Services
Michelle Viets – Regional Nurse Administrator
Bureau of Medical Services
Robyn Schaffer – Northern Psychology Director
Bureau of Mental Health Services

VI.

Training
Jennifer Clemans — MAS1 (Sept. 19)
Corrections Training Academy

VII.

Inmate Rights/Grievances
Don Coble – Assistant Inspector (Sept. 19)
Chief Inspector’s Office

Carol Smith – Quality Improvement Coordinator
Ohio State Penitentiary

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

A. INTRODUCTION
The Full Internal Management Audit of the Lake Erie Correctional Institution was conducted on
September 18-20, 2012. Jayne Haverfield, BIASC Audit Administrator served as the chairperson of the
audit and coordinated all audit issues through Andrew Albright, BIASC Chief. Lake Erie Correctional
Institution will be scheduled for an initial accreditation audit prior to February 28, 2013. This review of
operations serves as the annual internal audit of the facility, including all ACA and Ohio Standards,
since the previous annual audit.
During this audit, an annual sanitation inspection of the entire facility and an annual safety inspection of
all OPI and Career Technical Education areas were conducted by an independent and qualified person.
The completed inspection forms are sent to the facility as a supplement to this report.
B. EXAMINATION OF RECORDS
The team evaluated compliance levels with audit standards by reviewing both the prepared accreditation
files and observing institution operations throughout the facility. It should be noted that the audit team
considered all indicators of performance when determining compliance, including that represented
within the audit documentation and overall observations of institution procedures and practices. The
audit team did, however, focus on facility operations in the past year in determining compliance with
audit requirements.
1.

Accreditation File Preparation
The accreditation files were found in mixed condition. The Accreditation Contact, Ms. Bowser,
stated that although timeframes were set for staff to provide documentation for the files, the
deadlines were not adhered to by several departments. The files did not contain signed auditor
compliance checklists to illustrate they had been completed or reviewed by anyone at LAECI.
The rules and discipline and special management files were also especially difficult to review as
they did not follow DRC policy or DRC forms usage.
Despite these issues, many file sections were found to be in overall good shape, i.e. human
resources, training, education, library, inspector, and mental health. Several of the food service
files were found with no documentation provided. The medical files were well constructed,
however the incorporation of CCA policy did create some confusion. The department heads
need to review their own files and understand the documentation contained in them so that future
auditors do not have such a difficult time with some of the sections.
ACA standard 4-4003-1 was not reviewed during this audit as it is a new standard. The facility
will need to have this file constructed and prepared for their upcoming ACA audit.

2

Facility: Lake Erie Correctional Institution

2.

Audit Date: September 18-20, 2012

Significant Incidents/Outcome Measures
The Significant Incident Summary Report (SIS) and the Health Care Outcome Measures Report
(OM) were reviewed by the audit chair. Both reports are attached at the end of this report.
In comparing the SIS from DOTS with the SIS provided by the facility, the following are
contradictory:
• For offender on offender assaults, DOTS SIS shows 9 in July where the facility report
shows 4.
• Offender on Staff assaults from the DOTS SIS shows 13 occurred in August where the
facility report shows 12.
The Outcome Measures report needs to be reviewed and checked for the following:
• Number 1A(10) should reflect direct admissions only. This number should not include
any emergency trips that resulted in an admission. This also creates double-reporting
from number 1A(11).
• Numbers 1A(13) and 1A(14) need to reflect the numbers specified by BOMS in the
report sent from Jennifer Clayton in March to the Health Care Administrator.
• Number 4A(1) does not show that any problems identified by the quality assurance
process have been corrected.

3.

Status of Previous Non-Compliant Standards
This is the first internal management audit conducted at the Lake Erie Correctional Institution
under the management of Corrections Corporation of America. Therefore there are no previous
non-compliance issues to address.

4.

Previous ACA Reaccreditation Audit
a. Status of Approved Plan of Actions for Noncompliant Standards
The facility has not yet been accredited under the management of CCA so there is no prior
ACA report.
b. Status of Any Negative Issues/Observations/Concerns
The facility has not yet been accredited under the management of CCA so there is no prior
ACA report.

C. COMPLIANCE LEVELS
The institution achieved a compliance level of 94.7% among the ACA mandatory standards for Adult
Correctional Institutions. Of the sixty-one mandatory standards, three (3) were found in noncompliance, four (4) were judged to be non-applicable to the operation of this institution, and the
remaining fifty-four (54) standards were all found in compliance.
The institution achieved a compliance level of 94.4% among the ACA non-mandatory standards for
Adult Correctional Institutions. Twenty-four (24) of the non-mandatory standards were found in non3

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

compliance during the internal audit and an additional thirty-five (35) of the standards were judged to be
non-applicable to the operation of this institution.
The institution achieved a compliance level of 66.7 % with the Ohio Standards. A total of twenty (20)
of the Ohio standards were found in non-compliance, and an additional eighteen (18) of the Ohio
standards was judged to be non-applicable. A total of 68 Ohio standards were reviewed during the
internal audit.
D. AUDIT TEAM RECOMMENDATIONS/OBSERVATIONS
Based on the overall inspection of the facility and the review of the audit files, the audit team would like
to offer the following recommendations to the institution:
Conditions of Confinement/Quality of Life:
1. The institution staff needs to conduct a complete and thorough facility inspection of every area,
closet, storage room, mechanical room etc. throughout the facility to ensure all areas are clean, neat,
organized, and free from clutter, hazards, and/or any policy violations.
2. Staff was very professional, friendly, and helpful during the audit. Inmates were dressed
appropriately and found to be wearing their identification badges. The inmate atmosphere appeared
mostly calm. Outside grounds were clean. Buildings appeared in good repair, with some exceptions
noted in subsequent sections of the report.
3. It was apparent throughout certain departments that DRC policy and procedure is not being
followed. Staff was interviewed and some stated they are not sure what to do because of the
confusion between CCA policy and DRC policy. Some staff expressed safety concerns due to low
staffing numbers and not having enough coverage. Other staff stated that there is increased
confusion due to all the staffing transitions.
4. Fire Safety Concerns:
• Fire doors are not kept unobstructed and operable. In the Building and Maintenance Trades
area, the crash gate (501-C) opens into the path of egress and is padlocked with a dead bolt
lock. There are no exit signs. In the Evergreen Industries area, crash gates have been added
at doors 539/512C/512B that are padlocked and opening into the path of egress.
• The fire alarm panel had 2 trouble lights in central control.
• Hydraulic closures were removed from doors 207/208. Several other hydraulic doors were
held open with other items.
• In segregation, a power strip was the primary power for a microwave/refrigerator/and coffee
pot. Also there were no written procedures for evacuation, and employees were unfamiliar
with their keys. There were no food temp logs.
• In the food service area, a large plastic trash bag was tied to an oven door. The oven had
been used and the door was left open to cool down. This was a potential fire hazard.
• Of twelve staff interviewed, none knew which key opened the fire box. This key needs to be
the same for all fire boxes and all staff need to be familiar with this key.
5. Monthly inspections are being conducted by the Safety and Health Coordinator; however the
inspections could be more thorough by enforcing more consistency with the DRC Chemical Control
4

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

policy, sanitation, and maintenance issues. This effort could facilitate an improvement with
compliance issues relating to 4-4212M and 4-4329M.
6. Weekly inspections are being conducted of all food service areas; however many areas are being
repetitively documented as not in compliance with issues such as daily food production
temperatures, incorrect dish temperatures, no paper towels or soap at hand washing stations, and
incorrect cooler/freezer storage temperatures. (Relates to 4-4324M)
7. Security Concerns:
• During the audit, one auditor observed that one officer left his post for 10-15 minutes (Huron
C/D) and did not let his partner know that he left or where he was going.
• Several staff is not knowledgeable of the key notching of egress keys and need to be
provided further training. (Relates to 4-4195M)
• The PIM’s did not contain all the required information however the facility corrected this
during the audit.
• Log books do not show shift checks of equipment or chemicals as required by applicable
DRC policy.
• Tool Control was very good overall. Most vaults required minimal engraving or color
coding corrections. Officer Witt demonstrated great knowledge in DRC policy and
procedure with Key, Lock and Tool Control. A few recommendations include that
supervisors need to be consistently reviewing and signing the Daily/Weekly Tool Report
Forms. Staff are also not documenting properly with “closed” instead of a slash mark if the
area is not open during a shift. A copy of the broken tool report needs to remain in the vault
until corrected.
• Less than lethal munitions: The pepper ball system (two pepper ball guns) in central control
had an outdated inventory and was stored loaded and unsecured. The pepper ball guns are
also being issued by non-certified personnel, but are carried by certified personnel. The
facility needs to post a memo of who is authorized/certified to utilize the pepper ball guns
and when these are to be utilized as staff is currently allowed to carry it loaded as a show of
force, especially during chow.
• Key and Lock Control: Not all egress keys that are issued were notched.
• Contraband: Minor contraband is being held in Officer desk drawers. Officers indicated that
items are brought up to the vault weekly. The minor/major contraband vault was clean but
very full. Initial logging and accountability in the vault checked ok; however they were
unable to show proof or authorization for contraband that was destroyed. Dispositions were
not being logged on the form.
• Not all paperwork is up to date in Central Control. No emergency dedicated phone line is
available. The phone system does not have any type of “off hook alarm”. Central Control,
Maintenance, Sallyport Control, and Perimeter vehicles use non-MARCS radio systems as
well as MARCS. The auditors recommend one radio system be used if possible. The
key/door/lock reference book is incomplete: it does list the key ring, the ring count and the
key number, but the locations are not listed. Only the locksmith has access to the computer
program which contains the key/lock reference. Security auditors recommended that a readonly format is provided in Central Control on the computer for officers there.
• Post orders are not in DRC compliance or format – i.e. the language between CCA and
ODRC needs to reflect ODRC and be written on the DRC form.

5

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

8. Rules and Discipline Concerns:
Overall the accreditation files appeared good (15 out of 23) in the Rules and Discipline section.
However the practice does not follow DRC policy and required timeframes. The RIB system as a
whole needs to be reviewed to ensure future compliance with the required DRC processes.
• Conduct reports are not being heard at the Hearing Officer level and information is not being
entered into DOTS. One Sergeant informed the auditors that the conduct reports are
provided to the Hearing Officers and are not returned with disposition or entered into DOTS.
The partial log for August was reviewed (seven pages with 46 conduct reports per page), and
all tickets were expired with no dispositions.
• From the DRC DOTS report it was found that there were 229 total open cases going back to
May. In August, it shows that there were 78 open hearing cases, 52 closed cases (4 by
disposition and 4 referred to RIB with no hearing conducted, and 44 cases with no action and
expired).
• The ADO Report from May reports that 182 tickets were written in one week. DOTS does
not reflect these numbers; another demonstration of reports not being entered into DOTS.
9. Segregation Observations:
• Ranges were clean, however recreation cages were dirty, and not all cages have exercise
equipment.
• There were inmate complaints of no laundry, linen, or cell cleaning being provided and this
could not be disproved.
• There were no laundry schedules or structure available to staff.
• Supervisor rounds were observed but they were not addressing or resolving any inmate
concerns or issues.
• Officers were not observed talking to inmates when making rounds.
• About half of the DRC 4118’s reviewed were incomplete.
• There is no stock of jumpsuits, blankets, or sheets on hand. The quartermaster stated to the
auditor that they do not supply them to segregation, however segregation stated that the
quartermaster does supply them.
• All segregation cell shower windows were found to be covered with some sort of paper.
Most segregation cells were found to have blankets, clothes, etc. hanging on makeshift
clotheslines to cover sight into the cells. Many cells had posters, magazine pages or pictures
hanging on the walls. (Relate to 4-4140). Many of the clotheslines were removed after the
second day of the audit.
• Overall the documentation pertaining to special management privileges provided for the
accreditation files was very poor. Segregation Unit Individual Record Sheet (DRC 4118’s)
were not being consistently utilized prior to the audit week. Most individual records for
inmates in segregation did not document meal times, health care daily visits, linen exchange,
clothing exchange, cell cleaning or barber. This was also the case for any 4118/4117’s found
during the audit.
• There were questions raised whether inmates are able to shower in segregation. Showers are
only turned on for 30 minutes in the evening, and with 3 inmates per cell it was questioned
whether there is adequate shower time.
• Segregation logs do not reflect phone calls being made available to inmates per DRC policy
and comments reflected by the inmates in segregation. When staff were asked to explain the
process, it was explained differently in talking to SMU staff and unit staff. Both areas
reflected that the other area was responsible for the phone calls.
6

Facility: Lake Erie Correctional Institution

•
•

Audit Date: September 18-20, 2012

The eye wash station in segregation was empty.
A urine specimen was found sitting on the officers desk in segregation control. When
questioned about this, the officers stated it was there when they arrived for shift. There was
no label on the specimen.

10. The inmate orientation checklist was not consistently being signed by staff prior to the audit week.
Practice needs to be monitored to ensure staff are completing the forms properly and timely.
11. Unit Management concerns:
• One case manager is doing a good job of entering information into the system. However
there has been a big staff turnover and only one staff person is ORAS trained.
• Staff need to be trained to complete the PIT within 90 days.
• It is also recommended to contact the Office of Victim Services to request programs training
for PROVE and Victim Awareness.
• Also, the mission statements need to be posted in the units.
• Unit Manager Pfifer has maintained excellent records of his unit meetings and town hall
meetings.
12. The workplace violence liaison needs to be appointed, and trained by OVS. Victim Coordinator
needs to attend the last/next quarterly Victim Coordinator meeting/training on November 17, 2012.
13. The facility has a local written policy and procedure to address spill containment and clean-up
procedures for infectious waste, but do not have a specific cleaning team. All employees have been
trained to handle and manage infectious waste spills.
14. Medical:
• Pill call was observed and it was found that there is no officer is in the area where pills are
dispensed.
• The use of the chart review form found in the charts does not comply with the policy that
governs sick call.
• The refrigerator needed for medication in the pill should not be used for nutritional
substances also. There should be a separate refrigerator used for nutritional substances.
• The last peer review found for Dr. Tran (Mental Health) was conducted in 2010. The 2012
peer review needs to be added to the ACA Mandatory file for peer review.
• The mental health auditor also noted that with segregation so crowded, it is time intensive for
staff to conduct watches and rounds.
• The consult process needs to be rebuilt as it appears broken due to staff attempting to follow
2 systems – DRC and CCA. The process currently in place does not allow staff to backtrack
to find what has gone wrong.
• Staff seem unsafe. There are lots of inmates in medical but no correctional officers around
medical.
• The mental health department is functioning well overall but has challenges of complying
with two policies for the same procedure (CCA and DRC). It is recommended that staff
vacancies be filled as soon as a determination is made as to what discipline is needed.
15. Some inmates interviewed indicated to the auditors that they felt unsafe. Some inmates stated they
felt that staff had “their hands tied” and had little control over some situations.
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Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

16. Food Service concerns:
• The food service manager does not appear to understand the basics required by the food
service ACA standards.
• The DRC cycle menu had not been in place but was begun the week of the audit. This menu
needs to be continued and utilized daily per DRC Policy. Prior to this, LAECI did not have
approval from DRC to use their own cycle menu.
• All DRC food service forms need to be utilized daily.
• Temperatures of food products were not regularly taken. Food serving temperatures were not
taken one day of the audit because “we were too busy” as reported from a food service
coordinator.
• Sanitization of the pots and pans was not being completed in accordance with approved
methods. It is recommended to run the pots and pans through the dish machine to sanitize
them.
• On the third day of the audit, it was found that dish temps were recorded prior to the machine
being used.
• Inmate food service workers are not issued any extra clothes but are issued an apron which
they have to launder themselves.
• Due to the lack of documentation in several food service accreditation files, and the files
being returned multiple times when the auditor gave the opportunity to fix them, it was found
to be a very high probability that the documentation was being falsified. This was not proven
however the facility needs to be aware of this issue to monitor to ensure it is not occurring.
• Items in dry storage were stored up against the walls instead of 4” from the wall as required
for proper air circulation.
• A locking mechanism was on the dry storage door allowing someone to be locked inside the
room.
• There were no safety guards on the meat slicers and inmates were using them.
• Inmate workers in food service were found eating on the line and in the kitchen.
• A review of the inmate feeding line operation is recommended as the current inmate feeding
line takes several hours and this could possibly be improved.
17. Sanitation and Safety concerns:
• Several water fountains in units were inoperable and found with standing water and debris in
them.
• Heat producing appliances were not plugged directly into the wall in several areas
(microwaves, refrigerators, coffee pots). This is not compliant with Ohio Fire Code.
• Emergency Breathing Apparatus’s (EBA’s) were hard to find and had not been inspected.
Many were found locked inside file cabinets or behind items in storage closets.
• Most all ceiling fans and vents were found to be dirty.
• Huron C/D: The entrance was clean. Inmate bedding areas were clean. Beds that were
empty had no mattress and some were missing springs and wires. Some beds were now
rendered unusable due to these items missing.
The rest of the unit was found in poor
sanitation. Water fountains were backed up and inoperable. Showers had black spots/mildew
issues. Ceiling fans dirty. Door 114-B had a device holding open the door.
• Ontario C/D housing unit had dust/dirt in corners, on window sills, and on fans. Walls in the
dayrooms and entry were dirty from 2 feet down to the floor. Showers had black
spots/mildew issues. Inmate bedding areas were clean.
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Facility: Lake Erie Correctional Institution

•
•

•

Audit Date: September 18-20, 2012

Superior A/B was found in poor sanitation. The sink microwave area was very poorly kept.
Ontario A/B ceiling fans were dirty. Bathroom vents were totally obstructed with dirt and
the smoke detector was in alarm mode in the bathroom. Black spots/mildew on the ceiling.
The dog room had a blocked egress. The inmate barber was cutting hair using his own
personal equipment.
Recreation was very busy but found in poor sanitation. A vending machine was partially
blocking an exit.

18. In reviewing chemical control procedures, the H&S Auditor recommended that the bulk usage of
chemicals being used in areas be eliminated. One of the goals of chemical control and having a
chemical control room is to keep bulk storage of cleaning chemicals located in 1 area. At Lake Erie
Correctional 5 gallon containers are sent to areas allowing inmates to refill bottles as necessary. In
the chemical boxes there are limited amounts of bottles in each chemical box making it necessary to
refill the bottles several times before the chemical boxes are replenished. This methodology is much
more difficult for staff to track accountability and it also promotes more waste/usage than necessary.
Considering the poor level of sanitation in housing units at LaECI it appears that either cleaning is
very limited or a lot of cleaning chemicals are being misused and or wasted. On a positive note, the
medical and dental areas were found to be following excellent chemical control accountability
procedures.
19. Inmates housed in segregation complained about the hours that recreation is offered. Many
complained that is was offered late in the evening between 11:00 PM and 12:30 AM and the DRC
4118’s observed showed this was the practice for those inmates, with no indication that security or
safety concerns dictated otherwise. This is a quality of confinement concern that could be improved
and perhaps lessen inmate agitation within the unit.
E.

OHIO FACILITY OBSERVATION PERFORMANCE
OBS 02-03

Intrasystem Transfer. The Intra-system Receiving process shall be uniform in
order to facilitate continuity of care during the Receiving Process. Completion of
DRC 5255 Intra-system Transfer and Receiving Health Screening form shall be
completed in its entirety; however, completion of this form does not substitute for a
comprehensive assessment, file review, and appropriate documentation on the part
of the receiving institution.

The auditors found the following concerns: required patient demographic fields at the bottom are not
filled out in their entirety; all significant diagnoses/operations/invasive procedures for the patient are not
reflected on the problem list; and not all entries on the problem list have dates to indicate when they
were added to the problem list.
OBS 02-05

Medication Administration. The purpose of the Medication Administration
protocol is to provide guidelines for the safe administration of medication in
compliance with all legal and nursing standards.

The auditor found that there were blanks on the refrigerator temperature log, and that there is no officer
present during pill call. Oral cavity checks are not performed by a correctional officer after medication
administration to each inmate.

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Facility: Lake Erie Correctional Institution

OBS 02-07

Audit Date: September 18-20, 2012

Infirmary Care. The purpose of the Infirmary Services protocol is to provide an
enhanced level of care to those patients who have a need for an increased level of
health care services, but are not ill enough to require hospitalization or intensive
nursing services. Patients admitted to the infirmary shall be a high priority and
shall receive complete and thorough daily quality medical and nursing care.

It was found that patients are not seen timely. Nursing assessments were not completed minimally every
8 hours and documented on DRC 5396. A distinct discharge note was written by the ALP upon
discharge, and ALP progress notes are not always completed for every day the ALP is on site.
OBS 02-08

Telephone Triage. The purpose of the Nursing Telephone Triage protocol is to
outline the process utilized for telephone triage of urgent, emergent, and non-urgent
health services requests. Telephone triage of inmate patient medical concerns
represents a fundamental component of access to healthcare services.

There are not always progress note entries corresponding to the log entry. Documentation in the
progress note by the nurse who receives the call does not always include information received and any
other appropriate medication documentation or actions taken by the nurse.
OBS 02-09

Nurses Sick Call. The purpose of this standard is to evaluate the Nurse Sick Call
(NSC) process as the primary access for an inmate to access healthcare services.
Timely and appropriate NSC assessments are critical in providing quality health
care to our patients, as well as ensuring the quality of nursing triage and care
provided is appropriate to the complaint.

The Health Services request form DRC 5373 is not being triaged and signed off by the RN. Inmates
requesting to be seen are not always scheduled for sick call within 48 hours following the receipt of the
health services request, or immediately if indicated. The auditor found that medical staff are using a
chart review form which is not a DRC form for this process. Nurses sick call is not conducted daily in
special management housing areas (segregation). DRC 4118, Individual Segregation sheets were
missing signatures in segregation and segregation medical overflow.
OBS 02-10

Doctors Sick Call. Doctors’ Sick Call (DSC) serves as the primary mechanism
patients are seen and evaluated by Advanced Level Providers (ALP). ALPs see
patients in sick call for acute care issues, referral from NSC, post hospitalization
follow-up, routine medical care, post-emergency visits, and specialty consultation
reviews.

The auditor found that patients’ doctor appointments were often delayed. Again the use of a chart
review form is being used which is not in DRC policy. Patient education was found to be lacking often.
Follow-ups are often not found to take place. Problem lists are not updated as required.
OBS 02-11

Diabetes CCC. Treatment for offenders with diabetes should be provided in a
standardized manner that is consistent with nationally recognized disease treatment
guidelines and has the goal of improving patient outcomes while reducing morbidity
and mortality.

It was found that the type of diabetes is not always indicated on the problem list; The patients are not
10

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

always referred to the dietician for lifestyle/dist management. Immunizations against influenza and
pneumonia are not always provided or refused.
OBS 02-13

HIV CCC. The purpose of the HIV chronic care protocol is to provide coordinated
follow-up and treatment to all patients diagnosed with HIV disease.

From a review of 5 medical records for inmates in HIV chronic care clinic it was found that compliance
was not being monitored for two patients who are on antiretroviral therapy.
OBS 02-14

Emergency Services. Rapid emergency care is critical in decreasing mortality and
morbidity. Emergent assessment and intervention by nursing and medical staff will
improve the outcomes of patients in acute distress. Emergency service reviews all
aspects of the emergent event from initial event to follow up care at the institution.

The order for emergency transport does not always include the method of transportation (van vs. squad).
There was no mention of a follow-up appointment or needs indicated at the post emergency trip doctors
sick call visit.
OBS 02-15

Hospitalizations. Patient’s admitted to the hospital or FMC shall be evaluated by
medical and nursing staff upon return to the parent institution. The patient’s
treatment plan shall be updated to include care related to this hospitalization. A
complete and thorough review of the hospitalization documents is essential to
initiate or augment the institutional treatment plan.

From two patient files reviewed, one file did not show that the discharge medical summary was
reviewed and signed/dated by the ALP, and did not show that follow-up specialty consultation
recommendations were ordered or if there was documentation of the rationale for not ordering it.
OBS 02-17

Dental Pain. The purpose of this protocol is to clarify the process medical and
nursing staff follows to screen inmates for dental emergencies, both on arrival at the
institution and on a day-to-day basis. Early identification and referral is important
to alleviate pain and ensure appropriate care.

It was found that a complete set of vital signs was not recorded with the nurse’s assessment. The
patient’s weight was not taken or recorded.
F.

EXIT DISCUSSION
The final exit interview was held at 5:00 PM on Thursday September 20, 2012 in the Warden's
Conference Room with Warden Goodrich and Assistant Warden Vantell in attendance. The audit
chairperson reviewed the compliance levels with staff in attendance. The chairperson also explained the
procedures that would follow the audit for the reinspection visit.
Each auditor reviewed his or her portion of the audit standards and offered general observations during
individual close outs to the staff members in attendance. One of the two Assistant Wardens participated
in each these closeouts, with the Warden attending when he was available to attend.

11

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

The chairperson expressed appreciation for the cooperation of everyone concerned and congratulated the
facility team for the progress made and encouraged them to continue to strive toward even further
professionalism within the correctional field.

Adult Correctional Institutions
ACA Mandatory Standards
Noncompliance
4-4215

Mandatory. Written policy, procedure and practice govern the control and use of all
flammable, toxic and caustic materials.

All areas were examined for chemical inventories and for accuracy and completeness and area supervisors do
not have a current, accurate list of hazardous chemicals for their areas as required by DRC policy. Cleaning
chemicals not in usage were not secured in many areas. Invisible ink in the sallyport did not have an inventory
or MSDS. Several chemical products, including hazardous items, found in the warehouse were without an
MSDS, an inventory, or an 1885E. Chemicals in the maintenance chemical room had HMIS stickers with no
hazard numbers. The inventory on tank was last done in 2011 for Oxygen/Acetylene/Nitrogen, and the tanks
were found mixed together in maintenance. The inmate barber was using H-42 (Barbercide) that was not in a
marked container. In the food service area there were no chemical approval forms, with “Mothers Mag Wheel
Cleaner” being used on equipment. A gallon of paint was found in the storage closet of Huron A/B and was
not inventoried.
4-4222

Mandatory. Written policy, procedure and practice specify the means for the immediate
release of inmates from locked areas in case of emergency and provide for a backup
system.

The local fire plan is general and does not describe specific steps for staff to take for the means of immediate
release of inmates from locked areas in case of emergency or the specific steps for the backup system.
Employees interviewed could not demonstrate the following: a knowledge of the local fire plan; a knowledge
of the rapid release of inmates from cells in locked areas; or a knowledge of which keys used to activate the
alarm system; and many simply stated they had no idea what they should do.
4-4400

Mandatory. When an offender is transferred to segregation, health care personnel will be
informed immediately and will provide assessment and review as indicated by the protocols
established by the health authority. Unless medical attention is needed more frequently,
each offender in segregation receives a daily visit from a health care provider. The visit
ensured that offenders have access to the health care system. The presence of a health care
provider in segregation is announced and recorded. The frequency of physician visits to
segregation units is determined by the health authority.

There was no way to verify that each offender in segregation receives a daily visit from a qualified health care
professional. Nurses are not documenting visits on the DRC 4118 Individual Segregation Sheet. It could not be
verified that patients are being seen and offered daily health care in segregation.

12

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

Adult Correctional Institutions
ACA Non-Mandatory Standards
Noncompliance
4-4132

Revised January 2012. Cells/rooms used for housing inmates shall provide at a minimum,
25 square feet of unencumbered space per occupant. Unencumbered space is usable space
that is not encumbered by furnishings or fixtures. At least one dimension of the
unencumbered space is no less than seven feet. In determining unencumbered space in the
cell or room, the total square footage is obtained and the square footage of fixtures and
equipment is subtracted. All fixtures and equipment must be in operational position.

All housing units provide less than the requirement of 25 square feet of unencumbered space per occupant.
These ranged from 21.8 to 23.1 square feet of unencumbered space per occupant.
4-4134

Each inmate confined to a cell/room for ten or more hours daily is provided a sleeping area
with the following: a sleeping surface and mattress at least 12 inches off of the floor; a
writing surface and proximate area to sit; storage for personal items; and adequate storage
space for clothes and personal belongings.
Each inmate confined to a cell/room for less than ten hours daily is provided a sleeping
area with the following: a sleeping surface and mattress at least 12 inches off of the floor;
storage for personal items; and adequate storage space for clothes and personal belongings.

On the first day of the audit, 41 out of 50 cells were housing 3 inmates per cell. On day two of the audit, 12
inmates were transferred out, leaving 29 out of 50 cells housing 3 inmates per cell. Also, the single watch cells
were observed to have 2 inmates housed. In the triple bunked cells, the third inmate was sleeping on a mattress
on the floor. In one single watch cell, one inmate slept on the bed while another inmate slept on a mattress on
the floor. In one other single watch cell, one inmate slept on the bed while another inmate was observed on the
floor on a blanket (no mattress).
4-4141

All cells/rooms in segregation provide a minimum of 80 square feet, of which 35 square feet
is unencumbered space.

Each cell provides 97.75 square feet of total space and 46.25 square feet of unencumbered space for one inmate
per cell. On the first day of the audit, 41 out of 50 cells were housing 3 inmates per cell. On day two of the
audit, 12 inmates were transferred out, leaving 29 out of 50 cells housing 3 inmates per cell.
4-4183

Written policy, procedure, and practice require that correctional staff maintain a
permanent log and prepare shift reports that record routine information, emergency
situations, and unusual incidents.

In the log books, officers are not reviewing the log books or completing their close out of who is relieving them.

13

Facility: Lake Erie Correctional Institution

4-4184

Audit Date: September 18-20, 2012

Written policy, procedure, and practice provide that supervisory staff conduct a daily
patrol, including holidays and weekends, of all areas occupied by inmates and submit a
daily written report to their supervisor. Unoccupied areas are to be inspected weekly.

Documentation could not be provided to demonstrate weekly rounds in the unoccupied areas due to the weekly
unoccupied inspection report not being completed.
4-4185

Written policy, procedure, and practice require that the warden/superintendent or
designee, assistant warden/superintendent(s), and designated department heads visit the
institution's living and activity areas at least weekly to encourage informal contact with
staff and inmates and to informally observe living and working conditions.

Documentation could not be provided to show that weekly rounds are being conducted by executive staff.
4-4192

Revised August 2009. Written policy, procedure, and practice provide for searches of
facilities and inmates to control contraband and provide for its disposition. These policies
are made available to staff and inmates.

In segregation during the month of August, documentation reviewed showed that searches were conducted only
16 days out of 31 days for that month. Daily cell searches are required by 310-SEC-01.
4-4200

Revised January 2008. Written policy, procedure, and practice govern the inventory,
issuance and accountability of routine and emergency distributions of security equipment.

The pepper ball system in central control had an outdated inventory (not conducted monthly as required) and
routine issuances by non-certified personnel. Staff are also permitted to carry the pepper ball guns as a show of
force, especially during chow. This practice needs to be discontinued immediately and the facility needs to
follow permitted usage guidelines DRC policy 310-DRC-49, Pepper Ball System.
4-4207

Written policy, procedure, and practice provide for the preservation, control, and
disposition of all physical evidence obtained in connection with a violation of law and/or
institutional regulation. At a minimum, the procedures shall address the following:
• chain of custody
• evidence handling
• location and storage requirements

Contraband is not being processed daily to the contraband vault and instead being left in desks and unit areas.
The contraband vault needs to be organized and items need to be processed timely for proper disposal.
Required forms/documentation was not being completed properly on the contraband log for disposal of items.
4-4230

There are written guidelines for resolving minor inmate infractions, which include a
written statement of the rule violated and a hearing and decision within seven days,
excluding weekends and holidays, by a person not involved in the rule violation; the inmate
may waive their appearance at the hearing.

Hearing Officers are not reviewing and hearing tickets within the required seven days. The majority of tickets
are expiring due to not being heard at the hearing officer level.

14

Facility: Lake Erie Correctional Institution

4-4234

Audit Date: September 18-20, 2012

Written policy, procedure, and practice specify that, when an alleged rule violation is
reported, an appropriate investigation is begun within 24 hours of the time the violation is
reported and is completed without reasonable delay, unless there are exceptional
circumstances for delaying the investigation.

Documentation for extensions of security control could not be provided.
4-4238

Revised January 2008. Written policy, procedure, and practice provide that inmates
charged with rule violations are scheduled for a hearing as soon as practicable but no later
than seven days, excluding weekends and holidays, after being charged with a violation.
Inmates are notified of the time and place of the hearing at least 24 hours in advance of the
hearing.

Most tickets are not being heard or reviewed within seven days, and are expiring due to not being heard.
4-4253

Written policy, procedure, and practice provide for a review of the status of inmates in
administrative segregation and protective custody by the classification committee or other
authorized staff group every seven days for the first two months and at least every 30 days
thereafter

Due to not inconsistent utilization of the DRC4118, no documentation could be provided to show seven day
reviews for the first two months or 30 day reviews thereafter are being completed.
4-4255

There is a sanctioning schedule for institutional rule violations. Continuous confinement
for more than 30 days requires the review and approval of the warden/superintendent.
Inmates held in disciplinary detention for periods exceeding 60 days are provided the same
program services and privileges as inmates in administrative segregation and protective
custody.

Local Control Hearings are not being consistently conducted. As an example, 8 inmates from prior to August
20 were still waiting for hearings as of September 20, 2012. Although the one piece of documentation in the
file was good, there was no documentation found that the practice was being consistently completed.
4-4257

Written policy, procedure, and practice require that all special management inmates are
personally observed by a correctional officer at least every 30 minutes on an irregular
schedule. Inmates who are violent or mentally disordered or who demonstrate unusual or
bizarre behavior receive more frequent observation; suicidal inmates are under continuing
observation.

The one piece of documentation in the file was good however the practice is not consistently being done as
segregation logbooks were inconsistent with documented rounds/activities. Suicide observation logs are also
not consistently being maintained during watches. During the audit, the paperwork for one inmate on constant
watch was not updated for one hour from 12:30 PM to 1:30 PM. The officer responded that he catches his
paperwork up at one time.

15

Facility: Lake Erie Correctional Institution

4-4258

Audit Date: September 18-20, 2012

Written policy, procedure, and practice provide that inmates in segregation receive daily
visits from the senior correctional supervisor in charge, daily visits from a qualified health
care official (unless medical attention is needed more frequently), and visits from members
of the program staff upon request.

Daily visits from medical and the senior correctional supervisor are not being documented in employee log
books or on the DRC 4118’s. Numerous 4118’s during the days of the audit did not show medical making the
required rounds in segregation. Also, the employee log book did not show rounds of the correctional
supervisor.
4-4263

Written policy, procedure, and practice provide that inmates in segregation receive
laundry, barbering, and hair care services and are issued and exchange clothing, bedding,
and linen on the same basis as inmates in the general population. Exceptions are permitted
only when found necessary by the senior officer on duty; any exception is recorded in the
unit log and justified in writing.

Inmates in segregation are being not provided laundry exchange as required and the officers could not provide
information about how exchange occurs and there was no schedule for clothing exchange. Further, the
DRC4117’s do not document the process. DRC 4118’s and 4117’s also did not document any exchanges to
negate these findings.
4-4270

Written policy, procedure, and practice provide that inmates in segregation receive a
minimum of one hour of exercise per day outside their cells, five days per week, unless
security or safety considerations dictate otherwise.

Recreation is not always provided 5 times a week in segregation. The practice was reviewed by checking
individual documentation. Many records reviewed showed only 3-4 times per week or not being conducted at
all.
4-4318

Revised August 2004. Therapeutic diets are provided as prescribed by appropriate
clinicians. A therapeutic diet manual is available in the health services and food services
areas for reference and information. Prescriptions for therapeutic diets should be specific
and complete, furnished in writing to the food service manager, and rewritten annually, or
more often as clinically indicated. (Revised: 12/16/03 Errata)

The facility has not followed the DRC cycle menu and was using their own diet menu for the special diet. The
documentation for the inmate followed in the file did not match his diet required by the doctor or the same
timeframe.
4-4320

Written policy precludes the use of food as a disciplinary measure.

The facility was unable to provide complete documentation for the file, then added a memo stating that an
alternative meal had not been provided during the audit cycle. However in a separate special management file,
a meal loaf was shown as being served on June 1, 2012. The facility was not able to provide a DRC 4118
Individual Segregation sheet or show that a meal loaf was served per DRC Policy 60-FSM-05, Alternative Meal
Service.

16

Facility: Lake Erie Correctional Institution

4-4325

Audit Date: September 18-20, 2012

Written policy, procedure, and practice provide that stored shelf goods are maintained at
45 degrees to 80 degrees Fahrenheit; refrigerated foods at 35 degrees to 40 degrees
Fahrenheit, and frozen foods at 0 degrees Fahrenheit or below, unless national or state
health codes specify otherwise.

Temperature records that were reviewed showed consistently within compliance however the actual
temperatures checked during the audit were not in compliance. On the first and second day of the audit, the
auditor observed no temperatures checked when the food was put out onto the line. No staff on the line had
thermometers. When meals were served at the segregation satellite area, there were no thermometers and no
temperatures taken. Segregation staff interviewed stated that sometimes they checked the temperature however
they did not know the proper holding or serving temperatures for food nor did they have any paperwork to write
down the temperatures.
4-4328

Written policy, procedure, and practice require that at least three meals (including two hot
meals) are provided at regular meal times during each 24-hour period, with no more than
14 hours between the evening meal and breakfast. Variations may be allowed based on
weekend and holiday food service demands provided basic nutritional goals are met.

Most documentation provided showed that meals were being served more than 14 hours apart between the
evening meal and breakfast, especially in segregation.
4-4354-1

Added August 2006.
The management of offenders with Methicillin Resistant
Staphylococcus Aureus (MRSA) infection includes requirements identified in the
communicable disease and infection control program. In addition, the program for MRSA
management shall include procedures for:
• evaluating and treating infected inmates in accordance with an approved
practice guideline
• medical isolation, when indicated
• follow-up care, including arrangements with appropriate health care
authorities for continuity of care if offenders are relocated prior to the
completion of therapy.

When an inmate with MRSA is being transferred from LAECI to another facility, staff are not using the
intrasystem transfer summary to notify the next facility that the patient currently has MRSA and is under
treatment and wound care for the disease.
4-4425

Authorities having jurisdiction are promptly notified of an offender's death. Procedures
specify and govern the actions to be taken in the event of the death of an offender.

The shift commander log did not note the patient’s death or notifications regarding the death (occurred at OSU).
An incident report was written by an officer indicating that multiple attempts were made to contact the Captain
and Captains Office with the information but he received no answer.

17

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

Ohio Standards
Noncompliance
OH 04-01

All inmates who are placed in segregation from general population, or who are released
from segregation to general population housing shall have their personal property
accurately inventoried. This inventory shall be documented and a copy shall be retained in
the inmate property file.

It was found that each inmate does have a property file but they are either not being completed during the time
that housing assignments change or they are not being completed properly or not in the file.
OH 04-02

The Quartermaster shall update and maintain all Inmate Property Files in a secure
manner without the use of inmate workers and shall also maintain a written monthly
inventory of all clothing items and equipment in storage. The institution Quartermaster
will document all state property issuances to inmates on the Inmate Clothing Form
(DRC4077-Male/DRC4055-Female).

The quartermaster is not maintaining a monthly inventory of all clothing items and equipment in storage. Also,
food service uniforms are not issued or documented on DRC 4077.
OH 05-01

ODRC requires the Managing Officer, Deputy Wardens, and designated department heads
to visit the institution’s living and activity areas at least weekly to encourage informal
contact with staff and inmates and to informally observe living and working conditions. In
addition, each institution shall maintain a system of two-way communication between all
levels of staff and inmates.

The employee sign-in logs for three random housing units, health care, food service, programming areas, and
segregation were reviewed. It was found that rounds are not being made by the Warden, Assistant Warden or
department heads, but were being made by the Shift Supervisor and ADO.
OH 05-02

If areas that house inmates on psychotropic medications exceed 90 degrees Fahrenheit,
temperatures must be monitored regularly by the correctional officer and logged on a Cell
Temperature Log (DRC5292). The following measures will be taken:
a. Increased ventilation to the area through utilization of fans to improve airflow
and reduce room temperature to less than 90 degrees.
b. Provision of increased fluids and ice.
c. Allowance of additional showers to provide cooling.

There was no documentation that temperatures were being recorded if/when taken. Temperatures are not
documented on DRC 5292, Cell Temperature Log.

18

Facility: Lake Erie Correctional Institution

OH 06-09

Audit Date: September 18-20, 2012

The facility has a written confined space program that was developed by the Health and
Safety Coordinator and is made readily available to all staff. The program includes the
following elements:
•

•
•
•
•

The facility maintenance supervisor evaluates the workplace to determine the
locations of all confined spaces. In the event confined spaces are identified, the
maintenance supervisor is responsible for making the determination if a space is
permit or non-permit required.
Where a permit is required, the permit will be initiated by the maintenance
supervisor and authorized by the Health and Safety Coordinator.
The Confined Space Entry Permit, DRC Form 1682 is used to document the
procedure
All permit required confined spaces shall be marked as required by OSHA
1910.146.
A list of confined spaces and permit required spaces is maintained and updated as
each additional space is located.

Procedures are developed for rescue operations in the event of an emergency rescue as
required in OSHA 29 CFR 1910.146.
Training is provided to all employees and inmates affected by the confined space program.
Training records are maintained by the maintenance supervisor and training officer.
Equipment for confined space entry is provided at no cost to the employee. The supervisor
for each employee entering confined spaces shall maintain the equipment properly and
ensure it is used properly.
The facility does not have a written confined space program.
OH 06-10

The written local Fire Prevention and Safety Plan shall be reviewed annually and updated
as needed.
The plan shall also be reviewed by an independent outside inspector trained in the
application of national fire safety codes and be reissued to the local fire jurisdiction upon
each revision.
Facilities shall also develop and post written evacuation plans for each building/area of the
facility. Evacuation plans shall include building/room floor plans and the use of exit signs
and/or directional arrows for traffic flow.
The local Fire Prevention and Safety Plan and facility evacuation plans shall be publicly
posted for all interested parties.

The facility’s local fire prevention and safety program has not been updated to reflect institution specific
direction to be taken by staff during an actual emergency. General information is provided but not a specific
plan for staff to follow to direct them in what to actually do.

19

Facility: Lake Erie Correctional Institution

OH 07-02

Audit Date: September 18-20, 2012

Where the spider alert system is not in place, telephone systems are established with an off
hook alarm system to respond to staff emergencies. Where the spider alert system is in
place, all staff have in their possession the required spider alert mechanism. For both types
of alarms, staff must respond to the alarm and have it visually cleared by a supervisor.
NOTE: Telephone off-hook alarms cannot be eliminated without the approval of the
appropriate Regional Director.

The facility does not have telephone off-hook alarms or any documentation of an approval from the Regional
Director.
OH 11-01

Treatment for offenders with chronic illnesses should be provided in a standardized
manner that is consistent with nationally recognized disease treatment guidelines and has
the goal of improving patient outcomes while reducing morbidity and mortality.
Inmates diagnosed with a chronic illness that is not addressed through one of the other
established chronic care protocols shall still be enrolled into Chronic Care Clinic. Such
conditions may include, but are not limited to: Cancer, Multiple Sclerosis, Parkinson’s
Disease, Sickle Cell Anemia, Crohn’s Disease, and thyroid disorders.

Treatments are not being provided in the required standardized manner as indicated by nursing not consistently
following chronic care patients, the Advanced Level Providers not documenting clear treatment plans, and
Doctors are not addressing what needs to happen, and patients are not being referred back to the doctor when
they refuse treatment.
OH 11-02

The purpose of this protocol is to establish guidelines for complete, appropriate and timely
completion of specialty clinic referrals to FMC, OSUMC, and other specialty clinics; and to
facilitate and standardize the continuity of care received by inmates returning from
specialty consultation appointments.

A process needs to be put into place to review ATP’s with the patients. There is no documentation of this in the
files. Patients must be placed on sick call and a treatment plan discussed.
OH 11-03

The purpose of this protocol is to define the mechanism by which nursing competency is
evaluated for DRC medical nursing staff. All medical nursing staff in DRC shall
participate in the nursing competency training and assessment program.

The Health Care Administrator cannot demonstrate or explain an overall plan and schedule nurse competency
testing. Nursing competency evaluations have not been completed. The QIC cannot show documentation of
reporting to the CQI committee the number of nursing staff that tested and the overall results by competency,
nor can the QIC demonstrate documentation that shows this information was reported back to the nursing staff.

20

Facility: Lake Erie Correctional Institution

OH 11-04

Audit Date: September 18-20, 2012

Each medical CQI program shall develop a system that addresses real or potential
problems identified through investigation of complaints and grievances.
Each medical operation shall review the number and types of informal complaints and
grievances related to health care to assess for trends and commonalities in conjunction with
the Institutional Inspector.

The facility has not yet conducted quarterly ad hoc groups and needs to begin this process to address real or
potential problems identified through investigation of complaints and grievances. This needs to be conducted in
conjunction with the Institution Inspector.
OH 12-02

OCSS staff properly identifies inmates with special needs and suspected special needs
through the referral and red-flagging process, in compliance with Departmental Policy 57EDU-01, Inmate Assessment and Placement in Educational Programs. The Intervention
Assistance Team (IAT) interviews referred and red-flagged inmates.

Of fourteen IAT files reviewed: documentation could not be found to show that all red-flagged or referred
inmates were interviewed by the IAT or that the IAT consisted of the appropriate staff. It was found that red
flag letters are on grounds, but there was no documentation to show that IAT meetings were held since June
2012.
OH 12-03

OCSS staff properly serves inmates with special needs and suspected special needs through
the Evaluation Team Report (ETR) and Individual Education (IEP) Team procedures, in
compliance with Departmental Policy 57-EDU-11, Special Education.
Proper
documentation of the process is appropriately recorded.

The Special Education monthly report is incomplete and information stating completion of meetings is
incorrect. There was no documentation of classroom teacher involvement and IEP/ETR’s were not signed or
completed. Many red flagged students have not started in Special Education. Of the auditor observations sheet:
B, C, D, F, and I are not being completed.
OH 14-10

Bank Statement Reconciliation Verification Bank statements for all internal funds shall be
accurately reconciled to the appropriate checkbook at the end of each month. All internal
funds should be reconciled in the Cashless Commissary and Trust fund Accounting System
(CACTAS) bank reconciliation module monthly. At the end of each month, within 10 (ten)
days of receiving your bank statement, complete the on-line Monthly report of Cash Book
Balances and Bank Reconciliations. Any bank or savings and loan association holding
deposits shall be insured by federal insurance agencies.

The facility does not reconcile internal funds in the CACTUS bank reconciliation module monthly. Bank
statements for all internal funds are reconciled at CCA headquarters.
OH 15-01

It is mandatory that each institution offer reentry approved programs that clearly address
a criminogenic need in one or more of the eight dynamic domains/needs area and offer a
variety of non reentry approved programs, groups and activities.

Programs titled Cage Your Rage and Inside Out were the only two programs offered. No other programs or
activities are offered in the units.
21

Facility: Lake Erie Correctional Institution

OH 15-02

Audit Date: September 18-20, 2012

The Reentry Coordinator will work to ensure that program providers prioritize admission
based upon the static risk assessment, dynamic needs assessment, length of sentence,
statutory requirements, and the ability to complete the program before release.

DORAS/RAP waiting lists are not being maintained as a combined waiting list and a check of sign-up sheets
indicated that inmates are participating in programming with either no case plans or recommendations.
OH 15-04

The Unit Management Administrator or the responsible Deputy Warden are responsible
for monitoring the quality of the Prison Intake Tool (PIT) interview, documentation and
management of the Case Plan and Reentry Accountability Plan (RAP) and ensuring all
program providers are communicating through the inmate’s case plan and RAP screens.

The auditor found that there is no tracking in place for PIT reviews. Many Case Managers and Unit Managers
do not have ORAS access or training.
OH 15-05

The parent facility Unit Management Staff will complete a Prison Intake Tool (PIT) within
90 days of arrival at the prison on inmates rated as Moderate, High risk on the Prison
Screening Tool (PST) and have one year or more of prison time to serve.

No PIT screening processes were in place, therefore PITs are not being completed as required.
OH 17-01

Unit Management Staff will prepare a packet of information regarding release plans for
offenders who are incarcerated in order to ensure that all offenders released (parole, PRC)
are released on their POA, PRC date or as soon as possible.

Placement investigation packets are not being completed within 120 days. Many are completed within 90 days
or less and some were found to be less than 14 days. (DRC 101-PLA-01)
OH 17-04

The Deputy Warden will ensure that Unit Managers and Shift Captains meet weekly. The
Unit Management Administrator (UMA) will also ensure that Shift Commanders are
included in unit manager staff meetings as often as possible.

The auditor reviewed the unit meeting minutes and found that documentation did not show that shift supervisors
are being invited or attending the unit meetings. (DRC 74-UMA-01)

22

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

STANDARDS FOR ADULT CORRECTIONAL INSTITUTIONS
4th EDITION
COMPLIANCE TALLY
MANDATORY

NON-MANDATORY

Number of Standards

61

463

Number Non-Applicable

4

35

Number Applicable

57

428

Number Non-Compliance

3

24

Number in Compliance

54

404

94.7 %

94.4 %

PERCENTAGE OF COMPLIANCE

OHIO STANDARDS
COMPLIANCE TALLY
Number of Standards

68

Number Non-Applicable

18

Number Applicable

50

Number Non-Compliance

20

Number in Compliance

30

PERCENTAGE OF COMPLIANCE

66.7 %

23

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

ADULT CORRECTIONAL INSTITUTIONS
4TH Edition
ACA MANDATORY
NOT APPLICABLE
NON-COMPLIANT
4-4353
4-4215
4-4362
4-4222
4-4365
4-4400
4-4371
TOTALS
4

3

ADULT CORRECTIONAL INSTITUTIONS
4th Edition
ACA NON-MANDATORY
NOT APPLICABLE

NON-COMPLIANT

4-4128

4-4285

4-4383

4-4132

4-4253

4-4143

4-4286

4-4391

4-4134

4-4255

4-4147

4-4287

4-4436

4-4141

4-4257

4-4147-1

4-4307

4-4438

4-4183

4-4258

4-4150

4-4308

4-4439

4-4184

4-4263

4-4152

4-4309

4-4440

4-4185

4-4270

4-4181

4-4310

4-4441

4-4192

4-4318

4-4190-1

4-4311

4-4443

4-4200

4-4320

4-4208

4-4312

4-4459

4-4207

4-4325

4-4209

4-4323

4-4501

4-4230

4-4328

4-4210

4-4353-1

4-4502

4-4234

4-4354-1

4-4278

4-4364

4-4238

4-4425

TOTALS
35

24

24

Facility: Lake Erie Correctional Institution

Audit Date: September 18-20, 2012

OHIO STANDARDS
NOT APPLICABLE

NON-COMPLIANT

01-01

14-06

04-01

12-03

01-02

14-07

04-02

14-10

02-02

14-08

05-01

15-01

06-02

14-09

05-02

15-02

06-03

15-03

06-09

15-04

06-12

17-06

06-10

15-05

07-03

07-02

17-01

07-05

11-01

17-04

07-06

11-02

14-01

11-03

14-02

11-04

14-05

12-02
TOTALS
18

20

25

Significant Incident Summary
Facility:

LAKE ERIE OORf'

Reporting Dates:1/2012 -12/201;

~~~~~:~ =~-=~]- -------~-~=--~·~~=~h'p~-tN)~- _fp~ -ul~-t-_r~p'A4_~{ GpP3;-r~-~P~4-;--~'-

Assault.

lfll!lcat<: types (,nunl",
physical, etc.)

Urr..·ude]'s!
Ofknlkrs'

Ii With Weapon

5-0
H-O

::i-O
H-O

8-0

8-0

o

o

,------,-------

JliN

H-O

SO
H-O

8-0
H-O

H-O

P-4
8-0
H-O

8-0

8-0

8·0

8-0

8-0

4

3

4

3

4

s-o

P-3

JUt.

3 .. 0

Al1G

--- --- -P-4

OCT
SJ-:I'
-------1------p-o
p·o

o

Ol1i:nders!
Stafr

Indicate
(sexual"
physic;!J. d(;.)

Number of Furced
MllVeS Used'"

P-o

P-O

S-O

S-O

S-O

S-O

H-O

H-O
8-0

H-O

H-O

H·D

8-0

8-0

8-0

8-0

4

0

D

o

0

o

o

.... -------- 1---.. ---1-...._.. _-----

P-I

s-o

H-O

H-O

H-O

1-0
B·O

1-0

B-O

;t~:-~-~1--­

o

o
o

P-3

P-2

P-3

P-3

s-o

8-0
H-2

S-O
H-4
1-1
8-0

_oJo

o

f

olJefllkrs)

0

H-O

1-1
8-0

Numb"r

orTillJ~s

()tfeuder Mcdi,al
Referrab as a Result of
InjuriLo Sustained
Eseap,s

0

o

P-3
S-O

P-O
S-O

P-O

P--D

P-O

8-0

S-O

H-9

H-O

H-O

H-O

S-O
H-O

1-0

1-0

1-0

1-0

8-0

8-0

8-0

8-0

1-0
8-0

o

;'? 12
0
______ l.. ____ I -__
9

o

o

o

o
o
o
----_ . _-+o
o
o
---

u

o

2

o

o

o

o

o

o

o

o

o

0

o

- ------1----- - - - -

0

--_._---------.. --

000

._--_ .. .. _-- --------- -.--- ------_

3

5

0

0

. ------....------ -----------.--- - . - --------T-----

Special

Four!Five Poim
RestralJlts

o

---------- 1-------- - - - - -

'1

Number "I rimes
Chemical Agents Used
Reaction Team Us~d

o

5-0
H-1

o

"~tra(;{ioll

o

---+--

---1-----+----

P-l

o

or other
forwd relocation uf

ii (l 'dl

I

o

s-o

# With Weapon
# Without Weapon

o

0

S-O

P--l

types

Assault:

o

DEC

s..o

------.. -1----it Without Weapoll

NOV

o
------ -- - - -- .---

-- - -_.-

NUlllber

#iiPMS should Idlec!
lllcldmts on lhis form, 11l1t feC

0

---- - -- ---- 0

0

D

--0

U

o

o

0

--_._-- --

-----

1

0

0

0

0

o

-----...._-- ------_ .. ..---- ---- ------ ------

.--

-

o

o

o

Bed

Bed

Bed

Bed

8ed

8ed

8ed

o

o

2

o

o

o

o

o

o

o

o

o

o

o

o

or other source

o

o

o

o

Bed

8ed

o

o

o

0

o

o

o

o

o

---------- - - - + - - - Bed
8ed
Bed

o

o

---------.. ---------1------

o

0

o

o

----1-----

o

o

o

0

o

o

0

SuhsHllItiakU

l{t:i.!SOn lllh:d!L'UL i()O\L

UrkVtiIH':CS

religlulh dc.j

(res,)lved ill bvur
l,lIi:lllkr)

c

en (])

"r

q>'~

~
D

E

c.: 'iii
nl OJ
T ~
.----- ..- -.. ----..- 1----

NUlllher

o

---._+....... -....

s-o

Rc:ason (suicide. homicide.
Illjury. medically expected,
lIlcdil:ally unexpected)

S .. O
J·O
1-0
H-O
H-C
ME .. O ME-O
MU .. O MU-O

---------_._----_..+--Number

"U

0,)

c.c

CD
I\.)

-....J

o

~
:1

ro

-6

I - CO":;:;;'"

:>

0>

(f)

if)
if)

<! To £

.g ~) ~

t5
()

c

Q

9

~

'!?

ro ~
v, :>
0
ill
'0 () ~ Cl.
(; ~ .~ :l

'0

0
0

i'l

c
ill

n.

:?
i)

1:)

Eo:

0

.g
'(ij

~
'iii
9

ro

::t:: C
:::J
!!l 0

'0

ill

c:

~

0

.P
ill
Cl.

~

lU

'"
C:

::J

~
8u
(f)
U( uu
U(
U(
U, ill
~
~
'1 i!'u 'fur
...(f)
ro
N 0~
....--------...--.-1---.--------- ---------------1- - ...-.... -.- ...

ro

U( 0,
,- ,"

"7
-~
,- ('\l

,~-

"'~.

7

-;,

:::l

~-

2

J

I

.0

~

.. _..

_- -_._-

.3

-J-----..-

-.-- ......-..--1-......- . - - . - . - - -..- - - - - - - - - - - - -..-..--------f------- .. --- - ..-- - - - I - " - - - S .. O
1.. 0
H-O
ME-O
MU·O

---j--.---

o

~

2

()

__ ....._. ____ ...__._.. -.-.. f--- .....--.----------.-------4--.+---

Dc:aths

"S; 0>

c

u

c

0

'0

o

S-O
1-0
H-O
ME-1
MU-O

S-O
1.. 0
H-O
ME·O
MU-O

I-----j-- ..- - - - . - - - . - -

o

S-O

S-O
1-0
H-O
ME-O
MU-O

S-O
1-0
H-O
ME-O
MU-O

S .. O
1-0
H-O
ME-O
MU .. O

S .. O
1-0
H-O
ME ..O
MU-O

S .. O
1··0
H-O
ME-O
MU .. O

S-O
1-0
H-O
ME-O
MU-O

ME-O
MUO

o

o

o

o

o

o

o

- - . - . - .....- - - - - . - - - - - - - - 1---------..---1--...-

..-

1.. 0
H-O

Name of Facility Lake Erie Correctional Institution

Date January 1 2012
Number of Months Data Collected 12 months
J

Health Care Outcome Measures
Outcome

1A

divided

Number of offenders administered tests for TB infection in
the past twelve (12) months as part of periodic or clinicallybased test in but not intake screeni

102

7

divided

are
treated with highly active antiretroviral treatment (HAART)
at a'
int in time
Total number of offenders diagnosed with HIV infection at
that time
Number of selected offenders with HIV infection at a given
point in time who have been on antiretroviral therapy for at
least six months with a viral load of less than 50 simi
Total number of treated offenders with H1V infection that

5

6

o
6

ospitals in the

Page 28

Name of Facility Lake Erie Correctional Institution

Date January 1, 2012
Number of Months Data Collected 12 months

Health Care Outcome Measures
Standard

Outcome
Measure

Numerator I Denominator

specialty consults completed during the
months
Number of speciality consults (on-site or off-site) ordered by
primary health care practitioners in the past twelve (12)
months

Value

Calculated
O.M.

,......." ...,rt'''r

divided

678

3

divided

Total number of offenders with hypertension who were
reviewed
Number of selected diabetic offenders at a given point in
time who are under treatment for at least six months with a
r than 9 ,,<>,',..<>,,1
hem lobin A 1C level measuri

21

7

2A

Page 29

Name of Facility Lake Erie Correctional Institution

Date January 1, 2012
Number of Months Data Collected 12 months

Health Care Outcome Measures
Standard

Outcome
Measure

divided

3A

Numerator I Denominator
Number of direct care staff (employees and contractors)
with a conversion of a T8 test that indicated newly acquired
T8 infection in the
twelve
months
Number of direct care staff tested for T8 infection in the
past twelve (12) months during periodic or clinically
ations

0

o

Number of offender grievances related to health care found
in favor of the offender in the
twelve
months

4A

past twelve (12)

o

0.00

Page 30