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Bureau of Prisons: BOP Could Further Enhance its COVID-19 Response by Capturing and Incorporating Lessons Learned

GAO-21-502 Published: Jul 29, 2021. Publicly Released: Jul 29, 2021.
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Fast Facts

The Bureau of Prisons is responsible for the custody and care of about 129,000 federal inmates in BOP-managed facilities. COVID-19 has affected both inmates and staff at these facilities.

The Bureau has processes, such as teleconferences among officials and facility inspections, to identify best practices and lessons learned from its COVID-19 response. However, the Bureau doesn't capture or share some of this information Bureau-wide or have an approach for ensuring facilities apply them.

We recommended developing and implementing an approach to capture and share best practices and lessons learned, and ensuring that facilities apply them.

A Bureau of Prisons Facility’s Recreation Area Repurposed for Medical Isolation

 

A large room with several pink cots and plastic chairs.

 

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Highlights

What GAO Found

The Federal Bureau of Prisons (BOP) has developed COVID-19 guidance, with input in part from the Centers for Disease Control and Prevention, and periodically updates this guidance, but some BOP staff reported to GAO confusion in how to implement BOP's guidance. In addition, the Department of Justice's Office of Inspector General surveyed BOP staff and reported that of the 28 percent of employees who responded, 59 percent of respondents thought BOP's guidance was not clear. Routinely evaluating how it communicates its COVID-19 guidance to staff, and modifying its approach as needed based on staff feedback, would help BOP ensure that staff can understand and effectively implement the protocols for COVID-19 and any future public health emergency.

As of May 2021, BOP's data showed that:

BOP obligated nearly $63 million for personal protective equipment (PPE)—such as masks, hand sanitizers, gloves and COVID-19 testing kits—for staff and inmates.

45,660 inmates had tested positive, and 237 inmates had died from the virus. In addition, 6,972 staff members tested positive, with four deaths.

BOP fully vaccinated about 56 percent of all inmates in BOP-managed facilities (73,050 inmates) and about 50 percent of all staff (19,000 staff)

COVID-19 has affected inmates and staff. For example, inmates faced reduced access to certain programs, services, visitors and facility spaces. For staff, quarantining procedures have resulted in reduced staff availability and increased the use of overtime. BOP has processes, such as teleconferences among BOP officials and facilities inspections, to identify best practices and lessons learned related to its COVID-19 response. However, BOP does not capture or share, bureau-wide, the lessons and practices discussed at its teleconferences, or have an approach for ensuring facilities apply them, as appropriate. Implementing approaches for such actions would help BOP ensure that the lessons and practices it identifies reach all facilities that could benefit from them, and that facilities actively improve their COVID-19 response efforts.

A BOP Facility's Housing Tents for Inmates in Quarantine and Isolation

A BOP Facility's Housing Tents for Inmates in Quarantine and Isolation

Why GAO Did This Study

BOP was responsible for the custody and care of about 129,000 federal inmates in BOP-managed facilities, and employed more than 37,000 staff as of May 2021. Because of confined spaces, the prison population is particularly vulnerable during infectious disease outbreaks, such as COVID-19. About $620 million has been appropriated to or designated by BOP for COVID-19- related efforts.

GAO was asked to review BOP's approach to responding to COVID-19. This report addresses, among other objectives: (1) BOP's development and updates of COVID-19 guidance; (2) BOP's provision of PPE, COVID-19 tests and vaccines, and infection and fatality rates for inmates and staff; and (3) the impact of COVID-19 on inmates and staff, and the extent to which BOP has incorporated lessons learned into its response.

GAO reviewed BOP policies, data, and other documentation related to the impact of COVID-19 and how BOP addressed it. GAO also conducted non-generalizable interviews of officials from five BOP facilities and one private facility operating under contract with BOP, selected based on inmate infection rates and other factors.

Recommendations

GAO is making three recommendations that BOP evaluate communication of COVID-19 guidance, develop an approach to capture and share best practices and lessons learned; and develop an approach to ensure facilities apply these practices as appropriate. BOP concurred with all three recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status Sort descending
Bureau of Prisons The Director of BOP should routinely evaluate how it communicates its COVID-19 guidance to facility staff and modify its approach, as needed, based on the results to ensure BOP protocols are clearly communicated to staff. (Recommendation 1)
Closed – Implemented
BOP concurred with this recommendation and has taken action to implement it. In December 2021, BOP included two new questions in its annual staff feedback survey, asking respondents about the extent to which they agreed with two statements: (1) they knew where to find COVID-19 guidance and (2) they knew how to gather further information if they had questions. BOP deployed this survey with the same questions again in 2022. In April 2022, BOP officials reported that they had analyzed the 2021 survey results, and based on positive staff feedback, decided to continue with BOP's current communication strategy for COVID-19 guidance. In April 2023 BOP officials analyzed the 2022 survey results, and based on another year of positive feedback, said no further changes were needed. For example, about 80 percent of respondents to the 2022 survey somewhat agreed, agreed, or strongly agreed that they knew how to locate COVID-19 guidance and that they knew where to go for assistance if they had related questions. Though BOP officials told us that BOP would not be making significant changes to its communication strategy in response, they also noted that they have since created an intranet page where all its COVID-19 resources can be accessed from a single location. Going forward, officials said they will no longer include these COVID-19 questions in BOP's annual staff survey, but will continue to assess staff communication techniques through less formal means. They added that they may continue to include the questions about COVID-19 guidance in future staff surveys, depending on the broader public health landscape moving forward. These efforts are consistent with our recommendation.
Bureau of Prisons The Director of BOP should develop and implement an approach to capture and share best practices and lessons learned for responding to COVID-19 and future public health emergencies as discussed among BOP officials at their regular teleconferences. (Recommendation 2)
Closed – Implemented
We found that the Bureau had processes, such as teleconferences among officials and facility inspections, to identify best practices and lessons learned from its COVID-19 response. However, the Bureau did not capture or share some of this information Bureau-wide. As a result, we recommended that the Director of BOP should develop and implement an approach to capture and share best practices and lessons learned for responding to COVID-19 and future public health emergencies as discussed among BOP officials at their regular teleconferences. In response, BOP officials have developed and implemented two approaches, in addition to maintaining use of teleconferences that aim to capture and help share this information. In particular, BOP issued a memo in December 2021 outlining one specific new process for this purpose. The memo describes an email account where facility staff can send "any procedures or protocols believed to be effective in responding to the pandemic, not already outlined in agency policy or guidance." As they receive submissions, BOP officials from the appropriate office, such as the Health Services Division, will review them to determine their viability for implementation across the agency. BOP officials we spoke with in February 2022 noted that they deem a practice as "viable" if it is in alignment with BOP policy and guidance. If it is, then officials told us their next step is to assess whether or not the practice should be made mandatory across BOP. If officials determine that it should be, then BOP officials said they will update policy or guidance accordingly. In addition, they said they will also update the checklist that reviewers on the COVID-19 Compliance Review Team (CCRT) use to oversee COVID-19 policy implementation at each facility in the Bureau, to ensure that the new mandatory practice is reflected. Apart from the email account, BOP officials also noted that the CCRT review process itself serves as an additional way to capture lessons learned and best practices because during discussions about compliance with the checklist, reviewers often hear from facility officials about some novel approaches that they have found useful and effective. Both the use of the email account and the CCRT discussions reflect approaches that are consistent with our recommendation.
Bureau of Prisons The Director of BOP should develop and implement an approach for ensuring its facilities are applying, as appropriate, best practices and lessons learned related to COVID-19 and future public health emergency response efforts. (Recommendation 3)
Closed – Implemented
We found that the Bureau had processes to identify best practices and lessons learned from its COVID-19 response. However, the Bureau did not capture or share some of this information Bureau-wide or have an approach for ensuring facilities apply them. As a result we recommended that the Director of BOP should develop and implement an approach for ensuring its facilities are applying, as appropriate, best practices and lessons learned related to COVID-19 and future public health emergency response efforts. In response, BOP issued a memo in December 2021 outlining one specific new process for this purpose. The memo describes an email account where facility staff can send "any procedures or protocols believed to be effective in responding to the pandemic, not already outlined in agency policy or guidance." As they receive submissions, BOP officials from the appropriate office, such as the Health Services Division, will review them to determine their viability for implementation across the agency. BOP officials we spoke with in February 2022 noted that they deem a practice as "viable" if it is in alignment with BOP policy and guidance. If it is, then officials told us their next step is to assess whether or not the practice should be made mandatory across BOP. If officials determine that it should be, then BOP officials said they will update policy or guidance accordingly. In addition, they said they will also update the checklist that reviewers on the COVID-19 Compliance Review Team (CCRT) use to oversee COVID-19 policy implementation at each facility in the Bureau, to ensure that the new mandatory practice is reflected. While facility wardens will maintain discretion to implement new practices that are shared but that BOP has not made mandatory, the CCRT process will serve as the approach to ensure facilities are applying the new practices that are mandatory. This approach is consistent with our recommendation.

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Agency evaluationsBest practicesBroadcasting standardsCompliance oversightCorrectional facilitiesDeathsFacility managementFederal prisonsHealth careHealth care servicesHousingHuman capital managementLegal counselLessons learnedOvertime paypandemicsPrison overcrowdingPrivate facilitiesPublic health emergenciesTeleconferences