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is inconsistent with the statements of many other supervisors and BOP Lieutenant training, all of which emphasized the need for Lieutenants to walk down all of the SHU tiers during a round. During their interviews with the OIG, the Northeast Regional Director, the Warden, Associate Warden 1, and the Captain clarified that they expected a Lieutenant conducting a round in the SHU to check in with the officers, walk down each of the tiers in the SHU, speak with inmates, and address inmate concerns. They explained that the Lieutenants did not act responsibly if they did not walk down each of the tiers to check on the inmates in the SHU. As the Acting Evening Watch Activities Lieutenant explained, unlike inmates in general population, SHU inmates cannot approach a supervisor because they are confined within a cell. Further, the BOP Lieutenant training, which the Morning Watch Operations Lieutenant attended in 2011, taught that Operations Lieutenants were required to visit the SHU at least once during each shift and that “[t]his visit will be substantially more than just entering the unit, signing the log book, and talking with staff.” Instead, Operations Lieutenants were trained to, among other things, walk through each range (or tier), inspect logs and reports, observe activities, and periodically observe counts within the SHU. The OIG found that the failure of the Evening Watch Operations Lieutenant and the Morning Watch Operations Lieutenant to adequately supervise SHU staff, and of the Morning Watch Operations Lieutenant to adequately conduct a Lieutenant round in the SHU, which contributed to the SHU staff's failure to conduct mandatory rounds and counts, constituted a job performance failure. C. MCC New York Staff Allowed Epstein to Place an Unmonitored Telephone Call on August 9 The OIG’s investigation and review revealed that on the night before his death, Epstein placed an unrecorded, unmonitored telephone call using a non-Inmate Telephone System line from 6:58 p.m. to 7:19 p.m. Other than an MCC New York call log, no other BOP records exist regarding this unmonitored call, including the identity of the person Epstein called or a summary of the conversation. Federal regulations require that the Warden of each BOP institution establish procedures to monitor inmate telephone conversations, which is “done to preserve the security and orderly management of the institution and to protect the public.”** For safety and security reasons, BOP policy requires that all inmate telephone calls be made through the Inmate Telephone System.®° BOP policy recognizes that “on rare occasion, in times of crisis,” inmates may be permitted to make a telephone call outside of the Inmate Telephone System. In such circumstances, the telephone “must be placed in a secure area (e.g., a locked office), and “must be set to record telephone calls.” Additionally, the staff member coordinating the call must notify the BOP’s Special Investigative Services via email, providing the inmate’s name and register number, the date and time of the call, the number and name of the individual called, and the reason for the call. The Special Investigative Services must enter this information into the telephone recording system within 7 days. The OIG's investigation determined that on August 9, 2019, Epstein asked to call his mother. The Unit Manager told the OIG that after Epstein’s attorney visit had concluded, he agreed to allow Epstein to place a telephone call on an unrecorded legal line. The Unit Manager explained that it was his understanding that Epstein did not have the ability to place a telephone call through the Inmate Telephone System. The OIG’s 54 28 U.S.C. 8 540.102. 85 BOP Program Statement P5264.08. 107 DOJ-OGR- 00023474