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6. The BOP should continue to develop and implement plans to address staffing shortages at its prisons. Since at least 2015, the OIG has repeatedly found the need for BOP to address staffing shortages, including medical staffing shortages.®° This investigation and review revealed the direct impact of staffing deficiencies on inmate safety. For example, the Material Handler worked three consecutive shifts—24 hours straight— on August 9, 2019, which was certainly a contributory cause to the lack of adequate means of accounting for inmate location and wellbeing in the SHU. The Material Handler told the OIG that no one did the 10 p.m. SHU inmate count because they were tired. Additionally, the OIG’s investigation and review found that in connection with MCC New York's upgrade of its security camera system, the BOP’s Northeast Regional Office arranged for technicians from other BOP institutions to perform temporary duty (TDY) assignments to MCC New York to perform necessary mechanical, electrical, plumbing, and wiring work. Yet, during the course of the TDY rotations, work was not consistently conducted on the camera upgrade because sometimes TDY staff were used to cover shortages at MCC New York's custody posts. Without adequate staffing, the BOP cannot fulfill its mandate to ensure safe and secure correctional facilities. The OIG therefore recommends that the BOP continue to develop and implement plans to address staffing shortages at its institutions. 7. The BOP should evaluate its cell search procedures and make changes as may be appropriate to improve those procedures through policy, training, or other measures. The OIG’s investigation and review found that there was an excessive amount of linens in Epstein’s cell at the time of his death. BOP policy and MCC New York SHU Post Orders require that SHU cells be searched, but they do not specifically address the issue of excessive bed linens, which the Captain told the OIG present a safety hazard because an inmate can use them to harm themselves or escape from the institution. Therefore, the OIG recommends that the BOP evaluate its cell search procedures and make changes as may be appropriate to improve those procedures through policy, training, or other measures. ® U.S. DOJ OIG, Analysis of the Federal Bureau of Prisons’ Fiscal Year 2019 Overtime Hours and Costs, Management Advisory Memorandum 21-011 (December 2020); U.S. DOJ OIG, Review of the Federal Bureau of Prisons’ Use of Restrictive Housing for Inmates with Mental Illness, Evaluation and Inspections Division Report 17-05 (July 2017); U.S. DOJ OIG, Audit of the Federal Bureau of Prisons’ Contract No. DJBP0616BPA12004 Awarded to Spectrum Services, Inc., Victorville, California, Audit Division Report 17-20 (March 2017); U.S. DOJ OIG, Audit of the Federal Bureau of Prisons’ Contract with CoreCivic, Inc. to Operate the Adams County Correctional Center in Natchez, Mississippi, Audit Division Report 17-08 (December 2016); U.S. DOJ OIG, Review of the Federal Bureau of Prisons' Medical Staffing Challenges, Evaluation and Inspections Division Report 16-02 (March 2016); U.S. DOJ OIG, Review of the Impact of an Aging Inmate Population on the Federal Bureau of Prisons, Evaluation and Inspections Division Report 15-05 (May 2015). Additionally, multiple remote inspections the OIG conducted as part of its pandemic response oversight work revealed that staffing shortages impacted the BOP’s ability to respond to inmates’ medical needs during the Coronavirus Disease 2019 pandemic. These findings are summarized in the OIG’s Capstone report. 113 DOJ-OGR-00023480