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Speaker 1: What's up everyone, and welcome to another episode of the

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Epstein Chronicles. In this episode, we're going to pick up

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where we left off with the psychiatric breakdown and recreation

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of Jeffrey Epstein's death Number eight It made accountability and

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assignment accuracy. According to a Century Quarters roster generated on

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August tenth, twenty nineteen, at twelve fifty one am, there

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were three inmates assigned to mister Epstein's shoe cell Z

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zero four dash two zero six LAD, including him at

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the time of his death. However, his shoe cell was

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only a double occupancy cell. Inmate Patrick Avila, it made,

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Gregory Ferrer, and mister Epstein were all assigned to the

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same cell. On August thirteenth, twenty nineteen, at twelve oh

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six pm and twelve oh eight pm. A Quarter's History

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roster was generated for inmate of Villa and Ferr, respectively,

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and made a Villa cell assignment was Z zero zero

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four dash two six la D from August fifth, twenty

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nineteen until August eleventh, twenty nineteen, when he was moved

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to sell Z zero four dash two one two ua

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D and made. Farreer cell assignment was Z zero four

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dash two O six UA D from August first, twenty

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nineteen until August eleventh, twenty nineteen, when he was moved

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to sell Z zero four to zero seven LAD. A

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quarter's history roster was generated for mister Epstein on August thirteenth,

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twenty nineteen at nine oh seven am. His cell assignment

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was Z zero four DASH two zero six LA D

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from July twenty ninth, twenty nineteen until August tenth, twenty nineteen.

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On Monday, August twelfth, twenty nineteen, photographs of name tags

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on shoe cell doors and shoe lokeader forms were sent

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to Correctional Service Department in the North East region. The

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shoe locator form is dated August ninth, twenty nineteen. It

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shows inmate Ferror in cell two O seven L century

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states that he was moved to this cell on August eleventh,

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twenty nineteen. In mat of Vila in cell to twelve

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U century states that he was moved to this cell

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on August eleventh, twenty nineteen. Epstein in cell to twenty

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L century never shows them in a cell along with

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inmate reyes. The locator shows inmate copper and inmate dockery

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in Cell two O six. The photo sheets show the

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cell being two twenty with inmates Epstein and Reys identification

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cards on the door. Inmate Reyes ephrin regulation number eight

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five nine nine three DASH zero five four was in

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cell Z zero six to twenty U from August fifth,

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twenty nineteen to August ninth, twenty nineteen. Mcc New York

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has four suicide watch cells and each is for single

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occupancy use. The suicide watch cells are located in health Services.

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Each cell is abbreviated with the unit code HO one

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in Century, followed by four digit cell number. The doors

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are identified by a painted number from one to four.

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Two reviews were conducted. The first revealed mister Epstein was

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in H zero one zero zero IL according to Century,

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but the suicide Watch logbooks indicate he was in cell four.

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A second review was conducted on August thirteenth, twenty nineteen.

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While there were four inmates in these cells, Century showed

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two inmates assigned to ho I zero zero IL, one

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assigned to HO one DASH zero zero two one, and

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the fourth inmate assigned to a general population housing unit.

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Through physical observation of the dedicated suicide watch cells, there

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were four HO one cells. However, a review of bop

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ware inmate housing format only shows three cells. Inmate movement

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and assignments are not accurately reflected in Century is required

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by P five five zero zero dot one four Correctional

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Service Procedure Manual Institutional Response eight Inmate Accountability and assignment accuracy.

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With regard to accuracy and accountability of inmates placed on

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suicide watch status in the hospital area, Psychology Services now

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runs a daily Century roster of all inmates on suicide

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watch in that area. The roster is examined to ensure

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that the inmates placed on suicide watch in a suicide

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watch cell are keyed into centry with the correct cell

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assignment noted. The associate warden programs is notified if there

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are any inconsistencies. Moreover, the four suicide watch cells now

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all have Century assignments of H zero one zero zero

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one L through H zero one dash zero zero five. Further,

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Psychology Service Department reviews suicide watch logbooks on a daily

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basis to assess whether the lieutenants have conducted rounds during

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each shift and whether the Unit two sally Port and

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Unit two officers are conducting hourly rounds. Any inconsistencies noted

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in the logbooks by psychology staff will be reported immediately

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to the Captain and Associate Warden over programs to address appropriately.

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The Operations Lieutenant will physically check the PP thirty cell

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assignment roster when inmates are quartered on Suicide Watch. The

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lieutenant will ensure the counts and assignments officer key cell

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assignments correctly and annotate any errors in the daily log

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and contact the Captain immediately. Guidance was sent to the

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lieutenants regarding king of Suicide Watch BET assignments after hours.

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The lieutenants were instructed that upon placing an inmate on

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Suicide Watch, they're responsible for contacting CNA and providing the

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cell assignment. Additionally, the lieutenant will run PP thirty with

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the selection category for Suicide Watch. The Operations Lieutenant will

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email the roster to the Captain, as he will be

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responsible for verifying that each inmate is in an appropriate cell.

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This verification process will ensure inmates placed on Suicide Watch

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are keyed into accurate BET assignments and will eliminate inmates

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being keyed into the same cell. Additionally, the lieutenants were

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instructed to contact the captain and on call psychology staff

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by telephone when the need for suicide watch placement is

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determined after hours. Psychology staff have been instructed to contact

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the warden upon receiving said notification. After consultation with the warden,

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Psychology staff will designate whether a staff or inmate companion

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will be assigned. Psychology staff will in turn inform the

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shift lieutenant of this determination. To ensure that inmates are

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assigned to the correct sell Inside the Special Housing unit,

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periodic and unannounced checks are conducted specifically Century Roster PP

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thirty Quarters assignment are audited daily by the Shoe Lieutenant.

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Executive staff also conduct routine bed book counts and all

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units any and all discrepancies identified or addressed results will

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be maintained by correctional services in the Lieutenant's log. The

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morning watch lieutenant is responsible for observing one count during

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his or her shift in the Shoe, which is documented

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daily in the Lieutenant's log. In order to properly account

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for inmates in the unit, staff have been informed not

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to use the inmate locator form due to the form

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being unreliable in accounting for inmates and sell assignments. A

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Unit Accountability Board along with century PP thirty quarters Roster

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have been placed in the unit to establish better oversight

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over inmate accountability. Correctional staff are required to perform routine

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rounds on the second floor suicide watch area every hour

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on day watch Monday through Friday. The two sally officers

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are required to perform rounds on suicide Watch inmates as

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prescribed by the captain. After hours, the Unit two officer

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will be responsible for making rounds, serving mules, collecting trash

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in the area, and performing the count with the Internal

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one or Internal two officer assisting with duties as assigned

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by the captain to ensure that staff are informed of

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the importance of suicide prevention and responsibilities. When one occurs,

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lieutenants will reinforce the message through conference calls with staff.

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Roll call notes will be placed on truscope to notify

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staff of which inmates are currently on suicide watch. Nine

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attorney logbooks four logbooks were not secured following mister Epstein's death. Specifically,

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three attorney logbooks located in the attorney visiting in front

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lobby areas and an inmate search logbook located in the

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attorney visiting area were not secured. All four books were

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still in use at the outset of the reconstruction, and

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after the reconstruction team advised staff to secure them. P.

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Five three two four dot zero eight states in the

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event of a suicide, institution staff, particularly correction staff and

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other law enforcement personnel, will handle the site with the

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same level of protection as any crime scene in which

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a death has occurred. This policy further states all possible

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evidence in documentation will be preserved to provide data and

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support for subsequent investigators doing psychological reconstruction. Further, a review

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of the attorney logbooks identified many errors and signify a

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systemic concern. For example, there were two can currently open

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attorney logbooks in the attorney visiting area. Further, the different

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purposes of the two attorney logbooks, one in the attorney

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visit area and one in the front lobby, cannot be explained.

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BOP staff were unable to articulate a system of control

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for the logbooks, and during the reconstruction some of the

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logbooks could not be accounted for. With the logbooks, entries

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were made out of chronological order, attorneys did not consistently

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sign in and out, significant information was illegible or missing columns,

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were not consistently labeled, logbook opening and closing dates were inconsistent,

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and the cover had been torn off several books. At

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the current time, these logbooks are not functioning as an

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adequate system of control and monitoring. Institution Response number nine

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Attorney logbooks. On August tenth, twenty nineteen, logbooks deemed relevant

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to the investigation were removed from various locations throughout the facility.

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The reconstruction team did not identify pertinent logbooks that had

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been secured. At this time. All relevant logbooks have been

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removed and replaced. In addition, a logbook audit will conducted

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to ensure accuracy of the documentation and compliance with policy.

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Measures are being taken to ensure in the future that

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all relevant log books are identified, secured immediately and replaced

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with new ones to ensure the institution can continue to

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run efficiently. Ten Automatic external defibrillators. A review of available

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AEDs in the institution revealed that the list used for

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accountability and inspection purposes was inaccurate and complete. Institution Response

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ten Automatic external defibrillators. A review of the automatic external

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defibilators report presented by Great Lakes Biomedical Service dated July

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twenty second, twenty nineteen, revealed that all AEDs were accounted

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for and were placed in correct respective areas. The report

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was accurate and complete. New AEDs have been purchased and

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will be inspected Great Lakes Biomedical Services upon their arrival.

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The list reviewed by the reconstruction team was an old

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and outdated list from January of twenty eighteen. Medical staff

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provides training and conducts monthly inspections of all AEDs in

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the institution Great Lakes Biomedical Services. An outside contractor conducts

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a bi annual inspection and provides a report. Procedures on

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inspecting all AEDs in the institution have been prepared and

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are awaiting approval. These procedures are attached here. Two eleven

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post orders and shoe training. Shoe post orders sign in

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sheets were reviewed for the third quarter spanning June ninth,

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twenty nineteen to September seventh, twenty nineteen. Officer L. Gray

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failed to sign post orders for shoe number three post

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Quarterly shoe training sign in sheets were reviewed the twenty

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nineteen third quarter. Shoe training was conducted on June sixth,

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twenty nineteen. Three staff assigned to the third order, Shoe

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Roster and Shoe did not attend or receive Shoe training

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Officer David to Benzig, Officer Miguel Mongey, and Officer Robert

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Gravalla Institution Response eleven post orders and Shoe training. The

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suicide watch post orders are located in the Lieutenant's office

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and Shoe with a quarterly sign and sheet. A copy

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of the suicide watch post orders will also be placed

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in secure container outside of suicide watch cells on Tier

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H and Shoe. This container will also hold signature sheets

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and additional staff suicide watch logbooks. All staff members assigned

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to a suicide watch post are responsible for signing the

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post orders prior to performing the staff suicide watch. Attached,

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please find a copy of the narrow waiver permitting staff

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monitored suicide watches in the Shoe. With regard to Shoe

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suicide prevention training, this continues to be conducted on a

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quarterly basis. However, the sign in sheets for this training

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are now to be examined by the Shoe lieutenant for accuracy.

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If a staff member who is assigned to the Shoe

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misses the training, the sign in sheet will be routed

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to the captain who will coordinate with the chief Psychologist

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and schedule a time to receive a makeup session for

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the shoe suicide prevention training. Shoe training is conducted quarterly.

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Two weeks from the beginning of a new quarter, a

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representative from Psychology will provide the required suicide prevention training

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in addition to shoe training on bob learn will be

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completed by all staff assigned to the shoe that day

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of training. Shoe staff will be allotted time during the

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data complete the prescribed web based training as identified on

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the agenda. Staff who are assigned to the shoe but

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have not received the mandatory training before assuming the post

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will be roster adjusted to attend another training day as

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assigned by the Captain. Staff assigned to Suicide Walde shall

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maintain a chronological log of the inmate's behavior. Blank logbooks

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will be maintained in the Lieutenant's office and on the

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second floor. A chronological record of events will commence immediately

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upon the initiation of watch. It's the responsibility of the

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staff member initiating the watch to obtain a blank logbook

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prior to initiating the watch. Different logbooks will be used

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for each inmate on Suicide watch. Each logbook will contain

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entries for one suicide watch only. The name and register

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number of the inmate on watch shall be clearly printed

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on the front cover of the logbook and at the

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top of each page in the logbook in which entries

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are made. During some suicide watches, staff observers may cover

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some shifts and inmate companions may cover others. In the instance,

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two separate logbooks must be used, one of the shifts

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or one for the shifts excuse me during which staff

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are maintaining constant visual observation blue, and another for shifts

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during which inmate companions are providing constant visual observation yellow.

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When separate inmate companion logbooks are used, staff must sign

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the inmate's companion logbook every sixty minutes. Lights will remain

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on inside the cell twenty four hours a day to

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ensure the inmate on watch can be seen. A lieutenant

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will make rounds every shift and remove the inmate from

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the cell and perform a cursor research. No food items, trays,

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eating utensils, milk cartons, toilet paper, plastic bags, reading materials, pens, pencils,

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or anything else not prescribed by psychology. Staff should be

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in the cell. The inmate will be outfitted in a

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suicide preventive smock, suicide preventive blanket, suicide preventive mattress, and,

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if necessary, a suicide preventive helmet. Inmate companions will be

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searched prior to assuming duties. Inmate companions are not allowed

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to have radios, NP three players, magazines, books, or anything

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that would distract them from maintaining constant supervision. In may

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companions will not have direct or physical contact with inmates

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on suicide watch staffing. The drug Abuse Program Coordinator position

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at mcc New York was abolished during phase one of

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staff realignment during fiscal year twenty eighteen. Re Establishing the

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Drug Abuse Program Coordinator position would provide the institution with

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an additional supervisory psychologist to provide critical clinical services. Staffing

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in the Correctional Services Department is relevant to the reconstruction. However,

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the details about this topic are provided in an after

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action review completed separately from this report. Institutional Response twelve staffing.

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The drug Abuse Coordinator position is currently a share position.

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A warden has re established the Drug Abuse Coordinator position

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as a full time position to provide the psychology department

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with an additional supervisory psychologists to perform critical clinical service.

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At the current time, the position is pending selection. We

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are currently in the process of requesting to hire a

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staff psychologists position to provide additional psychological services to inmates

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in the Shoe, including therapy sessions with sy alert CC

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two MH and CC three MH inmates who are currently

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housed there. An additional psychologists could also monitor hot list

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inmates arriving to the Shoe and ensure that they're housed

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with appropriate cellmates. This psychologist could conduct daily rounds to

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look for signs of psychological distress and address the concerns

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of our long term Shoe inmates. Finally, an additional staff

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psychologist could assist with our daily crisis and revention and

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suicide risk assessments. Thirteen Sex offense risk factors a broad

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understanding of risk factors associated with sex offenders by staff

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at MCC New York did not appear to be present

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in all staff, but was vital to his adjustment and

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safety in prison. A more focused management strategy is recommended,

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particularly in complex and high profile cases. Supplemental training on

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sex offender specific risk factors is recommended for all staff

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and should be provided by executive staff and Psychology Services

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institutional response. The chief psychologist is a member of the

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executive staff. The chief Psychologist or her designee continues to

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present at all executive staff meetings, department head meetings, and

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shoe meetings. During these meetings, the chief psychologists offers feedback

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regarding the treatment and management of sex offender inmates. Additionally,

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the chief psychologist continues to educate all staff during introduction

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to correctional techniques and annual training about the sex offenders,

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specific risk factors and suicide risk. All right, folks, Well

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there you have it, the psychological reconstruction of what went

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down leading up to and on the night of Jeffrey

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Epstein's death. All the information that goes with this episode

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can be found in the description box.

