[Senate Hearing 117-535]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 117-535

                  CORRUPTION, ABUSE, AND MISCONDUCT AT
                       U.S. PENITENTIARY ATLANTA

=======================================================================

                                HEARING

                              BEFORE THE 

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 OF THE

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS


                             SECOND SESSION

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                             JULY 26, 2022

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        Available via the World Wide Web: http://www.govinfo.gov

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        Committee on Homeland Security and Governmental Affairs       
        

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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                   GARY C. PETERS, Michigan, Chairman
THOMAS R. CARPER, Delaware           ROB PORTMAN, Ohio
MAGGIE HASSAN, New Hampshire         RON JOHNSON, Wisconsin
KYRSTEN SINEMA, Arizona              RAND PAUL, Kentucky
JACKY ROSEN, Nevada                  JAMES LANKFORD, Oklahoma
ALEX PADILLA, California             MITT ROMNEY, Utah
JON OSSOFF, Georgia                  RICK SCOTT, Florida
                                     JOSH HAWLEY, Missouri

                   David M. Weinberg, Staff Director
                    Zachary I. Schram, Chief Counsel
                Pamela Thiessen, Minority Staff Director
                     Laura W. Kilbride, Chief Clerk
                     Thomas J. Spino, Hearing Clerk


                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                     JON OSSOFF, Georgia, Chairman
THOMAS R. CARPER, Delaware           RON JOHNSON, Wisconsin
MAGGIE HASSAN, New Hampshire         RAND PAUL, Kentucky
ALEX PADILLA, California             JAMES LANKFORD, Oklahoma
                                     RICK SCOTT, Florida

                  Douglas S. Pasternak, Staff Director
                 Brian Downey, Minority Staff Director
             Scott Wittman, Minority Deputy Staff Director
                      Kate Kielceski, Chief Clerk
                           
                           
                           C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Ossoff...............................................     1
    Senator Johnson..............................................     4
    Senator Padilla..............................................    36
Prepared statements:
    Senator Ossoff...............................................    45
    Senator Johnson..............................................    50

                               WITNESSES
                         Tuesday, July 26, 2022

Erika Ramirez, Ph.D., Former Chief Psychologist, U.S. 
  Penitentiary Atlanta...........................................     6
Terri Whitehead, Former Jail Administrator, U.S. Penitentiary 
  Atlanta........................................................     8
Rebecca Shepard, Staff Attorney, Federal Defender Program, Inc...    10
Michael Carvajal, Director, Federal Bureau of Prisons............    21

                     Alphabetical List of Witnesses

Carvajal, Michael:
    Testimony....................................................    21
    Prepared statement...........................................    86
Ramirez, Erika, Ph.D.:
    Testimony....................................................     6
    Prepared statement...........................................    52
Shepard, Rebecca:
    Testimony....................................................    10
    Prepared statement...........................................    63
Whitehead, Terri:
    Testimony....................................................     8
    Prepared statement...........................................    58

                                APPENDIX

Senator Grassley's July 25, 2022 Letter to FBI and DOJ...........    95
Senator Johnson's July 26, 2022 Letter to DOJ, FBI, ODNI, and DOJ 
  OIG............................................................    99
Letter from Judge Timothy C. Batten, Chief United States District 
  Judge..........................................................   102

Responses to post-hearing questions for the Record:
    Mr. Carvajal.................................................   105

 
     CORRUPTION, ABUSE, AND MISCONDUCT AT U.S. PENITENTIARY ATLANTA

                              ----------                              


                         TUESDAY, JULY 26, 2022

                                   U.S. Senate,    
              Permanent Subcommittee on Investigations,    
                    of the Committee on Homeland Security  
                                  and Governmental Affairs,
                                                    Washington, DC.
    Present: Senators Ossoff, Hassan, Padilla, Johnson, and 
Scott.

             OPENING STATEMENT OF SENATOR OSSOFF\1\

    Senator Ossoff. The Permanent Subcommittee on 
Investigations (PSI) will come to order.
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    \1\ The prepared statement of Senator Ossoff appears in the 
Appendix on page 45.
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    Today's hearing continues a 10-month bipartisan 
investigation of corruption, misconduct, and abuse at U.S. 
Penitentiary Atlanta (USPA), a Federal prison in the State of 
Georgia.
    The evidence the Subcommittee has secured to date reveals 
stunning long-term failures of Federal prison administration 
that likely contributed to loss of life, jeopardized the health 
and safety of inmates and staff, and undermined public safety 
and civil rights in the State of Georgia and the Southeast 
Region of the United States.
    The Subcommittee has secured and reviewed thousands of 
pages of internal documents from the Bureau of Prisons (BOP) 
and interviewed dozens of witnesses, including BOP 
whistleblowers, current and former staff, Federal judges, 
Federal defenders, and former senior leaders at the Bureau of 
Prisons.
    The investigation has revealed that gross misconduct 
persisted at this facility for at least 9 years, and that much 
of the damning information revealing misconduct, abuse, and 
corruption was known to BOP and accessible to BOP leadership 
during that period.
    For many years, this facility has been extremely dangerous 
and insecure. Correctional Services staff at USPA engaged in 
misconduct with impunity and, according to BOP's own internal 
investigations, lacked regard for human life. Vast quantities 
of contraband, including weapons and narcotics, flowed through 
the prison, enabled by staff corruption.
    Conditions for inmates and pretrial detainees have been 
abusive and inhumane and, in my view, violated both the Eighth 
Amendment right to be free from cruel and unusual punishment 
and the Sixth Amendment right to counsel.
    Interviews and records reveal a facility where inmates, 
including presumptively innocent pretrial detainees, were 
denied proper nutrition, access to clean drinking water, and 
hygiene products; lacked access to medical care; endured months 
of lockdowns with limited or no access to the outdoors or basic 
services; and had rats and roaches in their food and cells.
    One Federal judge told the Subcommittee that USPA is an 
embarrassment to the judicial system and noted that 
incarceration at USPA is like adding another layer of 
punishment due to the appalling conditions.
    Another Federal judge wrote a letter to the USPA warden in 
January of this year to express his deep concern regarding the 
persistently abusive conditions that were reported to him, 
including detainees subjected to ``a month of 24-hour solitary 
confinement with only a Bible for entertainment or reading,'' 
``no change of clothes for several weeks,'' ``lack of access to 
mail,'' ``a week with only a paper jumpsuit and paper blankets 
for an inmate on suicide watch,'' and ``blockage of written 
communications between attorney and client.''
    Given these conditions, it is perhaps not surprising that 
USPA has led the Nation's Federal prison facilities in 
suicides, and four of the last four inmates deceased from 
suicide were found to have been using narcotics at the time of 
their death--this despite repeated warnings from BOP's own 
investigators that the prison was failing to prevent the flow 
of contraband into the facility, failing to implement suicide 
prevention policies, failing to respond with urgency to suicide 
attempts by inmates, that there was a lack of, and I quote, 
``regard for human life'' among the staff and--this is another 
direct quote from the BOP's own internal investigations--``a 
dangerous and chaotic environment of hopelessness and 
helplessness, leaving inmates to their own means to improve 
their quality of life.''
    In a November 2020 suicide investigation report, one of 
thousands of pages of documents that this Subcommittee 
unearthed, BOP's own investigators found that the staff's 
delayed medical response ``represents gross indifference to 
preserving life and violates inmates' constitutional rights.'' 
That from the BOP's own internal investigators.
    Since at least 2014, BOP leadership was warned in its own 
internal audits and investigations, documents secured by this 
Subcommittee, that failures and misconduct were persistent and 
severe. Failures documented during this period include: failure 
to conduct rounds in the Special Housing Unit (SHU); improper 
handling and management of firearms; failure to search for 
contraband; failures to train staff in suicide prevention; 
improper storage of large quantities of narcotics; the free and 
open flow of contraband within the facility, including in the 
Special Housing Unit; mishandling of evidence related to inmate 
suicides; inoperable surveillance cameras; and inoperable 
perimeter security infrastructure.
    Here are some direct quotes, again, from the BOP's own 
internal audits which this Subcommittee secured: ``complacency, 
indifference, inattentiveness, and lack of compliance with BOP 
policies and procedures''; ``a lack of oversight throughout the 
institution''; and ``USP Atlanta presents significant security 
concern for the Southeast Region. Both national and local 
policies are being violated on a regular basis.'' Again, the 
BOP's own internal investigations and reports available to BOP 
leadership for years.
    In one instance cited by BOP internal investigators, prison 
staff had to borrow a razor blade from a prisoner to cut the 
ligature suspending a prisoner who had hanged himself in his 
cell. In another instance, officers intentionally disabled drug 
detection equipment used to identify trace amounts of narcotics 
coming into the prison at one of the entrances.
    Yet despite these unequivocal internal reports of abuse and 
misconduct, the situation continued to deteriorate.
    Today our witnesses include two individuals with more than 
45 years of combined experience working within the Bureau of 
Prisons and several years working at U.S. Penitentiary in 
Atlanta. Dr. Ramirez, who comes forward today as a 
whistleblower, previously served as the chief psychologist at 
USPA and remains employed by the BOP. Ms. Whitehead previously 
served as the jail administrator at USP Atlanta and recently 
retired after nearly 30 years of service.
    Dr. Ramirez, Ms. Whitehead, I applaud your courage in 
coming forward to speak publicly about your experiences working 
at the U.S. Penitentiary Atlanta and at the Federal Bureau of 
Prisons. I know this was not an easy decision for you, and I 
know I speak for the Subcommittee on a bipartisan basis when I 
say that we are grateful for your bravery today. We will look 
harshly upon and seek accountability for any retaliation you 
may experience as a result of your testimony.
    Our investigation is also about the impact of corruption 
and dysfunction at USP Atlanta on the criminal justice system 
and the rights of incarcerated people. Many of these 
individuals subjected to these conditions have not gone to 
trial or been convicted of a crime. They are presumptively 
innocent pretrial detainees. Today we will hear from Ms. 
Shepard, an experienced Federal defender, who will testify 
about her clients' experiences at USPA.
    Later we will hear from Bureau of Prisons Director Michael 
Carvajal, who was the Assistant Director for Correctional 
Programs from 2018 until 2020, with oversight over Correctional 
Services nationwide, and who has served as Director of the 
agency since 2020.
    Director Carvajal's testimony is critical to our ongoing 
investigation.
    After months of bipartisan requests for Director Carvajal's 
voluntary testimony, on July 14th the Subcommittee issued a 
subpoena to compel it. As an accommodation to the Department of 
Justice (DOJ), and in recognition of Director Carvajal's 
presence this morning, this subpoena has been withdrawn, and 
Director Carvajal is testifying today on a voluntary basis.
    My preference is always to pursue investigations in a 
cooperative spirit and without resorting to compulsory process. 
However, so long as I chair this Subcommittee, it will continue 
vigorously, professionally, and judiciously to pursue these 
investigations in the public interest. Where necessary, the 
Subcommittee will use all of its authorities to pursue the 
information vital to that work.
    Today is the next step in our investigation, but not the 
last.
    I thank Ranking Member Johnson and his staff for their 
continued cooperation during this bipartisan investigation. At 
this hearing there will be discussion of some difficult topics 
concerning treatments of people suffering from mental illness 
and suicide. I want to note that people experiencing mental 
health crises or thoughts of suicide can call a new nationwide 
hotline, 988, to be connected with trained counselors.
    I thank again the Ranking Member for his cooperation and 
yield to him for his opening statement.

              OPENING STATEMENT OF SENATOR JOHNSON

    Senator Johnson. Thank you, Mr. Chairman. I also want to 
thank the witnesses for your appearance here. Dr. Ramirez in 
particular, I want to say that we will unequivocally protect 
you from any retaliation that you may suffer because of this.
    I think the Chairman has done a very good job of 
summarizing the issues that we have uncovered here. I want to 
commend both the Chairman, your staff, and my staff for doing a 
really pretty thorough investigation here. I know we were not 
able to issue the report because we did not get cooperation. 
But we will be issuing a report, and I am looking forward to 
that. I think it will be very complete. Again, I to commend 
everybody involved in this.
    Mr. Chairman, I would like to enter my prepared statement 
in the record\1\ because it would repeat an awful lot of what 
you said. But I would like to spend a few minutes here. I did 
not come to the U.S. Senate to be an investigator. I came here 
because we are mortgaging our kids' future, and we still are. 
But when I became Chairman of the Senate Committee on Homeland 
Security and Governmental Affairs (HSGAC), a lot of people do 
not realize it because it is not in the title, that is the 
Senate's oversight committee. We have a responsibility to start 
looking into things, conduct oversight, and do investigations.
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    \1\ The prepared statement of Senator Johnson appear in the 
Appendix on page 50.
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    Now, of course, being Ranking Member on the Permanent 
Subcommittee on Investigations, that is what we do. I would 
hope this experience will start opening up your eyes. My 6 
years as Chairman of the Committee certainly opened up my eyes 
at how weakened congressional oversight has become over the 
years.
    We have very limited enforcement power, and as a result, 
the agencies thumb their nose at us. I think you saw that here. 
These are legitimate issues. These are longstanding problems. 
The fact that the Department of Justice, the Bureau of Prisons, 
were not fully cooperating in this is absurd.
    I held a hearing as Chairman of the full Committee on the 
Bureau of Prisons. I asked in 2018 for an investigation by the 
Office of Inspector General (OIG). We still do not have that 
report. I guess it is still in progress. This was in 2018.
    Again, this hearing is long overdue. This is on 
specifically with Atlanta, but we ought to be asking how 
prevalent is this? But because the agencies are not 
transparent, because they are not cooperating, we need 
whistleblowers to come forward. This is my appeal to anybody in 
Federal agencies who has worked diligently, with integrity, for 
your agencies: if you are working for an agency that has lost 
its credibility, is not operating with integrity, please come 
forward. We need to hear you. The agencies and the departments 
are not going to correct their own problems. They are not going 
to make them public. The only way these problems are corrected 
is if they are made public, and that is with congressional 
oversight and public exposure. We need whistleblowers.
    I have to highlight an extraordinary letter written 
yesterday by Senator Chuck Grassley involving a joint 
investigation we have been conducting for a couple of years. 
Finally some whistleblowers have come forward, and, quite 
honestly, I do not know if they are from the Federal Bureau of 
Investigation (FBI) or the Department of Justice. But it is 
extraordinary what he reveals in his letter to FBI Director 
Wray and Attorney General Garland. To quote, ``There was a 
scheme in place among certain FBI officials to undermine 
derogatory information connected to Hunter Biden by falsely 
suggesting it was disinformation.''
    Now, I do not want to go too far into this. This is not 
necessarily the forum for this, but it is exactly the forum to 
encourage more whistleblowers to come forward, because one of 
the reasons this is so near and dear to my heart is both 
Senator Grassley and I were falsely accused of accepting and 
disseminating Russian disinformation. Is this where this came 
from? Did those false accusations against the Chairmen of 
Senate Committees duly authorized with the responsibility to 
conduct oversight and investigations, were we smeared and 
undermined by our own FBI?
    I would like to enter Senator Grassley's letter into the 
record.\1\ I would also like to enter the letter I wrote to 
Attorney General Garland, to Christopher Wray, to Director of 
National Intelligence (DNI) Haines, as well as Inspector 
General (IG) Horowitz. I would also like to enter that in the 
record.\2\
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    \1\ The letter from Senator Grassley appear in the Appendix on page 
95.
    \2\ The letter from Senator Johnson appear in the Appendix on page 
99.
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    Senator Ossoff. Without objection.
    Senator Johnson. Again, if you are a whistleblower in the 
Department of Justice, the FBI, please come forward. If you 
want to restore integrity and credibility to your agencies, 
come forward and tell Congress so the American people 
understand the truth.
    I would also make that appeal to people working in our 
Federal health agencies. Our response to Coronavirus Disease 
2019 (COVID-19) has been a miserable failure, largely because 
our health agencies have not been transparent. I have written 
43 oversight letters to the agencies. Where I have gotten 
responses, they are non-responsive responses. Generally, I do 
not even get answers.
    This lack of transparency must end. We must restore 
congressional oversight, because the American people deserve 
the truth. Every one of the confirmed Secretaries or agency 
heads come before Congress, they raise their hand, and they 
swear that they will comply with legitimate congressional 
oversight. Then they do not. This has to end. The American 
people deserve transparency, they deserve honesty, they deserve 
the truth.
    Mr. Chairman, I appreciate the work you have done on this. 
This was important information. The only way this is going to 
get fixed in Atlanta and other prisons is if the American 
public is aware of what is going on, because obviously the 
Bureau of Prisons is not fixing it. They have not fixed it. 
This requires public pressure, and that requires congressional 
oversight.
    I commend you for drawing the line and insisting on 
cooperation. We did not get it. We finally got it at the 12th 
hour. But this is exactly what is required, and, again, I am 
hoping you are now realizing a fraction of the frustration I 
have been feeling for 6 years trying to get to the bottom and 
trying to provide the American people the truth.
    Thank you.
    Senator Ossoff. Thank you, Ranking Member Johnson, and I 
appreciate your will to investigate issues in the Bureau of 
Prisons at U.S. Penitentiary Atlanta and, indeed, at other 
facilities, and we will continue that work together.
    We will now call our first panel of witnesses for this 
morning's hearing.
    Dr. Erika Ramirez, a current Bureau of Prisons employee and 
the former chief psychologist at U.S. Penitentiary Atlanta.
    Ms. Terri Whitehead, retired from the Bureau of Prisons 
after more than 30 years of service, she served most recently 
as jail administrator at U.S. Penitentiary Atlanta before 
retiring in December 2021.
    Ms. Rebecca Shepard is a trial attorney with the Federal 
Defender Program in the Northern District of Georgia whose 
office has frequently represented inmates at the U.S. 
Penitentiary in Atlanta.
    I appreciate all of you being with us this morning, and I 
especially want to thank you for the courage to come forward 
and speak out. We look forward to your testimony.
    It is the custom of this Subcommittee to swear in all 
witnesses. At this time I would ask all of you to please stand 
and raise your right hand. Do you swear the testimony you will 
give before this Subcommittee will be the truth, the whole 
truth, and nothing but the truth, so help you, God?
    Ms. Ramirez. I do.
    Ms. Whitehead. I do.
    Ms. Shepard. I do.
    Senator Ossoff. Let the record reflect that the witnesses 
answered in the affirmative. You may take your seats.
    We will be using a timing system today. All of your written 
testimony will be printed in the record in its entirety, and we 
would ask that you try to limit your oral testimony to no 
longer than 5 minutes.
    We will begin with you, Dr. Ramirez. You may deliver your 
opening statement.

      TESTIMONY OF ERIKA RAMIREZ, PH.D.,\1\ FORMER CHIEF 
            PSYCHOLOGIST, U.S. PENITENTIARY ATLANTA

    Dr. Ramirez. Good morning. It is my professional and 
personal honor to participate in this hearing.
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    \1\ The prepared statement of Dr. Ramirez appear in the Appendix on 
page 52.
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    I am here today seeking accountability for the appalling 
situation at United States Penitentiary Atlanta, once the 
flagship of the BOP. It is now a penitentiary in name only.
    As the chief psychologist at USP Atlanta from 2018 to 2021, 
I repeatedly reported ongoing, uncorrected, gross mismanagement 
of suicide prevention practices, staff misconduct, and general 
operational deficiencies. Unfortunately, the only response I 
received was unlawful retaliation. I was involuntarily 
transferred to a Federal Correction Institution (FCI) in 
Seagoville, Texas.
    Though I am speaking today in my personal capacity, I have 
been an employee of the Federal Bureau of Prisons for 15 years. 
For the first 11, I was assigned to various psychology 
departments at high or maximum security male institutions. From 
2015 to 2018, I was a psychologist with a supervisory role in 
the supermax, also known as the Administrative Maximum Security 
(ADX), the facility in Florence, Colorado, the most secure 
institution in the country.
    In 2018, I accepted the chief psychologist position at USP 
Atlanta, where my mission was to turn around a deficient, 
failing psychology department. I was responsible for 
integrating standardized procedures on inmate mental health 
issues, the provision of sound clinical care to the inmate 
population, developing and implementing mental health treatment 
and best practices, and tracking and analyzing program 
adherence.
    Like most BOP employees, I am first and foremost a Federal 
law enforcement officer (FLEO). In addition to providing mental 
health care, I am responsible for ensuring the safety and 
security of the community, the staff, and the inmate 
population. That includes patdowns, searches, and other 
security-related duties.
    Upon my arrival and for the duration of my time at USP 
Atlanta, the facility was falling apart. Elevators were 
inoperable for months at a time. The walls were infested with 
mold. Whenever it rained, the sewer would back up and overflow 
onto the recreation yard--sometimes leaving a foot of human 
waste behind.
    Security-wise, there was little to speak of. Given the 
volume and flagrancy of the contraband, it was obvious that 
cell searches were not being properly conducted, if at all. For 
instance, I confiscated a microwave that I found while 
searching an inmate's cell. Two days later, I found the same 
microwave in another cell. It was the same serial number.
    Of course, my assignment and primary concern was inmate 
mental health and suicide prevention. In the roughly 4 years, 
eight inmates at USP Atlanta died by suicide--two prior to my 
arrival and six during my tenure. To put this into perspective, 
Federal prisons typically see between one and three suicides 
over a 5-year period. Any loss of life is tragic and 
unacceptable, which is why it is particularly devastating to 
see such disregard for human life at USP Atlanta.
    BOP policy requires that a suicide reconstruction team is 
sent to investigate circumstances of any inmate suicide. The 
team prepares a report detailing findings and making 
recommendations to prevent reoccurrences. This report is sent 
to onsite regional and national offices in the BOP, and the 
institution and region must provide a written response to any 
recommendations.
    While at USP Atlanta, I reviewed seven reconstruction 
reports, each prepared by different teams, and all seven 
reports featured some of the same issues: inmates suffering 
from ongoing substance abuse, easy access to drugs, unit rounds 
which were required to be done every half-hour were routinely 
skipped for hours at a time.
    I repeatedly expressed my concerns about other systematic 
failings to management, and nothing was done. Despite the 
desperate need for reform, any suggestion for change was met 
with resistance. ``That is not the Atlanta Way.''
    Some of the examples of the Atlanta Way included: an 
employee yelling threats and obscenities, aggressively 
approaching an executive staff member. Though I was 5 months 
pregnant and terrified, I stepped between the two and pushed 
the employee away. I reported the employee to local and 
regional management, and nothing was done.
    Another time, my husband was repeatedly hit by a staffer. 
He required medical attention, the attacker remained at work. I 
was warned to stay away from him.
    In 2020, a program review team found that the staff had 
broken machines intended to detect traces of drugs. This has 
been going on for a year. The agency's response was to move 43 
mid-level supervisors who were not involved in any misconduct 
across the country. During the height of the COVID pandemic. 
Our families had set down roots, and we had worked tirelessly 
trying to fix the institution. The agency refused to give us 
responses.
    Today I am asking that you help this agency. Staff it at 
100 percent. Provide mid-level management with tools to 
actually make changes. We have tremendous responsibility, and 
yet we have little authority being reassigned based on the 
agencies refusal to hold staff accountable. When there is 
discipline, make it fair and swift.
    I thank you for your time.
    Senator Ossoff. Thank you, Dr. Ramirez.
    Ms. Whitehead, you may now deliver your opening statement.

 TESTIMONY OF TERRI WHITEHEAD,\1\ RETIRED SENIOR MANAGER, U.S. 
     PENITENTIARY ATLANTA, FEDERAL BUREAU OF PRISONS, U.S. 
                     DEPARTMENT OF JUSTICE

    Ms. Whitehead. Good morning. Chairman Ossoff, Ranking 
Member Johnson, and Members of the Subcommittee, thank you for 
inviting me to testify today.
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    \1\ The prepared statement of Ms. Whitehead appear in the Appendix 
on page 58.
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    Who am I and why am I here? I am an upper-management 
retiree after serving more than 30 years with the Federal 
Bureau of Prisons. I am here because of the many abuses and 
gross mismanagement I personally witnessed while serving at USP 
Atlanta. I was shocked and appalled by the USP Atlanta big 
picture. On a daily basis, there were numerous policy 
violations which put the staff, inmates, and the local 
community in danger. For example, there were so many rats 
inside the facility dining hall and food preparation areas that 
staff intentionally left doors open so the many stray cats that 
hung around the prison could catch the rats. It is never a good 
idea to leave prison doors open.
    There was no professional pest control service in place 
because management officials could not work together and 
determine which departmental budget was responsible for the 
cost.
    I arrived at USP Atlanta in August 2020, 6 months into the 
pandemic, and at that time staff were not provided appropriate 
personal protective equipment (PPE) to perform their duties 
during the pandemic. Also, there were no designated COVID-19 
isolation or quarantine areas in the detention center unit.
    In August 2020, it was reported half of the 300 security 
cameras did not operate appropriately, and the other half were 
off by 3 hours. This was not the first time this had been 
reported. There were missing security controls and equipment to 
include keys, handcuffs, and pepper spray. Key control at other 
Bureau facilities that I have worked is paramount to 
maintaining safety and security.
    Then there is the Atlanta Way. The Atlanta Way is far from 
the norm and certainly not the Bureau of Prisons Way. Most of 
the staff at USP Atlanta are very proud that Atlanta does 
things intentionally different. The BOP has a policy on staff 
conduct and ethics. Reports of unethical behavior must be 
investigated and, if warranted, discipline is imposed. However, 
at USP Atlanta, the Atlanta Way is that staff are not held 
accountable for misconduct, inmates are not challenged for 
negative behavior, and the regular maintenance and routine 
repairs are non-existent.
    Staff members are actually involved in physical fights at 
work. Cases are uninvestigated and/or staff are subsequently 
promoted within. Marijuana is routinely smelled inside the 
prison, but there are no searches to determine which inmates 
are smoking. Inmates are observed in zombie state, and nothing 
is done in an effort to determine the source of illegal 
substances.
    All BOP staff members are correctional workers first, to 
include secretaries, psychologists, teachers, and wardens. 
Conducting searches is Corrections 101 at BOP facilities. I 
never saw a pat search conducted at USP Atlanta, and in August 
2020 and July 2021, reports indicate area searches were not 
being done.
    As the jail administrator at USP Atlanta, I tried to make 
positive changes by voluntarily training less experienced 
staff, by correcting security violations, and reporting staff 
misconduct. My efforts were very unappreciated. I was 
ostracized by staff. I was victimized by the agency with a 
forced relocation to a Texas facility, which led to my 
retirement much earlier than planned. In August 2021, the 
pseudo-solution to addressing the USP Atlanta problems was to 
move 43 management officials out of 432 staff members.
    What I witnessed was outrageous. I never expected to be 
here today. Now that I am, I ask for your immediate help. I 
truly believe the problems can be fixed with the right people 
and mind-set. Please continue the kind of oversight you are 
doing today. Hopefully it will result in real accountability 
and stop the abuses you are hearing about. Thank you for your 
time.
    Senator Ossoff. Thank you, Ms. Whitehead.
    Ms. Shepard, you may now deliver your opening statement. To 
our panelists, you may hear buzzes and bells from the camera, 
and they have nothing to do with you or your time. They are 
just indicators of what is happening on the floor, so do not be 
alarmed. Ms. Shepard.

   TESTIMONY OF REBECCA SHEPARD,\1\ ASSISTANT FEDERAL PUBLIC 
DEFENDER, FEDERAL PUBLIC DEFENDER FOR THE NORTHERN DISTRICT OF 
                            GEORGIA

    Ms. Shepard. Chairman Ossoff, Ranking Member Johnson, and 
Members of the Subcommittee, thank you for inviting to me this 
hearing.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Shepard appears in the Appendix 
on page 63.
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    Today I focus my testimony on the unacceptable conditions 
of confinement for clients who are detained pretrial, awaiting 
trial and presumed innocent, at USP Atlanta.
    Defenders see firsthand how USP Atlanta subjects people to 
inhumane and substandard conditions and limits their access to 
attorneys, which in turn interferes with their Sixth Amendment 
right to counsel. The result is deplorable and punitive 
conditions which courts, defenders, and our clients have 
observed for decades.
    I want to begin by sharing a clear picture of what life 
inside is like. One client--and I will call him ``Jacob'' for 
the purpose of this hearing--described his experience in a 2019 
affidavit that I have submitted at Exhibit B. Jacob was held in 
an overcrowded pod where he was locked into his cell for 24 
hours a day, 3 to 4 days at a time. He was one of three people 
squeezed into a two-person cell. When Jacob was allowed outside 
of his cell, it was for less than an hour every few days. The 
pod only had six showers and three phones that had to be shared 
by about 100 people, making it impossible for everyone to 
shower and make phone calls.
    When out of his cell, Jacob had to choose whether to call 
his family or to call his attorney, but he could not do both. 
Even worse, Jacob's cell was infested with roaches, and when he 
asked for cleaning supplies, the guards merely laughed.
    I am sorry to say that Jacob's experience is not at all 
unique for Atlanta pretrial detainees. During my 8 years as a 
defender, I have seen clients routinely locked down and allowed 
out of their cells for extremely limited periods of time, such 
as only 15 to 30 minutes, 3 to 4 times a week, or only an hour 
each day. These lockdowns persist for months. Clients are 
treated as though they are in solitary confinement, not because 
of their behavior but because of their misfortune in being 
placed at USP Atlanta.
    Lockdowns mean that my clients cannot meet their basic 
human needs, cannot communicate with their families, cannot 
visit with clergy, and cannot participate in productive 
programming.
    Jacob also described receiving substandard food and hygiene 
at USP Atlanta. His dinner was routinely slices of bread and 
packages of expired deli meat, and he could not supplement his 
diet with commissary because it was limited to only instant 
coffee and potato chips.
    Again, Jacob's experience is not unique. Our clients go 
months at a time with only sack lunches provided for every meal 
served in their cells. Sometimes they find bugs in their food, 
and we see the impact as our clients lose weight and become 
emaciated.
    Given these fundamental failures of care, it should come as 
no surprise that USP Atlanta routinely denies our clients 
access to mental health treatment, including medication, 
therapy, and access to mental health professionals. As Chairman 
Ossoff referenced earlier, one person on pretrial detention was 
held for a week on suicide watch without access to treatment or 
medication, provided only a paper gown and paper blankets.
    I want to turn to a different topic next, which is how USP 
Atlanta interferes with the Sixth Amendment guarantee of 
effective assistance of counsel. USP Atlanta's practices and 
policies do not allow us to fulfill our constitutional and 
ethical obligations of zealous advocacy.
    First, there are scheduling delays and difficulties, as USP 
Atlanta staff member fail to respond to requests for legal 
meetings, often for several days and despite repeated requests. 
It is not unusual for the date of the expected meeting to pass 
and for there to still be no response from staff members. 
Scheduling a meeting does not mean that the meeting will 
actually happen because of the facility's chaos and 
disorganization.
    When we do get to meet with our clients, it is often after 
hours of waiting. While we wait, we are on the clock, along 
with the experts and interpreters that often come along with 
us. Taxpayers are bearing the cost of USP Atlanta's 
incompetence.
    Clients' access to their discovery, the government's 
evidence against them, is also limited because clients do not 
have enough access to the law library due to the lockdowns and 
have no ability to review electronic discovery with their 
attorneys. Even when a court has intervened and ordered USP 
Atlanta to allow law library access, the facility has failed to 
comply.
    The circumstances that we detail today are inhumane and 
unjust, but they are avoidable, and they should not be the 
norm. Unfortunately, the problems at USP Atlanta are part of a 
larger story of systemic dysfunction. My written statement 
includes several recommendations for ways this body could 
address this unconscionable state of affairs.
    Thank you very much for the opportunity to testify today, 
and I welcome any questions you may have.
    Senator Ossoff. Thank you, Ms. Shepard, and to all of our 
panelists.
    I will now begin with my first round of questions. Ms. 
Shepard, I would like to begin with you. I am going to enter 
into the record a letter\1\ from Judge Timothy C. Batten, Chief 
United States District Judge, Northern District of Georgia, to 
the warden at U.S. Penitentiary Atlanta from just January of 
this year.
---------------------------------------------------------------------------
    \1\The letter referenced by Senator Ossoff appears in the Appendix 
on page 102.
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    Now, our review of internal BOP records demonstrates that a 
pattern of misconduct and dysfunction persists at least as far 
back as 2014 at this facility. This is from January of this 
year. The judge asks the warden for answers with respect to 
reports of rats in the building, roaches in the food, poor 
nutrition and emaciation of inmates; lack of access to hygiene 
products, lack of access to medication, lack of access to mail, 
limited access to toothbrush and toothpaste; no change of 
clothes for several weeks; a month of 24-hour solitary 
confinement with only a Bible for entertainment or reading; a 
week, as you mentioned with only a paper jumpsuit and paper 
blankets for an inmate on suicide watch without mental health 
treatment; only being permitted 15 minutes out of a cell every 
day to bathe, make phone calls, and use the library; blockage 
of written and other communications between attorney and 
client; and difficulty arranging interview between inmate and 
psychologist.
    Is this consistent with your experience? What does this say 
about the state of affairs--this is just in the jail at U.S. 
Penitentiary. I want to remind everyone, these are 
presumptively innocent pretrial detainees. These conditions 
would be appalling if any human being were subjected to them. 
We are talking about people who have been convicted not of the 
crime they have been charged, if any crime at all. Would you 
please comment?
    Ms. Shepard. Yes, Chairman Ossoff, that is representative 
of our experience. We have observed the same conditions that 
are detailed in that letter, and I would like to make clear to 
the Subcommittee, these are not conditions that were created or 
result from the COVID-19 pandemic. These are conditions that we 
have seen for as long as I have been going to USP Atlanta, 
which dates back to 2014, and for my colleagues, even further 
back. They have also been reflected in records established in 
front of the district court as well as in front of the Eleventh 
Circuit.
    Senator Ossoff. I cited in my opening statement a note in a 
BOP internal investigative document, the BOP's own staff 
stating on the record that they believed misconduct in the 
prison constituted a violation of constitutional rights. What 
do these conditions mean for access to counsel, the Sixth 
Amendment right that every defendant has to be in consultation 
with their attorney and receive effective counsel?
    Ms. Shepard. As I alluded to in my earlier statement, it is 
difficult to the point of, in some cases, impossible for us as 
attorneys to communicate with our clients. There are extremely 
lengthy delays in our clients receiving legal mail. But it is a 
necessary part of our representation of our clients to meet 
with them, to discuss the evidence against them, to discuss 
what their legal strategy will be. All of those conversations 
require contact with our clients.
    It is not unusual for it to take several weeks, if not 
longer, to even schedule an opportunity to go into the 
facility. Again, when we do get into the facility, our time 
with our clients is extremely limited, largely due to the chaos 
and dysfunction that exists within the facility.
    Just getting into the facility, being processed in, there 
is often--even if we have an approval from an administrator to 
come for the meeting, the people at the front gate do not have 
that. They did not know we were coming. No one is assigned to 
actually monitor the meeting. All of those delays end up 
creating a situation where our time with our clients is 
extremely limited. The consequence of that is that then 
hearings that the court has scheduled often have to be delayed. 
It is not unusual for us to have to ask the judge for 
continuance after continuance after continuance because we are 
not able to prepare for a hearing or to file motions because we 
simply do not have access.
    Senator Ossoff. Thank you, Ms. Shepard.
    Dr. Ramirez, I want to talk about access to narcotics in 
the facility, the impact on mental health. I noted that 
internal BOP reports that the Subcommittee secured dating back 
as far as 2014 noted severe deficiencies in the ability to 
manage and prevent the flow of contraband, including drugs and 
weapons, throughout the facility. I noted an event in the last 
5 years when BOP's own internal investigators found that the 
staff had deliberately disabled a spectrometer meant to detect 
trace amounts of narcotics entering the facility.
    In the summer of 2021--this is just in the very recent 
past--after 8 or 9 years of BOP's internal reports noting the 
failure to prevent contraband, there were seized heroin, 
methamphetamine, suboxone, marijuana, tobacco, more than 100 
instances that summer of locating narcotics, Ecstasy, synthetic 
marijuana, K2, not to mention a kilogram of marijuana found in 
a locked education storage closet, 300 grams of marijuana found 
on a worksite, 158 pills of a variety of loose prescriptions, 
170 grams of methamphetamine in a common area, weapons, and 
nearly 500 cell phones, all inside the facility, all found in a 
few sweeps in the summer of 2021.
    Please describe the problem at USP Atlanta with respect to 
access to narcotics and how it intersects with your work in 
mental health and the suicides that you saw while you were 
there.
    Dr. Ramirez. Unfortunately, the ease of access to drugs 
makes it very difficult for mental health providers to 
differentiate between genuine mental illness and the effects of 
whatever unknown substance the individual may be on. We spend 
much of our time initially assessing, what the individual is 
experiencing. Is this because of drugs? Have you had 
depression? It takes much longer to tease out whether this is 
an organic issue or something created by a chemical that was 
recently ingested.
    Unfortunately, the lack of security, routine searches, 
routine drug testing, it is such that we always have to assume 
that the inmate is intoxicated and is not necessarily 
presenting an organic mental illness. It certainly creates a 
delay in developing a treatment plan and moving forward on how 
to best help that individual.
    Senator Ossoff. Thank you, Dr. Ramirez. The suicide 
investigation reports that the Subcommittee secured over many 
years reveal negligent staff responses to suicides in progress, 
and negligent staff conduct before, during, and after suicides. 
This is April 2016: Correctional services staff had failed to 
locate the inmate for a scheduled mental health treatment. 
Census counts were not being properly conducted and documented. 
October 2017, this is a quote: ``Staff responded with no 
apparent sense of urgency to the inmate hanging in his cell, 
logged no rounds on the SHU that day. No evidence pertaining to 
the suicide was retained.'' This is the BOP's own internal 
findings.
    Another suicide October 2019: Rounds on the SHU were not 
performed; a delay in the initiation of life-saving measures; 
mishandling of evidence again.
    My final question, with the Ranking Member's indulgence, 
Ms. Whitehead, for you, staff misconduct, staff failure to 
follow policy. Based upon your experience, how deficient were 
the management processes that should have caused staff to 
adhere to BOP policies and procedures? Once you are concluded, 
it will be the Ranking Member's turn. Thank you.
    Ms. Whitehead. Thank you for that question, Senator. As I 
said, the BOP has a policy on misconduct, and the way it 
happens, if it is observed, you write a memo, you report it. I 
personally have reported maybe six instances when I was in 
Atlanta in about 16 months. I was never interviewed. There are 
fights; staff fight each other, physical fights in the prison. 
Those cases are not investigated. There are staff that curse 
each other in the presence of inmates. I have witnessed it. I 
have reported it. I have never been interviewed.
    When staff do not report to work, they are absent without 
leave (AWOL). Three hundred hours of AWOL, and that staff 
member continues to go to work. Without a system of controls in 
place to curb misconduct among staff, the inmates feel that 
they can do whatever they want to do.
    Senator Ossoff. Thank you, Ms. Whitehead.
    Ranking Member Johnson.
    Senator Johnson. Thank you, Mr. Chairman.
    Ms. Shepard, quickly, you are generally dealing with people 
in pretrial detention, correct?
    Ms. Shepard. My testimony was focused on that. We also 
represent--for example, I have a client right now who is 
charged with committing a criminal act while inside the 
facility, so we have different sorts of----
    Senator Johnson. OK. Are those individuals separated, those 
populations, pretrial detainees versus the general prison 
population?
    Ms. Shepard. Yes, and there is also an additional 
population at the facility, which is transferees. Inmates who 
are being transferred from one BOP facility to another, those 
should also be separated. We have seen, I have seen clients who 
were pretrial who were in the same pod or unit as transferees, 
people who were already serving a sentence.
    Senator Johnson. The whole prison sounds like a horror 
show, but is it particularly broken in terms of pretrial 
detention, or is there really no difference?
    Ms. Shepard. I believe that is accurate, yes. The egregious 
lockdown conditions that I have described, the egregious 
nutrition and hygiene conditions that I have described, are 
specific to pretrial detainees.
    Senator Johnson. OK. Ms. Whitehead, I am deaf in one ear, 
and you are very soft-spoken, so if you could get your 
microphone a little bit closer to you so I can hear better. You 
obviously have served in a number of prisons around the 
country. I think my main question to you is: How extraordinary, 
how out of the ordinary is Atlanta and the Atlanta Way versus 
other situations you have been in?
    Ms. Whitehead. As I indicated, I was shocked, I was 
appalled by the conditions at Atlanta. Cell phones. In July 
2021, approximately 700 cell phones were recovered in a sweep 
in Atlanta.
    Senator Johnson. Quickly, while we are on cell phones, 
describe why that is such a problem in a prison.
    Ms. Whitehead. Inmates are not allowed to have cell phones 
in a prison. Inmates can actually call hits on anybody outside 
of the prison using a cell phone. Cell phones are not 
monitored. Inmates can make drug transactions, commit further 
crime utilizing a cell phone.
    Senator Johnson. Again, that is a big problem when you have 
700 cell phones in a prison.
    Ms. Whitehead. It is huge.
    Senator Johnson. Go on.
    Ms. Whitehead. Cell phones are in other institutions. To 
put it in perspective, there may be one cell phone to 50 
inmates at another institution. Atlanta had approximately 1,400 
inmates and 700 phones were found. That is one to every other 
inmate.
    Senator Johnson. You started your career in Atlanta.
    Ms. Whitehead. I did.
    Senator Johnson. I do not want to age you but you had a 
career all over the country, and then you came back really at 
the tail end of your career.
    Ms. Whitehead. Yes.
    Senator Johnson. Do you have any idea how long conditions 
were as you found them? Is this something that had been going 
on for years?
    Ms. Whitehead. When I started my career as USP Atlanta as 
an intern, I was learning the Bureau, the Bureau Way I was 
learning the Bureau. I traveled to about eight institutions 
over 30 years gathering knowledge, learning policies, and I 
went back to Atlanta. I was very proud to go back to Atlanta. 
When I got to Atlanta and I saw that Atlanta operated totally 
differently from other institutions, it was a shocking moment 
that Atlanta is far off the grid when it comes to the BOP.
    Senator Johnson. There are problems at other Bureau of 
Prisons but nothing like Atlanta?
    Ms. Whitehead. Not that I have experienced.
    Senator Johnson. Not even close.
    Dr. Ramirez, there is generally somebody in charge, there 
is some leader of the pack, so to speak. There is somebody 
generally in charge. My guess is it is not necessarily the 
warden. Do either of you know who is in charge there, really? 
Who created the ``Atlanta Way''?
    Dr. Ramirez. I think the ``Atlanta Way'' has been ongoing 
for many years, long before I started at the Bureau and 
probably even before Ms. Whitehead. In my experience at USP 
Atlanta, I think the warden, though identified at the leader 
per se, has very little authority. The Southeast Regional 
Office where the regional director is is about 12 miles away. 
From my experience that office had a lot of input and oversight 
into what was going on in the institution, though they may or 
may not have been informed about the minutiae of what was going 
on at the institution they are aware of the state of the 
institution. I think it is kind of divided.
    Senator Johnson. I realize the sensitive nature of my 
question here, because I am shocked, quite honestly, how much 
retaliation we actually see within government agencies. I 
understand the fear. But I am trying to determine who is in the 
end responsible for this. You can say, the director; you can 
the warden. I am trying to figure out exactly why this 
continued to go on and on and on. I know both you and Ms. 
Whitehead attempted to report these things. Who did you report 
this to?
    Dr. Ramirez. I reported it both to the warden and the 
regional director. In some cases, as it related to the 
suicides, it was reported to Central Office D.C. I think a lot 
of what you are seeing is years and years of staff and 
management not being held accountable. It enables further 
misconduct, almost making it normal.
    Senator Johnson. When you reported that to the warden or 
somebody at the regional center, is it your assessment they 
were fully aware of this, they realized there was nothing they 
were going to do about it or could do about it and they ignored 
your concerns?
    Dr. Ramirez. Yes, my assessment was they were fully aware. 
I know they were fully aware because I advised them myself. In 
many cases, I believe they chose to take no action because it 
was far more difficult to take action than to look the other 
way.
    Senator Johnson. Would those people in charge, would they 
fear of retaliation themselves, and not necessarily career 
retaliation but physical retaliation from people in the prison?
    Dr. Ramirez. In my opinion, I do not believe that they 
would be in fear of physical retaliation, but I do believe that 
the regional director is a political position to some degree, 
and there is quite a bit of caution when attempting to address 
misconduct.
    Senator Johnson. With your indulgence, Mr. Chairman, Ms. 
Whitehead, can you bring some context? I think you understand 
the thrust of my questions here. When there are ongoing 
problems, it goes on and on and on, and people are aware of it, 
but they are simply not addressing it. Can you explain why?
    Ms. Whitehead. It appears the problems in Atlanta have been 
growing for years. Atlanta has a reputation. At one point it 
was the flagship of the Bureau of Prisons. Atlanta has a 
reputation; there is the Atlanta Way. Typically, wardens will 
make a round through Atlanta, maybe 2 to 3 years. They have a 
career to keep growing. If you go to Atlanta and you per se 
rock the boat or you do not go along with the Atlanta Way, then 
it can ruin your career.
    Senator Johnson. The people that report to you as the 
warden, they would be able to ruin your career if you do not 
discipline them and correct what is happening at the prison. 
Again, I am trying to understand this.
    Ms. Whitehead. The warden does have limited ability to make 
change, particularly at Atlanta. The regional director, who is 
the warden's supervisor, has more stake or more weight in 
making change in Atlanta. If the warden goes against the 
regional director's view of Atlanta, then the warden is going 
to be moved.
    Senator Johnson. OK. The responsibility really falls on the 
regional director's shoulders rather than the warden's 
shoulders.
    Ms. Whitehead. More so for Atlanta.
    Senator Johnson. OK. Thank you, Mr. Chairman.
    Senator Ossoff. The Ranking Member's line of questioning 
brings to mind, I think, something that is important that we 
establish here today, which is that these issues are 
longstanding, and these issues have been known to the BOP, this 
information has been accessible to BOP leadership dating back 
at least 9 years, according to the records that we have secured 
from the Bureau of Prisons. All the way back in 2014, we have 
internal BOP documents warning about deficiencies in suicide 
prevention practices, Dr. Ramirez, at the facility. Yet a full 
6 years later, November 2020, here is something from a suicide 
investigation, U.S. Penitentiary Atlanta: ``Past reconstruction 
teams''--the teams that conduct these investigations, this 
report reads. ``Past reconstruction teams have made many of the 
same recommendations noted below in this report. The need for 
attention to detail, adherence to BOP policy, and regard for 
human life among Correctional Services staff.''
    ``Regard for human life among Correctional Services 
staff.''
    Here is another report, another suicide about 8 months 
later: ``Once again this reconstruction revealed complacency, 
indifference, inattentiveness, and lack of compliance with BOP 
policies and procedures. These lapses contributed to a 
dangerous and chaotic environment of hopelessness and 
helplessness, leaving inmates to their own means to improve 
their quality of life.''
    What does it mean in a prison, Dr. Ramirez, if the 
Correctional Services staff--and these are not my words, folks; 
these are the words of the BOP's own internal investigators--
``lack a regard for human life''?
    Dr. Ramirez. It makes it impossible for psychology services 
or even health services to do their job. We are all one team, 
but certainly Correctional Services is the backbone of any 
institution. If they are not doing the minimum, we are then 
unable to provide the treatment necessary to help improve 
mental health across the institution. If we cannot stop inmates 
from accessing substances, from engaging in self-harm routinely 
and having access to various contraband, we cannot provide them 
mental health services. It just makes it impossible, sir.
    Senator Ossoff. Thank you, Dr. Ramirez.
    Ms. Shepard, the impact on the physical health of those 
incarcerated at this facility--and, again, I want to keep 
emphasizing this, that particularly in your case we are talking 
about pretrial detainees. Let me be clear that there is no 
excuse for this treatment and abuse of any human being in any 
facility of the U.S. Government or in the world. When we are 
talking about pretrial detainees, we are talking about folks 
who are being held before or while their cases are tried. They 
have not been convicted. They are presumptively innocent.
    We heard from a Federal judge that so depraved are the 
conditions at U.S. Penitentiary Atlanta that, if folks are 
convicted and sentenced, they depart downward from the 
Sentencing Guidelines because they consider incarceration at 
this facility to be punishment upon punishment.
    I would like for you to describe what you have seen in 
terms of the impact on detainees' and inmates' health of lack 
of access to nutrition, clean water, and so on?
    Ms. Shepard. We see this on a regular basis with clients 
who are detained pretrial at USP Atlanta, significant changes 
not only in physical health but also in mental health. In terms 
of physical health, we see, as I described earlier, clients who 
are losing weight, losing muscle mass, sleep-deprived. All of 
those take a very physical toll on our clients' health, and we 
see that and we point that out to the judges to help them 
understand and explain what these clients are subject to that 
is different, it is not what we expect out of Federal pretrial 
detention. It is not what clients at different Federal pretrial 
detention centers within the district experience.
    But there is also a significant toll on their mental 
health. The extreme isolation of being in these lockdown 
situations, unable to communicate with family members for days 
on end, and even when they are able to wait in line and make 
that phone call, there is a line behind them, and so the 
pressure to keep that communication short, even when they are 
able to make it, it is--again, these are individuals who are 
entitled to the presumption of innocence and who our system has 
taken custody of. This treatment is deplorable, and it bears 
visible consequences in terms of both physical and mental and 
emotional health.
    Senator Ossoff. In the land of the free, before you have 
been convicted of any crime, you can be locked up 23 hours a 
day without access to food or clean water, without enough time 
to take a shower, with paper clothes, without enough time to 
call your family, by the U.S. Department of Justice, without 
access to counsel. It is a disgrace to the U.S. Government.
    I want to ask you, Ms. Whitehead, for your response to the 
concluding paragraph from the 2020 Security Assessment--again, 
after years and years of warnings and internal BOP reports 
about gross deficiencies, misconduct, security lapses. Here is 
how that 2020 Security Assessment that the Subcommittee secured 
concluded: ``U.S. Penitentiary Atlanta presents significant 
security concern for the Southeast Region. Both national and 
local policies are being violated on a regular basis. The staff 
at USP Atlanta are quality staff, but without proper 
leadership, oversight, and accountability, failed to follow 
proper security procedures. USP Atlanta requires immediate 
corrective action.''
    We have heard that before in internal audits, the demand by 
those investigators for action now. What was it like for you 
and others working in the facility to work in that environment?
    Ms. Whitehead. When I arrived at Atlanta, my very first day 
I sat in my car, and I said, ``What the hell? Where does this 
happen in the Bureau of Prisons?'' I know that there are very 
good staff in Atlanta that want to follow policy, that want to 
do the right things. However, without that leadership, without 
being held accountable to follow those policies, it is a 
disservice to the staff and the inmates and the local 
community.
    The report saying that there must be immediate action is 
correct. However, I am still waiting on that immediate action. 
When I was in Atlanta, I did not see any action to the 2020 
report. I did not see any action to the July 2021 situation 
other than to move the management staff.
    Senator Ossoff. Thank you, Ms. Whitehead.
    Ranking Member Johnson.
    Senator Johnson. Thank you, Mr. Chairman.
    I want to go on. This concluding paragraph is quite short. 
It also says, ``The lieutenants' office is not being held 
accountable and is in need of additional oversight. The staff 
morale appears average to below average. There appears to be a 
great deal of animosity between line and executive staff.''
    Ms. Whitehead, can you describe the line of authority? Who 
is the lieutenant? You do not have to name names, but in terms 
of the line of management, what is the lieutenants' office?
    Ms. Whitehead. There is line staff. The lieutenants' office 
is the first-line supervisors of Correctional Services.
    Senator Johnson. This would be right underneath the warden?
    Ms. Whitehead. Right underneath the captain. It is the 
warden----
    Senator Johnson. The warden has captains reporting to him?
    Ms. Whitehead. At Atlanta, the captains report to the 
associate warden; the associate warden reports to the warden. 
Therefore, the lieutenants are the first-line supervisors. The 
captain would be the second; the associate warden, the third; 
and the warden is the fourth inside the institution.
    Senator Johnson. OK, basically four layers of management 
inside the prison.
    Ms. Whitehead. Absolutely.
    Senator Johnson. Then the warden reports to the regional 
director.
    Ms. Whitehead. Yes.
    Senator Johnson. It seems like this report is really 
calling out the lieutenants, four layers down. I have managed 
things in the past. I first go to the top, recognizing an awful 
lot of things happen underneath and the top management may be 
unaware of it. But I think it is interesting to note that this 
report really focuses on the fourth line of management inside 
that prison. Can you explain what is wrong with the top three 
layers that they are not providing proper oversight to the 
lieutenants? Is that where the power is? The lieutenant level, 
is that where the Atlanta Way got developed and the other three 
layers are just ignoring it?
    Ms. Whitehead. No. It is a collective problem. As far as 
that report goes, it talks a lot about Correctional Services, 
about making rounds, about conducting searches. The 
lieutenants' office is pretty much responsible for training the 
officers in those areas. The suicide reports and that August 
2020 report indicates staff were not conducting searches, staff 
were not making rounds. If the lieutenants are making the 
rounds and supervising the staff, the Correctional Services 
staff, then that report indicates some of those things should 
not have happened. It is a very tight institution, the 
different levels. The captain communicates with the lieutenants 
on a daily basis. The associate warden communicates with the 
lieutenants on a daily basis. Therefore, if the lieutenant 
knows that it is going on, then the captain should know. Then 
the captain should let the warden and the associate wardens 
know. It is not correct that the upper three levels did not 
know what was going on either.
    Senator Johnson. It says there is animosity between line 
and executive staff. So define ``line.'' Is executive staff the 
top two layers, three layers, four layers? Where is the 
animosity occurring?
    Ms. Whitehead. The executive staff is the top layer. The 
line staff would be the first layer. A lot of the line staff--
--
    Senator Johnson. Define it in terms of the lieutenants, 
captains, what we were just talking about earlier.
    Ms. Whitehead. That is the line staff. The very first line 
of supervisor will be the lieutenants' office.
    Senator Johnson. In this report, do you know where is the 
animosity between the first-line staff and the lieutenants' 
office and above?
    Ms. Whitehead. It appears that it is between the first-line 
staff and the lieutenants' office, and then it appears that the 
lieutenants' office have issues with the next level from that 
report.
    Senator Johnson. Dr. Ramirez, can you explain why there is 
all this animosity?
    Dr. Ramirez. In my experience at Atlanta, the bargaining 
staff, meaning the officers, the secretaries, oftentimes give 
pushback to their first-line supervisors, so the lieutenant, as 
is referenced there.
    Senator Johnson. You said the bargaining staff. That would 
be the unionized workers?
    Dr. Ramirez. Yes, sir. That is what they mean by line 
staff.
    Senator Johnson. Then lieutenant and above are outside the 
union?
    Dr. Ramirez. Yes, sir.
    Senator Johnson. There is one potential fault line.
    Dr. Ramirez. In my experience, what I witnessed at Atlanta 
was oftentimes the lieutenants would attempt to address an 
issue; the line staff may push back, and it created animosity 
because the captain, the associate warden, and the warden 
expect a job to be done. The lieutenant is in my experience I 
have witnessed them being very frustrated with being unable to 
get whatever done.
    Senator Johnson. Is that because they simply cannot enforce 
the directives because the union will not allow it to be 
enforced? I mean, is there some labor-management issue that is 
part of this? Is the Atlanta Way, is that really a bottom-up 
phenomenon that it is the unionized workers that have created 
this Atlanta Way and line management simply cannot enforce 
anything for whatever reason?
    Dr. Ramirez. I certainly think that there are challenges 
with the union and management at Atlanta. I would also say, as 
I mentioned in my testimony, that the agency's accountability 
for any type of staff misconduct, that entire process is so 
convoluted. If an employee----
    Senator Johnson. When you staff accountability, is that 
disciplining the union, the bargaining----
    Dr. Ramirez. Disciplining any staff member.
    Senator Johnson. Anybody?
    Dr. Ramirez. Yes----
    Senator Johnson. OK. Let me just--because I want to get to 
one other question. I think it was Dr. Ramirez, in your 
testimony you talked about teachers and classes, and there is 
plenty of staff to teach, but you have only seen one course 
being conducted there. My guess is we are going to hear from 
the Director, it is always a staff issue, it is always a money 
issue. Sometimes it certainly is. Can either one of you explain 
why you got teachers and education staff and no classes going 
on except for that one instance?
    Dr. Ramirez. Again, at least in my experience, what I 
witnessed at Atlanta, it was very difficult to account for the 
staff. There was quite a bit of animosity not only between the 
line staff and management but also between staff who were not 
Atlanta staff, meaning we came from other institutions.
    Senator Johnson. The outsiders.
    Dr. Ramirez. The outsiders. There was quite a bit of divide 
between the staff, and so it made for a somewhat cat-and-mouse 
game at times.
    Senator Johnson. Ms. Whitehead, do you have a comment on 
that?
    Ms. Whitehead. Dr. Ramirez is right on point.
    Senator Johnson. Thank you, Mr. Chairman.
    Senator Ossoff. Thank you, Ranking Member Johnson. Thank 
you again so much to our witnesses on this panel for your 
courage, for coming to speak out about what you have 
experienced at U.S. Penitentiary Atlanta.
    This concludes Panel 1, and the hearing will be in recess 
until approximately 11:30 a.m. while we vote, Ranking Member 
Johnson. You are excused with gratitude from the Subcommittee.
    [Recess.]
    The Subcommittee will return to order.
    We will now call our second panel of witnesses for this 
morning's hearing. Michael Carvajal is the Director of the 
Bureau of Prisons. He has served in the Bureau of Prisons for 
the past 30 years, most recently having served as the Assistant 
Director for the Correctional Programs Division, after which he 
was appointed to the position of Director of the Bureau of 
Prisons in February 2020.
    Director Carvajal, thank you for being here. It is the 
custom of this Subcommittee to swear in all witnesses, so at 
this time I would ask you to please stand and raise your right 
hand. Do you swear the testimony you will give before this 
Subcommittee will be the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Mr. Carvajal. Yes, I do.
    Senator Ossoff. Thank you, Director Carvajal. You may be 
seated. Let the record reflect that the witness answered in the 
affirmative.
    We will be using a timing system today, and, Director 
Carvajal, all of your written testimony will be printed in the 
record in its entirety, but we would respectfully ask you try 
to limit your oral testimony to no more than 5 minutes. You may 
begin with your opening statement.

 TESTIMONY OF MICHAEL D. CARVAJAL,\1\ DIRECTOR, FEDERAL BUREAU 
             OF PRISONS, U.S. DEPARTMENT OF JUSTICE

    Mr. Carvajal. Good morning, Chairman Ossoff, Ranking Member 
Johnson, and distinguished Members of the Subcommittee. I am 
pleased to be here voluntarily to speak on behalf of more than 
35,000 corrections professionals who diligently support the 
Bureau's critical law enforcement mission.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Carvajal appears in the Appendix 
on page 86.
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    I want to stress that what happened in Atlanta is 
unacceptable. We recognize the gravity of the alleged 
misconduct at that facility, and in July 2021, we determined 
that it was in the best interests of the institution to take 
significant action. We reassigned staff, transferred inmates, 
lowered the security level, and began updating infrastructure 
at the facility. Importantly, we refocused the staff toward 
changing the culture.
    The Bureau has expended significant resources, implemented 
corrective actions meant to ensure USP Atlanta's operational 
compliance with policies and expectations. Regional leadership 
routinely visits the institution to provide oversight and 
review progress.
    In April 2022, I conducted a site visit to personally 
inspect the facility and assess the culture. I found the staff 
to be receptive of and motivated by the recent changes that we 
instituted, and I observed firsthand the substantial physical 
improvements for the ongoing repairs.
    The regional office recently conducted a security 
assessment. While the report is not yet final, preliminary 
findings indicate that corrective actions have increased staff 
training, enhanced security measures, internal controls, 
improved internal auditing, and strengthened inmate and staff 
accountability.
    To address the aging infrastructure at USP Atlanta, we 
temporarily closed housing units to make necessary renovations. 
As repairs are completed and units are reopened, inmates will 
be returned to a safer environment.
    We are also in the process of upgrading the infrastructure 
and the installation of fiber optics that will support more 
modern security systems. That said, our ability to complete 
this critical work, including the replacement and addition of 
security systems and cameras, depends on our ability to fund 
these projects.
    For context, the current backlog of major modernization and 
repair projects throughout the Bureau is approximately $2 
billion. However, over the last 10 years, the Bureau has 
received an average of $95 million annually to address these 
projects. This gap means that we must continually make 
difficult decisions about what projects to prioritize 
throughout the agency, which creates challenges when addressing 
infrastructure issues at 100-year-old institutions such as USP 
Atlanta.
    We continually strive to improve suicide prevention efforts 
within the BOP. Inmate suicide rates historically run lower 
than those of the general public. In recent years, we have 
taken meaningful steps to reduce the likelihood of suicides at 
USP Atlanta and agency-wide.
    For example, in the spring of 2021, we created a task force 
to review strategies to reduce single celling, revised our 
suicide prevention policy, enhanced recommendation follow-up 
procedures, and expanded use of reintegration housing programs. 
We also provided additional suicide prevention training and 
added 100 new positions to our psychology services with at 
least 50 more anticipated this fiscal year (FY).
    Properly addressing this conduct is also an agency focus. 
The Bureau employs multiple levels of oversight intended to 
ensure that its institutions are operating according to policy. 
This includes reviews performed by central and regional 
offices, local institutions, and outside entities.
    In addition, all staff have a responsibility to protect 
inmates and each other by reporting misconduct. In fact, 
failure to report misconduct is a policy violation, and all 
potential violations are referred to the appropriate 
investigative authorities. We are constantly looking for ways 
to strengthen this oversight and do better.
    Part of the Bureau's effort to curb misconduct includes 
contraband interdiction. We continue to combat the threat of 
contraband such as drugs, weapons, and cell phones, which are 
introduced into our institutions through ever-evolving methods. 
In addition to our standard security practices, we are 
currently working on several new systems to address this issue, 
and we have provided supplemental training to staff.
    The Bureau has made significant strides in addressing these 
staffing needs over the past few years, and we created a 
national recruiting office, which uses creative methods and 
marketing to attract candidates. They also target recruitment 
efforts at institutions that have difficulty attracting 
applicants. Increasing and maintaining our staffing within 
appropriated funding levels remains a priority. In 2021, we 
hired over 3,000 staff, and this year we have added over 1,200 
new staff. We have proven that we can hire, and although hiring 
is not an issue at the majority of our locations, we are 
routinely outbid by competing corrections or law enforcement 
agencies that pay higher wages.
    Accordingly, we continue to consider how we can use 
additional incentives and hiring flexibilities so that we can 
be more competitive. USP Atlanta is currently staffed at nearly 
90 percent, while the inmate population is approximately 42 
percent. Recruitment and retention efforts are ongoing to 
maintain institution staffing at a safe and appropriate level.
    I appreciate the opportunity to discuss these issues with 
you, and I look forward to your questions.
    Senator Ossoff. Thank you, Director Carvajal, for your 
opening statement.
    You became Assistant Director for the Correctional Programs 
Division in August 2018. Without objection, I will enter into 
the record the BOP's job description for that role, providing 
``national policy direction and daily operational oversight of 
correctional services.''
    You were appointed Director in February 2020. Is it fair to 
say you have overseen corrections across the BOP from 2018 to 
present?
    Mr. Carvajal. Yes, Senator. As part of the leadership team 
for the agency, that is correct.
    Senator Ossoff. Thank you, Director Carvajal. You would 
agree with me, sir, that as Director, you are responsible for 
what happens at this agency?
    Mr. Carvajal. Senator, as the agency head, I am overall 
responsible for everything that occurs at the agency.
    Senator Ossoff. Thank you, Director Carvajal. The buck 
stops with you. Yes?
    Mr. Carvajal. Yes, Senator, as you are aware, we have a 
very large and complex organization, so there is a clear 
delineation of authority. The way our system is set up, as the 
Director, as I stated, yes, every facility has a senior-level 
manager, a chief executive officer (CEO), who is responsible 
for every facility. Above him is a Regional Director----
    Senator Ossoff. Understood, Director Carvajal, but my time 
is limited, and the buck stops with you, correct?
    Mr. Carvajal. Correct.
    Senator Ossoff. OK. I would suggest leaving the microphone 
on in the interest of time.
    It is the mission of the Bureau of Prisons to confine 
``offenders in the controlled environments of prisons and 
community-based facilities that are safe, humane, cost-
efficient, and appropriately secure.'' That is according to the 
BOP. Correct?
    Mr. Carvajal. Correct.
    Senator Ossoff. Thank you. If BOP is not doing these 
things, the buck stops with you. Correct?
    Mr. Carvajal. As I stated, Senator, ultimately I am 
responsible for everything that occurs in this agency, but this 
is a very large and complex organization. You have to----
    Senator Ossoff. Director Carvajal, I appreciate it is a 
large and complex agency, but you are the Director. I think we 
have established that the buck stops with you.
    As you know, USP Atlanta is a prison complex that holds 
pretrial detainees, meaning people who have been charged with 
crimes but not yet convicted. As you know, in our country they 
are presumed innocent.
    During our investigation we have uncovered horrific reports 
of conditions of incarceration for all prisoners at USP 
Atlanta, but in particular for the presumptively innocent 
pretrial detainees. What in brief, Director, does it mean for a 
detainee in your custody to be presumptively innocent?
    Mr. Carvajal. Senator, I am not sure I understand your 
question.
    Senator Ossoff. What does it mean for a detainee in your 
custody to be presumptively innocent?
    Mr. Carvajal. Precisely that, that they are presumed 
innocent until proven guilty. They are going through the 
system. They are pretrial.
    Senator Ossoff. That is right. They are presumed innocent 
until proven guilty. A Federal judge in the Northern District 
of Georgia wrote a letter to the warden of USP Atlanta in 
January of this year, which I entered into the record earlier 
in this hearing. I think it is an extraordinary letter. This is 
from January of this year. It cites credible accounts--this is 
a Federal district judge, in fact, the chief judge for the 
district panel--of the following issues at USP Atlanta, 
particularly for pretrial detainees who are presumptively 
innocent: ``rats in the building, roaches in the food, poor 
nutrition and emaciation, lack of access to hygiene products, 
lack of access to medical care, including prescription 
medication''; ``a month of 24-hour solitary confinement with 
only a Bible for entertainment or reading''; ``a week with only 
a paper jumpsuit and paper blankets for an inmate on suicide 
watch, without mental health treatment or medication.''
    Have you seen this letter before today?
    Mr. Carvajal. I would have to actually see it, Senator. I 
get lots of letters, and I am sure my staff are familiar with 
it.
    Senator Ossoff. But you have not seen this letter until 
today?
    Mr. Carvajal. No.
    Senator Ossoff. You understand that several of the 
witnesses we have heard from today have also cited unacceptable 
conditions of incarceration, particularly for pretrial 
detainees? You heard that testimony?
    Mr. Carvajal. The testimony of the panel before?
    Senator Ossoff. Yes.
    Mr. Carvajal. No, I did not hear it.
    Senator Ossoff. You did not hear that testimony. 
Understood. We will make sure to get you a copy.
    For a facility in as dire straits as U.S. Penitentiary 
Atlanta where the inmate population has been depopulated by 
somewhere around 50 percent as a result of extraordinary 
measures in the middle of 2021 after massive amounts of 
contraband and weapons were found, after years and years of 
documented failures, why would you not be aware of a letter 
from the chief judge of the Northern District of Georgia citing 
rats, roaches, emaciation of detainees, lack of access to 
hygiene products? You would not be aware of that? No one 
brought that to your attention?
    Mr. Carvajal. Senator, that is precisely how our 
organization works. We have a Regional Director that is 
responsible for oversight of that facility along with the CEO. 
That is precisely why, when I did become aware of the issues in 
Atlanta, I took the action that we took. That is precisely why 
we took that action, because when it did rise to my level, it 
rose to my level, and we took immediate action. We did the 
things that we did, including reducing the population, 
reassigning the leadership team so that we could address the 
cultural issue that had developed there.
    Senator Ossoff. Thank you, Director Carvajal. Now, you took 
over as the Assistant Director for Correctional Services, in 
2018. You would have familiarized yourself with some of the 
most significant problems at major BOP facilities entering that 
role, yes?
    Mr. Carvajal. If it was brought to my attention, Senator, 
again----
    Senator Ossoff. It was brought to your attention, or did 
you proactively familiarize yourself with conditions at 
facilities?
    Mr. Carvajal. Senator, I believe it is important for you to 
understand how our organization works. Regional Directors have 
primary responsibility oversight for those facilities. 
Assistant Directors are more at the central level headquarters 
who are in charge of implementing policies and ensuring that we 
follow the rules and regulations. There are distinct 
differences between those.
    It is assumed that the Regional Director will provide 
oversight, and they are responsible to ensure compliance with 
policies, rules, and regulations at the local level.
    Senator Ossoff. Thank you, Director Carvajal. You said you 
took immediate action when these issues were brought to your 
attention. A November 2018 suicide investigation found that 
staff who initially responded to the medical emergency did not 
appear to have a sense of urgency. You were the Assistant 
Director for Correctional Programs.
    August 2019, inspection by the Southeast Regional Office 
reported missing weapons, significant failures to follow use of 
force, medical, and rape prevention policies, improper or non-
use of metal detectors. At that point you were the Assistant 
Director for Correctional Services.
    An August 2020 suicide investigation--I believe now you are 
the Director--says, ``We have made many of the same 
recommendations noted in this report, the need for attention to 
detail, adherence to BOP policy, and regard for human life 
among Correctional Services staff.''
    What does it mean to you to hear as the Director of Bureau 
of Prisons a report from your own investigators that staff at 
this facility lack regard for human life?
    Mr. Carvajal. It is completely unacceptable, Senator. That 
is precisely why I took the actions that I did when I became 
aware of it.
    Senator Ossoff. Would it surprise you to learn that the 
BOP's own internal documentations show that it was aware of 
these conditions at USP Atlanta as far back as 2015?
    Mr. Carvajal. I am now aware of that, Senator. That is 
precisely why we took the actions that we did in reassigning 
the leadership team; and looking at the way the structure 
works, the Regional Director is responsible to implement and 
make sure of compliance with those things. It is apparent that 
we had an issue there. When it rose to my level, as the 
Director of the agency, we took immediate action.
    Senator Ossoff. Just to be clear, and then my time will be 
up and we will turn to Ranking Member Johnson. But when you 
were the Assistant Director for Correctional Programs, it had 
not risen to your level, that at this facility where BOP 
internal investigators had for more than half of a decade noted 
and referred to BOP leadership's significant deficiencies, some 
of them life-threatening, major security lapses. You were not 
aware that there were reports of missing weapons, failures to 
follow use of force, medical, and rape prevention policies, 
improper or non-use of metal detectors or spectrometers, 
failure to conduct rounds in the SHU, deficient inmate 
disciplinary processes? These are the BOP's own internal 
investigative records. You were the Assistant Director at the 
national level for Correctional Programs. Were you or were you 
not aware in 2019 that these conditions prevailed at this 
facility? It is a yes or no question.
    Mr. Carvajal. Senator, as I stated, the Regional Director 
has oversight, primary responsibility. We have internal 
processes in place where we speak about these issues----
    Senator Ossoff. You were not aware?
    Mr. Carvajal. I did not have primary responsibility over 
that area.
    Senator Ossoff. You say you did not have responsibility. My 
question is: Were you aware?
    Mr. Carvajal. I do not recall, Senator, without knowing--
truthfully, we have a lot going on in a very large, complex 
organization. I assure you that if I was aware, as with 
anything, I would have conducted or taken action. It was the 
primary responsibility----
    Senator Ossoff. Thank you, Director Carvajal. My time is 
up, and I yield to Ranking Member Johnson.
    Senator Johnson. Mr. Director, thanks for coming here. Let 
us try to clarify things in terms of the organization. I have 
been in large organizations. You have line operation authority, 
and then you have staff over here doing human resources and 
other types of things. They are completely separate. Is that 
what your testimony is when you were the Assistant Director for 
Correctional Programs? You were really outside of the line 
operation authority and it was not your responsibility to be 
aware of exactly what was happening operationally within the 
prisons?
    Mr. Carvajal. That is correct, Senator. I appreciate the 
opportunity to explain. As the Director of the agency, I am 
overall responsible. The buck stops with me. However, our 
organization is very large. Assistant Directors at the 
headquarters level are responsible for implementing policies 
and procedures. The operational daily oversight of a facility 
is the primary responsibility of the Regional Director and, 
more importantly, the CEO of that facility.
    By analogy, let me make it like this. A prison is like a 
city. The warden would be like the mayor, responsible. If they 
have issues or need assistance, they report up to the Regional 
Director, who would be in this case by analogy like a Governor, 
the central office being like Federal assistance. Without that 
information and requests coming up to us, we are not directly 
involved in that.
    We also have the approval of the Deputy Director or the 
Director to get involved in those operational----
    Senator Johnson. OK. I think that is clarified. Do you know 
generally when you first became aware of the problems in 
Atlanta? Because you have served in a bunch of other 
correctional facilities. When did it hit your radar screen?
    Mr. Carvajal. It hit my radar screen when I took the 
action. We have a lot going on. We have lots of facilities. 
There is no possible way--that is why we have a delineation----
    Senator Johnson. So when you became aware of it, you took 
immediate action----
    Mr. Carvajal. Took the action.
    Senator Johnson [continuing]. In the summer of 2021.
    Mr. Carvajal. Yes.
    Senator Johnson. When was the first time have you ever 
heard of the phrase ``the Atlanta Way''?
    Mr. Carvajal. I heard that phrase during--when I became 
aware and as we were getting reports back, that is how we 
determined that there was a cultural issue and a breakdown 
there, an obvious one. That is why we took the actions we did 
to reassign the leadership team.
    Senator Johnson. Which members of the leadership team--you 
do not have to name names. I mean give me the functions. Who 
did you replace?
    Mr. Carvajal. We looked at all of the leadership team. We 
started with the warden and the executive leadership, and we 
certainly reassigned them for various reasons. The majority of 
the leadership team, all middle managers and above, because the 
obvious breakdown----
    Senator Johnson. Are you talking about the mayor and his 
staff, or are you talking about the Governor--I am using your 
analogy.
    Mr. Carvajal. Yes.
    Senator Johnson. Did you replace anybody at the regional 
center?
    Mr. Carvajal. The mayor and his staff, according to the 
analogy. The Regional Director was due to mandatory retire in 
October. I made the decision to replace him with a new Regional 
Director approximately 5 months early.
    Senator Johnson. OK. As the Chairman pointed out, though, 
you took those actions in the summer. It did not fix the 
problem. I will take you at your word that you had not seen 
that letter from the judge, but in January 2022, it is still 
pretty shocking conditions at Atlanta. How close are you 
monitoring the situation and the effectiveness of your 
corrective action?
    Mr. Carvajal. As I stated, Senator, I made a visit there in 
April to ensure that things were----
    Senator Johnson. April 2022?
    Mr. Carvajal. April 2022. This is an ongoing challenge in 
old facilities. The warden I know is on it. What I observed 
there was that they were addressing these issues. We have 
constant challenges every day. When we become aware of them, we 
address them. I would expect that when that letter came in that 
the current warden, the permanent warden there is addressing 
those issues immediately, and that is what we expect at any 
facility.
    Senator Johnson. Ms. Whitehead, in her testimony, which you 
did not hear, she served in Atlanta in the early 1990s, came 
back at the tail end of her career, and her testimony was that 
she was shocked at the conditions. And, you have seen other 
prisons. You have been in different correctional facilities. 
You know how the procedures ought to work.
    When you first became aware of what was happening in 
Atlanta, what was your reaction?
    Mr. Carvajal. Exactly as I stated, Senator. It is 
absolutely unacceptable. That is why we took the actions we 
did.
    Senator Johnson. Again, you did not hear the testimony. I 
was trying to determine who really was in charge. We kind of 
went through the Regional Directors, then there is basically 
four layers of line management, ending at the lieutenant. You 
have the warden, and you have captains, and you have social 
workers, and then you have the lieutenants. I think we should 
call them those in the bargaining unit. You have the union line 
employees. One of the conclusions of the 2020 report was that 
the lieutenants' office is not being held accountable and is in 
need of additional oversight. Then it talked about how there 
appears to be a great deal of animosity between line and 
executive staff.
    Having run organizations, I realize sometimes people at the 
top, information just does not filter up. I have got that. 
People cover things up, they do not want to let the boss know, 
that type of thing. Having looked into this, do you have an 
analysis of what went so haywire, why things were so wrong for 
so long in Atlanta? I know you took care of some of the 
management team, but, was there a union component to this, 
animosity between the union line staff and management?
    Mr. Carvajal. We do have a collective bargaining agreement, 
and the union does represent the line staff. But the issue, the 
breakdown that happened here, which was completely 
unacceptable, was the cultural issue there of line staff not 
being held accountable. A failure to follow policy is 
unacceptable. We have to have leaders and managers that enforce 
and hold people accountable. That is why we made the decision 
to remove the team, because they obviously were not holding 
line staff who do the job accountable. That is precisely why we 
moved them.
    Senator Johnson. So, you replace the warden. Did you 
replace captains?
    Mr. Carvajal. I believe it was in the summer of 2021, the 
captain, the associate warden--the captain, who is considered 
the chief of police in that city, and the associate warden were 
both removed from their positions because of their failures. 
The warden was eventually removed. Keep in mind that we have 
due process and we have to respect their rights, too. We 
eventually removed the warden, so we had some actings. Then 
when I became aware of the overall cultural issue, which is 
completely unacceptable, we made a tough decision by removing 
the entire management team. These are all individuals--this was 
not----
    Senator Johnson. Does that include lieutenants and every--
--
    Mr. Carvajal. Yes.
    Senator Johnson. Did you bring those in from other 
facilities then?
    Mr. Carvajal. Yes, we did.
    Senator Johnson. When did you make that move?
    Mr. Carvajal. It was ongoing. In fact, there may be some 
that are still--it is an ongoing process because we do have to 
make sure that--our employees have rights. We are not doing 
this----
    Senator Johnson. I understand.
    Mr. Carvajal. We are following personnel guidelines.
    Senator Johnson. If I could have the indulgence of the 
Chairman here, did you ever have an overall meeting with 
individuals in the bargaining unit, the line guards? Did you 
ever meet with the lieutenants? What did you do or were you 
kind of talking to the warden and the captains when you went in 
there and did your analysis?
    Mr. Carvajal. I did not--that occurred below me, the 
different meetings. When I toured in April, I walked around 
that facility and interacted with all staff. In fact, my goal 
was to meet and speak to as many staff as possible in an 
informal environment. I answered many questions. I got lots of 
questions, and I had lots of interactions. That is why I 
visited the facility.
    Senator Johnson. How long was your visit and how many times 
did you visit it?
    Mr. Carvajal. I am sorry?
    Senator Johnson. How long was your visit and how many times 
did you visit it?
    Mr. Carvajal. That is the first time I visited there, and 
that was a day-long visit.
    Senator Johnson. OK. Thank you, Mr. Chairman.
    Senator Ossoff. Thank you, Ranking Member Johnson.
    Director Carvajal, I am going to begin with some citations, 
some reports prior to your tenure and leadership, then move to 
the present.
    July 2014, BOP scored USPA's Correctional Services 
Department as deficient. Deficiencies included unqualified 
staff assigned to armed posts, mishandled video footage, 
failure to conduct rounds, failure to use spectrometers to 
detect contraband, failure to implement suicide prevention 
policies. Let us discuss a few of these. That specific 
deficiency, unqualified staff assigned to armed posts--again, 
unqualified BOP staff assigned to armed posts shows up on the 
following Correctional Services audits for U.S. Penitentiary 
Atlanta, August 2015, December 2015, staff assist visit from 
November 2016, April 2019, while you are, as you earlier 
acknowledged, responsible for implementing policies and 
procedures for Correctional Services across the country, the 
October 2021 Operational Review and the August 2020 Security 
Assessment. In your view, is it OK for a prison to assign 
unqualified staff to armed posts?
    Mr. Carvajal. It is unacceptable, Senator.
    Senator Ossoff. Why didn't anyone fix this problem? We can 
limit the discussion to when you were in senior leadership, 
April 2019, August 2020, October 2021.
    Mr. Carvajal. I cannot answer why it was not fixed. It is 
unacceptable. That is why we took the action we did. The warden 
in that facility should have been ensuring that his staff were 
conducting these follow-ups and making sure of policy 
compliance, and ultimately the responsibility of that Regional 
Director who had oversight of that facility should have ensured 
compliance with those policies. It is unacceptable.
    Senator Ossoff. And you were not aware of any of these 
issues at USPA until last year? That is your testimony, 
correct?
    Mr. Carvajal. Correct.
    Senator Ossoff. Understood. Let us talk about contraband 
interdiction efforts. In addition to the July 2014 audit which 
found that staff had failed to use spectrometers to detect 
contraband, numerous other audits--recognizing some of this is 
before your tenure and leadership--reported issues with 
contraband interdiction at the prison, including June 2015, 
staff not using the ion spectrometry device to test contractors 
and volunteers entering the prison; November 2016, metal 
detectors at the facility not maintained or inspected; May 
2017, the Special Investigative Services Department was storing 
drugs ``in excess that are not needed as evidence'' and which 
could ``pose a potential threat to the security of the 
institution.''
    Now, those were before you assumed supervisory 
responsibility over BOP's Correctional Services or, as you put 
it, responsible for implementation of policies and procedures. 
I would have expected that that official would have reviewed 
some of these reports from problematic facilities. That is 
water under the bridge. Let us talk about while you were in 
charge.
    August 2019, Assistant Director for Correctional Programs, 
staff member entering the front lobby setting off metal 
detectors; front lobby officer waving them through; one ion 
spectrometry machine broken at the west gate; all contractors 
entering the facility using the front lobby and never screened; 
after, at this point, 5\1/2\ consecutive years of reports 
indicating failures to prevent contraband from entering.
    January 2020, USPA staff are damaging the ion scan to 
prevent the device from being used. The machine has not been 
utilized in over one year. Before you become Director at the 
Bureau of Prisons, staff are engaged in ``purposeful 
destruction of drug detection equipment.'' That is one month 
before you became Director.
    Now we continue. August 2020, you are the Director. The 
review team observes multiple USPA staff triggering the metal 
detector in the front lobby but continuing into the prison 
unimpeded; allowing for unauthorized items to be introduced 
into the institution.
    October 2021, you are the Director. Staff not routinely 
conducting pat searches; no documentation memorializing 
confiscated contraband; repeated suicide reconstruction reports 
at the facility with the most suicides of any prison in the 
country about how the deceased inmates are high when they 
killed themselves.
    Are these acceptable practices for one of your prisons?
    Mr. Carvajal. No, Senator, they are not acceptable. 
Precisely why we took the action that we did to cure the 
obvious cultural breakdown of people not following policy. 
Contraband interdiction is a daily process that relies on human 
beings doing their job, conducting searches and following 
proper rules and procedures. That is the basics of what we do. 
That is what ultimately led to this breakdown. But it takes 
leadership to provide oversight and make sure that these things 
are being done, and that is the ultimate responsibility of that 
warden, that leadership team, and the responsibility of the 
Regional Director to ensure compliance through oversight.
    Senator Ossoff. Respectfully, Director Carvajal, you are 
continuing to drive responsibility down the chain of command. 
But my question for you is this: You spent 2 years as the 
Assistant Director for Correctional Services, in your words, 
responsible for implementing policy and procedures at the 
national level. You are then the Director of the Bureau of 
Prisons, and you have not familiarized yourself with any of 
this. You are unaware of any issues at USP Atlanta. It is 
clearly your most troubled facility. You were ignorant of these 
problems until the middle of 2021. That is your testimony 
today.
    Mr. Carvajal. Senator, things like that, because of the 
delineation of authority, wouldn't normally rise to my level. 
We have a chain of command and procedures that are followed.
    Senator Ossoff. Yes, you were ignorant of this until the 
middle of 2021.
    Mr. Carvajal. Senator, it was obvious that there was a 
breakdown that that did not reach my level, and that is why we 
took the action that we took. There is a delineation of 
authority, and we trust people--these are Senior Executive 
Service (SES) people at the highest level who have that 
responsibility. We have very good policies, Senator, when they 
are followed. The breakdown here is that people consciously 
chose not to follow the policy. Not always. In those cases 
where it was a training issue--that is why we focused on 
training. It is our responsibility to make sure the staff know 
these policies and train them. It is ultimately the 
responsibility of every individual to follow those policies 
and, when people do not, to report misconduct. We have 
processes for all these things, and they all work very well. It 
is not our policies that were broken. It was the failure to 
follow those policies, and that is why we took the action that 
we did.
    Senator Ossoff. Director Carvajal, when in August 2020 the 
central office under your command conducted a Security 
Assessment of U.S. Penitentiary Atlanta and found that it posed 
``a security risk to the Southeast Region of the United 
States,'' you were not aware of that?
    Mr. Carvajal. I am not certain which document you are 
referring to, Senator.
    Senator Ossoff. I am referring to an August 2020 Security 
Assessment conducted by the central office under your authority 
which found extensive, pervasive security failures, and said, 
``U.S. Penitentiary Atlanta is a security threat to the 
Southeastern United States.'' This was not a routine 
inspection. This was a Security Assessment carried out by the 
central office while you were the Director of the Bureau of 
Prisons. You have testified here today you were unaware of any 
issues regarding this facility until the middle of 2021. Did 
you read the Security Assessment which identified that one of 
your facilities was ``a security threat to the Southeaster 
United States''? Yes or no.
    Mr. Carvajal. Senator, those reports normally would not 
rise to my level because they are handled----
    Senator Ossoff. You did not read it----
    Mr. Carvajal [continuing]. At that level of that authority.
    Senator Ossoff. Thank you, Director Carvajal.
    Ranking Member Johnson.
    Senator Johnson. Director Carvajal, one of the more 
troubling security breaches was the fact that out of 263 
cameras, 142 were inoperable or out of service. Has that been 
corrected?
    Mr. Carvajal. Senator, we are in the process of correcting 
all those issues. I am aware of that. Nationwide, we have 
challenges with cameras, and Atlanta is no different. We are 
correcting that problem. We have directed resources to address 
those issues.
    Senator Johnson. I would think that would be a top priority 
because it is such a crucial asset in terms of protecting 
everybody, Bureau of Prisons personnel, inmates. I am concerned 
that here we are in July 2022, and this was delineated in 2020.
    Mr. Carvajal. Senator, as I stated in some of my remarks, 
you have to understand the complexity. We have competing 
resources. Cameras are a great tool, first off, and we 
appreciate the support and the assistance to get those 
addressed. Cameras will not prevent contraband or crime or 
anything else. It is a tool that we use to manage it. The 
people are the ones doing their job----
    Senator Johnson. OK. I got you.
    Mr. Carvajal. We are correcting it, though.
    Senator Johnson. In the close of your testimony, you said 
you appreciate the opportunity to come before us. I do not envy 
your task. But let me ask you, why did it take a subpoena to 
get you to testify here?
    Mr. Carvajal. Senator, I am here voluntarily, and I would 
defer the process to the Department. But I have appeared before 
Congress five times in my tour, and I am voluntarily here, and 
I welcome the legitimate oversight that you provide.
    Senator Johnson. I do realize we withdrew the subpoena, and 
I agreed with that decision, because you did appear. But it 
took us issuing a subpoena to get you here. Were you involved 
in any discussions regarding your testimony here?
    Mr. Carvajal. Senator, to the best of my knowledge, we have 
complied with all the requests.
    Senator Johnson. No, please answer my question. Were you 
involved in discussions with anybody in the Department of 
Justice regarding you testifying before this Committee?
    Mr. Carvajal. I was aware of the request. I said I would--
--
    Senator Johnson. Were you involved in discussions? Did you 
talk to anybody in the Department of Justice about testifying 
here today?
    Mr. Carvajal. When I became aware of the request, I have 
spoken to appropriate people----
    Senator Johnson. Who?
    Mr. Carvajal [continuing]. In the Department of Justice.
    Senator Johnson. Who? Who did you speak to in the 
Department of Justice about testifying here today?
    Mr. Carvajal. The Office of Legislative Affairs.
    Senator Johnson. Who?
    Mr. Carvajal. Mr. Hyun.
    Senator Johnson. OK. It is not that hard to provide a name. 
What did those discussions involve?
    Mr. Carvajal. They involved making sure that we 
appropriately put the proper people up here to best answer your 
questions. In this case, operationally I know we provided a 
couple of staff to answer questions that were interviewed and 
to make sure that we provided all the documents.
    Senator Johnson. Did you have discussions once our subpoena 
was issued?
    Mr. Carvajal. Yes.
    Senator Johnson. What did those discussions involve? In 
other words, because you appreciated the opportunity, why 
didn't the Department of Justice allow you to just appear 
before us and take advantage of the opportunity to discuss 
these issues with us?
    Mr. Carvajal. Senator, I will defer those questions to the 
Department. I am here voluntarily----
    Senator Johnson. Yes, but you are here, and----
    Mr. Carvajal [continuing]. I never said I would not come.
    Senator Johnson. The reason I am asking these questions is 
congressional oversight has been significantly weakened over 
the years. I am fully aware of it. I understand the full 
frustration of Members of Congress trying to get the truth to 
the American public. That is our job. But the agencies thumb 
their nose at Congress with impunity. As important as your 
testimony is in terms of the problems at Atlanta, maybe even a 
bigger issue for me in this hearing is: Why did it take a 
subpoena to get the Director of the Bureau of Prisons to come 
here and testify before us, to help us conduct our oversight? 
What is going on in the Department of Justice that they refused 
to be transparent until Congress, the Senate, has to issue them 
a subpoena?
    We bring department heads before our committees, have them 
testify before us. We almost always ask them the question: Will 
you comply with congressional oversight requests? And to a 
person, because they apparently want the job, they always raise 
their hand and say, ``Absolutely, I will cooperate with you. I 
will work with you. I will provide you the information that you 
request.'' Then they rarely do. Not on the important stuff, not 
the things that might embarrass their agency. I think they even 
look at Presidents with the attitude that this, too, shall 
pass. That arrogance on the part of these agencies, on the part 
of the Department of Justice, the FBI, and our Federal health 
agencies must end. It is that arrogance, it is that lack of 
transparency, it is that dishonesty that have Americans losing 
confidence in these institutions that, quite honestly, they 
need to have confidence in.
    It is an unsustainable state of affairs in a democracy when 
the chief Federal law enforcement division, the FBI, cannot be 
trusted to be non-political, shows themselves to be completely 
political, when the Department of Justice blocks our ability to 
talk to one of their Directors with legitimate oversight, when 
our Federal health agencies have not been honest and 
transparent regarding a pandemic.
    This lack of transparency has to end, and congressional 
oversight needs to be kicked into high gear. I appreciate what 
Chairman Ossoff has done on this one issue, but there are just 
so many more.
    Thank you.
    Senator Ossoff. Thank you, Ranking Member Johnson.
    Director Carvajal, you no doubt pay attention to the number 
of inmate suicides in your various prisons. Yes?
    Mr. Carvajal. Yes.
    Senator Ossoff. Which BOP facility has the most inmate 
suicides over the past 5 years?
    Mr. Carvajal. I do not know that information right off my 
head.
    Senator Ossoff. It is U.S. Penitentiary Atlanta. I would 
think this would be a facility that would have been on your 
radar even if just for the number of inmate suicides leading 
the Nation.
    November 2018, for example, at that time you are the 
Assistant Director for Correctional Programs. An inmate died by 
hanging. BOP investigation finds staff who initially responded 
to the medical emergency did not appear to have a sense of 
urgency. Officers did not conduct rounds prior to the suicide. 
Inmate orderlies were caught on camera passing contraband to 
inmates under their cell doors. Did that concern you at the 
time?
    Mr. Carvajal. I am certain it did, Senator. I believe that 
is part of the issue here, is that we have been siloed in the 
past. That is part of the reason that we are looking at making 
these changes and improvements. The Reentry Services Branch 
oversees the Psychological Branch. Correctional Programs 
Division was not responsible for----
    Senator Ossoff. Hold on just a second. We are getting into 
the organization chart again. Listen, November 2018, inmate 
died by hanging. No sense of urgency in the staff response. 
This is a BOP internal document. Officers did not conduct 
rounds prior to the suicide. Inmate orderlies were caught on 
camera passing contraband to inmates under their cell doors.
    You said in the previous round of questions that you were 
not aware of these issues at USP Atlanta until mid-2021. You 
were not aware of this?
    Mr. Carvajal. Senator, we have 121 facilities at the 
highest level that I keep track of. That is why the delineated 
authority goes down----
    Senator Ossoff. This would not have risen to your level?
    Mr. Carvajal. I expect to be briefed by the appropriate 
people. In this case it would have been the Assistant Director, 
telling us there were issues at that facility.
    Senator Ossoff. This would not rise directly to your level?
    Mr. Carvajal. Without going back and knowing the 
individuals--I am notified of any suicide or major incident.
    Senator Ossoff. That is right.
    Mr. Carvajal. Ongoing. I am notified of that. We have 
reporting procedures.
    Senator Ossoff. That is right because you are cc'd on the 
report, and that is why I am having trouble with your testimony 
that you were not aware of any issues at this facility until 
the middle of 2021, because as the Assistant Director for 
Correctional Programs, you received the investigation reports 
for each of the suicides. Lack of urgency, failure to conduct 
rounds, inmate orderlies passing contraband under cell doors--
those came directly to you.
    Were you aware of these issues at U.S. Penitentiary Atlanta 
prior to the middle of 2021?
    Mr. Carvajal. Senator, we get all those reports, and part 
of our responsibility is to look at training and development 
and things of that nature. When I tell you I am not aware 
specifically, I cannot remember specifically what I did in that 
time.
    Senator Ossoff. OK.
    Mr. Carvajal. I do know that I read those reports----
    Senator Ossoff. Understood.
    Mr. Carvajal [continuing]. We took appropriate----
    Senator Ossoff. Your testimony is that you do not recall.
    Mr. Carvajal [continuing]. Action to address those issues.
    Senator Ossoff. You took appropriate action. OK. That was 
November 2018. You are the Assistant Director of Correctional 
Programs. The report was sent to you. You say you took 
appropriate action.
    October 2019, just under a year later, you are still in 
this position. Inmate died by hanging. ``Staff delayed the 
initiation of life-saving measures. Staff failed to perform 
rounds before, during, and after the suicide.''
    Same issues. What action had you taken to resolve these 
issues at the facility with the most suicides of any prison in 
the Federal system?
    Mr. Carvajal. We provide corrective action, internal 
controls. Keep in mind, Senator, that over time, when these 
repeat deficiencies and things, it is not always the same 
people in charge. That is the ongoing challenge that we face, 
that we have to continuously train staff. It is not always the 
same staff involved. We see repeat deficiencies. That is the 
frustration of the nature of our business, is that we have over 
35,000 staff. It is not the same people involved at all of 
these----
    Senator Ossoff. Yes, 35,000 staff----
    Mr. Carvajal [continuing]. Which is ongoing. It is an 
ongoing challenge.
    Senator Ossoff [continuing]. But you are here with us 
today, and you are the Director. We are going to get back to 
these reports and this timeline in a moment, but I am going to 
reserve the balance of my time and yield to my colleague 
Senator Padilla.

              OPENING STATEMENT OF SENATOR PADILLA

    Senator Padilla. Thank you, Mr. Chair. I am glad we had an 
opportunity to come back for the second panel. I know the first 
panel had a very focused emphasis on U.S. Penitentiary Atlanta. 
But with the number of Federal facilities in California that I 
have been hearing from, I wanted to take the opportunity to 
raise a couple of these questions.
    My office has received reports that BOP personnel at FCI 
Mendota were flouting COVID protocols, leading to the 
transportation of COVID-positive detainees and spikes in 
infections.
    Now, Senator Feinstein and I sent a letter to the Attorney 
General (AG) seeking answers concerning these allegations back 
in April. However, the agency response we received failed to 
reply to our specific concerns raised concerning FCI Mendota. 
Mr. Carvajal, I appreciate you looking through some notes here. 
Hopefully we can get some clear insight as to what is 
happening.
    My first question is: How do you respond to the allegations 
that I am raising here today that we first wrote about back in 
April?
    Mr. Carvajal. Senator, we certainly do not expect anyone to 
flout COVID--we have very good procedures in place, and they 
are followed. I am generally aware of that letter, and we have 
122 facilities. Again, I go back to that we have Regional 
Directors--we have processes in place to provide oversight. We 
take these allegations seriously. We look into them, and we do 
the corrective action. The continuous challenge is that it is 
different people. Zero tolerance for unacceptably not following 
policies. We look into these things, and we address them.
    Senator Padilla. You say there are protocols and they are 
followed. We sent you a letter saying we are hearing protocols 
are not being followed, and it is a dangerous situation, this 
pandemic. The response, again, is not informative or helpful 
whatsoever other than we have protocols and they are being 
followed, and if not, we are going to look into it. We already 
communicated to you months ago that we understand they were not 
being followed.
    As part of our follow-up with you, I am aware that BOP 
utilized compliance review teams to ensure that facilities 
comply with protocols. Now, after Senator Feinstein and I 
raised concerns about FCI Mendota, was a compliance review team 
deployed to ensure compliance with COVID protocols?
    Mr. Carvajal. Senator, I do not know in this particular 
instance, but we do use compliance teams. We also ensure that 
we follow the Center for Disease Control and Prevention (CDC) 
processes and guidelines. I would expect that they were, again, 
delegated. I have 122 facilities. There is the delineation of 
authority, and I fully expect those follow-ups to be done, and 
when they are not, that we have procedures to address that.
    Senator Padilla. I am beginning to share the frustration 
with the Chair here on lack of a definitive answer. Given what 
I have described so far, and you are familiar with the letter, 
it seems like you were perusing it in your binder, would you 
agree that it would be appropriate to deploy a compliance 
review team after such concerns are raised?
    Mr. Carvajal. Yes, Senator, and I do not know why we did 
not. I will ask that question and follow up. I would expect 
that the appropriate Regional Director requested the team or 
that the Assistant Director with oversight for that area would 
deploy a team. But I cannot answer that right now because I do 
not know.
    Senator Padilla. Let me try a different issue. 
Augmentation, the BOP practice involving the push of civilian 
employees into duties usually performed by correctional 
officers, has long been scrutinized. Unless you tell me you 
believe otherwise, I will continue. As of last year, nearly 
one-third of Federal correctional officer jobs were vacant. 
That is a significant percentage. As a result, staff members 
who serve as cooks, teachers, and nurses have been forced to 
guard detainees. Just this week, my office received reports 
that at FCI Dublin staffing has been so low that the drug 
treatment program had to be shut down. Now, this is clearly a 
dangerous and unsustainable situation.
    Mr. Carvajal, what efforts have you personally taken to 
overcome staffing shortages at BOP? Not what issues may be in 
place or efforts may be in place by others, but your personal 
involvement in addressing staffing shortages.
    Mr. Carvajal. Senator, my personal involvement as well as 
the agency's, it is a top priority. Staffing remains a concern. 
It has been a concern. We struggle like everyone to get 
employees, but we are using incentives. We are looking at 
offering more recruitment and retention incentives. We need to 
better our training. We certainly need to attract candidates to 
the area.
    One of the challenges at Dublin, as I referred to earlier, 
is that we have trouble competing with the pay scale in that 
area. We have a hard time attracting candidates. Certainly 
staffing is a priority. An institution is safer when it is well 
staffed, and we strive to add staff.
    I would like to address the augmentation and make sure that 
everyone understands that all of our staff are equally trained. 
They are all Federal law enforcement officers. They go through 
the same training. Although they may have a primary duty 
working in food service or another discipline, which we 
certainly want them to do, the safety and security mission 
comes first. Oftentimes, we do not like doing it, but we have 
to complete that mission first in order for anything else to 
happen. We have to use staff in those areas. They are properly 
trained. All of our staff are equally trained and expected to 
perform those functions as we call correctional workers first.
    Senator Padilla. You are saying nurses and teachers are 
equally trained and prepared to do the duty of all other 
correctional officers?
    Mr. Carvajal. Senator, they go through the exact same 
training that our correctional officers go through.
    Senator Padilla. Ongoing training or----
    Mr. Carvajal. Senator, that is one of the challenges that 
we are trying to do to improve the agency, is conduct more 
training. When we have the luxury of doing that training, we 
try to do advance training; we are implementing a new program 
for correctional officers. But at this point, all of our staff 
receive the same training, annually, refresher training. There 
is no advance training that correctional officers receive, 
Senator.
    Senator Padilla. That should ring alarm bells here as well. 
I know my time is running out, but let me conclude with this 
and emphasizing the point about vacancies are dangerous, both 
for detainees as well as for staff. It is critical that trained 
guards be available to respond to critical situations so that 
those who are not trained to do so are not placed in harm's 
way. Again, the lives of both detainees and staff are on the 
line.
    Now, my office has also received outreach due to a number 
of detainee suicides at FCI Mendota, and according to reports, 
the latest suicide occurred while Recreation Department staff 
members were supervising detainees. Recreation Department staff 
members were supervising detainees.
    Mr. Carvajal, I do not believe that the staff members 
should perform duties that lie outside the scope of their 
employment, especially when it comes to correctional 
supervision. I want to ask additional questions here because 
the responses are a recurring theme. You say it is a priority; 
you say there are incentives. But the number, a third of the 
positions vacant, shows failure, in my opinion. Something has 
to change, and you are the person at the top.
    Thank you, Mr. Chair.
    Senator Ossoff. Thank you, Senator Padilla.
    Director Carvajal, I want to pick up where we left off on 
this discussion of suicides at USP Atlanta. We noted that when 
you were the Assistant Director for Correctional Programs 
responsible for implementing policies and procedures 
nationwide, you directly received these suicide investigation 
reports.
    November 2018, officers not conducting rounds prior to a 
suicide; orderlies caught on camera passing contraband to 
inmates under their cell doors.
    October 2019, delayed initiation of life-saving measures; 
staff failure to perform rounds before, during, and after a 
suicide.
    Then you assumed the directorship. August 2020, inmate died 
by hanging; officer not conducting proper rounds; unsupervised 
inmate orderlies passing items under the cell doors to other 
inmates.
    Same pattern, same issues, but your testimony today--and I 
want to be clear about this because, Director Carvajal, I have 
to be frank with you, I find it hard to believe that you were 
not aware of these issues, as you have testified, until the 
middle of 2021 given that you had national responsibility for 
oversight and implementation of correctional programs. That is 
your testimony today as well. Given that you received these 
reports directly, given that internal BOP investigations found 
that over more than half a decade this was one of the most 
troubled facilities in the entire country, your testimony today 
is, nevertheless, that until the middle of last year, you were 
unaware of this.
    If that is true, it suggests that the directorship of the 
Bureau of Prisons is an office that has no idea what is 
happening within the system of Federal prisons.
    August 2020, here is what the investigation revealed. You 
are the Director. ``Once again this reconstruction revealed 
complacency, indifference, inattentiveness, and a lack of 
compliance with BOP policies and procedures.''
    By the way, the same policies and procedures for which you 
had national responsibility to implement in your prior role.
    Continuing the quote, ``These lapses contribute to a 
dangerous and chaotic environment of hopelessness and 
helplessness, leaving inmates to their own means to improve 
their quality of life.''
    You were unaware of this. You had no idea this was going on 
at U.S. Penitentiary Atlanta. That is your testimony today.
    Mr. Carvajal. Senator, the Psychology Services Branch is 
under the Reentry Services Branch. Correctional Programs works 
with them. Generally, those reports are routed to us. We get 
many reports. We have 122 facilities. We work together----
    Senator Ossoff. Director, it is a yes or--were you aware--
--
    Mr. Carvajal. Senator, I----
    Senator Ossoff [continuing]. We have been through the 
organization chart. Were you aware? Were you aware after you 
served for 2 years with national responsibility for the 
implementation of policies and procedures when you were 
personally copied on reports citing severe deficiencies in the 
conduct of these officials that contributed to the death of 
inmates? Were you aware prior to the middle of last year that 
there were serious problems at U.S. Penitentiary Atlanta? I do 
not want the organization chart. I want to know: Were you 
aware, yes or no, prior to the middle of last year of these 
serious problems at U.S. Penitentiary Atlanta? Very simple 
question.
    Mr. Carvajal. Senator, I was generally aware, but I do have 
responsibility for a very large organization----
    Senator Ossoff. OK, you were aware.
    Mr. Carvajal [continuing]. Which happen----
    Senator Ossoff. You were aware. Now let us discuss what 
action you took. When BOP's internal investigators reported 
that the corrections officers in this facility--and you were 
generally aware of the issues; we have now established that--
lacked regard for human life, what action did you take?
    [No response.]
    Let me ask another question. When in August 2020 your own 
head office, the central office--not the regional office, not 
the warden, not a staff assist visit--your office, August 2020, 
a year before you earlier said you first became aware of these 
issues and took action, said that this facility was a security 
risk to the Southeastern United States, what action did you 
take?
    Mr. Carvajal. It is the responsibility of the Regional 
Director to take those actions, and that is why I took the 
action I took when it rose to my level.
    Senator Ossoff. It was a central office report. It was a 
BOP central office Security Assessment. August 2020, the 
central office concludes this facility poses a threat to the 
security of the Southeastern United States. What action did you 
take?
    Mr. Carvajal. I would expect that the Assistant Director 
and the Regional Directors take the appropriate action and 
brief us on that. That is what did not occur----
    Senator Ossoff. But the buck stops with you. We established 
that, didn't we, Director?
    Mr. Carvajal. It absolutely does, Senator.
    Senator Ossoff. So you took no action----
    Mr. Carvajal. That did not----
    Senator Ossoff [continuing]. Director Carvajal?
    Mr. Carvajal [continuing]. Occur. If I did not take action, 
it is because it was not brought to my attention. That was a 
failure. That is why when it did get on my radar, we took the 
actions we took.
    Senator Ossoff. You took no action, and the buck stops with 
you. Correct?
    Mr. Carvajal. Correct.
    Senator Ossoff. Let me read you some more excerpts from 
reports of suicide when you were the Director of the Bureau of 
Prisons at this facility. ``The improper medical response 
represents gross indifference to preserving life and violates 
inmates' constitutional rights.'' November 2020. Would it not 
be brought to the attention of a Director of Bureau of Prisons 
that BOP investigators have found that there is gross 
indifference to the preservation of life and violations of 
constitutional rights in your facilities? If that is not the 
kind of thing that is brought to the attention of a Director of 
Bureau of Prisons, we have serious problems in this 
bureaucracy. Was that brought to your attention, November 2020?
    Mr. Carvajal. I do not recall, Senator, but that is 
precisely why we are making changes with the way that the 
Bureau is structured and looking at making changes, for that 
reason. It was an obvious breakdown in communication. There is 
much information in a large organization that comes to us, and 
I certainly expect people at that appropriate level to brief 
the Deputy Director and myself on these issues that should have 
been forefront of the radar. That is why we have taken the 
action we have taken.
    Senator Ossoff. November 14, 2021, the Associated Press 
(AP) reports that more than 100 BOP workers have been arrested, 
convicted, or sentenced for crimes since the start of 2019, 
including a warden indicted for sexual abuse, an associate 
warden charged with murder, officers taking cash to smuggle 
weapons, and supervisors stealing property. Your response?
    Mr. Carvajal. It is unacceptable. Their process of 
investigations, we have over 35,000 staff, 100 since 2019. Even 
one is unacceptable if it occurred and they are being 
investigated. But that is less than one-half percent of our 
staff. The majority of our staff do the right thing, Senator. 
When they do not----
    Senator Ossoff. Less than--100----
    Mr. Carvajal [continuing]. We expect them to be----
    Senator Ossoff. One hundred workers under your direction in 
less than 2 years, convicted or sentenced for crimes. Have you 
been successful in rooting out criminal activity at the Bureau 
of Prisons under your tenure?
    Mr. Carvajal. We absolutely think that is unacceptable. We 
expect people to follow the law. We take an oath. We are sworn 
law enforcement officers, and we have processes, and we work 
with outside entities to hold staff accountable. We take all 
allegations very seriously, but there is an investigative 
process that they must go through, and we respect those 
processes and support them.
    Senator Ossoff. Is the Bureau of Prisons able to keep 
female detainees safe from sexual abuse by staff? Yes or no.
    Mr. Carvajal. We strive to do that, Senator.
    Senator Ossoff. Is the Bureau of Prisons able--I am sure 
you strive. Is the Bureau of Prisons able to keep female 
detainees safe from sexual abuse by staff? Yes or no.
    Mr. Carvajal. Yes, we are.
    Senator Ossoff. You are.
    Mr. Carvajal. In those cases when things happen, we hold 
people appropriately accountable.
    Senator Ossoff. You are the Director at a time when one of 
your prisons is known to staff and inmates as a ``rape club.'' 
The Associated Press reports that, ``Inmates say they have been 
subjected to rampant sexual abuse by correctional officers, and 
even the warden, and were often threatened or punished when 
they tried to speak up.'' That is at Dublin. Is that true?
    Mr. Carvajal. A case is under investigation. I will not 
talk about the specifics, but I will tell you that it is 
unacceptable, and we expect people to be held accountable for 
breaking the law, if it occurred. We have taken measures to 
address those issues, and I find it completely unacceptable, as 
do most of the staff. But everyone has a responsibility. We 
cannot address something to that nature if we were unaware of 
it, and in those cases when we became aware of it, we should be 
doing something about it, and we are.
    Senator Ossoff. Is it true that one of your prisons is 
known to staff and inmates--this is Dublin--as a ``rape club''? 
Is it true?
    Mr. Carvajal. I do not know that----
    Senator Ossoff. You do not know?
    Mr. Carvajal [continuing]. Anyone calls it a ``rape club.''
    Senator Ossoff. This is the Associated Press reporting that 
staff and inmates at FCI Dublin called it ``rape club,'' and 
that ``inmates say they have been subjected to rampant sexual 
abuse by correctional officers and even the warden and were 
often threatened or punished when they tried to speak up. Do 
you know if that is true? Is that true?
    Mr. Carvajal. It is being investigated, and if anything----
    Senator Ossoff. I understand. My question is----
    Mr. Carvajal [continuing]. Is true, we are going----
    Senator Ossoff [continuing]. If it is true.
    Mr. Carvajal [continuing]. To hold people accountable.
    Senator Ossoff. Is it true?
    Mr. Carvajal. I do not know if it is true.
    Senator Ossoff. You do not know if it is true.
    Mr. Carvajal. It is being investigated. There is a process, 
Senator, that we respect, and it is going through. I do not go 
by what the Associated Press or anyone says. We have processes 
to investigate these things. It is unacceptable for any place 
to be known as a ``rape club'' or condone that. We do not 
expect it from our staff, and we certainly take the priority 
and the safety of all inmates in our custody, as well as our 
staff, completely seriously. That kind of language is 
unacceptable. We do not expect anyone to use it.
    Senator Ossoff. In 2021, the U.S. settled a lawsuit brought 
by 15 female inmates at a BOP facility in Florida--that is 
Coleman--who were raped, assaulted, and harassed by male 
officers. In one particularly harrowing account, an inmate said 
she was raped every Wednesday for 6 months at a warehouse where 
she had been assigned to work.
    Is the Bureau of Prisons able to keep female detainees safe 
from sexual abuse by assault? Your testimony remains yes?
    Mr. Carvajal. Yes.
    Senator Ossoff. Fifteen female inmates raped, assaulted, 
and harassed by male officers, a woman raped every Wednesday 
for 6 months at a warehouse, and your testimony today is that 
the Bureau of Prisons is able to keep female detainees safe 
from sexual assault.
    Mr. Carvajal. Senator, we have a complex mission, and if we 
could stop that from happening completely, we would. We would 
have zero suicides, no crimes would ever be committed, and we 
would absolutely not allow anything like that to happen. In 
those cases when they do, we hold people accountable. There is 
a process. I cannot speak to what happened at Coleman because I 
was not involved in it. I was not in the process of it. I am 
familiar with what you are speaking about. It makes me sick to 
see those things happen. We try our best to prevent them. When 
we can we do; and when we cannot, we do something about it. 
That is the best I can tell you. If I could have kept that from 
happening, Senator, it never would have happened.
    Senator Johnson. Director, a number of times you said you 
have a complex organization, and I do not doubt that. I do not 
think the Chairman doubts that. When you have a complex 
organization, you need reporting mechanisms in place to hold 
people accountable. I think what I find most troubling here is 
the fact that there were not those reporting systems in place. 
Apparently it is structural that these Regional Directors or 
these divisions are kind of fiefdoms of their own and 
apparently do not seem like they are responsible for reporting 
to the Director at all. That is a real problem. I think that 
the whole purpose of oversight is to understand what is 
happening, where the breakdowns are occurring so we can fix it.
    First of all, do you agree with that assessment, that there 
simply was not the reporting mechanism? I know the August 31, 
2020, report that I have been referring to, that is a 
memorandum for the Regional Director of the Southeast Region. 
But, something with those types of revelations, it ought to 
automatically go up to the top.
    When I ran an organization, I would always tell the people 
who reported to me, do not be making decisions that I really 
needed to be aware of, that I needed to make that decision, do 
not take that responsibility onto yourself. That is the whole 
job of being the boss, to get the tough ones, to hear the 
really bad news that needs to be corrected.
    To tie into what the Chairman has been talking about, is 
your testimony that you were literally completely out of the 
loop of all these reports to these regional divisions and that 
is the way the system is supposed to work?
    Mr. Carvajal. No, Senator, and I agree that that is one of 
the challenges. We are taking steps to look at reorganization 
or looking at--I think we have been stuck in a silo. I believe 
that is where some of these breakdowns occurred. We put a lot 
of trust in our senior level. These are Senior Executive 
Service members at the top of the leadership. They have 
delineated authority, and we expect them to use that good 
judgment----
    Senator Johnson. Listen, in any organization you delineate 
authority. But the person in charge, the people in charge--it 
is not just you. It is the Attorney General; it is people who 
serve in the Department of Justice.
    I have one follow-up question. In response to my question 
in terms of who did you discuss your testimony with, you did 
say an individual from the Office of Legislative Affairs. Is 
that the only person you discussed your testimony with? Inside 
the Department of Justice, was that the only person you 
discussed your testimony with?
    Mr. Carvajal. Yes, Senator. Me directly, my staff work with 
their staff. That is who I----
    Senator Johnson. You did not talk to anybody else inside 
the Department of Justice about the subpoena that was issued, 
whether or not you were going to appear here today or not, or 
about your testimony? You only spoke to one person in the 
Department of Justice? That is your testimony here.
    Mr. Carvajal. Yes, Senator. Not regarding this particular 
instance, this particular issue I worked through the Office of 
Legislative Affairs at the Department of Justice.
    Senator Johnson. What do you mean by ``this particular 
issue,'' about testifying here, cooperating with this Committee 
in terms of oversight?
    Mr. Carvajal. Senator, you asked me who I spoke to 
specifically about the subpoena.
    Senator Johnson. About the subpoena, OK. What about did you 
talk to anybody in the Department of Justice about the overall 
effort by this Subcommittee to investigate and conduct 
oversight over the Bureau of Prisons? Did you talk to anybody 
in the Department of Justice regarding that?
    Mr. Carvajal. I have not. My staff work closely with the 
Department of Justice, but I have not spoken to anybody 
directly about this Committee's work.
    Senator Johnson. It is almost willful ignorance. That is 
what I find disturbing. It almost appears to be willful 
ignorance. Do not want to know what is happening below me. Do 
not want to hear about rapes, do not want to hear about 
suicides. We have the structure set up. It is going to be the 
Regional Directors; it is their problem. That is what needs to 
change here. People have to be held accountable.
    Again, I appreciate you coming here. What I do not 
appreciate is how difficult it was to get you here. I do not 
appreciate, from my standpoint, the obstruction to this 
Committee's investigation and our oversight by somebody in the 
Department of Justice. I do not think it was this fellow from 
the Office of Legislative Affairs. I think somebody else or 
some other persons did not want this hearing to occur, did not 
want to cooperate with this investigation.
    I give kudos to the Chairman for pursuing this against 
resistance and obstruction. I think we see why this is so 
important. There are some serious problems. I am sorry, they 
have not been effectively addressed. They have not. I wish they 
had been. These are outstanding issues for years. Somebody has 
to be held accountable.
    Thank you, Mr. Chairman.
    Senator Ossoff. Thank you, Ranking Member Johnson, and, 
Director Carvajal, that is going to conclude the questions 
today.
    I want to close with this: I am sure I do not need to tell 
you that we are talking about human beings in the custody of 
the U.S. Government. We heard from a representative of the 
Federal Defender's Office: emaciated from lack of nutrition; 
with vermin crawling through their cells into which they are 
overcrowded and locked down for 23 hours a day with inadequate 
time to take a shower, call their family, or call their lawyer; 
people who have been convicted of no crime, pretrial detainees; 
inmates hanging themselves in Federal prisons, addicted to and 
high on drugs that flow into the facilities virtually openly; 
and as they hang and suffocate in the custody of the U.S. 
Government, there is no urgent response from members of the 
staff, year after year after year. It is a disgrace.
    For the answer to be other people deal with that, I got the 
report, I do not remember, it is completely unacceptable.
    Now, these issues are deeper than your leadership 
personally. This is clearly a diseased bureaucracy, and it 
speaks ill to our national values and our national spirit that 
we let this persist year after year and decade after decade. If 
this country is going to be real about the principles at the 
core of our founding and our highest ideals, there has to be 
change at the Bureau of Prisons, and it has to happen right 
now. With your departure and the arrival of a new Director, I 
hope that moment has arrived.
    With that, the hearing is adjourned.
    [Whereupon, at 12:43 p.m., the Subcommittee was adjourned.]

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