Failure to require employee health screenings, masking, social distancing and other safeguards led to one of the state’s largest single-site COVID-19 outbreaks this summer at the York County Jail, according to a new report initiated by the sheriff and county commissioners.

The jail operated on the false belief that once inmates entered the system with a negative COVID test they would be safe from infection, but that overlooked the risk of employees bringing the virus into the facility, which is exactly what happened, the report said. In all, 107 people – 48 inmates, 43 staff and 16 household members – were infected. COVID-19 was also cited as a factor in the death of one man infected during the jail outbreak.

Best practices have since been instituted, the county said in an accompanying news release.

“Importantly, the Maine Department of Corrections conducted a follow up inspection and determined that the York County Jail was fully compliant with the recommended COVID-19 protocols,” the release said. “In addition, prior to the outbreak and continuing through today, the appropriate COVID-19 protocols have been in place and followed in all other York County operations and facilities.”

County commissioners and Sheriff Bill King are independently reviewing the report and no immediate action is likely in response, the release said. It was unclear Friday whether any jail staff have or will be disciplined for shortcomings outlined in the report. Lt. Col. Michael Vitiello, the jail administrator, is currently on paid leave, according to County Manager Greg Zinser, though he did not say if that is related to the outbreak. Neither the sheriff nor the county commissioners would comment Friday beyond the report, the release said.

“While members of the media or the public may have questions at present on possible or future personnel decisions, it is important to remind everyone that those personnel matters are confidential pursuant to Maine law until a final decision has been reached and implemented,” the release said.

The county hired an independent investigator, attorney Leah Rachin of the firm Drummond Woodsum, and paid $35,202 for the investigation and 39-page report.

Among the report’s key findings are that while the jail did implement some COVID precautions prior to the outbreak, it largely failed to follow best practices recommended by the state Center for Disease Control and Prevention, Gov. Janet Mills and the state Department of Corrections. Specifically, the jail failed to prevent COVID from entering the building because it lacked proper health screenings for and communication with employees, and because it failed to implement best practices including mask mandates and social distancing.

The virus was introduced by a corrections officer who had attended the Aug. 7 Millinocket wedding subsequently linked to at least seven deaths and more than 170 cases of COVID around the state. The officer, who is not named in the report, is believed to have returned to work Aug. 13 and then worked about 10 shifts over five days while symptomatic.

“The evidence suggests that this corrections officer apparently did not believe that COVID-19 was a legitimate threat to public health and safety, which several witnesses report was a shared view by a number of corrections officers,” the report said.

Prior to the outbreak, the jail had taken some steps to respond to COVID, including halting in-person programming and visits, intensifying cleaning protocols and testing inmates before they entered the general population.

But other recommended protocols and procedures were not being followed. While staff were fitted for and issued N-95 masks last spring, they were told not to wear them, but to keep them in their lockers in case they were needed in the future.

Masks were prohibited for inmates other than when they were in the intake section of the jail. The investigation couldn’t find any written policy indicating masks were prohibited among staff, but several people said it was “universally understood” that corrections officers would not wear them on duty, the report said.

This stemmed from a belief that wearing masks would cause panic among inmates and that once inmates went through intake and received a negative COVID test, they were entering a “closed system” where the virus would not spread. This, however, overlooked the fact that jail employees could bring the virus in and proper employee screening was not done. A mask mandate for staff and inmates instituted since the outbreak has not resulted in widespread panic.

Prior to the outbreak, there were no daily screening and temperature checks of staff and little if any discussion about the need to social distance and to avoid getting together with friends and neighbors when off duty.

“This failure to address off-duty behavior is concerning given that there was a scare in the spring when it was discovered there was a gathering of corrections officers and that one of the participants was thought to have COVID,” the report said.

In addition to masking and employee screening, the jail also failed to follow social distancing recommendations for people in holding cells and waiting areas, stagger recreation times, and provide meals in cells or rearrange meal seating to provide more space prior to the August outbreak.

“The totality of the evidence suggests that the primary cause of the outbreak was the York County Jail’s failure to implement best practices that were being universally recommended by the CDC, Governor (Janet) Mills, and MDOC,” the report said.

In the wake of the outbreak, the jail has required all staff to wear masks and issued cloth face masks that inmates must wear when outside their cells. Staff are also required to perform daily self-screening evaluations that are kept on record at the jail and when numbers allow, staff are placed in cohorts to lower daily contact with others. Inmates have also been placed in cohorts and social distancing is being factored into meal times and recreation.

“It must be recognized that given the highly contagious nature of the virus, there is no guarantee that an outbreak would not have occurred even if the York County Jail had implemented best practices,” the report said. “However, the failure to implement guidance from many available resources … relating to masking, social distancing and staff health screening, was clearly a contributing factor to the introduction and spread of the virus at the York County Jail.”

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