11-FOIA-5082 Redacted Document With Bates

U.S.
Department of Homeland Security

Immigration and Customs Enforcement Office of Professional Responsibility Management Inspections and Detention Oversight Washington, DC 20536
Office of Detention Oversight

Follow-up Inspection
Enforcement and Removal Operations Atlanta Field Office Atlanta City Detention Center Atlanta, Georgia
August 25-26, 2010
FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law enforcement, management, and employee information. It has been written for the express use of the Department of Homeland Security to identify and correct management and operational deficiencies. In reference to OPR Directive 17006.1, issued 09/22/05; any disclosure, dissemination, or reproduction of this document, or any segments thereof, is prohibited without the approval of the Assistant Director, Office of Professional Responsibility.
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OFFICE OF PROFESSIONAL RESPONSIBILITY MISSION STATEMENT The Office of Professional Responsibility (OPR) is responsible for investigating allegations of employee misconduct impartially, independently, and thoroughly. OPR prepares timely and comprehensive reports of investigations for judicial or management action. OPR inspects and reviews Immigration and Customs Enforcement (ICE) field offices, operations and processes in order to provide executive management with an independent review of the agencys organizational health; and assesses the effectiveness and efficiency of the overall ICE mission.
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TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW. ICE NATIONAL DETENTION STANDARDS Admission and Release . Detainee Classification System.. Detention Files...... Environmental Health and Safety ............. Food Service.. Security Inspections . Staff-Detainee Communication Visitation . 1 1 2
3 3 3 4 4 5 5 6
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INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives include the evaluation of the welfare, safety and living conditions of detainees, and compliance with applicable laws, policies, regulations and procedures. In November 2008, ODO, formerly the Detention Facilities Inspection Group, conducted a Quality Assurance Review of the Atlanta City Detention Center (ACDC) in Atlanta, Georgia. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to ERO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Assistant Director, Office of Professional Responsibility.
INSPECTION TEAM MEMBERS

(b)(6), (b)(7)(C) (b)(6), (b)(7)(C)
Detention & Deportation Officer (Team Leader) ODO, OPR San Diego Special Agent ODO, OPR San Diego
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Office of Detention Oversight Augu OPR (b)(7)e
Atlanta City Detention Center ERO Atlanta
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OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material; Admission and Release; Detainee Classification System; Detainee Handbook; Detention Files; Disciplinary Policy; Environmental Health and Safety; Food Service; Hold Rooms in Detention Facilities; Hunger Strikes; Key and Lock Control; Medical Care; Post Orders; Recreation; Security Inspections; Special Management Unit; Staff-Detainee Communication; Suicide Prevention and Intervention; Terminal Illness, Advance Directives, and Death; Telephone Access; Tool Control; and Visitation. ODO staff identified 41 deficiencies during the Quality Assurance Review conducted in November 2008. During this Follow-up Inspection, ODO staff found 13 (32%) repeated deficiencies. Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at ACDC, to be noncompliant with the ICE NDS: Admission and Release Detainee Classification System Detention Files Environmental Health and Safety Food Service Security Inspections Staff-Detainee Communication Visitation ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards: Access to Legal Material Detainee Handbook Disciplinary Policy Hold Rooms in Detention Facilities Hunger Strikes Key and Lock Control Medical Care Post Orders Recreation Special Management Unit Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death Telephone Access Tool Control
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Office of Detention Oversight August 2010 OPR (b)(7)e
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ICE NATIONAL DETENTION STANDARDS

ADMISSION AND RELEASE
During the initial ODO inspection, two deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found uncorrected. ODO Initial Finding: In accordance with the ICE NDS, Admission and Release, section (III)(I), the FOD must ensure the officer completes a Report of Detainees Missing Property (Form I-387) when any newly-arrived detainee claims his or her property has been lost or left behind. Intergovernmental Service Agreement facilities shall forward the completed Form I-387 to ICE. ODO Follow-up Finding: A Lieutenant advised ODO, the facility does not use Form I-387 to document a detainees lost property when newly-arrived detainees claim their property has been lost or left behind.
DETAINEE CLASSIFICATION SYSTEM

During the initial ODO inspection, two deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found uncorrected. ODO Initial Finding: In accordance with the ICE NDS, Detainee Classification System, section (III)(B), the FOD must ensure the officer places all original paperwork relating to the detainees assessment and classification in his/her A-file (right side), with a copy placed in the detention file. ODO Follow-up Finding: The facility does not place copies of classification documents in the detention files until the detainee has left the facility and the file is closed.
DETENTION FILES
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found uncorrected. ODO Initial Finding: In accordance with the ICE NDS, Detention Files, section (III)(B), the FOD must ensure the detainees detention file contains either originals or copies of forms and other documents generated during the admissions process. ODO Follow-up Finding: The facility does not place a copy of the classification worksheet in the detainees detention file until the detainee has left the facility and the file is closed.
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ODO Initial Finding: In accordance with the ICE NDS, Detention Files, sections (III)(F)(d) and (e), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes the date and time returned, and the signature of the person returning the detention file. ODO Follow-up Finding: The facility maintains a log for recording the removal of detention files; however, the log does not have columns for recording the signature of the person returning the file, or the time the file was returned.
ENVIRONMENTAL HEALTH AND SAFETY

During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the following deficiency was found uncorrected. ODO Initial Finding: In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5)(c), the FOD must ensure, in addition to a general area diagram, the following information is provided on existing signs: emergency equipment locations. ODO Follow-up Finding: Various types of emergency equipment, such as flashlights, automated external defibrillators, fire extinguishers, self-sustained breathing apparatus, first aid kits, and biohazard kits are located throughout the facility; however, the facilitys evacuation/exit diagrams do not provide the locations of the emergency equipment.
FOOD SERVICE
During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found uncorrected. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(H)(3), the FOD must ensure all food service personnel (both staff and detainees) receive a pre-employment medical examination. The purpose of this examination is to exclude those who have a communicable disease in any transmissible stage or condition. The food service workers examination shall be conducted in sufficient detail to determine the absence of acute or chronic inflammatory condition of the respiratory system, acute or chronic infectious skin disease, communicable disease, and acute or chronic intestinal infection. ODO Follow-up Finding: According to the Lieutenant, all detainees are medically screened and cleared to work in the kitchen; however, food service employees contracted under Trinity Services Group (TSG) are only screened for tuberculosis. The Lieutenant stated TSG-contracted employees are not screened for infectious skin diseases, communicable diseases, or intestinal infections.
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SECURITY INSPECTIONS
During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up Inspection, the following three deficiencies were found uncorrected.
(b)(7)e
STAFF-DETAINEE COMMUNICATION
During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up Inspection, the following three deficiencies were found uncorrected. ODO Initial Finding: In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure ICE department heads conduct regular unannounced visits to the detention facilities living and activity areas to encourage
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informal communication between staff and detainees, and to observe living and working conditions. These visits must be documented. ODO Follow-up Finding: ODO reviewed ACDCs visitor register. Signatures of ICE department heads are not noted. ICE department heads are not conducting regular unannounced visits to the facility. ODO Initial Finding: In accordance with Change Order, ICE NDS, Staff-Detainee Communication, dated June 15, 2007, the FOD must ensure ICE officers conducting liaison visits document the occurrences and findings on the Facility Liaison Visit Checklist at least once a week in all facilities. ODO Follow-up Finding: ICE officers conducting liaison visits do not properly or routinely document occurrences and findings on the Facility Liaison Visit Checklist. Over a period of three months, only one officer filled out a checklist, but did not complete all of its sections. ODO Initial Finding: In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all detainee requests are recorded in a log specifically designed for that purpose. ODO Follow-up Finding: ACDC staff routinely collects ICE request forms, and forwards those requests to ICE. ICE staff does not retrieve detainee request forms directly from detainees. A review of ACDCs computer-generated detainee request log indicated ERO does not always provide answers to detainees within 72 hours.
VISITATION
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found uncorrected. ODO Initial Finding: In accordance with the ICE NDS, Visitation, section (III)(H)(1), the FOD must ensure the facilitys written rules specify time limits for each visit: 30 minutes minimum, under normal conditions. ODO Follow-up Finding: ODO confirmed ACDC provides general visiting privileges every Wednesday and Sunday from 8:30 a.m. to 9 p.m. All general visits are limited to 20 minutes each.
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Office of Detention Oversight August 2010 OPR 200901313
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U.S. Department of Homeland Security


Quality Assurance Review
Enforcement and Removal Operations Miami Field Office Baker County Detention Center MacClenny, Florida
July 27-29, 2010 ________________________________

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OFFICE OF PROFESSIONAL RESPONSIBILITY MISSION STATEMENT The Office of Professional Responsibility (OPR) is responsible for investigating allegations of employee misconduct impartially, independently and thoroughly. OPR prepares timely and comprehensive reports of investigations for judicial or management action. OPR inspects and reviews Immigration and Customs Enforcement (ICE) field offices, operations and processes in order to provide executive management with an independent review of the agencys organizational health, and assesses the effectiveness and efficiency of the overall ICE mission.
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QUALITY ASSURANCE REVIEW BAKER COUNTY DETENTION CENTER MIAMI FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization. Inspection Team Members. BACKGROUND History OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed.. Admission and Release Detainee Grievance Procedures Detention Files Environmental Health and Safety.. Food Service. Medical Care. Recreation. Staff-Detainee Communication Use of Force............ 1 1
5 5
7 8 9 10 12 13 14 15 16 17
APPENDIX ACRONYMS SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS A B
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INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO inspected the Baker County Detention Center (BCDC), in MacClenny, Florida, on July 27-29, 2010. ODO reviewed the processes employed at DCDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Assistant Director, Office of Professional Responsibility.

Detention and Deportation Officer (Team Leader) ODO, Headquarters
(b)(6), (b)(7)(C)
Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector Contract Inspector
ODO, Headquarters MGT of America MGT of America MGT of America MGT of America
Office of Detention Oversight July 2010 OPR (b)(7)e
Baker County Detention Center ERO Miami
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BACKGROUND
HISTORY
ICE utilizes the BCDC under an Intergovernmental Service Agreement. The facility, which opened June 4, 2009, is owned and operated by the Baker County Sheriffs Office. BCDC is authorized to house adult male and female ICE detainees over 72 hours. ICE detains only classification level three detainees at the BCDC. Medical care is provided by the Armor Correctional Health Care. ICE staff is not assigned to the BCDC on a permanent basis. The ERO Jacksonville, Florida is responsible for case management and all ICE related issues at BCDC. In May 2010, ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the 2000 NDS at BCDC. The final review received an overall rating of Acceptable.
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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed supervisory and nonsupervisory ICE and DCDC staff. Overall, all staff expressed good morale levels and excellent working relationships between the two agencies.
DETAINEE RELATIONS
ODO interviewed 13 detainees at BCDC to determine their concerns and to identify areas of possible noncompliance with the ICE NDS. ODO encouraged detainees to express their opinions about the facility, staff, ICE personnel, and the progress of their cases. This often results in examples and anecdotes, and in some cases detainees view these interviews as a self-serving opportunity. ODO cautions, due to the nature of the information obtained, it is not possible to verify each statement. Nonetheless, it is important to obtain information from the detainees point of view. Generally, detainees stated they were treated with respect and dignity by both ICE and BCDC staff. The majority of the detainees knew their Deportation Officer and stated ICE is available at BCDC on a regular basis. Some detainees complained about the food, citing small portions and lack of taste.
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This inspection was based on the 2000 NDS. The following 21 standards were reviewed: Access to Legal Material Admission and Release Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Medical Care Population Counts Recreation Special Management Unit Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Use of Force Visitation No deficiencies were noted in the following 12 standards: Access to Legal Material Detainee Handbook Disciplinary Policy Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Population Counts Special Management Unit Suicide Prevention and Intervention Telephone Access Terminal Illness, Advanced Directives, and Death Visitation As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.
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ADMISSION AND RELEASE (AR)

ODO reviewed the Admission and Release standard at the BCDC to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed detention files, forms, policies and procedures, and interviewed detainees and staff assigned to admission and release processing duties. Fifteen detainee admission files were reviewed by ODO. ICE is inconsistent in providing an Order to Detain or Release Aliens (Form I-203 or I-203a) for each detainee and BCDC is inconsistent in ensuring all required documentation is filed in the detainees detention file including the BCDC classification interview form and receipt for personal property, funds and valuables (Deficiency AR-1). ODO reviewed ten detainee files for detainees who are no longer in custody at BCDC. ICE is inconsistent in providing an Order to Detain or Release Aliens or Record of Persons and Property Transferred (Form I-216) and BCDC is inconsistent in ensuring all required documentation is completed and filed in the detainees detention file including return of personal property and funds and valuables (Deficiency AR-2).
STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(H) the FOD must ensure an Order to Detain or Release Aliens (Form I-203 or I-203a) bearing an appropriate official signature must accompany the newly arriving detainees. IGSA facilities must forward the detainees A-file or temporary work file to the ICE office with jurisdiction. Staff must prepare specific documents in conjunction with each new arrival to facilitate timely processing, classification, medical screening, accounting of personal effects and reporting of statistical data. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(J), the FOD must ensure the staff completes certain procedures before any detainees release, removal or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting; returning personal property; and reclaiming facility issued clothing, bedding, etc.
Office of Detention Oversight July OPR (b)(7)e
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DETAINEE GRIEVANCE PROCEDURES (DGP)

ODO reviewed the Detainee Grievance Procedures standard at the BCDC to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear or reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, accordance with the ICE NDS. ODO reviewed the grievance policy, logbooks, detainee handbook and interviewed staff and detainees. ODO observed copies of completed grievance forms are not placed in detainees detention files (DGP-1).

DEFICIENCY DGP- 1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance will remain in the detainees detention file for at least three years.
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DETENTION FILES (DF)

ODO reviewed the Detention Files standard at the BCDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed active and inactive detention files, facility policies and interviewed staff. Detention files do not consistently include classification worksheets, detainee personal property inventory or property receipt (Deficiency DF-1), or documents generated during the detainees time in the facility (Deficiency DF-2). Grievance documentation is maintained in a separate file by the grievance officer (Deficiency DF-3). The facility does not maintain a logbook to record when detention files are removed from the storage cabinets (Deficiency DF-4).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III), the FOD must ensure the detention file contains the classification level and any copies of receipts for items issued to or surrendered by the detainee. It must also document adverse behavior, special requests and complaints, and other information considered appropriate for the record. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, sections (III)(B)(2) and (C)(1), the FOD must ensure the detainees detention file contains documents generated during the detainees time at the facility. During the course of the detainees stay at the facility, staff must add documents associated with normal operations to the detainees detention file without prior approval: special requests; any property receipts or baggage checks closed-out during the detainees stay; disciplinary forms; grievances, complaints, and the dispositions of the same; all forms associated with disciplinary and or administrative segregation; strip search forms; and other approved documents, such as staff reports about detainees behavior or attitude. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(C)(1)(d), the FOD must ensure during the course of the detainees stay at a detention facility, the staff will add documents associated with normal operations to the detainees detention files without prior approval. Examples of such documents include grievances, complaints and associated dispositions.
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DEFICIENCY DF-4 In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure the detention file logbook must contain, at a minimum, the following fields: detainees name and A-file number; date and time removed; reason for removal; signature, title and department of person removing the file; date and time returned and signature of the person returning the file.
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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)

ODO reviewed the Environmental Health and Safety standard at the BCDC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies, documentation of inspections, hazardous chemical management, generator testing, and fire drills. BCDC does not conduct emergency key drills (Deficiency EH&S-1). Biweekly generator tests are conducted; however, the tests last only twenty minutes instead of the required hour. Quarterly testing and servicing of generators is not performed by an external service company (Deficiency EH&S-2). Barbering takes place in the multipurpose room. The area did not have a lavatory, water or all equipment necessary to maintain sanitary procedures (Deficiency EH&S-3).

EFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure emergency key drills are included in each fire drill, and timed. Emergency keys must be drawn and used by the appropriate staff to unlock one set of emergency exit doors, not in daily use. The National Fire Protection Association recommends a limit of four and one-half minutes for drawing keys and unlocking emergency doors. DEFICIENCY EH&S-2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure bi-weekly tests of the emergency electrical generator last for one hour. The emergency generator must also receive quarterly testing and servicing from an external generator-service company. DEFICIENCY EH&S-3 In accordance with ICE NDS, Environmental Health & Safety, sections (III)(P)(1) and (III)(P)(2), the FOD must ensure barber operations are located in a separate room not used for any other purpose. At least one lavatory must be provided and both hot and cold water must be available. Each shop must be provided with all equipment and facilities necessary for maintaining sanitary procedures of hair care.
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FOOD SERVICE (FS)

ODO reviewed the Food Service standard at the BCDC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed policy and relevant documentation. The temperature of food transported to housing units was 120.9 degrees, below the required 140 degrees (Deficiency FS-1). ODO discovered leftover meat retained longer than the maximum of 24 hours (Deficiency FS-2). The three-compartment sink was not labeled to identify sections for washing, rinsing, and sanitizing (Deficiency FS-3). Food items were not stored at least two inches from the wall (Deficiency FS-4).

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section (III)(C)(2)(a)(3), the FOD must ensure food transported to satellite food service areas meets sanitary guidelines and hot foods are maintained at a temperature of 140 degrees F. DEFICIENCY FS-2 In accordance with ICE NDS, Food Service, section (III)(D)8), the FOD must ensure prepared food items which have not been placed on the serving line are retained for no more than 24 hours. DEFICIENCY FS-3 In accordance with ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least three labeled compartments is available for manually washing, rinsing, and sanitizing utensils and equipment. DEFICIENCY FS-4 In accordance with ICE NDS, Food Service, section (III)(J)(3)(e), the FOD must ensure food items are stored at least two inches from the walls.
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MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at the BCDC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 30 medical records, inspected staff clinical files and training records and interviewed staff. A review of ten training records for detention staff revealed all do not have current first aid and cardiopulmonary resuscitation (CPR) certification (Deficiency MC-1). When a detainee is transferred to another detention facility, the detainees medical records are not transferred with the detainee unless requested (Deficiency MC-2). Staff informed ODO medical information is forwarded by way of Medical Summary of Federal Prisoner/Alien in Transit forms in sealed, properly marked envelopes.
STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS

DEFICIENCY MC -1 In accordance with ICE NDS, Medical Care, section (III)(H), the FOD must ensure staff are trained to respond to health-related emergencies within a four-minute response time. Training must include the administration of first aid and cardiopulmonary resuscitation (CPR). DEFICIENCY MC- 2 In accordance with ICE NDS, Medical Care, section (III)(N), the FOD must ensure when a detainee is transferred to another detention facility, the detainees medical records, or copies, are transferred with the detainee. These records must be placed in a sealed envelope or other container labeled with the detainees name and A-number and marked MEDICAL CONFIDENTIAL.
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RECREATION (R)
ODO reviewed the Recreation standard at the BCDC to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO inspected the recreation areas, reviewed the policies and documentation and interviewed staff and detainees.
(b)(7)e
(b)(7)e
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STAFF-DETAINEE COMMUNICATION (SDC)

ODO reviewed the Staff-Detainee Communication standard at the BCDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed policy and documentation and interviewed detainees and staff. ODO was informed the AFOD does not interview detainees or visit all designated areas during visits to the facility (Deficiency SDC-1). Procedures are not in place for documenting visits conducted by ICE staff (Deficiency SDC-2). Although ICE staff makes regular visits to BCDC; the Facility Liaison Visit Checklist is not completed (Deficiency SDC-3). BCDC has procedures for detainees to submit requests to ICE but a log is not maintained for the purpose of recording the date ICE received the request and the date the request is returned to the detainee (Deficiency SDC-4).

DEFICIENCY SDC-1 In accordance with ICE NDS, Staff-Detainee Communication, section (lll)(A)(1) the FOD must ensure and document the ICE officer in charge, assistant officer in charge and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and informally observe living and working conditions. Visits must include but not be limited to housing units, food service, recreation, and Special Management Units (SMU). While visiting the SMU, the detainees must be interviewed, living conditions observed, and housing records reviewed. DEFICIENCY SDC-2 In accordance with ICE NDS, Staff Detainee Communication, section (III)(A)(2)(b), the FOD must have procedures for documenting visits. DEFICIENCY SDC-3 In accordance with ICE DRO Change Notice, NDS Staff/Detainee Communication Model Protocol dated June 15, 2007, the FOD must ensure model protocol forms are completed documenting facility liaison visits. DEFICIENCY SDC-4 In accordance with ICE NDS, Staff-Detainee Communication, section (lll)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose.
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USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at the BCDC to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed policies, use of force documentation, and inspected equipment and inventories. Staff was interviewed to determine their level of knowledge and understanding of the circumstances warranting immediate and calculated uses of force.
(b)(7)e
(b)(7)e
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APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DSCU EABM EADM EOIR ERO FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS PBNDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU TAR TB American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Enforcement and Removal Operations Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets Performance Based National Detention Standards National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis
UDC
Unit Disciplinary Committee

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APPENDIX B
SUMMARY OF POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(H) the FOD must ensure an Order to Detain or Release Aliens (Form I-203 or I-203a) bearing an appropriate official signature must accompany the newly arriving detainees. IGSA facilities must forward the detainees A-file or 8 temporary work file to the ICE office with jurisdiction. Staff must prepare specific documents in conjunction with each new arrival to facilitate timely processing, classification, medical screening, accounting of personal effects and reporting of statistical data. In accordance with the ICE NDS, Admission and Release, section (III)(J), the FOD must ensure the staff completes certain procedures before any detainees release, removal or transfer from the facility. Necessary 8 steps include completing and processing forms, closing files, fingerprinting; returning personal property; and reclaiming facility issued clothing, bedding, etc. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a 9 copy of the grievance will remain in the detainees detention file for at least three years.
Admission and Release
AR-1
AR-2
Detainee Grievance Procedures
DGP-1
19
ICE.11.5082.000033
DETENTION STANDARD
Detention Files
DF-1
Detention Files
DF-2
Detention Files
DF-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (III), the FOD must ensure the detention file contains the classification level and any copies of receipts for items issued to or 10 surrendered by the detainee. It must also document adverse behavior, special requests and complaints, and other information considered appropriate for the record. In accordance with the ICE NDS, Detention Files, sections (III)(B)(2) and (C)(1), the FOD must ensure the detainees detention file contains documents generated during the detainees time at the facility. During the course of the detainees stay at the facility, staff must add documents associated with normal operations to the detainees detention file without prior approval: special requests; any 10 property receipts or baggage checks closed-out during the detainees stay; disciplinary forms; grievances, complaints, and the dispositions of the same; all forms associated with disciplinary and or administrative segregation; strip search forms; and other approved documents, such as staff reports about detainees behavior or attitude. In accordance with the ICE NDS, Detention Files, section (III)(C)(1)(d), the FOD must ensure during the course of the detainees stay at a detention facility, the staff will add documents 10 associated with normal operations to the detainees detention files without prior approval. Examples of such documents include grievances, complaints and associated dispositions.
Office of Detention Oversight July (b)(7)e OPR
20
ICE.11.5082.000034
DETENTION STANDARD
Detention Files
DF-4
Environmental Health and Safety
EH&S-1
EH&S-2
EH&S-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure the detention file logbook must contain, at a minimum, the following fields: detainees name and A-file number; date and time 11 removed; reason for removal; signature, title and department of person removing the file; date and time returned and signature of the person returning the file. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure emergency key drills are included in each fire drill, and timed. Emergency keys must be drawn and 12 used by the appropriate staff to unlock one set of emergency exit doors, not in daily use. The National Fire Protection Association recommends a limit of four and one-half minutes for drawing keys and unlocking emergency doors. In accordance with ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure bi-weekly tests of the emergency electrical generator last for one hour. 12 The emergency generator must also receive quarterly testing and servicing from an external generator-service company. In accordance with ICE NDS, Environmental Health & Safety, sections (III)(P)(1) and (III)(P)(2), the FOD must ensure barber operations are located in a separate room not used for any other purpose. At least one 12 lavatory must be provided and both hot and cold water must be available. Each shop must be provided with all equipment and facilities necessary for maintaining sanitary procedures of hair care.
21
ICE.11.5082.000035
DETENTION STANDARD
Food Service
FS-1
Food Service
FS-2
Food Service
FS-3
Food Service
FS-4
Medical Care
MC-1
Medical Care
MC-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Food Service, section (III)(C)(2)(a)(3), the FOD must ensure food transported to satellite food service areas meets 13 sanitary guidelines and hot foods are maintained at a temperature of 140 degrees F. In accordance with ICE NDS, Food Service, section (III)(D)8), the FOD must ensure prepared food items which 13 have not been placed on the serving line are retained for no more than 24 hours. In accordance with ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least 13 three labeled compartments is available for manually washing, rinsing, and sanitizing utensils and equipment. In accordance with ICE NDS, Food Service, section (III)(J)(3)(e), the FOD 13 must ensure food items are stored at least two inches from the walls. In accordance with ICE NDS, Medical Care, section (III)(H), the FOD must ensure staff are trained to respond to health-related emergencies within a 14 four-minute response time. Training must include the administration of first aid and cardiopulmonary resuscitation (CPR). In accordance with ICE NDS, Medical Care, section (III)(N), the FOD must ensure when a detainee is transferred to another detention facility, the detainees medical records, or copies, are transferred with the detainee. 14 These records must be placed in a sealed envelope or other container labeled with the detainees name and Anumber and marked MEDICAL CONFIDENTIAL.
22
ICE.11.5082.000036
DETENTION STANDARD
PAGE
Recreation
R-1
(b)(7)e
15
Staff-Detainee Communication
SDC-1
SDC-2
SDC-3
SDC-4
Detainee Communication, section (lll)(A)(1) the FOD must ensure and document the ICE officer in charge, assistant officer in charge and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and informally observe living and working conditions. Visits must include but not be limited to housing units, food service, recreation, and Special Management Units (SMU). While visiting the SMU, the detainees must be interviewed, living conditions observed, and housing records reviewed. In accordance with ICE NDS, Staff Detainee Communication, section (III)(A)(2)(b), the FOD must have procedures for documenting visits. In accordance with ICE DRO Change Notice, NDS Staff/Detainee Communication Model Protocol dated June 15, 2007, the FOD must ensure model protocol forms are completed documenting facility liaison visits. In accordance with ICE NDS, StaffDetainee Communication, section (lll)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose.
16
16
16
16
Office of Detention Oversight July 2 (b)(7)e OPR
23
ICE.11.5082.000037
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS PAGE
Use of Force
UOF-1
(b)(7)e
17
Use of Force
UOF-2
(b)(7)e
17
24
ICE.11.5082.000038

Immigration and Customs Enforcement Office of Professional Responsibility Management Inspections and Detention Oversight Washington, DC 20536-5501

Enforcement and Removal Operations New York Field Office Bergen County Jail Hackensack, New Jersey
November 30 December 2, 2010 ________________________________

ICE.11.5082.000039
QUALITY ASSURANCE REVIEW BERGEN COUNTY JAIL NEW YORK FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY.. INSPECTION PROCESS Report Organization.. Inspection Team Members.................................................................... OPERATIONAL ENVIRONMENT Internal Relations....... Detainee Relations..... ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed.. Access to Legal Material..... Admission and Release...... Detainee Classification System...... Detention Files..... Detainee Grievance Procedures.......... Environmental Health and Safety....... Food Service....... Funds and Personal Property....... Issuance and Exchange of Clothing, Bedding, and Towels............ Medical Care..... Staff-Detainee Communication....... Telephone Access........ Visitation....... 1
3 3
4 5
6 7 9 10 11 12 13 15 17 18 19 21 23 25
APPENDIX ACRONYMS A
ICE.11.5082.000040
EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO) conducted a Quality Assurance Review (QAR) of the Bergen County Jail (BCJ) in Hackensack, New Jersey. The QAR took place during the period of November 30 December 2, 2010. BCJ was built in 1963 and underwent a major renovation in 2000. The ICE Enforcement and Removal Operations (ERO) New York Field Office Director (FOD) utilizes BCJ under an intergovernmental service agreement (IGSA) to house ICE male and female detainees of all classification levels for periods in excess of 72 hours. The IGSA began in March 2009. ICE began housing detainees at BCJ on September 1, 1996. Medical care is contracted through the Correctional Health Services, which provides doctors and billing services. Health care is provided by Bergen County. Food service is contracted through Aramark. The FOD does not have staff permanently assigned to BCJ. Deportation Officers and one Immigration Enforcement Agent, who are assigned to the FOD, visit BCJ on a regular basis. BCJ employs 287 correctional officers and 73 management and administrative staff. BCJ has contracted space for approximately 146 detainees. On November 30, 2010, the facility housed 119 male detainees. BCJ currently maintains accreditation with the National Correctional Commission Health Care Services (NCCHC), Certificate and Core Certification with the American Correctional Association (ACA), and New Jersey Department of Corrections Annual Inspection Compliance certification. In February 2007, a Focus Review (FR) was conducted by the former ICE OPR Detention Facilities Inspection Group (DFIG) at BCJ. The FR noted concerns relating to employee training, sanitation issues, and access to medical care. Deficiencies were discovered in the Medical Care, Staff-Detainee Communication, and Telephone Access areas of the ICE NDS. The report also cited unsanitary conditions in the male detainee housing units at BCJ. ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the ICE NDS at BCJ in February 2010. BCJ received an overall rating of acceptable, and was found to be compliant in all of the 37 standards reviewed. During its current inspection, ODO reviewed a total of 26 NDS areas; 13 in full compliance and 13 with deficiencies. The review of the 13 standards resulted in the discovery of 35 deficiencies, summarized as follows: Access to Legal Material (4), Admission and Release (2), Detainee Classification System (2), Detainee Grievance Procedures (3), Detention Files (1), Environmental Health and Safety (3), Food Service (4), Funds and Personal Property (2), Issuance and Exchange of Clothing, Bedding and Towels (2), Medical Care (3), Staff-Detainee Communication (5), Telephone Access (3), and Visitation (1). ODO identified a conflict between ICE policy and the medical services provisions documented in the current IGSA. ODO found ICE detainees at the facility are charged a co-payment for medical services and prescriptions. An ICE policy memorandum, dated May 18, 2001 and entitled Fees for Services, Reimbursement under Intergovernmental Service Agreements states, service fees or co-payments are not permitted without the authority of Federal law. Likewise, pill fees or over-the-counter items directed by a medical authority cannot be
Office of Detention Oversight December 2010 OPR (b)(7)e Bergen County Jail ERO New York
ICE.11.5082.000041
charged to ICE detainees regardless of any authority the facility may have to charge other nonfederal detainees or prisoners. BCJ has a fully functioning medical unit and an on-site dental facility to address detainee health care. All medical staff are properly licensed and certified. FOD management staff does not conduct regular unannounced visits to the facilitys housing and activity areas; however, nonsupervisory personnel visit three times per week to address detainee requests. Detainee requests are not maintained in a logbook as required by the Staff-Detainee Communication of the NDS. Detainees have the opportunity to file requests to ICE; however, a written procedure for ICE detainees to submit written questions, requests or concerns to ICE staff does not exist at BCJ. Detainees have the opportunity to file informal and formal grievances. Grievances are reviewed by supervisors at BCJ, but no grievance committee is in place for ICE detainees to submit the paperwork to the facilitys committee. BCJ has not implemented procedures for identifying and handling emergency grievances at the facility. ODO discovered the facility does not maintain detention files for any detainees. At the closeout brief, BCJ was advised of the deficiency. ODO discovered ICE detainees are not provided socks and undergarments; those items must be purchased through the facility commissary. This is in direct conflict with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels. ODO noted several safety concerns during a review of the Environmental Health and Safety and Food Service standards. The master index of Material Safety Data Sheets (MSDS) does not include storage locations of hazardous materials and no documentation of a semi-annual review was found. The BCJ food service area has two knives permanently tethered to work tables stored in open holders. This represents a safety concern as direct supervision of workers at all times is not possible given the size of the area. Invoices were presented documenting pest extermination services; however, evidence of rodent infestation was observed in the dry storage area. No other areas of concern were noted in the NDS and they appeared to be well-managed. This report includes descriptions of all the deficiencies and refers to the specific, relevant NDS. The report will be provided to ERO to develop corrective actions to resolve the 35 deficiencies.
Office of Detention Oversight December 2010 OPR (b)(7)e
Bergen County Jail ERO New York
ICE.11.5082.000042
INSPECTION PROCESS
The ODO primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS) or the Performance Based National Detention Standards (PBNDS), as applicable. In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at BCJ to determine compliance with current policies and detention standards. Prior to the inspection, ODO collected and analyzed relevant allegations and detainee information from multiple ICE databases, including the Joint Integrity Case Management System (JICMS), the ENFORCE Alien Booking Module (EABM) and Alien Removal Module (EARM). ODO also gathered facility facts and inspection-related information from ERO headquarters staff to best prepare for the site visit at BCJ.
REPORT ORGANIZATION
This report contains a detailed synopsis of those NDS areas reviewed by ODO that were found to be deficient in at least one aspect of the standard. Instances in which detention standards and/or policies are not being adhered to are reported as deficiencies. When possible, ODO will provide the reader with contextual and quantitative information that is relevant to the cited standard. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. ODO strives to ensure that its detention facility inspection reports convey pertinent and useful feedback to best enable expeditious corrective actions where needed, and to assist in the ongoing process of incorporating best practices across the spectrum of nation-wide detention facility operations. This report documents inspection results, serves as an official record, and is intended to provide ICE and detention facility management with a comprehensive evaluation of compliance with policies and detention standards. Comments and questions regarding the report findings should be forwarded to the OPR Deputy Division Director, Office of Detention Oversight.

Special Agent (Team Leader) Special Agent Detention and Deportation Officer Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
(b)(6), (b)(7)(C)
Office of Detention Oversight Dece OPR (b)(7)e
ICE.11.5082.000043
INTERNAL RELATIONS
ODO conducted interviews with ICE and facility management staff. Both ICE and BCJ lower level staff expressed the morale of employees is good overall. ODO observed high tensions between executive level BCJ and ICE management. BCJ management staff indicated the relationship is in need of serious improvement with upper level ICE management. ICE staff stated sometimes BCJ staff is selective with respect to which ICE detainee is admitted to BCJ and BCJ does not always process ICE detainees for admission in the order in which Immigration Enforcement Agents (IEAs) arrive at the facility. ICE management stated morale would improve if additional ICE personnel were available to help reduce mandatory overtime assignments for current ERO personnel. ICE management claimed insufficient bed space in the ERO New York Field Office is a critical concern. ICE management also expressed a need for a contractor to perform transportation services for the ERO New York Field Office. ICE management also cited two factors that contribute to extended periods of detention for ICE detainees. First, the number of Immigration Judges assigned to hear immigration cases has not been proportionate with the increased number of detainees placed in removal proceedings. ICE management noted the detainee population was at approximately 376 in December, 2007 compared to a current population of approximately 800. Two Immigration Judges were assigned to immigration cases since 2007 until a third Immigration Judge was assigned as of November, 2010. The second factor cited by ICE management is the unusually high number of petitions for stays of removal submitted by ICE detainees before the Second Circuit Court of Appeals. Detainees who file a petition for a stay of removal in the Second Circuit Court of Appeals are always affirmatively approved. Detainees who are granted judicial stays of removal may become eligible for temporary release from ICE custody. ICE personnel stated they could benefit from more training for required duties. The ERO New York Field Office receives the detainee request forms in writing and by telephone, and responses are provided to ICE detainees in writing. Immigration Enforcement Agents (IEAs) attempt to address detainee requests and, if IEAs are unable to resolve the request, requests are referred to Deportation Officers (DOs) for resolution.
ICE.11.5082.000044
DETAINEE RELATIONS
ODO interviewed a total of ten detainees. Several detainees complained about the lack of sufficient undergarments, stating they are not issued undergarments during the Bergen County Jail (BCJ) intake process. Detainees further stated undergarments must be purchased through the BCJ commissary. Several detainees stated they are charged $15 for medical services and $2 per prescribed drug. ODO reviewed the aforementioned complaint and determined that the complaints are founded per the IGSA contract. Several detainees complained about their access to the law library stating they are permitted access to the library only once a week and less than one hour per visit. ODO reviewed the aforementioned complaint and determined the complaints are substantiated. Detainees stated the portions of food served for meals were small and inadequate. Several detainees stated that they are not provided religious services and meals based upon their religious practices. ODO reviewed the aforementioned complaints and determined the complaints are unfounded. Several detainees stated they have heard discriminating statements made towards them and other detainees by staff. A letter of complaint was provided to ODO on November 30, 2010 by an ICE detainee and forwarded to the Joint Intake Center (JIC) for investigation.
ICE.11.5082.000045

A total of 26 National Detention Standards were reviewed during the ODO inspection. The following 13 areas were found to be deficient with respect to adherence to the ICE NDS, as required: Access to Legal Material Admission and Release Detainee Classification System Detainee Grievance Procedures Detention Files Environmental Health and Safety Food Service Funds and Personal Property Issuance and Exchange of Clothing, Bedding, and Towels Medical Care Staff-Detainee Communication Telephone Access Visitation The following 13 standards were found to be well-managed: Detainee Handbook Disciplinary Policy Hold Rooms in Detention Facilities Hunger Strikes Population Counts Post Orders Recreation Religious Practices Special Management Unit (Administrative Segregation) Special Management Unit (Disciplinary Segregation) Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death Use of Force As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.
ICE.11.5082.000046
ACCESS TO LEGAL MATERIAL (ALM)

ODO reviewed the Law Libraries and Legal Material standard at BCJ to determine if detainees have access to a law library, legal materials, and document copying equipment to facilitate the preparation of legal documents, in accordance with the NDS. ODO observed the law library, interviewed staff, and reviewed policies and the detainee handbook. BCJ has a dedicated law library for detainees to use. The law library did not contain all the materials listed in ALM-Appendix A. In addition, the facility did not have a posted list of its holdings in the law library. ODO inspected BCJ law librarys computers and found that they did not have Lexis-Nexis software installed; however, each dorm that housed ICE detainees did have a computer with Lexis-Nexis software but did not meet the requirements of a law library according to the NDS (Deficiency ALM-1). ODO recommends BCJ equip the dorms with the law library materials or install Lexis-Nexis material on each computer located in the law library. The law library does not permit the detainees usage of the law library for a minimum of five hours per week. Detainees can only use the library upon request and only for 45 minutes or less. It was reported by law library staff that ICE detainees primarily utilize the law library to make phone calls for legal services (Deficiency ALM-2). According to BCJ staff, BCJ does not provide assistance to indigent detainees who request to mail items via certified mail (Deficiency ALM-3). The law library and the detainee handbook do not provide procedures for requesting legal reference material not maintained in the law library or procedures for notifying a designated employee that library materials are missing or damaged. In addition, the Notice to Detainees policies and procedures are not posted in the law library along with the list of the law librarys holdings (Deficiency ALM-4). ODO recommends this information be posted and be added to the detainee handbook.

DEFICIENCY ALM-1 In accordance with the NDS, Access to Legal Material, Section (III)(C), the law library shall contain the materials listed in Attachment A. ICE shall provide an initial set of these materials. The facility shall post a list of its holdings in the law library. DEFICIENCY ALM-2 In accordance with the NDS, Access to Legal Material, Section (III)(G), the law library shall devise a flexible schedule to permit all detainees, regardless of housing or classification, to use the law library on a regular basis. Each detainee shall be permitted to use the law library for a minimum of five hours per week. DEFICIENCY ALM-3 In accordance with the NDS, Access to Legal Material, Section (III)(P), the facility shall provide assistance to any unrepresented detainee who requests a notary public, certified mail, or other
Office of Detention Oversight Dece OPR (b)(7)e Bergen County Jail ERO New York
ICE.11.5082.000047
such services to pursue legal matters, and if the detainee is unable to meet the need through a family, member, friend, or community organization. DEFICIENCY ALM-4 In accordance with the NDS, Access to Legal Material, Section (III)(Q), the detainee handbook or equivalent, shall provide detainees with the rules and procedures governing access to legal materials, including the following information: 1) that the law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedure for requesting access to the law library; 4) the procedure for requesting additional time in the law library (beyond the 5 hours per week minimum); 5) the procedure for requesting legal reference materials not maintained in the law library; 6) the procedure for notifying a designated employee that library material is missing or damaged. These policies and procedures shall also be posted in the law library along with a list of the law librarys holdings.
ICE.11.5082.000048

ODO reviewed the Admission and Release standard at BCJ to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO interviewed staff and detainees, and reviewed detention files and the admission process. ODO reviewed 15 records and property files to ascertain all admission documents are enclosed. The files contained ICE-completed classification forms. The facility does not properly classify newly-arriving detainees upon admission to the facility (Deficiency AR-1). This area was found deficient during the February 2010 ERO annual inspection. The classification system will ensure that each detained alien is placed in the appropriate category and physically separated from detainees in other categories. ICE classifies each detainee before transferring to the facility. ICE does not provide proper documentation to BCJ to assist in the classification of each new arrival (Deficiency AR-2).

DEFICIENCY AR-1 In accordance with the ICE NDS, Detainee Classification System, section (III)(A)(1), the FOD must ensure all detainees are classified upon arrival, prior to placement into general population. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(B), the FOD must ensure the admission staff uses the documentation accompanying each new arrival for identification and classification purposes.
ICE.11.5082.000049
DETAINEE CLASSIFICATION SYSTEM (DCS)

ODO reviewed the Detainee Classification System standard at BCJ to determine if there is a requirement for a formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE NDS. ODO reviewed detention files, interviewed staff and reviewed policy regarding detainee classification at BCJ. BCJ does not maintain detention files. Consequently, ODO reviewed classification files to ascertain all had the correct documentation to allow BCJ staff to properly classify newly-arrived detainees. The files reviewed had no Record of Deportable/Inadmissible Alien (Form I-213) or other documentation to reveal the detainees background (Deficiency DCS-1). Consequently, the BCJ staff was unable to properly classify incoming detainees (Deficiency DCS-2). This could be problematic if a detainee is not classified properly, potentially resulting in the commingling of detainees of different classification levels, which is prohibited per the NDS. Detainees must be properly classified to maintain the safety and security of themselves, staff, and visitors.

DEFICIENCY DCS-1
(b)(7)e
DEFICIENCY DCS-2
(b)(7)e
10
ICE.11.5082.000050

ODO reviewed the Detention Files standard at BCJ to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed procedures and interviewed staff. BCJ does not maintain detention files (Deficiency DF-1). The significance of detention files is to maintain documentation generated during the detainees entire stay at a detention facility. The detention file is an all encompassing view of the detainees stay at the facility. This issue was addressed with ICE and BCJ during the ODO inspection closeout briefing.

DEFICIENCY DF-1 In accordance with the ICE National Detention Standard, Detention Files, section (III)(A), the FOD must ensure when a detainee is admitted into a facility, staff creates a detainee detention file as part of the in-processing (admissions) procedures.
11
ICE.11.5082.000051

ODO reviewed the Detainee Grievance Procedures standard at BCJ to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff and reviewed files, policy, procedures and logs. Detainees have the opportunity to file informal and formal grievances and also appeal the decisions of grievances. Forms are available for detainee use to file formal, written grievances. BCJ has policies and procedures addressing the detainee grievance process. At the time of the inspection, a review of the BCJ ICE grievance log revealed 33 formal grievances were filed by ICE detainees for the calendar year 2010. Thirty-two grievances had listed resolutions and one grievance was in a pending status. The majority of grievances focused on food service, telephone serviceability, religious practices and medical care. Each grievance is reviewed by a supervisor and not a grievance committee (Deficiency DGP-1). BCJ does not have a procedure of identifying and handling emergency grievances (Deficiency DGP-2). BCJ does not maintain detention files; therefore grievances can not be filed in a detainees detention file as required per the NDS (Deficiency DGP-3).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(2), the FOD must ensure the detainee is allowed to submit a formal, written grievance to the facilitys grievance committee. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure each facility implements procedures for identifying and handling an emergency grievance. DEFICIENCY DGP-3 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance will remain in the detainees detention file for at least three years.
12
ICE.11.5082.000052

ODO reviewed the Environmental Health and Safety standard at BCJ to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical management, and fire drills. Facility sanitation is maintained at a high level. Flammable and combustible chemicals were properly stored, issued, and accounted for, and inventory records were accurate in food service, maintenance, and living units. Interviews with staff revealed they are knowledgeable of inventory control and safety during issuance and use. Monthly fire drills were conducted on each shift and documentation is maintained by the safety officer. Pest control invoices and reports for generator maintenance and water testing were current. Three deficiencies were found. The master index of Material Safety Data Sheets (MSDS) does not include storage locations and documentation of semi-annual review (Deficiency EH&S-1). This index must be readily available to emergency responders to identify chemicals and their storage location; and semi-annual review ensures the MSDS are current and accurate. Exit diagrams do not include emergency equipment locations (Deficiency EH&S-2) required for ready reference in situations where use of fire extinguishers, safety masks and other fire suppression equipment is necessary. Barbering is conducted in a multi-purpose room with no lavatory or hot and cold water. Hair sanitation regulations were not posted and ODO observed barbering tools were not cleaned and disinfected between use (Deficiency EH&S-3). This area was found deficient during the February 2010 ERO annual inspection. Observance of hair care sanitation regulations is critical in preventing transfer of diseases through direct contact or by towels, combs or clippers.
STANDARD POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

DEFICIENCY EH&S-1 In accordance with ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure a master index of all hazardous substances used in the facility is compiled, including locations, along with a master file of MSDS. He/she will maintain this information in the safety office (or equivalent), with a copy to the local fire department. Documentation of the semiannual reviews will be maintained in the MSDS master file. DEFICIENCY EH&S-2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD must ensure exit diagrams include emergency equipment locations. DEFICIENCY EH&S-3 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1), (3) and (4), the FOD must ensure barber operations are conducted in a separate room not used for any other purpose. The room must have at least one lavatory and both hot and cold water. Between detainees, all hair care tools coming in contact with the detainees will be cleaned and effectively
Office of Detention Oversight December 2010 OPR (b)(7)e 13 Bergen County Jail ERO New York
ICE.11.5082.000053
disinfected. Each barbershop will have detailed hair care sanitation regulations posted in a conspicuous location for use of all hair care personnel and detainees.
14
ICE.11.5082.000054
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at BCJ to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed policy and relevant documentation. The facility contracts with Aramark, Inc. for management of the food service operation. Review of required inspections, production sheets, and temperature logs revealed the staff has been properly trained on local, state, and federal requirements. All menus, to include medical and religious, were certified by a registered dietitian. Three meals were observed during the plating process and proper temperatures were maintained, however, menu items were not appropriately placed on the tray. Improvements were made to this process prior to completion of the inspection. ODO observed the variety of kosher meals was excellent, though review of a complaint alleging repetitious meals revealed there was no schedule for rotation of menu items. This was corrected during the inspection. Four deficiencies were identified. The facilitys food service department has two knives permanently tethered to work tables stored in open holders (Deficiency FS-1). This represents a safety concern as direct supervision of workers at all times is not possible given the size of the area. ODO observed the knife holders were dirty and knives were not consistently cleaned prior to placement in the holders. Additionally, knives were not properly sanitized prior to usage (Deficiency FS-2). Invoices were presented documenting pest extermination services, however, evidence of rodent infestation was observed in the dry storage area (Deficiency FS-3). During inspection of food items stored in the refrigerator, ODO discovered leftover chicken dated two days earlier (Deficiency FS-4). Using or discarding leftovers within the required 24-hour period assures potentially spoiled food is not served.

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section (III)(B)(2), the FOD must ensure knives are stored in a knife cabinet equipped with an approved locking device. The on-duty cook foreman, under direct supervision of the Cook Supervisor (CS), must maintain control of the key that locks the device. DEFICIENCY FS-2 In accordance with ICE NDS, Food Service, section (III)(D)(7), the FOD must ensure the surfaces of equipment, containers, cutting boards, and utensils used for preparation and subsequent storage of potentially hazardous food are effectively cleaned after each use.
15
ICE.11.5082.000055
DEFICIENCY FS-3 In accordance with ICE NDS, Food Service, section (III)(D)(5), the FOD must ensure food is protected from insects and rodents and other sources of contamination. This protection will be continuous, whether the food is in storage, in preparation, or in transit. DEFICIENCY FS-4 In accordance with ICE NDS, Food Service, section (III)(D)(8), the FOD must ensure prepared food items which have not been placed on the serving line are retained for no more than 24 hours.
16
ICE.11.5082.000056
FUNDS AND PERSONAL PROPERTY (F&PP)

ODO reviewed the Funds and Personal Property standard at BCJ to determine if controls are in place to inventory, receipt, and store and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed local policy and procedures, logbooks, and the detainee handbook, and interviewed facility staff. ODO interviewed staff and was informed the facility maintains detainees identity documents in their property instead of forwarding the documents to ICE (Deficiency F&PP-1). It was also noted the detainee handbook does not include notices stating detainees, upon request, can be provided with an ICE ERO certified copy of identity documents held in their Alien Files or the procedure for filing a claim for lost or damaged property (Deficiency F&PP-2).

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(B)(3), the FOD must ensure identity documents will be held in the detainees A-file. DEFICIENCY F&PP-2 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, must notify the detainees they will be provided, upon request, an ICE-certified copy of any identity document taken from their property, the rules for storing or mailing property not allowed in their possession, the procedure for claiming property upon release, transfer or removal and the procedure for filing a claim for lost or damaged property.
17
ICE.11.5082.000057
ISSUANCE AND EXCHANGE OF CLOTHING, BEDDING AND TOWELS (IECB&T)

ODO reviewed the Issuance and Exchange of Clothing, Bedding, and Towels standard at BCJ to determine if the facility provides clean clothing, bedding, linens, and towels to every detainee upon arrival; and to determine if the facility provides ICE detainees with regular exchanges of clothing, linens, and towels for as long as they remain in detention, in accordance with the ICE NDS. ODO observed the intake and admissions process, reviewed policies and procedures, and interviewed staff and detainees. New detainees are issued clean bedding, linens, towels and uniforms upon arrival. Socks and undergarments are not provided and must be purchased through the facility commissary (Deficiency IECB&T- 1). ODO was informed indigent detainees are issued these items upon request and free of charge; however, there are no written procedures addressing this process. ODO recommends addressing provision of clothing items to indigent detainees in its policy and the detainee handbook. Socks and undergarments may be turned in for laundering twice per week rather than exchanged on a daily basis (Deficiency IECB&T- 2). Deficiencies IECB&T-1 and 2 were found deficient during the February 2010 ERO annual inspection.

DEFICIENCY IECB&T-1 In accordance with ICE NDS, Issuance and Exchange of Clothing, Bedding and Towels, section (I), the FOD must ensure facilities provide clean clothing, bedding, linens and towels to every detainee upon arrival. DEFICIENCY IECB&T-2 In accordance with ICE NDS, Issuance and Exchange of Clothing, Bedding and Towels, section (III)(E), the FOD must ensure detainees are provided with clean clothing, linen and towels on a regular basis to ensure proper hygiene. Socks and undergarments must be exchanged daily.
18
ICE.11.5082.000058
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at BCJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the clinic, interviewed staff, and reviewed medical policies and procedures, 25 medical records, and medical staff credentials. Healthcare is provided by Bergen County employees and administered by a Chief Nursing Officer (CNO). The jail is accredited by the National Commission of Correctional Health Care and has participated in a preliminary American Correctional Association survey. Overall, BCJ is in compliance with the Medical Care standard. Staffing is currently at 100 percent and is sufficient to meet detainee health care needs. Systems are in place to provide timely intake screening, medications, treatment for special and chronic needs, and emergency and follow up care Deficiencies in three components of the standard were identified. Copies of all licenses and certifications were maintained by the medical secretary, however, ODO discovered licenses or certifications for the clinical director, two dentists, three psychiatrists, two social workers, and one nurse practitioner had not been primary source verified with the issuing board (Deficiency MC-1). This practice is necessary to authenticate the validity of a license. The medical record review revealed three of 25 new arrival physical examinations were completed in excess of 14 days (Deficiency MC-2). Upon inquiry, ODO learned there were no extenuating circumstances to justify the delay. ODO recommends implementation of a monitoring system to ensure completion of physical examinations within the required 14 days. Per local policy J-E-07, Non-emergency Healthcare Requests and Service, sick call slips are to be available from health care personnel during medication administration and in all housing units. The policy further requires that request slips be stamped with the date and time and placed in the medical record. During the facility tour, ODO discovered there were no sick call slips in three of three units visited. Upon inquiry, ODO was informed slips cannot be maintained in the units because detainees use them for scratch paper, and issuance by officers upon request would violate detainees privacy rights. The medical record review revealed requests for health services written on paper other than sick call request forms. The requests submitted in alternative format were not dated, and were not consistently stamped with the time and date received. Absent documentation of the date submitted and received, ODO was unable to verify receipt of requests for services in a timely manner (Deficiency MC-3). ODO recommends making sick call request forms available to detainees to promote recording of the request date, and consistent date and time stamping upon receipt by medical personnel. ODO also observed there were two different sized, unmarked receptacles mounted on the walls in housing areas. ODO received contradictory information about which box was for sick call slips. On the housing units, the smaller of the two is for sick call slips; in the segregation unit, the larger. ODO recommends clear marking of sick call request receptacles to ensure timely receipt and protect the privacy of detainee health information.
Office of Detention Oversight Dece OPR (b)(7)e 19 Bergen County Jail ERO New York
ICE.11.5082.000059

DEFICIENCY MC-1 In accordance with ICE NDS, Medical Care, section (III)(C), the FOD must ensure health care staff have valid professional licensure and/or certification. The ICE Health Services Corp (IHS) will be consulted to determine appropriate credential requirements for health care providers. In accordance with IHS Policy 4.3.1.1, each licensed independent practitioner portfolio must contain, at a minimum, written evidence the professional licensure or certification (all current, past, active, and inactive) have been verified at the primary source. DEFICIENCY MC-2 In accordance with ICE NDS Medical Care, section (III)(D), the FOD must ensure detention facilities perform a health appraisal and physical examination within 14 days of arrival. DEFICIENCY MC-3 In accordance with ICE NDS, Medical Care, section (III)(F) the FOD must have procedures ensuring all sick call requests are received and triaged by health care staff in a timely manner.
20
ICE.11.5082.000060

ODO reviewed the Staff-Detainee Communication standard at BCJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed logs and interviewed staff. ICE staff conducts visits to BCJ three times a week to handle detainee requests; however ERO field office management does not conduct regular unannounced visits to BCJ to include the facilitys living and activity areas: housing, food service, recreation, segregation and medical (Deficiency SDC-1). ICE detainees have the opportunity to submit requests to ICE; however, no policies or procedures exists for ICE detainees to submit written questions, requests or concerns to ICE staff (Deficiency SDC-2) and the request policy is not referenced in the detainee handbook (Deficiency SDC-3). Per interviews with ICE personnel, no log book is maintained for the detainee requests (Deficiency SDC-4). Although ICE staff receives written requests from detainees and responds within 72 hours, the requests are not maintained in detention files for at least three years as BCJ does not maintain detention files for ICE detainees (Deficiency SDC-5). During staff interviews and the closeout briefing, ODO recommended scheduled quarterly meetings between BCJ and ICE department heads to address concerns regarding ICE detainees and to conduct joint visits of housing areas, medical care facility, recreation periods, and food service operation at BCJ. Additionally, ODO recommended visits be documented by ICE management as required by the NDS.

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure the ICE Officer in Charge (OIC), Assistant Officer in Charge and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and observe living and working conditions. Each facility will develop a method to document the visits. ICE will develop a method to document the visits independent of the facilitys documentation. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must ensure the facility has written procedures to route detainee requests to the appropriate ICE official.. DEFICIENCY SDC-3 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3), the FOD must ensure ICE request procedures are referenced in the detainee handbook.
Office of Detention Oversight Dece OPR (b)(7)e 21 Bergen County Jail ERO New York
ICE.11.5082.000061
DEFICIENCY SDC-4 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. DEFICIENCY SDC-5 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file and remain in the detainees detention file for at least three years.
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ICE.11.5082.000062
TELEPHONE ACCESS (TA)

ODO reviewed the Telephone Access standard at BCJ to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the NDS. ODO toured the facility, checked the functionality of approximately 10 telephones, reviewed logbooks, and interviewed staff and detainees. ODO has determined that there is a sufficient number of phones for the number of detainees in each housing unit. In addition, ODO has determined that all telephones are operational and are functioning properly. Detainees are not allowed to call immediate family members detained at another facility per detainee staff (Deficiency TA-1). ODO observed ICE detainees making legal phones calls in the law library; however, these phone calls are observed and can be easily overheard by the law library staff. It should be noted that these phones calls are made at the law librarians desk. It is recommended that the law librarian staff relocate the phone or remove themselves from the general area to give detainees privacy while making legal phone calls (Deficiency TA-2). Detainee telephone calls are monitored and no notices advising of such were located by telephones in detainee housing units. No procedures were found advising detainees of the procedures for obtaining an unmonitored call to a court, or a legal representative (Deficiency TA-3).

DEFICIENCY TA-1 In accordance with the NDS, Telephone Access, section (III)(H), upon a detainees request, the facility shall make special arrangements permitting the detainee to speak by telephone with an immediate family member detained in another facility. DEFICIENCY TA-2 In accordance with the NDS, Telephone Access, section (III)(J), the facility shall ensure privacy for detainees telephone calls regarding legal matters. For this purpose, the facility shall provide a reasonable number of telephones on which detainees can make such calls without being overheard by officers, other staff or other detainees. Facility staff shall not electronically monitor detainee telephone calls on their legal matters, absent a court order. DEFICIENCY TA-3 In accordance with the NDS, Telephone Access, section (III)(J), the facility shall ensure privacy for detainees telephone calls regarding legal matters. For this purpose, the facility shall provide a reasonable number of telephones on which detainees can make such calls without being overheard by officers, other staff or other detainees. Facility staff shall not electronically monitor detainee telephone calls on their legal matters, absent a court order. In accordance with the NDS, Telephone Access, section (III)(K), if the facility telephone calls are monitored, the facility shall notify detainees handbook or equivalent provided upon admission. It shall also place a notice at each monitored telephone stating, 1) the detainee calls
Office of Detention Oversight December 2010 OPR (b)(7)e 23 Bergen County Jail ERO New York
ICE.11.5082.000063
are subject to monitoring, and 2) the procedure for obtaining an unmonitored call to a court, legal representative, or for the purpose of obtaining legal representation.
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ICE.11.5082.000064
VISITATION (V)
ODO reviewed the Visitation standard at BCJ to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO reviewed the local policy and detainee handbook, inspected the visiting area, and interviewed staff and detainees. The facility has written visiting procedures, including a schedule and hours of visitation. Detainees are notified of visitation rules and hours by way of the detainee handbook and visiting information is available to the public by way of telephone recording, postings, and the facilitys website. Separate logs for general visitors and legal representatives are maintained. Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, was not available in the legal visitors reception area (Deficiency V-1). Form G-28 documents verifies attorney-client relationships and notify ICE of detainees legal representation. Availability of those forms in the legal visiting area facilitates form completion.

DEFICIENCY V-1 In accordance with ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative is available in the legal visitors reception area.
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ICE.11.5082.000065
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS ERO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU TAR TB UDC American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Enforcement and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee
26
ICE.11.5082.000066


Enforcement and Removal Operations

Philadelphia Field Office Berks Family Residential Center Leesport, Pennsylvania
September 20-23, 2010
________________________________
ICE.11.5082.000067
OFFICE OF PROFESSIONAL RESPONSIBILITY MISSION STATEMENT The Office of Professional Responsibility (OPR) is responsible for investigating allegations of employee misconduct impartially, independently and thoroughly. OPR prepares timely and comprehensive reports of investigations for judicial or management action. OPR inspects and reviews Immigration and Customs Enforcement (ICE) field offices, operations and processes in order to provide executive management with an independent review of the agencys organizational health, and assesses the effectiveness and efficiency of the overall ICE mission. OPR screens potential ICE employees for character and suitability.
ICE.11.5082.000068
QUALITY ASSURANCE REVIEW BERKS FAMILY RESIDENTIAL CENTER PHILADELPHIA FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. OPERATIONAL ENVIRONMENT Internal Relations........ Detainee Relations.. Areas of Concern. ICE RESIDENTIAL STANDARDS Residential Standards Reviewed Admission and Release... Emergency Plans... Environmental Health and Safety.. Food Service.. Funds and Personal Property. Grievance System. Hunger Strikes Key and Lock Control Law Libraries and Legal Material Legal Rights Group Presentations.. Medical Care .. Post Orders. Recreation... Residential Files..... Sexual Abuse and Assault Prevention and Intervention.. Staff-Resident Communication. Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death. Tool Control. Transfer of Residents. Visitation....... APPENDIX ACRONYMS SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS A B 1 1
3 3 3
5 6 7 8 9 10 11 12 13 16 17 19 21 22 23 25 26 27 28 30 32 33
ICE.11.5082.000069
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE Family Residential Standards (RS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of the Berks Family Residential Center (BFRC) in Leesport, Pennsylvania, on September 20-23, 2010. ODO reviewed the processes employed at BFRC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed data from the ENFORCE Alien Booking Module, ERO Headquarters, the Joint Integrity Case Management System, and pertinent media reports.
REPORT ORGANIZATION

Senior Special Agent (Team Leader) Detention and Deportation Officer Detention and Deportation Officer Management and Program Analyst Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
(b)(6), (b)(7)(C)
Office of Detention Oversight September 2010 OPR ODO (b)(7)e
Berks Family Residential Center ERO Philadelphia ICE.11.5082.000070 Juvenile and Family Residential Management Unit
BACKGROUND
HISTORY
BFRC is an ICE-dedicated intergovernmental service agreement (IGSA) residential facility which opened in March 2001. BFRC is an 85-bed facility authorized to house undocumented family units over 72 hours, and is operated and managed by the Berks County Youth Center. The facilitys total capacity for ICE detainees is 96. BFRC is one of the only authorized facilities able to accommodate family units. The ERO Juvenile and Family Residential Management Unit (JFRMU), in coordination with the ERO Philadelphia Field Office, utilizes BFRC to detain families, including juveniles, who are under immigration proceedings. On September 20, 2010, BFRC housed approximately 70 detainees, hereinafter referred to as residents. The Berks County Youth Center employs 53 full-time staff members. The food service department is operated by Berks County Youth Center staff. Medical services are provided by the ICE Health Services Corps. The facilitys total capacity for ICE residents is 96. In March 2010, the ERO JFRMU contractors, the Nakamoto Group, Inc., conducted a biannual review of the ICE RS at BFRC. The facility was found fully compliant in all 37 standards reviewed. The facility holds no current accreditations.
INTERNAL RELATIONS
ODO interviewed five supervisory and 17 nonsupervisory ICE and BFRC staff. Based on the interviews, ICE and BFRC maintain an excellent working relationship. All ICE and BFRC staff interviewed said morale is good. ODO interviewed ICE management staff, including the Deputy Field Office Director, supervisory detention and deportation officers, and supervisory immigration enforcement agents. ODO also interviewed non-supervisory ICE staff including immigration enforcement agents and deportation officers. The majority of staff reported employee morale is good and they receive significant cooperation from BFRC staff. Further, ERO staff stated the ERO field office could benefit from having more positions, specifically immigration enforcement agents. Both ICE and BFRC supervisory staff expressed concerns regarding ODOs findings during the closeout-briefing, stating the frequent audits and inspections conducted by JFRMUs contractor, the Nakamoto Group, Inc., had led them to believe the facility was fully compliant with the ICE RS. Supervisory staff also expressed the need for uniformity in audits, policies, and application of both.
DETAINEE RELATIONS
ODO interviewed 17 ICE residents housed at BFRC. Residents had no major complaints. All residents knew the status of their immigration case and the name of their Deportation Officer. The residents did not have any complaints regarding the services offered at the facility, and stated they received hygiene supplies and a resident handbook upon arrival. Two residents stated the food was sufficient, but complained about the variety of food. The residents stated they prefer to eat Spanish food instead of American food. One resident reported not knowing how to send and receive mail.
AREAS OF CONCERN
The ICE RS does not include standards related to security. Security and control standards would ensure facilities housing ICE residents are appropriately staffed and safeguarded to prevent events that pose a risk of harm to persons and property. ERO is in charge of creating and amending the ICE RS, and should consider including a security-related residential standard.
(b)(7)e ODO conducted interviews and analyzed data from the Alien Booking Module. ODO found a resident and her child were previously encountered by immigration officials. During that encounter, the child was issued an Alien File number (A#) other than the A# number currently assigned to the child. According to ERO policy, after making physical determinations of which A# is the primary, files are required to be
Office of Detention Oversight September OPR ODO (b)(7)e
consolidated under the primary A#, both electronically and physically. ODO notified ERO of the inconsistency.
ICE RESIDENTIAL STANDARDS

This review was based on the ICE RS. The following 29 standards were reviewed: Admission and Release Discipline and Behavior Management Emergency Plans Environmental Health and Safety Escorted Trips for Non-Medical Emergencies Food Service Funds and Personal Property Grievance System Housekeeping and Voluntary Work Program Hunger Strikes Key and Lock Control Law Libraries and Legal Material Legal Rights Group Presentations Marriage Requests Medical Care Personal Hygiene Post Orders Recreation Religious Practices Residential Files Sexual Abuse and Assault Prevention and Intervention Staff-Resident Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Transfer of Residents Transportation Visitation No deficiencies were noted in the following eight standards: Discipline and Behavior Management Escorted Trips for Non-Medical Emergencies Housekeeping and Voluntary Work Program Marriage Requests Personal Hygiene Religious Practices Telephone Access Transportation As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

ODO reviewed the Admission and Release standard at BFRC to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE RS. ODO reviewed policies and residential files, and interviewed staff and residents. The five resident admission records reviewed did not contain the Alien Booking Record (Form I-385) (Deficiency AR-1). BFRC uses a form similar to Form I-385; however, the ICE RS specifically requires the use of Form I-385, as does the BFRC policy on residential files.

DEFICIENCY AR-1 In accordance with the ICE RS, Admission and Release, section (V)(4), the FOD must ensure an order to detain or release the resident (Form I-203 or I-203a), bearing the appropriate official signature, is with each newly arriving resident. Forms requiring completion include, but are not limited to: Form I-385, the medical questionnaire, the housing assignment card, and any others used by the booking entity.
EMERGENCY PLANS (EP)

ODO reviewed the Emergency Plans standard at BFRC to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with the ICE RS. ODO interviewed staff, reviewed policies and emergency plans, and inspected command post equipment.
(b)(7)e
(b)(7)e
(b)(7)e
Berks Family Residential Center ERO Juvenile and Family Residential Unit ICE.11.5082.000076 ERO Philadelphia

ODO reviewed the Environmental Health and Safety standard at BFRC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE RS. ODO toured the facility, interviewed staff, reviewed policies, and inspected documentation of inspections, fire drills, and management of chemical hazards. The Maintenance Supervisor had not compiled a master list of all hazardous substances, and did not have an up-to-date list of emergency telephone numbers (Deficiency EH&S-1). This deficiency was corrected prior to completion of the review. There was no documentation verifying an approved state laboratory tests samples of drinking and wastewater (Deficiency EH&S-2), or verifying emergency generators are tested as required (Deficiency EH&S-3).

DEFICIENCY EH&S-1 In accordance with the ICE RS, Environmental Health and Safety, section (V)(5)(a)(c), the FOD must ensure the Maintenance Supervisor compiles a master list of all hazardous substances in the facility, with their locations and a comprehensive, up-todate list of emergency telephone numbers. DEFICIENCY EH&S-2 In accordance with the ICE RS, Environmental Health and Safety, section (IX)(4), the FOD must ensure an approved state laboratory tests samples of drinking and wastewater, in compliance with applicable standards. DEFICIENCY EH&S-3 In accordance with the ICE RS, Environmental Health and Safety, section (IX)(5), the FOD must ensure emergency power generators are tested at least every two weeks for one hour. The oil, water, hoses, and belts must be inspected for mechanical readiness to perform in an emergency situation. The emergency generator must also receive quarterly testing and servicing from an external generator service company.
Berks Family Residential Center ERO Philadelphia Juvenile and Family Residential Management Unit
ICE.11.5082.000077
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at the BFRC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE RS. ODO reviewed policies, menus, temperature logs, and documentation of inspections; interviewed food service staff; and observed food preparation and service, sanitation, and control of chemicals. ODO discovered six kitchen knives located in a computer supply closet, stored in a crate and wrapped in a towel (Deficiency FS-1). The three-compartment sink used for washing, rinsing, and sanitizing utensils and equipment was not labeled (Deficiency FS-2). There was no documentation verifying pest control services are conducted by an outside exterminator (Deficiency FS-3).

DEFICIENCY FS-1 In accordance with the ICE RS, Food Service, section (V)(2)(b)(c), the FOD must ensure knives are secured in a knife cabinet equipped with an approved locking device. DEFICIENCY FS-2 In accordance with the ICE RS, Food Service, section (V)(9)(k)(a), the FOD must ensure a sink with at least three labeled compartments is used for manually washing, rinsing, and sanitizing utensils and equipment. DEFICIENCY FS-3 In accordance with the ICE RS, Food Service, section (V)(9)(p), the FOD must ensure pest control services are conducted in the food service department, including contracting services of an outside contractor.
ICE.11.5082.000078

ODO reviewed the Funds and Personal Property standard at BFRC to determine if controls are in place to inventory, receipt, store, and safeguard residents personal property, in accordance with the ICE RS. ODO reviewed policies, the resident handbook, and residential files; observed the process for receiving and releasing personal property, as well as the secure storage area for residents property; and interviewed staff and residents. The BFRC resident handbook does not notify residents of policies and procedures regarding how to obtain a certified copy of identity documents (Deficiency F&PP-1). BFRC does not have written procedures for inventorying and auditing residents funds, valuables, and personal property (Deficiency F&PP-2).

DEFICIENCY F&PP-1 In accordance with the ICE RS, Funds and Personal Property, section (V)(3)(b), the FOD must ensure the residents handbook or equivalent notifies residents of facility policies and procedures concerning personal property, including the procedures for requesting a certified copy of any identity document (passport, birth certificate) placed in their A-files. DEFICIENCY F&PP-2 In accordance with the ICE RS, Funds and Personal Property, section (V)(10), the FOD must ensure each facility has a written procedure for the inventory and audit of residents funds, valuables, and personal property.
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ICE.11.5082.000079
GRIEVANCE SYSTEM (GS)

ODO reviewed the Grievance System standard at BFRC to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE RS. ODO reviewed residential grievances, grievance logs, and residential files. After reviewing residential files and interviewing facility staff, ODO noted a copy of the grievance disposition is not placed in the residents residential file (Deficiency GS-1).

DEFICIENCY GS-1 In accordance with the ICE RS, Grievance System, section (V)(8), the FOD must ensure a copy of the grievance disposition is placed in the residents residential file.
Office of Detention Oversight September 2010 (b)(7)e OPR ODO
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ICE.11.5082.000080
HUNGER STRIKES (HS)

ODO reviewed the Hunger Strikes standard at BFRC to determine if the facility protects detainees health and well-being by monitoring, counseling, and treating detainees on hunger strikes, in accordance with the ICE RS. ODO reviewed the hunger strike policy, and interviewed the Health Services Administrator and the Medical Director. There have been no hunger strikes in the past year. ODO was informed BFRC is a well facility, and a hunger-striking resident would be transferred. The policy does not address restrictions of a residents commissary/vending privileges while on hunger strike, and removal of all food items from the living area. Review of training records revealed three of fourteen medical staff, and ten of ten custody staff did not receive hunger strike training during orientation and annually (Deficiency HS-1).

DEFICIENCY HS-1 In accordance with the ICE RS, Hunger Strikes, section (V)(1), the FOD must ensure all staff are initially and annually trained to recognize the signs of a hunger strike, and to follow the procedures for medical assessment referral.
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ICE.11.5082.000081
KEY AND LOCK CONTROL (K&LC)

ODO reviewed the Key and Lock Control standard at BFRC to determine if facility safety and security is maintained by requiring keys and locks to be controlled and maintained, in accordance with the ICE RS. ODO reviewed policies, toured the facility, interviewed staff, and inspected key inventories.
(b)(7)e
(b)(7)e
(b)(7)e
13
ICE.11.5082.000082
(b)(7)e
(b)(7)e
DEFICIENCY K&LC-5
(b)(7)e
DEFICIENCY K&LC-6
(b)(7)e
(b)(7)e
(b)(7)e
(b)(7)e
(b)(7)e
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ICE.11.5082.000083
(b)(7)e
DEFICIENCY K&LC-11
(b)(7)e
(b)(7)e
(b)(7)e
(b)(7)e
(b)(7)e
15
ICE.11.5082.000084
LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)

ODO reviewed the Law Libraries and Legal Material standard at BFRC to determine if residents have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE RS. ODO observed the law library, reviewed policies, and interviewed staff and residents. According to facility policy, a maximum number of ten residents are permitted to use the law library simultaneously; however, the law library is not furnished with a sufficient number of tables and chairs to facilitate ten residents legal research and writing (Deficiency LL&LM-1). The resident handbook and the law library postings do not provide residents with all rules and procedures governing access to legal materials (Deficiency LL&LM-2).

DEFICIENCY LL&LM-1 In accordance with the ICE RS, Law Libraries and Legal Material, section (V)(1), the FOD must ensure the law library is furnished with a sufficient number of tables and chairs to facilitate residents legal research and writing. DEFICIENCY LL&LM-2 In accordance with the ICE RS, Law Libraries and Legal Material, section (V)(14), the FOD must ensure the resident handbook or equivalent provides residents with the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for resident use; 2) scheduled hours of access to the law library; 3) procedures for requesting additional time in the law library (beyond the five-hour per week minimum); 4) procedures for requesting legal reference materials not maintained in the law library; and 5) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library.
Office of Detention Oversight September (b)(7)e OPR ODO
16
ICE.11.5082.000085
LEGAL RIGHTS GROUP PRESENTATIONS (LRGP)

ODO reviewed the Legal Rights Group Presentations standard at BFRC to determine if authorized persons and organizations are permitted to make presentations to groups of residents for the purpose of providing information on immigration law and procedures, in accordance with the ICE RS. ODO reviewed policies, postings, and legal rights videos, observed the housing units, and interviewed staff and residents. The facility has a legal rights group, approved through the Legal Orientation Program, who presents to new and current residents twice a month. The facility has not received requests for new legal rights group presentations within the last year. Informational posters regarding legal rights group presentations are not displayed in each housing unit, and do not provide the general contents of the presentation, the intended audience, or the languages in which the presentation will be conducted. The posters and corresponding sign-up sheets are also not displayed in the housing units (Deficiency LRGP-1). According to ICE and facility staff, group presenters are not required to check into the facility at least 30 minutes prior to the presentation (Deficiency LRGP-2). When distributing materials, presenters do not distribute them to ICE and/or facility staff at the same time the materials are distributed to residents (Deficiency LRGP-3). The Know Your Rights video, produced by human rights lawyers in the late 1990s, is shown to all incoming residents at the facility. The video is outdated and in poor viewing condition. The Detention Services Manager has sent written requests to the local legal rights group asking for a more current video, but has not sent a written notice to the producer of the video (Deficiency LRGP-4).

DEFICIENCY LRGP-1 In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(2), the FOD must ensure the presenter provides a one-page poster (no larger than 8.5 by 11 inches) to inform residents of the general nature and contents of the presentation, the intended audience, and the languages in which it will be conducted. The informational posters provided by the presenter must be prominently displayed in housing units, by designated facility staff, at least 48 hours before the scheduled presentation. Each housing unit staff must make a sign-up sheet available for residents who plan to attend. DEFICIENCY LRGP-2 In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(4), the FOD must ensure group presenters are required to check into the facility at least 30 minutes prior to the presentation.
17
ICE.11.5082.000086
DEFICIENCY LRGP-3 In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(6), the FOD must ensure presenters distribute materials to residents and ICE and/or facility staff at the same time. DEFICIENCY LRGP-4 In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(9), the FOD must ensure, if ICE believes that aspects of the presentation have become dated or inaccurate, ICE may discontinue showing the videotape and promptly send written notice to the submitter. In the event a presentation becomes unavailable or unusable, the facility must promptly request that ICE obtain a replacement from the originating person or organization.
18
ICE.11.5082.000087
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at BFRC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE RS. ODO toured the medical clinic, reviewed policies and procedures, examined 20 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed the Health Services Administrator (HSA), the Medical Director, and staff. The facility is not accredited and does not maintain compliance with the standards of Joint Commission on the Accreditation of Health Care Organizations (Deficiency MC-1). The facilitys infection control plan does not address media relations (Deficiency MC-2). The medical clinic is located along a corridor shared by other facility functions and is unrestricted from resident access. The clinic has no dedicated waiting area. Residents waiting to see medical staff are seated in chairs in the corridor and are not supervised by custody staff (Deficiency MC -3). Current and retired medical records are not stored in a securely locked area within the medical unit (Deficiency MC-4). The room used for storing pharmaceuticals does not have a solid core door with a high security lock. Pharmaceuticals not requiring refrigeration are stored in a locked cabinet within the room; however, immunizations are not stored in a secured refrigerator (Deficiency MC-5).

DEFICIENCY MC-1 In accordance with the ICE RS, Medical Care, section (V)(1), the FOD must ensure the health care program and the medical facilities are accredited and maintain compliance with the standards of Joint Commission on the Accreditation of Health Care Organizations. DEFICIENCY MC-2 In accordance with the ICE RS, Medical Care, section (V)(2)(a), the FOD must ensure the facilitys written plan addressing the management of infectious and communicable diseases includes media relations. DEFICIENCY MC-3 In accordance with the ICE RS, Medical Care, section (V)(4)(a), the FOD must ensure the medical facility is located within the primary perimeter, in an area restricted from general resident access, and has its own perimeter to ensure restricted access. The waiting area must be located at the entrance to the medical facility and be under the direct supervision of custodial staff, not medical staff. DEFICIENCY MC-4 In accordance with the ICE RS, Medical Care, section (V)(4)(b), the FOD must ensure medical records are kept separate from residents records, and are stored in a securely locked area within the medical unit.
19
ICE.11.5082.000088
DEFICIENCY MC-5 In accordance with the ICE RS, Medical Care, section (V)(5), the FOD must ensure all pharmaceuticals are stored in a secure area with a solid core door that has a high security lock and a secure medication storage area.
20
ICE.11.5082.000089
POST ORDERS (PO)

ODO reviewed the Post Orders standard at BFRC to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE RS. ODO toured the facility, reviewed security post orders, and interviewed staff. The Facility Administrators designee did not sign and date each post order on the last page of each section, and initial and date all other pages (Deficiency PO-1). This deficiency was corrected prior to completion of the review.

DEFICIENCY PO-1 In accordance with the ICE RS, Post Orders, section (V)(3)(a-b), the FOD must ensure the Facility Administrator (or designee) approves, signs, and dates each post order on the last page of each section, and initials and dates all other pages.
21
ICE.11.5082.000090
RECREATION (R)
ODO reviewed the Recreation standard at BFRC to determine if residents are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE RS. ODO observed the recreation areas, reviewed facility policies and documentation, and interviewed staff and residents. ODO observed recreation areas which were not under continuous supervision by staff equipped with radios or other communication devices (Deficiency R-1).

DEFICIENCY R-1 In accordance with the ICE RS, Recreation, section (V)(5)(g), the FOD must ensure recreation areas are under continuous supervision by staff equipped with radios and other communication devices, to ensure the safety of the residents.
22
ICE.11.5082.000091
RESIDENTIAL FILES (RF)

ODO reviewed the Residential Files standard at BFRC to determine if files are created containing all significant information relating to residents who are housed at the facility for 24 hours or more, in accordance with the ICE RS. ODO reviewed residential files, policies, and other documentation; observed the administrative areas; and interviewed staff and residents. Residential files do not contain Form I-385, with one or more photographs attached; housing worksheets; housing identification cards; property receipts (Form G-589); baggage checks (Form I-77); special requests; grievances; or complaint forms (Deficiency RF-1). Although the Residential File standard allows for facility equivalents of the above forms, the BFRC policy does not provide the option to use equivalents to the ICE forms. ODO observed several residential files awaiting archiving sitting on a desk, in a semisecured location (Deficiency RF-2). Archived detention files are not always placed in storage boxes, with the dates of the files clearly marked on the outside of the boxes (Deficiency RF-3). The residential file logbook does not include all required information, and residential files are not always returned by the end of the administrative workday (Deficiency RF-4). According to facility staff, ICE and the JFRMU are not contacted prior to the destruction of archived files (Deficiency RF-5).

DEFICIENCY RF-1 In accordance with the ICE RS, Residential Files, section (2)(a-b) and (e)(1), the FOD must ensure the residential file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the residential file may include copies of material contained in the residents A-file. The file must, at a minimum, contain the following forms and documents, or facility equivalents: Form I-385, with one or more photographs attached; housing worksheet; housing identification card; Form G-589; and Form I-77. During the course of the residents stay at the facility, staff must add documents related to resident activities, for example: special requests, grievances, complaints, and the dispositions of the same. Upon the residents release from the facility, staff must add final documents to the file before closing and archiving it. Before the file is closed, the original Form I-385 and other documentation must be inserted into the residential file. DEFICIENCY RF-2 In accordance with the ICE RS, Residential Files, section (2)(c), the FOD must ensure active residential files are maintained in a secure area, using lockable cabinets in the
23
ICE.11.5082.000092
admissions processing area unless the Facility Administrator designates otherwise. Cabinets must remain locked when not in use. The Facility Administrator must designate restricted-access storage space for archived files. DEFICIENCY RF-3 In accordance with the ICE RS, Residential Files, section (2)(c), the FOD must ensure archived files are placed in storage boxes with the dates covered clearly marked as follows: from [mm/dd/yyyy] to [mm/dd/yyyy]. DEFICIENCY RF-4 In accordance with the ICE RS, Residential Files, section (2)(d)(3), the FOD must ensure staff accommodates requests for a residents residential file from other departments that have a documented need for the material. Each borrowed file must be returned by the end of the administrative workday. At a minimum, a logbook entry recording the files removal from the cabinet must include the following: the residents name and A-number; date and time the residential file was removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file. DEFICIENCY RF-5 In accordance with the ICE RS, Residential Files, section (2)(e)(5), the FOD must ensure ICE and JFRMU are contacted prior to the destruction of any archived residential files.
24
ICE.11.5082.000093
SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (SAAPI)

ODO reviewed the Sexual Abuse and Assault Prevention and Intervention standard at BFRC to determine if facilities act to prevent sexual abuse and assaults on residents, provide prompt and effective intervention and treatment for victims of sexual abuse and assault, and control, discipline, and prosecute the perpetrators, in accordance with the ICE RS. ODO reviewed policies, the resident handbook, and interviewed staff and residents. BFRC maintains separate general and investigative files for cases of sexual abuse or assault; however, the BFRC policy does not require the general and investigative files to be kept separately (Deficiency SAAPI-1).

DEFICIENCY SAAPI-1 In accordance with the ICE RS, Sexual Abuse and Assault Prevention and Intervention, section (V)(M), the FOD must ensure all case records associated with claims of sexual abuse (including incident reports, investigative reports, offender information, case disposition, medical and counseling evaluation findings, and recommendations for postrelease treatment and/or counseling) are maintained in appropriate files in accordance with Residential Standards and applicable policies, and retained in accordance with established schedules. Monitoring and evaluation are essential to assess both sexual assault levels and agency effectiveness in reducing sexually abusive behavior. Accordingly, the Facility Administrator must maintain two types of files. General files include: the victim(s) and assailant(s) of a sexual assault; crime characteristics; and formal or informal action taken. Investigative files include all reports; medical forms; supporting memos and videotapes, and any other evidentiary materials pertaining to the allegation.
25
ICE.11.5082.000094
STAFF-RESIDENT COMMUNICATION (SRC)

ODO reviewed the Staff-Resident Communication standard at BFRC to determine if procedures are in place to allow formal and informal contact between residents and key ICE and facility staff; and, if residents are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE RS. ODO reviewed procedures and logbooks, and interviewed staff and detainees. Although ERO department heads conduct frequent unannounced, unscheduled visits to the facility, ERO and the facility could not produce documents recording department heads observing living and activity areas. ODO reviewed the log of management visits and observed the visits are not conducted weekly (Deficiency SRC-1). A review of the residential files revealed copies of residents answered request forms are not inserted into the residents files (Deficiency SRC-2).

DEFICIENCIES SRC-1 In accordance with the ICE RS, Staff-Resident Communication, section (V)(1)(a), the FOD must ensure department heads conduct frequent unannounced, unscheduled visits to the facility's living and activity areas to informally observe living and working conditions, and encourage informal communication among staff and residents. Such unannounced visits must include, but not be limited to: housing units; food service, preferably during the lunch meal; recreation areas; and infirmary rooms. These unannounced visits must be conducted at least weekly. Each facility must develop a method to document the unannounced visits, and ERO staff must also document their visits to facilities. DEFICIENCY SRC-2 In accordance with the ICE RS, Staff-Resident Communication, section (V)(1)(d-e), the FOD must ensure a copy of each completed resident request is placed in each residents residential file, and is retained for at least three years.
26
ICE.11.5082.000095
SUICIDE PREVENTION AND INTERVENTION (SP&I)

ODO reviewed the Suicide Prevention and Intervention standard at BFRC to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE RS. ODO reviewed policies; interviewed the HSA, the psychologist, and staff; and reviewed medical and facility staff training records. There have been no suicides in the past year. Training records indicate one of fourteen medical staff members did not receive training during orientation and periodically (Deficiency SP&I-1).

DEFICIENCY SP&I-1 In accordance with the ICE RS, Suicide Prevention and Intervention, section (I), the FOD must ensure residential staff are trained to prevent suicide by recognizing potential risk signs and situations, and to intervene with appropriate sensitivity, supervision, referral, and treatment.
27
ICE.11.5082.000096
TERMINAL ILLNESS, ADVANCE DIRECTIVES AND DEATH (TIADD)

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donation, at BFRC to determine if the facilitys policies and practices are in accordance with the ICE RS. ODO reviewed policies, and interviewed the HSA and staff. There have been no deaths in the past year. ODO was informed BFRC is a well facility, and residents who become seriously ill or injured are transferred. Policies do not address fatal injury (Deficiency TIADD-1), ERO requirements for disposition of remains (Deficiency TIADD-2) and case closure (Deficiency TIADD-3), death certificates (Deficiency TIADD-4), or autopsies (Deficiency TIADD-5).

DEFICIENCY TIADD-1 In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure health care services address terminal illness, fatal injury, and advance directives. DEFICIENCY TIADD-2 In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(6), the FOD must ensure, upon the death of a resident, the family has the opportunity to claim the remains within seven calendar days of the date of notification. If family cannot be located or declines the remains, orally or in writing, ERO must notify the consulate in writing. If neither the family nor the consulate claims the remains, ERO must schedule an indigents burial consistent with local procedures. DEFICIENCY TIADD-3 In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(8), the FOD must ensure procedures for closing the case of a deceased resident includes: sending the residents fingerprint card to the FBI, stamped Deceased, and identifying the place of death; placing the residents death certificate or medical examiners report in the residents A-file; placing a copy of the gravesite title in the A-file (indigent burial, only); and closing any electronic records on the resident. DEFICIENCY TIADD-4 In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(9), the FOD must ensure the Facility Administrator specifies policy and procedures identifying the staff member responsible for proper distribution of the death certificate.
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ICE.11.5082.000097
DEFICIENCY TIADD-5 In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(10), the FOD must ensure each facility has written policy and procedures to implement the provisions for an autopsy, if necessary.
29
ICE.11.5082.000098
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at BFRC to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE RS. ODO reviewed policies, interviewed staff, and inspected all areas where tools are stored and maintained. ODO observed kitchen knives not marked to make them readily identifiable (Deficiency TC-1). BFRC policies do not include schedules and procedures for the daily inventory of tools, procedures for issuance of tools to staff and resident workers, or documentation of tool issuance to staff and residents (Deficiency TC-2). The Facility Administrator has not established a policy on facility tool use and storage which includes separate, comprehensive, alphabetical lists of restricted and non-restricted tools (Deficiency TC-3). The BFRC recreation department does not maintain a tool inventory (Deficiency TC-4). The tool control policy does not address tool storage in all areas of the facility (Deficiency TC-5), and does not include written procedures for the receipt of tools (Deficiency TC-6). The Facility Administrator has not established procedures for quarterly inventorying all tools (Deficiency TC-7), and for control of ladders, extension cords, and ropes (Deficiency TC-8).

DEFICIENCY TC-1 In accordance with the ICE RS, Tool Control, section (V)(B)(3-4), the FOD must ensure procedures are in place for marking tools so they are readily identifiable. DEFICIENCY TC-2 In accordance with the ICE RS, Tool Control, section (V)(B)(5-7), the FOD must ensure the Officer in Charge develops and implements a written tool control system that establishes procedures and schedules for daily inventory of tools, procedures for issuance of tools to staff and residents, and procedures for documentation of tool issuance to staff and resident workers. DEFICIENCY TC-3 In accordance with the ICE RS, Tool Control, section (V)(C), the FOD must ensure the Officer in Charge establishes a policy document on facility tool use and storage that includes a separate, comprehensive, alphabetical list of restricted and non-restricted tools.
30
ICE.11.5082.000099
DEFICIENCY TC-4 In accordance with the ICE RS, Tool Control, section (V)(F), the FOD must ensure the following departments maintain a tool inventory: facility maintenance, medical department, food service department, electronics shop, recreation department, and armory. DEFICIENCY TC-5 In accordance with the ICE RS, Tool Control, section (V)(H), the FOD must ensure the Officer in Charge establishes written procedures for a tool storage system that ensures accountability. Commonly used, mounted tools must be stored so that a tools disappearance would not escape attention. DEFICIENCY TC-6 In accordance with the ICE RS, Tool Control, section (V)(I), the FOD must ensure the Officer in Charge establishes procedures for the receipt of tools. DEFICIENCY TC-7 In accordance with the ICE RS, Tool Control, section (V)(J), the FOD must ensure the Officer in Charge schedules and establishes procedures for quarterly inventorying of all tools. DEFICIENCY TC-8 In accordance with the ICE RS, Tool Control, section (V)(K), the FOD must ensure each facility has procedures in place to control ladders, extension cords, and ropes.
31
ICE.11.5082.000100
TRANSFER OF RESIDENTS (TR)

ODO reviewed the Transfer of Residents standard at BFRC to determine if transfers of residents from one facility to another are responsibly managed in regard to notification, resident records, safety, and security, and protection of resident funds and property, in accordance with the ICE RS. ODO reviewed the admission and release logbooks, (b)(7)e reports, residential files, and A-files; interviewed ERO and BFRC staff; and observed residents being admitted and released. ODO reviewed five A-files of residents that were transferred to another ICE facility after January 2010. ERO does not use two required forms: the Resident Transfer Notification (Deficiency TR-1), and the Resident Transfer Checklist (Deficiency TR-2).

DEFICIENCY TR-1 In accordance with the ICE RS, Transfer of Residents, section (V)(2)(c), the FOD must ensure, at the time of transfer of the resident, ERO provides the resident, in writing, the name, address, and telephone number of the facility to which he or she is being transferred, using the Resident Transfer Notification form. Staff must place a copy of the form in the residents A-file. DEFICIENCY TR-2 In accordance with the ICE RS, Transfer of Residents, section (V)(4), the FOD must ensure the sending facility staff completes the Resident Transfer Checklist to ensure all procedures are completed before the resident is transferred to another ICE facility.
32
ICE.11.5082.000101
VISITATION (V)
ODO reviewed the Visitation standard at BFRC to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE RS. ODO reviewed visitation logs, rules, and accommodations, and interviewed staff. During review of the legal visitor log, ODO discovered the representatives address is requested, but not required. Several address spaces were found blank (Deficiency V-1).

DEFICIENCY V-1 In accordance with the ICE RS, Visitation, section (V)(10)(n), the FOD must ensure log entries include: the date, time of arrival, visitors name, visitors address, supervising attorneys name, residents name and A-number, purpose of visit, time visit began, and time visit ended.
33
ICE.11.5082.000102
APPENDIX A
Acronyms
ACA COTR CXR DOS ERO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA IHS JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PBNDS PE PHS POA PPD RN RS SIR SMU TAR TB UDC American Corrections Association Contracting Officer Technical Representative Chest X-ray Detention Operations Supervisor Enforcement and Removal Operations Detention Standards Compliance Unit ENFORCE Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent ICE Health Service Corps Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Performance Based National Detention Standards Physical Examination Public Health Service Plan of Action Purified Protein Derivative Registered Nurse Residential Standards Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee
34
ICE.11.5082.000103
APPENDIX B
SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Admission and Release, section (V)(4), the FOD must ensure an order to detain or release the resident (Form I-203 or I203a), bearing the appropriate official 6 signature, is with each newly arriving resident. Forms requiring completion include, but are not limited to: Form I385, the medical questionnaire, the housing assignment card, and any others used by the booking entity.
AR-1 Admission and Release
Emergency Plans
EP-1
(b)(7)e
35
ICE.11.5082.000104
DETENTION STANDARD
Emergency Plans
EP-2
(b)(7)e
EH&S-1 Environmental Health and Safety
EH&S-2
EH&S-3
Food Service
FS-1
Environmental Health and Safety, section (V)(5)(a)(c), the FOD must ensure the Maintenance Supervisor compiles a master list of all hazardous substances in the facility, with their locations and a comprehensive, up-todate list of emergency telephone numbers. In accordance with the ICE RS, Environmental Health and Safety, section (IX)(4), the FOD must ensure an approved state laboratory tests samples of drinking and wastewater, in compliance with applicable standards. In accordance with the ICE RS, Environmental Health and Safety, section (IX)(5), the FOD must ensure emergency power generators are tested at least every two weeks for one hour. The oil, water, hoses, and belts must be inspected for mechanical readiness to perform in an emergency situation. The emergency generator must also receive quarterly testing and servicing from an external generator service company. In accordance with the ICE RS, Food Service, section (V)(2)(b)(c), the FOD must ensure knives are secured in a knife cabinet equipped with an approved locking device. 36
ICE.11.5082.000105
DETENTION STANDARD
Food Service
FS-2
Food Service
FS-3
F&PP-1 Funds and Personal Property
Funds and Personal Property
F&PP-2
Grievance System
GS-1
Hunger Strikes
HS-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Food Service, section (V)(9)(k)(a), the FOD must ensure a sink with at least three 9 labeled compartments is used for manually washing, rinsing, and sanitizing utensils and equipment. In accordance with the ICE RS, Food Service, section (V)(9)(p), the FOD must ensure pest control services are 9 conducted in the food service department, including contracting services of an outside contractor. In accordance with the ICE RS, Funds and Personal Property, section (V)(3)(b), the FOD must ensure the residents handbook or equivalent notifies residents of facility policies and 10 procedures concerning personal property, including the procedures for requesting a certified copy of any identity document (passport, birth certificate) placed in their A-files. In accordance with the ICE RS, Funds and Personal Property, section (V)(10), the FOD must ensure each facility has a 10 written procedure for the inventory and audit of residents funds, valuables, and personal property. In accordance with the ICE RS, Grievance System, section (V)(8), the 11 FOD must ensure a copy of the grievance disposition is placed in the residents residential file. In accordance with the ICE RS, Hunger Strikes, section (V)(1), the FOD must ensure all staff are initially and annually trained to recognize the signs of a 12 hunger strike, and to follow the procedures for medical assessment referral.
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ICE.11.5082.000106
DETENTION STANDARD
PAGE
Key and Lock Control
K&LC-1
13
K&LC-2
13
K&LC-3
14
K&LC-4 Key and Lock Control

(b)(7)e
14
K&LC-5
14
K&LC-6
14
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ICE.11.5082.000107
DETENTION STANDARD
PAGE
K&LC-7
14
K&LC-8
K&LC-9 Key and Lock Control
(b)(7)e
14
K&LC-10
14
K&LC-11
15
39
ICE.11.5082.000108
DETENTION STANDARD
PAGE
K&LC-12
15
K&LC-13
15
K&LC-14
(b)(7)e
15
K&LC-15
15
Law Libraries and Legal Material
LL&LM-1
Libraries and Legal Material, section (V)(1), the FOD must ensure the law library is furnished with a sufficient number of tables and chairs to facilitate residents legal research and writing.
16
40
ICE.11.5082.000109
DETENTION STANDARD
LL&LM-2
LRGP-1
Legal Rights Group Presentations
LRGP-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Law Libraries and Legal Material, section (V)(14), the FOD must ensure the resident handbook or equivalent provides residents with the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for resident use; 2) scheduled hours of access to the law library; 3) procedures 16 for requesting additional time in the law library (beyond the five-hour per week minimum); 4) procedures for requesting legal reference materials not maintained in the law library; and 5) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library. In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(2), the FOD must ensure the presenter provides a one-page poster (no larger than 8.5 by 11 inches) to inform residents of the general nature and contents of the presentation, the intended audience, and the languages 17 in which it will be conducted. The informational posters provided by the presenter must be prominently displayed in housing units, by designated facility staff, at least 48 hours before the scheduled presentation. Each housing unit staff must make a sign-up sheet available for residents who plan to attend. In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(4), the FOD must ensure group 17 presenters are required to check into the facility at least 30 minutes prior to the presentation.
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ICE.11.5082.000110
DETENTION STANDARD Legal Rights Group Presentations
LRGP-3
LRGP-4
MC-1 Medical Care
Medical Care
MC-2
Medical Care
MC-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(6), the FOD must ensure presenters 18 distribute materials to residents and ICE and/or facility staff at the same time. In accordance with the ICE RS, Legal Rights Group Presentations, section (V)(9), the FOD must ensure, if ICE believes that aspects of the presentation have become dated or inaccurate, ICE may discontinue showing the videotape and promptly 18 send written notice to the submitter. In the event a presentation becomes unavailable or unusable, the facility must promptly request that ICE obtain a replacement from the originating person or organization. In accordance with the ICE RS, Medical Care, section (V)(1), the FOD must ensure the health care program and the medical facilities are accredited and 19 maintain compliance with the standards of Joint Commission on the Accreditation of Health Care Organizations. In accordance with the ICE RS, Medical Care, section (V)(2)(a), the FOD must ensure the facilitys written plan 19 addressing the management of infectious and communicable diseases includes media relations. In accordance with the ICE RS, Medical Care, section (V)(4)(a), the FOD must ensure the medical facility is located within the primary perimeter, in an area restricted from general resident access, and has its own perimeter to ensure 19 restricted access. The waiting area must be located at the entrance to the medical facility and be under the direct supervision of custodial staff, not medical staff.
42
ICE.11.5082.000111
DETENTION STANDARD
Medical Care
MC-4
Medical Care
MC-5
PO-1 Post Orders
Recreation
R-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Medical Care, section (V)(4)(b), the FOD must ensure medical records are kept 19 separate from residents records, and are stored in a securely locked area within the medical unit. In accordance with the ICE RS, Medical Care, section (V)(5), the FOD must ensure all pharmaceuticals are stored in 20 a secure area with a solid core door that has a high security lock and a secure medication storage area. In accordance with the ICE RS, Post Orders, section (V)(3)(a-b), the FOD must ensure the Facility Administrator 21 (or designee) approves, signs, and dates each post order on the last page of each section, and initials and dates all other pages. In accordance with the ICE RS, Recreation, section (V)(5)(g), the FOD must ensure recreation areas are under continuous supervision by staff 22 equipped with radios and other communication devices, to ensure the safety of the residents.
43
ICE.11.5082.000112
DETENTION STANDARD
RF-1
Residential Files
Residential Files
RF-2
Residential Files
RF-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Residential Files, section (2)(a-b) and (e)(1), the FOD must ensure the residential file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the residential file may include copies of material contained in the residents A-file. The file must, at a minimum, contain the following forms and documents, or facility equivalents: Form I-385, with one or more photographs attached; housing worksheet; housing identification card; 23 Form G-589; and Form I-77. During the course of the residents stay at the facility, staff must add documents related to resident activities, for example: special requests, grievances, complaints, and the dispositions of the same. Upon the residents release from the facility, staff must add final documents to the file before closing and archiving it. Before the file is closed, the original Form I-385 and other documentation must be inserted into the residential file. In accordance with the ICE RS, Residential Files, section (2)(c), the FOD must ensure active residential files are maintained in a secure area, using lockable cabinets in the admissions processing area unless the Facility 23 Administrator designates otherwise. Cabinets must remain locked when not in use. The Facility Administrator must designate restricted-access storage space for archived files. In accordance with the ICE RS, Residential Files, section (2)(c), the FOD must ensure archived files are 24 placed in storage boxes with the dates covered clearly marked as follows: from [mm/dd/yyyy] to [mm/dd/yyyy].
44
ICE.11.5082.000113
DETENTION STANDARD
Residential Files
RF-4
RF-5 Residential Files
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Residential Files, section (2)(d)(3), the FOD must ensure staff accommodates requests for a residents residential file from other departments that have a documented need for the material. Each borrowed file must be returned by the end of the administrative workday. At a minimum, a logbook entry 24 recording the files removal from the cabinet must include the following: the residents name and A-number; date and time the residential file was removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file. In accordance with the ICE RS, Residential Files, section (2)(e)(5), the FOD must ensure ICE and JFRMU are 24 contacted prior to the destruction of any archived residential files.
45
ICE.11.5082.000114
DETENTION STANDARD
SAAPI-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Sexual Abuse and Assault Prevention and Intervention, section (V)(M), the FOD must ensure all case records associated with claims of sexual abuse (including incident reports, investigative reports, offender information, case disposition, medical and counseling evaluation findings, and recommendations for postrelease treatment and/or counseling) are maintained in appropriate files in accordance with Residential Standards and applicable policies, and retained in accordance with established schedules. 25 Monitoring and evaluation are essential to assess both sexual assault levels and agency effectiveness in reducing sexually abusive behavior. Accordingly, the Facility Administrator must maintain two types of files. General files include: the victim(s) and assailant(s) of a sexual assault; crime characteristics; and formal or informal action taken. Investigative files include all reports; medical forms; supporting memos and videotapes, and any other evidentiary materials pertaining to the allegation.
Sexual Abuse and Assault Prevention and Intervention
46
ICE.11.5082.000115
DETENTION STANDARD
Staff-Resident Communication
SRC-1
SRC-2 Staff-Resident Communication
Suicide Prevention and Intervention
SP&I
Terminal Illness, Advance Directives, and Death
TIADD-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, StaffResident Communication, section (V)(1)(a), the FOD must ensure department heads conduct frequent unannounced, unscheduled visits to the facility's living and activity areas to informally observe living and working conditions, and encourage informal communication among staff and residents. Such unannounced visits 26 must include, but not be limited to: housing units; food service, preferably during the lunch meal; recreation areas; and infirmary rooms. These unannounced visits must be conducted at least weekly. Each facility must develop a method to document the unannounced visits, and ERO staff must also document their visits to facilities. In accordance with the ICE RS, StaffResident Communication, section (V)(1)(d-e), the FOD must ensure a copy of each completed resident 26 request is placed in each residents residential file, and is retained for at least three years. In accordance with the ICE RS, Suicide Prevention and Intervention, section (I), the FOD must ensure residential staff are trained to prevent suicide by 27 recognizing potential risk signs and situations, and to intervene with appropriate sensitivity, supervision, referral, and treatment. In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must 28 ensure health care services address terminal illness, fatal injury, and advance directives.
47
ICE.11.5082.000116
DETENTION STANDARD
TIADD-2
TIADD-3
TIADD-4
TIADD-5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(6), the FOD must ensure, upon the death of a resident, the family has the opportunity to claim the remains within seven calendar days of the date of notification. 28 If family cannot be located or declines the remains, orally or in writing, ERO must notify the consulate in writing. If neither the family nor the consulate claims the remains, ERO must schedule an indigents burial consistent with local procedures. In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(8), the FOD must ensure procedures for closing the case of a deceased resident includes: sending the residents fingerprint card to the FBI, stamped Deceased, and 28 identifying the place of death; placing the residents death certificate or medical examiners report in the residents A-file; placing a copy of the gravesite title in the A-file (indigent burial, only); and closing any electronic records on the resident. In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(9), the FOD must ensure the Facility Administrator 28 specifies policy and procedures identifying the staff member responsible for proper distribution of the death certificate. In accordance with the ICE RS, Terminal Illness, Advance Directives, and Death, section (V)(10), the FOD 29 must ensure each facility has written policy and procedures to implement the provisions for an autopsy, if necessary.
48
ICE.11.5082.000117
DETENTION STANDARD
Tool Control
TC-1
Tool Control
TC-2
TC-3 Tool Control
Tool Control
TC-4
Tool Control
TC-5
Tool Control
TC-6
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Tool Control, section (V)(B)(3-4), the FOD must ensure procedures are in place 30 for marking tools so they are readily identifiable. In accordance with the ICE RS, Tool Control, section (V)(B)(5-7), the FOD must ensure the Officer in Charge develops and implements a written tool control system that establishes 30 procedures and schedules for daily inventory of tools, procedures for issuance of tools to staff and residents, and procedures for documentation of tool issuance to staff and resident workers. In accordance with the ICE RS, Tool Control, section (V)(C), the FOD must ensure the Officer in Charge establishes a policy document on facility tool use 30 and storage that includes a separate, comprehensive, alphabetical list of restricted and non-restricted tools. In accordance with the ICE RS, Tool Control, section (V)(F), the FOD must ensure the following departments 31 maintain a tool inventory: facility maintenance, medical department, food service department, electronics shop, recreation department, and armory. In accordance with the ICE RS, Tool Control, section (V)(H), the FOD must ensure the Officer in Charge establishes written procedures for a tool storage 31 system that ensures accountability. Commonly used, mounted tools must be stored so that a tools disappearance would not escape attention. In accordance with the ICE RS, Tool Control, section (V)(I), the FOD must 31 ensure the Officer in Charge establishes procedures for the receipt of tools.
49
ICE.11.5082.000118
DETENTION STANDARD
Tool Control
TC-7
Tool Control
TC-8
Transfer of Residents
TR-1
TR-2
Visitation
V-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Tool Control, section (V)(J), the FOD must ensure the Officer in Charge schedules 31 and establishes procedures for quarterly inventorying of all tools. In accordance with the ICE RS, Tool Control, section (V)(K), the FOD must ensure each facility has procedures in 31 place to control ladders, extension cords, and ropes. In accordance with the ICE RS, Transfer of Residents, section (V)(2)(c), the FOD must ensure, at the time of transfer of the resident, ERO provides the resident, in writing, the name, 32 address, and telephone number of the facility to which he or she is being transferred, using the Resident Transfer Notification form. Staff must place a copy of the form in the residents A-file. In accordance with the ICE RS, Transfer of Residents, section (V)(4), the FOD must ensure the sending facility staff completes the Resident 32 Transfer Checklist to ensure all procedures are completed before the resident is transferred to another ICE facility. In accordance with the ICE RS, Visitation, section (V)(10)(n), the FOD must ensure log entries include: the date, time of arrival, visitors name, 33 visitors address, supervising attorneys name, residents name and A-number, purpose of visit, time visit began, and time visit ended.
50
ICE.11.5082.000119

Immigration and Customs Enforcement Office of Professional Responsibility Washington, DC 20024

Detention and Removal Operations Buffalo Field Office Buffalo Federal Detention Facility Batavia, New York
April 12-15, 2010
________________________________
FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law enforcement, management, and employee information. It has been written for the express use of the Department of Homeland Security to identify and correct management and operational deficiencies. In reference to OPR Directive 08006.1, issued 09/22/05; any disclosure, dissemination, or reproduction of this document, or any segments thereof, is prohibited without the approval of the Director, Office of Professional Responsibility.
ICE.11.5082.000120
ICE.11.5082.000121
ICE.11.5082.000122
QUALITY ASSURANCE REVIEW BUFFALO FEDERAL DETENTION FACILITY BUFFALO FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. Areas of Concern. OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS Admission and Release. Correspondence and Other Mail.. Detainee Handbook Detention Files Emergency Plans Environmental Health and Safety. Food Service Funds and Personal Property Grievance System.. Hold Rooms in Detention Facilities.. Key and Lock Control. Law Libraries and Legal Material. Legal Rights Group Presentations Marriage Requests. Medical Care Post Orders. Religious Practices. Searches of Detainees.. Staff-Detainee Communication..... Tool Control.. Transfer of Detainees. Transportation. Use of Force and Restraints.. Visitation... 1 1
3 3
5 5
8 9 10 12 13 14 15 16 17 20 22 23 24 25 26 27 28 29 30 31 34 36 37 38
ICE.11.5082.000123
APPENDIX ACRONYMS SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS SUMMARY OF RECOMMENDATIONS A B C
ICE.11.5082.000124
INSPECTION PROCESS
The Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE Performance Based National Detention Standards (PBNDS). In addition, focus may be applied to the inspection with information provided by the Office of Detention and Removal Operations (DRO) Headquarters and DRO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. ODO conducted an inspection of the Buffalo Federal Detention Facility (BFDF), located in Batavia, New York, on April 12-15, 2010. All 41 Performance Based National Detention Standards (PBNDS) were reviewed. ODO reviewed the processes employed at BFDF to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the Enforce Alien Booking Module (EARM), the Joint Integrity Case Management System, DRO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. Recommendations are provided to improve the effectiveness, efficiency, and overall living conditions at the detention center. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Director, Office of Professional Responsibility.

Special Agent (Team Leader) Section Chief Special Agent Special Agent Special Agent Detention and Deportation Officer Detention and Deportation Officer Management and Program Analyst Management and Program Analyst Contract Inspector Contract Inspector
1
(b)(6), (b)(7)(C)
ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America MGT of America
Office of Detention Oversight April (b)(7)e OPR
Buffalo Federal Detention Facility DRO Buffalo
ICE.11.5082.000125
(b)(6), (b)(7)(C)
Contract Inspector Contract Inspector Contract Inspector
MGT of America MGT of America MGT of America
Office of Detention Oversight April 2010 OPR (b)(7)e
ICE.11.5082.000126
BACKGROUND
HISTORY
BFDF has a capacity of 666 ICE detainees and pre-trial United States Marshals Service (USMS) inmates. BFDF houses adult males of all classification levels. At the time of the review, BFDF had an ICE detainee population of 505 and a USMS population of 101. There are 231 contract workers and 116 DRO staff assigned to the facility. The correctional staff, warehouse and food service operations are contracted to Valley Metro Barbosa Group (VMBG). Medical services are provided by the Division of Immigration Health Services (DIHS). Maintenance and sanitation support are contracted to The Centurion Group, Inc. BFDF is accredited by the American Correctional Association (August 2008), the National Commission on Correctional Health Care (October 2008), and the Joint Commission on Accreditation of Healthcare Organizations (June 2008). In September 2009, the DRO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the ICE Performance Based National Detention Standards (PBNDS) at BFDF. The final overall rating for the review was Meets Standards.
AREA OF CONCERN
BFDF was found deficient in two mandatory components; one in the Food Service standard and one in the Tool Control standard.
ICE.11.5082.000127
ICE.11.5082.000128
INTERNAL RELATIONS
ODO interviewed numerous ICE and VMBG staff. Most staff stated morale was very good. A few immigration enforcement agents (IEA) stated some coworkers are allowed to perform less work than others. Some ICE staff stated they are uncertain of their future roles at BFDF, due to the new contract with VBMG for corrections officers which began in December 2009. The IEAs feel VBMG may be taking over responsibility for many duties previously assigned to IEAs. One IEA mentioned Administratively Uncontrollable Overtime (AUO) issues, and told ODO when assigned to Justice Prisoner and Alien Transportation System (JPATS), IEAs work overtime before they are allowed to claim AUO, which can cause a loss of AOU status. Several ICE staff mentioned Headquarters tasking requests often interfere with daily work assignments. It was also mentioned that Headquarters seems to change priorities, direction and expectations regularly, making it difficult to know what is expected. Some staff stated the need for new equipment and vehicles, but knew budget constraints were preventing upgrades. Most VMBG officers seemed to have a good working knowledge of facility procedures; however, many did not know for sure if they had ever had ICE detention standard training. One VMBG officer stated he had overheard racial and/or discriminating jokes among the contract staff; this information was discussed with the Field Office Director. Both ICE and VMBG employees stated they share a good working relationship and communicate well with each other, although some staff mentioned there are ICE employees who think they are superior to the contractors, and vice versa. Both groups also stated ICE staff makes required visits to the detainee living areas.
DETAINEE RELATIONS
ODO interviewed 34 detainees. These detainees were from several of the facilitys housing areas, including the SMU. Detainees are aware of their deportation officers names and most know the status of their immigration cases. Detainees stated they know how to send and receive mail, and are aware of the procedures to use the telephones. They further stated they are offered outside recreation on a daily basis. Many detainees told ODO food portions at BFDF are too small; ODO verified the daily calorie counts for the meals are adequate. Two detainees told ODO they were not receiving their special diet meals. They indicated requests were made, and they are waiting for approval or denial. ODO determined one detainees request for a kosher diet was processed through proper channels for clearance. His request had not reached the Food Service Department as of the conclusion of the inspection. The other detainee had requested a special diet due to an egg allergy. Food service staff was informed of the detainees need for a special diet, and the request was granted prior to the conclusion of the ODO inspection.
Office of Detention Oversight April 2010 OPR (b)(7)e Buffalo Federal Detention Facility DRO Buffalo
ICE.11.5082.000129
Some detainees stated they had witnessed racial or discriminatory actions by three VMBG corrections officers, who had allegedly singled out Muslims for retribution. The officers referred to Muslims in a derogatory manner, treated them differently than other detainees, and told them they could not pray. ODO interviewed several Muslim detainees who reported they were moved from their regular housing unit to inprocessing, where they were held without justification for up to four hours at a time. One Muslim detainee reported receiving threats and intimidating comments from the three VMBG officers. ODO made notification to the Joint Intake Center (JIC) and immediately notified local senior ICE management regarding these allegations. One detainee stated there were no television programs in Spanish. Another detainee said he was not allowed to shower upon admission because it was too late in the day. One detainee said he was not receiving his medication; however, ODO checked his medical records, which reflected he was receiving it. ODO verified the OIG hotline was in working order after a few detainees stated it was inoperable.
ICE.11.5082.000130
ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS

Out of the 41 PBNDS reviewed by ODO, no deficiencies were noted in the following 17 standards: Classification System; Contraband; Disciplinary System; Escorted Trips for Non-Medical Emergencies; Facility Security and Control; Hunger Strikes; News Media Interviews and Tours; Personal Hygiene; Population Counts; Recreation; Sexual Abuse and Assault Prevention and Intervention; Special Management Units; Staff Training; Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives, and Death; and Voluntary Work Program. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.
ICE.11.5082.000131

ODO reviewed the Admission and Release standard at BFDF to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE PBNDS. ODO reviewed policies, observed the admission process, and interviewed staff and detainees. ODO observed items are stored in the showers in the processing area, and noted detainees admitted to the facility were not required to shower prior to entering their assigned housing units (Deficiency AR-1). DRO staff advised, and ODO observed, every detainee entering the facility with a criminal history is strip searched during inprocessing (Deficiency AR-2 and SD-2). The orientation video at BFDF is outdated and lacking required information. There is not a question-and-answer session after detainees view the video (Deficiency AR-3).

DEFICIENCY AR-1 In accordance with the ICE PBNDS, Admission and Release, section (V)(B)(2), the FOD must ensure, to maintain standards of personal hygiene and to prevent the spread of communicable diseases and other unhealthy conditions within the housing units, every detainee must shower before entering his or her assigned unit. DEFICIENCY AR-2 and SD-2 In accordance with the ICE PBNDS, Admission and Release, sections (V)(B)(4)(a) and (c), the FOD must ensure staff do not routinely require a detainee to remove clothing or require a detainee to expose private parts of his or her body to search for contraband. The articulable facts supporting the conclusion that reasonable suspicion exists should be documented. Staff may conduct a strip search only where there is reasonable suspicion contraband may be concealed on the person. DEFICIENCY AR-3 In accordance with the ICE PBNDS, Admission and Release, section (V)(F), the FOD must ensure, during the admissions process, the facilitys orientation video is played for every detainee, and following the video, staff conducts a question-and-answer session.
RECOMMENDATIONS TO IMPROVE EFFECTIVENESS AND EFFICIENCY

ODO recommends BFDF contact DRO Headquarters for assistance in making an updated orientation video.
Office of Detention Oversight 8

(b)(7)e
ICE.11.5082.000132
CORRESPONDENCE AND OTHER MAIL (C&OM)

ODO reviewed the Correspondence and Other Mail standard at BFDF to determine if the facility provides detainees the opportunity to send and receive correspondence, in a timely manner, subject to limitations required for the safe and orderly operation of the facility, in accordance with the ICE PBNDS. ODO observed the mailroom, interviewed staff, and reviewed logbooks and the detainee handbook. A review of the detainee handbook revealed notification of the facility correspondence policy is not provided in Spanish, the language spoken by the majority of the detainee population at BFDF. Also, according to the detainee handbook, mail issued in the housing units is not opened and inspected in the detainees presence. (Deficiency C&OM-1 and DH-6).

DEFICIENCY C&OM-1 and DH-6 In accordance with the ICE PBNDS, Correspondence and Other Mail, sections (V)(C) and (V)(C)(3), the FOD must ensure the facility notifies detainees of its rules on correspondence and other mail through the detainee handbook, or supplement, provided to each detainee upon admittance. At a minimum, the notification must specify general correspondence and other mail addressed to detainees will be opened and inspected in the detainees presence, unless the Facility Administrator authorizes inspection without the detainees presence for security reasons. The facility must provide key information to detainees in languages spoken by any significant portion of the facilitys detainee population.

None

(b)(7)e
ICE.11.5082.000133
DETAINEE HANDBOOK (DH)

ODO reviewed the Detainee Handbook standard at BFDF to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE PBNDS. ODO interviewed staff, and reviewed the detainee handbook and detention files. The facility-specific detainee handbook is not translated into Spanish or any other language spoken by significant numbers of detainees at the facility (Deficiency DH-1). The handbook does not provide procedures for requesting interpretive services for essential communication (Deficiency DH-2). The handbook also does not provide procedures for filing a claim for lost or damaged property, or accessing personal funds for legal services (Deficiency DH-3 and F&PP-2). The handbook does not contain the notification that facility procedures require strip searches after contact visits with legal representatives; however, the facility provides an option for non-contact visits with legal representatives, in an environment allowing for confidentiality and not requiring strip searches (Deficiency DH-4 and V-2). Although the detainee handbook explains the policy and procedures for the law library, it does not explain Lexis-Nexis is used at the facility or state instructions for its use are available (Deficiency DH-5 and LL&LM-1). The handbook states mail is issued in the housing units already opened and inspected (Deficiency DH-6 and C&OM-1). The detainee handbook lacks appeals procedures for instances when marriage requests are denied, or approvals are revoked (Deficiency DH-7 and MR-1).

DEFICIENCY DH-1 In accordance with the ICE PBNDS, Detainee Handbook, section (V)(3), the FOD must ensure the ICE National Detainee Handbook is provided in English, Spanish and other languages as determined necessary by the FOD. The Facility Administrator must ensure the local supplement is translated into Spanish and any other language spoken by significant numbers of detainees in the facility. DEFICIENCY DH-2 In accordance with the ICE PBNDS, Detainee Handbook, section (V)(2), the FOD must ensure each local supplemental notifies each detainee of procedures for requesting interpretive services for essential communication. DEFICIENCY DH-3 and F&PP-2 In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must ensure the detainee handbook, or equivalent, notifies detainees of facility policies and procedures concerning personal property, including: the procedures for
Office of Detention Oversight April 2010 OPR 201006754 Buffalo Federal Detention Facility DRO Buffalo
10
ICE.11.5082.000134
filing a claim for lost or damaged property, and the procedures for accessing detainee personal funds to pay for legal services. DEFICIENCY DH-4 and V-2 In accordance with the ICE PBNDS, Visitation, section (V)(J)(11), the FOD must ensure each facility has written procedures to govern detainee searches, consistent with the ICE/DRO Detention Standard on Searches of Detainees. If standard operating procedures require strip searches after every contact visit with a legal representative, the facility must provide an option for non-contact visits with legal representatives in an environment allowing confidentiality. Each detainee must receive a copy of these search procedures in the detainee handbook or local supplement given each detainee upon admission. DEFICIENCY DH-5 and LL&LM-1 In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(O)(8), the FOD must ensure the detainee handbook or supplement provides detainees with the rules and procedures governing access to legal materials including, if applicable, Lexis-Nexis is used at the facility, and instructions for its use are available. DEFICIENCY DH-6 and C&OM-1 In accordance with the ICE PBNDS, Correspondence and Other Mail, sections (V)(C) and (V)(C)(3), the FOD must ensure the facility notifies detainees of its rules on correspondence and other mail through the detainee handbook or supplement provided to each detainee upon admittance. At a minimum, the notification must specify general correspondence and other mail addressed to detainees will be opened and inspected in the detainees presence, unless the Facility Administrator authorizes inspection without the detainees presence for security reasons. The facility must provide key information to detainees in languages spoken by any significant portion of the facilitys detainee population. DEFICIENCY DH-7 and MR-1 In accordance with the ICE PBNDS, Marriage Requests, sections (V)(B), (V)(E)(2) and (V)(F), the FOD must ensure the detainee handbook, provided to each detainee upon admittance, advises detainees of the facilitys marriage request procedures.

None

(b)(7)e
ICE.11.5082.000135

ODO reviewed the Detention Files standard at BFDF to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE PBNDS. ODO reviewed detention files, toured the admissions and release area, and interviewed staff. Some detention files did not include a housing identification card, and the cards included in the files did not specify the housing unit or the bed assigned to the detainee (Deficiency DF-1). The detention files removed from the intake area were not signed out using a designated logbook; BFDF uses temporary cards and annotates the name of the person removing the file and the date. The cards are used for multiple files, are eventually discarded and do not contain: the reason for removal; the signature of the person removing the file; the title and department of the person removing the file; or the date, time and signature of the person returning the file (Deficiency DF-2). This deficiency was corrected prior to the conclusion of review.

DEFICIENCY DF-1 In accordance with the ICE PBNDS, Detention Files, section (V)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-File. The file must, at a minimum, contain: Alien Booking Record (Form I-385), with one or more original photograph(s) attached; Classification Worksheet; the Personal Property Inventory Sheet; Housing Identification Card; Property Receipt (Form G-589), or facility equivalent; and Baggage Check(s) (Form I-77). DEFICIENCY DF-2 In accordance with the ICE PBNDS, Detention Files, section (V)(F)(3), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

None

(b)(7)e
ICE.11.5082.000136

ODO reviewed the Emergency Plans standard at BFDF to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with the ICE PBNDS. ODO reviewed the facilitys emergency plans and documentation of drills, interviewed staff, and inspected emergency evacuation plans and routes. ODO was provided with three letters from local and state law enforcement agencies agreeing to support the facility in the event of an emergency; however, BFDF does not have Memoranda of Understanding (MOUs) formalizing the agreements (Deficiency EP-1).

DEFICIENCY EP-1 In accordance with the ICE PBNDS, Emergency Plans, section (V)(C)(1)(b), the FOD must ensure the facility develops contingency plans with local, State and Federal law enforcement agencies, and formalize those agreements with MOUs. The Facility Administrator and representatives from the affected agencies must cosign the MOUs.

None

(b)(7)e
ICE.11.5082.000137

ODO reviewed the Environmental Health and Safety standard at BFDF to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE PBNDS. ODO toured the facility, interviewed staff, reviewed policies, and inspected documentation of inspections, fire drills and management of chemical hazards. ODO observed an employee in the property room working on a lift above the four-foot level not wearing a safety harness, as required by Occupational Safety and Health Administration (OSHA) 29CFR 1910.67(c)(vi). The warehouse inventory of Simple Green chemical concentrate was not current (Deficiency EH&S-1). This deficiency was corrected during the ODO inspection. The master index of hazardous substances, with locations and telephone numbers, had not been provided to the local fire department (Deficiency EH&S-2).

DEFICIENCY EH&S-1 In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(C), the FOD must ensure every area maintains a current inventory of the hazardous substances (flammable, toxic or caustic) used and stored there. DEFICIENCY EH&S-2 In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(E), the FOD must ensure the Maintenance Supervisor compiles a master index of all hazardous substances in the facility and their locations; a master file of Material Safety Data Sheets; and a comprehensive, up-to-date list of emergency telephone numbers (fire department, poison control, etc). The Maintenance Supervisor must maintain this information in the Safety Office (or equivalent), and ensure a copy is sent to the local fire department.

ODO recommends the FOD conducts OSHA safety training and ensures facility staff follows all OSHA requirements.

(b)(7)e
ICE.11.5082.000138
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at BFDF to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE PBNDS. ODO interviewed food service staff; inspected food and chemical storage areas, the scullery, and equipment; observed meal preparation and service; and reviewed policies, menus, temperature logbooks, certifications, and health screenings. Food temperatures were obtained throughout the meal service, from meal plating to service to detainees in the housing units. The shadow board in the knife cabinet is not color-coded with red shadows signifying the tools are restricted (Mandatory)(Deficiency FS-1 and TC-3). Items from the kosher menu are offered as the Common Fare option. The kosher menu contains meat as part of the main protein source (Deficiency FS-2). A Common Fare menu has been proposed by the contractor; however, the facility has not approved its implementation.

DEFICIENCY FS-1and TC-3 (Mandatory) In accordance with the ICE PBNDS, Food Service, section (V)(B)(2), and Tool Control, section (V)(H)(2), the FOD must ensure knives are inventoried and stored in accordance with the Detention Standard on Tool Control, which states, the FOD must ensure commonly used, mounted tools are stored so a tools disappearance will not escape attention. Shadow boards must provide storage for tools that can be mounted, as follows: one tool per shadow; tool and shadow identical in size and shape; and color-coded: white backgrounds for all shadow boards, red shadows for restricted tools, and black shadows for non-restricted tools. DEFICIENCY FS-2 In accordance with the ICE PBNDS, Food Service, section (V)(K)(1), the FOD must ensure facilities provide detainees requesting a religious diet a reasonable and equitable opportunity to observe their religious dietary practice within the constraints of budget limitations and the security and orderly running of the facility by offering a Common Fare menu. Common Fare refers to a no-flesh protein option provided whenever an entre containing flesh is offered as part of a meal.

None
Office of Detention Oversight April 2010

(b)(7)e
15
ICE.11.5082.000139

ODO reviewed the Funds and Personal Property standard at BFDF to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE PBNDS. ODO reviewed policies and detention files, and interviewed staff. ODO reviewed over 30 detention files, and observed several property receipts (Form G-589) were signed by only one officer (Deficiency F&PP-1). The handbook does not provide procedures for filing a claim for lost or damaged property, or for accessing personal funds for legal services (Deficiency F&PP-2 and DH-3).

DEFICIENCY F&PP-1 In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(G)(1), the FOD must ensure, for recordkeeping and accounting purposes, Form G-589 is mandatory to inventory any funds removed from a detainees possession, and a separate Form G-589 is required for each kind of currency and negotiable instrument. The removal and inventory must be conducted in the detainees presence, and at least two officers must be present to remove funds from a detainees possession and to inventory the property on Form G-589. The two officers and the detainee must sign all copies of Form G-589. DEFICIENCY F&PP-2 and DH-3 In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must ensure the detainee handbook, or equivalent, notifies detainees of facility policies and procedures concerning personal property, including: the procedures for filing a claim for lost or damaged property, and the procedures for accessing detainee personal funds to pay for legal services.

None

(b)(7)e
ICE.11.5082.000140

ODO reviewed the Grievance System standard at BFDF to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE PBNDS. ODO reviewed grievance procedures, the grievance logbook, detention files, and the appeals process. ODO also interviewed detainees and staff, including the Grievance Officer (GO). A procedure to ensure all medical grievances are received by the Administrative Health Authority within 24 hours or the next business day is not included in BFDF policy 3.5.6, Detainee Grievance Procedure (Deficiency GS-1). The detainee handbook does not state detainees always have the right to file a formal grievance and pursue the formal grievance process. Instead, the handbook states detainees must go through the informal grievance process before submitting a formal grievance. The handbook also does not include the process for filing emergency grievances (Deficiency GS-2). When a detainee makes an oral grievance, BFDF staff does not document the outcome of the grievance and place the document in the detainees detention file or log the oral grievance in the grievance logbook (Deficiency GS-3). A review of the grievance policy showed the protocol for emergency grievances does not include immediately notifying the Facility Administrator. The GO stated the shift supervisor is notified of emergency grievances and the Facility Administrator is later notified by a report (Deficiency GS-4). The Detainee Grievance Committee (DGC) is not chaired by the Assistant Chief of Security (Deficiency GS-5). The grievance logbook does not include a column for the date the grievance was resolved, including its disposition. Staff does not log oral grievances, nuisance and petty grievances, or grievances rejected or denied by the facility (Deficiency GS-6). The grievance policy does not require oral or written grievances to be reviewed by the next level in the grievance process if it is determined the grievance should not be fully processed, such as the GO sending the grievance to the DGC for review. Rejected grievances are not logged as rejected in the grievance logbook (Deficiency GS-7).

DEFICIENCY GS-1 In accordance with the ICE PBNDS, Grievance System, section (V)(A), the FOD must ensure procedures are in place requiring receipt of all medical grievances by the Administrative Health Authority within 24 hours or the next business day.
(b)(7)e
17
ICE.11.5082.000141
DEFICIENCY GS-2 In accordance with the ICE PBNDS, Grievance System, sections (V)(B) and (V)(C)(1), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or local supplement, in which the grievance section provides notice of: the expectation, to the greatest extent possible, complaints and grievances should be handled orally and informally by staff in their daily interaction with detainees. Nevertheless, the detainee always has the right to file a formal grievance and pursue the formal grievance process. The FOD must ensure a detainee is free to bypass or terminate the informal grievance process at any point and proceed directly to the formal grievance stage. The grievance section in the detainee handbook must also provide notice of the process for filing emergency grievances. DEFICIENCY GS-3 In accordance with the ICE PBNDS, Grievance System, section (V)(C)(1), the FOD must ensure, if an oral grievance is resolved, the employee need not provide the detainee with written confirmation of the outcome, but must document the result for the record in the detainees detention file, and in any logs or data systems the facility has established to track such actions. DEFICIENCY GS-4 In accordance with the ICE PBNDS, Grievance System, section (V)(C)(2), the FOD must ensure the protocol for emergency grievance procedures brings the matter to the immediate attention of the Facility Administrator, even if it is later determined it is not a true emergency and the grievance is subsequently routed through normal, nonemergency channels. DEFICIENCY GS-5 In accordance with the ICE PBNDS, Grievance System, section (V)(D)(1), the FOD must ensure the Assistant Chief of Security chairs the DGC, along with two department heads or their representatives. DEFICIENCY GS-6 In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure the detainee grievance log includes the receipt date and disposition. Nuisance or petty grievances, and grievances rejected or denied, must also be logged with the appropriate notation and justification (for example, petty). DEFICIENCY GS-7 In accordance with the ICE PBNDS, Grievance System, section (V)(F), the FOD must ensure, if the shift supervisor or other employee designated to receive grievances believes the grievance is one that should not be fully processed, he or she documents the determination and refers the grievance to the GO or DGC. If the GO or DGC concurs, the grievance must be logged in the detainee grievance log with rejected as the disposition, and a copy of the grievance must be placed in the detainees detention file.

(b)(7)e
18
ICE.11.5082.000142

None

(b)(7)e
19
ICE.11.5082.000143
HOLD ROOMS IN DETENTION FACILITIES (HR)

ODO reviewed the Hold Rooms in Detention Facilities standard at BFDF to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure and comfortable environment, and not held confined in hold rooms for over 12 hours, in accordance with the ICE PBNDS. ODO observed the physical conditions of the hold rooms, as well as the detainee search procedures; reviewed logbooks, operational procedures and evacuation plans; and interviewed staff and detainees. A large hold room had only one stainless steel, combination lavatory/toilet fixture (Deficiency HR-1). ODO observed a hold room with graffiti on the wall (Deficiency HR-2). Staff told ODO detainees are not provided with disposable cups while in hold rooms (Deficiency HR-3), however, the combination lavatory/toilet fixture has a drinking fountain. The hold room log does not include space for the date and time of an age determination, or for security concerns (Deficiency HR-4).

DEFICIENCY HR-1 In accordance with the ICE PBNDS, Hold Rooms, section (V)(A)(6), the FOD must ensure each hold room is equipped with stainless steel, combination lavatory/toilet fixtures with modesty panels, in compliance with the Americans with Disabilities Act of 1990. Consistent with the International Plumbing Code: each small hold room (up to 14 detainees) must have one combi-unit; each large hold room (15 to 49 detainees) must have at least two combi-units. DEFICIENCY HR-2 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(D)(4)(9), the FOD must ensure staff ensures that sanitation in hold rooms is maintained at acceptable and comfortable levels. When the last detainee has been removed, officers must ensure the hold room is thoroughly cleaned and inspected for any evidence of tampering with doors, locks, windows, grills, plumbing, or electrical fixtures, and report any such problems to the shift supervisor for corrective action or repair. DEFICIENCY HR-3 In accordance with the ICE PBNDS, Hold Rooms, section (V)(B)(6), the FOD must ensure detainees are provided with basic personal hygiene items, for example, water, disposable cups, soap, toilet paper, feminine-hygiene items, diapers, and sanitary wipes. DEFICIENCY HR-4 In accordance with the ICE PBNDS, Hold Rooms, section (V)(D)(2), the FOD must ensure the detention log records the date and time of new age determinations and provides space to record meal times, visual checks, security concerns (which may also necessitate an incident report), and comments.
(b)(7)e
20
ICE.11.5082.000144

None

(b)(7)e
21
ICE.11.5082.000145

ODO reviewed the Key and Lock Control standard at BFDF to determine if facility safety and security is maintained by requiring keys and locks to be controlled and maintained, in accordance with the ICE PBNDS. ODO reviewed policies, inventories, and training plans; toured the facility; interviewed staff; observed lock shop operations; and inspected key cabinets. The Security Officer does not have a written position description (Deficiency K&LC-1). Envelopes containing safe combinations are not stored in the lock shop; instead, they are secured in the Facility Managers office, in accordance with a memorandum issued by the Assistant Field Office Director (AFOD) (Deficiency K&LC-2).
(b)(7)e

None

(b)(7)e
ICE.11.5082.000146

ODO reviewed the Law Libraries and Legal Material standard at BFDF to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE PBNDS. ODO interviewed staff and detainees, reviewed policies and the detainee handbook, and observed procedures and the law library. The detainee handbook does not state Lexis-Nexis is used at the facility and instructions for its use are available (Deficiency LL&LM-1 and DH-5).

DEFICIENCY LL&LM-1 and DH-5 In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(O)(8), the FOD must ensure the detainee handbook or supplement provides detainees with the rules and procedures governing access to legal materials including, if applicable, Lexis-Nexis is being used at the facility, and instructions for its use are available.

None

(b)(7)e
ICE.11.5082.000147

ODO reviewed the Legal Rights Group Presentations standard at BFDF to determine if authorized persons and organizations are permitted to make presentations to groups of detainees for the purpose of providing information on immigration law and procedures, in accordance with the ICE PBNDS. ODO interviewed staff and reviewed presentation requests. The facility does not require attorneys to present state-issued bar cards or other proof of bar membership (Deficiency LRGP-1). Although the facility requires advance approval, it does not require the presenter to list published or unpublished materials proposed for distribution. Of the two sets of materials requested to be distributed during group presentations, one set of materials identified the submitter and the preparer of the material, but the other set did not furnish the required identifications (Deficiency LRGP-2). The presentation request also did not clearly state ICE/DRO did not prepare, and is not responsible for, the contents of the material presented (Deficiency LRGP-2).

DEFICIENCY LRGP-1 In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(H), the FOD must ensure attorneys present state-issued bar cards or, in states where these are not available, other proof of bar membership. If such documentation is not readily available to attorneys licensed in a particular state, they must indicate where they are licensed as attorneys and how it may be verified prior to their admittance. DEFICIENCY LRGP-2 In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(J), the FOD must ensure requests for approval of a presentation list any published or unpublished materials proposed for distribution, and ensure the requestor provides a copy of any unpublished material, with a cover page: identifying the submitter and the preparer of the material, including the date of preparation; and stating clearly ICE/DRO did not prepare, and is not responsible for, the contents of the material. If the material is in a language other than English, an English translation must be provided.

None

(b)(7)e
24
ICE.11.5082.000148
MARRIAGE REQUESTS (MR)

ODO reviewed the Marriage Requests standard at BFDF to determine if marriage requests from detainees are reviewed on a case-by-case basis, based on internal guidelines for approval of such requests, in accordance with the ICE PBNDS. ODO interviewed staff, and reviewed the detainee handbook, and policies and procedures. The detainee handbook lacks appeals procedures for instances when marriage requests are denied or approvals are revoked (Deficiency MR-1 & DH-7).

DEFICIENCY MR-1 and DH-7 In accordance with the ICE PBNDS, Marriage Requests, sections (V)(B), (V)(E)(2) and (V)(F), the FOD must ensure the detainee handbook, provided each detainee upon admittance, advises detainees of the facilitys marriage request procedures.

None

(b)(7)e
ICE.11.5082.000149
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at BFDF to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE PBNDS. ODO toured the medical clinic, reviewed policies and procedures, examined 28 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by the Division of Immigration Health Services (DIHS), and holds American Correctional Association, National Commission on Correctional Health Care, and Joint Commission on Accreditation of Healthcare Organizations accreditations. A Consent for Medical Treatment form was not included in one record reviewed (Deficiency MC-1), and one record had a consent that was not dated. The Health Services Administrator informed ODO health screenings are conducted by Registered or Licensed Vocational Nurses, and mid-level providers perform health appraisals. Health screenings are not reviewed within 24 hours to assess the priority for treatment (Deficiency MC-2).

DEFICIENCY MC-1 In accordance with the ICE PBNDS, Medical Care, section (V)(T), the FOD must ensure, upon admission at the facility, documented informed consent is obtained for the provision of health care services. DEFICIENCY MC-2 In accordance with the ICE PBNDS, Medical Care, section (V)(I), the FOD must ensure the Clinical Medical Authority is responsible for the review of all health screening forms within 24 hours or the next business day to assess the priority for treatment (for example, Urgent, Today, or Routine).

None

(b)(7)e
26
ICE.11.5082.000150
POST ORDERS (PO)

ODO reviewed the Post Orders standard at BFDF to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE PBNDS. ODO reviewed post orders, observed facility posts, and interviewed staff. BFDF does not have post orders for the Security Officer in charge of key and lock control (Deficiency PO-1). Post orders for each post are issued in folders, but are not organized into the required sections and do not include the ICE/DRO detention standards, or policies and facility practices relevant to the posts (Deficiency PO-2). ODO observed the Special Housing Unit post orders were not initialed and dated on all pages by the Facility Administrator or designee (Deficiency PO-3). This deficiency was corrected during the review; however, the initials were back-dated to match the original signature on the last page of the post order and were the initials of the AFOD, who was on leave during the review.

DEFICIENCY PO-1 In accordance with the ICE PBNDS, Post Orders, section (V)(A), the FOD must ensure there are written post orders for each security post. DEFICIENCY PO-2 In accordance with the ICE PBNDS, Post Orders, section (V)(D), the FOD must ensure the post orders for each post are issued in six-part classification folders and organized as follows: Section 1: Specific post orders, listing activities chronologically, with responsibilities clearly defined; Section 2: Special instructions, if any, relating to the specific post; Section 3: General post orders applicable to all posts; Section 4: Memoranda changing or updating the post orders; Section 5: ICE/DRO detention standards, and policies and facility practices relevant to the post; and Section 6: Review and Signature Form, with the officers name printed, signed and dated. DEFICIENCY PO-3 In accordance with the ICE PBNDS, Post Orders, section (V)(C), the FOD must ensure the Facility Administrator (or designee) approves, signs and dates each post order on the last page of each section, initials and dates all other pages, and initials and dates any subsequent changes to the post order.

None

(b)(7)e
27
ICE.11.5082.000151
RELIGIOUS PRACTICES (RP)

ODO reviewed the Religious Practices standard at BFDF to determine if the detainees of different religious beliefs are provided reasonable and equitable opportunities to participate in the practices of their respective faiths, in accordance with the ICE PBNDS. ODO conducted interviews with staff, and reviewed BFDF policies, procedures, the detainee handbook, electronic records, and detention files. ICE staff assigned to the in-processing area stated incoming detainees religious preferences are not obtained or documented (Deficiency RP-1).

DEFICIENCY RP-1 In accordance with the ICE PBNDS, Religious Practices, section (V)(B), the FOD must ensure each detainee designates any or no religious preference during in-processing.

ODO recommends BFDF obtain any or no religious preference for all detainees during in-processing and document this information in EABM.

(b)(7)e
28
ICE.11.5082.000152
SEARCHES OF DETAINEES (SD)

ODO reviewed the Searches of Detainees standard at BFDF to determine the level of protection of detainees and staff, and overall facility security and order, through the detection, control and disposition of all contraband, in accordance with the ICE PBNDS. ODO reviewed policies, observed the admission process, and interviewed staff and detainees.
(b)(7)e
(b)(7)e

None

(b)(7)e
ICE.11.5082.000153

ODO reviewed the Staff-Detainee Communication standard at BFDF to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE PBNDS. ODO reviewed policies, procedures and logbooks, and interviewed staff and detainees. ODO found facility housing units do not have secure mailboxes for detainee communication. Detainees are required to give their request forms to contract housing officers, who hold the requests in a folder until an ICE representative visits the unit (Deficiency SDC-1). According to ICE staff, the facility exceeds the standard by requiring ICE line and management staff to visit each housing unit no less than nine times each day.

DEFICIENCY SDC-1 In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(B), the FOD must ensure each facility provides a secure drop box for ICE detainees to correspond directly with ICE management. Only ICE personnel will have access to the drop box.

None

(b)(7)e
ICE.11.5082.000154
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at BFDF to determine if tools are properly classified, identified, inventoried, stored and issued, in accordance with the ICE PBNDS. ODO reviewed local policies, toured the facility, inspected inventories and documentation, and interviewed staff. BFDF policy 3.1.15 does not establish a tool control system addressing procedures required by the standard or identify a staff person responsible for the tool control program (Mandatory)(Deficiency TC-1). Absent a policy establishing comprehensive procedures and designating responsibility, control of tools is handled inconsistently across facility departments, and documentation is decentralized and not reviewed. BFDF does not have a tool classification system and does not consistently designate tools as restricted or non-restricted. Separate, comprehensive, alphabetical listings of restricted and non-restricted tools are not maintained (Deficiency TC-2). Shadow boards are used for tool storage; however, the knife cabinet in the Food Service Department does not have white backgrounds with red shadows signifying restricted tools (Deficiency TC-3 and FS-1). BFDF does not have a master tool inventory. Department heads maintain current listings of tools in their areas, and conduct periodic inventories to ensure accuracy. The Facility Administrator does not schedule and has not established procedures for inventorying all facility tools. Tool inventories are not conducted quarterly or annually, and inventory files are not maintained (Deficiency TC-4). BFDF does not have procedures regarding: the issuance of tools to staff and detainees; security issues of restricted and unrestricted tools; or control of ladders, extension cords, and ropes (Deficiency TC-5). The Maintenance Department is responsible for destroying broken and worn out tools, and maintaining documentation of disposal; however, no written procedures exist (Deficiency TC-6). During the inspection, a revision to the tool control policy was drafted to address these deficiencies.
STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
(b)(7)e

(b)(7)e
ICE.11.5082.000155
(b)(7)e

(b)(7)e
ICE.11.5082.000156

None

(b)(7)e
33
ICE.11.5082.000157
TRANSFER OF DETAINEES
ODO reviewed the Transfer of Detainees standard at BFDF to determine if transfers of detainees from one facility to another are responsibly managed in regard to notification, detention records, safety and security, and protection of detainee funds and property, in accordance with the ICE PBNDS. ODO reviewed policies and other documentation, interviewed staff, and toured the admissions and release area. At the time of transfer, ODO did not observe DRO provide, in writing, the name, address and telephone number of the facility in which detainees were being transferred on a Detainee Transfer Notification form. ODO interviewed detainees being transferred, and none were able to state the name of the facility to which they were being transferred (Deficiency TD-1). Upon staff questioning, ODO learned, during transport, detainees are only permitted to have dentures and prescription eyeglasses in their possession (Deficiency TD-2). Although food was provided to detainees, ODO did not see the transporting crew maintain a constant supply of drinking water, or ice, in water containers or paper cups for detainee use (Deficiency TD-3 and T-2).

DEFICIENCY TD-1 In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(B)(3), the FOD must ensure, at the time of transfer, ICE/DRO provides the detainee, in writing, the name, address and telephone number of the facility to which he or she is being transferred, using the Detainee Transfer Notification form. Staff must place a copy of the form in the detainees detention file. DEFICIENCY TD-2 In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(D)(1), the FOD must ensure, before transfer, the sending facility returns all funds and small valuables to the detainee and closes out all Form G-589s, in accordance with the Detention Standard on Funds and Personal Property. During transport, a detainee will ordinarily have the following items in his or her possession: cash; all legal material; small valuables, such as jewelry; address books, phone lists, correspondence; dentures, prescription glasses; small religious items; photos; similar small personal property items. However, items that might present a security risk or are particularly bulky may be transported separately in the vehicles storage area. DEFICIENCY TD-3 and T-2 In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(E)(3), and Transportation, section (V)(L), the FOD must ensure food and water, during transfer, is provided in accordance with the Detention Standard on Transportation (By Land). The FOD must ensure, in transit, the crew maintains a constant supply of drinking water (and ice) in the water container(s), along with paper cups.
(b)(7)e
ICE.11.5082.000158

None

(b)(7)e
35
ICE.11.5082.000159
TRANSPORTATION (T)
ODO reviewed the Transportation standard at BFDF to determine if vehicles are properly equipped, maintained and operated, and if detainees are transported in a safe, secure and humane manner under supervision of trained and experienced staff, in accordance with the ICE PBNDS. ODO observed early preparations for a detainee transport, and reviewed files, pertinent transfer documents, and prescribed medicine. ODO was present during the inspections of one bus and one van. ODO reviewed BFDF policies and procedures, which cover most transportation procedures. BFDF does not have written procedures for handling the transportation of females (Deficiency T-1). ODO observed the transporting crew did not maintain a constant supply of drinking water, or ice, in water containers or paper cups for detainee use (Deficiency T-2 and TD-3). The van, P74205, used to transport two females, did not contain a first-aid equipment bag (Deficiency T-3).

DEFICIENCY T-1 In accordance with the ICE PBNDS, Transportation, section (V)(T), the FOD must ensure the Facility Administrator develops written procedures for vehicle crews transporting females. DEFICIENCY T-2 and TD-3 In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(E)(3), and Transportation, section (V)(L), the FOD must ensure food and water, during transfer, is provided in accordance with the Detention Standard on Transportation (By Land). The FOD must ensure, in transit, the crew maintains a constant supply of drinking water (and ice) in the water container(s), along with paper cups. DEFICIENCY T-3 In accordance with the ICE PBNDS, Transportation, section (V)(Q)(5), the FOD must ensure the field office provides all vehicles with a first-aid equipment bag (disaster kit), auxiliary to the first-aid kit in the drivers compartment.

None

(b)(7)e
36
ICE.11.5082.000160
USE OF FORCE AND RESTRAINTS (UOF&R)

ODO reviewed the Use of Force and Restraints standard at BFDF to determine if necessary use of force and the use of restraints is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE PBNDS. ODO inspected the facility, reviewed logs, and interviewed staff and detainees. BFDF did not designate, or include in any post orders, the responsibility for maintaining cameras and audiovisual equipment (Deficiency UOF&R-1). Prior to completion of the inspection, responsibility was designated to the ICE shift supervisors by amendment to BFDF Policy 3.1.8, Use of Force and Restraints. ODO was informed the post order for shift supervisors will be revised accordingly.
(b)(7)e

None

(b)(7)e
ICE.11.5082.000161
VISITATION (V)
ODO reviewed the Visitation standard at BFDF to determine if authorized persons, including legal representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE PBNDS. ODO conducted interviews with staff, and reviewed policies, procedures, logbooks, the detainee handbook, and detention files. ODO observed visitation information was not posted in all major languages spoken at the facility. Visitation information, including hours of operation, was only listed in English (Deficiency V-1). The detainee handbook does not contain notification that facility procedures require strip searches after contact visits with legal representatives; however, the facility provides an option for non-contact visits with legal representatives, in an environment allowing confidentiality and not requiring a strip search (Deficiency V-2 and DH-4).

DEFICIENCY V-1 In accordance with the ICE PBNDS, Visitation, section (V)(C), the FOD must ensure each facility: provides written notification of visitation rules and hours in the detainee handbook or local supplement given each detainee upon admission, and posts those rules and hours where detainees can easily see them. Information must be posted in each housing unit, and the schedule and procedures must be available to the public, both in written form and telephonically. A live voice or recording must provide telephone callers the rules and hours for all categories of visitation. Information must be posted in the visitor waiting area in English, Spanish, and other major languages spoken in the facility. DEFICIENCY V-2 and DH-4 In accordance with the ICE PBNDS, Visitation, section (V)(J)(11), the FOD must ensure each facility has written procedures to govern detainee searches, consistent with the ICE/DRO Detention Standard on Searches of Detainees. If standard operating procedures require strip searches after every contact visit with a legal representative, the facility must provide an option for non-contact visits with legal representatives in an environment allowing confidentiality. Each detainee must receive a copy of these search procedures in the detainee handbook or local supplement, given each detainee upon admission.

None

(b)(7)e
ICE.11.5082.000162
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DRO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS PBNDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU TAR TB UDC American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets Performance Based National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee

(b)(7)e
ICE.11.5082.000163
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Admission and Release, section (V)(B)(2), the FOD must ensure, to maintain standards of personal hygiene and to prevent the spread of communicable diseases and other unhealthy conditions within the housing units, every detainee must shower before entering his or her assigned unit. In accordance with the ICE PBNDS, Admission and Release, section (V)(B)(4)(a) and (c), the FOD must ensure staff do not routinely require a detainee to remove clothing or require a detainee to expose private parts of his or her body to search for contraband. The articulable facts supporting the conclusion that reasonable suspicion exists should be documented. Staff may conduct a strip search only where there is reasonable suspicion contraband may be concealed on the person. In accordance with the ICE PBNDS, Admission and Release, section (V)(F), the FOD must ensure, during the admissions process, the facilitys orientation video is played for every detainee, and, following the video, staff conducts a question-and-answer session. PAGE
AR-1
Admission and Release Searches of Detainees
AR-2
SD-2
29
AR-3

(b)(7)e
40
ICE.11.5082.000164
DETENTION STANDARD
Correspondence and Other Mail
C&OM-1
Detainee Handbook
DH-6
Detainee Handbook
DH-1
Detainee Handbook
DH-2
DEFICIENCIES AND PAGE REQUIREMENTS In accordance with the ICE PBNDS, Correspondence and Other Mail, sections (V)(C) and (V)(C)(3), the FOD must ensure the facility notifies detainees of its rules on correspondence and other mail through the detainee handbook, or supplement, provided to each detainee upon admittance. At a 9 minimum, the notification must specify general correspondence and other mail addressed to detainees will be opened and inspected in the 10 detainees presence, unless the Facility Administrator authorizes inspection without the detainees presence for security reasons. The facility must provide key information to detainees in languages spoken by any significant portion of the facilitys detainee population. In accordance with the ICE PBNDS, Detainee Handbook, section (V)(3), the FOD must ensure the ICE National Detainee Handbook is provided in English, Spanish and other languages as determined 10 necessary by the FOD. The Facility Administrator must ensure the local supplement is translated into Spanish and any other language spoken by significant numbers of detainees in the facility. In accordance with the ICE PBNDS, Detainee Handbook, section (V)(2), the FOD must ensure each local supplemental notifies each detainee 10 of procedures for requesting interpretive services for essential communication.

(b)(7)e
41
ICE.11.5082.000165
DETENTION STANDARD
Detainee Handbook
DH-3
F&PP-2
Detainee Handbook
DH-4
Visitation
V-2
Detainee Handbook Law Libraries and Legal Materials
DH-5
LL&LM-1
DEFICIENCIES AND PAGE REQUIREMENTS In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must ensure the 10 detainee handbook, or equivalent, notifies detainees of facility policies and procedures concerning personal property, including: the procedures for filing a claim for lost or damaged 16 property, and the procedures for accessing detainee personal funds to pay for legal services. In accordance with the ICE PBNDS, Visitation, section (V)(J)(11), the FOD must ensure each facility has written procedures to govern detainee searches, consistent with the ICE/DRO Detention Standard on Searches of Detainees. If standard 11 operating procedures require strip searches after every contact visit with a legal representative, the facility must provide an option for non-contact visits with legal representatives in an 38 environment allowing confidentiality. Each detainee must receive a copy of these search procedures in the detainee handbook or local supplement given each detainee upon admission. In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(O)(8), the FOD must ensure the detainee handbook or 11 supplement provides detainees with the rules and procedures governing access to legal materials including, if 23 applicable, Lexis-Nexis is used at the facility, and instructions for its use are available.

(b)(7)e
42
ICE.11.5082.000166
DETENTION STANDARD
Detainee Handbook Marriage Request
DH-7 MR-1
Detention Files
DF-1
Detention Files
DF-2
DEFICIENCIES AND PAGE REQUIREMENTS In accordance with the ICE PBNDS, Marriage Requests, sections (V)(B), (V)(E)(2) and (V)(F), the FOD must 11 ensure the detainee handbook, provided to each detainee upon 25 admittance, advises detainees of the facilitys marriage request procedures. In accordance with the ICE PBNDS, Detention Files, section (V)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A12 File. The file must, at a minimum, contain: Alien Booking Record (Form I-385), with one or more original photograph(s) attached; Classification Worksheet; the Personal Property Inventory Sheet; Housing Identification Card; Property Receipt (Form G-589), or facility equivalent; and Baggage Check(s) (Form I-77). In accordance with the ICE PBNDS, Detention Files, section (V)(F)(3), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date 12 and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

(b)(7)e
ICE.11.5082.000167
DETENTION STANDARD
Emergency Plans
EP-1
EH&S-1
EH&S-2
DEFICIENCIES AND PAGE REQUIREMENTS In accordance with the ICE PBNDS, Emergency Plans, section (V)(C)(1)(b), the FOD must ensure the facility develops contingency plans with local, State and Federal law 13 enforcement agencies, and formalize those agreements with MOUs. The Facility Administrator and representatives from the affected agencies must cosign the MOUs. In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(C), the FOD must ensure every area maintains a current 14 inventory of the hazardous substances (flammable, toxic or caustic) used and stored there. In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(E), the FOD must ensure the Maintenance Supervisor compiles a master index of all hazardous substances in the facility and their locations; a master file of Material Safety Data Sheets; and a 14 comprehensive, up-to-date list of emergency telephone numbers (fire department, poison control, etc). The Maintenance Supervisor must maintain this information in the Safety Office (or equivalent), and ensure a copy is sent to the local fire department.

(b)(7)e
ICE.11.5082.000168
DETENTION STANDARD
DEFICIENCIES AND
PAGE
Food Service
FS-1 (MANDATORY)
(b)(7)e
15
Tool Control
TC-3
31
Food Service
FS-2
In accordance with the ICE PBNDS, Food Service, section (V)(K)(1), the FOD must ensure facilities provide detainees requesting a religious diet a reasonable and equitable opportunity to observe their religious dietary practice within the constraints of budget limitations and the security and orderly running of the facility by offering a Common Fare menu. Common Fare refers to a no-flesh protein option provided whenever an entre containing flesh is offered as part of a meal.
15

(b)(7)e
ICE.11.5082.000169
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS

In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(G)(1), the FOD must ensure, for recordkeeping and accounting purposes, Form G-589 is mandatory to inventory any funds removed from a detainees possession, and a separate Form G-589 is required for each kind of currency and negotiable instrument. The removal and inventory must be conducted in the detainees presence, and at least two officers must be present to remove funds from a detainees possession and to inventory the property on Form G-589. The two officers and the detainee must sign all copies of Form G-589.
PAGE
F&PP-1
16
Grievance System
GS-1
In accordance with the ICE PBNDS, Grievance System, section (V)(A), the FOD must ensure procedures are in place requiring receipt of all medical grievances by the Administrative Health Authority within 24 hours or the next business day.
17

(b)(7)e
ICE.11.5082.000170
DETENTION STANDARD
Grievance System
GS-2
DEFICIENCIES AND PAGE REQUIREMENTS In accordance with the ICE PBNDS, Grievance System, sections (V)(B) and (V)(C)(1), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or local supplement, in which the grievance section provides notice of: the expectation, to the greatest extent possible, complaints and grievances should be handled orally and informally by staff in their daily interaction with detainees. 18 Nevertheless, the detainee always has the right to file a formal grievance and pursue the formal grievance process. The FOD must ensure a detainee is free to bypass or terminate the informal grievance process at any point and proceed directly to the formal grievance stage. The grievance section in the detainee handbook must also provide notice of the process for filing emergency grievances.
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(1), the FOD must ensure, if an oral grievance is resolved, the employee need not provide the detainee with written confirmation of the outcome, but must document the result for the record in the detainees detention file, and in any logs or data systems the facility has established to track such actions.
Grievance System
GS-3
18
Grievance System
GS-4
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(2), the FOD must ensure the protocol for emergency grievance procedures brings the matter to the immediate attention of the Facility Administrator, even if it is later determined it is not a true emergency and the grievance is subsequently routed through normal, non-emergency channels.
18

(b)(7)e
47
ICE.11.5082.000171
DETENTION STANDARD
Grievance System
GS-5
Grievance System
GS-6
Grievance System
GS-7
Hold Rooms in Detention Facilities
HR-1
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Grievance System, section (V)(D)(1), the FOD must ensure the Assistant Chief of Security chairs the DGC, along with two department heads or their representatives. In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure the detainee grievance log includes the receipt date and disposition. Nuisance or petty grievances, and grievances rejected or denied, must also be logged with the appropriate notation and justification (for example, petty). In accordance with the ICE PBNDS, Grievance System, section (V)(F), the FOD must ensure, if the shift supervisor or other employee designated to receive grievances believes the grievance is one that should not be fully processed, he or she documents the determination and refers the grievance to the GO or DGC. If the GO or DGC concurs, the grievance must be logged in the detainee grievance log with rejected as the disposition, and a copy of the grievance must be placed in the detainees detention file. In accordance with the ICE PBNDS, Hold Rooms, section (V)(A)(6), the FOD must ensure each hold room is equipped with stainless steel, combination lavatory/toilet fixtures with modesty panels, in compliance with the Americans with Disabilities Act of 1990. Consistent with the International Plumbing Code: each small hold room (up to 14 detainees) must have one combi-unit; each large hold room (15 to 49 detainees) must have at least two combi-units.
PAGE
18
18
18
20

(b)(7)e
48
ICE.11.5082.000172
DETENTION STANDARD
HR-2
HR-3
HR-4
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(D)(4)(9), the FOD must ensure staff ensures that sanitation in hold rooms is maintained at acceptable and comfortable levels. When the last detainee has been removed, officers must ensure the hold room is thoroughly cleaned and inspected for any evidence of tampering with doors, locks, windows, grills, plumbing, or electrical fixtures, and report any such problems to the shift supervisor for corrective action or repair. In accordance with the ICE PBNDS, Hold Rooms, section (V)(B)(6), the FOD must ensure detainees are provided with basic personal hygiene items, for example, water, disposable cups, soap, toilet paper, femininehygiene items, diapers, and sanitary wipes. In accordance with the ICE PBNDS, Hold Rooms, section (V)(D)(2), the FOD must ensure the detention log records the date and time of new age determinations and provides space to record meal times, visual checks, security concerns (which may also necessitate an incident report), and comments.
PAGE
20
20
20
K&LC-1
(b)(7)e
22

(b)(7)e
ICE.11.5082.000173
DETENTION STANDARD
PAGE
K&LC-2
(b)(7)e
22
LRGP-1
LRGP-2
Medical Care
MC-1
In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(H), the FOD must ensure attorneys present state-issued bar cards or, in states where these are not available, other proof of bar membership. If such documentation is not readily available to attorneys licensed in a particular state, they must indicate where they are licensed as attorneys and how it may be verified prior to their admittance. In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(J), the FOD must ensure requests for approval of a presentation list any published or unpublished materials proposed for distribution, and ensure the requestor provides a copy of any unpublished material, with a cover page: identifying the submitter and the preparer of the material, including the date of preparation; and stating clearly ICE/DRO did not prepare, and is not responsible for, the contents of the material. If the material is in a language other than English, an English translation must be provided. In accordance with the ICE PBNDS, Medical Care, section (V)(T), the FOD must ensure, upon admission at the facility, documented informed consent is obtained for the provision of health care services.
24
24
26

(b)(7)e
ICE.11.5082.000174
DETENTION STANDARD
Medical Care
MC-2
Post Orders
PO-1
Post Orders
PO-2
Post Orders
PO-3
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Medical Care, section (V)(I), the FOD must ensure the Clinical Medical Authority is responsible for the review of all health screening forms within 24 hours or the next business day to assess the priority for treatment (for example, Urgent, Today, or Routine). In accordance with the ICE PBNDS, Post Orders, section (V)(A), the FOD must ensure there are written post orders for each security post. In accordance with the ICE PBNDS, Post Orders, section (V)(D), the FOD must ensure the post orders for each post are issued in six-part classification folders and organized as follows: Section 1: Specific post orders, listing activities chronologically, with responsibilities clearly defined; Section 2: Special instructions, if any, relating to the specific post; Section 3: General post orders applicable to all posts; Section 4: Memoranda changing or updating the post orders; Section 5: ICE/DRO detention standards, and policies and facility practices relevant to the post; and Section 6: Review and Signature Form, with the officers name printed, signed and dated. In accordance with the ICE PBNDS, Post Orders, section (V)(C), the FOD must ensure the Facility Administrator (or designee) approves, signs and dates each post order on the last page of each section, initials and dates all other pages, and initials and dates any subsequent changes to the post order.
PAGE
26
27
27
27

(b)(7)e
51
ICE.11.5082.000175
DETENTION STANDARD
Religious Practices
RP-1
Searches of Detainees
SD-1
SDC-1
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Religious Practices, section (V)(B), the FOD must ensure each detainee designates any or no religious preference during in-processing. In accordance with the ICE PBNDS, Searches of Detainees, section (V)(A), the FOD must ensure all facilities have written policy and procedures consistent with this standard for close observation in dry cells to detect contraband. In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(B), the FOD must ensure each facility provides a secure drop box for ICE detainees to correspond directly with ICE management. Only ICE personnel will have access to the
PAGE
28
29
30
Tool Control
TC-1 (MANDATORY)
31

(b)(7)e
ICE.11.5082.000176
DETENTION STANDARD
DEFICIENCIES AND
PAGE
Tool Control
TC-2
32
(b)(7)e
Tool Control
TC-4
32
Tool Control
TC-5
32

(b)(7)e
ICE.11.5082.000177
DETENTION STANDARD
PAGE
Tool Control
TC-6
(b)(7)e
32
Transfer of Detainees
TD-1
Transfer of Detainees, section (V)(B)(3), the FOD must ensure, at the time of transfer, ICE/DRO provides the detainee, in writing, the name, address and telephone number of the facility to which he or she is being transferred, using the Detainee Transfer Notification form. Staff must place a copy of the form in the detainees detention file.
34

(b)(7)e
54
ICE.11.5082.000178
DETENTION STANDARD
TD-2
TD-3
Transportation
T-2
Transportation
T-1
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(D)(1), the FOD must ensure, before transfer, the sending facility returns all funds and small valuables to the detainee and closes out all Form G-589s, in accordance with the Detention Standard on Funds and Personal Property. During transport, a detainee will ordinarily have the following items in his or her possession: cash; all legal material; small valuables, such as jewelry; address books, phone lists, correspondence; dentures, prescription glasses; small religious items; photos; similar small personal property items. However, items that might present a security risk or are particularly bulky may be transported separately in the vehicles storage area. In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(E)(3), and Transportation, section (V)(L), the FOD must ensure food and water, during transfer, is provided in accordance with the Detention Standard on Transportation (By Land). The FOD must ensure, in transit, the crew maintains a constant supply of drinking water (and ice) in the water container(s), along with paper cups. In accordance with the ICE PBNDS, Transportation, section (V)(T), the FOD must ensure the Facility Administrator develops written procedures for vehicle crews transporting females.
PAGE
34
34
36
36

(b)(7)e
ICE.11.5082.000179
DETENTION STANDARD
Transportation
T-3
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Transportation, section (V)(Q)(5), the FOD must ensure the field office provides all vehicles with a first-aid equipment bag (disaster kit), auxiliary to the first-aid kit in the drivers compartment.
PAGE
36
Use of Force and Restraints
UOF&R-1
(b)(7)e
37
Visitation
V-1
Visitation, section (V)(C), the FOD must ensure each facility: provides written notification of visitation rules and hours in the detainee handbook or local supplement given each detainee upon admission, and posts those rules and hours where detainees can easily see them. Information must be posted in each housing unit, and the schedule and procedures must be available to the public, both in written form and telephonically. A live voice or recording must provide telephone callers the rules and hours for all categories of visitation. Information must be posted in the visitor waiting area in English, Spanish, and other major languages spoken in the facility.
38

(b)(7)e
ICE.11.5082.000180
APPENDIX C
SUMMARY OF RECOMMENDATIONS
DETENTION STANDARD Admission and Release RECOMMENDATIONS ODO recommends BFDF contact DRO Headquarters for assistance in making a new orientation video. ODO recommends the FOD conducts OSHA safety training and ensures facility staff follows all OSHA requirements. ODO recommends BFDF obtain any or no religious preference for all detainees during inprocessing and document this information in EABM. PAGE 8
14
Religious Practices
28

(b)(7)e
57
ICE.11.5082.000181


Enforcement and Removal Operations Detroit Field Office Calhoun County Jail Battle Creek, MI
November 16-17, 2010
ICE.11.5082.000182
OFFICE OF PROFESSIONAL RESPONSIBILITY MISSION STATEMENT The Office of Professional Responsibility (OPR) is responsible for investigating allegations of employee misconduct impartially, independently, and thoroughly. OPR prepares comprehensive reports of investigation for judicial or management action. OPR inspects and reviews Immigration and Customs Enforcement (ICE) offices, operations and processes in order to provide executive management with an independent review of the agencys organizational health, and assesses the effectiveness and efficiency of the overall ICE mission. OPR screens potential ICE employees for character and suitability.
ICE.11.5082.000183
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization. Inspection Team Members. OVERVIEW .. Areas of Concern ICE NATIONAL DETENTION STANDARDS Detainee Grievance Procedures... Detainee Handbook. Disciplinary Policy... Emergency Plans Environmental Health and Safety. Food Service Funds and Personal Property Hold Rooms in Detention Facilities. Key and Lock Control. Medical Care Post Orders.. Security Inspections Special Management Unit (Administrative and Disciplinary) Terminal Illness, Advance Directives, and Death Tool Control.. Use of Force. 1 1 2 3
4 4 5 5 6 6 7 8 8 9 9 10 10 11 12 13
ICE.11.5082.000184
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. In September 2009, ODO conducted a Quality Assurance Review of the Calhoun County Jail (CCJ), located in Battle Creek, Michigan. The Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to ERO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Deputy Division Director, Office of Professional Responsibility.

Management & Program Analyst (Lead) Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters MGT of America Inc. MGT of America Inc. MGT of America Inc.
(b)(6), (b)(7)(C)
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000185
Calhoun County Jail ERO Detroit, MI
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material Detainee Grievance Procedures Detainee Handbook Disciplinary Policy Emergency Plans Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Issuance and Exchange of Clothing, Bedding, and Towels Key and Lock Control Medical Care Post Orders Security Inspections Special Management Unit (Administrative and Disciplinary) Staff-Detainee Communication Terminal Illness, Advance Directives, and Death Tool Control Use of Force ODO staff identified 90 deficiencies during the Quality Assurance Review conducted in September 2009. During this Follow-up Inspection, ODO staff found 37 (41%) repeated deficiencies. ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards: Access to Legal Material Issuance and Exchange of Clothing, Bedding, and Towels Staff-Detainee Communication Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at CCJ, to be noncompliant with the ICE NDS: Detainee Grievance Procedures Detainee Handbook Disciplinary Policy Emergency Plans Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Key and Lock Control Medical Care
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000186
Post Orders Security Inspections Special Management Unit (Administrative and Disciplinary) Terminal Illness, Advanced Directives, and Death Tool Control Use of Force
AREAS OF CONCERN
ODO conducted a Quality Assurance Review in September 2009. The FOD, AFOD and CCJ staff informed ODO the facility did not receive a copy of the QAR report from ERO; therefore, the facility did not have adequate time to address the deficiencies identified in the QAR report. The ERO Detroit Field Office also was not able to prepare a comprehensive Plan of Action. During the inspection of the Food Service area, ODO observed the supervisory kitchen staff had a copy of the food service deficiencies taken from the QAR conducted in September 2009. During an ensuing discussion, the supervisor informed ODO the deficiencies were provided by CCJ management.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000187

DETAINEE GRIEVANCE PROCEDURES
During the initial ODO inspection, three deficiencies were identified. During this Followup Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The grievance section in the detainee handbook must provide notices of: the opportunity to file a grievance, both informal and formal; the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance; the procedures for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved; the procedures for contacting ICE to appeal the decision; and the policy prohibiting staff from harassing, disciplining, punishing, or otherwise retaliating against any detainee for filing a grievance. It should also provide notice of the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Securitys (DHS) Office of Inspector General (OIG) by calling 1-800-323-8603, or by writing to DHS OIG, 245 Murray Drive, Washington, D.C. 20538. ODO Follow-up Finding: CCJ staff informed ODO, all detainees are not issued a detainee handbook upon admission to the facility. Facility staff informed ODO detainees are provided information via an orientation video. ODO reviewed the video and found it did not adequately address detainee grievance procedures.
DETAINEE HANDBOOK
During the initial ODO inspection, seven deficiencies were identified. During this Follow-up Inspection, the following three deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Detainee Handbook, section (I), the FOD must ensure every detainee receives a copy of the detainee handbook upon admission to the facility. ODO Follow-up Finding: CCJ staff informed ODO, all detainees do not receive a copy of the detainee handbook upon admission to the facility. ODO Initial Finding: In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5), the FOD must ensure the detainee handbook or equivalent, issued to each detainee upon admittance, provides notice of the facilitys rules of conduct, and of the sanctions for violations of the rules. Among other things, the handbook must advise detainees of the following: the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000188
damage, and harassment; as well as the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs. ODO Follow-up Finding: ODO reviewed the handbook and determined it does not state detainees have the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment. The detainee handbook also does not inform detainees of their rights of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs. ODO Initial Finding: In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(4-5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including the procedure for claiming property upon release, transfer, or removal, and the procedures for filing a claim for lost or damaged property. ODO Follow-up Finding: The CCJ handbook does not contain information on the procedures for filing claims for lost or damaged property, or for claiming property upon release, transfer, or removal.
DISCIPLINARY POLICY
During the initial ODO inspection, one deficiency was identified. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Disciplinary Policy, section (III)(D), the FOD must ensure the facility establishes an intermediate level of investigation and/or adjudication to adjudicate low or moderate infractions. ODO Follow-up Finding: CCJ has not established an intermediate level of investigation and/or adjudication. The facility does not have a process to adjudicate low or moderate infractions, such as those classified by CCJ as Class I or II. CCJ staff stated there is no appeal process for punishments resulting from Class I or II offenses.
EMERGENCY PLANS
During the initial ODO inspection, three deficiencies were identified in this area. During the Follow-up Inspection, the following three deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Emergency Plans, section (III)(B)(2), the FOD must ensure each facility designates an individual(s) to be responsible for scheduling and keeping the emergency plans current. ODO Follow-up Finding: ODO found no documentation designating the person(s) responsible for scheduling and keeping the emergency plans updated.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000189
ODO Initial Finding: In accordance with the ICE NDS, Emergency Plans, section (III)(D), the FOD must ensure facilities compile ICE-approved contingency plans that include specified components, including internal search, environmental hazard, detainee transportation system emergency, and service-wide lockdown. ODO Follow-up Finding: CCJs emergency plans have not been revised to include specific plans for internal search, environmental hazard, detainee transportation system emergency, and service-wide lockdown. ODO Initial Finding: In accordance with the ICE NDS, Emergency Plans, section (III)(B)(4), the FOD must ensure that every plan includes a statement prohibiting unauthorized plan disclosure. This applies to developmental stages and to finished plans. ODO Follow-up Finding: CCJs emergency plans did not include a statement prohibiting unauthorized plan disclosure.

During the initial ODO inspection, thirteen deficiencies were identified in this area. During the follow-up inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of hazardous substances used and stored in that area. Inventory records must be maintained separately for each substance, with entries for each logged on a separate card (or equivalent). ODO Follow-up Finding: ODOs inspection of the Safety Officers chemical storage area revealed inventories for Ajax oxygen cleanser, enviromox cleanser, and bleach are not maintained. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(2), the FOD must ensure hazardous substances are issued in single-day increments, i.e., the amount needed for one days work. Inventory records for a hazardous substance must be kept current before, during, and after each use. ODO Follow-up Finding: Bleach is stored in housing units in excess of the amounts needed for daily use. ODO observed three gallons of bleach stored in one housing unit.
FOOD SERVICE
During the initial ODO inspection, fifteen deficiencies were identified in this area. During the follow-up inspection, the following three deficiencies were found not corrected.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000190
ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(B)(5), the FOD must ensure all facilities establish daily searches (shakedowns) of detainee work areas (trash, etc.) as standard operating procedures, paying particular attention to trash receptacles. Also required are searches of detainees leaving certain work areas (e.g., bakery, vegetable preparation, dining room, warehouse). These searches reduce the possibility that hot food or contraband will leave the restricted area. Unless directed otherwise by facility policy or special instructions, staff shall prevent detainees from leaving the food service department with any food item. ODO Follow-up Finding: ODO was informed inmate workers are searched when leaving the food service at the end of each shift; however, they are not searched upon release for visits, medical appointments, or other activities for which departure from the area is required. Inmates are not housed separately from detainees; therefore, detainees may access food items or other contraband removed from the food service area. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(D)(8), the FOD must ensure prepared food items that have not been placed on the serving line are retained for no more than 24 hours. Leftovers offered for service a second time must not be retained for later use, but must be discarded immediately after offering. All leftovers must be labeled to identify the product, and preparation date and time. ODO Follow-up Finding: ODO observed leftover food items labeled with the product and preparation date; however, the preparation time was not documented. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(H)(b), the FOD must ensure all staff members know where and how much toxic, flammable, or caustic material is on hand, and are aware their use must be controlled and accounted for daily. ODO Follow-up Finding: ODO observed a container of Solid Power dishwashing solution on top of the dishwasher. The item was not controlled and was accessible to inmates.
FUNDS AND PERSONAL PROPERTY

During the initial ODO inspection, five deficiencies were identified in this area. During the follow-up inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(4) and (5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including the procedure for claiming property upon release, transfer, or removal, and the procedures for filing a claim for lost or damaged property.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000191
ODO Follow-up Finding: The handbook does not contain information on the procedures for filing claims for lost or damaged property, or for claiming property upon release, transfer or removal from the facility. ODO Initial Finding: In accordance with the ICE NDS, Funds and Personal Property, section (III)(H)(7), the FOD must ensure all Intergovernmental Service Agreement (IGSA) facilities have and follow a policy for loss of, or damage to, properly-receipted detainee property, as follows: the senior contract officer must immediately notify the designated ICE officer of all claims and outcomes. ODO Follow-up Finding: The CCJ written policy for lost or damaged detainee property does not include notification to a designated ICE officer regarding all claims and outcomes.
HOLD ROOMS IN DETENTION FACILITIES

During the initial ODO inspection, two deficiencies were identified in this area. During the Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(D)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which involves "irregular" visual monitoring every 15 minutes (each time recording the time and officer's star number in the detention log). When the hold room is not in the officer's direct line of sight, the officer must maintain continuous auditory monitoring. ODO Follow-up Finding: The facility maintains an electronic log which documents the time a detainee is booked into the facility; however, hold room logs documenting officer supervision and visual monitoring of detainees are not maintained.
KEY AND LOCK CONTROL

During the initial ODO inspection, five deficiencies were identified in this area. During the follow-up inspection, the following two deficiencies were found not corrected.
(b)(7)e
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000192
(b)(7)e
MEDICAL CARE
During the initial ODO inspection, seven deficiencies were identified in this area. During the follow-up inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Medical Care, section (III)(L), the FOD must ensure medical treatment is not administered against the detainee's will. The facility health care provider must obtain signed and dated consent forms from all detainees before any medical examination or treatment, except in emergency circumstances. If a detainee refuses treatment, ICE must be consulted in determining whether forced treatment will be administered, unless the situation is an emergency. In emergency situations, ICE must be notified as soon as possible. ODO Follow-up Finding: The medical record review revealed signed and dated consent forms were present in 25 of 25 files. However, CCJ policy, Right to Refuse Treatment, does not require consultation with ICE to determine whether forced treatment will be administered, and in emergency situations, does not require notifying ICE as soon as possible. ODO Initial Finding: In accordance with the ICE NDS, Medical Care, section (III)(N), the FOD must ensure, when a detainee is transferred to another detention facility, the detainee's medical records, or copies, are transferred with the detainee. These records should be placed in a sealed envelope or other container labeled with the detainee's name and A-number, and marked "MEDICAL CONFIDENTIAL." ODO Follow-up Finding: CCJ policy, J-H-02.00, Confidentiality of Health Records and Health Information, requires sealing of health information in an envelope marked Confidential Health Information for transportation by non-healthcare providers. The policy does not require labeling the envelope with the detainees name and A-number. During the review, the Health Services Administrator (HSA) submitted a revised policy requiring the facility to document the detainees name and A-number on the envelope.
POST ORDERS
During the initial ODO inspection, one deficiency was identified in this area. During the follow-up inspection, the deficiency was found not corrected.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000193
ODO Initial Finding: In accordance with the ICE NDS, Post Orders, section (III)(F), the FOD must ensure post orders for armed and perimeter-access post assignments, among other things, describe and explain the proper care and safe handling of firearms, and circumstances and conditions when use of firearms is authorized. Post orders for armed posts and posts that control access to the institution perimeter must clearly state that any staff member who is taken hostage is considered to be under duress. Any order and/or directive issued by such a person, regardless of his or her position of authority, are to be disregarded. ODO Follow-up Finding: Post orders for the Master and Visitation Control Centers include a copy of the facilitys hostage situation plan, and address procedures to follow if a staff member is taken hostage. The post orders do not include procedures for the proper care and safe handling of firearms, or circumstances and conditions when the use of firearms is authorized.
During the initial ODO inspection, one deficiency was identified in this area. During the follow-up inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Security Inspections, section (III)(D)(3)(1)(a), the FOD must ensure facilities have policies and procedures to control and document all vehicular traffic entering the facility. ODO Follow-up Finding: CCJs Master Control Operator post regulates access to external and internal entrances to various areas of the facility, including vehicular entry and exit. A video-monitoring system records vehicle traffic; however, video data is maintained for only 30 days. A log or other written documentation is not maintained.
SPECIAL MANAGEMENT UNIT

During the initial ODO inspection, five deficiencies were identified in this area. During the follow-up inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Special Management Unit, Administrative Segregation, section (III)(B), the FOD must ensure a written order is completed and approved by a supervisory officer before a detainee is placed in administrative segregation, except when exigent circumstances make this impracticable. In such cases, an order must be prepared as soon as possible. A copy of the order must be given to the detainee within 24 hours, unless delivery would jeopardize the safety, security, or orderly operation of the facility. . ODO Follow-up Finding: A written order is not completed and approved by a supervisory officer before a detainee is placed in administrative segregation. A copy of the order, when completed, is not given to the detainee within 24 hours.
_____________________________________________________________________________________________
Office of Detention Oversight November 2010

(b)(7)e
10
Calhoun County Jail ERO Detroit,
ICE.11.5082.000194
ODO Initial Finding: In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(17), and Visitation, section (III)(H)(5), the FOD must ensure the facility follows the Visitation standard in setting visitation rules for detainees in disciplinary segregation; under no circumstances are detainees to participate in general visitation while in restraints. ODO Follow-up Finding: ODO was informed detainees housed in disciplinary segregation typically wear leg shackle restraints when participating in visitation.
TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH

During the initial ODO inspection, three deficiencies were identified in this area. During the follow-up inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(B), the FOD must ensure each medical facility uses the State Advance Directive Form for implementing living wills and advance directives. The guidelines for completing the form include instructions for detainees who wish to have a living will (different from the generic document available from the ICE Division of Immigration Health Services) and/or authorize or refuse permission to perform extraordinary measures to prolong the detainees life. The guidelines should note that private attorneys can prepare such documents. ODO Follow-up Finding: CCJ does not have a policy addressing living wills and advance directives. The HSA informed ODO the state of Michigan does not recognize living wills; further, if a detainee requested an Advance Directive, a standard form would be obtained from the Internet. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(D), the FOD must ensure the following procedures govern organ donations by detainees: the organ recipient must be a member of the donor's immediate family; all costs associated with the organ donation (hospitalization, fees, etc.) must be at the expense of the detainee, involving no government funds; the detainee must sign a statement documenting his or her decision to donate the organ to the specified family member; the detainee must confirm that he or she understands and accepts the risks associated with the operation of his or her own free will, and that the government will not be held responsible for any medical complications or financial responsibilities; resources permitting, ICE must assist in the preliminary medical evaluation; the facility housing the detainee must coordinate arrangements for transportation, custody, classification, etc.; and the detainee is not authorized to donate blood or blood products. ODO Follow-up Finding: CCJ does not have a policy addressing organ donation.
_____________________________________________________________________________________________

(b)(7)e
11
ICE.11.5082.000195
TOOL CONTROL
During the initial ODO inspection, seven deficiencies were identified in this area. During the follow-up inspection, the following six deficiencies were found not corrected.
(b)(7)e

(b)(7)e
12
ICE.11.5082.000196
(b)(7)e
USE OF FORCE
During the initial ODO inspection, seven deficiencies were identified in this area. During the follow-up inspection, the following six deficiencies were found not corrected.
(b)(7)e
_____________________________________________________________________________________________

(b)(7)e
13
ICE.11.5082.000197
(b)(7)e
_____________________________________________________________________________________________

(b)(7)e
14
ICE.11.5082.000198


Enforcement and Removal Operations Phoenix Field Office Central Arizona Detention Center Florence, Arizona
November 16 - 17, 2010
ICE.11.5082.000199
ICE.11.5082.000200
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW. ICE NATIONAL DETENTION STANDARDS Access to Legal Material..... Key and Lock Control... 1 1 2
3 3
ICE.11.5082.000201
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives include the evaluation of the welfare, safety, and living conditions of detainees, and compliance with applicable laws, policies, regulations, and procedures. In November 2009, ODO, formerly the Detention Facilities Inspection Group, conducted a Quality Assurance Review of the Central Arizona Detention Center (CADC) in Florence, Arizona. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to ERO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Deputy Division Director, Office of Professional Responsibility.

(b)(6), (b)(7)(C)
Special Agent (Team Leader) Detention and Deportation Officer
ODO, OPR San Diego ODO, OPR San Diego
_____________________________________________________________________________________________
1
(b)(7)e
Central Arizona Detention Center ERO Phoenix
ICE.11.5082.000202
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material; Detainee Grievance Procedures; Detention Files; Disciplinary Policy; Emergency Plans; Environmental Health and Safety; Key and Lock Control; Special Management Unit; Telephone Access; Terminal Illness, Advanced Directives, and Death; and Use of Force. ODO staff identified 21 deficiencies during the Quality Assurance Review conducted in November 2009. During this Follow-up Inspection, ODO staff found two (10%) repeated deficiencies. Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at CADC, to be noncompliant with the ICE NDS: Access to Legal Material Key and Lock Control ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards: Detainee Grievance Procedures Detention Files Disciplinary Policy Emergency Plans Environmental Health and Safety Special Management Unit Telephone Access Terminal Illness, Advanced Directives, and Death Use of Force
_____________________________________________________________________________________________
2
(b)(7)e
ICE.11.5082.000203

ACCESS TO LEGAL MATERIAL
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Access to Legal Material, sections (III)(Q)(4), (5) and(6), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including: the procedure for requesting additional time in the law library (beyond the five hours per week minimum); the procedure for requesting legal reference materials not maintained in the law library; and the procedure for notifying a designated employee that library material is missing or damaged. These policies and procedures must be posted in the law library along with a list of the law librarys holdings. ODO Follow-up Finding: Rules and procedures governing access to legal materials were not posted in the facilitys law library. During the follow-up inspection, corrective action was taken by facility staff to post the rules and procedures in the law library.

During the initial ODO inspection, two deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected.
(b)(7)e
_____________________________________________________________________________________________
3
(b)(7)e
ICE.11.5082.000204


Enforcement and Removal Operations Dallas Field Office David L. Moss Criminal Justice Center Tulsa, Oklahoma
July 2022, 2010
ICE.11.5082.000205
ICE.11.5082.000206
ICE.11.5082.000207
QUALITY ASSURANCE REVIEW DAVID L. MOSS CRIMINAL JUSTICE CENTER DALLAS FIELD OFFICE TABLE OF CONTENTS INSPECTION PROCESS
Report Organization 1 Inspection Team Members 1
BACKGROUND
History.. 3
Internal Relations....... 5 Detainee Relations. 5

National Detention Standards Reviewed 7 Access to Legal Material... 8 Admission and Release. 9 Detainee Grievance Procedures.. 10 Detainee Handbook.. 11 Detention Files. 12 Disciplinary Policy13 Environmental Health and Safety. 14 Food Service 15 Funds and Personal Property16 Hold Rooms in Detention Facilities.. 17 Medical Care 18 Recreation 19 Special Management Unit. 20 Staff-Detainee Communication.... 21 Telephone Access.. 22 Tool Control. 24 Use of Force 25 Visitation.. 26
ICE.11.5082.000208
ICE.11.5082.000209
INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of the David L. Moss Criminal Justice Center (DMCJC) in Tulsa, Oklahoma, July 20-22, 2010. ODO reviewed the processes employed at DCDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION

Detention and Deportation Officer (Team Lead) ODO, San Diego, CA
(b)(6), (b)(7)(C)
Detention & Deportation Officer Special Agent Special Agent Contract Inspector Contract Inspector Contract Inspector
ODO, Headquarters ODO, Phoenix, AZ ODO, Headquarters MGT of America, Inc MGT of America, Inc MGT of America, Inc
Office of Detention Oversight July 2010

(b)(7)e
David L. Moss Criminal Justice Center ERO Dallas, TX
ICE.11.5082.000210

(b)(7)e
ICE.11.5082.000211
BACKGROUND
HISTORY
ICE utilizes DMCJC under an intergovernmental service agreement (IGSA). DMCJC opened in August 1999 and ERO began using the facility to house ICE detainees in 2008. DMCJC is authorized to house adult male and female ICE detainees over 72 hours. The facility has a total housing capacity of 1,714 inmates, with 140 beds allocated for ICE detainees. DMCJC is owned by the Tulsa County Criminal Justice Authority and managed by the Tulsa County Sheriff. ICE staff consists of an Acting Supervisory Detention Deportation Officer (ASDDO), a Deportation Officer (DO), two Immigration Enforcement Agents (IEA), and a Detention Removal Assistant (DRA). DMCJC employs 360 full-time staff. Correctional Healthcare Management operates the medical clinic. Food service operations are contracted and managed by Aramark Services. In 2009 and 2010, ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted annual reviews of the ICE NDS at DMCJC. The final overall rating was Good in both years. DMCJC holds American Correctional Association accreditation and was reaccredited November 13, 2009.

(b)(7)e
ICE.11.5082.000212

(b)(7)e
ICE.11.5082.000213
INTERNAL RELATIONS
ODO interviewed ICE and DMCJC personnel. Facility management and officers familiar with ICE NDS reported DMCJC had no issues with meeting the level of care required by ICE NDS, and reported a low number of detainee complaints and grievances. DMCJC staff indicated they maintain a positive relationship with ICE and morale is good. ICE supervisory personnel described the relationship with DMCJC as good and positive. ICE and DMCJC supervisory personnel expressed concerns in reference to a lack of sufficient ICE ERO personnel permanently assigned to the DMCJC. Both agencies stated the current SDDO has too many tasks and more DOs are needed. DMCJC staff informed ODO there is only one IDENT scanner available for use. According to DMCJC officials, ICE Homeland Security Investigations (HSI) personnel assigned to the facility have several IDENT scanners stored within a closet and not being used. DMCJC staff reported notifying ICE personnel regarding abandoned detainee property. According to staff, ICE ERO does not collect abandoned detainee funds and personal property, as required.
DETAINEE RELATIONS
ODO interviewed seven detainees housed at DMCJC to determine their concerns and to identify areas of possible noncompliance with the ICE NDS. ODO encouraged detainees to express their opinions about the facility, staff, ICE personnel, and the progress of their cases. This often results in examples and anecdotes, and in some cases detainees view these interviews as a self-serving opportunity. ODO cautions, due to the nature of the information obtained, it is not possible to verify each statement. Nonetheless, it is important to obtain information from the detainees point of view. Detainees stated they receive insufficient food portions and the food is cold. ODO determined DMCJC is adhering to the dietician approved menu and the food was served at appropriate temperature. Some detainees lacked knowledge on how to contact ICE or their assigned DO. ODO provided information to the detainees on how to contact ICE personnel.

(b)(7)e
ICE.11.5082.000214

(b)(7)e
ICE.11.5082.000215

This inspection was based on the 2000 NDS. The following 29 standards were reviewed: Access to Legal Material Admission and Release Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strike Medical Care Population Counts Recreation Special Management Unit Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Use of Force Visitation No deficiencies were noted in the following four standards: Hunger Strike Population Counts Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e
ICE.11.5082.000216

ODO reviewed the Access to Legal Material standard at DMCJC to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO interviewed staff and detainees, reviewed the detainee handbook and policies, and observed the law library. Although the law library is available for detainee use five days a week, there is no set schedule for each housing unit. Detainees must make a special request to use the law library through an automated electronic kiosk system (Deficiency ALM-1). A review of the detainee handbook revealed the following items were absent from the handbook: schedule of access hours to the law library; the procedure for requesting access to the law library; the procedure for requesting additional time in the law library (beyond the five hours per week minimum); the procedure for requesting legal reference materials not maintained in the law library; and the procedure for notifying a designated employee that library material is missing or damaged. These rules and procedures were not posted in the law library (Deficiency ALM-2).

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(G), the FOD must ensure DMCJC devises a flexible schedule to permit all detainees, regardless of housing or classification, to use the law library on a regular basis. Each detainee must be permitted to use the law library for a minimum of five hours per week. Detainees may not be forced to forgo their minimal recreation time, as provided in the Recreation standard, to use the law library. DEFICIENCY ALM-2 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: (1) a law library is available for detainee use; (2) scheduled hours of access to the law library; (3) procedure for requesting access to the law library; (4) procedure for requesting additional time in the law library (beyond the five hours per week minimum); (5) procedure for requesting legal reference materials not maintained in the law library; and (6) procedure for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library along with a list of the law library's holdings.

(b)(7)e
ICE.11.5082.000217

ODO reviewed the Admission and Release standard at DMCJC to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO interviewed staff and detainees, reviewed detention files, and observed the admission process. DMCJCs orientation process is not supported by an ICE video (Deficiency AR-1). ICE does not provide DMCJC with the necessary documents to properly classify each detainee (Deficiency AR-2).

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(A)(1), the FOD must ensure the orientation process is supported by an ICE video and handbook to inform new arrivals about facility operations, programs, and services. DEFICIENCY AR-2 In accordance with the ICE NDS, Detainee Classifications System, section (III)(D), the FOD must ensure ICE offices provide non-INS facilities with the necessary information for the facility to classify ICE detainees. Because ICE selectively releases material from the detainee's record to persons who are not ICE employees (e.g., CDF or IGSA facility personnel), non-ICE officers must rely on the judgment of the ICE personnel who select material from the files for facility use.

(b)(7)e
ICE.11.5082.000218

ODO reviewed the Detainee Grievance Procedures standard at DMCJC to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff, and reviewed detainee grievance procedures and the DMCJC detainee handbook. The facility has not implemented procedures for identifying and handling emergency grievances (Deficiency DGP-1). Based on ODOs review of detention files and interviews with staff, completed grievance forms are not placed in detention files (Deficiency DGP-2).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure each facility implements procedures for identifying and handling emergency grievances. An emergency grievance involves an immediate threat to a detainees safety or welfare. Once the receiving staff member, approached by a detainee, determines he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures will apply. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance remains in the detainees detention file for at least three years. The facility will maintain that record for a minimum of three years and subsequently, until the detainee leaves ICE custody.

(b)(7)e
10
ICE.11.5082.000219

ODO reviewed the Detainee Handbook standard at the DMCJC to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO reviewed the handbook and facility policies. DMCJC does not provide detainees with the ICE National Detainee Handbook (Deficiency DH-1). The DMCJC handbook does not state the detainee has the opportunity to submit written questions, requests, or concerns to ICE personnel, and the procedures for doing so, including the availability of assistance in preparing the request (Deficiency DH-2). The DMCJC handbook does not provide instructions stating that, upon request, all detainees will be provided an ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files (Deficiency DH-3).

DEFICIENCY DH-1 In accordance with the ICE Memorandum dated November 2, 2007, titled ICE National Detainee Handbook, from Director of DRO, John P. Torres, the FOD must ensure the ICE National Detainee Handbook is distributed to all those in the area of responsibility who address detainee issues, and to all detention facilities for immediate distribution to all ICE detainees. In addition to this handbook, the detention facility will provide a local supplement to the detainee handbook that addresses all facility day-to-day concerns. Some examples of items to include in the supplement are count times, meal schedules, and visiting procedures. DEFICIENCY DH-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook must state that the detainee has the opportunity to submit written questions, requests, or concerns to ICE personnel, and the procedures for doing so, including the availability of assistance in preparing the request. DEFICIENCY DH-3 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must ensure the detainee handbook or equivalent notifies the detainees of facility policies and procedures concerning personal property, including upon request, detainees will be provided an ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files.

(b)(7)e
ICE.11.5082.000220

ODO reviewed the Detention Files standard at DMCJC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed 30 detention files and interviewed staff. DMCJC does not keep required documentation inside the detainee files such as forms related to discipline, grievances, funds, personal property, and receipt of personal hygiene items (Deficiency DF-1).

DEFICIENCY DF-1 In accordance with the ICE National Detention Standard, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admission process. If necessary, the detention file may include copies of material contained in the detainees A-File. The file will, at a minimum, contain the following: Alien Booking Record (Form I-385), one or more original photograph(s) attached; classification work sheet; personal property inventory sheet; housing identification card; Property Receipt (Form G-589); and Baggage Check(s) (Form I-77).

(b)(7)e
ICE.11.5082.000221
DISCIPLINARY POLICY (DP)

ODO reviewed the Disciplinary Policy standard at DMCJC to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO interviewed detainees and staff, reviewed the disciplinary policy and the detainee handbook, and examined disciplinary files. The DMCJC handbook does not advise detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment, or of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DP-1).

DEFICIENCY DP-1 In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(a)and(b), the FOD must ensure the handbook advises detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment, and of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs.

(b)(7)e
13
ICE.11.5082.000222

ODO reviewed the Environmental Health and Safety standard at DMCJC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical management, and fire drills. Material Safety Data Sheets (MSDS) are up to date for all substances in all areas; however, there is no master index of hazardous substances (Deficiency EH&S-1). Exit diagrams in living areas do not include location of emergency equipment (Deficiency EH&S-2). Barber operations are conducted in the dayrooms of living areas (Deficiency EH&S-3). Observation of barbering practices revealed clippers are not properly cleaned and sanitized between use on detainees (Deficiency EH&S-4).

DEFICIENCY EH&S-1 In accordance with ICE NDS, Environmental Health and Safety, section (III)(C),the FOD must ensure the Maintenance Supervisor or designate compiles a master index of all hazardous substances in the facility, including locations, along with a master file of MSDS. DEFICIENCY EH&S-2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5)(c), the FOD must ensure location of emergency equipment is provided on the general area exit diagram. DEFICIENCY EH&S-3 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barber operation is located in a separate room not used for any other purpose. DEFICIENCY EH&S-4 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(3),the FOD must ensure all hair care tools coming into contact with the detainees are cleaned and effectively disinfected.

(b)(7)e
ICE.11.5082.000223
FOOD SERVICE (FS)

ODO reviewed the Food Service Standard at DMCJC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed food service policy and documentation, interviewed contract food service employees and detainees, inspected storage areas, and observed meal preparation and service. There was no documentation of pre-employment medical examinations for food service employees (Deficiency FS-1).

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel (both staff and detainee) receive a pre-employment medical examination.

(b)(7)e
ICE.11.5082.000224

ODO reviewed the Funds and Personal Property standard at the DMCJC to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with ICE NDS. ODO reviewed policies and procedures, logbooks, detainee handbook, and interviewed facility staff. DMCJC does not have written policies or procedures to conduct an inventory or audit of funds and personal property (Deficiency F&PP-1).

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must ensure each facility has a written procedure for inventory and audit of detainee funds, valuables, and personal property.

(b)(7)e
ICE.11.5082.000225

ODO reviewed the Hold Rooms in Detention Facilities standard at DMCJC to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure, and comfortable environment, and not confined in hold rooms for over 12 hours, in accordance with the ICE NDS. ODO interviewed staff, inspected the hold rooms, and reviewed policies and all available documentation. The facility does not maintain a manual or electronic detention log for every detainee placed in a hold cell (Deficiency HR-1). Detention officers do not conduct and document irregular visual monitoring of occupied hold rooms every 15 minutes (Deficiency HR-2).

DEFICIENCY HR-1 In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(D)(2), the FOD must ensure each facility maintains a detention log (manually or electronically) for every detainee placed in a hold cell. The log is used to record custodial information about new arrivals (e.g., a voluntary return waiting for a scheduled transportation run); detainees awaiting legal visitation; and detainees awaiting interviews with supervisory staff or other officials. DEFICIENCY HR-2 In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(D)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which involves irregular visual monitoring every 15 minutes, each time recording the time and officers staff number in the detention log.

(b)(7)e
ICE.11.5082.000226
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at DMCJC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 25 detainee medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by Correctional Healthcare and holds National Commission on Correctional Health Care and American Correctional Association accreditations. ODO found one staff members cardiopulmonary resuscitation (CPR) certification had expired (Deficiency MC-1). The Health Services Administrator informed ODO the staff member is scheduled for CPR training July 28, 2010.

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (lll)(H)(2), the FOD must ensure detention staff is trained on the administration of first aid and cardiopulmonary resuscitation.

(b)(7)e
18
ICE.11.5082.000227
RECREATION (R)
ODO reviewed the Recreation standard at DMCJC to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO reviewed local policies and procedures, observed recreation areas, and interviewed staff and detainees. DMCJC does not have a Recreation Specialist who is responsible for the development and oversight of the recreation program (Deficiency R-1). DMCJC has not established facility policies concerning television viewing in dayrooms, or the schedules that are subject to OIC approval (Deficiency R-2). For detainees housed in SMU, DMCJC does not require the concurrence of the OIC and health care professional for the denial of recreation privileges for more than 15 days (Deficiency R-3).

DEFICIENCY R-1 In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure all facilities have an individual responsible for the development and oversight of the recreation program. DEFICIENCY R-2 In accordance with the ICE NDS, Recreation, section (III)(G)(10), the FOD must establish facility policy concerning television viewing in dayrooms. All television viewing schedules must be subject to the OICs approval. DEFICIENCY R-3 In accordance with the ICE NDS, Recreation, section (III)(H)(4), the FOD must ensure denial of recreation privileges for more than 15 days requires the concurrence of the OIC and health care professional. It is expected that such denials will rarely occur, and only in extreme circumstances.

(b)(7)e
ICE.11.5082.000228
SPECIAL MANAGEMENT UNIT (SMU)

ODO reviewed the Special Management Unit (SMU) standard at DMCJC to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. ODO toured the SMUs, reviewed policies, logbooks, and other documentation, and interviewed staff. The facility operates three SMUs; two for males, and one for females. During the ODO review, one male detainee was housed in SMU. Based on ODOs interviews with facility staff assigned to the SMUs, detainees are not issued a copy of a written administrative segregation order (Deficiency SMU-1).

DEFICIENCY SMU-1 In accordance with the ICE NDS, Special Management Unit (Administrative Segregation) section (III)(B), the FOD must ensure a written order is completed and approved by a supervisory officer before a detainee is placed in administrative segregation, except when exigent circumstances make this impracticable. In such cases, an order must be prepared as soon as possible. A copy of the order must be given to the detainee within 24 hours, unless delivery would jeopardize the safety, security, or orderly operation of the facility.

(b)(7)e
20
ICE.11.5082.000229

ODO reviewed the Staff-Detainee Communication standard at DMCJC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE personnel and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed policies, procedures, and logbooks, and interviewed staff and detainees. Interviews with staff revealed the ICE Field Office Director (FOD), Assistant Field Office Director (AFOD), and other designated department heads do not conduct regular, unannounced visits to DMCJC. There are no policies and procedures present to ensure and document the FOD, AFOD, and other designated department heads are conducting regular unannounced visits to the DMCJC (Deficiency SDC-1). A review of policies revealed there are no written procedures to route detainee requests to appropriate ICE officials (Deficiency SDC-2). Detainee nationalities are not recorded in the electronic detainee request logbook (Deficiency SDC-3).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure policies and procedures are in place to document that the ICE FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and to informally observe living and working conditions. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must ensure DMCJC has written procedures to route detainee requests to the appropriate ICE official. DEFICIENCY SDC-3 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. The log, at a minimum, must contain: (a) date the detainee request was received; (b) detainees name; (c) A-number; (d) nationality; (e) officer logging the request; (f) date that the request, with staff response and action, is returned to the detainee; and (g) any other site-specific pertinent information.

(b)(7)e
21
ICE.11.5082.000230

ODO reviewed the Telephone Access standard at DMCJC to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the ICE NDS. ODO reviewed access, notification, quantity, maintenance, direct and free calls, restrictions, SMU telephone privileges, interfacility calls, incoming calls, privacy, and monitoring. ODO also observed postings and tested telephones in all housing units. DMCJC does not have telephone rules posted where detainees can easily see them (Deficiency TA-1). DMCJC detainees housed in the SMU for other than disciplinary purposes (protective custody, suicide risk) are not permitted telephone access similar to detainees in the general population, but in a manner consistent with the special security and safety requirements of detainees in these units (Deficiency TA-2). DMCJC does not allow interfacility telephone calls between immediate family members detained at other facilities nor does it grant requests for interfacility family calls (Deficiency TA-3). DMCJC monitors detainee telephone calls; however, the facility handbook does not include the written notification of monitoring detainee telephone calls (Deficiency TA-4).

DEFICIENCY TA-1 In accordance with the ICE NDS, Telephone Access, section (III)(B), the FOD must ensure the facility provides telephone access rules in writing to each detainee upon admittance, and posts these rules where detainees may easily see them. DEFICIENCY TA-2 In accordance with the ICE NDS, Telephone Access, section (III)(G), the FOD must permit detainees in the Special Management Unit for other than disciplinary reasons (e.g., protective custody, suicide risk) to have telephone access similar to detainees in the general population, but in a manner consistent with the special security and safety requirements of detainees in these units. DEFICIENCY TA-3 In accordance with the ICE NDS, Telephone Access, section (III)(H), the FOD must make special arrangements permitting detainees to speak by telephone with an immediate family member detained in another facility. (Immediate family members include the detainee's spouse, mother, father, stepparents, foster parents, brothers, sisters, and natural or adopted children.) Reasonable limitations may be placed on the frequency and duration of such calls. The facility must liberally grant requests for interOffice of Detention Oversight 22
(b)(7)e
ICE.11.5082.000231
facility family calls to discuss legal matters. For such calls, the detainees conversation must be afforded privacy to the extent possible, while maintaining adequate security. DEFICIENCY TA-4 In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure the facility has a written policy on the monitoring of detainee telephone calls. If telephone calls are monitored, the facility must notify detainees in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each monitored telephone stating detainee calls are subject to monitoring, and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

(b)(7)e
ICE.11.5082.000232
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at DMCJC to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO reviewed policies and tool inventories, interviewed staff, and inspected areas where tools are stored and maintained.
(b)(7)e
(b)(7)e

(b)(7)e
24
ICE.11.5082.000233
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at DMCJC to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed policies and use of force documentation, inspected equipment and inventories, and interviewed staff to determine their level of knowledge and understanding of the circumstances warranting immediate and calculated uses of force.
(b)(7)e

(b)(7)e
25
ICE.11.5082.000234
VISITATION (V)
ODO reviewed the Visitation standard at DMCJC to determine if authorized persons, including legal representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO inspected the visitation areas and reviewed the local policies, detainee handbook, and visitation schedule. Notice of Entry of Appearance as Attorney or Representative (Form G-28) was not available in the visiting reception areas (Deficiency V-1).

DEFICIENCY V-1 In accordance with ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitors reception area.

(b)(7)e
ICE.11.5082.000235
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DSCU EABM ERO EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU
TAR
American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement and Removal Operations Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit
Treatment Authorization Request

Tuberculosis Unit Disciplinary Committee
27
(b)(7)e
TB UDC
ICE.11.5082.000236
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(G), the FOD must ensure DMCJC devises a flexible schedule to permit all detainees, regardless of housing or classification, to use the law library on a regular basis. 8 Each detainee must be permitted to use the law library for a minimum of five hours per week. Detainees may not be forced to forgo their minimal recreation time, as provided in the Recreation standard, to use the law library. In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: (1) a law library is available for detainee use; (2) scheduled hours of access to the law library; (3) procedure for requesting access to the law library; (4) 8 procedure for requesting additional time in the law library (beyond the five hours per week minimum); (5) procedure for requesting legal reference materials not maintained in the law library; and (6) procedure for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library along with a list of the law library's holdings. In accordance with the ICE NDS, Admission and Release, section (III)(A)(1), the FOD must ensure the orientation process is supported by an ICE video and 9 handbook to inform new arrivals about facility operations, programs, and services.
Access to Legal Material
ALM-1
ALM-2
AR-1

(b)(7)e
28
ICE.11.5082.000237
DETENTION STANDARD
AR-2
DGP-1
DGP-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detainee Classifications System, section (III)(D), the FOD must ensure ICE offices provide non-INS facilities with the necessary information for the facility to classify ICE detainees. Because ICE selectively releases material from the 9 detainee's record to persons who are not ICE employees (e.g., CDF or IGSA facility personnel), non-ICE officers must rely on the judgment of the ICE personnel who select material from the files for facility use. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure each facility implements procedures for identifying and handling emergency grievances. An emergency grievance involves an 10 immediate threat to a detainees safety or welfare. Once the receiving staff member, approached by a detainee, determines he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures will apply. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance remains in the detainees 10 detention file for at least three years. The facility will maintain that record for a minimum of three years and subsequently, until the detainee leaves ICE custody.

(b)(7)e
ICE.11.5082.000238
DETENTION STANDARD
Detainee Handbook
DH-1
Detainee Handbook
DH-2
Detainee Handbook
DH-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE Memorandum dated November 2, 2007, titled ICE National Detainee Handbook, from Director of DRO, John P. Torres, the FOD must ensure the ICE National Detainee Handbook is distributed to all those in the area of responsibility who address detainee issues, and to all detention facilities for immediate distribution to all 11 ICE detainees. In addition to this handbook, the detention facility will provide a local supplement to the detainee handbook that addresses all facility dayto-day concerns. Some examples of items to include in the supplement are count times, meal schedules, and visiting procedures. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook 11 must state that the detainee has the opportunity to submit written questions, requests, or concerns to ICE personnel, and the procedures for doing so, including the availability of assistance in preparing the request. In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must ensure the detainee handbook or equivalent notifies the detainees of facility policies and 11 procedures concerning personal property, including upon request, detainees will be provided an ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files.

(b)(7)e
ICE.11.5082.000239
DETENTION STANDARD
Detention Files
DF-1
Disciplinary Policy
DP-1
EH&S-1
EH&S-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE National Detention Standard, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admission process. If necessary, the detention file may include copies of material contained in the detainees A12 File. The file will, at a minimum, contain the following: Alien Booking Record (Form I-385), one or more original photograph(s) attached; classification work sheet; personal property inventory sheet; housing identification card; Property Receipt (Form G-589); and Baggage Check(s) (Form I-77). In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(a)and(b), the FOD must ensure the handbook advises detainees of the right to protection from personal abuse, corporal punishment, unnecessary or 13 excessive use of force, personal injury, disease, property damage, harassment, and of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs. In accordance with ICE NDS, Environmental Health and Safety, section (III)(C),the FOD must ensure the Maintenance Supervisor or designate 14 compiles a master index of all hazardous substances in the facility, including locations, along with a master file of MSDS. In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5)(c), the FOD must ensure 14 location of emergency equipment is provided on the general area exit diagram.

(b)(7)e
ICE.11.5082.000240
DETENTION STANDARD Environmental Health and Safety
EH&S-3
EH&S-4
Food Service
FS-1
F&PP-1
Hold Rooms
HR-1
Hold Rooms
HR-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the 14 barber operation is located in a separate room not used for any other purpose. In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(3),the FOD must ensure all hair 14 care tools coming into contact with detainees are cleaned and effectively disinfected. In accordance with ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel 15 (both staff and detainee) receive a preemployment medical examination. In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must ensure each facility has a 16 written procedure for inventory and audit of detainee funds, valuables, and personal property. In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(D)(2), the FOD must ensure each facility maintains a detention log (manually or electronically) for every detainee placed in a hold cell. The log is used to record 17 custodial information about new arrivals (e.g., a voluntary return waiting for a scheduled transportation run); detainees awaiting legal visitation; and detainees awaiting interviews with supervisory staff or other officials. In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(D)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which 17 involves irregular visual monitoring every 15 minutes, each time recording the time and officers staff number in the detention log.

(b)(7)e
32
ICE.11.5082.000241
DETENTION STANDARD
Medical Care
MC-1
Recreation
R-1
Recreation
R-2
Recreation
R-3
Special Management Unit
SMU-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Medical Care, section (lll)(H)(2), the FOD must ensure detention staff is trained on the 18 administration of first aid and cardiopulmonary resuscitation. In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure all facilities have an individual 19 responsible for the development and oversight of the recreation program. In accordance with the ICE NDS, Recreation, section (III)(G)(10), the FOD must establish facility policy concerning 19 television viewing in dayrooms. All television viewing schedules must be subject to the OICs approval. In accordance with the ICE NDS, Recreation, section (III)(H)(4), the FOD must ensure denial of recreation privileges for more than 15 days requires the 19 concurrence of the OIC and health care professional. It is expected that such denials will rarely occur, and only in extreme circumstances. In accordance with the ICE NDS, Special Management Unit (Administrative Segregation) section (III)(B), the FOD must ensure a written order is completed and approved by a supervisory officer before a detainee is placed in administrative segregation, except when 20 exigent circumstances make this impracticable. A copy of the order must be given to the detainee within 24 hours, unless delivery would jeopardize the safety, security, or orderly operation of the facility.

(b)(7)e
33
ICE.11.5082.000242
DETENTION STANDARD
Staff Detainee Communication
SDC-1
SDC-2
SDC-3
Telephone Access
TA-1
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE NDS, StaffDetainee Communication, section (III)(A)(1), the FOD must ensure policies and procedures are in place to document that the ICE FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and to informally observe living and working conditions. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B), the FOD must ensure DMCJC has written procedures to route detainee requests to the appropriate ICE official. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. The log, at a minimum, must contain: (a) date the detainee request was received; (b) detainees name; (c) A-number; (d) nationality; (e) officer logging the request; (f) date the request, with staff response and action, is returned to the detainee; and (g) any other site-specific pertinent information. In accordance with the ICE NDS, Telephone Access, section (III)(B), the FOD must ensure the facility provides telephone access rules in writing to each detainee upon admittance, and posts these rules where detainees may easily see them.
PAGE
21
21
21
22

(b)(7)e
34
ICE.11.5082.000243
DETENTION STANDARD
Telephone Access
TA-2
Telephone Access
TA-3
Telephone Access
TA-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Telephone Access, section (III)(G), the FOD must permit detainees in the Special Management Unit for other than disciplinary reasons (e.g., protective 22 custody, suicide risk) to have telephone access similar to detainees in the general population, but in a manner consistent with the special security and safety requirements of detainees in these units. In accordance with the ICE NDS, Telephone Access, section (III)(H), the FOD must make special arrangements permitting detainees to speak by telephone with an immediate family member detained in another facility. (Immediate family members include the detainee's spouse, mother, father, stepparents, foster parents, brothers, 22 sisters, and natural or adopted children.) Reasonable limitations may be placed on the frequency and duration of such calls. The facility must liberally grant requests for inter-facility family calls to discuss legal matters. For such calls, the detainees conversation must be afforded privacy to the extent possible, while maintaining adequate security. In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure the facility has a written policy on the monitoring of detainee telephone calls. If telephone calls are monitored, the facility must notify detainees in the detainee handbook or equivalent provided upon admission. The 23 facility must also place a notice at each monitored telephone stating detainee calls are subject to monitoring, and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

(b)(7)e
35
ICE.11.5082.000244
DETENTION STANDARD
PAGE
Tool Control
TC-1
24
Use of Force
UOF-1
(b)(7)e
25
Use of Force
UOF-2
25
Visitation
V-1
In accordance with ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitors reception area.
26

(b)(7)e
36
ICE.11.5082.000245
ICE.11.5082.000246
ICE.11.5082.000247
ICE.11.5082.000248
(b)(6), (b)(7)(C)
(b)(7)e
ICE.11.5082.000249
(b)(7)e
ICE.11.5082.000250
(b)(7)e
ICE.11.5082.000251
(b)(7)e
(b)(7)e
ICE.11.5082.000252
(b)(7)e
(b)(7)e
ICE.11.5082.000253
(b)(7)e
(b)(7)e
ICE.11.5082.000254


Enforcement and Removal Operations Chicago Field Office Dodge County Detention Facility Juneau, Wisconsin
August 17-19, 2010 ________________________________

ICE.11.5082.000255
ICE.11.5082.000256
QUALITY ASSURANCE REVIEW DODGE COUNTY DETENTION FACILITY CHICAGO FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. Areas of Concern ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed Admission and Release. Detainee Grievance Procedures.. Detainee Handbook Detention Files. Disciplinary Policy Environmental Health and Safety. Food Service Funds and Personal Property Hold Rooms in Detention Facilities.. Medical Care Recreation Special Management Unit. Terminal Illness, Advance Directives, and Death.. Tool Control.. Visitation... 1 1
5 5 5
7 8 9 10 12 13 14 15 16 17 18 19 20 21 22 23
ICE.11.5082.000257
ICE.11.5082.000258
INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. ODO inspected Dodge County Detention Facility (DCDF) in Juneau, Wisconsin, on August 17-19, 2010. ODO reviewed the processes employed at DCDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. Recommendations are provided to improve the effectiveness, efficiency, and overall living conditions at the detention center. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Assistant Director, Office of Professional Responsibility.

Management Analyst (Team Leader) ODO, Headquarters Detention and Deportation Officer ODO, Headquarters Contract Inspector MGT of America, Inc. Contract Inspector MGT of America, Inc. Contract Inspector MGT of America, Inc. Contract Inspector MGT of America, Inc.
(b)(6), (b)(7)(C)

(b)(7)e
Dodge County Detention Facility ERO Chicago
ICE.11.5082.000259
Office of Detention Oversight August 2010

(b)(7)e
ICE.11.5082.000260
BACKGROUND
HISTORY
DCDF was established in 2000, upon completion of a new facility. The previous facility was called the Dodge County Jail. DCDF entered into an intergovernmental service agreement with ICE in 2001, to house ICE detainees of all classification levels. Medical care is contracted through the Correctional Healthcare Corporation. Food service is contracted through Aramark. The ERO Chicago field office does not have personnel permanently located at DCDF. A Detention Service Manager, as well as deportation officers and immigration enforcement agents, visit DCDF regularly. DCDF has 83 correctional officers, as well as management and administrative staff. DCDF currently does not have any vacancies. In April 2010, ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the ICE NDS at DCDF. The facility received an overall rating of Acceptable. Currently, DCDF does not hold any accreditations.

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ICE.11.5082.000261

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ICE.11.5082.000262
INTERNAL RELATIONS
ODO conducted interviews with ICE and facility management and staff. Both ICE and DCDF staff expressed the morale of employees is good overall, and a positive relationship exists between ICE and DCDF. ICE personnel stated ICE employees could benefit from more training for required duties. ICE personnel also stated the officers conducting staff-detainee communication could use more support from the ERO Chicago field office. ICE personnel stated the Chicago field office receives the detainee request and grievance forms, and faxes the responses back to the facility. ERO officers performing staff-detainee communication responsibilities do not see or respond to these requests or grievances. DCDF often receives detainees who are simply awaiting travel documents before they are deported. DCDF has two video teleconferencing units to use for immigration court; however, the units have yet to be used. DCDF receives numerous calls from family members of detainees who complain they are unable to reach an ICE officer using the main office number for the ERO Chicago field office. ICE staff stated the main office number gives several options for directing the call prior to transferring the call to an ICE officer. ICE staff stated the numerous options may confuse some callers. Facility management noted DCDF does not currently have an on-site dentist. DCDF previously used a single dentist for all detainee oral care; however, the dentist did not receive prompt payment from ICE for dental work due to ICE budget issues. DCDF currently takes detainees to available dentists in the area, as needed.
DETAINEE RELATIONS
ODO interviewed 19 detainees at DCDF, four of whom were female. Overall, detainees stated they were treated with dignity and respect by both ICE and DCDF staff. One female detainee stated she was having stomach aches due to the food from the dining facility. When asked if treatment was requested for the condition, the detainee stated she just does not like non-Spanish food. All of the male detainees interviewed stated the food quality is good and portions are satisfactory. Detainees knew their deportation officer, and confirmed ICE officials make weekly visits to their housing units. No complaints about health care were expressed.
AREAS OF CONCERN
During the transport of incoming detainees, ODO observed a female detainee being transported with other male detainees while inside a transport vehicle. According to the ICE memorandum titled Update to the Detention and Deportation Officers Field Manual:
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ICE.11.5082.000263
Appendix 16-4, Part 2; Enforcement Standard Pertaining to the Escorting of Aliens, section (B)(2), unaccompanied females are to be separated from unrelated adult males by passenger compartments or any empty row of seats.

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ICE.11.5082.000264

This inspection was based on the 2000 ICE NDS. The following 22 standards were reviewed: Access to Legal Material Admission and Release Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Medical Care Population Counts Recreation Special Management Unit Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Use of Force Visitation No deficiencies were noted in the following six standards: Access to Legal Material Hunger Strikes Population Counts Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ICE.11.5082.000265

ODO reviewed the Admission and Release standard at DCDF to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO interviewed staff and detainees, and reviewed detention files and the admission process. ODO observed ICE does not provide the necessary documents for the facility to conduct a proper classification on each detainee (Deficiency AR-1). The facility does not provide detainees with an ICE National Detainee Handbook (Deficiency AR-2 and DH-1).

DEFICIENCY AR-1 In accordance with the ICE NDS, Detainee Classification System, section (III)(D), the FOD must ensure ICE offices provide non-ICE facilities with the necessary information for the facility to classify ICE detainees. Because ICE selectively releases material from the detainee's record to persons who are not ICE employees (e.g., intergovernmental service agreement facility personnel), non-ICE officers must rely on the judgment of the ICE staff who select material from the files for facility use. Examples of acceptable forms and information: Order to Show Cause (Form I-221) and Notice of Hearing, with bond conditions; Notice to Appear (Form I-862); Notice to Applicant for Admission, and Detained for Hearing before Immigration Judge (Forms I-110 and I-122); Record of Deportable Alien (Form I-213); all conviction documents relating to charges on Forms I-221, I-862, I-110/122, or I-213 above; criminal history including National Crime Information Center (NCIC), etc.; and any other official record or observation that is verifiable and can be justified under review by official means. DEFICIENCY AR-2 and DH-1 In accordance with the ICE memorandum titled ICE National Detainee Handbook, dated November 2, 2007, from Director of DRO John P. Torres, the FOD must ensure the ICE National Detainee Handbook is distributed to all those in the FODs area of responsibility that address detainee issues, and to all detention facilities for immediate distribution to all ICE detainees. All detention facilities are to develop and implement a local supplement to the ICE National Detainee Handbook.

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ICE.11.5082.000266

ODO reviewed the Detainee Grievance Procedures standard at DCDF to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO reviewed the grievance policy, logbooks, and detainee handbook; and interviewed staff and detainees. Procedures for contacting ICE to appeal the decision of the Officer in Charge regarding a detainee grievance are not included in the detainee handbook, and the handbook does not provide a contact number for filing a complaint about officer misconduct directly with the DHS Office of Inspector General (Deficiency DGP-1 and DH-4).

DEFICIENCY DGP-1 and DH-4 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(4)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the following: procedures for contacting ICE to appeal the decision of the Officer in Charge of the facility, and the opportunity to file a complaint about officer misconduct directly with the DHS Office of Inspector General by calling 1-800-323-8603 or by writing to: DHS Office of Inspector General, 245 Murray Drive, SE, Building 410 Washington, DC 20538.

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ICE.11.5082.000267

ODO reviewed the Detainee Handbook standard at DCDF to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO interviewed staff, and reviewed policies and procedures regarding the detainee handbook. The facility does not provide detainees with an ICE National Detainee Handbook (Deficiency DH-1 and AR-2). The supplemental DCDF detainee handbook does not provide instructions for detainees to request identity documents stored within their A-file (Deficiency DH-2 and F&PP-2), or to file a claim for lost or damaged property (Deficiency DH-3 and F&PP-3). Procedures for contacting ICE to appeal the decision of the Officer in Charge regarding a detainee grievance are not included in the detainee handbook, and the handbook does not provide a contact number for filing a complaint about officer misconduct directly with the DHS Office of Inspector General (Deficiency DH-4 and DGP-1). The handbook does not advise detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, or harassment (Deficiency DH-5 and DP-1); or the right to freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DH-6 and DP-2).

DEFICIENCY DH-1 and AR-2 In accordance with the ICE memorandum titled ICE National Detainee Handbook, dated November 2, 2007, from Director of DRO John P. Torres, the FOD must ensure the ICE National Detainee Handbook is distributed to all those in the FODs area of responsibility that address detainee issues, and to all detention facilities for immediate distribution to all ICE detainees. All detention facilities are to develop and implement a local supplement to the ICE National Detainee Handbook. DEFICIENCY DH-2 and F&PP-2 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including, upon request, detainees will be provided an ICE-certified copy of any identity document, such as a passport or birth certificate, placed in their A-files.

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ICE.11.5082.000268
DEFICIENCY DH-3 and F&PP-3 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including the procedures for filing a claim for lost or damaged property. DEFICIENCY DH-4 and DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(4)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the following: procedures for contacting ICE to appeal the decision of the Officer in Charge of the facility, and the opportunity to file a complaint about officer misconduct directly with the DHS Office of Inspector General by calling 1-800-323-8603 or by writing to: DHS Office of Inspector General, 245 Murray Drive, SE, Building 410 Washington, DC 20538. DEFICIENCY DH-5 and DP-1 In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(a), the FOD must ensure the detainee handbook or equivalent advises detainees of their right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage and harassment. DEFICIENCY DH-6 and DP-2 In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(b), the FOD must ensure the detainee handbook or equivalent advises detainees of their right to freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs.

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ICE.11.5082.000269

ODO reviewed the Detention Files standard at DCDF to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed 30 detention files and interviewed staff. DCDF does not keep all required documentation in the detention files, such as: forms related to discipline, classification, and grievances; receipts of personal hygiene items; medical questionnaires; or receipts for detainee handbooks (Deficiency DF-1). DCDF staff stated all documents in the detention file upon the detainees departure are scanned and stored digitally. ODO reviewed the archived digitized files and found files were missing the required documentation listed above. ODO observed DCDF does not keep a logbook for signing in/out detention files from the storage cabinet (Deficiency DF-2).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, sections (III)(B)(1) and (C), the FOD must ensure the detention file contains either originals or copies of forms and other documents generated during the admission process. If necessary, the detention file may include copies of material contained in the detainees A-file. The file must, at a minimum, contain the following: Alien Booking Record (Form I-385), with one or more original photograph(s) attached; classification worksheets; personal property inventory sheets; housing identification card; property receipt (Form G-589); and baggage checks (Form I-77). During the course of the detainees stay at the facility, staff must add documents associated with normal operations to the detainees detention file without prior approval, e.g.: special requests; any Form G-589s and/or I-77s closed-out during the detainees stay; disciplinary forms; grievances, complaints, and disposition(s) of same; all forms associated with disciplinary and/or administrative segregation; strip search forms, and other approved documents, e.g., staff reports about the detainees behavior, attitude, etc. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(F), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

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ICE.11.5082.000270

ODO reviewed the Disciplinary Policy standard at DCDF to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO interviewed staff, and reviewed policy, disciplinary records, and the detainee handbook. The handbook does not advise detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, or harassment (Deficiency DP-1 and DH-5); or the right to freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DP-2 and DH-6). DCDF policy does not address the handling of confidential informant information (Deficiency DP-3).

DEFICIENCY DP-1 and DH-5 In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(a), the FOD must ensure the detainee handbook or equivalent advises detainees of their right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage and harassment. DEFICIENCY DP-2 and DH-6 In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(b), the FOD must ensure the detainee handbook or equivalent advises detainees of their right to freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs. DEFICIENCY DP-3 In accordance with the ICE NDS, Disciplinary Policy, section (III)(K), the FOD must ensure when a decision relies on information from a confidential informant, the Unit Disciplinary Committee or Institutional Disciplinary Panel records in the hearing the factual basis for finding the information reliable.

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ICE.11.5082.000271

ODO reviewed the Environmental Health and Safety standard at DCDF to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility; interviewed staff; and reviewed chemical inventories, Material Safety Data Sheets (MSDS), and the master index of hazardous substances. Additionally, documentation of fire and safety inspections, fire drills, water and generator testing, and vermin and pest control were reviewed. A running inventory of chemicals was not maintained by the Food Service Department (Deficiency EH&S-1). The facility does not produce written reports documenting weekly fire and safety inspections (Deficiency EH&S-2). During the review, the facility established an inventory of chemicals maintained in the Food Service Department, as well as fire and safety inspection reporting procedures. Emergency evacuation instructions were posted in living areas; however, exit diagrams were available only to staff members, diagrams are not visible by detainees due to security concerns (Deficiency EH&S-3). Barbering takes place in counselor interview rooms (Deficiency EH&S-4).

DEFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of the hazardous substances used and stored in that area. Inventory records must be maintained separately for each substance. DEFICIENCY EH&S-2 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure written reports for fire and safety inspections are forwarded to the Officer in Charge for review, and, if necessary, for corrective action determinations. DEFICIENCY EH&S-3 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(h), the FOD must ensure exit diagrams are conspicuously posted in each area. DEFICIENCY EH&S-4 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1-2), the FOD must ensure barber operations are located in a separate room not used for any other purpose, with least one lavatory provided.

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ICE.11.5082.000272
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at DCDF to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed policies and relevant documentation. There is no documentation of pre-employment medical examinations for food service staff (Deficiency FS-1).

DEFICIENCY FS-1 In accordance with the ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel (both staff and detainee) receive a pre-employment medical examination.

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ICE.11.5082.000273

ODO reviewed the Funds and Personal Property standard at DCDF to determine if controls are in place to inventory, receipt, store and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed local policies and procedures, logbooks, and the detainee handbook; and interviewed facility staff. Upon a detainees arrival at DCDF, the detainees funds are deposited into a detainee account for commissary expenditures. ICE officers have not collect abandoned detainee funds and personal property from DCDF since 2004 (Deficiency F&PP-1). The supplemental DCDF detainee handbook does not provide instructions for detainees to request identity documents stored within their A-file (Deficiency F&PP-2 and DH-2), or to file a claim for lost or damaged property (Deficiency F&PP-3 and DH-3).

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III) (I), the FOD must ensure that all CDFs and IGSA facilities shall report and turn over to ICE all detainee abandoned property. DEFICIENCY F&PP-2 and DH-2 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including, upon request, detainees will be provided an ICE-certified copy of any identity document, such as a passport or birth certificate, placed in their A-files. DEFICIENCY F&PP-3 and DH-3 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including the procedures for filing a claim for lost or damaged property.

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ICE.11.5082.000274

ODO reviewed the Hold Room in Detention Facilities standard at DCDF to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure and comfortable environment, and not confined in hold rooms for over 12 hours, in accordance with the ICE NDS. ODO inspected the hold rooms, interviewed staff, and reviewed policies and documentation. Detention logs do not record the reason for a detainees placement in a hold room (Deficiency HR-1). Officers routinely carry pepper spray into hold rooms (Deficiency HR-2).

DEFICIENCY HR-1 In accordance with the ICE NDS, Hold Rooms In Detention Facilities, section (III)(D)(2), the FOD must ensure detention logs are maintained for every detainee placed in a holding cell. The log must record custodial information about new arrivals (e.g., a voluntary return waiting for a scheduled transportation run), detainees awaiting legal visitation, and detainees awaiting interviews with supervisory staff or other officials. DEFICIENCY HR-2 In accordance with the ICE NDS, Hold Rooms In Detention Facilities, section (III)(D)(6), the FOD must ensure officers do not carry firearms, Oleoresin Capsicum (OC) spray, batons, or other non-deadly force devices into a hold room.

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ICE.11.5082.000275
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at DCDF to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 20 detainee medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by Correctional Healthcare and holds no accreditations. The Charge Nurse informed ODO there has not been a dentist on staff for the past six months due to non-payment from ICE. Treatment Authorization Requests (TAR) are submitted for dental care as needed. The record review revealed one record without a physical examination. ODO was informed physical examinations were not being completed prior to May 5, 2010 (Deficiency MC-1). Records for detainees who have arrived at the facility since May 2010 included documentation of completed physicals.

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure the healthcare provider of each facility conducts a health appraisal and physical examination on each detainee within 14 days of arrival at the facility.

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ICE.11.5082.000276
RECREATION (R)
ODO reviewed the Recreation standard at DCDF to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO inspected the recreation area, reviewed policies and documentation, and interviewed staff and detainees. Outdoor recreation is not offered at DCDF. The indoor recreation area does not have exercise equipment or direct sunlight access (Deficiency R-1). Detainees in disciplinary segregation are not afforded recreation privileges (Deficiency R-2 and SMU-1).

DEFICIENCY R-1 In accordance with the ICE NDS, Recreation, section (III)(A)(1), the FOD must ensure every effort is made to place a detainee in a facility that provides outdoor recreation. If a facility does not have an outdoor area, a large recreation room with exercise equipment and access to sunlight must be provided. DEFICIENCY R-2 and SMU-1 In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(13), and Recreation, section (III)(H), the FOD must ensure recreation is provided to detainees in disciplinary segregation in accordance with the Recreation standard. The standard provisions must be carried out, absent compelling security or safety reasons documented by the Officer in Charge. Detainees in the SMU must be offered at least one hour of recreation per day, scheduled at a reasonable time, at least five days per week. A detainee in the SMU for disciplinary purposes may temporarily lose recreation privileges upon a disciplinary panels written determination that he or she poses an unreasonable risk to the facility, him or herself, or others.

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ICE.11.5082.000277

ODO reviewed the Special Management Unit (SMU) standard at DCDF to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. ODO interviewed staff; inspected the SMU; and reviewed policies and procedures, SMU logs, and pertinent documentation. Detainees on disciplinary segregation are not afforded recreational privileges (Deficiency SMU-1 and R-2). Detainees in disciplinary segregation are also not permitted visits except with legal counsel (Deficiency SMU-2 and V-3).

DEFICIENCY SMU-1 and R-2 In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(13), and Recreation, section (III)(H), the FOD must ensure recreation is provided to detainees in disciplinary segregation in accordance with the Recreation standard. The standard provisions must be carried out, absent compelling security or safety reasons documented by the Officer in Charge. Detainees in the SMU must be offered at least one hour of recreation per day, scheduled at a reasonable time, at least five days per week. A detainee in the SMU for disciplinary purposes may temporarily lose recreation privileges upon a disciplinary panels written determination that he or she poses an unreasonable risk to the facility, him or herself, or others. DEFICIENCY SMU-2 and V-3 In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(17), and Visitation, section (III)(H)(5), the FOD must ensure the facility follows the Visitation standard in setting visitation rules for detainees in disciplinary segregation. A detainee must ordinarily retain visiting privileges while in disciplinary segregation status. The facility may restrict or disallow general visits for a detainee in segregation status who violates the visiting guidelines, or whose behavior indicates that he or she threatens the order or security of the visiting room.

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ICE.11.5082.000278
TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (TIADD)

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate (DNR) orders and organ donations, at DCDF to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO reviewed polices and interviewed the Charge Nurse. There have been no deaths in the past year. DCDF policies do not require notification of ICE when a detainee is seriously injured or ill (Deficiency TIADD-1), and do not include procedures governing DNR orders (Deficiency TIADD-2).

DEFICIENCY TIADD-1 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(A)(4), the FOD must ensure ICE is notified when a detainee is seriously injured or ill. DEFICIENCY TIADD-2 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C), the FOD must ensure each facility holding ICE detainees establishes and implements, through written procedures, policy governing DNR orders.

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ICE.11.5082.000279
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at DCDF to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO inspected all areas where tools are maintained, reviewed policies, and interviewed staff.
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ICE.11.5082.000280
VISITATION (V)
ODO reviewed the Visitation standard at DCDF to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO reviewed local policies and the detainee handbook, inspected the visiting area, and interviewed staff and detainees. DCDF uses the same log for both general visitors and legal visitors (Deficiency V-1). Separate logs were established during the review. Notice of Appearance (Form G-28) was not available in the legal visitors reception area (Deficiency V-2). Detainees in disciplinary segregation are not permitted visits except with legal counsel (Deficiency V-3 and SMU-2).

DEFICIENCY V-1 In accordance with the ICE NDS, Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all general visitors and a separate log of legal visitors. DEFICIENCY V-2 In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure Form G-28 is available in the legal visitors reception area. DEFICIENCY V-3 and SMU-2 In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(17), and Visitation, section (III)(H)(5), the FOD must ensure the facility follows the Visitation standard in setting visitation rules for detainees in disciplinary segregation. A detainee must ordinarily retain visiting privileges while in disciplinary segregation status. The facility may restrict or disallow general visits for a detainee in segregation status who violates the visiting guidelines, or whose behavior indicates that he or she threatens the order or security of the visiting room.

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ICE.11.5082.000281
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS ERO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU
TAR
American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Enforcement and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit

TB UDC

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APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detainee Classification System, section (III)(D), the FOD must ensure ICE offices provide non-ICE facilities with the necessary information for the facility to classify ICE detainees. Because ICE selectively releases material from the detainee's record to persons who are not ICE employees (e.g., intergovernmental service agreement facility personnel), non-ICE officers must rely on the judgment of the ICE staff who select material from the files for facility use. Examples of acceptable forms and information: Order to Show Cause (Form I-221) and Notice of 8 Hearing, with bond conditions; Notice to Appear (Form I-862); Notice to Applicant for Admission, and Detained for Hearing before Immigration Judge (Forms I-110 and I-122); Record of Deportable Alien (Form I-213); all conviction documents relating to charges on Forms I-221, I-862, I-110/122, or I-213 above; criminal history including National Crime Information Center (NCIC), etc.; and any other official record or observation that is verifiable and can be justified under review by official means.
AR-1

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ICE.11.5082.000283
DETENTION STANDARD
AR-2
DH-1 Detainee Handbook
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE memorandum titled ICE National Detainee Handbook, dated November 2, 2007, from Director of DRO John P. Torres, the FOD must ensure the ICE National Detainee Handbook is 8 distributed to all those in the FODs area of responsibility that address detainee issues, and to all detention facilities for immediate distribution to all 10 ICE detainees. All detention facilities are to develop and implement a local supplement to the ICE National Detainee Handbook. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(4)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the following: procedures for contacting ICE to appeal the decision of the Officer in Charge of the facility, and the opportunity to file a complaint about officer misconduct directly with the DHS Office of Inspector General by calling 1800-323-8603 or by writing to: DHS Office of Inspector General, 245 Murray Drive, SE, Building 410 Washington, DC 20538. In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including, upon request, detainees will be provided an ICEcertified copy of any identity document, such as a passport or birth certificate, placed in their A-files.
DGP-1
Detainee Handbook
DH-4
10
Detainee Handbook
DH-2
10
F&PP-2
16

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ICE.11.5082.000284
DETENTION STANDARD
Detainee Handbook
DH-3
F&PP-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(5), the FOD must ensure the detainee handbook or equivalent 10 notifies detainees of facility policies and procedures concerning personal property, including the procedures for 16 filing a claim for lost or damaged property. In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(a), the FOD must ensure the detainee handbook or equivalent advises detainees of their right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage and harassment. In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(b), the FOD must ensure the detainee handbook or equivalent advises detainees of their right to freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs.
Detainee Handbook
DH-5
10
Disciplinary Policy
DP-1
13
Detainee Handbook
DH-6
10
Disciplinary Policy
DP-2
13

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27
ICE.11.5082.000285
DETENTION STANDARD
Detention Files
DF-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, sections (III)(B)(1) and (C), the FOD must ensure the detention file contains either originals or copies of forms and other documents generated during the admission process. If necessary, the detention file may include copies of material contained in the detainees A-file. The file must, at a minimum, contain the following: Alien Booking Record (Form I-385), with one or more original photograph(s) attached; classification worksheets; personal property inventory sheets; housing identification card; property receipt (Form G-589); and baggage 12 checks (Form I-77). During the course of the detainees stay at the facility, staff must add documents associated with normal operations to the detainees detention file without prior approval, e.g.: special requests; any Form G589s and/or I-77s closed-out during the detainees stay; disciplinary forms; grievances, complaints, and disposition(s) of same; all forms associated with disciplinary and/or administrative segregation; strip search forms, and other approved documents, e.g., staff reports about the detainees behavior, attitude, etc. In accordance with the ICE NDS, Detention Files, section (III)(F), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.
Detention Files
DF-2
12

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28
ICE.11.5082.000286
DETENTION STANDARD
Disciplinary Policy
DP-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Disciplinary Policy, section (III)(K), the FOD must ensure when a decision relies on information from a confidential informant, the Unit Disciplinary 13 Committee or Institutional Disciplinary Panel records in the hearing the factual basis for finding the information reliable. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of the hazardous substances used and stored in that area. Inventory records must be maintained separately for each substance. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure written reports for fire and safety inspections are forwarded to the Officer in Charge for review, and, if necessary, for corrective action determinations. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(h), the FOD must ensure exit diagrams are conspicuously posted in each area. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1-2), the FOD must ensure barber operations are located in a separate room not used for any other purpose, with least one lavatory provided.
EH&S-1
14
EH&S-2
14
EH&S-3
14
EH&S-4
14

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ICE.11.5082.000287
DETENTION STANDARD
Food Service
FS-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel 15 (both staff and detainee) receive a preemployment medical examination. In accordance with the ICE NDS, Funds and Personal Property, section (III) (I), the FOD must ensure that all CDFs and IGSA facilities shall report and turn over to ICE all detainee abandoned property. In accordance with the ICE NDS, Hold Rooms In Detention Facilities, section (III)(D)(2), the FOD must ensure detention logs are maintained for every detainee placed in a holding cell. The log must record custodial information about new arrivals (e.g., a voluntary return waiting for a scheduled transportation run), detainees awaiting legal visitation, and detainees awaiting interviews with supervisory staff or other officials. In accordance with the ICE NDS, Hold Rooms In Detention Facilities, section (III)(D)(6), the FOD must ensure officers do not carry firearms, Oleoresin Capsicum (OC) spray, batons, or other non-deadly force devices into a hold room. In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure the healthcare provider of each facility conducts a health appraisal and physical examination on each detainee within 14 days of arrival at the facility.
F&PP-1
16
Hold Rooms
HR-1
17
Hold Rooms
HR-2
17
Medical Care
MC-1
18

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30
ICE.11.5082.000288
DETENTION STANDARD
Recreation
R-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Recreation, section (III)(A)(1), the FOD must ensure every effort is made to place a detainee in a facility that provides outdoor recreation. If a facility 19 does not have an outdoor area, a large recreation room with exercise equipment and access to sunlight must be provided. In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(13), and Recreation, section (III)(H), the FOD must ensure recreation is provided to detainees in disciplinary segregation in accordance with the Recreation standard. The standard provisions must be carried out, absent compelling security or safety reasons documented by the Officer in Charge. Detainees in the SMU must be offered at least one hour of recreation per day, scheduled at a reasonable time, at least five days per week. A detainee in the SMU for disciplinary purposes may temporarily lose recreation privileges upon a disciplinary panels written determination that he or she poses an unreasonable risk to the facility, him or herself, or others.
Recreation
R-2
19
SMU-1
20

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ICE.11.5082.000289
DETENTION STANDARD
SMU-2
Visitation
V-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(17), and Visitation, section (III)(H)(5), the FOD must ensure the facility follows the Visitation standard in setting visitation 20 rules for detainees in disciplinary segregation. A detainee must ordinarily retain visiting privileges while in disciplinary segregation status. The facility may restrict or disallow general 23 visits for a detainee in segregation status who violates the visiting guidelines, or whose behavior indicates that he or she threatens the order or security of the visiting room. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(A)(4), the FOD must ensure ICE is notified when a detainee is seriously injured or ill. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C), the FOD must ensure each facility holding ICE detainees establishes and implements, through written procedures, policy governing DNR orders.
TIADD-1
21
TIADD-2
21
Tool Control
TC-1
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22
Visitation
V-1
Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all general visitors and a separate log of legal visitors.
23

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ICE.11.5082.000290
DETENTION STANDARD
Visitation
V-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure Form G-28 is available in 23 the legal visitors reception area.

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ICE.11.5082.000291



Saint Paul Field Office Douglas County Department of Corrections Omaha, Nebraska
July 13-15, 2010 ________________________________

ICE.11.5082.000292
ICE.11.5082.000293
ICE.11.5082.000294
QUALITY ASSURANCE REVIEW DOUGLAS COUNTY DEPARTMENT OF CORRECTIONS SAINT PAUL FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. OPERATIONAL ENVIRONMENT Internal Relations........ Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Access to Legal Material Admission and Release. Correspondence and Other Mail.. Detainee Classification System Detainee Grievance Procedures.. Detainee Handbook Detention Files. Emergency Plans Environmental Health and Safety. Food Service Funds and Personal Property Issuance and Exchange of Clothing, Bedding, and Towels. Key and Lock Control. Medical Care Population Counts.. Post Orders.. Security Inspections Special Management Unit (Administrative and Disciplinary) Staff-Detainee Communication..... Suicide Prevention and Intervention. Telephone Access... Terminal Illness, Advance Directives, and Death... Tool Control.. Use of Force. Visitation 1 1
5 5
8 10 11 12 13 14 15 16 17 18 19 21 22 23 24 25 26 27 28 29 30 31 32 33 34
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ICE.11.5082.000296
INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of Douglas County Department of Corrections (DCDC) in Omaha, Nebraska, on July 13-15, 2010. ODO reviewed the processes employed at DCDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION

Special Agent (Team Leader) Special Agent Special Agent Special Agent (Section Chief) Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, San Diego ODO, Houston ODO, Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
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Douglas County Department of Corrections ERO St. Paul
ICE.11.5082.000297

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BACKGROUND
HISTORY
DCDC is an intergovernmental service agreement (IGSA) detention facility. DCDC opened in February 1979, is designated as a maximum, medium, and minimum security facility, and is authorized to house adult male and female ICE detainees over 72 hours. The ERO Saint Paul Field Office Director (FOD) utilizes DCDC to detain and process aliens who have been placed in removal proceedings. The facility was initially designed to support a population of 202 detainees and inmates; however, through expansion and new construction, the facility can now support a population of 1,458 detainees and inmates. DCDCs population consists of pre-trial detainees, sentenced misdemeanants, and sentenced felons awaiting transfer to state facilities, state and federal prisoners awaiting trial and/or hearings, and individuals who are returned from community programs due to alleged program violations. Through inter-county agreements, DCDC also houses pre-trial and sentenced inmates from various nearby counties. The facility also houses individuals who have holds from ICE and the U.S. Marshals office. No juvenile or youth offenders are housed at DCDC. DCDC executive staff consists of the Director, Deputy Director, Administrative Services Manager, Chief of Security, Chief of Admissions and Classification, Accreditation Manager, Admissions Manager, and Community Corrections Manager. The facility is 450,000 square feet, and employs 435 full-time and 3 part-time correctional staff. The medical department employs 17 full-time and 48 part-time medical staff. Aramark manages the food service program with five full-time employees. In December 2009, the ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the 2000 NDS at DCDC. The facility received an overall rating of Acceptable. The facility was accredited by the American Correctional Association in January 2009, and the medical department was accredited by the National Commission on Correctional Health Care in November 2009.

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ICE.11.5082.000299

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ICE.11.5082.000300
INTERNAL RELATIONS
ODO interviewed supervisory and nonsupervisory ICE and DCDC staff, including the Assistant Field Office Director (AFOD) and Supervisory Detention and Deportation Officers (SDDO). ODO also interviewed non-supervisory ICE staff including Immigration Enforcement Agents and Deportation Officers (DO). The majority of staff reported employee morale is good; although they stated employees lack direction overall. ICE staff reported receiving inconsistent cooperation and courtesy from DCDC facility staff. For example, ICE staff reported not receiving notifications of alleged criminal aliens who were incarcerated at DCDC. ICE staff stated these individuals are not screened, and are released into the community upon the termination of their state or federal sentence. The facility Director expressed concerns regarding frequent audits and inspections, stating they can negatively impact the daily operations of the facility and reduce its operational efficiency. The Director stated he believes a facility like DCDC, accredited by the American Correctional Association should be audited and inspected less frequently if it is found to be compliant.
DETAINEE RELATIONS
ODO interviewed 20 ICE detainees at DCDC to determine their concerns and to identify areas of possible noncompliance with the ICE NDS. ODO encouraged detainees to express their opinions about the facility, staff, ICE personnel, and the progress of their cases. This often results in examples and anecdotes, and in some cases detainees view these interviews as a self-serving opportunity. ODO cautions, due to the nature of the information obtained, it is not possible to verify each statement. Nonetheless, it is important to obtain information from the detainees point of view. Two major complaints by the detainees pertained to the facility's medical care and the lack of ICE personnel presence in the housing units. Several detainees reported not receiving medication or treatment when they arrived at the facility with pre-existing health conditions. One detainee stated he requested pain killers, and the nurse asked for his health insurance card. Some detainees stated a medical staff member wanted them to pay for the medications. ODO interviewed medical staff and found detainees are not charged for medications. Sixteen detainees said they do not know their DO. Ten detainees said they were strip-searched at the facility. ODO reviewed the detention files of the detainees and found the detainees were strip-searched according to policy requirements.

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ICE.11.5082.000301

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ICE.11.5082.000302

This inspection was based on the 2000 NDS. The following 29 standards were reviewed: Access to Legal Material Admission and Release Correspondence and Other Mail Detainee Classification System Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Emergency Plans Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Issuance and Exchange of Clothing, Bedding, and Towels Key and Lock Control Medical Care Population Counts Post Orders Recreation Security Inspections Special Management Unit (Administrative and Disciplinary Segregation) Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Use of Force Visitation No deficiencies were noted in the following four standards: Disciplinary Policy Hold Rooms in Detention Facilities Hunger Strikes Recreation As these standards were compliant at the time of the review, a synopsis for these four areas was not prepared for this report.

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ICE.11.5082.000303

ODO reviewed the Access to Legal Material standard at DCDC to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed policies and the detainee handbook, observed procedures and the law library, and interviewed staff and detainees. ODO interviewed the part-time library officer who stated the library does not have a set schedule and detainees must request to be scheduled to use the library. The library is open three days a week with separation of genders and classification levels, not allowing detainees a minimum of five hours a week (Deficiency ALM-1). Requests for additional legal material not available in the law library are not forwarded to ICE for response (Deficiency ALM-2). The six rules and procedures governing access to legal materials are not posted, nor are they all included in the handbook (Deficiency ALM-3). A computer checked to determine the last loaded Lexis-Nexis software program update reflected October 9, 2009 (Deficiency ALM-4).

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(G), the FOD must ensure the facility devises a flexible schedule to permit all detainees, regardless of housing or classification, to use the law library on a regular basis. Each detainee must be permitted to use the law library for a minimum of five (5) hours per week. DEFICIENCY ALM-2 In accordance with the ICE NDS, Access to Legal Material, section (III)(I), the FOD must ensure detainees who require additional legal material, not available in the facility law library, make a written request to the employee responsible for maintaining and updating library materials. The facility must inform the ICE contact person of the request as quickly as possible. Requests for copies of court decisions will normally be available within three business days. DEFICIENCY ALM-3 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for detainee use; 2) scheduled hours of access to the law library; 3) procedures for requesting access to the law library; 4) procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) procedures for requesting legal reference materials not maintained in the law library; and 6) procedures for notifying a designated employee that library material is missing or
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ICE.11.5082.000304
damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. DEFICIENCY ALM-4 In accordance with the ICE NDS, Change notice memo dated June 14, 2007, titled Access to Legal Reference Materials and Lexis-Nexis CD-ROMs, the FOD must ensure the facility follows OPLAs advisement to update the Lexis-Nexis CD-ROM and distribute quarterly.

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ICE.11.5082.000305

ODO reviewed the Admission and Release standard at DCDC to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed detention files, forms, policies, and procedures; and interviewed detainees and staff assigned to admission and release processing duties. Identity documents, such as passports, are inventoried in the presence of detainees during the intake and admissions process; however, they are not forwarded or turned over to ICE/ERO for placement in the detainees A-file (Deficiency AR-1 and F&PP-1). All identity documents are stored and secured with detainee personal property and valuables.

DEFICIENCY AR-1 and F&PP-1 In accordance with the ICE NDS, Admission and Release, section (III)(E), the FOD must ensure identity documents, such as passports, birth certificates, etc., are inventoried then given to ICE/ERO for placement in the detainees A-file.

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ICE.11.5082.000306

ODO reviewed the Correspondence and Other Mail standard at DCDC to determine if the facility provides detainees the opportunity to send and receive correspondence, in a timely manner, subject to limitations required for the safe and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed policies and procedures, interviewed staff, and observed the distribution of mail to detainees. ODO observed DCDC staff issue special correspondence to a detainee without first inspecting it. The envelope identified the sender as the U.S. District Court and remained sealed when given to the detainee (Deficiency C&OM-1). Detainees are not notified and do not receive a receipt when mail has been confiscated or withheld (Deficiency C&OM-2).

DEFICIENCY C&OM-1 In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(E)(2), the FOD must ensure facilities implement procedures for inspecting special correspondence for contraband. Any such inspection must be in the presence of the detainee. Special correspondence includes written communication from courts. DEFICIENCY C&OM-2 In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(G), the FOD must ensure all facilities implement policies and procedures addressing the issue of acceptable and unacceptable mail. The affected detainees must be notified when incoming or outgoing mail is confiscated or withheld. The detainee must receive a receipt for the confiscated or withheld item(s).

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ICE.11.5082.000307

ODO reviewed the Detainee Classification System standard at DCDC to determine if there is a formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE NDS. ODO interviewed staff assigned to classify detainees, and reviewed detention files, forms, policies, and procedures. ODO reviewed 30 detention files and observed detainees being processed during admissions. During the admissions process, ERO provides an Order to Detain or Release (Form I-203) and an incomplete Record of Person and Property Transferred (Form I-216) to DCDC staff for the classification of a detainee (Deficiency DCS-1).

DEFICIENCY DCS-1 In accordance with the ICE NDS, Detainee Classification System, sections (III)(A)(1) and (III)(D), the FOD must ensure ICE provides facilities with the data they need from each detainees file to complete the classification process. ICE offices must provide non-ICE facilities with the necessary information for the facility to classify ICE detainees.

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ICE.11.5082.000308

ODO reviewed the Detainee Grievance Procedures standard at DCDC to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff and detainees, and reviewed policies and logbooks. The facility does not have procedures for identifying and handling emergency grievances (Deficiency DGP-1). The grievance section of the facilitys detainee handbook does not mention the procedures for resolving a grievance or appeal, including the right to have a grievance referred to higher levels if a detainee is not satisfied that the grievance has been adequately resolved (Deficiency DGP-2). Additionally, the grievance section of the facilitys detainee handbook does not notify detainees of procedures for contacting ICE to appeal the decision of the facilitys OIC (Deficiency DGP-3).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure the facility implements procedures for identifying and handling an emergency grievance. An emergency grievance involves an immediate threat to a detainees safety and welfare. Once the receiving staff member approached by a detainee determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures will apply. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(3), the FOD must ensure the grievance section of the detainee handbook provides notice of procedures for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved. DEFICIENCY DGP-3 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(4), the FOD must ensure the grievance section of the detainee handbook provides notice of procedures for contacting ICE to appeal the decision of the facilitys OIC.

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ICE.11.5082.000309

ODO reviewed the Detainee Handbook standard at DCDC to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO interviewed staff, and reviewed the detainee handbook and detention files. The detainee handbook does not notify detainees of facility policies and procedures concerning personal property (Deficiency DH-1 and F&PP-1). Notifications regarding recorded telephone calls are not mentioned in the detainee handbook (Deficiency DH-2 and TA-2).

DEFICIENCY DH-1 and F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies detainees of the facility policies and procedures concerning personal property. DEFICIENCY DH-2 and TA-2 In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure, if telephone calls are monitored, detainees are notified in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each monitored telephone stating detainee calls are subject to monitoring, and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

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ICE.11.5082.000310

ODO reviewed the Detention Files standard at DCDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files, logbooks, policies and procedures, and interviewed staff. ODO reviewed 30 detention files and found DCDC does not keep required documentation in detention files, such as special requests, disciplinary forms, and grievances (Deficiency DF-1). The facility does not keep detention files in a secured area. Detention files are located in a high-traffic processing area, and the door to the processing area is not locked (Deficiency DF-2). DCDC does not keep a logbook documenting the removal of detention files from the processing area (Deficiency DF-3).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(C), the FOD must ensure, during the course of the detainees stay at the facility, staff adds documents associated with normal operations to the detainees detention file without prior approval. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(D), the FOD must ensure detainee detention files are located and maintained in a secured area. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the detention files removal from the cabinet includes: the detainees name and A-file number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

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ICE.11.5082.000311

ODO reviewed the Emergency Plans standard at DCDC to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with ICE NDS. ODO interviewed staff, and reviewed policies, emergency plans, and memoranda of understanding.
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ICE.11.5082.000312

ODO reviewed the Environmental Health and Safety standard at DCDC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, reviewed policies, and inspected documentation of inspections, hazardous chemical management, and fire drills. Information on exit diagrams was only provided in English (Deficiency EH&S-1). Emergency key drills are conducted during fire drills, but are not timed (Deficiency EH&S-2).

DEFICIENCY EH&S-1 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a), the FOD must ensure exit diagrams provide instructions in English and Spanish. DEFICIENCY EH&S- 2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure emergency key drills are included in each fire drill, and timed. Emergency keys will be drawn and used by the appropriate staff to unlock one set of emergency exit doors not in daily use. NFPA recommends a limit of four and one-half minutes for drawing keys and unlocking emergency doors.

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ICE.11.5082.000313
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at DCDC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed policies and documentation, interviewed staff; inspected food, chemical, and utensil storage areas, and observed meal preparation and service. The kitchen is equipped with a three-compartment sink for washing, rinsing, and sanitizing utensils and equipment; however, the sink is not properly labeled (Deficiency FS-1). This deficiency was corrected during the review.

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least three, labeled compartments is available for manually washing, rinsing, and sanitizing utensils and equipment.

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ICE.11.5082.000314

ODO reviewed the Funds and Personal Property standard at DCDC to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed policies and procedures, and interviewed staff regarding the control and safeguarding of detainees personal property, funds, and valuables. Detainee identity documents, such as passports, are stored and secured with personal property and valuables at DCDC and are not placed in the detainees A-file (Deficiency F&PP-1 and AR-1). The facility does not have a written procedure for inventory and audit of detainee funds, valuables, and personal property (Deficiency F&PP-2). DCDCs policy for lost and/or damaged property does not require a senior contact officer to immediately notify the designated ICE/ERO officer of all claims and outcomes for lost or damaged detainee property that was properly receipted (Deficiency F&PP-3). The facility notifies ICE/ERO via telephone about abandoned detainee property; however, abandoned property is not turned over to ICE/ERO and is destroyed by DCDC 30 days after written notification has been made to the detainee (Deficiency F&PP-4). The facilitys detainee handbook does not notify detainees they will be provided an ICE-certified copy of any identity document placed in their A-files; the rules for storing or mailing property not allowed in their possession; the procedure for claiming property upon release, transfer, or removal; and the procedures for filing a claim for lost or damaged property (Deficiency F&PP-5).

DEFICIENCY F&PP-1 and AR-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(B)(3), the FOD must ensure identity documents, such as passports, birth certificates, etc., are held in the detainees A-file. DEFICIENCY F&PP-2 In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must ensure the facility has a written procedure for inventory and audit of detainee funds, valuables, and personal property. DEFICIENCY F&PP-3 In accordance with the ICE NDS, Funds and Personal Property, section (III)(H)(7), the FOD must ensure the facility has and follow a policy requiring the senior contract officer to immediately notify the designated ICE officer of all claims and outcomes for lost or damaged detainee property which was properly receipted.
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ICE.11.5082.000315
DEFICIENCY F&PP-4 In accordance with the ICE NDS, Funds and Personal Property, section (III)(I), the FOD must ensure the facility reports and turns over to ICE all detainee abandoned property. DEFICIENCY F&PP-5 In accordance with the ICE NDS, Funds and Personal Property, sections (III)(J)(2-5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: upon request, they will be provided an ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files; rules for storing or mailing property not allowed in their possession; procedure for claiming property upon release, transfer, or removal; and procedures for filing a claim for lost or damaged property.

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ICE.11.5082.000316
ISSUANCE AND EXCHANGE OF CLOTHING, BEDDING, AND TOWELS (IECB&T)

ODO reviewed the Issuance and Exchange of Clothing, Bedding, and Towels standard at DCDC to determine if the facility provides clean clothing, bedding, linens, and towels to every detainee upon arrival; and to determine if the facility provides ICE detainees with regular exchanges of clothing, linens, and towels for as long as they remain in detention, in accordance with the ICE NDS. ODO observed the intake and admissions process, interviewed DCDC staff, and reviewed policies and procedures. ODO interviewed two clothing officers at DCDC. Both officers stated the facility issues socks and underwear to detainees on Mondays, Wednesdays, and Fridays (Deficiency IECB&T-1).

DEFICIENCY IECB&T-1 In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure socks and undergarments are exchanged daily.

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ICE.11.5082.000317

ODO reviewed the Key and Lock Control standard at DCDC to determine if facility safety and security is maintained by requiring keys and locks to be controlled and maintained, in accordance with the ICE NDS. ODO toured the facility, interviewed the Security Officer, reviewed policies and documentation, and observed the use, accountability, and maintenance of keys and locks.
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ICE.11.5082.000318
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at DCDC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 40 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The facility does not notify ICE each time detainee medical records are released (Deficiency MC-1). When a detainee is transferred to another detention facility, the detainees medical records, or copies, are not transferred with the detainee unless requested. ODO was informed Medical Summary of Federal Prisoner/Alien in Transit forms are forwarded to the receiving facility in sealed envelopes; however, the detainees name and A-number is not documented on the front of the envelope, marked Medical Confidential (Deficiency MC-2).

DEFICIENCY MC-1 In accordance ICE NDS, Medical Care, section (III)(M), the FOD must ensure the facility notifies ICE each time detainee medical records are released. DEFICIENCY MC-2 In accordance ICE NDS, Medical Care, section (III)(N), the FOD must ensure when a detainee is transferred to another detention facility, the detainees medical records, or copies, are transferred with the detainee. These records must be placed in a sealed envelope or other container labeled with the detainees name and A-number and marked MEDICAL CONFIDENTIAL.

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23
ICE.11.5082.000319
POPULATION COUNTS (PC)

ODO reviewed the Population Counts standard at DCDC to determine if the facility has an effective system of conducting population counts, which ensures detainee accountability, in accordance with the ICE NDS. ODO reviewed policies, observed the count process, and interviewed staff. Formal counts are conducted once per shift; however, the shift supervisor does not verify the accuracy of the counts (Deficiency PC-1). The out-count number and the destination of all detainees who have temporarily left the facility are maintained by booking officers, not the Control Officer (Deficiency PC-2).

DEFICIENCY PC-1 In accordance with the ICE NDS, Population Counts, section (III)(A), the FOD must ensure a formal count is conducted at least once per shift, with a shift supervisor verifying its accuracy. DEFICIENCY PC-2 In accordance with the ICE NDS, Population Counts, section (III)(E), the FOD must ensure the Control Officer maintains an out-count record of the number and destination of all detainees who temporarily leave the facility.

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24
ICE.11.5082.000320
POST ORDERS (PO)

ODO reviewed the Post Orders standard at DCDC to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE NDS. ODO interviewed staff, reviewed training files, inspected post order binders on posts, and verified the availability of post orders to all staff via the facilitys intranet. A review of the post orders revealed varying effective dates going back to 1996. ODO was informed post orders are reviewed for training purposes as part of shift briefings; however, there was no documentation of annual reviews or updates (Deficiency PO-1).

DEFICIENCY PO-1 In accordance with the ICE NDS, Post Orders, section (III)(D), the FOD must ensure post orders are kept current at all times. Post orders must be reviewed and updated yearly, or sooner when deemed necessary.

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25
ICE.11.5082.000321
SECURITY INSPECTIONS (SI)

ODO reviewed the Security Inspections Standard at the DCDC to determine if the facility security is maintained, and events posing a risk of harm are prevented, in accordance with the ICE NDS. ODO interviewed staff, observed security operations, and reviewed policies, inspection reports, logbooks, other pertinent documentation.
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(b)(7)e

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26
ICE.11.5082.000322

ODO reviewed the Special Management Unit (SMU) standard at DCDC to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. ODO reviewed policies, inspected the SMU, reviewed logs and detention files, and interviewed staff and detainees. No detainees were held in the SMU during the inspection. DCDC does not permit detainees in disciplinary segregation status to have soft-bound, non-legal books (Deficiency SMU-1), and they are also restricted from receiving nonlegal visits; only attorneys may visit detainees on disciplinary segregation (Deficiency SMU-2).

DEFICIENCY SMU-1 In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(15)(d), the FOD must ensure detainees in Disciplinary Segregation have access to soft-bound, non-legal books on a rotating basis, provided no detainee has more than two books(excluding religious material) at a time. DEFICIENCY SMU-2 In accordance with ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(17), the FOD must ensure the facility follows the Visitation standard in setting visitation rules for detainees in disciplinary segregation. As a rule, a detainee retains visiting privileges while in disciplinary segregation.

(b)(7)e
ICE.11.5082.000323

ODO reviewed the Staff-Detainee Communication standard at DCDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed procedures and logbooks, and interviewed staff and detainees. The facility does not have procedures allowing detainees to submit written questions, requests, or concerns to ICE staff (Deficiency SDC-1), and for detainees to receive timely responses from ICE (Deficiency SDC-2). Detainee requests to ICE are not promptly routed and delivered to ICE staff, and detainees do not receive a written response within 72 hours (Deficiency SDC-3). The facility does not maintain a logbook for recording detainee requests submitted to ICE (Deficiency SDC-4).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must ensure all detainees have the opportunity to submit written questions, requests, or concerns to ICE staff. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (I), the FOD must ensure procedures are in place for all detainees to receive an answer from ICE, in an acceptable time frame, to a submitted request. DEFICIENCY SDC-3 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(1)(b), the FOD must ensure detainee requests are forwarded to the ICE office of jurisdiction within 72 hours and answered as soon as possible and practicable, but not later than within 72 hours from receiving the request. DEFICIENCY SDC-4 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all detainee requests are recorded in a logbook specifically designed for that purpose. The log, at a minimum, must contain: date detainee request received; detainees name, A-number, and nationality; name of the officer logging the request; date that the request, with staff response and action, is returned to the detainee; and any other site-specific pertinent information. IGSAs must also record the date the request was forwarded to ICE, and the date it was returned.

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28
ICE.11.5082.000324

ODO reviewed the Suicide Prevention and Intervention standard at DCDC to determine if the health and well being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO inspected the suicide watch rooms in the booking area; interviewed staff; and reviewed ten staff training records, the medical records of two detainees on suicide watch, the Suicide Prevention Handbook, and the Suicide Prevention and Intervention Manual. The Suicide Prevention Handbook and Suicide Prevention and Intervention Manual serve as DCDC policy. Both meet ICE NDS requirements, with one exception. Neither addresses ICE reporting requirements for detainees who are suicidal or require special housing for suicide risk (Deficiency SP&I-1). DCDC does not maintain a log of detainees placed on suicide watch during the year; however, ODO was able to identify two detainees who had recently been on suicide watch. A review of the medical records for these two detainees revealed suicide prevention management was consistent with DCDC written procedures and ICE NDS requirements.

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD must ensure detention facilities include, in policy, ICE reporting procedures regarding detainees who are suicidal or require special housing for suicide risk.

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29
ICE.11.5082.000325

ODO reviewed the Telephone Access standard at DCDC to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the ICE NDS. ODO interviewed staff and detainees; reviewed facility policies, procedures, and the detainee handbook; and tested the telephones in detainee housing units. DCDC records all telephone conversations, including privileged calls; there is no privacy for detainees making legal calls (Deficiency TA-1). Detainees are not notified telephone calls are recorded. Notifications regarding recorded telephone calls are not mentioned in the detainee handbook, or posted on the telephones or on housing unit bulletin boards (Deficiency TA-2 and DH-2).

DEFICIENCY TA-1 In accordance with the ICE NDS, Telephone Access, section (III)(J), the FOD must ensure the facility ensures privacy for detainees telephone calls regarding legal matters. The facility must provide a reasonable number of telephones on which detainees can make such calls without being overheard by officers, other staff, or other detainees. Facility staff must not electronically monitor detainee telephone calls for legal matters, absent a court order. DEFICIENCY TA-2 and DH-2 In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure, if telephone calls are monitored, the facility notifies detainees in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each monitored telephone stating: that detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

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30
ICE.11.5082.000326

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donation, at DCDC to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO reviewed the policies and interviewed the HSA and staff. There have been no deaths in the past year. DCDC has policies addressing terminal illness, living wills, advance directives, and Do Not Resuscitate Orders (DNR). The policies do not address fatal injuries (Deficiency TIADD-1) or organ donations (Deficiency TIADD-2). The HSA developed a policy on organ donation during the review.

DEFICIENCY TIADD1 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure the facility has policies and procedures addressing fatal injury. DEFICIENCY TIADD-2 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(D), the FOD must ensure the facility has procedures governing organ donation.

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ICE.11.5082.000327
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at DCDC to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO observed all areas maintaining tools, reviewed policies, and interviewed staff.
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ICE.11.5082.000328
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at DCDC to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO interviewed staff, inspected equipment, reviewed policies and use of force documentation, and viewed video recordings of two calculated use of force incidents on inmates.
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(b)(7)e

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ICE.11.5082.000329
VISITATION (V)
ODO reviewed the Visitation standard at DCDC to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO observed visitation practices, reviewed policies, and interviewed staff. DCDC does not maintain separate logbooks for general and legal visitors (Deficiency V-1). Detainees are allowed to visit privately with their legal representatives during normal visitation hours, but not during meal times (Deficiency V-2). There were no copies of Notice of Entry of Appearance as Attorney or Accredited Representative (Form G-28) available in the visitors reception area (Deficiency V-3). This deficiency was corrected prior to the conclusion of the review.

DEFICIENCY V-1 In accordance with the ICE NDS, Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all general visitors, and a separate log of legal visitors. DEFICIENCY V-2 In accordance with the ICE NDS, Visitation, section (III)(I)(2), the FOD must ensure, on regular business days, legal visitations may proceed through a scheduled meal period. In such cases, the detainee must receive a tray or sack meal after the visit. DEFICIENCY V-3 In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure copies of Form G-28 are readily available in the legal visitors reception area.

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34
ICE.11.5082.000330
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DSCU EABM EADM EOIR ERO FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU TAR TB UDC American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Enforcement and Removal Operations Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee

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35
ICE.11.5082.000331
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(G), the FOD must ensure the facility devises a flexible schedule to permit all detainees, regardless of housing or 8 classification, to use the law library on a regular basis. Each detainee must be permitted to use the law library for a minimum of five (5) hours per week. In accordance with the ICE NDS, Access to Legal Material, section (III)(I), the FOD must ensure detainees who require additional legal material, not available in the facility law library, make a written request to the employee responsible for maintaining and 8 updating library materials. The facility must inform the ICE contact person of the request as quickly as possible. Requests for copies of court decisions will normally be available within three business days.
Access To Legal Material
ALM-1
ALM-2

(b)(7)e
ICE.11.5082.000332
DETENTION STANDARD
ALM-3
ALM-4
Admission and Release Funds and Personal Property
AR-1
F&PP-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for detainee use; 2) scheduled hours of access to the law library; 3) procedures for requesting access to the law library; 4) 8 procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) procedures for requesting legal reference materials not maintained in the law library; and 6) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with the ICE NDS, Change notice memo dated June 14, 2007, titled Access to Legal Reference Materials and Lexis-Nexis CD-ROMs, 9 the FOD must ensure the facility follows OPLAs advisement to update the LexisNexis CD-ROM and distribute quarterly. In accordance with the ICE NDS, Admission and Release, section (III)(E), 10 the FOD must ensure identity documents, such as passports, birth certificates, etc., are inventoried then 19 given to ICE/ERO for placement in the detainees A-file.

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37
ICE.11.5082.000333
DETENTION STANDARD
C&OM-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(E)(2), the FOD must ensure facilities implement procedures for inspecting special correspondence for 11 contraband. Any such inspection must be in the presence of the detainee. Special correspondence includes written communication from courts.
In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(G), the FOD must ensure all facilities implement policies and procedures addressing the issue of acceptable and unacceptable mail. The affected detainees must be notified when incoming or outgoing mail is confiscated or withheld. The detainee must receive a receipt for the confiscated or withheld item(s).
C&OM-2
11
Detainee Classification System
DCS-1
DGP-1
In accordance with the ICE NDS, Detainee Classification System, sections (III)(A)(1) and (III)(D), the FOD must ensure ICE provides facilities with the data they need from each detainees file to complete the classification process. ICE offices must provide nonICE facilities with the necessary information for the facility to classify ICE detainees. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure the facility implements procedures for identifying and handling an emergency grievance. An emergency grievance involves an immediate threat to a detainees safety and welfare. Once the receiving staff member approached by a detainee determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures will apply.
12
13

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38
ICE.11.5082.000334
DETENTION STANDARD
DGP-2
DGP-3
Detainee Handbook
DH-1
F&PP-1
Detainee Handbook
DH-2
Telephone Access
TA-2
Detention Files
DF-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(3), the FOD must ensure the grievance section of the detainee handbook provides notice of procedures 13 for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(4), the FOD must ensure the grievance section of the detainee 13 handbook provides notice of procedures for contacting ICE to appeal the decision of the facilitys OIC. In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), 14 the FOD must ensure the detainee handbook or equivalent notifies detainees of the facility policies and 19 procedures concerning personal property. In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure, if telephone calls are monitored, detainees are notified in the 14 detainee handbook or equivalent provided upon admission. The facility must also place a notice at each monitored telephone stating detainee calls are subject to monitoring, and the 30 procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation. In accordance with the ICE NDS, Detention Files, section (III)(C), the FOD must ensure, during the course of the detainees stay at the facility, staff 15 adds documents associated with normal operations to the detainees detention file without prior approval.

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39
ICE.11.5082.000335
DETENTION STANDARD
Detention Files
DF-2
Detention Files
DF-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (III)(D), the FOD must ensure detainee detention 15 files are located and maintained in a secured area. In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the detention files removal from the cabinet includes the detainees name and A-file number; 15 date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.
Emergency Plans
EP-1
16
Emergency Plans
EP-2
(b)(7)e
16
Emergency Plans
EP-3
16
EH&S-1
In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a), the FOD must ensure exit diagrams provide instructions in English and Spanish.
17

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40
ICE.11.5082.000336
DETENTION STANDARD
EH&S -2
Food Service
FS-1
F&PP-2
F&PP-3
F&PP-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure emergency key drills are included in each fire drill, and timed. Emergency keys will be drawn and used 17 by the appropriate staff to unlock one set of emergency exit doors not in daily use. NFPA recommends a limit of four and one-half minutes for drawing keys and unlocking emergency doors. In accordance with ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least 18 three, labeled compartments is available for manually washing, rinsing, and sanitizing utensils and equipment. In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must ensure the facility has a 19 written procedure for inventory and audit of detainee funds, valuables, and personal property. In accordance with the ICE NDS, Funds and Personal Property, section (III)(H)(7), the FOD must ensure the facility has and follow a policy requiring the senior contract officer to 19 immediately notify the designated ICE officer of all claims and outcomes for lost or damaged detainee property which was properly receipted. In accordance with the ICE NDS, Funds and Personal Property, section (III)(I), the FOD must ensure the facility reports 20 and turns over to ICE all detainee abandoned property.

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41
ICE.11.5082.000337
DETENTION STANDARD
F&PP-5
Issuance and Exchange of Clothing, Bedding, and Towels
IECB&T-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, sections (III)(J)(2-5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: upon request, they will be provided an ICE-certified copy of 20 any identity document (passport, birth certificate, etc.) placed in their A-files; rules for storing or mailing property not allowed in their possession; procedure for claiming property upon release, transfer, or removal; and procedures for filing a claim for lost or damaged property. In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), 21 the FOD must ensure socks and undergarments are exchanged daily.
K&LC-1
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22
Medical Care
MC-1
Medical Care
MC-2
Population Counts
PC-1
section (III)(M), the FOD must ensure the facility notifies ICE each time detainee medical records are released. In accordance ICE NDS, Medical Care, section (III)(N), the FOD must ensure when a detainee is transferred to another detention facility, the detainees medical records, or copies, are transferred with the detainee. These records must be placed in a sealed envelope or other container labeled with the detainees name and A-number and marked MEDICAL CONFIDENTIAL. In accordance with the ICE NDS, Population Counts, section (III)(A), the FOD must ensure a formal count is conducted at least once per shift, with a shift supervisor verifying its accuracy.
23
23
24

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42
ICE.11.5082.000338
DETENTION STANDARD
Population Counts
PC-2
Post Orders
PO-1
Security Inspections
SI-1
SI-2
Special Management Unit (Administrative Segregation and Disciplinary Segregation)
SMU-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Population Counts, section (III)(E), the FOD must ensure the Control Officer 24 maintains an out-count record of the number and destination of all detainees who temporarily leave the facility. In accordance with the ICE NDS, Post Orders, section (III)(D), the FOD must ensure post orders are kept current at 25 all times. Post orders must be reviewed and updated yearly, or sooner when deemed necessary. In accordance with ICE NDS, Security Inspections, section (III)(D)(2)(5), the FOD must ensure the file containing the recall list prominently features the following notice: This information must be safeguarded. Use is restricted to those needing the information in the 26 performance of their official duties. Misuse will subject the user to criminal liability. This agency will view any misuse of this information as a serious violation of the employee code of conduct, which may result in disciplinary action, including removal. In accordance with ICE NDS, Security Inspections, section (III)(D)(3)(1)(a), the FOD must ensure facilities have policies 26 and procedures to control and document all vehicular traffic entering the facility. In accordance with the ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(15)(d), the FOD must ensure detainees in Disciplinary Segregation have access to 27 soft-bound, non-legal books on a rotating basis, provided no detainee has more than two books(excluding religious material) at a time.

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ICE.11.5082.000339
DETENTION STANDARD
SMU-2
Staff-Detainee Communications
SDC-1
SDC-2
SDC-3
SDC-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Special Management Unit, Disciplinary Segregation, section (III)(D)(17), the FOD must ensure the facility follows the Visitation standard in setting visitation 27 rules for detainees in disciplinary segregation. As a rule, a detainee retains visiting privileges while in disciplinary segregation. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B), the FOD must ensure all 28 detainees have the opportunity to submit written questions, requests, or concerns to ICE staff. In accordance with the ICE NDS, StaffDetainee Communication, section (I), the FOD must ensure procedures are in 28 place for all detainees to receive an answer from ICE, in an acceptable time frame, to a submitted request. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(1)(b), the FOD must ensure detainee requests are forwarded to the 28 ICE office of jurisdiction within 72 hours and answered as soon as possible and practicable, but not later than within 72 hours from receiving the request. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure all detainee requests are recorded in a logbook specifically designed for that purpose. The log, at a minimum, must contain: date detainee request received; detainees name, A-number, and 28 nationality; name of the officer logging the request; date that the request, with staff response and action, is returned to the detainee; and any other site-specific pertinent information. IGSAs must also record the date the request was forwarded to ICE, and the date it was returned.

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44
ICE.11.5082.000340
DETENTION STANDARD
SP&I-1
Telephone Access
TA-1
TIADD-1
TIADD-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD must ensure detention facilities include, in policy, ICE 29 reporting procedures regarding detainees who are suicidal or require special housing for suicide risk. In accordance with the ICE NDS, Telephone Access, section (III)(J), the FOD must ensure the facility ensures privacy for detainees telephone calls regarding legal matters. The facility must provide a reasonable number of telephones on which detainees can 30 make such calls without being overheard by officers, other staff, or other detainees. Facility staff must not electronically monitor detainee telephone calls for legal matters, absent a court order. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must 31 ensure the facility has policies and procedures addressing fatal injury. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(D), the FOD 31 must ensure the facility has procedures
Tool Control
TC-1
32
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Tool Control
TC-2
32

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ICE.11.5082.000341
DETENTION STANDARD
PAGE
Tool Control
TC-3
32
Use of Force
UOF-1
33
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Use of Force
UOF-2
33
Visitation
V-1
Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all general visitors, and a separate log of legal visitors.
34

(b)(7)e
ICE.11.5082.000342
DETENTION STANDARD
Visitation
V-2
Visitation
V-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Visitation, section (III)(I)(2), the FOD must ensure, on regular business days, legal visitations may proceed through a 34 scheduled meal period. In such cases, the detainee must receive a tray or sack meal after the visit. In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure copies of Form G-28 are 34 readily available in the legal visitors reception area.

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ICE.11.5082.000343


Enforcement and Removal Operations El Paso Field Office El Paso Processing Center El Paso, Texas
December 8-9, 2010
ICE.11.5082.000344
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW. ICE NATIONAL DETENTION STANDARDS Hold Rooms in Detention Facilities.... Medical Care.. Staff-Detainee Communications. 1 1 2
3 4 5
ICE.11.5082.000345
INSPECTION PROCESS
The Office of Professional Responsibilitys (OPR) Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards or the Performance Based National Detention Standards (PBNDS), as applicable. In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. In February 2010, ODO conducted a Quality Assurance Review of the El Paso Processing Center (EPC) in El Paso, Texas. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to ERO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE Performance Based National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the OPR ODO Deputy Division Director, Office of Professional Responsibility.

Special Agent (Team Leader) Special Agent Contract Inspector ODO, OPR Phoenix ODO, OPR San Diego MGT of America, Inc.
(b)(6), (b)(7)(C)
______________________________________________________________________________________
1
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El Paso Processing Center ERO El Paso
ICE.11.5082.000346
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Admission and Release, Contraband, Correspondence and Other Mail, Detainee Handbook, Detention Files, Disciplinary System, Environmental Health and Safety, Facility Security and Control, Food Service, Funds and Personal Property, Grievance System, Hold Rooms in Detention Facilities, Law Libraries and Legal Material, Marriage Requests, Medical Care, Personal Hygiene, Post Orders, Religious Practices, Searches of Detainees, Sexual Abuse and Assault Prevention and Intervention, Special Management Units, Staff-Detainee Communication, Telephone Access, Tool Control, Transfer of Detainees, Use of Force and Restraints, and Visitation. ODO staff identified 69 deficiencies during the Quality Assurance Review conducted in February 2010. During this Follow-up Inspection, ODO staff found four (2%) repeated deficiencies. The deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at EPC, to be noncompliant with the ICE PBNDS: Hold Rooms in Detention Facilities; Medical Care; Staff-Detainee Communication.
______________________________________________________________________________________
2
(b)(7)e
ICE.11.5082.000347

During the initial ODO inspection, four deficiencies were identified in this area. During follow-up inspection, one deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE PBNDS, Hold Rooms, section (V)(A)(7), the FOD must ensure each hold room shall have a floor drain. ODO Follow-up Finding: ODOs inspection of the hold rooms revealed they do not have floor drains.
______________________________________________________________________________________
3
(b)(7)e
ICE.11.5082.000348
MEDICAL CARE
During the initial ODO inspection, four deficiencies were identified in this area. During follow-up inspection, one deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE PBNDS, Medical Care, section (V)(E), the FOD must ensure adequate space and equipment shall be furnished in all facilities so that all detainees may be provided basic health examinations and treatment in private while ensuring safety. ODO Follow-up Finding: When ODO toured the medical department, interviews with staff revealed adequate space is not available to conduct basic health screenings and assessments in a private setting while ensuring safety. Expansion of the medical department to add more screening and assessment rooms has been approved, but work has not commenced. ODO was informed completion of the expansion is projected for April, 2012.
______________________________________________________________________________________
4
(b)(7)e
ICE.11.5082.000349
During the initial ODO inspection, three deficiencies were identified in this area. During the Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(B)(1)(a), the FOD must ensure the staff member receiving the request shall normally respond in person or in writing as soon as possible and practicable, but no longer than within 72 hours of receipt. ODO Follow-up Finding: Requests pertaining to personal property matters are not recorded in a log. Logs pertaining to visitation requests are maintained; however, the logs do not contain a column for recording the date of response. Therefore, ODO was unable to determine the response time for requests pertaining to personal property matters and visitation requests. ODO Initial Finding: In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(B)(2), the FOD must ensure all requests shall be recorded in a logbook (or electronic logbook) specifically designed for that purpose. At a minimum, the log must record: Date of receipt; Detainees name; Detainees A-number; Detainees nationality; Name of the staff member who logged the request; Date the request, with staff response and action, was returned to the detainee; and Any other pertinent site-specific information. ODO Follow-up Finding: Requests for immigration case related matters are properly logged and recorded by the deportation officer logging the request. Requests for visitation are also logged; however, requests regarding personal property matters are not recorded in a log.
______________________________________________________________________________________
5
(b)(7)e
ICE.11.5082.000350
ICE.11.5082.000351
ICE.11.5082.000352
ICE.11.5082.000353
(b)(6), (b)(7)(C)
(b)(7)e
ICE.11.5082.000354
(b)(7)e
ICE.11.5082.000355
(b)(7)e
ICE.11.5082.000356


Enforcement and Removal Operations Newark Field Office Essex County Correctional Facility Newark, New Jersey
November 3-4, 2010
ICE.11.5082.000357
ICE.11.5082.000358
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW.. ICE NATIONAL DETENTION STANDARDS Environmental Health and Safety. Food Service 1 1 2
4 4
ICE.11.5082.000359
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. In October 2009, ODO conducted a Quality Assurance Review of the Essex County Correctional Facility (ECCF) in Newark, NJ. A Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review.
REPORT ORGANIZATION

(b)(6), (b)(7)(C)
Detention and Deportation Officer (Team Lead)
Contract Inspector
ODO, OPR HQ MGT of America, Inc.
_____________________________________________________________________________________________
1
(b)(7)e
Essex County Correctional Facility ERO Newark
ICE.11.5082.000360
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material Admission and Release Correspondence and Other Mail Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Emergency Plans Environmental Health and Safety Food Service Hold Rooms in Detention Facilities Medical Care Staff-Detainee Communication Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death Tool Control Use of Force ODO staff identified 40 deficiencies during the Quality Assurance Review conducted in October 2009. During this Follow-up Inspection, ODO staff found four (10%) repeated deficiencies. ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards: Access to Legal Material Admission and Release Correspondence and Other Mail Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Emergency Plans Hold Rooms in Detention Facilities Medical Care Staff-Detainee Communication Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death Tool Control Use of Force
_____________________________________________________________________________________________
2
(b)(7)e
ICE.11.5082.000361
Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at the ECCF, to be noncompliant with the ICE NDS: Environmental Health and Safety Food Service
_____________________________________________________________________________________________
3
(b)(7)e
ICE.11.5082.000362

During the initial ODO inspection, seven deficiencies were identified in this area. During this follow-up inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(F)(3-4), the FOD must ensure hazardous material storage rooms are labeled and constructed with either a four-inch sill or a four-inch depressed floor. ODO Follow-up Finding: ODO inspected the hazardous materials storage room, located in the facilitys generator area, and found it is not constructed with either a fourinch sill or a four-inch depressed floor. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1)(2)(4), the FOD must ensure barber operations are located in a separate room not used for any other purpose, and are provided with all equipment and supplies necessary for maintaining sanitary procedures for hair care. Each barbershop must have detailed hair care sanitation regulations posted in a conspicuous location for the use of all hair care personnel and detainees. ODO Follow-up Finding: The facility barber operations are not located in a separate room that is not used for any other purpose. All haircuts are performed in the housing units, next to the officers station.
FOOD SERVICE
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(G)(3), the FOD must ensure meals provided are nutritionally adequate. ODO Follow-up Finding: ODO checked the portions of the current meal, labeled as Week 6-lunch. The roast beef was weighed and equaled 3.5 ounces, instead of the 4 ounces listed in the dietician-approved lunch menu. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(H)(13)(a), the FOD must ensure water temperatures are checked daily and results are recorded. ODO Follow-up Finding: ODO reviewed the food service temperature logs. Although the dishwasher temperatures are checked and recorded daily, the water temperature at the three-compartment sink is not checked and recorded daily.
_____________________________________________________________________________________________
4
(b)(7)e
ICE.11.5082.000363


Enforcement and Removal Operations Atlanta Field Office Etowah County Detention Center Gadsden, Alabama
October 19-21, 2010
ICE.11.5082.000364
QUALITY ASSURANCE REVIEW ETOWAH COUNTY DETENTION CENTER ATLANTA FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY. INSPECTION PROCESS Report Organization... Inspection Team Members OPERATIONAL ENVIRONMENT Internal Relations........ Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed... Access to Legal Material Admission and Release. Detainee Handbook Detention Files. Environmental Health and Safety. Food Service Funds and Personal Property Hold Rooms in Detention Facilities.. Issuance and Exchange of Clothing, Bedding, and Towels. Medical Care Population Counts.. Recreation Staff-Detainee Communication..... Telephone Access... 1
3 3
4 4
5 6 7 9 10 11 13 14 15 16 17 18 19 20 21
ICE.11.5082.000365
EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR) Office of Detention Oversight (ODO) conducted an inspection of the Etowah County Detention Center (ECDC) located in Gadsden, Alabama, on October 19-21, 2010. ECDC opened in March 1984 and is designated as a minimum to maximum security facility. ICE utilizes ECDC under an intergovernmental service agreement (IGSA) to house ICE male and female detainees of all classification levels over 72 hours. ICE Enforcement and Removal Operations (ERO) began housing detainees at ECDC on November 28, 2000. Medical care is provided by Doctors Care Physicians, P.C. Food service is provided by ECDC. ECDC was accredited by the American Correctional Association and National Commission on Correctional Health Care in 2010.
(b)(7)e
The ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the ICE National Detention Standards (NDS) at ECDC in August 2010.. ECDC received an overall rating of acceptable, and was found to be in compliance in all 36 standards inspected. ODO reviewed a total of 25 NDS; 12 were in full compliance and 13 had deficiencies. In the review of those 13 standards deficient, a total of 24 deficiencies were discovered by ODO which included: Access to Legal Material (1); Admission and Release (4); Detainee Handbook (1); Detention Files (3); Environmental Health and Safety (5); Food Service (2); Funds and Personal Property (1); Hold Rooms in Detention Facilities (1); Medical Care (1); Population Counts (1); Recreation (1); Staff-Detainee Communication (2); Telephone Access (1). Several of these deficiencies were of a clerical nature, such as the improper placement of paperwork in detention files and the omission of critical information from the detainee handbook. Two issues were recurring from the previous ODO review conducted in November 2007 in accordance with the detention file standard (NDS 2000). The detention files are missing required documentation and ERO management visits to the facility are not documented as required. Several deficiencies identified involved administrative matters such as failing to have copies of grievances and detainee request forms placed in detention files as required by the NDS. Additionally, required information was omitted from the detainee handbook. The ECDC has a fully operational medical unit onsite that is operated and managed by Doctors Care Physicians, P.C. One area of concern observed by ODO was the failure to document staff training in cardio-pulmonary resuscitation (CPR) and first aid training.
(b)(7)e
Etowah County Detention Center ERO Atlanta
ICE.11.5082.000366
The facility reported that training was conducted; however the facility and staff were unable to provide documentation that the training had been completed in accordance with the 2000 NDS for Medical Care. The ECDC has processes in place for affording detainees the opportunity to file grievances and appeal unfavorable decisions. No deficiencies were found in the Detainee Grievance Procedure standard. In reviewing the Issuance and Exchange of Clothing, Bedding, and Towels standard, ODO found that detainees are only issued one set of clothing (including one pair of socks and undergarments). Detainees have no other garments to wear while clothing is exchanged or laundered. Several areas of concern were discovered during a review of the Environmental Health and Safety standard which included non-compliance with maintaining a master index of all hazardous substances and the lack of evacuation plans. Weekly fire and safety inspections are not being conducted as well. This report includes descriptions of all the deficiencies and refers to the specific, relevant NDS. The report will be provided to ERO to develop corrective actions to resolve the 24 deficiencies.

(b)(7)e
ICE.11.5082.000367
INSPECTION PROCESS
The OPR, ODO primarily focuses on areas of noncompliance with the ICE NDS. In addition, focus may be applied to the inspection with information provided on detention management by the ICE ERO Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at ECDC to determine compliance with current ICE policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module (EABM), ENFORCE Alien Removal Module (EARM) Joint Integrity Case Management System (JICMS), Enforcement and Removal Operations (ERO), Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Deputy Division Director for the Office of Detention Oversight, Office of Professional Responsibility.

Management & Program Analyst (Team Lead) Special Agent Special Agent Special Agent Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Houston ODO, Houston ODO, Houston MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
(b)(6), (b)(7)(C)

(b)(7)e
ICE.11.5082.000368
INTERNAL RELATIONS
ODO interviewed supervisory ECDC staff and non-supervisory ICE staff, including IEAs and deportation officers. The majority of staff reported employee morale is good, and a positive relationship exists between ICE and ECDC.
DETAINEE RELATIONS
ODO interviewed 27 detainees at ECDC, including seven females. Female detainees complained they are locked up for approximately 20.5 hours per day, and only have access to the dayroom three times per day for 1.5 hours each. (Note: as of December 19, 2010, female detainees were no longer housed at ECDC). Both male and female detainees complained about food service issues such as small portions and a lack of variety with the meals. ODO observed daily menus that offered a wide variety of food items. Additionally, ODO observed meal preparation, and found no violations of the food service standard relating to the portion size or serving temperature. Many detainees complained about the cost of the telephone services provided and their inability to access government offices, such as immigration court, at no charge. ECDC staff noted a new telephone service contract was signed on October 12, 2010, and many detainees were still adjusting to the new provider. A test of phones by ODO provided good connectivity to both government offices and the immigration court at no cost. Many detainees stated they did not see medical staff after completing medical request forms for health-related issues. These claims were investigated by ODO and resulted in no finding of detainees not receiving adequate and timely medical care.

(b)(7)e
ICE.11.5082.000369

A total of 25 National Detention Standards were reviewed during the ODO inspection. The following 13 areas were found to be deficient with respect to adherence to the ICE NDS, as required: Access to Legal Material Admission and Release Detainee Handbook Detention Files Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Medical Care Population Counts Recreation Staff-Detainee Communication Telephone Access The following 12 areas were found to be well-managed and compliant with the ICE NDS, as required: Detainee Grievance Procedures Disciplinary Policy Hunger Strikes Issuance and Exchange of Clothing, Bedding, and Towels Religious Practices Special Management Unit (Administrative Segregation) Special Management Unit (Disciplinary Segregation) Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death Tool Control Use of Force Visitation As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e
ICE.11.5082.000370

ODO reviewed the Access to Legal Material standard at ECDC to determine if detainees have access to a law library, legal materials, courts, counsel and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed policies, procedures, and the detainee handbook; inspected the law library; and interviewed staff and detainees. A review of the ECDC detainee handbook showed the handbook does not address the procedures for requesting additional time in the law library beyond the five hours per week minimum, the procedure for requesting legal reference materials not maintained in the law library; or the procedure for notifying a designated employee that library material is missing or damaged. Additionally, this information is not posted in the law library (Deficiency ALM-1) and DH-1). ODO recommends ECDC incorporate the omitted required information into the next revision of the detainee handbook and post the required information in the law library.

DEFICIENCY ALM-1 and DH-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

(b)(7)e
ICE.11.5082.000371

ODO reviewed the Admission and Release standard at ECDC to determine if procedures are in place to protect the health, safety, security, and welfare of detainees during the admission and release process, in accordance with the ICE NDS. ODO reviewed detention files, forms, policies, and procedures; and interviewed detainees and staff assigned to admission and release processing duties. A review of this standard showed detainees are not always provided a receipt for their personal property. ODO found the return of property was either not documented in the detention file, or the documentation in the file was missing signatures of the detainee, officer, witness, or a combination thereof (Deficiency AR-1). ECDC does not have a policy that addresses the inventory or receipt of detainee property (Deficiency AR-2). A review of detention files showed some detention files did not have copies of the Order to Detain or Release (Form I-203) (Deficiency AR-3). Also, some of the detention files reviewed contained I-203s that did not include a signature of the authorizing ICE official (Deficiency AR-4). The review found that detainees are issued only one pair of socks and undergarments. Although this meets the requirement of the standard, ODO observed detainees showering while wearing their one set of undergarments in order to clean them. ODO has found in past reviews that the issuance of more than one pair of socks and undergarments is beneficial for detainees since it allow detainees to wear a clean pair of clothing while the other pair is being laundered.

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(D), the FOD must ensure each facility institutes procedures for the inventory and receipt of detainee funds and valuables (other than baggage and personal property) in accordance with the Funds and Personal Property standard. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(E), the FOD must ensure each facility has a procedure for the inventory and receipt of detainee baggage and personal property (other than funds and valuables) in accordance with the Funds and Personal Property standard. DEFICIENCY AR-3 In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an order to detain or release (Form I-203 or I-203a) bearing the appropriate signature accompanies the newly-arrived detainee.

(b)(7)e
ICE.11.5082.000372
DEFICIENCY AR-4 In accordance with the ICE NDS, Admission and Release, section (III)(J), the FOD must ensure staff completes certain procedures before any detainees release, removal, or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting, returning personal property, and reclaiming facility-issued clothing, bedding, etc.

(b)(7)e
ICE.11.5082.000373

ODO reviewed the Detainee Handbook standard at ECDC to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO reviewed the detainee handbook and detention files, and interviewed staff and detainees. Detainee handbooks are available in English and Spanish. A review of the ICE ENFORCE Alien Removal Module (EARM) database showed the majority of detainees housed at ECDC are from Mexico and Central America. ECDC staff indicated that if a detainee speaks a language other than English or Spanish, accommodations can be made to supply those detainees with translation services.
The ECDC detainee handbook does not address the procedures for requesting additional time in the law library beyond the five hours per week minimum, the procedure for requesting legal reference materials not maintained in the law library; or the procedure for notifying a designated employee that library material is missing or damaged (Deficiency DH-1). As discussed in the Access to Legal section, this issue can be resolved when ECDC revises the detainee handbook.

DEFICIENCY DH-1 and ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

(b)(7)e
ICE.11.5082.000374

ODO reviewed the Detention Files standard at ECDC to determine if files are created containing all required information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed 15 detention files, along with logbooks, policies, and procedures; and interviewed staff. Fifteen detention files did not contain booking cards, housing identification cards, or baggage checks (Deficiency DF-1). Ten detention files were not compliant in that the return of detainee property was either not documented in the detention file, or the documentation in the file was missing signatures of the detainee, officer, witness, or a combination thereof. Nine files had release documents either missing or did not have a signature with the authorizing ICE official (Deficiency DF-2). ODO recommends ICE review the requirements of this standard with ECDC staff to ensure compliance in this area. The detention file logbook does not include the reason for removal, the removing officers title and department, the name of the detainee, or the date and time returned (Deficiency DF-3).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B), the FOD must ensure the detainee detention file, at a minimum, contains the Alien Booking Record (Form I-385); the housing identification card; and the baggage check(s) (Form I-77). DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(E), the FOD must ensure, upon the detainees release from the facility, staff adds final documents to the file before closing and archiving it. Staff must insert into the released detainees detention file copies of completed release documents, the original closed out receipts for property and valuables, the original Alien Booking Record, Form I-385, and other documentation. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-file number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.
Office of Detention Oversight October 2010

(b)(7)e
10
ICE.11.5082.000375

ODO reviewed the Environmental Health and Safety standard at the ECDC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical management, generator testing, and fire drills. ODOs inspection revealed all chemicals, flammable and combustible materials were stored and issued as required. Monthly fire drills were conducted on each shift and documentation is maintained by the safety officer. Reports for water testing and pest control were current. Facility sanitation is maintained at a high level. Five deficiencies with life-safety implications were identified. The facility does not maintain a master index of all hazardous substances (Deficiency EH&S-1). In the event of an emergency, a master index assures responders can quickly identify the quantity, locations, and types of hazardous substances maintained in the facility. ECDC has not developed a fire prevention, control, and evacuation plan (Deficiency EH&S-2). Fire plans serve a critical life-safety function and are required by National Fire Protection Association code. ODO recommends immediate establishment of a hazardous substance listing and fire prevention, control and evacuation plan. Weekly fire and safety inspections are not conducted in all areas of the facility (Deficiency EH&S-3). Routine, comprehensive inspections allow identification and correction of potential problems before they become life-safety issues. ODO was informed the generator is tested weekly, however, no supporting documentation was produced (Deficiency EH&S-4). Likewise, ODO was informed the functionality of emergency keys is tested but not documented (Deficiency EH&S-5). ODO recommends the facility document all tests and drills to support compliance with the standard.

DEFICIENCY EH&S- 1 In accordance with ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the maintenance supervisor or designee compiles a master index of all hazardous substances in the facility, including locations, along with a master file of MSDS. He/she must maintain this information in the safety office (or equivalent), with a copy to the local fire department. Documentation of the semi-annual reviews must be maintained in the MSDS file. The master index will also include a comprehensive, up-todate list of emergency phone numbers (fire department, poison control center, etc.). DEFICENCY EH&S-2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(3), the FOD must ensure the facility develops a fire prevention, control, and evacuation plan.
(b)(7)e
ICE.11.5082.000376
DEFICIENCY EH&S-3 In accordance with ICE NDS, Environmental Health, section (III)(L)(2), the FOD must ensure a qualified departmental staff member conducts weekly fire and safety inspections as required. DEFICIENCY EH&S-4 In accordance with ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure power generators are tested at least every two weeks. Other emergency equipment and systems will undergo quarterly testing, with follow-up or replacement as necessary. DEFICIENCY EH&S-5 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure emergency-key drills are included in each fire drill, and timed. Emergency keys will be drawn and used by the appropriate staff to unlock one set of emergency exit doors not in daily use. NFPA recommends a limit of four and one half minutes for drawing keys and unlocking emergency doors.

(b)(7)e
ICE.11.5082.000377
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at the ECDC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed policy and relevant documentation. Inspection of the food service area revealed knives and utensils were properly controlled, sanitation was maintained, and food temperature requirements were met. The menu was certified by a registered dietitian based on a complete nutritional analysis of every master cycle menu, and religious and medical diets were provided in accordance with standard. Documentation was available verifying all food service personnel receive medical screening. A review of available documentation and interview with the Food Service Administrator (FSA), ODO discovered the fire suppression system for the ventilation hood over the food grills had not been inspected in the past six months (Deficiency FS-1). Whereas this is a life-safety issue and required by the National Fire Protection Association code, ODO recommends immediate inspection of the fire suppression system and development of a mechanism to ensure future inspections are not missed. The facility maintains only a four-day food supply (Deficiency FS-2). ODO was informed the supply is set at four days due to the facilitys limited space to store food items; further, that additional food may be readily accessed if necessary. ODO confirmed storage space is limited; however, ECDCs 4-day supply is almost 75% below the 15-day minimum supply required by NDS. A 4-day supply may be problematic should an emergency arise cutting off access to external sources of food. One additional identified deficiency was corrected during the inspection. At initiation of the review, ECDC did not have a written schedule for stock rotation. The FSA informed ODO that stock was rotated on a scheduled, though unwritten, basis. While ODO was onsite, the FSA developed and provided ODO a written schedule meeting the standard.

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section (III)(H)(12)(f), the FOD must ensure an approved, fixed, fire-suppression system is installed in ventilation hoods over all grills, deep fryers and open flame devices. A qualified contractor must inspect the system every six months. DEFICIENCY FS-2 In accordance with ICE NDS, Food Service, section (III)(J)(4), the FOD must ensure that while Food Services Administrators base inventory on facility needs, each facility must at all times stock a 15-day-minimum food supply.

(b)(7)e
ICE.11.5082.000378

ODO reviewed the Funds and Personal Property standard at ECDC to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed policies and procedures; and interviewed staff regarding the control and safeguarding of detainees personal property, funds, and valuables. ECDC does not have a policy that addresses the inventory or receipt of property once the detainee is assigned housing (Deficiency F&PP-1). This issue was identified during a detainee interview. A female detainee stated that her wedding band had been taken away while she was assigned to a housing pod. The correctional officer who took the ring did not provide the detainee a receipt for the property; therefore there was no documentation present to show when the property was received by ECDC and where it was held. ODO determined the ring was securely stored with the detainees property and ECDC updated the detainees property record. Although the jewelry was accounted for, the current procedure at EDCD lacks accountability in securing and protecting detainees personal property.

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(E), the FOD must ensure the facility has a written procedure for the inventory and receipt of detainee baggage and personal property.

(b)(7)e
ICE.11.5082.000379

ODO reviewed the Hold Rooms in Detention Facilities standard at the ECDC to determine if detainees placed temporarily in hold rooms, awaiting processing, are in a safe, secure and comfortable environment, and not confined in hold rooms over 12 hours, in accordance with the ICE NDS. Inspection of the hold rooms revealed the rooms are well lit and equipped with restroom facilities, adequate seating, and telephones. An occupancy level is posted for each room. The rooms are under constant observation by the staff working in the area, and review of logs confirmed detainees are not confined in hold rooms more than 12 hours. ODO observed a group of newly arriving detainees placed in a hold room immediately following removal of jail inmates from the same room. The room was not inspected or cleaned prior to the detainees placement in the room (Deficiency HR-1). Inspection and cleaning of rooms between detainees reduces health risks, and ensures contraband has not been left behind and nothing has been tampered with that could pose a safety or security concern.

DEFICIENCY HR-1 In accordance with ICE NDS, Hold Rooms in Detention Facilities, section (III)(D)(7), the FOD must ensure that after the last detainee has been removed from the hold room, it is given a thorough cleaning and inspection.

(b)(7)e
ICE.11.5082.000380

ODO reviewed the Issuance and Exchange of Clothing, Bedding, and Towels standard at ECDC to determine if the facility provides clean clothing, bedding, linens, and towels to every detainee upon arrival; and to determine if the facility provides ICE detainees with regular exchanges of clothing, linens, and towels for as long as they remain in detention, in accordance with the ICE NDS. ODO observed the intake and admissions process, interviewed ECDC staff, and reviewed policies and procedures. Detainees are issued one pair of socks, and one pair of underwear. Additional undergarments are available for purchase through the commissary. During the inspection, ODO found detainees had no other garments to wear while their issued clothing is being laundered. ODO observed detainees showering while wearing their only pair of undergarments in order to clean them. Although ECDC is compliant with this standard, ODO has found in past reviews that the issuance of more than one pair of socks and undergarments is beneficial for detainees since it allow detainees to wear a clean pair of clothing while the other pair is being laundered.

None However, an area of concern is stated in the narrative above.

(b)(7)e
ICE.11.5082.000381
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at Etowah County Detention Center to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 30 detainee medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by Doctors Care Physicians, P.C. and holds American Correctional Association and National Commission on Correctional Health Care accreditations. The clinic is adequately staffed to meet detainee health needs. ODO verified intake screening, physical examinations, medications, treatment for special and chronic needs, and follow up care are provided in accordance with the standard. Sick call requests are triaged in a timely manner to determine priority for care. Overall, ECDC is in compliance with the standard. ODOs review of training files revealed no documentation of current training in cardiopulmonary resuscitation (CPR) and first aid (Deficiency MC-1). The training manager reported the last training occurred in January 2010 and produced as documentation a roster of names, with no signatures to document attendance. When asked for copies of CPR/first aid certification cards, the training manager indicated they are given to the trainees and copies are not maintained in the training files. ODO then interviewed approximately six staff members, including two whose names appeared on the training roster provided by the manager. None of the employees were able to produce current certification cards and when ODO inquired about when they were last trained, all indicated September or October 2009. ODO recommends that ECDC improve its documentation of training, including retaining copies of certification cards in training files. ODO discovered sick call slips written in Spanish were, for a brief time, returned to detainees for translation into English. Detainees requesting services were expected to use other detainees for this purpose, if necessary. If they chose not to do so, care was denied. The Health Services Administrator was unaware this had occurred and addressed the matter with her staff. ODO is not citing deficiencies in relevant components of the Medical Care standard because the matter was addressed. ODO recommends monitoring to ensure detainees access to medical services is not hampered by inability to speak English.

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (lll)(H), the FOD must ensure detention staff is trained to administer first aid and cardiopulmonary resuscitation.

(b)(7)e
ICE.11.5082.000382

ODO reviewed the Population Counts standard at ECDC to determine if the facility has an effective system of conducting population counts, which ensures detainee accountability, in accordance with the ICE NDS. ODO reviewed policies, toured the facility, interviewed staff and detainees, and observed population counts. ODO was informed a Sergeant outside the control center maintains the out-count record. No documentation was provided verifying out-counts are maintained (Deficiency PC-1).

DEFICIENCY PC-1 In accordance with the ICE NDS, Population Counts, section (III)(E), the FOD must ensure the Control Officer maintains an out-count record of the number and destination of all detainees who temporarily leave the facility.

(b)(7)e
ICE.11.5082.000383
RECREATION (R)
ODO reviewed the Recreation standard at ECDC to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO conducted a tour of recreational areas; reviewed the detainee handbook, policies, and procedures; and interviewed detainees and facility staff. The facility does not have an individual who is responsible for the development and oversight of the recreation program (Deficiency R-1).

DEFICIENCY R-1 In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure all facilities have an individual responsible for the development and oversight of the recreation program.

(b)(7)e
ICE.11.5082.000384

ODO reviewed the Staff-Detainee Communication standard at ECDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed policies, procedures, and logbooks and interviewed staff and detainees. There are no policies or procedures in place to ensure and document the FOD, AFOD, and designated department heads conduct regular unannounced visits to ECDC and this information was confirmed by interviews with ECDC staff (Deficiency SDC-1). It is vitally important for ERO management staff to conduct regular visits to detention facilities to observe and monitor conditions of confinement for detainees. This was previously identified as deficient by ODO during the previous 2007 inspection. ODO found the facility does not file copies of completed detainee requests in the detainees detention file (Deficiency SDC-2). Detainees receive a copy of the request and the Atlanta ERO Field Office maintains a log of detainee requests as required; however, the facility does not make a copy to be filed in the detention files.

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure policy and procedures are in place to ensure and document that the ICE FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and observe living and working conditions. The facility must develop a method to document the unannounced visits, and ICE must document visits to facilities. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and remain in the detainees detention file for at least three years.

(b)(7)e
ICE.11.5082.000385

ODO reviewed the Telephone Access standard at ECDC to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the ICE NDS. ODO interviewed staff and detainees; reviewed policies, procedures, and the detainee handbook; and tested the telephones in detainee housing units. According to the ECDC handbook, inmates may not take more than 20 minutes per call. Interviews with staff and detainees revealed ECDC restricts all calls, including calls to legal representatives, to 15 minutes (Deficiency TA-1).

DEFICIENCY TA-1 In accordance with the ICE NDS, Telephone Access, section (III)(F), the FOD must ensure the facility does not restrict the number of calls a detainee places to his or her legal representatives, nor limit the duration of such calls by rule or automatic cut-off, unless necessary for security purposes or to maintain orderly and fair access to telephones. If time limits are necessary for such calls, they must be no shorter than 20 minutes, and the detainee must be allowed to continue the call if desired, at the first available opportunity.

(b)(7)e
21
ICE.11.5082.000386
APPENDIX A
Acronyms

(b)(7)e
22
ICE.11.5082.000387
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law 6 library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional 9 time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with the ICE NDS, Admission and Release, section (III)(D), the FOD must ensure each facility institutes procedures for the inventory and receipt of detainee funds and 7 valuables (other than baggage and personal property) in accordance with the Funds and Personal Property standard. In accordance with the ICE NDS, Admission and Release, section (III)(E), the FOD must ensure each facility has a procedure for the inventory and receipt 7 of detainee baggage and personal property (other than funds and valuables) in accordance with the Funds and Personal Property standard.
Access To Legal Material Detainee Handbook
ALM-1 and DH-1
AR-1
AR-2

(b)(7)e
ICE.11.5082.000388
DETENTION STANDARD
AR-3 Admission and Release
AR-4
AR-5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(F), the FOD must ensure staff issues detainees clothing and bedding in 7 quantities and weights appropriate for the facility environment and local weather conditions. In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an order to detain or release (Form I-203 or I-203a) 8 bearing the appropriate signature accompanies the newly-arrived detainee. In accordance with the ICE NDS, Admission and Release, section (III)(J), the FOD must ensure staff completes certain procedures before any detainees release, removal, or transfer from the facility. Necessary steps 8 include completing and processing forms, closing files, fingerprinting, returning personal property, and reclaiming facility-issued clothing, bedding, etc.

(b)(7)e
ICE.11.5082.000389
DETENTION STANDARD
Detainee Handbook Access to Legal Materials DH-1 and ALM-1
Detention Files
DF-1
Detention Files
DF-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the 9 procedures for requesting access to the law library; 4) the procedures for 6 requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with the ICE NDS, Detention Files, section (III)(B), the FOD must ensure the detainee 10 detention file, at a minimum, contains the Alien Booking Record (Form I-385); the housing identification card; and the baggage check(s) (Form I-77). In accordance with the ICE NDS, Detention Files, section (III)(E), the FOD must ensure, upon the detainees release from the facility, staff adds final documents to the file before closing and 10 archiving it. Staff must insert into the released detainees detention file copies of completed release documents, the original closed out receipts for property and valuables, the original Form I-385, and other documentation.

(b)(7)e
ICE.11.5082.000390
DETENTION STANDARD
Detention Files
DF-3
EH&S-1
EH&S-2
EH&S-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS Detention Files, section (III)(F), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees 10 name and A-file number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file. In accordance with ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the maintenance supervisor or designee compiles a master index of all hazardous substances in the facility, including locations, along with a master file of MSDS. He/she must maintain this 11 information in the safety office (or equivalent), with a copy to the local fire department. Documentation of the semi-annual reviews must be maintained in the MSDS file. The master index will also include a comprehensive, up-to-date list of emergency phone numbers (fire department, poison control center, etc.). In accordance with ICE NDS, Environmental Health and Safety, 11 section (III)(L)(3), the FOD must ensure the facility develops a fire prevention, control, and evacuation plan. In accordance with ICE NDS, Environmental Health, section (III)(L)(2), the FOD must ensure a qualified 12 departmental staff member conducts weekly fire and safety inspections as required.

(b)(7)e
ICE.11.5082.000391
DETENTION STANDARD
EH&S-4
EH&S-5
Food Service
FS-1
Food Service
FS-2
F&PP-1
HR-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure power generators are tested at least 12 every two weeks. Other emergency equipment and systems will undergo quarterly testing, with follow-up or replacement as necessary. In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure emergency-key drills are included in each fire drill, and timed. Emergency keys will be drawn and 12 used by the appropriate staff to unlock one set of emergency exit doors not in daily use. NFPA recommends a limit of four and one half minutes for drawing keys and unlocking emergency doors. In accordance with ICE NDS, Food Service, section (III)(H)(12)(f), the FOD must ensure an approved, fixed, firesuppression system is installed in 13 ventilation hoods over all grills, deep fryers and open flame devices. A qualified contractor must inspect the system every six months. In accordance with ICE NDS, Food Service, section (III)(J)(4), the FOD must ensure that while Food Services 13 Administrators base inventory on facility needs, each facility must at all times stock a 15-day-minimum food supply. In accordance with the ICE NDS, Funds and Personal Property, section (III)(E), the FOD must ensure the facility has a 14 written procedure for the inventory and receipt of detainee baggage and personal property. In accordance with ICE NDS, Hold Rooms in Detention Facilities, section (III)(D)(7), the FOD must ensure that 15 after the last detainee has been removed from the hold room, it is given a thorough cleaning and inspection.

(b)(7)e
ICE.11.5082.000392
DETENTION STANDARD
Medical Care
MC-1
Population Counts
PC-1
Recreation
R-2
SDC-1
SDC-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Medical Care, section (lll)(H), the FOD must ensure detention staff is trained to 17 administer first aid and cardiopulmonary resuscitation. In accordance with the ICE NDS, Population Counts, section (III)(E), the FOD must ensure the Control Officer 18 maintains an out-count record of the number and destination of all detainees who temporarily leave the facility. In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure all facilities have an 19 individual responsible for the development and oversight of the recreation program. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(A)(1), the FOD must ensure policy and procedures are in place to ensure and document that the ICE FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys 20 living and activity areas to encourage informal communication between staff and detainees, and observe living and working conditions. The facility must develop a method to document the unannounced visits, and ICE must document visits to facilities. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in 20 the detainees detention file, and remain in the detainees detention file for at least three years.

(b)(7)e
ICE.11.5082.000393
DETENTION STANDARD
Telephone Access
TA-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Telephone Access, section (III)(F), the FOD must ensure the facility does not restrict the number of calls a detainee places to his or her legal representatives, nor limit the duration of such calls by rule or automatic cut-off, 21 unless necessary for security purposes or to maintain orderly and fair access to telephones. If time limits are necessary for such calls, they must be no shorter than 20 minutes, and the detainee must be allowed to continue the call if desired, at the first available opportunity.

(b)(7)e
29
ICE.11.5082.000394


Enforcement and Removal Operations Phoenix Field Office Florence Service Processing Center Florence, Arizona
October 26-28, 2010
ICE.11.5082.000395
QUALITY ASSURANCE REVIEW FLORENCE SERVICE PROCESSING CENTER PHOENIX FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY ...............................................................................................1 INSPECTION PROCESS Report Organization .................................................................................................3 Inspection Team Members .......................................................................................3 OPERATIONAL ENVIRONMENT Internal Relations .....................................................................................................4 Detainee Relations ...................................................................................................4 ICE PERFORMANCED BASED NATIONAL DETENTION STANDARDS Detention Standards Reviewed ................................................................................5 Environmental Health and Safety ............................................................................6 Hold Rooms in Detention Facilities .........................................................................7 Law Libraries and Legal Material............................................................................8 Medical Care ............................................................................................................9 Special Management Units ....................................................................................10 Use of Force and Restraints ...................................................................................11 LIST OF ACRONYMS ...................................................................................................13
ICE.11.5082.000396
EXECUTIVE SUMMARY
The Office of Professional Responsibilitys (OPR), Office of Detention Oversight (ODO) conducted a Quality Assurance Review (QAR) of the Florence Service Processing Center (FSPC), located in Florence, Arizona, on October 26-28, 2010. FSPC was built in 1942 to hold prisoners of war during World War II. Since 1983, the former U.S. Immigration and Naturalization Service (INS), now ICE, administrative immigration violations. (b)(7)e
(b)(7)e (b)(7)e
At the time of the review, there were 138 ICE employees permanently stationed at FSPC. The facility also has 426 contract employees. Medical services at FSPC are provided by the ICE Health Service Corps (IHSC). FSPC received the National Commission on Correctional Health Care (NCCHC) accreditation in 1997, and the American Correctional Association (ACA) accreditation in 2009. In 2010, the facility received accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Asset Protection and Security Services (APSS) provides security. Ahtna Technical Services Incorporated (ATSI) is contracted to provide food service and Rosemark is the maintenance contractor. In May 2010, ERO contractors, MGT of America, Inc. (MGT), conducted an annual review of the ICE PBNDS at FSPC. The facility received an overall rating of Meets Standards. ODO, formerly DFIG, conducted a Quality Assurance Review (QAR) in September 2008 using the 2000 National Detention Standards and found the facility to in compliance with most of the standards reviewed. In February 2010, ODO conducted a Follow-up inspection at FSPC. The majority of the previously identified deficiencies were corrected; however, ODO found unresolved issues in the following areas: Correspondence and Other Mail, Detainee Classification System, Emergency Plans, Funds and Personal Property, Hold Rooms in Detention Facilities, Medical Care, and Population Counts. During the current inspection, ODO discovered all but one (Hold Rooms) previously identified deficiencies to be resolved. ODO reviewed a total of 23 PBNDS, 17 of which were in full compliance at the time of the QAR. The remaining 6 standards encompassed 11 deficiencies: Environmental Health and Safety (1); Hold Rooms in Detention Facilities (3); Law Libraries and Legal Material (1); Medical Care (1); Special Management Units (2); and Use of Force and Restraints (3). Overall, ODO found FSPC to be well-managed and in compliance with the standards areas inspected. Critical standards such as Staff-Detainee Communications, Grievance System, Telephone Access and Detainee Handbook were all found to be in compliance with the PBNDS. Consistently, ODO has often observed that facilities in compliance with the above-mentioned standards are less apt to experience more egregious issues and concerns on behalf of the detainee population, and are generally operating in a very effective manner. Among the 11 discovered deficiencies, most should be easily resolved. ODO did address those issues during the Closeout Brief on October 28th to best ensure that the facility and ERO staff would have the opportunity to initiate actions to expeditiously correct the deficiencies.
1
(b)(7)e
Florence Service Processing Center ERO Phoenix
ICE.11.5082.000397
Among the cited deficiencies, there are some findings of heightened importance. The North and South hold rooms, each with a capacity of 18 detainees, are not equipped with two stainless steel combination lavatory/toilet fixtures with modesty panels, in compliance with the Americans with Disabilities Act of 1990, and the International Plumbing Code. The hold rooms also lack floor drains, and do not provide detainees access to drinking water. It should be noted the Hold Room deficiency in all previous reports is structural in nature due to the age of the facility. ERO is aware of this and is making arrangements to modify the deck drains in the hold rooms to be compliant with the ICE PBNDS; this does not affect the operational readiness of the facility. Not all employees who participate in calculated use of force incidents have received training. Audio-visual recordings of calculated use of force incidents do not include introductions by the team leaders, naming of the camera operators, or debriefings of the incidents. During the inspection, ODO observed a use of force team with fewer than five members who were not properly outfitted in protective gear. Overall, Florence SPC is in compliance with the Medical Care standard. The clinic is adequately staffed to meet detainee health needs. ODO verified intake screening, physical examinations, medications, treatment for special and chronic needs, and follow up care are provided in accordance with the standard. Sick call requests are triaged in a timely manner to determine priority for care. The lone deficiency in this standard area relates to detainee health appraisals being completed by mid-level providers, but not reviewed by the Clinical Director. In the area of Environmental Health and Safety, the inspection revealed all chemicals, flammables and combustible materials are stored and issued as required. Throughout the facility, sanitation is maintained at a high level. ODO verbally conveyed these positive outcomes to all ERO command staff during the ODO close out briefing conducted on the final day of the inspection. All deficiencies identified in this QAR refer to specific, relevant sections of the ICE PBNDS. Enforcement and Removal Operations (ERO) will be provided a copy of the report to assist in developing corrective actions to resolve the 11 identified deficiencies.
2
(b)(7)e
ICE.11.5082.000398
INSPECTION PROCESS
The ODO primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS) or the Performance Based National Detention Standards (PBNDS), as applicable. In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at FSPC to determine compliance with current policies and detention standards (in this case, the PBNDS). Prior to the inspection, ODO collected and analyzed relevant detainee information from multiple ICE databases, including the Joint Integrity Case Management System (JICMS), the ENFORCE Alien Booking Module (EABM) and the Alien Removal Module (EARM). ODO also gathered facility facts and inspection-related information from ERO headquarters staff to fully prepare for the site visit at FSPC.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the OPR Deputy Division Director, Office of Detention Oversight.

Special Agent (Team Leader) Special Agent (Acting Section Chief) Special Agent Special Agent Special Agent Contract Inspector Contract Inspector Contract Inspector OPR/ODO, San Diego OPR/ODO, Phoenix OPR/ODO, Phoenix OPR/ODO, Phoenix OPR/ODO, Phoenix MGT of America MGT of America MGT of America
(b)(6), (b)(7)(C)
3
(b)(7)e
ICE.11.5082.000399
INTERNAL RELATIONS
ODO interviewed supervisory and non-supervisory ICE and contract staff at FSPC. Overall, all personnel interviewed reported high levels of morale at the facility and excellent working relations between ICE and contract staff. ICE staff stated the facility has adequate and sufficient equipment to carry out its operations. Facility staff stated executive management at the ERO Phoenix Field Office is very receptive and supportive of the facilitys operational needs. More than one Immigration Enforcement Agent (IEA) expressed concern about friction between IEA and Deportation Officer (DO) personnel. Two IEAs stated longer tenured employees are treated more favorably than newer employees. One IEA stated, although a DO is at a higher pay grade than an IEA, DOs are often offered overtime work and escort assignments. Additionally, a Lieutenant employed by ATSI expressed concern that ATSI employees, who receive fewer benefits and a lower salary than APSS employees, are applying for jobs elsewhere.
DETAINEE RELATIONS
ODO conducted interviews with 13 detainees to determine the extent of their concerns with respect to FSPC adherence to the ICE PBNDS. ODO encouraged detainees to express their opinions and concerns relating to the facility, including its staff and ICE personnel. Overall, the detainees were pleased with the conditions at FSPC and did not express any specific concerns or complaints with respect to the personnel or the facility.
4
(b)(7)e
ICE.11.5082.000400

A total of 23 Performance Based National Detention Standards (PBNDS) were reviewed during the ODO inspection of FSPC. The following six areas were found to be deficient with respect to adherence to the ICE PBNDS, as required: Environmental Health and Safety Hold Rooms in Detention Facilities Law Libraries and Legal Material Medical Care Special Management Units Use of Force and Restraints The following 17 areas were found to be in compliance with the ICE PBNDS: Admission and Release Detainee Handbook Detention Files Disciplinary System Food Service Funds and Personal Property Grievance System Hunger Strikes Personal Hygiene Recreation Religious Practices Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Visitation As these 17 standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.
5
(b)(7)e
ICE.11.5082.000401

ODO reviewed the Environmental Health and Safety standard at FSPC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE PBNDS. ODO toured the facility, interviewed staff, reviewed policies and documentation of inspections, hazardous chemical management, generator testing, and fire drills. ODOs inspection revealed all chemicals, flammables and combustible materials are stored and issued as required. Procedures for handling caustic and toxic substances are in place and followed. Hazardous substances are strictly controlled and when used, personal safety equipment is worn. Monthly fire drills were conducted on each shift and documentation is on file in the Safety Officers office. Pest control services are under contract and monthly inspections are conducted. Barbering services are conducted in a separate building and hair care sanitation requirements are met. Throughout the facility, sanitation is maintained at a high level. One deficiency was identified. Exit/evacuation diagrams do not provide the locations of emergency equipment and Areas of Safe Refuge (Deficiency EH&S-1). Inclusion of this information on diagrams ensures ready availability in situations where use of fire extinguishers, safety masks and other fire suppression equipment is necessary, and/or situations requiring evacuation of area(s) of the facility.

DEFICIENCY EH&S-1 In accordance with ICE PBNDS, Environmental Health and Safety, section (VII)(E), the FOD must ensure emergency equipment locations and Area of Safe Refuge locations, with explanation, are provided on existing exit/evacuation diagrams.
6
(b)(7)e
ICE.11.5082.000402

ODO reviewed the Hold Rooms in Detention Facilities standard at FSPC to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure and comfortable environment, and not held confined in hold rooms for over 12 hours, in accordance with the ICE PBNDS. ODO interviewed staff, inspected the hold rooms, reviewed logbooks and policies, and observed the processing of detainees. Overall, ODO found compliance with the standard. Inspection of the hold rooms revealed the rooms are clean, well ventilated and well lit. Each hold room contains sufficient seating for the maximum room-capacity. The rooms are under constant observation by the staff working in the area. ODOs review of logs confirmed detainees are not confined in hold rooms more than 12 hours. Based on the review of the PBNDS by ODO, three deficiencies were discovered. The North and South hold rooms are not equipped with lavatory and toilet fixtures (Deficiency HR-1) or with water for drinking (Deficiency HR-2). Detainees having to use restroom facilities must wait for officers to escort them to another area. Hold rooms which are equipped with lavatory/toilet fixtures do not have floor drains to prevent accidental or intentional flooding (Deficiency HR-3).

DEFICIENCY HR-1 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(6), the FOD must ensure each hold room is equipped with stainless steel, combination lavatory/toilet fixtures, with modesty panels, in compliance with the Americans with Disabilities Act of 1990. Consistent with International Plumbing Code, each large hold room, holding 15 to 49 detainees, must have at least two combination units. The Hold Room Design Standards A-E, HDR Architecture, recommends a third combination unit for a Hold Room with 30 or more detainees, or one combination unit for every 15 detainees. DEFICIENCY HR-2 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(B)(13), the FOD must ensure detainees have access to water in hold rooms. DEFICIENCY HR-3 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(7), the FOD must ensure each hold room has a floor drain(s).

(b)(7)e
ICE.11.5082.000403

ODO reviewed the Law Libraries and Legal Material standard at FSPC to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE PBNDS. ODO interviewed staff and detainees, reviewed the detainee handbook, examined policies and procedures, and observed law library operations. Overall, the library is being well-managed and it is supplied with the required materials for ICE detainees. ODO discovered one deficiency. Unpublished materials located in the law library do not have a cover page identifying who submitted and prepared the materials. Additionally, the materials did not contain a statement indicating ICE/ERO did not prepare the material and is not responsible for its contents. The date of preparation of the unpublished materials was also not provided (Deficiency LL&LM-1).

DEFICIENCY LL&LM-1 In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(F)(2), the FOD must ensure the Facility Administrator forwards, as soon as possible, any unpublished immigration-related material received to the Field Office Director for review and approval. Unpublished materials located in the law libraries must have a cover page that: 1) identifies the submitter and the preparer of the material; 2) clearly states that ICE/DRO did not prepare and is not responsible for the contents, and 3) provides the date of preparation.
8
(b)(7)e
ICE.11.5082.000404
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at the FSPC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE PBNDS. ODO toured the medical clinic, reviewed policies and procedures, examined 30 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. Medical services at FSPC are provided by the ICE Health Service Corps and hold American Correctional Association, National Commission on Correctional Health Care (NCCHC), and Joint Commission on Accreditation of Healthcare Organizations accreditations. Overall, Florence SPC is in compliance with the standard. The clinic is adequately staffed to meet detainee health needs. ODO verified intake screening, physical examinations, medications, treatment for special and chronic needs, and follow up care are provided in accordance with the standard. Sick call requests are triaged in a timely manner to determine priority for care. The clinical director (CD) and mid-level providers perform physical examinations. Only one deficiency is cited. Health appraisals completed by mid-level providers are not reviewed by the CD (Deficiency MC-1). ODO notes the requirement for CD review of appraisals conducted by mid-level providers exceeds NCCHC standard J-E-04 requiring review only if significant findings are present. However, ODO recommends the facility comply with the PBNDS to avoid future deficiencies in this area. Additionally, ODO discovered one of 30 medical records reviewed included a consent form for medical treatment which was not dated and witnessed. This deficiency was corrected when called to the attention of medical personnel.

DEFICIENCY MC-1 In accordance with the ICE PBNDS, Medical Care, section (V)(J), the FOD must ensure the clinical medical authority reviews all health appraisals to assess the priority for treatment.
9
(b)(7)e
ICE.11.5082.000405
SPECIAL MANAGEMENT UNITS (SMU)

ODO reviewed the Special Management Unit (SMU) standard at FSPC to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE PBNDS. ODO toured the Special Management Unit, reviewed policies and documentation, and interviewed staff and detainees. Overall, ODO found compliance with the standard. The facility has written procedures in place to temporarily segregate detainees for disciplinary and administrative reasons. ODOs tour of the SMU revealed the units are well ventilated, adequately lit, appropriately heated and maintained in a sanitary condition. Detainees in SMU are afforded basic living conditions that approximate those provided to detainees in the general population. Two deficiencies were found. Detainees are not permitted to retain religious items (Deficiency SMU-1). ODO recommends the facility develop procedures to allow detainees to retain religious items, unless the item is determined to pose a security concern that is specific and articulated. A separate log is not maintained for recording visitors to the SMU (Deficiency SMU-2). Given the nature of segregated housing, ODO recommends creation of a log to ensure SMU visits and other activities are documented separately from the officers post log.

DEFICIENCY SMU-1 In accordance with the ICE PBNDS, Special Management Unit, section (V)(B)(15), the FOD must ensure each facility develops procedures to allow detainees to retain religious items within their possession consistent with good security practices (e.g., religious wearing apparel, religious headwear, prayer rugs, beads, prayer rocks, medallions). DEFICIENCY SMU-2 In accordance with the ICE PBNDS, Special Management Unit, section (V)(E)(2), the FOD must ensure a separate log is maintained in the SMU of all persons visiting the unit. This separate record must include notation of the time and date of the visit, and any unusual activity or behavior of an individual detainee, with a follow-up memorandum sent through the facility administrator to the detainee's file.
10
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ICE.11.5082.000406

ODO reviewed the Use of Force and Restraints standard at FSPC to determine if necessary use of force and the use of restraints is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE PBNDS. ODO toured the facility, viewed use of force videos, inspected equipment, and reviewed the local policies, training records, and other pertinent documentation.
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ICE.11.5082.000407
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LIST OF ACRONYMS
ACA AFOD DIHS CO DO DDO EH&S ERO DSCU DSM EABM EADM EARM ERO FOD FR FSA FU HQ ICE IDP IEA IGSA JICMS MGT MSDS NDS OIC ODO OPR PBNDS POA R&D RS SDDO SIR SMU TAR QAR UDC American Correctional Association Assistant Field Office Director Division of Immigration Health Services Correctional Officer Deportation Officer Detention and Deportation Officer Environmental Health and Safety Enforcement and Removal Operations Detention Standards Compliance Unit Detention Service Manager ENFORCE Alien Booking Module ENFORCE Alien Detention Module ENFORCE Alien Removal Module Enforcement and Removal Operations Field Office Director Focus Review Food Service Administrator Follow-Up Headquarters U. S. Immigration and Customs Enforcement Institutional Disciplinary Panel Immigration Enforcement Agent Intergovernmental Service Agreement Joint Integrity Case Management System MGT of America, Inc Material Safety Data Sheets National Detention Standards Officer in Charge Office of Detention Oversight Office of Professional Responsibility Performance Based National Detention Standards Plan of Action Receiving and Discharge Residential Standards Supervisory Detention and Deportation Officer Significant Incident Report Special Management Unit Treatment Authorization Request Quality Assurance Review Unit Disciplinary Committee
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ICE.11.5082.000409
ICE.11.5082.000410
ICE.11.5082.000411
ICE.11.5082.000412
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ICE.11.5082.000413
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ICE.11.5082.000414
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ICE.11.5082.000415
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ICE.11.5082.000416



Washington Field Office Hampton Roads Regional Jail Portsmouth, Virginia
October 19-21, 2010
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QUALITY ASSURANCE REVIEW HAMPTON ROADS REGIONAL JAIL WASHINGTON FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY.. INSPECTION PROCESS Report Organization Inspection Team Members OPERATIONAL ENVIRONMENT Internal Relations........ Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed Admission and Release. Detention Files. Detainee Grievance Procedures.. Detainee Handbook Environmental Health and Safety.. Medical Care Staff-Detainee Communication..... Suicide Prevention and Intervention. Telephone Access... Terminal Illness, Advance Directives, and Death... Tool Control.. Visitation 1
3 3
4 4
5 6 7 8 9 11 12 13 15 16 17 18 19
ICE.11.5082.000418
EXECUTIVE SUMMARY
ODO conducted an inspection of Hampton Roads Regional Jail (HRRJ), located in Portsmouth, VA, on October 19-21, 2010. HRRJ was opened March 16, 1998, and serves as a regional jail which houses detainees received from area law enforcement jurisdictions in addition to ICE detainees. HRRJ is owned and operated by the Hampton Roads Regional Jail Authority. ICE utilizes HRRJ under an intergovernmental service agreement (IGSA) to house ICE male and female detainees of all classification levels over 72 hours. ICE Enforcement and Removal Operations (ERO) began housing detainees at HRRJ on October 28, 2002. Medical care is provided under contract by First Medical Management. Food service is provided under contract by Aramark. ICE staff is assigned to the HRRJ on a permanent basis, including two Immigration Enforcement Agents and a Detention Services Manager. The Assistant Field Office Director ld (b)(7)e Office.
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Additional is provided. HRRJ received accreditations with the American Correctional Association in January 2010 and National Commission on Correctional Health Care in May 2008.
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The ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the ICE National Detention Standards (NDS) at HRRJ in February 2010. HRRJ received an overall rating of acceptable, and was found to be in compliance with 34 of 36 standards reviewed. The two areas in which deficiencies were discovered are Food Service and Recreation. This is the first ODO inspection conducted at HRRJ. ODO reviewed a total of 25 NDS; 13 were in full compliance and 12 had deficiencies. In the review of those 12 standards, a total of 22 deficiencies were discovered by ODO which included: Admission and Release (2); Detention Files (3); Detainee Grievance Procedures (2); Detainee Handbook (2); Environmental Health and Safety (3); Medical Care (2); Staff-Detainee Communication (2); Suicide Prevention and Intervention (1); Telephone Access (1); Terminal Illness, Advance Directives, and Death (2); Tool Control (2); and Visitation (1). Several of these deficiencies were of a clerical nature, such as the improper placement of paperwork in detention files and the omission of critical information from the detainee handbook One major area of ODO concern is that all detainee telephone calls are monitored and recorded, including those to a legal representative. This was confirmed and verified by interviews with staff and a review of the detainee handbook. ICE and HRRJ were advised of this activity at the closeout brief on October 21, 2010. ODO emphasized that the facilitys action is a significant violation of the ICE NDS, specifically Telephone Access. Another area of concern is that detainees were being charged for hygiene supplies if their commissary accounts contained 51 cents or more. This is in direct
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Hampton Roads Regional Jail ERO Washington
ICE.11.5082.000419
conflict with the NDS, Admission and Release, which provides that hygiene supplies are to be replenished as needed and does not state detainees can be charged for these items. No major deficiencies were found in security or environmental health and safety standards. HRRJ has a fully functioning medical unit to address detainee health care and ODO noted no major areas of concern. ICE staff conducts daily regular and irregular visits to housing units to address detainee concerns and inquiries. HRRJ has processes in place to ensure detainees have the opportunity to file grievances and appeal the decisions of grievances. This report includes descriptions of all the deficiencies and refers to the specific, relevant NDS. The report will be provided to ERO to develop corrective actions to resolve the 22 deficiencies.

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INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at HRRJ to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module (EABM), ENFORCE Alien Removal Module (EARM), Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Deputy Division Director for the Office of Detention Oversight, Office of Professional Responsibility.

Special Agent (Team Leader) Detention and Deportation Officer Detention and Deportation Officer Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc
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ICE.11.5082.000421
INTERNAL RELATIONS
ODO interviewed supervisory ICE and HRRJ staff, including the HRRJ Superintendent, Assistant Superintendent, Captains, and the AFOD. ODO also interviewed nonsupervisory ICE staff, including Immigration Enforcement Agents and Corrections Officers. Overall, HRRJ and ICE staff expressed good morale levels and an excellent working relationship exists between the two entities. Several HRRJ staff expressed confusion over communication issues with ICE regarding which set of detention standards are applicable to the facility; the 2008 Performance Based National Detention Standards or the 2000 NDS. ODO advised HRRJ staff that under the terms of the current IGSA, HRRJ is obligated to comply with the 2000 ICE NDS.
DETAINEE RELATIONS
ODO randomly selected 18 detainees at HRRJ to interview to asses the detention conditions of HRRJ. Detainees stated they are able to send and receive mail, use the telephones, and access the law library. Since Deportation Officers (DOs) do not normally visit HRRJ, most detainees stated they have not met their DOs; however, detainees have access to ICE staff at HRRJ who handle inquiries involving their removal cases. One detainee complained about not having access to hot water in the shower area in his housing unit. ODO checked the showers in the housing unit of the detainee and found hot water was available. Several detainees complained they did not receive hygiene supplies when initially admitted to HRRJ. Several detainees complained about food portions and a lack of variety. Five detainees complained they did not see medical staff after filing medical request forms. ODO reviewed these complaints and found that all five detainees had been seen by medical staff for the issues specified in their medical requests. Overall, the majority of the detainees stated they were treated with dignity and respect.

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ICE.11.5082.000422

A total of 25 National Detention Standards were reviewed during the ODO inspection. The following 12 areas were found to be deficient with respect to adherence to the ICE NDS, as required: Admission and Release Detention Files Detainee Grievance Procedures Detainee Handbook Environmental Health and Safety Medical Care Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Visitation The following 13 standards were found to be well-managed: Access to Legal Material Disciplinary Policy Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Issuance and Exchange of Clothing, Bedding, and Towels Population Counts Recreation Religious Practices Special Management Unit (Administrative Segregation) Special Management Unit (Disciplinary Segregation) Use of Force As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ICE.11.5082.000423

ODO reviewed the Admission and Release standard at HRRJ to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed policies and files, observed the admission process, and interviewed staff and detainees. ODO reviewed 20 detention files to determine if all documents created during the duration of the detainees custody are enclosed in the detainees detention file. None of the detention files reviewed contained Alien Booking Records, Form I-385, personal property inventory sheets, or grievances; and two did not contain proof of hygiene items issued (Deficiency AR-1). Detainee interviews revealed that if a detainee has more than 51 cents in a commissary account, he or she is charged for hygiene items (Deficiency AR-2). The ICE NDS for Admission and Release, provides that hygiene items must be replenished as needed and does not state that a detainee must have a required monetary amount in their commissary account to have hygiene items replenished.

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(A), the FOD must ensure staff opens a detainee detention file as part of the admissions process. This file must contain all paperwork generated by the detainees stay at the facility. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(G), the FOD must ensure facility staff provides and replenishes personal hygiene items as needed.

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ICE.11.5082.000424

ODO reviewed the Detention Files standard at HRRJ to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files, logbooks, policies and procedures; toured the admissions and release area; and interviewed staff. ODO reviewed 20 detention files and found HRRJ does not keep required documentation in the detention files, such as the Alien Booking Record, Form I-385, housing identification cards, personal property inventory sheets, and grievances (Deficiency DF-1). Detainee grievances and requests are not filed in detention files. Detainee grievances are filed and recorded; however they are stored in areas separate from the detention files (Deficiency DF-2). HRRJ does not maintain a logbook to record the entry or removal of detainee detention files, including the person who removed the file and the reason for removing it (Deficiency DF-3).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-file. The file must, at a minimum, contain the following: Alien Booking Record, Form I-385, personal property inventory sheet, and housing identification card. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(C), the FOD must ensure, during the course of the detainees stay at the facility, that staff add documents associated with normal operations to the detainees detention file without prior approval, e.g., special requests; any Property Receipts, Form G-589s and/or Baggage Check(s), Form, I-77s, closed-out during the detainees stay; disciplinary forms; grievances, complaints, and the disposition(s) of the same; all forms associated with disciplinary and/or administrative segregation; strip search forms; and other approved documents, such as staff reports about the detainees behavior, attitude, etc. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F)(2)(a-e), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

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ICE.11.5082.000425

ODO reviewed the Detainee Grievance Procedures standard at HRRJ to determine if a process to submit formal or emergency grievances exists and if so, whether detainees have a fear of reprisal and whether responses to the grievances are provided in a timely manner. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained in accordance with the ICE NDS. ODO interviewed staff and reviewed files, policies, procedures, and logbooks. Processes exist for detainees to submit informal, formal and emergency grievances. Detainees can appeal a grievance decision within three days of receipt of the decision of a grievance. For the month of September 2010, HRRJ received a total of eight grievances which focused on the following issues: allegations of staff misconduct (2), conditions of confinement (1), food service (2), and medical (3). A review of grievance paperwork showed HRRJ staff provided responses ranging from the same day to ten days. The HRRJ detainee handbook advises detainees they may file a grievance without fear of reprisal. Grievances are reviewed by the Unit Manager or department supervisor, not by a grievance committee (Deficiency DGP-1). ODO interviewed HRRJ staff and reviewed detention files, and found grievance forms are not filed in detainees detention files. The grievances are indeed filed, but maintained in a separate area and not consolidated in the detention files (Deficiency DGP-2).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(2), the FOD must ensure the detainee is allowed to submit a formal, written grievance to the facilitys grievance committee. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance remains in the detainees detention file for at least three years.

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ICE.11.5082.000426

ODO reviewed the Detainee Handbook standard at HRRJ to determine if the facility provides each detainee with a handbook, and whether the handbook is available in languages other than English. ODOs review includes determining whether the handbook sufficiently describes the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO reviewed the handbook, and interviewed detainees and staff. HHRJ detainee handbooks are available in both English and Spanish. A review of the ICE ENFORCE Alien Removal Module (EARM) database showed the majority of detainees housed at HRRJ are from Mexico and Central America. HRRJ staff indicated that if a detainee speaks a language other than English or Spanish, accommodations can be made to supply those detainees with a detainee handbook in their native language. During detainee interviews, one detainee out of eighteen stated he had not received a handbook upon arrival at the facility. This detainees detention file was reviewed and revealed the detainee was not issued a detainee handbook; a notation was present that stated out of handbooks. ODO randomly inspected 11 detention files to determine if those detainees received the detainee handbook, which revealed all those detainees received the detainee handbook. Although there was one incident discovered by ODO where a detainee was not issued a handbook, this does not reflect a systemic problem in the issuance of detainee handbooks and should be noted as an area of concern. ODO recommends HRRJ staff monitor the number of detainee handbooks available on a weekly or bi-weekly basis to ensure newly arrived detainees are issued a detainee handbook. The detainee handbooks do not provide procedures for filing a claim for lost or damaged property, or rules for storing or mailing property (Deficiency DH-1). The detainee handbook does not cover what are considered restricted areas (Deficiency DH-2). ODO recommends that the handbook be revised to avoid future deficiencies in these areas.

DEFICIENCY DH-1 In accordance with the ICE NDS, Detainee Handbook, section (III)(B), the FOD must ensure the handbook briefly describes individual programs and services, and associated rules. Among others, these include recreation, visitation, education, voluntary work, telephone use, correspondence, library use, and the canteen/commissary. The overview must also cover medical policy (sick-cell); facility-

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ICE.11.5082.000427
issued items, e.g., clothing, bedding, etc.; access to personal property; and meal service. DEFICIENCY DH-2 In accordance with the ICE NDS, Detainee Handbook, section (III)(C), the FOD must ensure the handbook specifies in detail the rules, regulations, policies, and procedures with which every detainee must comply, including, but not limited to: smoking policy, restricted areas, contraband, and so forth.

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ICE.11.5082.000428

ODO reviewed the Environmental Health and Safety standard at HRRJ to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility; interviewed staff; and reviewed policies and documentation of inspections, hazardous chemical management, generator testing, and fire drills. Overall, ODO found compliance with the standard. Staff verbalized an understanding of proper storage and handling of all chemicals, and inventory of chemicals was accurate and well documented. All flammable and combustible materials were stored in approved storage cabinets. Fire drills were conducted monthly on each shift and documentation is maintained with the safety officer. Reports for water and generator testing, pest control, and removal of sharp tools were current and readily available. The sanitation of the facility was maintained at a high level. Deficiencies in three components of the standard were identified. The master index of Material Safety Data Sheets does not include an up-to-date listing of emergency phone numbers (Deficiency EH&S-1). ODO was informed responsibility for making external contacts lies with the Control Center, which maintains emergency phone numbers. Exit/evacuation diagrams do not provide instructions in Spanish, locations of emergency equipment, or You are Here markers (Deficiency EH&S-2); however, ODO observed lighted Exit signs in place throughout the facility in accordance with National Fire Protection Association standards. ODO found proper barbering sanitation requirements were posted and observed as required by the standard, though barbering does not take place in a dedicated room (Deficiency EH&S-3).

DEFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the master index of Material Safety Data Sheets includes a comprehensive, up-to-date list of emergency telephone numbers (fire department, poison control center, etc.). DEFICIENCY EH&S-2 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD must ensure existing exit diagrams provide instructions in Spanish, You are Here markers, and emergency equipment locations. DEFICIENCY EH&S-3 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barber operation is located in a separate room not used for any other purpose.

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ICE.11.5082.000429
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at HRRJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 30 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed the Health Services Administrator, Director of Nursing and staff. Medical services at HRRJ are contracted with First Medical Management (FMM) and are accredited by ACA and NCCHC. Overall, ODO found compliance with the Medical Care standard. The clinic is staffed by a Medical Director, Health Services Administrator (HSA), Director of Nursing, Physician Assistants, Nurse Practitioners, psychiatrists, dentist, nurses and other support staff, and is sufficient to address the health care needs of detainees. ODO verified intake screening, physical examinations, medications, treatment for special and chronic needs, and follow-up care are provided in accordance with the standard. Detainees access care by depositing medical requests in secure boxes in housing units, which are then retrieved and triaged by medical staff to determine priority for treatment. HRRJ was unable to produce documentation of training in first aid or cardio-pulmonary resuscitation (CPR) for two of sixty-eight medical staff (Deficiency MC-1). Though training in responding to health emergencies is required for all HRRJ personnel, the HSA confirmed two physicians did not have current certification. ODO recommends the facility improve its tracking of compliance with training requirements to assure appropriate emergency response by all staff. ODO verified written authorization is obtained before a detainee medical record is released; however, notification to ICE is neither a formal policy at HRRJ nor does it occur in practice as required by the NDS (Deficiency MC-2). Notification that a medical record has been released is particularly important as it can serve as an alert to possible issues relating to care.

DEFICIENCY MC -1 In accordance with the ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure all detention staff are trained to respond to health-related emergencies within a 4-minute response time. This training must be provided by a responsible medical authority in cooperation with the Officer in Charge, and will include the following: the administration of first aid and CPR. DEFICIENCY MC- 2 In accordance with the ICE NDS, Medical Care, section (III)(M), the FOD must ensure IGSA facilities notify ICE each time a detainee medical record is released.

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STAFF DETAINEE COMMUNICATION (SDC)

ODO reviewed the Staff-Detainee Communication standard at HRRJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed logbooks, and interviewed staff and detainees. ODO found that ICE staff made daily regular and irregular visits in responding to ICE detainee requests and concerns. ICE was available to conduct daily visits to housing units based on the fact that staff is permanently assigned to HRRJ. ODO found that in facilities where ICE is permanently staffed or where ICE staff visit facilities on a daily basis, detainee requests and concerns are met in a timelier manner, which can result in less anxiety and behavioral issues on the part of detainees. A review of logbooks indicates the FOD, AFOD, and department heads do not conduct regular unannounced (unscheduled) visits to the HRRJ (Deficiency SDC-1). It is vitally important for ERO management staff to conduct regular visits to detention facilities to observe and monitor conditions of confinement for detainees. ODO reviewed the ICE detainee request logbook and found the columns for the detainees nationality and for the name of the officer logging the request are not included in the logbook. ODO reviewed detention files and observed the detainee requests to ICE are not included in the detention files (Deficiency SDC-2).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure that a policy and procedure is in place to ensure and document that the ICE Officer in Charge, the Assistant Officer in Charge, and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and informally observe living and working conditions. These unannounced visits must include, but not be limited to: housing units; food service, preferably during lunch meal; recreation areas; Special Management Units (administrative and disciplinary segregation), and infirmary rooms. While visiting the Special Management Unit, the detainees must be interviewed, living conditions must be observed, and detaineehousing records must be reviewed. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure detainee record keeping requests are recorded in a logbook specifically designed for that purpose. The log, at a minimum, must contain: the date the detainee request was received, detainees name, A-number, nationality, officer logging the request, the date of the request (with staff response and action), the date
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ICE.11.5082.000431
the request is returned to the detainee, and any other site-specific pertinent information. In IGSAs, the date the request was forwarded to ICE and the date it was returned must also be recorded. All completed detainee requests must be filed in the detainees detention file, and remain in the detainees detention file for at least three years.

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ICE.11.5082.000432

ODO reviewed the Suicide Prevention and Intervention standard at HRRJ to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO reviewed policies; interviewed the Mental Health Social Worker, Director of Nursing, and staff; and reviewed medical and facility staff training records. There have been no suicides in the past year. ODO verified screening for suicide potential occurs as part of intake screening, and detainees at risk for suicide are referred to medical staff, housed, and monitored in accordance with the standard. The HRRJ Suicide Prevention Awareness training curriculum includes the required elements, including recognizing signs of suicidal thinking; facility referral procedures; suicide-prevention techniques; responding to an in-progress suicide attempt; identification of suicide risk factors; and the psychological profile of a suicidal detainee. The inspection of training records and an ODO interview of the HSA indicates four of sixty-eight medical staff members had not completed the training as required by the standard and HRRJ (Deficiency SP&I1). Whereas suicide is a leading cause of death in correctional institutions, and suicide prevention and intervention are life-safety issues, ODO recommends that the four untrained staff members complete training as soon as possible. ODO further recommends the facility improve its tracking of compliance with training requirements to ensure all personnel are able to recognize verbal and behavioral cues indicating potential for suicide and respond appropriately.

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(A), the FOD must ensure all staff are trained during orientation and periodically in the following: recognizing signs of suicide thinking, including suspect behavior; facility referral procedures; suicide-prevention techniques; and responding to an in-progress suicide attempt. All training must include the identification of suicide risk factors and the psychological profile of a suicidal detainee.

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ICE.11.5082.000433

ODO reviewed the Telephone Access standard at HRRJ to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the ICE NDS. ODO reviewed policies and the detainee handbook, interviewed staff and detainees, and tested a sampling of telephones. A review of the detainee handbook and interviews with staff revealed all detainee telephone calls are recorded regardless of whether or not the telephone call is in regard to legal matters (Deficiency TA-1). This issue is of serious concern to ODO and should cease immediately as it is clearly deficient according to the ICE NDS. This issue was addressed at the closeout briefing with HRRJ and ERO management staff.

DEFICIENCY TA-1 In accordance with the ICE NDS, Telephone Access, (III)(J) and (K), the FOD must ensure the facility has privacy for detainees telephone calls regarding legal matters. Facility staff must not electronically monitor detainee telephone calls on their legal matters, absent a court order. The facility must have a written policy on the monitoring of detainee telephone calls. If telephone calls are monitored, the facility must notify detainees in the detainee handbook or equivalent provided upon admission. It must also place a notice at each monitored telephone stating detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation. A detainees call to a court, a legal representative, or for the purposes of obtaining legal representation must not be aurally monitored absent a court order. The Officer in Charge retains the discretion to have other calls monitored for security purposes.

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ICE.11.5082.000434
TERMINAL ILLNESS, ADVANCE DIRECTIVES AND DEATH (TIADD)

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donation, at HRRJ to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO reviewed policies and interviewed the HSA, Director of Nursing, and custody staff. There have been no deaths in the past year. HRRJ has policies addressing advance directives, Do Not Resuscitate orders, and organ donation. Policy 1.1, amending Policy 17.1, Death and Serious Illness, requires notification of ICE in the event of a detainees death; however, it does not require ICE notification of terminal illness or fatal injury (Deficiency TIADD-1). ODO recommends inclusion of notification requirements for terminal illness and fatal injury so that ICE may take appropriate action. ODO also notes HRRJ policies do not include reference to ICE responsibilities for notification of next of kin in the event of a detainees serious illness or injury; disposition of property following a detainees death, case closure, and processing the death certificate; or reference to the authority of the Federal Bureau of Investigation, U.S. Public Health Service, or ICE Health Service to order an autopsy. Whereas these requirements are addressed in the standard, ODO recommends referencing them in facility policies.

DEFICIENCY TIADD -1 In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section(III)(A)(4), the FOD must ensure detention facilities immediately notify ICE when a detainee is seriously injured or ill. ICE, in turn, shall immediately contact (or make reasonable efforts to contact) the next of kin, who will be notified of the medical condition/medical status, the detainees location, and the visiting hours and rules at that location. ICE will provide family members a much opportunity for visitation as possible.

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ICE.11.5082.000435
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at HRRJ to determine if tools are properly classified, identified, inventoried, stored and issued, in accordance with the ICE NDS. ODO reviewed policy, interviewed staff, and inspected tools, inventories, and all areas where tools are stored and maintained.
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ICE.11.5082.000436
VISITATION (V)
ODO reviewed the Visitation standard at HRRJ to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO reviewed visitation logbooks, policies, and procedures; and observed the visitation area. The detainee handbook states detainees are normally allowed two visits per week, 20 minutes for each visit. This 20 minute time-frame allowed for visits was verified when ODO reviewed a sampling of visitation records for eight detainees, some of whom had multiple visits from individuals. A review of these visitation records showed a consistent pattern of visits being limited to 20 minutes (Deficiency V-1).

DEFICIENCY V-1 In accordance with the ICE NDS, Visitation, section (III)(H)(1), the FOD must ensure the facilitys written rules specify time limits for visits: 30 minutes minimum, under normal conditions. ICE encourages more generous limits when possible, especially for family members traveling significant distances to visit. In unforeseen circumstances, such as the number of visitors exceeding visiting room capacity, the Officer in Charge may modify visiting periods.

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ICE.11.5082.000437
APPENDIX A
Acronyms

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ICE.11.5082.000438
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(A), the FOD must ensure staff opens a 6 detainee detention file as part of the admissions process. This file must contain all paperwork generated by the detainees stay at the facility. In accordance with the ICE NDS, Admission and Release, section (III)(G), the FOD must ensure facility staff 6 provides and replenishes personal hygiene items as needed. In accordance with the ICE NDS, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admissions 7 process. If necessary, the detention file may include copies of material contained in the detainees A-file. The file must, at a minimum, contain the following: alien booking record (Form I385), personal property inventory sheet, and housing identification card.
AR-1
AR-2
DF-1
Detention Files

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ICE.11.5082.000439
DETENTION STANDARD
Detention Files
DF-2
Detention Files
DF-3
DGP-1
DGP-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (III)(C), the FOD must ensure, during the course of the detainees stay at the facility, staff add documents associated with normal operations to the detainees detention file without prior approval, e.g., special requests; any G-589s and/or I-77s 7 closed-out during the detainees stay; disciplinary forms; grievances, complaints, and the disposition(s) of the same; all forms associated with disciplinary and/or administrative segregation; strip search forms; and other approved documents, such as staff reports about the detainees behavior, attitude, etc. In accordance with the ICE NDS, Detention Files, section (III)(F)(2)(a-e), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date 7 and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(2), the FOD must ensure 8 the detainee is allowed to submit a formal, written grievance to the facilitys grievance committee. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a 8 copy of the grievance remains in the detainees detention file for at least three years.

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ICE.11.5082.000440
DETENTION STANDARD
Detainee Handbook
DH-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detainee Handbook, section (III)(B), the FOD must ensure the handbook briefly describes individual programs and services, and associated rules. Among others, these include recreation, visitation, education, voluntary work, 9 telephone use, correspondence, library use, and the canteen/commissary. The overview must also cover medical policy (sick-cell); facility-issued items, e.g., clothing, bedding, etc.; access to personal property; and meal service
Detainee Handbook
DH-2
EH&S-1
Environmental Health and Safety EH&S-2
EH&S-3
In accordance with the ICE NDS, Detainee Handbook, section (III)(C), the FOD must ensure the handbook specifies in detail the rules, regulations, policies, and procedures with which every detainee must comply, including, but not limited to: smoking policy, restricted areas, contraband, and so forth. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the master index of Material Safety Data Sheets includes a comprehensive, up-to-date list of emergency telephone numbers (fire department, poison control center, etc.). In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD must ensure existing exit diagrams provide instructions in Spanish, You are Here markers, and emergency equipment locations. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barber operation is located in a separate room not used for any other purpose.
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ICE.11.5082.000441
DETENTION STANDARD
Medical Care
MC -1
Medical Care
MC- 2
SDC-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure all detention staff are trained to respond to health-related emergencies within a 4-minute 12 response time. This training must be provided by a responsible medical authority in cooperation with the Officer in Charge, and will include the following: the administration of first aid and CPR. In accordance with the ICE NDS, Medical Care, section (III)(M), the FOD must ensure IGSA facilities notify ICE 12 each time a detainee medical record is released. accordance with the ICE NDS, StaffDetainee Communication, section (III)(A)(1), the FOD must ensure that a policy and procedure is in place to ensure and document that the ICE Officer in Charge, the Assistant Officer in Charge, and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and informally observe 13 living and working conditions. These unannounced visits must include, but not be limited to: housing units; food service, preferably during lunch meal; recreation areas; Special Management Units (administrative and disciplinary segregation), and infirmary rooms. While visiting the Special Management Unit, the detainees must be interviewed, living conditions must be observed, and detainee-housing records must be reviewed.

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ICE.11.5082.000442
DETENTION STANDARD
SDC-2
SP&I -1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure detainee record keeping requests are recorded in a logbook specifically designed for that purpose. The log, at a minimum, must contain: the date the detainee request was received, detainees name, A-number, nationality, officer logging the request, the date the 13 request (with staff response and action), the date the request is returned to the detainee, and any other site-specific pertinent information. In IGSAs, the date the request was forwarded to ICE and the date it was returned must also be recorded. All completed detainee requests must be filed in the detainees detention file, and remain in the detainees detention file for at least three years. In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(A), the FOD must ensure all staff are trained during orientation and periodically in the following: recognizing signs of suicide thinking, including 15 suspect behavior; facility referral procedures; suicide-prevention techniques; and responding to an inprogress suicide attempt. All training must include the identification of suicide risk factors and the psychological profile of a suicidal detainee.

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ICE.11.5082.000443
DETENTION STANDARD
TA-1
Telephone Access
TIADD -1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Telephone Access, (III)(J)(K), the FOD must ensure the facility has privacy for detainees telephone calls regarding legal matters. Facility staff must not electronically monitor detainee telephone calls on their legal matters, absent a court order. The facility must have a written policy on the monitoring of detainee telephone calls. If telephone calls are monitored, the facility must notify detainees in the detainee handbook or equivalent provided upon admission. It must also 16 place a notice at each monitored telephone stating detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation. A detainees call to a court, a legal representative, or for the purposes of obtaining legal representation must not be aurally monitored absent a court order. The Officer in Charge retains the discretion to have other calls monitored for security purposes. In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section(III)(A)(4), the FOD must ensure detention facilities immediately notify ICE when a detainee is seriously injured or ill. ICE, in turn, shall immediately contact (or make reasonable efforts to 17 contact) the next of kin, who will be notified of the medical condition/medical status, the detainees location, and the visiting hours and rules at that location. ICE will provide family members a much opportunity for visitation as possible.

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ICE.11.5082.000444
DETENTION STANDARD TC-1
Tool Control
18
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Tool Control
TC-2
18
Visitation
V-1
Visitation, section (III)(H)(1), the FOD must ensure the facilitys written rules specify time limits for visits: 30 minutes minimum, under normal conditions. ICE encourages more generous limits when possible, especially for family members traveling significant distances to visit. In unforeseen circumstances, such as the number of visitors exceeding visiting room capacity, the Officer in Charge may modify visiting periods.
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ICE.11.5082.000445


Enforcement and Removal Operations Houston Field Office Houston Contract Detention Facility Houston, Texas
August 30-September 2, 2010 ________________________________

ICE.11.5082.000446
ICE.11.5082.000447
QUALITY ASSURANCE REVIEW HOUSTON CONTRACT DETENTION FACILITY HOUSTON FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. Areas of Concern OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS Detention Standards Reviewed Admission and Release. Classification System. Detainee Handbook Detention Files Emergency Plans Facility Security and Control. Grievance System...... Hold Rooms in Detention Facilities.. Key and Lock Control. Legal Rights Group Presentations... Medical Care Population Counts .... Post Orders... Recreation.... Special Management Units... Staff-Detainee Communication..... Tool Control.. Transfer of Detainees. Transportation..... Use of Force and Restraints.. 1 1
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3 3
4 6 7 8 9 10 11 12 14 15 16 14 18 19 20 21 22 23 24 25 26
ICE.11.5082.000448
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE Performance Based National Detention Standards (PBNDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of the Houston Contract Detention Facility (HCDF) in Houston, TX, on August 30 - September 2, 2010. ODO reviewed the processes employed at HCDF to determine compliance with the PBNDS and current ICE policies. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies, and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Assistant Director, Office of Professional Responsibility.

Special Agent (Team Leader) Special Agent Special Agent Special Agent Special Agent Special Agent Special Agent Special Agent Special Agent Special Agent Contract Inspector Contract Inspector Contract Inspector 1 ODO, Houston ODO, Houston ODO, Houston ODO, Houston ODO, Houston ODO, Houston ODO, Houston ODO, Houston ODO, HQ ODO, HQ MGT of America MGT of America MGT of America
Houston Contract Detention Facility ERO Houston
(b)(6), (b)(7)(C)
Office of Detention Oversight September 2010

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ICE.11.5082.000449
BACKGROUND
HISTORY
HCDF opened in April 1984, and is owned and operated by Corrections Corporation of America (CCA). (b)(7)e
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. The correctional staff, warehouse, maintenance, and commissary are operated by CCA. CCA contract staff provides transportation of ICE detainees within a 50-mile radius; however, CCA subcontracts transportation of detainees beyond a 50-mile radius to a separate transportation company, TRANSCOR. Compass Group, LLC, provides food service for the facility. Medical services are provided by the ICE Health Services Corps (IHS).
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HCDF is accredited by the American Correctional Association (October 2007), the National Commission on Correctional Health Care (November 2007), and the Joint Commission on Accreditation of Healthcare Organizations (December 2009). ODO reviewed HCDF in May 2008 using the ICE National Detention Standards. During that review, ODO found 51 deficiencies in 21 of the 27 standards reviewed. In November 2009, ODO conducted a Follow-up Inspection, in which it assessed the corrective actions taken on the deficiencies identified in the Quality Assurance Review report. During the Follow-up Inspection, ODO found nine repeated deficiencies. These deficiencies were in the following standards: Disciplinary Policy, Environmental Health and Safety, Group Presentations on Legal Rights, Key and Lock Control, Staff-Detainee Communication, Telephone Access, and Visitation. Although this report is based on the PBNDS rather than the ICE National Detention Standards, none of the repeated deficiencies noted in the November 2009 Follow-up Inspection were found in PBNDSrelated areas during this review. In February 2008, an ERO Detention Standards Compliance Unit contractor, Creative Corrections, conducted an annual review of the ICE National Detention Standards at HCDF. The overall rating for the review was Acceptable.
AREAS OF CONCERN
This ICE PBNDS review found HCDF deficient in one mandatory standard, Emergency Plans, section (V)(C)(1)(a), regarding the facilitys emergency plans.

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ICE.11.5082.000450
INTERNAL RELATIONS
ODO interviewed supervisory and non-supervisory ICE and CCA staff. Most personnel reported morale is high. Some ICE employees stated the current budget does not allocate enough funds for space and facilities, management of the detained docket is not a priority, and additional personnel are required to properly staff HCDF. ICE staff expressed concern that additional bed space will be required in the near future. Several ICE employees stated tasking requests from ERO Headquarters often interfere with daily work assignments, and constantly changing priorities from ERO Headquarters make it difficult to know what is expected. Some staff expressed a need for new equipment and vehicles. During the past year, four CCA officers have been disciplined by the Warden. One employee was terminated for an inappropriate relationship with a detainee, one employee resigned in lieu of termination due to a violation of the use of force policy, and two employees received suspensions for abusive treatments toward detainees. No substantial physical contact was involved in any of these incidents. ODO verified that CCA officers have been counseled for yelling and cursing at detainees.
DETAINEE RELATIONS
ODO interviewed 41 detainees. These detainees were from various housing areas (male and female), including the Special Management Units. Most detainees were aware of the availability of deportation officers to assist in obtaining information about the status of their immigration cases, but found it difficult to establish contact with them. Many detainees complained that meal portions at HCDF are too small and are of very poor quality. A majority of the detainees interviewed stated HCDF lacks fruit and vegetable options. Detainees stated the only available beverages were milk in the morning and tap water throughout the day. ODO verified daily calorie counts for meals are adequate, and meals include beverages other than milk and water. Thirteen Spanish-speaking detainees expressed concerns about receiving disparate treatment from English-speaking detainees. The Spanish-speaking detainees stated, in general, that English-speaking detainees were treated better. ODO informed ERO and HCDF staff about the detainees concerns. A detainee complained about not receiving effective medication for an ailment; ODO reviewed the detainees medical file and determined that the detainee had been provided proper medication for the condition.

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ICE.11.5082.000451

The following 41 standards from the 2008 PBNDS were reviewed: Admission and Release Classification System Contraband Correspondence and Other Mail Detainee Handbook Detention Files Disciplinary System Emergency Plans Environmental Health and Safety Escorted Trips for Non-Medical Emergencies Facility Security and Control Food Service Funds and Personal Property Grievance System Hold Rooms in Detention Facilities Hunger Strikes Key and Lock Control Law Libraries and Legal Material Legal Rights Group Presentations Marriage Requests Medical Care News Media Interviews and Tours Personal Hygiene Population Counts Post Orders Recreation Religious Practices Searches of Detainees Sexual Abuse and Assault Prevention and Intervention Special Management Units Staff-Detainee Communication Staff Training Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Transfer of Detainees Transportation Use of Force and Restraints Visitation Voluntary Work Program

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ICE.11.5082.000452
No deficiencies were noted in the following 21 standards: Contraband Correspondence and Other Mail Disciplinary System Environmental Health and Safety Escorted Trips for Non-Medical Emergencies Food Service Funds and Personal Property Hunger Strikes Law Libraries and Legal Material Marriage Requests News Media Interviews and Tours Personal Hygiene Religious Practices Searches of Detainees Sexual Abuse and Assault Prevention and Intervention Staff Training Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Visitation Voluntary Work Program As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ICE.11.5082.000453

ODO reviewed the Admission and Release standard at HCDF to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE PBNDS. ODO reviewed detention files, forms, policies, and procedures, and interviewed staff and detainees. ODO reviewed 30 detention files, 9 of which did not contain an Alien Booking Record (Form I-385) or its equivalent (Deficiency AR-1).

DEFICIENCY AR-1 In accordance with the ICE PBNDS, Admission and Release, section (V)(E), the FOD must ensure staff prepare specific documents in conjunction with each new arrival to facilitate timely processing, classification, medical screening, accounting of personal effects, and reporting of statistical data. Forms requiring completion include, but are not limited to, an Alien Booking Record (Form I-385 or equivalent), the medical questionnaire, the housing assignment card, and all other forms prescribed by the booking facility.

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ICE.11.5082.000454
CLASSIFICATION SYSTEM (CS)

ODO reviewed the Classification System standard at HCDF to determine if there is a formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE PBNDS. ODO reviewed policies and documents, and interviewed staff.
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ICE.11.5082.000455

ODO reviewed the Detainee Handbook standard at HCDF to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE PBNDS. ODO interviewed HCDF staff and detainees, and reviewed the national detainee handbook, HCDF detainee handbook, and detainee handbook policies. ODO reviewed 20 detention files, and found 10 of the files did not contain an acknowledgement form signed by the detainee verifying receipt of a detainee handbook (Deficiency DH-1).

DEFICIENCY DH-1 In accordance with the ICE PBNDS, Detainee Handbook, section (V)(5), the FOD must ensure staff require each detainee to verify, by signature, receipt of the handbook and maintain that acknowledgment in the detainees detention file.

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ICE.11.5082.000456

ODO reviewed the Detention Files standard at HCDF to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE PBNDS. ODO interviewed HCDF officers and reviewed 20 detention files. The review of detention files revealed four files were missing Form I-385, eight files were missing classification worksheets, and ten files were missing signed acknowledgement forms verifying receipt of a detainee handbook (Deficiency DF-1).

DEFICIENCY DF-1 In accordance with the ICE PBNDS, Detention Files, section (V)(B)(1), the FOD must ensure every detainees detention file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-File. The file must, at a minimum, contain Form I-385, with one or more original photographs attached, and a classification worksheet. The file must also contain the following original documents, if used by the facility: acknowledgement forms, documenting receipt of a handbook, orientation, locker key, etc.

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ICE.11.5082.000457

ODO reviewed the Emergency Plans standard at HCDF to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with the ICE PBNDS. ODO conducted staff interviews, reviewed emergency plans, and inspected command post equipment. The HCDF emergency plans do not include procedures for rendering emergency assistance to another ICE facility, such as transportation, supplies, and temporary housing for detainees (Deficiency EP-1). The command center does not have building-specific assault/breaching plans, or video recordings of building interiors within the secure perimeter showing doors, windows, closets, ceilings and floors (Deficiency EP-2). The control center does not maintain a current roster of field office or ERO Headquarters Detention Management and Response Coordination Division telephone numbers for emergency response purposes (Deficiency EP-3). HCDF has not formulated Work/Food Strike, Civil Disturbance, or Detainee Transportation System Emergency contingency plans (Mandatory - Deficiency EP-4).

DEFICIENCY EP-1 In accordance with the ICE PBNDS, Emergency Plans, section (V)(C)(1)(a), the FOD must ensure each plan includes procedures for rendering emergency assistance to another ICE/ERO facility, for example, supplies, transportation, and temporary housing for detainees, personnel, and/or TDY staff. DEFICIENCY EP-2 In accordance with the ICE PBNDS, Emergency Plans, section (V)(D)(2)(a), the FOD must ensure the facility sets up a primary command post outside the secure perimeter that, at a minimum, is equipped with: video recordings of building interiors within the secure perimeter (showing doors, windows, closets, ceilings, floors, etc.); escape-post kits, including maps, directions, etc. (as detailed under the contingency-specific plan for escape); one or more copies of contingency plans; assault/breaching plans (buildingspecific, as appropriate for the facility); and a supply kit containing general supplies that may be needed (at a minimum, logbooks, blank rosters, purchase orders, and writing utensils). DEFICIENCY EP-3 In accordance with the ICE PBNDS, Emergency Plans, section (V)(D)(3), the FOD must ensure, for emergency response purposes, the control center must maintain a current roster of all field office and ERO Headquarters Detention Management and Response Coordination Division telephone numbers.
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ICE.11.5082.000458
DEFICIENCY EP-4 (MANDATORY) In accordance with the ICE PBNDS, Emergency Plans, section (V)(E), the FOD must ensure the facility compiles individual, contingency-specific plans, as needed, in the following order: Fire, Work/Food Strike, Disturbance, Escape, Hostages (Internal), Search (Internal), Bomb Threat, Adverse Weather, Civil Disturbance, Environmental Hazard, Detainee Transportation System Emergency, Evacuation, ICE-wide Lockdown, Staff Work Stoppage, and, if needed, other site-specific plans.

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ICE.11.5082.000459
FACILITY SECURITY AND CONTROL (FS&C)

ODO reviewed the Facility Security and Control standard at HCDF to determine if the facility security is maintained, and events posing a risk of harm are prevented, in accordance with the ICE PBNDS. ODO toured the facility, reviewed policies and documentation, interviewed staff, and observed staff and visitors enter the facility. ICE employees and official visitors were not properly identified, searched, and logged when entering the secure facility by way of the C-building and rear vehicle sally-port entrances. ODO was informed the facility does not have sufficient staff to man the entry post from C-building (Deficiency FS&C-1).

DEFICIENCY FS&C-1 In accordance with the ICE PBNDS, Facility Security and Control, section (V)(C)(1)(a)(b)(1-2), the FOD must ensure officers assigned to entry posts check the identification documents of every visitor, employee, and other person entering or leaving the facility. The post officer must also maintain the visitor logbook, the bound ledger in which all non-staff visits are recorded. Every entry in the logbook must identify the person or department visited, date and time of visitor's arrival, purpose of visit, unusual requests, and time of departure.

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ICE.11.5082.000460

ODO reviewed the Grievance System standard at HCDF to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE PBNDS. ODO reviewed grievance procedures, logbooks, detention files, and appeal policies. ODO also interviewed facility staff and detainees. A procedure to ensure all medical grievances are received by the Administrative Health Authority within 24 hours or the next business day is not included in HCDF policy 14-5, Inmate/Resident Grievance Procedures (Deficiency GS-1). HCDF assigns log numbers to formal grievances; however, grievances other than formal grievances are not assigned log numbers (Deficiency GS-2).

DEFICIENCY GS-1 In accordance with the ICE PBNDS, Grievance System, section (V)(A), the FOD must ensure the facility has written policies and procedures for a detainee grievance system that ensures a procedure in which all medical grievances are received by the Administrative Health Authority within 24 hours, or the next business day. DEFICIENCY GS-2 In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure facility staff assigns each grievance a log number, enters it in the space provided on the Detainee Grievance Form, and records it in the Detainee Grievance Log in chronological order.

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ICE.11.5082.000461

ODO reviewed the Hold Rooms in Detention Facilities standard at HCDF to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure and comfortable environment, and not held confined in hold rooms for over 12 hours, in accordance with the ICE PBNDS. ODO interviewed staff, inspected the hold rooms, reviewed logbooks, and observed detainee processing. ODO found the female hold room contained a metal wheeled TV cart, with an unsecured TV, VCR, and audio/video cables (Deficiency HR-1).

DEFICIENCY HR-1 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(4), the FOD must ensure each hold rooms are designed and constructed to comply with the following criteria: each hold room must contain sufficient seating for the maximum room-capacity, but must not contain moveable furniture.

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ICE.11.5082.000462

ODO reviewed the Key and Lock Control standard at HCDF to determine if facility safety and security is maintained by requiring keys and locks to be controlled and maintained, in accordance with the ICE PBNDS. ODO reviewed policies, toured the facility, interviewed staff, and inspected lock shop and key inventories.
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ICE.11.5082.000463

ODO reviewed the Legal Rights Group Presentations standard at HCDF to determine if authorized persons and organizations are permitted to make presentations to groups of detainees for the purpose of providing information on immigration law and procedures, in accordance with the ICE PBNDS. ODO interviewed facility and ERO staff, and reviewed the legal rights group presentations policies and procedures at HCDF. HCDF and the Houston Field Office did not provide ODO with any presentation requests or requests for continuing presentations; however, ODO was informed the Vera Institute of Justice, through the YMCA, provides a continuing Know Your Rights presentation several times per week to HCDF detainees (Deficiency LRGP-1). HCDF does not require attorneys to present state-issued bar cards when entering the facility for presentations (Deficiency LRGP-2).

DEFICIENCY LRGP-1 In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(A)and(C), the FOD must ensure attorneys or legal representatives interested in making a group presentation on legal rights submit a written request, to include, but not limited to: a syllabus or outline of the presentation, a list of any published or unpublished materials proposed for distribution, a statement of the languages in which the presentation will be conducted, biographical and professional information of the presenters, and intended presentation dates. The FOD must ensure requests for additional or continuing presentations are submitted in writing and refer to any previously-approved materials used by the requestor, notes any proposed changes in the content or personnel, and identifies the proposed dates or continuing period. DEFICIENCY LRGP-2 In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(H), the FOD must ensure attorneys present state-issued bar cards or, in states where these are not available, other proof of bar membership. If such documentation is not readily available to attorneys licensed in a particular state, they must indicate where they are licensed as attorneys and how those credentials can be verified prior to being approved for entry to the facility.

(b)(7)e
16
ICE.11.5082.000464
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at HCDF to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE PBNDS. ODO toured the medical clinic, reviewed policies and procedures, examined 31 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by IHS and holds certifications by the American Correctional Association, National Commission on Correctional Health Care, and Joint Commission on Accreditation of Healthcare Organizations. A review of medical records revealed a physical examination conducted by a registered nurse had not been reviewed by a physician. This deficiency was corrected prior to completion of the review (Deficiency MC-1).

DEFICIENCY MC-1 In accordance with the ICE PBNDS, Medical Care, section (V)(J), the FOD must ensure the clinical medical authority reviews all health appraisals to assess the priority for treatment.

(b)(7)e
17
ICE.11.5082.000465

ODO reviewed the Population Counts standard at HCDF to determine if the facility has an effective system of conducting population counts, which ensures detainee accountability, in accordance with the ICE PBNDS. ODO reviewed policies, toured the facility, observed a formal count, and interviewed staff and detainees. ODO observed an officer conducting a population count in a housing unit without the assistance of a second officer (Deficiency PC-1). ODO observed the facility does not report the count prior to delivering the count slips. ODO also observed count slips were not signed as required, thus the control center accepted improperly prepared count slips (Deficiency PC-2).

DEFICIENCY PC-1 In accordance with the ICE PBNDS, Population Counts, section (V)(A)(1), the FOD must ensure an unaccompanied officer never performs a count in an open area (housing units, food service area, etc.). One officer must count while a second officer observes all detainee movements, to ensure that no detainee shifts from one location to another, to be counted twice. Upon completing the first count, the officers must change positions and count again. DEFICIENCY PC-2 In accordance with the ICE PBNDS, Population Counts, section (V)(A)(5), the FOD must ensure the counting officer from each location reports his or her count to the facility Control Officer, who is responsible for collecting and maintaining the count. After the count is reported in, a signed paper count slip must be delivered to the control center. This count slip must be used to verify the area count. Therefore, count slips must be prepared and signed in indelible ink. Both officers conducting the count must sign the count slip. The control center must not accept an improperly prepared count slip or one that contains erasures or alterations of any kind.

(b)(7)e
18
ICE.11.5082.000466
POST ORDERS (PO)

ODO reviewed the Post Orders standard at HCDF to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE PBNDS. ODO reviewed policies, procedures, and schedules for recreation programs. Post orders exist for every post and are signed by the Facility Administrator; however, the Facility Administrator failed to initial and date all other pages on the Shift Supervisor and Assistant Shift Supervisor post orders (Deficiency PO-1). The six-part classification folder for post orders is not organized in the required format; the chronological listing of activities is maintained in Section 2, and not Section 1 (Deficiency PO-2).

DEFICIENCY PO-1 In accordance with the ICE PBNDS, Post Orders, section (V)(C), the FOD must ensure the Facility Administrator (or designee) approves, signs, and dates each post order on the last page of each section, and initial and date all other pages. DEFICIENCY PO-2 In accordance with the ICE PBNDS, Post Orders, section (V)(D), the FOD must ensure post orders for each post are issued in a six-part classification folder and are organized as follows: Section 1: Specific Post Orders, listing activities chronologically, with responsibilities clearly defined; Section 2: Special instructions, if any, relating to the specific post.

(b)(7)e
19
ICE.11.5082.000467
RECREATION (R)
ODO reviewed the Recreation standard at HCDF to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE PBNDS. ODO reviewed policies, procedures, and schedules, and inspected the indoor and outdoor recreation areas and equipment. ODO found the exercise equipment in the indoor male recreation area was not maintained for cleanliness or functionality. Of the eleven pieces of equipment tested, six were in need of repair (Deficiency R-1).

DEFICIENCY R-1 In accordance with the ICE PBNDS, Recreation, section (V)(D)(6), the FOD must ensure detention or recreation staff search recreation areas before and after their use to detect altered or damaged equipment, hidden contraband, and security breaches. They must also issue all portable items, and check each item for damage and general condition upon its return.

(b)(7)e
20
ICE.11.5082.000468
SPECIAL MANAGEMENT UNITS (SMU)

ODO reviewed the Special Management Units standard at HCDF to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE PBNDS. ODO reviewed policies, procedures, the detainee handbook, and detention files, and interviewed staff. ODO found HCDF does not require a signature on the Disciplinary Segregation Order (Form I-883 or equivalent), before placing a detainee in disciplinary segregation (Deficiency SMU-1).

DEFICIENCY SMU-1 In accordance with the ICE PBNDS, Special Management Units, section (V)(D)(2), the FOD must ensure a written order is completed and signed by a chair of the Institutional Disciplinary Panel or (disciplinary hearing officer) before a detainee is placed into disciplinary segregation. A copy of the order must be given to the detainee within 24 hours, unless delivery would jeopardize the safety, security, or the orderly operation of the facility or the safety of another detainee. The Institutional Disciplinary Panel chairman must prepare the Disciplinary Segregation Order (Form I-883 or equivalent), detailing the reasons for placing a detainee in disciplinary segregation, before his or her actual placement. All relevant documentation must be attached to the order.

(b)(7)e
21
ICE.11.5082.000469

ODO reviewed the Staff-Detainee Communication standard at HCDF to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE PBNDS. ODO interviewed staff and detainees, and reviewed policies, procedures, and logbooks. ERO supervisors are not conducting weekly unannounced visits (Deficiency SDC-1). ERO is not completing the weekly facility liaison visit checksheet (Deficiency SDC-2).

DEFICIENCY SDC-1 In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(A)(1), the FOD must ensure each field office has policies and procedures to ensure and document that the ICE/ERO-assigned supervisory staff conduct frequent, unannounced, unscheduled visits to the facilitys living and activity areas to informally observe living and working conditions, and encourage informal communication among staff and detainees. DEFICIENCY SDC-2 In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(E), the FOD must ensure Model Protocol forms are completed weekly for contract detention facilities, and submitted annually with the required Annual Detention Reviews.

(b)(7)e
22
ICE.11.5082.000470
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at HCDF to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE PBNDS. ODO toured tool storage areas, reviewed policies, inspected tool inventories, and interviewed staff.
(b)(7)e
(b)(7)e

(b)(7)e
23
ICE.11.5082.000471
TRANSFER OF DETAINEES (TD)

ODO reviewed the Transfer of Detainees standard at HCDF to determine if transfers of detainees from one facility to another are responsibly managed in regard to notification, detention records, safety and security, and protection of detainee funds and property, in accordance with the ICE PBNDS. ODO toured the facility, reviewed records, observed procedures for the transfer of detainees, and interviewed staff. ODO found the Detainee Transfer Checklist was not completed and attached to detainees A-files or work folders (Deficiency TD-1).

DEFICIENCY TD-1 In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(D)(1), the FOD must ensure sending facility staff complete the Detainee Transfer Checklist to ensure all procedures are completed. The A-file or proper work folder must include copies of the following executed documents, fastened to the top right side of the file: Detainee Transfer Checklist.

(b)(7)e
24
ICE.11.5082.000472
TRANSPORTATION (T)
ODO reviewed the Transportation standard at HCDF to determine if vehicles are properly equipped, maintained and operated, and if detainees are transported in a safe, secure, and humane manner under supervision of trained and experienced staff, in accordance with the ICE PBNDS. ODO reviewed policies and procedures, and interviewed staff.
(b)(7)e
(b)(7)e

(b)(7)e
25
ICE.11.5082.000473

ODO reviewed the Use of Force and Restraints standard at HCDF to determine if necessary use of force and the use of restraints is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE PBNDS. ODO toured the facility, viewed use of force videos, and inspected equipment. ODO also reviewed policies, training records, and other pertinent documentation.
(b)(7)e
(b)(7)e

(b)(7)e
26
ICE.11.5082.000474
(b)(7)e

(b)(7)e
27
ICE.11.5082.000475
APPENDIX A
Acronyms
ACA COTR CXR DOS ERO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA IHS JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PBNDS PE PHS POA PPD RN RS SIR SMU TAR TB UDC American Corrections Association Contracting Officer Technical Representative Chest X-ray Detention Operations Supervisor Enforcement and Removal Operations Detention Standards Compliance Unit ENFORCE Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent ICE Health Service Corps Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Performance Based National Detention Standards Physical Examination Public Health Service Plan of Action Purified Protein Derivative Registered Nurse Residential Standards Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee

(b)(7)e
28
ICE.11.5082.000476
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Admission and Release, section (V)(E), the FOD must ensure staff prepare specific documents in conjunction with each new arrival to facilitate timely processing, classification, medical screening, accounting of personal 6 effects, and reporting of statistical data. Forms requiring completion include, but are not limited to, an Alien Booking Record (Form I-385 or equivalent), the medical questionnaire, the housing assignment card, and all other forms prescribed by the booking facility. In accordance with the ICE PBNDS, Classification System, section (V)(F), the FOD must ensure Level 3 detainees 7 are not comingled with Level 1 detainees. In accordance with the ICE PBNDS, Detainee Handbook, section (V)(5), the FOD must ensure staff require each detainee to verify, by signature, receipt 8 of the handbook and maintain that acknowledgment in the detainees detention file.
AR-1
CS-1 Classification System
Detainee Handbook
DH-1

(b)(7)e
29
ICE.11.5082.000477
DETENTION STANDARD
Detention Files
DF-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Detention Files, section (V)(B)(1), the FOD must ensure every detainees detention file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-File. The 9 file must, at a minimum, contain Form I385, with one or more original photographs attached, and a classification worksheet. The file must also contain the following original documents, if used by the facility: acknowledgement forms, documenting receipt of a handbook, orientation, locker key, etc. In accordance with the ICE PBNDS, Emergency Plans, section (V)(C)(1)(a), the FOD must ensure each plan includes procedures for rendering emergency assistance to another ICE/ERO facility, for example, supplies, transportation, and temporary housing for detainees, personnel, and/or TDY staff.
EP-1 Emergency Plans
10

(b)(7)e
30
ICE.11.5082.000478
DETENTION STANDARD
Emergency Plans
EP-2
EP-3 Emergency Plans
Emergency Plans
EP-4 (Mandatory)
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Emergency Plans, section (V)(D)(2)(a), the FOD must ensure the facility sets up a primary command post outside the secure perimeter that, at a minimum, is equipped with: video recordings of building interiors within the secure perimeter (showing doors, windows, closets, ceilings, floors, etc.); escapepost kits, including maps, directions, 10 etc. (as detailed under the contingencyspecific plan for escape); one or more copies of contingency plans; assault/breaching plans (buildingspecific, as appropriate for the facility); and a supply kit containing general supplies that may be needed (at a minimum, logbooks, blank rosters, purchase orders, and writing utensils). In accordance with the ICE PBNDS, Emergency Plans, section (V)(D)(3), the FOD must ensure, for emergency response purposes, the control center must maintain a current roster of all field 10 office and ERO Headquarters Detention Management and Response Coordination Division telephone numbers. In accordance with the ICE PBNDS, Emergency Plans, section (V)(E), the FOD must ensure the facility compiles individual, contingency-specific plans, as needed, in the following order: Fire, Work/Food Strike, Disturbance, Escape, Hostages (Internal), Search (Internal), 11 Bomb Threat, Adverse Weather, Civil Disturbance, Environmental Hazard, Detainee Transportation System Emergency, Evacuation, ICE-wide Lockdown, Staff Work Stoppage, and, if needed, other site-specific plans.

(b)(7)e
31
ICE.11.5082.000479
DETENTION STANDARD
Facility Security and Control
FS&C-1
GS-1 Grievance System
Grievance System
GS-2
HR-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Facility Security and Control, section (V)(C)(1)(a)(b)(1-2), the FOD must ensure officers assigned to entry posts check the identification documents of every visitor, employee, and other person entering or leaving the facility. 12 The post officer must also maintain the visitor logbook, the bound ledger in which all non-staff visits are recorded. Every entry in the logbook must identify the person or department visited, date and time of visitor's arrival, purpose of visit, unusual requests, and time of departure. In accordance with the ICE PBNDS, Grievance System, section (V)(A), the FOD must ensure the facility has written policies and procedures for a detainee 13 grievance system that ensures a procedure in which all medical grievances are received by the Administrative Health Authority within 24 hours, or the next business day. In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure facility staff assigns each grievance a log number, enters it 13 in the space provided on the Detainee Grievance Form, and records it in the Detainee Grievance Log in chronological order. In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(4), the FOD must ensure each hold rooms are designed and constructed to comply with the following 14 criteria: each hold room must contain sufficient seating for the maximum room-capacity, but must not contain moveable furniture.

(b)(7)e
32
ICE.11.5082.000480
DETENTION STANDARD
PAGE
K&LC-1
15
(b)(7)e
K&LC-2
15
LRGP-1
Legal Rights Group Presentations, section (V)(A)and(C), the FOD must ensure attorneys or legal representatives interested in making a group presentation on legal rights submit a written request, to include, but not limited to: a syllabus or outline of the presentation, a list of any published or unpublished materials proposed for distribution, a statement of the languages in which the presentation will be conducted, biographical and professional information of the presenters, and intended presentation dates. The FOD must ensure requests for additional or continuing presentations are submitted in writing and refer to any previously-approved materials used by the requestor, notes any proposed changes in the content or personnel, and identifies the proposed dates or continuing period.
16

(b)(7)e
33
ICE.11.5082.000481
DETENTION STANDARD
LRGP-2
Medical Care
MC-1
Population Counts
PC-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(H), the FOD must ensure attorneys present state-issued bar cards or, in states where these are not available, other proof of bar 16 membership. If such documentation is not readily available to attorneys licensed in a particular state, they must indicate where they are licensed as attorneys and how those credentials can be verified prior to being approved for entry to the facility. In accordance with the ICE PBNDS, Medical Care, section (V)(J), the FOD must ensure the clinical medical 17 authority reviews all health appraisals to assess the priority for treatment. In accordance with the ICE PBNDS, Population Counts, section (V)(A)(1), the FOD must ensure an unaccompanied officer never performs a count in an open area (housing units, food service area, etc.). One officer must count while a second officer 18 observes all detainee movements, to ensure that no detainee shifts from one location to another, to be counted twice. Upon completing the first count, the officers must change positions and count again.

(b)(7)e
34
ICE.11.5082.000482
DETENTION STANDARD
Population Counts
PC-2
Post Orders
PO-1
Post Orders
PO-2
Recreation
R-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Population Counts, section (V)(A)(5), the FOD must ensure the counting officer from each location reports his or her count to the facility Control Officer, who is responsible for collecting and maintaining the count. After the count is reported in, a signed paper count slip must be delivered to the control center. 18 This count slip must be used to verify the area count. Therefore, count slips must be prepared and signed in indelible ink. Both officers conducting the count must sign the count slip. The control center must not accept an improperly prepared count slip or one that contains erasures or alterations of any kind. In accordance with the ICE PBNDS, Post Orders, section (V)(C), the FOD must ensure the Facility Administrator (or designee) approves, signs, and 19 dates each post order on the last page of each section, and initial and date all other pages. In accordance with the ICE PBNDS, Post Orders, section (V)(D), the FOD must ensure post orders for each post are issued in a six-part classification folder and are organized as follows: 19 Section 1: Specific Post Orders, listing activities chronologically, with responsibilities clearly defined; Section 2: Special instructions, if any, relating to the specific post. In accordance with the ICE PBNDS, Recreation, section (V)(D)(6), the FOD must ensure detention or recreation staff search recreation areas before and after their use to detect altered or 20 damaged equipment, hidden contraband, and security breaches. They must also issue all portable items, and check each item for damage and general condition upon its return.

(b)(7)e
35
ICE.11.5082.000483
DETENTION STANDARD
Special Management Units
SMU-1
SDC-1
SDC-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Special Management Units, section (V)(D)(2), the FOD must ensure a written order is completed and signed by a chair of the Institutional Disciplinary Panel or (disciplinary hearing officer) before a detainee is placed into disciplinary segregation. A copy of the order must be given to the detainee within 24 hours, unless 21 delivery would jeopardize the safety, security, or the orderly operation of the facility or the safety of another detainee. The Institutional Disciplinary Panel chairman must prepare the Disciplinary Segregation Order (Form I-883 or equivalent), detailing the reasons for placing a detainee in disciplinary segregation, before his or her actual placement. All relevant documentation must be attached to the order. In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(A)(1), the FOD must ensure each field office has policies and procedures to ensure and document that the ICE/ERO-assigned supervisory staff 22 conduct frequent, unannounced, unscheduled visits to the facilitys living and activity areas to informally observe living and working conditions, and encourage informal communication among staff and detainees. In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(E), the FOD must ensure Model Protocol forms are completed weekly 22 for contract detention facilities, and submitted annually with the required Annual Detention Reviews.

(b)(7)e
36
ICE.11.5082.000484
DETENTION STANDARD
PAGE
Tool Control
TC-1
(b)(7)e
23
TD-1
Transportation
T-1
Transfer of Detainees, section (V)(D)(1), the FOD must ensure sending facility staff complete the Detainee Transfer Checklist to ensure all procedures are completed. The Afile or proper work folder must include copies of the following executed documents, fastened to the top right side of the file: Detainee Transfer Checklist. In accordance with the ICE PBNDS, Transportation, section (V)(J)(3), the FOD must ensure, to confirm the identities of the detainees they are transporting, the vehicle crew asks the detainee to state his or her complete
24
25
UOF&R-1
(b)(7)e
26

(b)(7)e
37
ICE.11.5082.000485
DETENTION STANDARD
PAGE
UOF&R-2
26
UOF&R-3
(b)(7)e
26
UOF&R-4
27

(b)(7)e
38
ICE.11.5082.000486


Follow-Up Inspection
Enforcement and Removal Operations Houston Field Office Joe Corley Detention Facility Conroe, Texas
ICE.11.5082.000487
ICE.11.5082.000488
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW.. 1 1 2
ICE.11.5082.000489
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. In November 2009, ODO conducted a Focus Review of the Joe Corley Detention Facility in Conroe, TX. A Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Focus Review.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Focus Review report submitted to ERO. A summary of findings is provided in the Overview. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Assistant Director, Office of Professional Responsibility.

(b)(6), (b)(7)(C)
Detention and Deportation Officer (Team Lead) ODO, OPR HQ Management and Program Analyst ODO, OPR HQ
_____________________________________________________________________________________________

(b)(7)e
Joe Corley Detention Facility ERO Houston
ICE.11.5082.000490
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material Detainee Grievance Procedures Detainee Handbook Detention Files Food Service Hold Rooms in Detention Facilities Key and Lock Control Medical Care Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Visitation ODO staff identified 27 deficiencies during the Focus Review conducted in November 2009. During this Follow-up Inspection, ODO staff found no (0%) repeated deficiencies.
_____________________________________________________________________________________________

(b)(7)e
Joe Corley Detention Facility ERO Houston
ICE.11.5082.000491


Enforcement and Removal Operations Dallas Field Office Johnson County Detention Center Cleburne, TX
FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law enforcement, management and employee information. It has been written for the express use of the Department of Homeland Security to identify and correct management and operational deficiencies. In reference to OPR Directive 17006.1, issued 09/22/05, any disclosure, dissemination, or reproduction of this document, or any segments thereof, is prohibited without the approval of the Assistant Director, Office of Professional Responsibility.
ICE.11.5082.000492
ICE.11.5082.000493
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization. Inspection Team Members. OVERVIEW .. ICE NATIONAL DETENTION STANDARDS Detainee Grievance Procedures Detainee Handbook Staff-Detainee Communication . 1 1 2
4 4 5
ICE.11.5082.000494
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. In November 2009, ODO conducted a Focus Review of the Johnson County Detention Center (JCDC), located in Cleburne, Texas. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Focus Review.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Focus Review report submitted to ERO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Deputy Division Director, Office of Professional Responsibility.

Management & Program Analyst (Team Lead) ODO, Headquarters
(b)(6), (b)(7)(C)
Detention and Deportation Officer
ODO, Headquarters
_____________________________________________________________________________________________

(b)(7)e
Johnson County Detention Center ERO Dallas
ICE.11.5082.000495
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material Admission and Release Detainee Classification System Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Emergency Plans Food Service Funds and Personal Property Issuance and Exchange of Clothing, Bedding and Towels Medical Care Recreation Staff-Detainee Communication Telephone Access Terminal Illness, Advance Directives, and Death Use of Force ODO staff identified 39 deficiencies during the Focus Review conducted in November 2009. During this Follow-up Inspection, ODO staff found three (7%) repeated deficiencies. ODO, along with ERO management at JCDC, found corrective actions were taken on all deficiencies revisited in the following standards: Access to Legal Material Admission and Release Detainee Classification System Detention Files Disciplinary Policy Emergency Plans Food Service Funds and Personal Property Issuance and Exchange of Clothing, Bedding and Towels Medical Care Recreation Telephone Access Terminal Illness, Advanced Directives and Death Use of Force Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at JCDC, to be noncompliant with the ICE NDS: Detainee Grievance Procedures
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000496
Detainee Handbook Staff-Detainee Communication It should be noted that the deficiencies found not corrected during ODOs Follow-up Inspection were corrected on-site prior to the end of the inspection.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000497

During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up inspection, the deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(2-4), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The grievance section in the detainee handbook must provide notices of: the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance; the procedures for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved; the procedures for contacting ICE to appeal the decisions; and the policy prohibiting staff from harassing, disciplining, punishing, or otherwise retaliating against any detainee for filing a grievance. It should also provide notice of the opportunity to file a complaint about officer misconduct directly with the DHS Office of Inspector General (OIG) by calling 1-800-323-8603, or by writing to DHS OIG, 245 Murray Drive, Washington, DC 20538. ODO Follow-up Finding: ODOs review of the handbook found the process for filing an appeal or having a grievance referred to a higher authority was not included in the detainee handbook. Although this deficiency was not corrected when the follow-up inspection team commenced its review, the deficiency was corrected while the team was on-site.
DETAINEE HANDBOOK
During the initial ODO inspection, six deficiencies were identified in this area. During this Follow-up inspection, one deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2)(5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: that upon request, detainees will be provided an ICE-certified copy of any identity document, such as a passport or birth certificate, placed in their A-files; and the procedures for claiming property upon release, transfer, or removal. ODO Follow-up Finding: The procedures for claiming lost or damaged property were posted in the housing area, but were not included in the detainee handbook. Although this deficiency was not corrected when the follow-up inspection team commenced its review, the deficiency was corrected while the team was on-site.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000498
During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up inspection, one deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2)(b), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. The log, at a minimum, must contain: a) the date the detainee request was received; b) detainees name; c) A-number; d) nationality; e) officer logging the request; f) the date that the request, with staff response and action, is returned to the detainee; and g) any other site-specific pertinent information. In Intergovernmental Service Agreement facilities, the date the request was forwarded to ICE, and the date it was returned, must also be recorded. ODO Follow-up Finding: ICE field office staff maintains a log for detainees requests; however, the log did not include detainees nationalities. Although this deficiency was not corrected when the follow-up inspection team commenced its review, the deficiency was corrected while the team was on-site.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000499
ICE.11.5082.000500
ICE.11.5082.000501
ICE.11.5082.000502
(b)(6), (b)(7)(C)
(b)(7)e
ICE.11.5082.000503
(b)(7)e
ICE.11.5082.000504
(b)(7)e
ICE.11.5082.000505
(b)(7)e
(b)(7)e
ICE.11.5082.000506


Enforcement and Removal Operations Chicago Field Office

McHenry County Adult Detention Center
Woodstock, Illinois October 27-28, 2010
ICE.11.5082.000507
ICE.11.5082.000508
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW. ICE NATIONAL DETENTIONSTANDARDS Medical Care.. 1 1 2
ICE.11.5082.000509
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. In October 2009, ODO conducted a Quality Assurance Review of the McHenry County Adult Detention Center (MCADC) in Woodstock, Illinois. A Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION

Detention & Deportation Officer (Team Leader) ODO, OPR San Diego Contract Inspector MGT of America Inc. Contract Inspector MGT of America Inc.
(b)(6), (b)(7)(C)
_____________________________________________________________________________________________

(b)(7)e
McHenry County Adult Detention Center ERO Chicago
ICE.11.5082.000510
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material Detainee Classification System Detainee Grievance Procedures Detention Files Emergency Plans Environmental Health and Safety Food Service Key and Lock Control Medical Care Post Orders Special Management Unit Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Visitation ODO staff identified 31 deficiencies during the Quality Assurance Review conducted in November 2008. During this Follow-up Inspection, ODO staff found two (6%) repeated deficiencies. ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards: Access to Legal Material Detainee Classification System Detainee Grievance Procedures Detention Files Emergency Plans Environmental Health and Safety Food Service Key and Lock Control Post Orders Special Management Unit Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Visitation
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000511
Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at the MCADC, to be noncompliant with the ICE NDS: Medical Care
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000512

MEDICAL CARE
During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Medical Care, section (lll)(B), the FOD must ensure detention facilities provide privacy for health examinations and treatment. ODO Follow-up Finding: ODO observed correctional officers standing in the open doorways and inside the examination rooms while detainees were being treated in the clinic. ODO Initial Finding: In accordance with ICE NDS, Medical Care, section (III)(D), the FOD must ensure detention facilities perform prompt testing and screening to detect the presence of tuberculosis (TB). ODO Follow-up Finding: ODO reviewed the admission logbook for the months of August and September, and identified 14 detainees who had tested positive for TB and required a subsequent chest x-ray (CXR). A review of the medical records of the 14 detainees revealed 3 of the required CXRs were not completed within 72 hours. One of the three records did not contain a CXR report to indicate it had been performed.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000513


Detention and Removal Operations

Los Angeles Field Office Mira Loma Detention Center Lancaster, California
May 4 - 5, 2010
________________________________
ICE.11.5082.000514
ICE.11.5082.000515
ICE.11.5082.000516
QUALITY ASSURANCE REVIEW MIRA LOMA DETENTION CENTER LOS ANGELES FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. Current Structure Areas of Concern OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Access to Legal Material Admission and Release. Contraband.. Correspondence and Other Mail.. Detainee Classification System Detainee Grievance Procedures.. Detainee Transfers. Detention Files. Emergency Plans. Environmental Health and Safety. Food Service Hold Rooms in Detention Facilities.. Medical Care Post Orders... Recreation..... Security Inspections. Staff-Detainee Communication..... Terminal Illness, Advance Directives, and Death Transportation Use of Force.. Visitation.... 1 1 3 3 4 5 5 8 9 10 11 12 13 14 15 17 18 20 22 23 25 26 27 28 29 31 33 34
ICE.11.5082.000517
INSPECTION PROCESS
The Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided by the Office of Detention and Removal Operations (DRO) Headquarters and DRO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. ODO conducted an inspection of the Mira Loma Detention Center (MLDC) in Lancaster, California, on May 4-6, 2010. ODO reviewed the processes employed at MLDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the Joint Integrity Case Management System (JICMS), DRO Headquarters, and pertinent media reports.
REPORT ORGANIZATION

Special Agent (Team Lead) Detention and Deportation Officer Special Agent Special Agent Detention and Deportation Officer Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector ODO, OPR Headquarters ODO, OPR Headquarters ODO, OPR San Diego, CA ODO, OPR Headquarters ODO, OPR Headquarters ODO, OPR Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
(b)(6), (b)(7)(C)
Office of Detention Oversight May 2010

(b)(7)e
Mira Loma Detention Center DRO Los Angeles
ICE.11.5082.000518

(b)(7)e
ICE.11.5082.000519
BACKGROUND
HISTORY
MLDC is an ICE-dedicated intergovernmental service agreement (IGSA) detention facility. The facility opened in February 1997. MLDC is authorized to house adult male ICE detainees over 72 hours, and is operated and managed by the Los Angeles County
(b)(7)e (b)(7)e (b)(7)e
The DRO Detention Standards Compliance Unit (DSCU) conducted an annual review of the facility in August 2006 and July 2007. MLDC received a final overall rating of Acceptable and Deficient. The Deficient rating was a result of the use of ElectroMuscular Disruption Devices (EMDD, also known as Tasers) at the facility. According to DRO DSCU compliance records, dated October 1, 2009, the facility received a rating of Deficient again in an annual review conducted in July 2008 due to the use of EMDDs. The DRO DSCU contractors, MGT of America, Inc., conducted an annual review of the ICE NDS at MLDC in September 2009, in which the facility received an Acceptable overall rating. The facility holds no detention accreditations.
CURRENT STRUCTURE
(b)(7)e
. LASD employs 323 full-time staff members at the facility. The DRO Los Angeles field office has staff located within the facility Monday through Friday from 5:00am until midnight. The DRO staff members assigned to MLDC are: the Assistant Field Office Director (AFOD), two supervisory detention and deportation officers (SDDO), two supervisory immigration enforcement agents (SIEA), one mission support specialist, one administrative assistant, nine deportation officers (DO), seven deportation removal assistants, and eighteen immigration enforcement agents (IEA).
(b)(7)e
The MLDC food service operation is managed by the LASD Food Service Bureau. The Food Service Manager supervises 11 cooks and 35 to 40 detainees daily. LASD deputies are assigned in the food service area to enhance security. The MLDC medical clinic is operated by the LASD Medical Services Bureau. MLDC is described as a well facility, because detainees with serious illnesses or maladies are considered unsuitable for housing at the facility. If detainees are determined to not meet the well facility criteria, they are not admitted to MLDC. The facility holds no medical accreditations.

(b)(7)e
ICE.11.5082.000520
AREAS OF CONCERN
ODO requested medical records from the LASD Captain, Clinical Director, and medical staff for an ICE detainee alleging poor medical care. ODOs request for medical records was denied. ODO was told to serve a subpoena to obtain medical records held by LASD. In November 1996, physical and information security specialists assigned to the U.S. Department of Justice, Federal Bureau of Prisons, Community Corrections Office conducted an inspection tional (b)(7)e efficiency of the facility.
(b)(7)e
ODO did not review the ICE NDS Tool Control standard; however, in the course of reviewing the Food Service standard, ODO found MLDC does not have mechanisms in place to ensure tools are effectively controlled. MLDC must establish procedures for the classification, inventory, inspection, and storage of tools (including tools in Food Service) to comply with the ICE NDS Tool Control standard.

(b)(7)e
ICE.11.5082.000521
INTERNAL RELATIONS
ODO interviewed ICE management staff, including the Assistant Field Office Director, supervisory detention and deportation officers, and non-supervisory ICE staff, including immigration enforcement agents, and deportation officers (DO). Additionally, several LASD staff members were interviewed, including the Captain and LASD correctional officers. Based on the interviews, ICE and LASD officials share a positive working relationship; however, both ICE and LASD management staff expressed frustration with the yearly renegotiation of the original 1997 IGSA contract. Both parties reported the contract does not clearly identify roles and responsibilities of each party; therefore, requests and payments for services are not clearly defined. Additionally, ICE supervisory and non-supervisory staff reported a lack of resources to sufficiently staff the program to accomplish the mission. Reportedly, there are currently 21 positions vacant. The majority of ICE staff reported morale is generally mediocre. Staff reported morale being low due to the lack of information and the lack of a rotation policy. Staff reported communication from management is nonexistent, including a lack of email updates and staff meetings. When asked about logistical issues, some staff reported not having access to basic ICE systems including (b)(7)e The MLDC correctional officers were familiar with local policies and procedures, and appeared to have very high morale. None of the officers have had specific training in the ICE NDS. All officers identified the need for additional training in proper use of the facilitys radios to ensure effective communication.
DETAINEE RELATIONS
ODO selected and interviewed over 20 ICE detainees housed at MLDC. Three major complaints reported by detainees were the facilitys food service program, the lack of ICE DOs presence in the housing units, and the lack of medical care. Detainees stated their food was bland and lacked variety. Detainees stated ICE DOs do not visit the housing units as often as needed to answer questions regarding detainee cases. Detainees also stated they noticed an increased presence of ICE DOs in the housing units approximately one week before the ODO review. Detainees also complained about medical care. Detainees reported being given Tylenol and being told to drink more water to cure or prevent ailments. Additionally, two detainees stated they had problems with the floppy discs they were given to save and retrieve documents on the law librarys computers.

(b)(7)e
ICE.11.5082.000522

(b)(7)e
ICE.11.5082.000523

Out of the 32 NDS reviewed by ODO, no deficiencies were noted in the following 11 standards: Detainee Handbook, Detainee Searches, Disciplinary Policy, Funds and Personal Property, Hunger Strikes, Key and Lock Control, Population Counts, Special Management Unit, Suicide Prevention and Intervention, and Telephone Access. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e
ICE.11.5082.000524

ODO reviewed the Access to Legal Material standard at MLDC to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO observed the law library, interviewed staff, and reviewed the detainee handbook and local policies. Detainees and the librarian complained detainees have problems saving and retrieving documents when using different computers in the law library. The law library computer in the Special Management Unit (SMU) does not have the current version of LexisNexis installed (Deficiency ALM-1). The detainee handbook provides detainees with the rules and regulations governing the use of the law library; however, the handbook does not provide the procedures for accessing the library, the procedures for requesting additional time in the law library (beyond the five hours per week minimum), the procedures for notifying a designated employee that library material is missing or damaged, or the procedures for requesting legal reference materials not maintained in the law library (Deficiency ALM-2). These policies and procedures were also not posted in the law library at the time of the inspection.
STANDARDS/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare documents for legal proceedings. The facility must designate an employee with the responsibility to inspect the equipment at least weekly, ensuring it is in good working order, and stock sufficient supplies. DEFICIENCY ALM-2 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook, or equivalent, provides the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for detainee use; 2) scheduled hours of access to the law library; 3) procedures for requesting access to the law library; 4) procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) procedures for requesting legal reference materials not maintained in the law library; and 6) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library.

None
(b)(7)e
ICE.11.5082.000525

ODO reviewed the Admission and Release standard at MLDC to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO staff reviewed policies, procedures, and detention files; interviewed staff; and observed the admission and release processes. A review of 15 active and 10 inactive detention files revealed some initial medical screening forms were maintained in detention files, and classification worksheet were not consistently maintained in the detention files (Deficiency AR-1 and DCS-1).

DEFICIENCY AR-1 and DCS-1 In accordance with the ICE NDS, Detainee Classification System, section (III)(B), the FOD must ensure the officer places all original paperwork relating to the detainees assessment and classification in the detention file.

In order to ensure confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations, all initial medical screening forms must be maintained in the detainees medical record, not in the detainees detention file.

(b)(7)e
ICE.11.5082.000526
CONTRABAND (C)
ODO reviewed the Contraband standard at MLDC to determine if procedures are in place to protect detainees and staff, enhance security, and identify, detect, control, and properly dispose of contraband, in accordance with the ICE NDS. ODO toured the facility, interviewed detention staff, and reviewed policies, procedures, and documentation of contraband destruction.
(b)(7)e
(b)(7)e

None
Office of Detention Oversight May 2010 Angeles

(b)(7)e
10
Mira Loma Detention Center DRO Los
ICE.11.5082.000527

ODO reviewed the Correspondence and Other Mail standard at MLDC to determine if the facility provides detainees the opportunity to send and receive correspondence in a timely manner, subject to limitations required for the safe and orderly operation of the facility, in accordance with the ICE NDS. ODO interviewed MLDC staff members, and reviewed local policies, logbooks, and the detainee handbook. MLDC does not maintain a logbook to record contraband found in correspondence (Deficiency C&OM-1).

DEFICIENCY C&OM-1 In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(H)(1-6), the FOD must ensure, when an officer finds an item that must be removed from a detainees mail, he or she makes a written record. This must include: 1) the detainees name and A-number, 2) the name of the sender and recipient, 3) a description of the mail in question, 4) a description of the action taken and the reason for it (including significant dates), 5) the disposition of the item and the date of disposition, and 6) the signature of the officer.

None

(b)(7)e
11
ICE.11.5082.000528

ODO reviewed the Detainee Classification System standard at MLDC to determine if there is formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE NDS. ODO reviewed policies and detention files, and interviewed staff.
(b)(7)e
(b)(7)e

None

(b)(7)e
12
ICE.11.5082.000529

ODO reviewed the Detainee Grievance System standard at MLDC to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed detainees and staff, and reviewed the grievance policy, grievance reports, the grievance logbook, and the detainee handbook. MLDC does not have a grievance committee (Deficiency DGP-1). The Medical Department does not maintain a logbook for medical grievances (Deficiency DGP-2). According to the Clinical Director, the facility does not have a process for detainees to appeal a medical grievance response (Deficiency DGP-3). The facility does not maintain copies of grievances in detainees detention files, and the Medical Department does not maintain copies of medical grievances in detainees medical files (Deficiency DGP-4).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance System, section (III)(A)(2), the FOD must ensure detainees are permitted to submit a formal, written grievance to the facilitys grievance committee. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance System, section (III)(E), the FOD must ensure each facility devises a method for documenting detainee grievances. At a minimum, the facility must maintain a detainee grievance log. DEFICIENCY DGP-3 In accordance with the ICE NDS, Detainee Grievance System, section (III)(C), the FOD must ensure, if the detainee does not accept the grievance committees decision, procedures are in place for a detainee to appeal it to the Officer in Charge. DEFICIENCY DGP-4 In accordance with the ICE NDS, Detainee Grievance System, section (III)(E), the FOD must ensure a copy of all grievances filed by detainees are placed in detention files, and remain in the detainees detention files for at least three years.

ODO recommends the facility establish one system to track or log all grievances.

(b)(7)e
13
ICE.11.5082.000530
DETAINEE TRANSFERS (DT)

ODO reviewed the Detainee Transfers standard at MLDC to determine if transfers of detainees from one facility to another are responsibly managed in regard to notification, detention records, safety and security, and protection of detainee funds and property, in accordance with the ICE NDS. ODO interviewed ICE staff and reviewed documents pertaining to the transfer of detainees from MLDC to other facilities. According to a SDDO, Detainee Transfer Notification Sheets are not used by DRO to notify detainees of their transfers to other facilities (Deficiency DT-1). The SDDO also said Detainee Transfer Checklists are not completed by DRO prior to transferring detainees out of MLDC (Deficiency DT-2).

DEFICIENCY DT-1 In accordance with the ICE NDS, Detainee Transfers, section (III)(A)(3), the FOD must ensure, at the time of transfer, ICE provides detainees, in writing, with the name, address, and telephone number of the facility he or she is transferred to. The Detainee Transfer Notification Sheet must be used for this purpose. The detainee must also be instructed that it is his or her responsibility to notify family members. A copy of the transfer notification sheet must be placed in the detainees detention file. DEFICIENCY DT-2 In accordance with the ICE NDS, Detainee Transfers, section (III)(D), the FOD must ensure the Detainee Transfer Checklist is filled out and completed prior to transferring a detainee to another field office in order to ensure all procedures are completed. The Detainee Transfer Checklist must be placed in the detainees A-file or work folder.

None

(b)(7)e
14
ICE.11.5082.000531

ODO reviewed the Detention Files standard at MLDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files and interviewed staff. ODO reviewed 20 active detention files. The officer completing the admission portion of the detention files does not note the file has been activated (Deficiency DF-1). ODO reviewed 15 archived detention files stored by LASD and observed the files are missing the original detainee booking cards (Form I-385) (Deficiency DF-2). LASD uses an out card to keep track of the files removed from the processing area. A logbook designed to record the removal of detention files from the processing area does not exist (Deficiency DF-3). ODO found the ICE Los Angeles field office does not create and maintain detention files on all detainees admitted to MLDC (Deficiency DF-4).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(A)(2), the FOD must ensure the officer completing the admission portion of the detention file notes the file has been activated. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(E)(2)(c), the FOD must ensure staff inserts copies of completed release documents, original closed-out receipts for property and valuables, the original Form I-385, and other documentation into the released detainees detention file. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F)(2)(a-f), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-file number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file. DEFICIENCY DF-4 In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office creates and maintains detention files on all detainees admitted to an IGSA facility. These files must contain the same materials, such as forms and other documents, as service processing center or contract detention facility detention files, to the extent possible. The file must also contain copies of all forms related to the alien.
(b)(7)e
15
ICE.11.5082.000532
The FOD must ensure the IGSA facility forwards all documents relating to the individuals detention to the ICE field office of jurisdiction for inclusion into the detention file.

None

(b)(7)e
16
ICE.11.5082.000533

ODO reviewed the Emergency Plans standard at MLDC to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed local policies and emergency plans.
(b)(7)e
(b)(7)e
RECOMMENDATIONS TO IMPROVE EFFICIENCY AND EFFECTIVENESS

None

(b)(7)e
17
ICE.11.5082.000534

ODO reviewed the Environmental Health and Safety standard at MLDC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility; interviewed staff; observed barbershop operations; inspected documentation of inspections and fire drills; and reviewed policy, Material Safety Data Sheets (MSDS), pest and vermin extermination records, and emergency generator test records. MSDS are maintained in areas where hazardous materials are used. The facility does not maintain a master index, and there was no documentation of semi-annual reviews, or documentation indicating the reviews were forwarded to the local fire department (Deficiency EH&S-1). Fire and safety inspections are conducted daily by qualified staff members; however, maintenance staff does not conduct monthly inspections (Deficiency EH&S- 2). ODO was provided with documentation of a fire drill conducted in one area of the facility in February 2010. There was no documentation of any fire drills since that time (Deficiency EH&S-3). MLDC conducts monthly inspections of fire extinguishers; however, a fire extinguisher in the control room had not been inspected for three months (Deficiency EH&S-4). Exit diagrams do not provide information in Spanish, do not identify the location of emergency equipment, and do not include YOU ARE HERE markers (Deficiency EH&S-5). The fire prevention control and evacuation plan does not include the components required by the standard (Deficiency EH&S-6). The facilitys barbershop does not have hot water (Deficiency EH&S-7).

DEFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the Maintenance Supervisor or designate compiles a master index of all hazardous substances in the facility, including their locations, along with a master file of MSDS. A copy must be maintained in the safety office (or equivalent), with a copy to the local fire department. Documentation of semiannual reviews must be maintained in the MSDS master file. The master index must also include a comprehensive, up-to-date list of emergency telephone numbers. DEFICIENCY EH&S-2 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure the maintenance (safety) staff conducts monthly fire and safety inspections.

(b)(7)e
18
ICE.11.5082.000535
DEFICIENCY EH&S-3 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4), the FOD must ensure monthly fire drills are conducted and documented separately in each department. DEFICIENCY EH&S-4 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(1), the FOD must ensure every facility complies with standards and regulations issued by the Environmental Protection Agency, the Occupational Safety and Health Administration, and the American Correctional Association, as well as local and national fire safety codes. The National Fire Prevention Association (NFPA) 10, section 7.2.1.2, requires inspection of fire extinguishers at a minimum of 30-day intervals. DEFICIENCY EH&S-5 In accordance with the ICE NDS, Environmental Health and Safety, section(III)(L)(5), the FOD must ensure, in addition to general area diagrams, existing exit diagrams provide English and Spanish instructions, YOU ARE HERE markers, and emergency equipment locations. DEFICIENCY EH&S-6 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3), the FOD must ensure every institution develops a fire prevention, control, and evacuation plan, which includes: control of ignition sources; control of combustible and flammable load sources; provisions for occupant protection from fire and smoke; inspection, testing, and maintenance of fire protection equipment in accordance with NFPA codes, etc.; monthly fire inspections; installing fire protection equipment throughout the facility; accessible, current floor plans (buildings and rooms); prominently posted evacuation maps and plans, exit signs, and directional arrows for traffic flow, with a copy of each revision filed with the local fire department; and conspicuously posted exit diagrams. DEFICIENCY EH&S-7 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure both hot and cold water are available in the barbershop. Hot water must be capable of maintaining a constant flow of water between 105 degrees and 120 degrees.

None

(b)(7)e
19
ICE.11.5082.000536
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at MLDC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO interviewed staff, inspected food preparation and storage areas, observed meal preparation and service, and reviewed documentation. Knives are not stored in locked cabinets (Deficiency FS-1). When not in use, knives remain tethered to work stations, submersed in disinfectant solution, and are removed only when washed at the end of each shift. ODO discovered one knife was not mounted through a steel shank (Deficiency FS-2). A shadow board system is not in place for all commonly-used, mountable cooking utensils (Deficiency FS-3). The daily log sheets for hazardous materials used in the Food Service Department were not up-to-date (Deficiency FS-4). The log sheets were made current before ODOs departure. The facility does not have a three-compartment sink (Deficiency FS-5); however, a system has been established for cleaning, rinsing, and sanitizing utensils and equipment following the three-step process.

DEFICIENCY FS-1 In accordance with the ICE NDS, Food Service, section (III)(B)(2), the FOD must ensure proper knife control. Knife cabinets must be equipped with approved locking devices. The on duty cook foreman, under direct supervision of the Cook Supervisor, must maintain control of the key that locks the device. DEFICIENCY FS-2 In accordance with the ICE NDS, Food Service, section (III)(B)(2), the FOD must ensure knives authorized for use in food service have a steel shank through which a metal cable can be mounted. DEFICIENCY FS-3 In accordance with the ICE NDS, Tool Control, section (III)(E), the FOD must ensure the tool storage system ensures accountability. Commonly-used, mounted tools must be stored so that a tools disappearance would not escape attention. DEFICIENCY FS-4 In accordance with the ICE NDS, Food Service, section (III)(H)(11)(b), the FOD must ensure all staff members know where and how much toxic, flammable, or caustic material is on hand, and control and account for its use daily.

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ICE.11.5082.000537
DEFICIENCY FS-5 In accordance with the ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least three labeled compartments is used for manual washing, rinsing, and sanitizing utensils and equipment. Each compartment must have the capacity to accommodate items to be cleaned. Each must be supplied with hot and cold water.

None

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21
ICE.11.5082.000538

ODO reviewed the Hold Rooms in Detention Facilities standard at MLDC to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure, and comfortable environment, and not confined in hold rooms for over 12 hours, in accordance with the ICE NDS. ODO interviewed staff, reviewed local policies and all available documentation, and inspected the hold rooms. MLDC does not maintain logbooks for the hold rooms (Deficiency HR-1). Hold rooms not in the direct sight of an officer do not have detention logbooks to record 15-minute checks (Deficiency HR-2). The hold rooms are not sanitized after each group of detainees is removed (Deficiency HR-3).

DEFICIENCY HR-1 In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(2), the FOD must ensure each facility maintains a detention log (manually or electronically) for every detainee placed in a hold cell. The log is used to record custodial information about new arrivals (e.g., a voluntary return waiting for a scheduled transportation run); detainees awaiting legal visitation; and detainees awaiting interviews with supervisory staff or other officials. DEFICIENCY HR-2 In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which involves irregular visual monitoring every 15 minutes, each time recording the time and officers staff number in the detention log. DEFICIENCY HR-3 In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(7), the FOD must ensure, when the last detainee has been removed from the hold room, it is given a thorough cleaning and inspection.

None

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22
ICE.11.5082.000539
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at MLDC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the clinic; interviewed the Clinical Nurse Director, Day Supervisor and staff; reviewed medical policies and procedures; and inspected 30 detainee medical records, medical staff credentials, and staff clinical files. ODO was informed sick call is held Monday through Friday from 7:00am until all detainees are seen. MLDC does not use sick call request forms. Detainees requesting health services are required to notify the housing unit officer, who allows them to go to sick call at designated locations. A nurse enters the date, detainees name, booking number, and problem on a Call to Clinic list, stored in boxes on the floor of the clinic. The Call to Clinic form does not conclusively support that all detainees needing health care services have access; it only serves to document which detainees were allowed to go to sick call and were seen by a nurse on a particular day (Deficiency MC-1). There are no procedures to ensure requests for services are received by the medical unit in a timely manner, if at all (Deficiency MC-2). There is no system for review of requests by the health care provider to determine when detainees will be seen (Deficiency MC-3). Local policy #M101.01, Medical Record from External Entity, provides guidelines for requesting medical records from other facilities or providers. MLDC does not have a policy addressing confidentiality and release of records to a detainee or a detainees designee. ODO was provided with an Authorization to Use and Disclose Protected Health Information form; however, requirements for its use are not described, including providing the form to detainees, and retention in the health record and detainees A-file. Procedures are not in place for notification of ICE when medical records are released (Deficiency MC-4). ODO reviewed ten training records and found three detention staff members did not have current first aid and cardiopulmonary resuscitation (CPR) training (Deficiency MC-5).

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (I), the FOD must ensure detainees have access to medical services that promote detainee health and well being. DEFICIENCY MC-2 In accordance with the ICE NDS, Medical Care, section (III)(F), the FOD must ensure all facilities have a procedure in place to ensure all request slips are received by the medical facility in a timely manner.

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ICE.11.5082.000540
DEFICIENCY MC-3 In accordance with the ICE NDS, Medical Care, section (III)(F), the FOD must ensure the health care provider reviews request slips to determine when detainees will be seen. DEFICIENCY MC-4 In accordance with the ICE NDS, Medical Care, section (III)(M), the FOD must ensure medical providers protect the privacy of detainees medical information while permitting the exchange of health information required to fulfill program responsibilities and provide for the well being of detainees. Copies of health records may be released by the facility health care provider directly to a detainee, or any person designated by the detainee, upon receipt by the facility health care provider of a written authorization from the detainee. Following release of health information, the written authorization must be maintained in the health record, and a copy placed in the detainees A-file. IGSA facilities must notify ICE each time a detainee medical record is released. Detainees who indicate they wish to obtain copies of their medical records must be provided with the appropriate form. DEFICIENCY MC-5 In accordance ICE NDS, Medical Care, section (III)(H), the FOD must ensure staff are trained to respond to health-related emergencies within a 4-minute timeframe. Training must include the administration of first aid and CPR.

ODO recommends implementation of written sick call request forms to ensure all detainees requesting health care services may access them without having to go through custody staff, and to ensure Medical Department accountability, with respect to timeliness of review and delivery of service.

(b)(7)e
24
ICE.11.5082.000541
POST ORDERS (PO)

ODO reviewed the Post Orders standard at MLDC to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE NDS. ODO reviewed logbooks and policies, observed operations, and interviewed staff.
(b)(7)e
(b)(7)e

None

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25
ICE.11.5082.000542
RECREATION (R)
ODO reviewed the Recreation standard at MLDC to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO conducted a tour of recreational areas; reviewed the detainee handbook, policies, and procedures; and interviewed detainees and facility staff. MLDC does not have a recreation specialist or recreation assistant on staff (Deficiency R-1).


None

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26
ICE.11.5082.000543

ODO reviewed the Security Inspections standard at MLDC to determine if the facility security is maintained, and events posing a risk of harm are prevented, in accordance with the ICE NDS. ODO interviewed staff, toured the facility and perimeter, observed security operations, and reviewed policies and supporting documentation.
(b)(7)e
(b)(7)e

None

(b)(7)e
27
ICE.11.5082.000544

ODO reviewed the Staff-Detainee Communication standard at MLDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed procedures and logbooks, and interviewed staff and detainees. Detainee requests are not forward directly to ICE staff and detainees do not receive a written response within 72 hours (Deficiency SDC-1). A copy of the completed detainee request is not maintained in the detainees detention file (Deficiency SDC-2).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(1)(b), the FOD must ensure detainee requests are forwarded to the ICE office of jurisdiction within 72 hours, and answered as soon as possible and practicable, but not later than within 72 hours from receiving the request. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and will remain in the detainees detention file for at least three years.

None

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ICE.11.5082.000545

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donations, at MLDC to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO reviewed policies and procedures, and interviewed the Clinical Nurse Director and Day Supervisor. There have been no deaths in the past year. ODO was informed MLDC is a well facility and does not accept terminally-ill detainees. Detainees who become seriously or terminally ill or injured are transferred to local hospitals. MLDC policies address advance directives and reports of death; however, the facility does not have policies or procedures addressing terminal illness or fatal injury (Deficiency TIADD-1), Do Not Resuscitate orders (Deficiency TIADD-2), or organ donations (Deficiency TIADD-3). MLDC policy 304.1, Report of Death, does not address notifications of ICE officials (Deficiency TIADD-4). ODO was provided with ICE policy 7-9.0, Notification and Reporting of Detainee Deaths. Neither the ICE policy nor the facility policy addresses the disposition of property (Deficiency TIADD-5), the disposition of remains (Deficiency TIADD-6), or case closures (Deficiency TIADD-7).

DEFICIENCY TIADD-1 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure all facilities have policies and procedures addressing the issues of terminal illness, fatal injury, advance directives, and detainee death. The FOD must ensure each area addresses notifications of all concerned, from family to ICE. DEFICIENCY TIADD-2 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(C), the FOD must ensure facilities establish and implement, through written procedures, policy governing Do Not Resuscitate orders. DEFICIENCY TIADD-3 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(D), the FOD must ensure specified procedures govern organ donations. DEFICIENCY TIADD-4 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(E), the FOD must ensure the facility follows written procedures when notifying ICE officials, immediate family members, and consulate offices of a detainees death.

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ICE.11.5082.000546
DEFICIENCY TIADD-5 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(F), the FOD must ensure, if a detainee dies while in an IGSA facility, the Officer in Charge turns his or her property over to ICE for processing and disposition. DEFICIENCY TIADD-6 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(G), the FOD must ensure, within seven calendar days of notification of death, the family has the opportunity to claim the detainees remains. If family members cannot be located, or decline orally or in writing to claim the remains, ICE must notify the consulate in writing. DEFICIENCY TIADD-7 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(H), the FOD must ensure the facility has procedures for closing the case of a detainee, including: sending the detainees fingerprint card to the FBI, stamped deceased, and identifying the place of death; placing a copy of the gravesite title in the A-file; and closing the detainees Deportable Alien Control System file.

Though MLDC does not accept detainees for whom this standard applies, it is possible a detainee may become seriously or terminally ill or injured while in MLDC custody. ODO recommends establishment of policies addressing procedures required by the standard pending transfer to a hospital or alternative facility.

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ICE.11.5082.000547
TRANSPORTATION (T)
ODO reviewed the Transportation standard at MLDC to determine if vehicles are properly equipped, maintained, and operated, and if detainees are transported in a safe, secure, and humane manner under supervision of trained and experienced staff, in accordance with the ICE NDS. ODO observed the transportation of detainees, inspected ICE-operated vehicles and equipment, interviewed staff, and reviewed vehicle operator files, policies, and procedures. ODO reviewed ten vehicle operator files and found none of the files contained the Certificate of Completion from the ICE Bus Training Program for each vehicle operator Eight of the ten files did not have a copy of the vehicle operators commercial drivers license (CDL). Three of the ten files did not have a copy of the most current physical examination used to obtain the commercial drivers license (Deficiency T-1). ODO observed an IEA, who also holds a commercial drivers license, conduct a safety inspection of an ICE bus prior to the transportation of ICE detainees; however, the IEA did not utilize a checklist to conduct the vehicle inspection. ODO interviewed the IEA and was informed he does not use a checklist to conduct vehicle inspections (Deficiency T-2). ODO also inspected the ICE bus and did not find bolt cutters in the forward compartment of the bus. The IEA and a SIEA both stated all ICE vehicles used for the transportation of detainees do not have bolt cutters (Deficiency T-3). The ICE bus was missing: two equipment boxes In the forward baggage compartment, a cellular phone, a portable Citizens Band (CB) radio, 50 emergency blankets, a boarding bag, and restraining equipment (Deficiency T-4).

DEFICIENCY T-1 In accordance with the ICE NDS, Transportation, section (III)(C), the FOD must ensure the facility maintains all vehicle-operators files at the official duty station. Each file must contain a Certificate of Completion from the ICE Bus Training Program; a copy of the most current physical examination used to obtain the CDL; and a copy of the CDL. DEFICIENCY T-2 In accordance with the ICE NDS, Transportation, section (III)(C), the FOD must ensure transporting officers inspect vehicles using a checklist and note any defect that could render the vehicle unsafe or inoperable. DEFICIENCY T-3 In accordance with the ICE NDS, Transportation, section (III)(N), the FOD must ensure the transportation crew keeps bolt cutters in the forward compartment, with the outer equipment for use in an emergency.
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31
ICE.11.5082.000548
DEFICIENCY T-4 In accordance with the ICE NDS, Transportation, section (III)(Z)(2-4, 6,7 and 9), the FOD must ensure all vehicles have: (2) a cellular phone as a back-up communication system, (3) a portable CB radio for emergency use only, (4) the forward baggage compartment of buses contains two equipment boxes. Box 1 must have large bolt cutters, fuses, fan belts, a jack, small hand tools, a flashlight, a lantern, rags, disposable trash bags, a broom, a ground cloth, two sets of coveralls, and work gloves. The Fleet Officer or Shop Supervisor must maintain the inventory, and check the written inventory quarterly. Box 2 must have transmission fluid, water for the radiator, oil, toilet disinfectant, extra fire extinguisher(s), road flares, and reflectors. Transporting officers must record the amount and date used, and by whom, on inventory sheets kept in Box 2, as well as maintain MSDS sheets, as necessary. Other equipment may be added as necessary. Transporting officers must provide supervisors with written notifications of inventory needs, including items that need replenishing or replacing. (6) have 50 emergency blankets, (7) a boarding bag containing extra forms, a camera that produces instant photographs, film, batteries, and emergency telephone numbers for: ICE offices, local police, State police, etc. and (9) restraining equipment, including, at a minimum: 50 sets of waist chains; 50 sets of leg irons; 2 sets of leg irons modified for use as hand cuffs (extra-large); 2 sets of group (daisy) chains, 25-feet each, and keyed-alike padlocks (for an emergency evacuation). All restraining equipment must be of high quality, maintained in good operating condition, and kept in the forward baggage compartment with the other supplies.

None

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ICE.11.5082.000549
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at MLDC to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO interviewed staff; inspected equipment and inventories; and reviewed policies, use of force documentation, and video recordings.
(b)(7)e
(b)(7)e

None

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ICE.11.5082.000550
VISITATION (V)
ODO reviewed the Visitation standard at MLDC to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO interviewed staff, reviewed policies and procedures, and observed the visitation areas. MLDC has written procedures establishing visitation requirements; however; written procedures do not include instructions regarding the news media (Deficiency V-1). The facility maintains records of all visitors; however, the general visitors logbook does not contain spaces to record a detainees alien registration number (A-number), the visitors address and immigration status, the visitors relationship to the detainee, or the time in (Deficiency V-2). MLDC has not established written procedures noting legal service providers and legal assistants are permitted to telephone the facility in advance of a visit for the purpose of determining whether or not a particular individual is detained within the facility (Deficiency V-3). Notice of Appearance as Attorney or Representative (Form G-28) is not available to legal representatives in the legal visitors reception area, and staff does not collect completed Form G-28s or forward the forms to ICE (Deficiency V-4). MLDC does not have written legal visitation procedures indicating the process of exchanging documents between detainee and legal representative, or legal assistant (Deficiency V-5). MLDC also does not have a site-specific, written, legal visitation policy (Deficiency V-6).

DEFICIENCY V-1 In accordance with the ICE NDS, Visitation, section (III)(A), the FOD must ensure the facility establishes written visiting procedures, including a schedule and hours of visitation, taking into account the visitation requirements of family, including minors, friends, legal representatives, consular officials, interested non-governmental organizations, and the news media. DEFICIENCY V-2 In accordance with the ICE NDS, Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all visitors, and a separate log of legal visitors. The general visitors logbook must record the name and A-number of the detainee visited, the visitors name and address, the visitors immigration status, the visitors relationship to the detainee, and the date and time-in and-out.

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ICE.11.5082.000551
DEFICIENCY V-3 In accordance with the ICE NDS, Visitation, section (III)(I)(6), the FOD must ensure the facility establishes a written procedure to allow legal service providers and legal assistants to telephone the facility in advance of a visit to determine whether a particular individual is detained within the facility. DEFICIENCY V-4 In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure, once an attorney-client relationship has been established, the legal representative completes and submits Form G-28, available in the legal visitors reception area. Staff must collect completed forms and forward them to ICE. DEFICIENCY V-5 In accordance with the ICE NDS, Visitation, section (III)(I)(10), the FOD must ensure the facilitys written legal visitation procedures provide for the exchange of documents between detainees and legal representatives, or legal assistants, even when contact visitation rooms are unavailable. DEFICIENCY V-6 In accordance with the ICE NDS, Visitation, section (III)(I)(16), the FOD must ensure the facilitys written legal visitation policy is available upon request. The site-specific policy must specify visitation hours, procedures, and standards, including but not limited to: telephone inquiries, dress code, legal assistants working under the supervision of an attorney, pre-representational meetings, Form G-28 requirements, identification and search of legal representatives, identification of visitors, materials provided to detainees by legal representatives, confidential group legal meetings, and detainee sign-up.

None

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ICE.11.5082.000552
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DRO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU
TAR
American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit

TB UDC

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ICE.11.5082.000553
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare 8 documents for legal proceedings. The facility must designate an employee with the responsibility to inspect the equipment at least weekly, ensuring it is in good working order, and stock sufficient supplies. In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook, or equivalent, provides the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for detainee use; 2) scheduled hours of access to the law library; 3) procedures for requesting 8 access to the law library; 4) procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) procedures for requesting legal reference materials not maintained in the law library; and 6) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library. In accordance with the ICE NDS, Detainee Classification System, section 9 (III)(B), the FOD must ensure the officer places all original paperwork relating to the detainees assessment and 12 classification in the detention file.
ALM-1
ALM-2
Admission and Release Detainee Classification System
AR-1
DCS-1

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ICE.11.5082.000554
DETENTION STANDARD
Contraband
C-1
C&OM-1
DGP-1
DGP-2
DGP-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Contraband, section (I), the FOD must ensure contraband is destroyed in the presence of at least one official 10 observer; those involved must document every instance of contraband destruction. In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(H)(1-6), the FOD must ensure, when an officer finds an item that must be removed from a detainees mail, he or she makes a written record. This must include: 1) the detainees name and A-number, 2) the name of the 11 sender and recipient, 3) a description of the mail in question, 4) a description of the action taken and the reason for it (including significant dates), 5) the disposition of the item and the date of disposition, and 6) the signature of the officer. In accordance with the ICE NDS, Detainee Grievance System, section (III)(A)(2), the FOD must ensure 13 detainees are permitted to submit a formal, written grievance to the facilitys grievance committee. In accordance with the ICE NDS, Detainee Grievance System, section (III)(E), the FOD must ensure each facility devises a method for 13 documenting detainee grievances. At a minimum, the facility must maintain a detainee grievance log. In accordance with the ICE NDS, Detainee Grievance System, section (III)(C), the FOD must ensure, if the detainee does not accept the grievance 13 committees decision, procedures are in place for a detainee to appeal it to the Officer in Charge.

(b)(7)e
38
ICE.11.5082.000555
DETENTION STANDARD
DGP-4
Detainee Transfers
DT-1
Detainee Transfers
DT-2
Detention Files
DF-1
Detention Files
DF-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detainee Grievance System, section (III)(E), the FOD must ensure a copy of all grievances filed by detainees are 13 placed in detention files, and remain in the detainees detention files for at least three years. In accordance with the ICE NDS, Detainee Transfers, section (III)(A)(3), the FOD must ensure, at the time of transfer, ICE provides detainees, in writing, with the name, address, and telephone number of the facility he or she is transferred to. The Detainee 14 Transfer Notification Sheet must be used for this purpose. The detainee must also be instructed that it is his or her responsibility to notify family members. A copy of the transfer notification sheet must be placed in the detainees detention file. In accordance with the ICE NDS, Detainee Transfers, section (III)(D), the FOD must ensure the Detainee Transfer Checklist is filled out and completed prior to transferring a 14 detainee to another field office in order to ensure all procedures are completed. The Detainee Transfer Checklist must be placed in the detainees A-file or work folder. In accordance with the ICE NDS, Detention Files, section (III)(A)(2), the FOD must ensure the officer completing 15 the admission portion of the detention file notes the file has been activated. In accordance with the ICE NDS, Detention Files, section (III)(E)(2)(c), the FOD must ensure staff inserts copies of completed release documents, original closed-out receipts 15 for property and valuables, the original Form I-385, and other documentation into the released detainees detention file.
39 Mira Loma Detention Center DRO Los

(b)(7)e
ICE.11.5082.000556
DETENTION STANDARD
Detention Files
DF-3
Detention Files
DF-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (III)(F)(2)(a-f), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-file number; 15 date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file. In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office creates and maintains detention files on all detainees admitted to an IGSA facility. These files must contain the same materials, such as forms and other documents, as service processing center or contract detention facility 15 detention files, to the extent possible. The file must also contain copies of all forms related to the alien. The FOD must ensure the IGSA facility forwards all documents relating to the individuals detention to the ICE field office of jurisdiction for inclusion into the
Emergency Plans
EP-1
17
(b)(7)e
Emergency Plans
EP-2
17

(b)(7)e
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ICE.11.5082.000557
DETENTION STANDARD
EH&S-1
EH&S-2
EH&S-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the Maintenance Supervisor or designate compiles a master index of all hazardous substances in the facility, including their locations, along with a master file of MSDS. A copy must be 18 maintained in the safety office (or equivalent), with a copy to the local fire department. Documentation of semiannual reviews must be maintained in the MSDS master file. The master index must also include a comprehensive, up-to-date list of emergency telephone numbers. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the Maintenance Supervisor or designate compiles a master index of all hazardous substances in the facility, including their locations, along with a master file of MSDS. A copy must be 18 maintained in the safety office (or equivalent), with a copy to the local fire department. Documentation of semiannual reviews must be maintained in the MSDS master file. The master index must also include a comprehensive, up-to-date list of emergency telephone numbers. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4), the FOD must ensure 19 monthly fire drills are conducted and documented separately in each department.

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ICE.11.5082.000558
DETENTION STANDARD
EH&S-4
EH&S-5
EH&S-6
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(1), the FOD must ensure every facility complies with standards and regulations issued by the Environmental Protection Agency, the Occupational Safety and Health 19 Administration, and the American Correctional Association, as well as local and national fire safety codes. The National Fire Prevention Association (NFPA) 10, section 7.2.1.2, requires inspection of fire extinguishers at a minimum of 30-day intervals. In accordance with the ICE NDS, Environmental Health and Safety, section(III)(L)(5), the FOD must ensure, in addition to general area diagrams, 19 existing exit diagrams provide English and Spanish instructions, YOU ARE HERE markers, and emergency equipment locations. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3), the FOD must ensure every institution develops a fire prevention, control, and evacuation plan, which includes: control of ignition sources; control of combustible and flammable load sources; provisions for occupant protection from fire and smoke; inspection, testing, and maintenance of fire protection 19 equipment in accordance with NFPA codes, etc.; monthly fire inspections; installing fire protection equipment throughout the facility; accessible, current floor plans (buildings and rooms); prominently posted evacuation maps and plans, exit signs, and directional arrows for traffic flow, with a copy of each revision filed with the local fire department; and conspicuously posted exit diagrams.

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ICE.11.5082.000559
DETENTION STANDARD
EH&S-7
Food Service
FS-1
Food Service
FS-2
Food Service
FS-3
Food Service
FS-4
Food Service
FS-5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure both hot and cold water are available in 19 the barbershop. Hot water must be capable of maintaining a constant flow of water between 105 degrees and 120 degrees. In accordance with the ICE NDS, Food Service, section (III)(B)(2), the FOD must ensure proper knife control. Knife cabinets must be equipped with 20 approved locking devices. The on duty cook foreman, under direct supervision of the Cook Supervisor, must maintain control of the key that locks the device. In accordance with the ICE NDS, Food Service, section (III)(B)(2), the FOD must ensure knives authorized for use 20 in food service have a steel shank through which a metal cable can be mounted. In accordance with the ICE NDS, Tool Control, section (III)(E), the FOD must ensure the tool storage system ensures accountability. Commonly-used, 20 mounted tools must be stored so that a tools disappearance would not escape attention. In accordance with the ICE NDS, Food Service, section (III)(H)(11)(b), the FOD must ensure all staff members know 20 where and how much toxic, flammable, or caustic material is on hand, and control and account for its use daily. In accordance with the ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least three labeled compartments is used for manual washing, rinsing, and sanitizing 21 utensils and equipment. Each compartment must have the capacity to accommodate items to be cleaned. Each must be supplied with hot and cold water.

(b)(7)e
ICE.11.5082.000560
DETENTION STANDARD
HR-1
HR-2
HR-3
Medical Care
MC-1
Medical Care
MC-2
Medical Care
MC-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(2), the FOD must ensure each facility maintains a detention log (manually or electronically) for every detainee placed in a hold cell. The log is used to record custodial information 22 about new arrivals (e.g., a voluntary return waiting for a scheduled transportation run); detainees awaiting legal visitation; and detainees awaiting interviews with supervisory staff or other officials. In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which 22 involves irregular visual monitoring every 15 minutes, each time recording the time and officers staff number in the detention log. In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(7), the FOD must ensure, when 22 the last detainee has been removed from the hold room, it is given a thorough cleaning and inspection. In accordance with the ICE NDS, Medical Care, section (I), the FOD must ensure detainees have access to 23 medical services that promote detainee health and well being. In accordance with the ICE NDS, Medical Care, section (III)(F), the FOD must ensure all facilities have a 23 procedure in place to ensure all request slips are received by the medical facility in a timely manner. In accordance with the ICE NDS, Medical Care, section (III)(F), the FOD must ensure the health care provider 24 reviews request slips to determine when detainees will be seen.

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44
ICE.11.5082.000561
DETENTION STANDARD
Medical Care
MC-4
Medical Care
MC-5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Medical Care, section (III)(M), the FOD must ensure medical providers protect the privacy of detainees medical information while permitting the exchange of health information required to fulfill program responsibilities and provide for the well being of detainees. Copies of health records may be released by the facility health care provider directly to a detainee, or any person designated by the detainee, 24 upon receipt by the facility health care provider of a written authorization from the detainee. Following release of health information, the written authorization must be maintained in the health record, and a copy placed in the detainees A-file. IGSA facilities must notify ICE each time a detainee medical record is released. Detainees who indicate they wish to obtain copies of their medical records must be provided with the appropriate form. In accordance ICE NDS, Medical Care, section (III)(H), the FOD must ensure staff are trained to respond to health24 related emergencies within a 4-minute timeframe. Training must include the administration of first aid and CPR.
Post Orders
PO-1
25
(b)(7)e
Post Orders
PO-2
25

(b)(7)e
Center 45 DRO Los
ICE.11.5082.000562
DETENTION STANDARD
Post Orders
PO-3
(b)(7)e
25
Recreation
R-1
Recreation, section (III)(F), the FOD must ensure all facilities have an individual responsible for the development and oversight of the recreation program.
26
SI-1
27
SI-2
(b)(7)e
27
SI-3
27

(b)(7)e
46
ICE.11.5082.000563
DETENTION STANDARD
SDC-1
SDC-2
TIADD-1
TIADD-2
TIADD-3
TIADD-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(1)(b), the FOD must ensure detainee requests are forwarded to the 28 ICE office of jurisdiction within 72 hours, and answered as soon as possible and practicable, but not later than within 72 hours from receiving the request. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in 28 the detainees detention file, and will remain in the detainees detention file for at least three years. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure all facilities have policies and procedures addressing the issues of 29 terminal illness, fatal injury, advance directives, and detainee death. The FOD must ensure each area addresses notifications of all concerned, from family to ICE. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(C), the FOD must ensure facilities establish and 29 implement, through written procedures, policy governing Do Not Resuscitate orders. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(D), the FOD 29 must ensure specified procedures govern organ donations. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(E), the FOD must ensure the facility follows written 29 procedures when notifying ICE officials, immediate family members, and consulate offices of a detainees death.

(b)(7)e
47
ICE.11.5082.000564
DETENTION STANDARD
TIADD-5
TIADD-6
TIADD-7
Transportation
T-1
Transportation
T-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(F), the FOD must ensure, if a detainee dies while in 30 an IGSA facility, the Officer in Charge turns his or her property over to ICE for processing and disposition. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(G), the FOD must ensure, within seven calendar days of notification of death, the family 30 has the opportunity to claim the detainees remains. If family members cannot be located, or decline orally or in writing to claim the remains, ICE must notify the consulate in writing. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(H), the FOD must ensure the facility has procedures for closing the case of a detainee, including: sending the detainees 30 fingerprint card to the FBI, stamped deceased, and identifying the place of death; placing a copy of the gravesite title in the A-file; and closing the detainees Deportable Alien Control System file. In accordance with the ICE NDS, Transportation, section (III)(C), the FOD must ensure the facility maintains all vehicle-operators files at the official duty station. Each file must contain a 31 Certificate of Completion from the ICE Bus Training Program; a copy of the most current physical examination used to obtain the CDL; and a copy of the CDL. In accordance with the ICE NDS, Transportation, section (III)(C), the FOD must ensure transporting officers 31 inspect vehicles using a checklist and note any defect that could render the vehicle unsafe or inoperable.

(b)(7)e
ICE.11.5082.000565
DETENTION STANDARD
Transportation
T-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Transportation, section (III)(N), the FOD must ensure the transportation crew 31 keeps bolt cutters in the forward compartment, with the outer equipment for use in an emergency.
In accordance with the ICE NDS, Transportation, section (III)(Z)(2-4, 6,7 and 9), the FOD must ensure all vehicles have: (2) a cellular phone as a back-up communication system, (3) a portable CB radio for emergency use only, (4) the forward baggage compartment of buses contains two equipment boxes. Box 1 must have large bolt cutters, fuses, fan belts, a jack, small hand tools, a flashlight, a lantern, rags, disposable trash bags, a broom, a ground cloth, two sets of coveralls, and work gloves. The Fleet Officer or Shop Supervisor must maintain the inventory, and check the written inventory quarterly. Box 2 must have transmission fluid, water for the radiator, oil, toilet disinfectant, extra fire extinguisher(s), road flares, and reflectors. Transporting officers must record the amount and date used, and by whom, on inventory sheets kept in Box 2, as well as maintain MSDS sheets, as necessary. Other equipment may be added as necessary. Transporting officers must provide supervisors with written notifications of inventory needs, including items that need replenishing or replacing. (6) have 50 emergency blankets, (7) a boarding bag containing extra forms, a camera that produces instant photographs, film, batteries, and emergency telephone numbers for: ICE offices, local police, State police, etc. and (9) restraining equipment, including, at a minimum: 50 sets of waist chains; 50 sets of leg irons; 2 sets of leg irons modified for use as hand cuffs (extralarge); 2 sets of group (daisy) chains, 25feet each, and keyed-alike padlocks (for an emergency evacuation). All restraining equipment must be of high quality, maintained in good operating condition, and kept in the forward baggage compartment
Transportation
T-4
32
with the other supplies.

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49
ICE.11.5082.000566
DETENTION STANDARD
PAGE
Use of Force
UOF-1
33
Use of Force
UOF-2
(b)(7)e
33
Use of Force
UOF-3
33
Visitation
V-1
Visitation
V-2
Visitation, section (III)(A), the FOD must ensure the facility establishes written visiting procedures, including a schedule and hours of visitation, taking into account the visitation requirements of family, including minors, friends, legal representatives, consular officials, interested non-governmental organizations, and the news media. In accordance with the ICE NDS, Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all visitors, and a separate log of legal visitors. The general visitors logbook must record the name and A-number of the detainee visited, the visitors name and address, the visitors immigration status, the visitors relationship to the detainee, and the date and time-in andout.
34
34

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50
ICE.11.5082.000567
DETENTION STANDARD
Visitation
V-3
Visitation
V-4
Visitation
V-5
Visitation
V-6
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Visitation, section (III)(I)(6), the FOD must ensure the facility establishes a written procedure to allow legal service 35 providers and legal assistants to telephone the facility in advance of a visit to determine whether a particular individual is detained within the facility. In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure, once an attorney-client relationship has been established, the legal representative completes and 35 submits Form G-28, available in the legal visitors reception area. Staff must collect completed forms and forward them to ICE. In accordance with the ICE NDS, Visitation, section (III)(I)(10), the FOD must ensure the facilitys written legal visitation procedures provide for the 35 exchange of documents between detainees and legal representatives, or legal assistants, even when contact visitation rooms are unavailable. In accordance with the ICE NDS, Visitation, section (III)(I)(16), the FOD must ensure the facilitys written legal visitation policy is available upon request. The site-specific policy must specify visitation hours, procedures, and standards, including but not limited to: telephone inquiries, dress code, legal assistants working under the 35 supervision of an attorney, prerepresentational meetings, Form G-28 requirements, identification and search of legal representatives, identification of visitors, materials provided to detainees by legal representatives, confidential group legal meetings, and detainee sign-up.

(b)(7)e
51
ICE.11.5082.000568
APPENDIX C
DETENTION STANDARD RECOMMENDATIONS PAGE In order to ensure confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations, all initial medical screening forms must be maintained in the 9 detainees medical record, and not in the detainees detention file. ODO recommends the facility establish one system to track or log all grievances. ODO recommends implementation of written sick call request forms to ensure all detainees requesting health care services may access them without having to go through custody staff, and to ensure Medical Department accountability, with respect to timeliness of review and delivery of service. Though MLDC does not accept detainees for whom this standard applies, it is possible a detainee may become seriously or terminally ill or injured while in MLDC custody. ODO recommends establishment of policies addressing procedures required by the standard pending transfer to a hospital or alternative facility.
13
Medical Care
24
30

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ICE.11.5082.000569



Atlanta Field Office North Georgia Detention Center Gainesville, Georgia
January 12-14, 2011
________________________________
ICE.11.5082.000570
QUALITY ASSURANCE REVIEW NORTH GEORGIA DETENTION CENTER ATLANTA FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY ...............................................................................................1 INSPECTION PROCESS Report Organization .................................................................................................3 Inspection Team Members .......................................................................................3 OPERATIONAL ENVIRONMENT Internal Relations .....................................................................................................4 Detainee Relations ...................................................................................................4 ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed ................................................................................5 Detainee Grievance Procedures ...............................................................................6 Detention Files .........................................................................................................7 Disciplinary Policy...................................................................................................8 Issuance and Exchange of Clothing, Bedding, and Towels .....................................9 Special Management Unit (Administrative Segregation) ......................................10 Staff-Detainee Communication .............................................................................11 LIST OF ACRONYMS ...................................................................................................12
ICE.11.5082.000571
EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR) Office of Detention Oversight (ODO) conducted a Quality Assurance Review (QAR) of the North Georgia Detention Center (NGDC), located in Gainesville, GA, on January 12-14, 2011. The review was the first completed at NGDC by ODO. The facility was opened in October 2009, and is owned by Hall County, GA and operated by the Correction Corporation of America (CCA). At that time, ICE began to place male and female detainees of all classification levels at NGDC through an intergovernmental service agreement (IGSA). The facility solely accommodates ICE detainees, for periods in (b)(7)e excess of 72 hours. (b)(7)e . Medical care is provided under contract by Northeast Georgia Health System, Inc. Food service is provided under a contract with Canteen Correctional Services. ICE personnel are assigned to the NGDC on a permanent basis, including one Supervisory Detention and Deportation Officer (SDDO), six Immigration Enforcement Agents (IEAs), six Deportation Officers (DOs), and one Detention and Removal Assistant (DRA). The total number of non-ICE staff employed at NGDC is 119. ERO contractors, MGT of America, Inc. (MGT), conducted an annual review of the ICE National Detention Standards (NDS) at NGDC in August 2010. The facility received an overall rating of good, and was found to be in compliance with all 38 standards reviewed. ODO reviewed a total of 24 NDS; 18 areas were found to be fully compliant, while 6 had a total of 9 deficiencies, including the following: Detention Files (2 deficiencies); Detainee Grievance Procedures (2); Disciplinary Policy (1); Issuance and Exchange of Clothing, Bedding, and Towels (1); Special Management Unit (Administrative Segregation) (1); and Staff-Detainee Communication (2). Several of these deficiencies were primarily clerical in nature. Examples of these deficiencies are personnel excluding copies of detainee classification worksheets in detention files and ICE staff failing to create detention files in accordance with the NDS requirements. With respect to the August 2010 ERO MGT inspection, ODO did not find any repeat deficiencies in the course of the review of the NDS. Overall, ODO found NGDC to be in compliance with the standards areas inspected; however, some of the administrative deficiencies cited in this report are important items to remedy to best ensure the health and safety of all ICE detainees. Detention standards such as Staff-Detainee Communication and Detainee Grievance Procedures are critically important detainee-centric areas that often serve to prevent negative occurrences at facilities, when in full compliance. ODO did fully address these issues and concerns during the Closeout Brief on January 14th to best ensure that the facility and ERO staff would have the opportunity to initiate actions to expeditiously correct the deficiencies. ICE staff conducts daily regular and irregular visits to housing units to address detainee concerns and inquiries. NGDC has processes in place to ensure detainees have the opportunity to file grievances and appeal the decisions of grievances. No deficiencies or areas of concern were found in standards covering security, environmental health and safety, and food service.

(b)(7)e
North Georgia Detention Center ERO Atlanta
ICE.11.5082.000572
NGDC has a fully functioning medical unit to address detainee health care. ODO noted no deficiencies or areas of concern in any standards that covered medical issues. Detainees have ample access to both indoor and outdoor recreation areas. NGDC has a designated law library equipped with computers and updated with the most recent version of Lexis-Nexis. NGDC employs a full-time chaplain and detainees have access to religious services. No issues or complaints were noted in these areas. This report includes descriptions of all the deficiencies and refers to the specific, relevant NDS. The report will be provided to ERO to develop corrective actions to resolve the nine deficiencies. Prior to the conclusion of the ODO inspection, ICE and NGDC staff began to take action to correct the deficient areas.
Office of Detention Oversight January 2011

(b)(7)e
ICE.11.5082.000573
INSPECTION PROCESS
The ODO primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS) or the Performance Based National Detention Standards (PBNDS), as applicable. In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at NGDC to determine compliance with current policies and detention standards (in this case, the NDS). Prior to the inspection, ODO collected and analyzed detainee information from multiple ICE databases including the (b)(7)e (b)(7)e and . ODO also gathered facility (b)(7)e facts and inspection-related inf staff to fully prepare for the inspection at NGDC.
REPORT ORGANIZATION
This report contains a detailed synopsis of those NDS areas reviewed by ODO that were found to be deficient in at least one aspect of the standard. Instances in which detention standards and/or policies are not being adhered to are reported as deficiencies. When possible, the report includes contextual and quantitative information that is relevant to the cited standard. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. ODO strives to ensure that its detention facility inspection reports convey pertinent and useful feedback to best enable expeditious corrective actions where needed, and to assist in the ongoing process of incorporating best practices across the spectrum of nation-wide detention facility operations. This report documents inspection results, serves as an official record, and is intended to provide ICE and detention facility management with a comprehensive evaluation of compliance with policies and detention standards. Comments and questions regarding the report findings should be forwarded to the OPR Deputy Division Director, Office of Detention Oversight.

Detention and Deportation Officer Detention and Deportation Officer Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters MGT of America, Inc MGT of America, Inc. MGT of America, Inc.
(b)(7)e

(b)(7)e
ICE.11.5082.000574
INTERNAL RELATIONS
ODO interviewed supervisory ICE and NGDC staff, including the NGDC Warden, Assistant Warden, Chief of Security, and Captain; and the ICE ERO Assistant Field Office Director (AFOD). ODO also interviewed non-supervisory staff, including ICE IEAs and DOs, and NGDC Corrections Officers (COs). Overall, NGDC and ICE staff expressed good morale levels and an excellent working relationship exists between the two entities. ICE staff assigned to NGDC expressed their respect and appreciation for the SDDO assigned to the facility. The Warden and the ICE SDDO at NGDC stated the average length of stay for detainees at NGDC would decrease if the facility had an Immigration Court Video Telephone Conference (VTC). The SDDO stated the average length of stay is 11 days. Both ICE and NGDC staff supervisors stated security clearance documentation for newly-hired employees takes too long to process at ICE HQ, in some cases up to two years to grant a security clearance to NGDC employees. This has impeded the hiring process for NGDC staff. Two NGDC COs stated ICE needs to increase its presence within the ICE detainee housing areas. ICE staff stated processing for obtaining travel documents for detainees is hindered due to lack of office supplies such as a camera and photo equipment. ICE staff at the sub-office at NGDC stated that in comparison to the Atlanta field office, they have a reduced chance to receive promotional opportunities, training, assigned vehicles, and participation in ERO fugitive operations. IEAs mentioned there is an overlapping of responsibilities between DOs and IEAs. IEAs complained that they frequently conduct removal case management activities involving Justice Prisoner Alien Transportation System (JPATS) issues.
DETAINEE RELATIONS
ODO randomly selected 25 detainees at NGDC to interview and asses the detention conditions. Overall, the majority of the detainees stated they were treated with dignity and respect. Detainees stated they are able to send and receive mail, use the telephones, and access the law library. Detainees complimented the facilitys food services, religious services, recreation, and medical services. Some detainees voiced complaints about the laundry services, a need for hair cuts, and four specifically complained about a rude facility CO. The four detainees qualified their concerns about the officer as not being misconduct; rather, simply bossy in behavior. The complaint about the CO was communicated to NGDC and ICE management personnel by ODO.

(b)(7)e
ICE.11.5082.000575

A total of 24 National Detention Standards were reviewed during the ODO inspection. The following six areas were found to be deficient with respect to adherence to the ICE NDS, as required: Detainee Grievance Procedures Detention Files Disciplinary Policy Issuance and Exchange of Clothing, Bedding, and Towels Special Management Unit (Administrative Segregation) Staff-Detainee Communication The following 18 areas were found to be in compliance with the NDS: Access to Legal Material Detainee Handbook Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Medical Care Population Counts Recreation Religious Practices Special Management Unit (Disciplinary Segregation) Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Use of Force Visitation As these 18 standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e
ICE.11.5082.000576

ODO reviewed the Detainee Grievance Procedures standard at the NGDC to determine if a process to submit formal or emergency grievances exists, if detainees have a fear of reprisal, and whether responses to the grievances are provided. The review also determined whether detainees have an opportunity to appeal grievances and the accuracy of records maintained. ODO also interviewed staff and reviewed files, policy, procedures and logs. NGDC has written procedures and a system in place for detainees to file both informal and formal grievances. Detainees also have the opportunity to appeal the decisions of grievances. Procedures exist in the facility for identifying and handling emergency grievances. NGDC maintains a grievance log detailing the detainee filing the grievance, the reason for the grievance, and the resulting disposition. Each grievance is reviewed by the grievance officer at the facility. ODO reviewed eight detention files of detainees who had filed grievances. Copies of the grievances were not filed in the detention files (Deficiency DGP-1). The detainee handbook contains a section providing the grievance procedures but it does not include the required information on the availability of assistance in filing the grievance (Deficiency DGP-2).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance will remain in the detainees detention file for at least three years. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(2), the facility must provide each detainee, upon admittance, a copy of the detainee handbook or equivalent. The grievance section of the detainee handbook will provide notice of the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance.

(b)(7)e
ICE.11.5082.000577

ODO reviewed the Detention Files standard at the NGDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours. ODO reviewed a sample of 20 detention files to ascertain whether all required documentation was included. NGDC creates and maintains a detention file for each detainee booked into the facility. Each detention file is noted when listed as active or closed. The files are maintained in a secure area. A logbook is maintained to record the detention files removal from the cabinet. The detention files contain documents generated during the admission process and during the detainees time in the facility. Only one of the reviewed twenty detention files reviewed contained a classification work sheet (Deficiency DF-1). The classification worksheet is required to assure each detainee is properly classified before admission to the general population to prevent intermingling of different classifications in the housing units. While the NGDC maintains a detention file for each detainee in the facility, interviews with ERO staff revealed the ICE field office does not maintain required separate detention files for detainees admitted to NGDC (Deficiency DF-2). ERO maintains these files to ensure that when a detainee is transferred to another facility, the receiving facility can receive a copy of the important records in the detainees file. The receiving facility must be aware of all issues and historical records, such as criminal and institutional background, during the detainees tenure at the transferring facility. This information will assist the receiving facility on how to manage the detainee.

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B)(1)(b), the FOD must ensure the detainee detention file will contain either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-file. The file will, at a minimum, contain the classification work sheet. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, Section (IV), the FOD must ensure the field office with IGSA-facility jurisdiction shall create and maintain detention files on all detainees admitted to IGSA facilities.

(b)(7)e
ICE.11.5082.000578

ODO reviewed the Disciplinary Policy standard at the NGDC to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO interviewed detainees and staff, reviewed the disciplinary policy and the detainee handbook, and examined disciplinary files. NGDCs detainee disciplinary system includes required progressive levels of review, appeals, and documentation procedures. The disciplinary policy and detainee handbook clearly define detainee rights and responsibilities. Procedures are in place to ensure incident reports are investigated within 24 hours of the incident. ODO requested to review incident reports that have been generated over the past year. ODOs review of documentation on seven completed incident reports revealed all were investigated within 24 hours of the incident. The facility conducts hearings for instances that involve high-moderate and low-moderate charges by way of a Unit Disciplinary Committee (UDC). Unresolved cases and charges in the greatest and high offense category are forwarded to the Institutional Disciplinary Panel (IDP) for hearings and adjudication. ODO found no deficiencies in its review of three completed IDP packets. Review of four completed UDC packets revealed the UDC imposed a sanction of disciplinary segregation in one of the four cases (Deficiency DP-1). As per the ICE NDS, the FOD must ensure that the IDP is the sole group to impose detainee disciplinary segregation.

DEFICIENCY DP-1 In accordance with the ICE NDS, Disciplinary Policy, section (III)(F), the FOD must ensure only the Institutional Disciplinary Panel places detainees into disciplinary segregation.

(b)(7)e
ICE.11.5082.000579
ISSUANCE AND EXCHANGE OF CLOTHING, BEDDING AND TOWELS (IECB&T)

ODO reviewed the Issuance and Exchange of Clothing, Bedding and Towels standard at the NGDC to determine if the facility provides clean clothing, bedding, linens, and towels to every detainee upon arrival, and to ascertain if the facility provides ICE detainees with regular exchanges of clothing, linens, and towels for as long as they remain in detention. ODO interviewed staff and detainees, observed in-processing, and reviewed local policy. ODO found the facility has procedures in place for regular issuance and exchange of clothing, bedding, linens and towels. During ODOs observation of in-processing, detainees were issued clean, temperature-appropriate, presentable clothing, including linens and towels. Detainees are required to sign a receipt for items issued and the receipt is maintained in the detention files. All detainees are issued three colored uniforms, which are exchanged on Tuesdays and Thursdays. Detainees are issued two pairs of white socks, and two sets of undergarments (tshirts and underwear). These items are exchanged on Wednesdays and Fridays, not on a daily basis as required by the standard (Deficiency IECB&T-1). Exchange of undergarments on a daily basis supports proper hygiene, sanitation, and good health.

DEFICIENCY IECB&T-1 In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure that detainees shall be provided with clean clothing, linen and towels on a regular basis to ensure proper hygiene. Socks and undergarments will be exchanged daily, outer garments at least twice weekly and sheets, towels, and pillowcases at least weekly.

(b)(7)e
ICE.11.5082.000580
SPECIAL MANAGEMENT UNIT (SMU) (Administrative Segregation)

ODO reviewed the Special Management Unit (SMU) (Administrative Segregation) standard at the NGDC to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. NGDC operates two separate SMUs, one for male detainees, the second for female detainees. ODO toured the SMUs, reviewed policies, logbooks, and other documentation, and interviewed staff. Overall, ODO found compliance with the standard. Written procedures are in place to temporarily segregate detainees for disciplinary and administrative reasons. During the ODO review, both SMUs were empty. ODOs inspection revealed the units are well ventilated, adequately lit, appropriately heated, and maintained in a sanitary condition. All cells are equipped with two beds which are securely fastened to the cell floor.
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(b)(7)e

(b)(7)e
ICE.11.5082.000581

ODO reviewed the Staff-Detainee Communication standard at the NGDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed logs and interviewed staff. ODO found that ICE staff makes daily regular and irregular visits in response to ICE detainee requests and concerns. ICE staff daily visits are recorded on an electronic log and a separate form is filled out with detailed information. ICE staff presented a schedule to ODO explaining ICE ERO management conduct regular unannounced visits. ODO reviewed the facility visitor log to determine if ICE ERO management were implementing the unannounced visits. The facility visitor log does not have any evidence verifying if ICE ERO management conduct unannounced visits, specifically the living and activity areas such as housing, food service, recreation, segregation and medical (Deficiency SDC-1). It is vitally important for ERO management staff to conduct regular visits to detention facilities to observe and monitor conditions of confinement for detainees. ODO reviewed the detainee request log to assure all requests sent to ICE are reviewed and answered within 72 hours. During the 2010 period of October through December, 421 requests were received from detainees. Of the 421 requests, 54 were not answered by ICE at all. Of the 367 that were answered, 15 were answered past the 72-hour period (Deficiency SDC-2). ODO observed detainee requests were filed in the detainee detention files which are maintained in excess of the required three years. All procedures for filing a detainee request are referenced in the detainee handbook.

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure that the ICE Officer in Charge (OIC), Assistant Officer in Charge and designated department heads must conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and observe living and working conditions. Each facility will develop a method to document the visits. ICE will develop a method to document the visits independent of the facilitys documentation. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(1)(a), the FOD must ensure the officer receiving the request shall normally respond in person or in writing as soon as possible and practicable, not later than within 72 hours from receiving the request.

(b)(7)e
ICE.11.5082.000582
LIST OF ACRONYMS

(b)(7)e
ICE.11.5082.000583


Enforcement and Removal Operations Salt Lake City Field Office North Las Vegas Detention Center North Las Vegas, Nevada
August 11-12, 2010
ICE.11.5082.000584
OFFICE OF PROFESSIONAL RESPONSIBILITY MISSION STATEMENT The Office of Professional Responsibility (OPR) is responsible for investigating allegations of employee misconduct impartially, independently, and thoroughly. OPR prepares timely and comprehensive reports of investigations for judicial or management action. OPR inspects and reviews Immigration and Customs Enforcement (ICE) field offices, operations and processes in order to provide executive management with an independent review of the agencys organizational health, and assesses the effectiveness and efficiency of the overall ICE mission.
ICE.11.5082.000585
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW. AREAS OF CONCERN. ICE NATIONAL DETENTION STANDARDS Access to Legal Material..... Admission and Release. Detainee Grievance Procedures.. Disciplinary Policy... Emergency Plans.... Environmental Health and Safety. Food Service Hold Rooms in Detention Facilities.. Issuance and Exchange of Clothing, Bedding, and Towels. Population Counts... Recreation. Staff-Detainee Communication.. Tool Control... 1 1 2 3
4 4 5 6 6 7 7 8 9 9 9 10 10
ICE.11.5082.000586
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives include the evaluation of the welfare, safety and living conditions of detainees, and compliance with applicable laws, policies, regulations and procedures. In April 2009, ODO, formerly the Detention Facilities Inspection Group, conducted a Quality Assurance Review of the North Las Vegas Detention Center (NLVDC) in North Las Vegas, Nevada. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION

Special Agent (Team Leader) Detention and Deportation Officer Contract Inspector ODO, OPR San Diego ODO, OPR San Diego MGT of America, Inc.
(b)(7)e
_____________________________________________________________________________________________

(b)(7)e
North Las Vegas Detention Center ERO Salt Lake City
ICE.11.5082.000587
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material; Admission and Release; Detainee Classification System; Detainee Grievance Procedures; Detention Files; Disciplinary Policy; Emergency Plans; Environmental Health and Safety; Food Service; Hold Rooms in Detention Facilities; Hunger Strikes; Issuance and Exchange of Clothing, Bedding, and Towels; Key and Lock Control; Medical Care; Population Counts; Recreation; Security Inspections; Staff-Detainee Communication; Suicide Prevention and Intervention; Use of Force; Terminal Illness, Advanced Directives, and Death; and Tool Control. ODO staff identified 73 deficiencies during the Quality Assurance Review conducted in April 2009. During this Follow-up Inspection, ODO staff found 22 (30%) repeated deficiencies. Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at NLVDC, to be noncompliant with the ICE NDS: Access to Legal Material Admission and Release Detainee Grievance Procedures Disciplinary Policy Emergency Plans Environmental Health and Safety Food Service Hold Rooms in Detention Facilities Issuance and Exchange of Clothing, Bedding, and Towels Population Counts Recreation Staff-Detainee Communication Tool Control ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards: Detainee Classification System Detention Files Hunger Strikes Key and Lock Control Medical Care Security Inspections Suicide Prevention and Intervention Use of Force Terminal Illness, Advanced Directives, and Death
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000588
AREAS OF CONCERN
During this Follow-up Inspection, ODO noticed a posting in the law library stating detainees can only access the facilitys law library during their scheduled recreation times. The facilitys Detention Services Manager confirmed this to be the case and was informed by ODO access to the law library must be scheduled separate from and independent of scheduled recreation hours, per the ICE NDS, Access to Legal Material. The facility utilizes a computer program called Offendertrak to electronically monitor and record all grievances filed by U.S. Marshals Service (USMS) inmates and ICE detainees housed at NLVDC. This program, which is developed and sold by Motorola, cannot sort or separate grievances filed between USMS inmates and ICE detainees, making the process of tracking grievances filed by ICE detainees very difficult. Specifically, the computer program cannot generate a grievance log which captures only the grievances filed by ICE detainees. The Detention Services Manager and a corrections officer advised ODO the facility will contact Motorola and attempt to have the Offendertrak computer program modified to have the ability to sort and separate all grievances filed between USMS inmates and ICE detainees.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000589

During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Access to Legal Material, section (III)(P), the FOD must ensure detention facilities provide assistance to any unrepresented detainee who requests a notary public, certified mail, or other such service to pursue a legal matter, if the detainee is unable to meet the need through a family member, friend, or community organization. If it is unclear whether the requested service is necessary for the pursuit of a legal matter, the District Counsel should be consulted. ODO Follow-up Finding: The facilitys grievance officer informed ODO, NLVDC does not provide or pay for outgoing certified mail sent by detainees. ODO Initial Finding: In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook, or equivalent, provides the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for detainee use; 2) scheduled hours of access to the law library; 3) procedures for requesting access to the law library; 4) procedures for requesting additional time in the law library (beyond the 5 hours per week minimum); 5) procedures for requesting legal reference materials not maintained in the law library and; 6) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law library's holdings. ODO Follow-up Finding: Scheduled law library hours are not posted in the law library. Instead, a posting in the law library notifies detainees they are allowed access to the law library during recreation time, but does not provide specific times. Also, the procedures for requesting legal reference materials not maintained in the law library are not posted in the law library or mentioned in the facilitys detainee handbook.

During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure detainees are provided with clean clothing, linens, and towels on a regular basis to ensure proper hygiene. Socks and undergarments must be exchanged daily; outer garments at least twice weekly; and sheets, towels, and pillowcases at least weekly.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000590
ODO Follow-up Finding: According to the Detention Services Manager and an ICE Supervisory Detention and Deportation Officer, all detainees are issued two pairs of new underwear by ICE prior to arriving at the facility. Detainees who wish to obtain additional pairs of underwear must purchase them from the facility. According to the Detention Services Manager, detainees can submit soiled clothes for washing at anytime; however, the turnaround time for laundered clothes to be returned to detainees is 2 to 3 days. Based on this turnaround time, detainees do not have the opportunity to exchange or obtain clean underwear on a daily basis.

During the initial ODO inspection, five deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(2), the FOD must ensure detainees are allowed to submit a formal, written grievance to the facilitys grievance committee. ODO Follow-up Finding: According to the Grievance Officer and the Detention Services Manager, NLVDC does not have a grievance committee. ODO Initial Finding: In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G), the FOD must ensure the facility provides each detainee, upon admittance, with a copy of the detainee handbook or equivalent. The grievance section of the detainee handbook will provide notice of the following: 1) the opportunity to file a grievance, both informal and formal; 2) the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance; 3) the procedures for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved. The level above the facilitys Officer in Charge (OIC) is the ICE OIC; 4) the procedures for contacting ICE to appeal the decision of the facilitys OIC; 5) the policy prohibiting staff from harassing, disciplining, punishing or otherwise retaliating against any detainee for filing a grievance; and 6) the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Security, Office of the Inspector General (DHS OIG). ODO Follow-up Finding: The facilitys detainee handbook includes its policy prohibiting retaliation by staff against detainees who submit grievances, and also notifies detainees of how to file a complaint about staff misconduct with DHS OIG. However, the handbook does not mention the procedures for detainees to contact ICE to appeal the grievance decision of the OIC at NLVDC.
_____________________________________________________________________________________________
5
(b)(7)e
ICE.11.5082.000591
DISCIPLINARY POLICY
During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(d), the FOD must ensure the detainee handbook advises detainees of the right to correspond with persons or organizations, consistent with safety, security, and the orderly operation of the facility. ODO Follow-up Finding: The facilitys detainee handbook does not mention the right to correspond with persons or organizations, consistent with safety, security, and the orderly operation of the facility.
EMERGENCY PLANS
During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Emergency Plans, section (III)(B)(1), the FOD must ensure detention facilities designate an individual(s) responsible for scheduling and keeping the emergency plans current. The facility must plan and schedule annual reviews. ODO Follow-up Finding: ODO reviewed the emergency plans and interviewed facility staff. The emergency plans have not been reviewed on an annual basis; the cover sheet for the emergency plans states the plans were reviewed on October 20, 2008. A few of the individual plans are dated March 2009. ODO Initial Finding: In accordance with the ICE NDS, Emergency Plans, section (III)(D), the FOD must ensure detention facilities compile ICE-approved individual contingency plans, as needed, in the following order: 1) Fire, 2) Work/Food Strike, 3) Disturbance, 4) Escape, 5) Hostages (Internal), 6) Search (Internal), 7) Bomb Threat, 8) Adverse Weather, 9) Civil Disturbance, 10) Environmental Hazard, 11) Detainee Transportation System Emergency, 12) Evacuation, 13) Service-wide Lockdown, and #) Site-specific concerns, if any. These mini-plans will specify only contingency-specific divergences from the general plan. ODO Follow-up Finding: ODO reviewed the emergency plans and found the facility does not have individual plans for work/food strike, internal search, adverse weather, detainee transportation system, evacuation, or service-wide lockdown.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000592

During the initial ODO inspection, six deficiencies were identified in this area. During this follow-up inspection, the following three deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure a qualified departmental staff member conducts weekly fire and safety inspections, and safety staff conducts monthly inspections. Written reports of the inspections will be forwarded to the OIC for review and, if necessary, corrective action. Inspection reports and records of corrective action must be maintained in the safety office. ODO Follow-up Finding: Based on an interview with the Safety Lieutenant, as well as a lack of documentation, ODO determined a qualified departmental staff member does not conduct weekly fire and safety inspections, and safety staff does not conduct monthly inspections. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD must ensure each detention facilitys fire evacuation diagrams, in addition to a general area diagram, have the following provided on existing signs: English and Spanish instructions, You Are Here markers, and emergency equipment locations. New signs and sign replacements must also identify and explain Areas of Safe Refuge. ODO Follow-up Finding: ODO toured the facility and observed posted exit diagrams do not provide instructions in Spanish. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barbershop operation is located in a separate room not used for any other purpose. ODO Follow-up Finding: ODO toured the facility and interviewed staff. The barbershop is not located in a separate room, not used for any other purpose. All haircuts are performed in the housing units located next to the officers station.
FOOD SERVICE
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(B)(4), the FOD must ensure controlled ingredients used in food service preparation, such as nutmeg, cloves, and alcohol-based flavoring, are stored in a secured area, inventoried, and a log kept of their usage.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000593
ODO Follow-up Finding: The Food Service Supervisor advised ODO, the kitchen staff does not maintain an inventory of nutmeg, or keep a log to document its usage.

During the initial ODO inspection, five deficiencies were identified in this area. During this Follow-up Inspection, the following four deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(B)(4), the FOD must ensure detainees are provided with basic personal-hygiene items, e.g., water, disposable cups, soap, toilet paper, feminine hygiene items, diapers, and sanitary wipes. ODO Follow-up Finding: A corrections officer advised ODO, the facility does not provide or issue soap to detainees who are placed in holding cells. A corrections officer also informed ODO, the holding cells do not have soap. ODO Initial Finding: In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which involves irregular visual monitoring every 15 minutes (each time recording the time and officers star number in the detention log). When the hold room is not in the officers direct line of sight, he or she must maintain continuous auditory monitoring. ODO Follow-up Finding: According to a corrections officer, visual checks are conducted every 30 minutes for detainees placed in holding cells. ODO Initial Finding: In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(B), the FOD must ensure the maximum aggregate time an individual may be held in a hold room is 12 hours. ODO Follow-up Finding: ODO inspected the hold room entries for five ICE detainees, and found three of the five detainees were placed in holding cells for more than 12 consecutive hours. ODO Initial Finding: In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(6), the FOD must ensure no officer enters a hold room unless another officer is stationed outside the door, ready to respond as needed. Officers must not carry firearms, oleoresin capsicum (OC) spray, batons, or other non-deadly force devices into the hold room. ODO Follow-up Finding: According to a corrections officer, officers cannot enter a holding cell without another officer present; however, officers can enter holding cells carrying handcuffs, tasers, OC sprays, and collapsible batons.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000594
ISSUANCE AND EXCHANGE OF CLOTHING, BEDDING, AND TOWELS

During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure detainees are provided with clean clothing, linens, and towels on a regular basis to ensure proper hygiene. Socks and undergarments must be exchanged daily; outer garments at least twice weekly; and sheets, towels, and pillowcases at least weekly. ODO Follow-up Finding: According to the Detention Services Manager and an ICE Supervisory Detention and Deportation Officer, all detainees are issued two pairs of new underwear by ICE prior to arriving at the facility. Detainees who wish to obtain additional pairs of underwear must purchase them from the facility. According to the Detention Services Manager, detainees can submit soiled clothes for washing at anytime; however, the turnaround time for laundered clothes to be returned to detainees is 2 to 3 days. Based on this turnaround time, detainees do not have the opportunity to exchange or obtain clean underwear on a daily basis.
POPULATION COUNTS
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Population Counts, section (III)(A), the FOD must ensure a formal count is conducted at least once per shift. ODO Follow-up Finding: Formal counts are conducted by detention staff at 9 p.m., 12 a.m., and 4 a.m. Based on this schedule, formal counts are not conducted by the day shift between 4 a.m. and 9 p.m.
RECREATION
During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure all facilities have an individual responsible for the development and oversight of the recreation program. ODO Follow-up Finding: The Detention Services Manager and the Captain for detention operations advised ODO, NLVDC does not have an individual designated or responsible for the development and oversight of the recreation program.
_____________________________________________________________________________________________
9
(b)(7)e
ICE.11.5082.000595
During the initial ODO inspection, six deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and remain in the detainees detention file for at least 3 years. ODO Follow-up Finding: Not all completed detainee requests are placed in the detainees detention file. Therefore, the completed detainee requests do not remain in the detainees detention files for at least 3 years.
TOOL CONTROL
During the initial ODO inspection, six deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Tool Control, section (III)(G), the FOD must ensure all detention facilities have procedures for the control of ladders, extension cords, and ropes. ODO Follow-up Finding: The facility does not have procedures in place ensuring the control of ladders, extension cords, and ropes. ODO Initial Finding: In accordance with the ICE NDS, Tool Control, section (III)(E), the FOD must ensure all detention facilities establish written procedures for storing tools. The tool storage system must ensure accountability. Commonly used, mounted tools must be stored so a tools disappearance does not escape attention. ODO Follow-up Finding: Tools maintained in the laundry area and in the commissary are stored so that a missing tool will be noticed. Tools are secured within a locked box, and are inventoried at the beginning and end of each shift. However, bolt cutters maintained in the Shift Supervisors office are not properly secured, and are not placed on a shadow board.
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(b)(7)e
10
ICE.11.5082.000596


Enforcement and Removal Operations Seattle Field Office Northwest Detention Center Tacoma, WA
January 25 - 26, 2011
ICE.11.5082.000597
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization .................................................................................................1 Inspection Team Members .......................................................................................1 OVERVIEW .......................................................................................................................2 ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS Hold Rooms in Detention Facilities .........................................................................3 Recreation ................................................................................................................4 Religious Practices ...................................................................................................5 Searches of Detainees ..............................................................................................6 LIST OF ACRONYMS..7
ICE.11.5082.000598
INSPECTION PROCESS
The Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS) or the Performance Based National Detention Standards (PBNDS), as applicable. In addition, ODO may focus on the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. In March 2010, the ODO conducted a Quality Assurance Review (QAR) of the Northwest Detention Center (NWDC) in Tacoma, WA, which is under the jurisdiction of the Field Office Director (FOD), ERO, Seattle, WA (ERO/Seattle). This Follow-up Inspection was conducted to determine whether corrective actions had been taken to correct deficiencies identified in the QAR report.
REPORT ORGANIZATION
This report documents corrected and remaining deficiencies identified in the QAR report submitted to ERO. A summary of findings is provided in the Overview. Uncorrected deficiencies are detailed in the ICE PBNDS section. This report documents Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. Further, it provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the OPR Deputy Division Director, Office of Detention Oversight.

Special Agent (Team Leader) Special Agent Contract Inspector ODO, OPR Phoenix ODO, OPR Phoenix MGT of America, Inc.
(b)(6), (b)(7)(C)

(b)(7)e
Northwest Detention Center ERO Seattle
ICE.11.5082.000599
OVERVIEW
A total of 29 areas were found to be deficient with respect to adherence to the ICE PBNDS during the March 2010 ODO QAR. The following is a list of those PBNDS areas that contained an overall total of 61 deficiencies that needed to be addressed and corrected following the ODO inspection: Admission and Release Classification System Correspondence and Other Mail Detainee Handbook Detention Files Disciplinary System Emergency Plans Environmental Health and Safety Facility Security and Control Food Service Funds and Personal Property Grievance System Hold Rooms in Detention Facilities Law Libraries and Legal Material Legal Rights Group Presentations Marriage Requests Medical Care News Media Interviews and Tours Population Counts Post Orders Recreation Religious Practices Searches of Detainees Staff-Detainee Communication Transfer of Detainees Transportation Tool Control Use of Force and Restraints Visitation During the Follow-up Inspection, ODO noted that corrective actions were taken in almost all of the above-referenced PBNDS deficient areas. ODO staff noted five (8%) repeated deficiencies within the following four PBNDS: Hold Rooms in Detention Facilities Recreation Religious Practices Searches of Detainees
(b)(7)e
ICE.11.5082.000600
PERFORMANCE BASED NATIONAL DETENTION STANDARDS

ODO identified four deficiencies during the QAR. During this follow-up inspection, the ODO found that two deficiencies had not yet been corrected. While the contractor operating the facility has approved renovation requests to correct these, the facility is still awaiting bids on the projects. ODO QAR Findings: In accordance with the PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(7), the FOD must ensure that each hold room shall have floor drain(s). The hold rooms did not have the required floor drains at the time of the initial inspection. ODO Follow-up Finding: Inspection of the hold rooms by ODO revealed they still do not have floor drains. GEO Group, Incorporated (GEO), the contractor operating the facility, has approved a renovation request. NWDC is currently awaiting bids on the project. ODO QAR Findings: In accordance with the PBNDS, Hold Rooms in Detention Facilities, section (V)(D)(5), the FOD must ensure that officers shall closely supervise Hold Rooms through direct supervision that includes: continuous auditory monitoring, even when the Hold Room is not in the officers direct line of sight. Inspection of the hold rooms by ODO revealed they did not have a continuous auditory monitoring system when the hold room is not in the officers direct line of sight. ODO Follow-up Finding: The hold rooms still do not have a continuous auditory monitoring system. A renovation request has been approved by the GEO Group, the private owner of the facility. NWDC is currently awaiting bids on the project.

(b)(7)e
ICE.11.5082.000601
RECREATION
During the QAR, one deficiency was identified in this area, having to do with failure to meet the minimum square footage of recreation space. The square footage is very close to the standard. Further, though the size of the recreation areas is below the minimum square footage requirement, ODO notes NWDC was constructed approximately four years prior to the implementation of the PBNDS in 2008. No corrective action had been taken or is planned. ODO QAR Findings: In accordance with the ICE PBNDS, Recreation, section (V)(A), the FOD must ensure that each outdoor exercise area must provide a minimum of 750 square feet of unencumbered space -- or 1,500 square feet of unencumbered space if 100 or more detainees are expected to use the space at the same time. The general population housing areas include eight units with capacity for 80 detainees, and four housing areas with capacity for 116. Unencumbered space in the outdoor exercise area for the 80-bed units measures 733.8 square feet; the recreation area for the 116-bed units measures 1,467.6 square feet. ODO Follow-up Finding: The recreation areas are the same size as during the QAR, and no renovations are planned. ODO does not consider this to be a serious problem, but is reporting it as an on-going deficiency.

(b)(7)e
ICE.11.5082.000602
RELIGIOUS PRACTICES
During the QAR, three deficiencies were identified in this area. During the follow-up inspection, the following deficiency remained. ODO QAR Findings: In accordance with the ICE PBNDS, Religious Practices, section (V)(E), the FOD must ensure that detainees in a Special Management Unit (SMU) shall have regular access to the chaplain or other religious service providers. The chaplain shall provide pastoral care in SMUs and hospital units at least weekly. NWDC did not have a full-time chaplain on its staff. Services were provided by a volunteer chaplain who visits the facility on an infrequent basis. The chaplain did not make weekly visits to the SMU and hospital unit. ODO was informed that the chaplain visits those areas on an unscheduled basis and/or upon receipt of a request from a detainee. ODO Follow-up Finding: The chaplain does not make weekly visits to the SMU and hospital unit, and the chaplain visits those areas on an unscheduled basis and/or upon receipt of a request from a detainee.

(b)(7)e
ICE.11.5082.000603
SEARCHES OF DETAINEES
(b)(7)e

(b)(7)e
ICE.11.5082.000604
LIST OF ACRONYMS

(b)(7)e
ICE.11.5082.000605


Detention and Removal Operations Seattle Field Office Northwest Detention Center Tacoma, Washington
March 8-11, 2010
FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law enforcement, management and employee information. It has been written for the express use of the Department of Homeland Security to identify and correct management and operational deficiencies. In reference to OPR Directive 08006.1, issued 09/22/05, any disclosure, dissemination, or reproduction of this document, or any segments thereof, is prohibited without the approval of the Director, Office of Professional Responsibility.
ICE.11.5082.000606
ICE.11.5082.000607
ICE.11.5082.000608
ODO QUALITY ASSURANCE REVIEW NORTHWEST DETENTION CENTER SEATTLE FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History..................... Current Structure. AREAS OF CONCERN.. OPERATIONAL ENVIRONMENT Internal Relations Detainee Relations.. ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS Admission and Release .. Classification System... Correspondence and Other Mail. Detainee Handbook...... Detention Files... Emergency Plans . Environmental Health and Safety. .. Facility Security and Control ... Food Service .. Funds and Personal Property... Grievance System .... Hold Rooms in Detention Facilities.. Law Libraries and Legal Material. Legal Rights Group Presentations Marriage Requests. Medical Care News Media Interviews and Tours Population Counts Post Orders.. Recreation Religious Practices.. Searches of Detainees ... Staff-Detainee Communication Tool Control Transfer of Detainees 1 1
3 3 5
7 7
10 12 13 14 16 17 18 19 20 22 23 24 26 27 28 29 30 31 32 33 34 35 36 37 38
ICE.11.5082.000609
Transportation. Use of Force and Restraints. Visitation.................................................
39 40 41
APPENDIX
ACRONYMS SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS SUMMARY OF RECOMMENDATIONS A B C
ICE.11.5082.000610
INSPECTION PROCESS
The Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE Performance Based National Detention Standards (PBNDS). In addition, focus may be applied to the level of management provided by the Office of Detention and Removal Operations (DRO) Headquarters and DRO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. ODO inspected the Northwest Detention Center (NWDC), a contract detention facility located in Tacoma, WA, on March 8-11, 2010. In performing this inspection, ODO reviewed current policies and detention standards, and applied them against the processes employed at NWDC. Prior to the inspection, ODO gathered and analyzed relevant data from the Enforce Alien Detention Module, DRO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. Recommendations are provided to improve the effectiveness, efficiency, and overall living conditions at the detention center. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Director, Office of Professional Responsibility.

Deportation Officer (Team Leader) Section Chief Special Agent Special Agent Deportation Officer Deportation Officer Deportation Officer Deportation Officer Contract Inspector Contract Inspector Contract Inspector Contract Inspector ODO, OPR HQ ODO, OPR HQ ODO, OPR HQ ODO, OPR HQ ODO, OPR HQ ODO, OPR HQ ODO, OPR HQ ODO, OPR HQ MGT of America MGT of America MGT of America MGT of America
Northwest Detention Center DRO Seattle
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Office of Detention Oversight March 2010

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ICE.11.5082.000611

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ICE.11.5082.000612
BACKGROUND
HISTORY
The Northwest Detention Center is located at 1623 East J Street, Tacoma, WA. The facility is approximately 35 miles south of downtown tract
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. NWDC medical care is provided by Public Health Services (PHS). NWDC food service is provided by GEO. NWDC attained American Correctional Association (ACA) accreditation in February 2009. NWDC has also attained National Commission on Correctional Health Care (NCCHC) accreditation in October 2008, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation in April 2009.
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ICE employs a full-time staff of 19 officers, to include the Assistant Field Office Director (AFOD), three supervisory detention and deportation officers (SDDO), ten deportation officers (DO), a senior immigration enforcement agent (SIEA) and four immigration enforcement agents (IEA). The total number of facility staff (non-ICE) employed at NWDC is 234. An annual review of the ICE National Detention Standards was conducted at NWDC in June 2009, by the DRO Detention Standards Compliance Unit contractors, MGT of America. The final overall rating for the review was Good.
CURRENT STRUCTURE
NWDC is managed by a combination of ICE and GEO staff. The AFOD, who is the Officer in Charge of the facility, manages detention and removal of aliens housed at NWDC. The AFOD has three SDDOs assigned to detention and one SIEA assigned to transportation at the facility. GEO has 234 on-site contracted employees, to include the Warden and Assistant Warden, whose responsibilities encompass all aspects of NWDC. (b)(7)e . (b)(7)e

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ICE.11.5082.000613

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ICE.11.5082.000614
AREAS OF CONCERN
NWDC was found deficient in one mandatory component within the Emergency Plans standard. ODO reviewed emergency plans, policies and procedures, and interviewed staff. The facility does not have Memoranda of Understanding with local, state, and federal law enforcement agencies formalizing agreements on contingency plans. A functional security camera exists, which overlooks the detainee strip search/change out area. Several individuals have access to view the security camera from their office. The new telephone contractor, Talton, does not allow detainees to use calling cards to make telephone calls. If Talton is to become the nationwide contractor, the Telephone Access standard needs to be revised by DRO Headquarters, indicating the use of calling cards is not a requirement. This will not be cited as a deficiency in the Telephone Access standard, of this report.

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ICE.11.5082.000615

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ICE.11.5082.000616
INTERNAL RELATIONS
ODO conducted interviews with the AFOD, SDDOs, the SIEA, DOs, and IEAs, as well as with the GEO contract staff. The staff overall reported good morale levels. Some staff felt the conditions were improving due to new construction, with additional offices and detention space becoming available. Many DRO staff members stated they felt the morale has declined at NWDC, which they attributed to their workload increasing. ICE and GEO staff stated additional staff is needed overall to assist with the new influx of detainees and increased bed space capabilities at NWDC. Both ICE and GEO stated they have a good working relationship. Staff stated refresher training, as well as a field training program for new hires, is needed.
DETAINEE RELATIONS
ODO interviewed 46 detainees at NWDC. Overall, detainees stated they were treated with respect and dignity by both ICE and GEO staff. Many detainees had issues with the newly-installed telephone system. Many detainees stated there is a member of the library staff that is rude and unhelpful. A few detainees stated they had been strip searched. ODO reviewed the intake procedures and found detainees are visually observed while changing into their detention facility-issued clothing. Additionally this area is monitored by a video surveillance camera, which is connected to the facility security area. This issue was brought to the attention of both GEO and ICE staff. Prior to the close of this review, NWDC was in the process of resolving this issue, by disabling the camera. Some detainees complained about the food. The main concern was the majority of meals contained the same items, and the meals rarely contained fruit. One detainee stated she had a special diet order for no soy and no fish, but she is still receiving soy products in her meals. ODO discovered she had an order for a special diet in her medical file. The GEO housing staff confirmed the detainee continues to receive meal trays with the incorrect diet, even though she has been on a specialized diet for over six months. One detainee stated she filed a grievance about threats she received from another detainee. After she filed the grievance, the detainee who was threatening her boiled water in the microwave provided to detainees in the housing unit, and threw it in her face. ODO interviewed staff in regard to this incident, and was provided a memo from GEO staff stating that an offer of protective custody (PC) was extended to the detainee once she filed the above-mentioned grievance. The memo indicates the detainee declined to be moved into PC. ODO reported this incident to the Joint Intake Center for follow-up.

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ICE.11.5082.000617

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ICE.11.5082.000618
PERFORMANCE BASED NATIONAL DETENTION STANDARDS REVIEWED

Out of the 41 PBNDS reviewed by ODO, no deficiencies were noted in the following 13 standards: Contraband; Disciplinary System; Escorted Trips for Non-Medical Emergencies; Hunger Strikes; Key and Lock Control; Personal Hygiene; Sexual Abuse and Assault Prevention and Intervention; Special Management Units; Staff Training; Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives, and Death; and Voluntary Work Program. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ICE.11.5082.000619

ODO reviewed the Admission and Release standard at NWDC to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE PBNDS. ODO reviewed detention files, forms, policies, and procedures; and interviewed detainees and staff assigned to admission and release processing duties. NWDC written policy recommends detainees shower when it is deemed necessary during intake processing. ODO observed there is only one shower room in the intake processing area for both male and female detainees. The shower room has been converted into a storage room, and is also used as an area for detainees to change into facility-issued clothing. Therefore, detainees are not showering before entering their assigned housing units (Deficiency AR-1). There is no question and answer session between detainees and staff following the orientation video (Deficiency AR-2). Baggage checks (Form I-77) are used; however, detainees do not sign the form (Deficiency AR-3). Some property receipt forms did not contain the signature of the second officer who witnessed the inventory (Deficiency AR-4 and F&PP-2).

DEFICIENCY AR-1 In accordance with the ICE PBNDS, Admission and Release, section (V)(A) and section (V)(B)(2), the FOD must ensure each facility implements written policies and procedures for the intake and reception of newly-arrived detainees, and provides them with information about facility policies, rules and procedures. At intake, detainees must be searched, and their personal property and valuables checked for contraband, inventoried, receipted, and stored. Each detainees identification documents must be secured in the detainees A-file. Medical screening protects the health of the detainee and others in the facility, and the detainee must be given an opportunity to shower and be issued clean clothing, bedding, towels, and personal hygiene items. All detainees must be screened upon admission, ordinarily including: screening with a metal detector, a thorough pat search, and a search of his or her clothing (or the issuance of institutional clothing). Staff must permit the detainee to change clothing and shower in a private room, without being visually observed by staff, unless there is reasonable suspicion to search the detainee in accordance with the section below on Strip Searches and the Detention Standard on Searches of Detainees. A staff member of the same gender must be present immediately outside the room where the detainee changes clothing and showers, with the door ajar to hear what transpires inside. The staff member must be prepared to intervene or provide assistance if he or she hears or observes any indication of a possible emergency or contraband smuggling.

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DEFICIENCY AR-2 In accordance with the ICE PBNDS, Admission and Release, section (V)(F), the FOD must ensure, following the video, staff conducts a question-and-answer session. Staff must respond to the best of their ability. Under no circumstances may staff give advice about a legal matter or recommend a professional service. DEFICIENCY AR-3 In accordance with the ICE PBNDS, Admission and Release, section (V)(H)(9), the FOD must ensure, before returning the property to the detainee, the officer explains the form and requires the detainee to sign his or her name on the bottom of Form I-77, or on a separate piece of paper. The officer must compare this signature with the signature on the back of the top portion of Form I-77 that is attached to the property. If the signatures appear the same, the officer must return the items to the detainee. DEFICIENCY AR-4 and F&PP-2 In accordance with the ICE PBNDS, Admission and Release, section (V)(B)(5), and Funds and Personal Property, section (V)(I), the FOD must ensure each facility has a procedure for the inventory and receipt of detainee funds and valuables. The personal property inventory form must contain, at a minimum, signatures of the officer completing the inventory and of the detainee.

None

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ICE.11.5082.000621
CLASSIFICATION SYSTEM (CS)

ODO reviewed the Classification System standard at NWDC to determine if there is a formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE PBNDS. ODO interviewed the classification processing staff, and reviewed detention files, forms, policies, and procedures.
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ICE.11.5082.000622

ODO reviewed the Correspondence and Other Mail standard at NWDC to determine if the facility provides detainees the opportunity to send and receive correspondence, in a timely manner, subject to limitations required for the safe and orderly operation of the facility, in accordance with the ICE PBNDS. ODO interviewed a contracted employee who processes detainee mail, and observed the mail delivery process. Detainees do not confirm, via signature, receipt of incoming priority, overnight, and certified mail or deliveries. The facility does not maintain a logbook to record detainees signatures in regards to the certification or receipt of such mail (Deficiency C&OM-1). The detainee handbook does not state identity documents, such as passports and birth certificates, in a detainees possession are contraband (Deficiency C&OM-2 and DH-2).

DEFICIENCY C&OM-1 In accordance with the ICE PBNDS, Correspondence and Other Mail, section (V)(D), the FOD must ensure incoming mail is distributed to detainees on the day it is received by the facility. Incoming priority, overnight, and certified mail, and deliveries from a private package delivery service, etc., must be recorded in a logbook maintained by the facility, with detainee signatures. DEFICIENCY C&OM-2 and DH-2 In accordance with the ICE PBNDS, Correspondence and Other Mail, section (V)(C)(8), the FOD must notify detainees of rules on correspondence and other mail through the detainee handbook. The notification must specify that identity documents, such as passports, birth certificates, etc., in a detainees possession are contraband and may be used by ICE/DRO as evidence against the detainee or for other purposes authorized by law; however, upon request, the detainee will be provided a copy of each document, certified by an ICE/DRO officer to be a true and correct copy.

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ICE.11.5082.000623

ODO reviewed the Detainee Handbook standard at NWDC to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE PBNDS. ODO interviewed staff and detainees, and reviewed the national detainee handbook, the facilitys site-specific detainee handbook, and detention files. NWDC issues Spanish and English versions of the ICE National Detainee Handbook and the site-specific handbook to detainees. The handbooks do not outline the procedures for requesting interpretive services for essential communication (Deficiency DH-1). The detainee handbooks do not state identity documents, found in a detainees possession, are contraband and may be used by ICE/DRO as evidence against the detainee or for other purposes authorized by law (Deficiency DH-2 and C&OM-2). The handbooks do not include information on the facilitys pork free menu (Deficiency DH-3 and FS-4). The handbooks do not fully address procedures for filing a claim for lost or missing property or for accessing personal funds for legal services (Deficiency DH-4 and F&PP-1). Procedures for appealing revocation of approval for marriage requests are not included in the handbooks (Deficiency DH-5 and MR-1). Some required rules and procedures governing law library access and usage are absent from the handbooks (Deficiency DH-6 and LL&LM-1).

DEFICIENCY DH-1 In accordance with the ICE PBNDS, Detainee Handbook, section (V)(2), the FOD must ensure, while all applicable topics from the ICE National Detainee Handbook must be addressed, it is particularly important that each local supplement notify each detainee of the procedures for requesting interpretive services for essential communication. DEFICIENCY DH-2 and C&OM-2 In accordance with the ICE PBNDS, Correspondence and Other Mail, section (V)(C)(8), the FOD must notify detainees of rules on correspondence and other mail through the detainee handbook. The notification must specify that identity documents, such as passports, birth certificates, etc., in a detainees possession are contraband and may be used by ICE/DRO as evidence against the detainee or for other purposes authorized by law; however, upon request, the detainee will be provided a copy of each document, certified by an ICE/DRO officer to be a true and correct copy.

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ICE.11.5082.000624
DEFICIENCY DH-3 and FS-4 In accordance with the ICE PBNDS, Food Service, section (V)(G)(5), the FOD must ensure, if a facility has a no-pork menu, in order to alleviate any confusion for those who observe no-pork diets for religious reasons, this information should be included in the facilitys handbook and in the facility orientation. If the facility has a Chaplain, he or she should also be made aware of the policy. DEFICIENCY DH-4 and F&PP-1 In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: the procedures for filing a claim for lost or damaged property, and the procedures for accessing detainee personal funds to pay for legal services. DEFICIENCY DH-5 and MR-1 In accordance with the ICE PBNDS, Marriage Requests, section (V)(B)(F), the FOD must ensure the National Detainee Handbook and local facility supplement provided each detainee upon admittance advise detainees of the facilitys marriage request procedures. The AFOD may revoke approval of a marriage request for good cause in writing to the detainee. In those instances, the detainee may file an appeal. DEFICIENCY DH-6 and LL&LM-1 In accordance with the ICE PBNDS, Law Libraries and Legal Material, sections (V)(O)(2, 3, 5-8), the FOD must ensure the detainee handbook or supplement provides detainees with the rules and procedures governing access to legal materials, including the following information: that a law library is available for detainee use; the procedures for requesting access to the law library; the procedures for requesting additional time in the law library (beyond the five hours per week minimum); the procedures for requesting legal reference materials not maintained in the law library; the procedures for notifying a designated employee that library material is missing or damaged; required access to computers, printers, and other supplies; and Lexis-Nexis is used at the facility, and instructions for its use are available. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

None

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ICE.11.5082.000625

ODO reviewed the Detention Files standard at NWDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE PBNDS. ODO reviewed detention files, logbooks, policies and procedures, and interviewed staff. When staff members at NWDC forward requested documents, they do not update the archived file, noting the document request, and the name and title of the requester (Deficiency DF-1). The logbook designated to record the status of detention files, such as their removal from the cabinet, did not have the signature of the person returning the file, or the date the file was returned (Deficiency DF-2).

DEFICIENCY DF-1 In accordance with the ICE PBNDS, Detention Files, section (V)(E)(3), the FOD must ensure closed detention files are not transferred with the detainee to another facility. However, staff may forward copies of file documents at the request of supervisory personnel at the receiving facility or office. When forwarding requested documents, staff at the sending office must update the archived file, noting the document request, and the name and title of the requester. DEFICIENCY DF-2 In accordance with the ICE PBNDS, Detention Files, section (V)(F)(3), the FOD must ensure staff accommodate all requests for detainee detention files from other departments that require the material for official purposes, such as disciplinary hearings. Unless the Chief of Security (or equivalent) determines otherwise, each borrowed file must be returned by the end of the administrative workday. A representative of the department requesting the file is responsible for obtaining the file, logging it out, and ensuring its return. At a minimum, a logbook entry recording the files removal from the cabinet must include: the date and time returned; and the signature of the person returning the file. Upon request by the detainee, the detention file must be provided to the detainee, or his or her designated attorney of record.

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ICE.11.5082.000626

ODO reviewed the Emergency Plans standard at NWDC to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with the ICE PBNDS. ODO interviewed staff, and reviewed the facilitys emergency plans and documentation.
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RECOMMENDATION TO IMPROVE EFFECTIVENESS AND EFFICIENCY

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ICE.11.5082.000627

ODO reviewed the Environmental Health and Safety standard at NWDC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE PBNDS. ODO toured the facility, interviewed staff, reviewed policies, and inspected documentation of inspections, fire drills and management of chemical hazards. The master list of the facilitys hazardous substances, including locations, was not sent to the local fire department (Deficiency EH&S-1). The inventory of hazardous materials in the laundry area was not up-to-date (Deficiency EH&S-2).

DEFICIENCY EH&S-1 In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(E), the FOD must ensure the Maintenance Supervisor compiles: a master index of all hazardous substances in the facility and their locations; a master file of Material Safety Data Sheets; and a comprehensive, up-to-date list of emergency telephone numbers (fire department, poison control center, etc.). The Maintenance Supervisor must maintain this information in the safety office (or equivalent), and ensures a copy is sent to the local fire department. DEFICIENCY EH&S-2 In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(C), the FOD must ensure every area maintains a current inventory of the hazardous substances (flammable, toxic, or caustic) used and stored there. Inventory records must be maintained separately for each substance. Entries for each must be logged on a separate card (or equivalent) filed alphabetically by substance. The entries must contain relevant data, including purchase dates and quantities, use dates and quantities, and quantities on hand.

ODO was informed the Safety Officer has not completed any Occupational Safety and Health Administration (OSHA) training. ODO recommends completion of the 10-hour OSHA Outreach Program for General Industry.

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ICE.11.5082.000628
FACILITY SECURITY AND CONTROL (FS&C)

ODO reviewed the Facility Security and Control standard at NWDC to determine if the facility security is maintained, and events posing a risk of harm are prevented, in accordance with the ICE PBNDS. ODO toured the facility, interviewed staff, and reviewed local policies, staffing plans, logbooks, and other documentation pertaining to the security inspection process. ODO also observed personnel and vehicles entering the facility and the secure perimeter. Contractual construction personnel entering the secure area do not wear orange visitor passes (Deficiency FS&C-1). The master listing of telephone numbers in the control room did not feature the required safeguard notice (Deficiency FS&C-2); this deficiency was corrected during the review.

DEFICIENCY FS&C-1 In accordance with the ICE PBNDS, Facility Security and Control, section (V)(C)(1)(c)(3), the FOD must ensure the Facility Administrator establishes procedures for issuing color-coded visitor passes to all visitors entering the facility at the main gate/front entrance. The visitor must prominently display this pass on an outer garment, where staff can see it at a glance. Orange visitor passes (or color-code equivalent) must be used for contractual construction service personnel, including: representatives of the Corps of Engineers; contractors, including sub-contractors; employees; laborers; supervisors; etc. DEFICIENCY FS&C-2 In accordance with the ICE PBNDS, Facility Security and Control, section (V)(B)(5), the FOD must ensure the facility maintains a list of the current home and cellular telephone numbers of every officer, administrative/support services staff, SRTs, HNTs, and law enforcement agencies. (If any staff member is inaccessible by telephone, other means of off-duty contact approved by the Facility Administrator, such as a pager number or e-mail address, may be listed.) The list must: be on file in both the Control Center and the shift supervisors office; be maintained in a secure file; comply with the Privacy Act; be used for emergency recall or urgent business only; and be updated at least quarterly. The list must prominently feature the following notice: This information must be safeguarded. Use is restricted to those needing the information in the performance of their official duties. Misuse will subject the user to criminal liability. This agency will view any misuse of this information as a serious violation of the Employee Code of Conduct, which may result in disciplinary action, including removal.
RECOMMENDATIONS TO IMPROVE EFFICTIVENESS AND EFFICIENCY

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ICE.11.5082.000629
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at NWDC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE PBNDS. ODO interviewed staff, inspected food preparation and storage areas, observed meal preparation and service, and reviewed policies and documentation. NWDC does not have special handling procedures for ordering, storing, inventorying, or using sugar (Deficiency FS-1). A recent purchase request for sugar was not marked to require special handling (Deficiency FS-2). Food carts are not covered and do not have locking devices (Deficiency FS-3). The detainee handbook does not include information on the facilitys pork-free menu (Deficiency FS-4 and DH-3). Detainees do not complete Authorization for Common Fare Participation forms (Deficiency FS-5). NWDC does not have a Chaplain; therefore, verification by the Chaplain of detainees religious dietary requirements; review of requests for common fare participation, removal or withdraw from the program; and annual ceremonial meal scheduling does not take place (Deficiency FS-6).

DEFICIENCY FS-1 In accordance with the ICE PBNDS, Food Service, section (V)(B)(4)(b), the FOD must ensure all facilities have procedures for handling food items that pose a security threat, including sugar. Purchase orders must specify special-handling requirements for delivery; the item must be stored and inventoried in a secure area in the Food Service Department; and staff must directly supervise use. DEFICIENCY FS-2 In accordance with the ICE PBNDS, Food Service, section(V)(K)(1), the FOD must ensure, on the purchase requests for potentially dangerous items (knives, mace, yeast, nutmeg, cloves and other items considered contraband if found in a detainee's possession), the Food Service Administrator (FSA) marks them "hot, signaling the need for special handling. DEFICIENCY FS-3 In accordance with the ICE PBNDS, Food Service, section (V)(D)(2)(g), the FOD must ensure food is delivered from one place to another in covered containers. These may be individual containers, such as pots with lids, or larger conveyances that can move objects in bulk, such as enclosed, satellite-meals carts. Food carts must have locking devices. In any facility, if food carts are delivered to housing units by detainees, they must be locked unless they are under constant supervision of staff.

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ICE.11.5082.000630
DEFICIENCY FS-4 and DH-3 In accordance with the ICE PBNDS, Food Service, section (V)(G)(5), the FOD must ensure, if a facility has a no-pork menu, in order to alleviate any confusion for those who observe no-pork diets for religious reasons, this information is included in the facilitys handbook and the facility orientation. If the facility has a Chaplain, he or she should also be made aware of the policy. DEFICIENCY FS-5 In accordance with the ICE PBNDS, Food Service, section (V)(G)(1), the FOD must ensure ICE/DRO requires the facilities to provide detainees requesting a religious diet a reasonable and equitable opportunity to observe their religious dietary practice within the constraints of budget limitations, and the security and orderly running of the facility by offering a Common Fare menu. The detainee must provide a written statement articulating the religious motivation for participation in the Common Fare program. To participate in the religious diet program, a detainee must initiate an Authorization for Common Fare Participation form for consideration by the Chaplain. DEFICIENCY FS-6 In accordance with the ICE PBNDS, Food Service, section (V)(G)(1)(9)(10), the FOD must ensure detainees whose religious beliefs require adherence to particular dietary laws or generally accepted religious guidelines and practices are referred to the Chaplain. The Chaplain must verify the religious diet requirement by reviewing files and consulting with religious representatives. The Chaplain and FSA must collectively verify the requirement and issue specific written instructions for the implementation of the diet as soon as practicable, but within ten business days of verification. The Facility Administrator, in consultation with the Chaplain, must be the approving official for a detainee's removal from the Common Fare program. A detainee who has been approved for a Common Fare menu must notify the Chaplain, in writing, if he or she wishes to withdraw from the religious diet. The Chaplain, in consultation with local religious leaders if necessary, must develop the ceremonial meal schedule for the following calendar year and provide it to the Facility Administrator. This schedule must include the date, religious group, estimated number of participants, and special foods required. Ceremonial and commemorative meals must be served in the food service facility, unless otherwise approved by the Facility Administrator.

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ICE.11.5082.000631

ODO reviewed the Funds and Personal Property standard at NWDC to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE PBNDS. ODO reviewed policies, procedures, and property forms, and interviewed staff regarding the control and safeguarding of detainees personal property, funds, and valuables. Notices provided in the handbook do not include the procedures for filing claims for lost or damaged property, or for accessing personal funds to pay for legal services (Deficiency F&PP-1 and DH-4). Form I-77s do not contain detainees signatures on both the top (Part I) and the bottom (Part III) of the form. The property inventory forms do not contain the time of admission, or a description of the general condition of the property. Not all property receipt forms reviewed had a second signature of the officer who witnessed the inventory (Deficiency F&PP-2 and AR-4).

DEFICIENCY F&PP-1 and DH-4 In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: the procedures for filing a claim for lost or damaged property, and the procedures for accessing detainee personal funds to pay for legal services. DEFICIENCY F&PP-2 and AR-4 In accordance with the ICE PBNDS, Admission and Release, section (V)(B)(5), and Funds and Personal Property, section (V)(I), the FOD must ensure each facility has a procedure for the inventory and receipt of detainee funds and valuables. The personal property inventory form must contain, at a minimum, signatures of the officer completing the inventory and of the detainee.

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ICE.11.5082.000632

ODO reviewed the Grievance System standard at NWDC to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE PBNDS. ODO reviewed grievance policies and procedures; visited housing areas of detainees; reviewed the detainee handbook, detention files, and electronic logs of grievances; and interviewed staff. Grievance log entries from NWDC staff, NWDC medical staff, and ICE staff are missing a column, indicating whether the detainees grievance was resolved, along with the date of resolution (Deficiency GS-1). Prior to the conclusion of the inspection, the facility, medical and ICE staff corrected the grievance logs and added the column to indicate when grievances are resolved. ODO reviewed informal grievance forms within detainee detention files. The informal grievance form has a space for the detainees signature; however, none of the forms reviewed were signed by the detainees.

DEFICIENCY GS-1 In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure the facility devises a method for documenting detainee grievances; at a minimum, a Detainee Grievance Log. The documentation must include the date of the grievance; nature of the grievance, in detail; and the date the grievance was resolved.

Written resolved informal grievance forms should be acknowledged with a signature by the detainee before being placed in the detention file.

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ICE.11.5082.000633

ODO reviewed the Hold Rooms in Detention Facilities standard at NWDC to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure and comfortable environment, and not held confined in hold rooms for over 12 hours, in accordance with the ICE PBNDS. ODO observed hold room operations in intake and the Medical Unit, and reviewed policy, logbooks, and documentation. One intake hold room has a posted capacity of 100 people, and is equipped with two combination lavatory/toilet fixtures. The facility does not meet the required ratio of at least two combination lavatory/toilet fixtures in a hold room designed to hold up to 49 detainees (Deficiency HR-1). The medical unit hold rooms do not have floor drains (Deficiency HR-2). ODO observed detainees were not searched prior to placement in medical unit hold rooms (Deficiency HR-3). Hold rooms that are not in officers direct line of sight do not have continuous auditory monitoring (Deficiency HR-4).

DEFICIENCY HR-1 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(6), the FOD must ensure each hold room is equipped with stainless steel, combination lavatory/toilet fixtures, with modesty panels, in compliance with the Americans with Disabilities Act of 1990. Consistent with International Plumbing Code, each large hold room, holding 15 to 49 detainees, must have at least two combination units. The Hold Room Design Standards A-E, HDR Architecture, recommends a third combination unit for a Hold Room with 30 or more detainees, or one combination unit for every 15 detainees. DEFICIENCY HR-2 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(7), the FOD must ensure that each hold room has a floor drain(s). DEFICIENCY HR-3 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(C), the FOD must ensure, before placing a detainee in a room, staff does a pat down search for weapons or contraband. The pat down search must be done by a staff member of the same gender as the detainee, unless one is not available. A pat down search is required, even if another section or agency claims to have completed one. DEFICIENCY HR-4 In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(D)(5), the FOD must ensure officers closely supervise hold rooms through direct supervision that includes: continuous auditory monitoring, even when the hold room is not in the officers direct line of sight.

(b)(7)e
ICE.11.5082.000634

None

(b)(7)e
ICE.11.5082.000635

ODO reviewed the Law Libraries and Legal Material standard at NWDC to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE PBNDS. ODO observed the law library, interviewed detainees and staff, and reviewed the detainee handbooks. The detainee handbooks do not contain procedures to request additional law library access beyond the minimum five hours each week, to request reference materials not located in the library, or to notify an employee of missing and/or damaged materials. Also missing from the handbooks are notifications that Lexis-Nexis is used, and instructions are available. Additionally, the law library lacked postings stating the availability of the library for detainee use, and the procedures to request regular access. Informational postings regarding required access to computers, printers and supplies, and instructions for notifying an employee of missing and/or damaged materials were absent in the library (Deficiency LL&LM-1 and DH-6). NWDC staff began addressing these issues prior to the inspection close-out. Capacity at NWDC is approximately 1,500 detainees, and the law library has 5 computers available. Staff stated a new library will be opening soon.

DEFICIENCY LL&LM-1 and DH-6 In accordance with the ICE PBNDS, Law Libraries and Legal Material, sections (V)(O)(2, 3, 5-8), the FOD must ensure the detainee handbook or supplement provides detainees with the rules and procedures governing access to legal materials, including the following information: that a law library is available for detainee use; the procedures for requesting access to the law library; the procedures for requesting additional time in the law library (beyond the five hours per week minimum); the procedures for requesting legal reference materials not maintained in the law library; the procedures for notifying a designated employee that library material is missing or damaged; required access to computers, printers, and other supplies; and Lexis-Nexis is used at the facility, and instructions for its use are available. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

None

(b)(7)e
ICE.11.5082.000636

ODO reviewed the Legal Rights Group Presentation standard at NWDC to determine if authorized persons and organizations are permitted to make presentations to groups of detainees for the purpose of providing information on immigration law and procedures, in accordance with the ICE PBNDS. ODO observed the detainee living areas and interviewed staff. NWDC allows on-going legal rights group presentations by the Northwest Immigrant Rights Project (NWIRP) on Mondays, Tuesdays, Wednesdays and Thursdays; however the posters NWIRP provides do not state the general nature or contents of the presentations, the intended audience, or the language in which the presentations will be conducted. The posters also lacked instructions regarding the requirement for detainees to sign up to attend (Deficiency LRGP-1). Unpublished material distributed by NWIRP does not include a cover page identifying the submitter and preparer of the material, the date of preparation, or a statement that ICE/DRO did not prepare the materials and therefore, is not responsible for the contents (Deficiency LRGP-2).

DEFICIENCY LRGP-1 In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(F), the FOD must ensure the requestor provides a one-page poster (no larger than 8.5 by 11 inches) to inform detainees of the general nature and contents of the presentation, the intended audience, and the language(s) in which it will be conducted. The poster should instruct detainees to contact the housing officer if they wish to sign up to attend. For poster text in languages other than English, an English translation must be provided. DEFICIENCY LRGP-2 In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(J), the FOD must ensure the request for approval of a presentation lists any published or unpublished materials proposed for distribution. The requestor must provide a copy of any unpublished material, with a cover page, that: identifies the submitter and the preparer of the material; includes the date of preparation; and states clearly that ICE/DRO did not prepare, and is not responsible for, the contents of the material. If any material is provided in a language other than English, an English translation must be provided.

None

(b)(7)e
ICE.11.5082.000637
MARRIAGE REQUESTS (MR)

ODO reviewed the Marriage Requests standard at NWDC to determine if marriage requests from detainees are reviewed on a case-by-case basis, based on internal guidelines for approval of such requests, in accordance with the ICE PBNDS. ODO reviewed policies, files, and the Detainee Marriage Request Logbook. Procedures for appealing revocation of approval for marriage requests are not included in the detainee handbooks (Deficiency MR-1 and DH-5). The AFOD stated there has never been a denial of a marriage request. ODO reviewed a detention and an A-file of a detainee whose marriage was approved. Original copies of the documentation were not placed in the A-file, and copies were not placed in the detention file (Deficiency MR-2).

DEFICIENCY MR-1 and DH-5 In accordance with the ICE PBNDS, Marriage Requests, section (V)(B)(F), the FOD must ensure the National Detainee Handbook and local facility supplement provided each detainee upon admittance advise detainees of the facilitys marriage request procedures. The AFOD may revoke approval of a marriage request for good cause in writing to the detainee. In those instances, the detainee may file an appeal. DEFICIENCY MR-2 In accordance with the ICE PBNDS, Marriage Requests, section (V)(G), the FOD must ensure, once the marriage has taken place, the Facility Administrator forwards original copies of all documentation to the detainees A-file, and maintains copies in the facilitys detention file.

None

(b)(7)e
28
ICE.11.5082.000638
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at NWDC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE PBNDS. ODO toured the medical clinic, reviewed policies and procedures, examined 30 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by Division of Immigration Health Services (DIHS), and holds American Correctional Association, National Commission on Correctional Health Care and Joint Commission on Accreditation of Healthcare Organizations accreditations. Intake screenings are not reviewed within 24 hours to assess the priority for treatment and health appraisals are not reviewed by a clinical medical authority (Deficiency MC-1). The Medical Director from DIHS Headquarters and a physician from the Florence Service Processing Center are available to consult as needed, but do not review intake screenings or health appraisals as required. The Health Services Administrator informed ODO the facility does not have a physician on staff. She is awaiting security clearances for two physician candidates.

DEFICIENCY MC-1 In accordance with the ICE PBNDS, Medical Care, section (lll)(I)(J), the FOD must ensure the clinical medical authority is responsible for reviewing all health screening forms within 24 hours or the next business day to assess the priority for treatment (for example, Urgent, Today, or Routine). The clinical medical authority must be responsible for reviewing all health appraisals to assess the priority for treatment.

None

(b)(7)e
29
ICE.11.5082.000639
NEWS MEDIA INTERVIEWS AND TOURS (NMI&T)

ODO reviewed the News Media Interviews and Tours standard at the NWDC to determine if the public and media are informed of events within the facility through interviews and tours, in accordance with the ICE PBNDS. ODO interviewed staff, and reviewed policies and procedures, as well as email records pertaining to news media requests.
(b)(7)e
(b)(7)e

None

(b)(7)e
ICE.11.5082.000640

ODO reviewed the Population Counts standard at NWDC to determine if the facility has an effective system of conducting population counts, which ensures detainee accountability, in accordance with the ICE PBNDS. ODO observed two formal count processes, one from within a housing unit and another from within the Control Center.
(b)(7)e
(b)(7)e

None

(b)(7)e
ICE.11.5082.000641
POST ORDERS (PO)

ODO reviewed the Post Orders standard at NWDC to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE PBNDS. ODO observed operations, interviewed staff, and reviewed logbooks, policies, procedures, and the master file of post orders, as well as housing unit, and armed and perimeter access post orders.
(b)(7)e
(b)(7)e

None

(b)(7)e
32
ICE.11.5082.000642
RECREATION (R)
ODO reviewed the Recreation standard at NWDC to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE PBNDS. ODO interviewed staff, and observed the indoor and outdoor recreation areas. The outdoor exercise area does not provide a minimum of 750 square feet of unencumbered space (Deficiency R-1).

DEFICIENCY R-1 In accordance with the ICE PBNDS, Recreation, section (V)(A), the FOD must ensure each outdoor exercise area provides a minimum of 750 square feet of unencumbered space, or 1,500 square feet of unencumbered space if 100 or more detainees are expected to use the space at the same time.

None

(b)(7)e
33
ICE.11.5082.000643
RELIGIOUS PRACTICES (RP)

ODO reviewed the Religious Practices standard at NWDC to determine if the detainees of different religious beliefs are provided reasonable and equitable opportunities to participate in the practices of their respective faiths, in accordance with the ICE PBNDS. ODO reviewed policies and procedures and interviewed staff. A Chaplain is not on staff; therefore, the Chaplain does not monitor patterns of changes in declarations of religious preference (Deficiency RP-1). Additionally, no one on staff possesses minimum qualifications of clinical pastoral education or equivalent specialized training, or endorsement by the appropriate religious-certifying body (Deficiency RP-2). Detainees in the Special Management Unit (SMU) or the hospital unit do not have regular access to the Chaplain or other religious service providers at least weekly (Deficiency RP-3).

DEFICIENCY RP-1 In accordance with the ICE PBNDS, Religious Practices, section (V)(B), the FOD must ensure, in the interest of maintaining the security and orderly running of the facility and to prevent abuse or disrespect by detainees of religious practice or observance, the Chaplain monitor patterns of changes in declarations of religious preference. DEFICIENCY RP-2 In accordance with the ICE PBNDS, Religious Practices, section (V)(C), the FOD must ensure the Chaplain possesses minimum qualifications of clinical pastoral education or equivalent specialized training, and endorsement by the appropriate religious-certifying body. DEFICIENCY RP-3 In accordance with the ICE PBNDS, Religious Practices, section (V)(E), the FOD must ensure detainees in the SMU have regular access to the Chaplain or other religious service providers. The Chaplain must provide pastoral care in the SMUs and hospital units at least weekly.

None

(b)(7)e
ICE.11.5082.000644
SEARCHES OF DETAINEES (SD)

ODO reviewed the Searches of Detainees standard at NWDC to determine the level of protection of detainees and staff, and overall facility security and order, through the detection, control and disposition of all contraband, in accordance with the ICE PBNDS. ODO interviewed NWDC detainees and staff; reviewed policies and procedures, the detainee handbook, logbooks, and staff training; and inspected the intake processing area.
(b)(7)e
(b)(7)e

None

(b)(7)e
ICE.11.5082.000645

ODO reviewed the Staff-Detainee Communication standard at NWDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE PBNDS. ODO reviewed procedures and logbooks, and interviewed staff and detainees. DRO staff does not consistently list the response or action taken on detainee requests in the logbook (Deficiency SDC-1).

DEFICIENCY SDC-1 In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. At a minimum, the logbook must record the date the request, with staff response and action, was returned to the detainee.
RECOMMENDATIONS TO IMPROVE EFFECTIVENESS

None

(b)(7)e
36
ICE.11.5082.000646
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at NWDC to determine if tools are properly classified, identified, inventoried, stored and issued, in accordance with the ICE PBNDS. ODO interviewed staff, reviewed policies and inventories, and observed storage and issuance of tools.
(b)(7)e
(b)(7)e

None

(b)(7)e
37
ICE.11.5082.000647
TRANSFER OF DETAINEES (TD)

ODO reviewed the Transfer of Detainees standard at NWDC to determine if transfers of detainees from one facility to another are responsibly managed in regard to notification, detention records, safety and security, and protection of detainee funds and property, in accordance with the ICE PBNDS. ODO reviewed facility policies, procedures, and detention files, and interviewed facility staff. ODO examined detention files and found Detainee Transfer Notification forms are not placed in the transferring detainees detention file (Deficiency TD-1).

DEFICIENCY TD-1 In accordance with the ICE PBNDS, Transfer of Detainees, section (V)(B)(3), the FOD must ensure, at the time of the transfer, ICE/DRO provides the detainee, in writing, with the name, address and telephone number of the facility to which he or she is being transferred, using the Detainee Transfer Notification form. Staff must place a copy of the form in the detainees detention file.

None

(b)(7)e
38
ICE.11.5082.000648
TRANSPORTATION (T)
ODO reviewed the Transportation standard at NWDC to determine if vehicles are properly equipped, maintained, and operated, and if detainees are transported in a safe, secure, and humane manner under supervision of trained and experienced staff, in accordance with the ICE PBNDS. ODO interviewed staff, reviewed policies and procedures, and inspected transportation equipment and documentation.
(b)(7)e
(b)(7)e

None

(b)(7)e
39
ICE.11.5082.000649

ODO reviewed the Use of Force and Restraints standard at NWDC to determine if necessary use of force and the use of restraints is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE PBNDS. ODO interviewed staff, and reviewed policies, training files, and use-of-force documentation.
(b)(7)e
(b)(7)e
RECOMENDATIONS TO IMPROVE EFFECTIVENESS AND EFFICIENCY

None

(b)(7)e
ICE.11.5082.000650
VISITATION (V)
ODO reviewed the Visitation standard at NWDC to determine if authorized persons, including legal representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE PBNDS. ODO interviewed staff, observed the visiting area and reviewed logs, policies, procedures, and the detainee handbook. Visitation logs did not always include the detainees alien number or the visitors address (Deficiency V-1). ODO observed Notice of Entry of Appearance as Attorney or Accredited Representative (Form G-28) was not available in the legal visitation reception area (Deficiency V-2). NWDC policy states visitors and volunteers from community groups must read and sign a disclaimer releasing ICE and NWDC of all responsibility in case of injury during visits. The acknowledgment form provided to ODO specified it did not constitute a waiver of liability (Deficiency V-3). Staff interviews and a review of visitation records revealed visitation restrictions for attorneys do not include documentation regarding the reasons for the restriction. The attorney visitation hours listed in the detainee handbook and GEO policy 5.2.3, titled Detainee Visitation, are not the same.

DEFICIENCY V-1 In accordance with the ICE PBNDS, Visitation, section (V)(D) and section (V)(J)(15), the FOD must ensure each facility maintains a log of all general visitors, and a separate log of legal visitors as described below. Staff must record in the general visitors log: the name and alien-registration number (A-number) of the detainee visited, and the visitors name and address. DEFICIENCY V-2 In accordance with the ICE PBNDS, Visitation, section (V)(J)(8), the FOD must ensure, once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitation reception area. Staff must collect completed forms and forward them to ICE/DRO. Each completed Form G-28 becomes a permanent part of the detainees A-file, and it remains valid until ICE/DRO receives written notice of the relationships termination from the detainee or the legal representative. Staff must place such notices in the A-file on top of the Form G-28.

(b)(7)e
ICE.11.5082.000651
DEFICIENCY V-3 In accordance with the ICE PBNDS, Visitation, section (V)(N)(4), the FOD must ensure volunteers read and sign a waiver of liability that releases ICE/DRO of all responsibility in case of injury during the visit before being admitted to any secure portion of the facility, or a location where detainees are present.

ODO recommends the FOD discuss with GEO the possibility of updating the detainee handbook, page 12, and/or the GEO policy 5.2.3 (III)(G)(2), to reflect the same attorney visitation hours. ODO recommends the FOD discuss the possibility of documenting reasons for terminating or suspending an attorneys visitation privileges.

(b)(7)e
ICE.11.5082.000652
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DRO DSCU EABM EADM EOIR ENFORCE FOD FSA HSA ICE IDP IEA JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SMU TAR TB UDC American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforce Alien Detention Module Executive Office of Immigration Review Enforcement Case Tracking Field Office Director Food Service Administrator Health Services Administrator Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Justice Prisoner Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee

(b)(7)e
43
ICE.11.5082.000653
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS
In accordance with the ICE PBNDS, Admission and Release, section (V)(A) and section (V)(B)(2), the FOD must ensure each facility implements written policies and procedures for the intake and reception of newly-arrived detainees, and provides them with information about facility policies, rules and procedures. At intake, detainees must be searched, and their personal property and valuables checked for contraband, inventoried, receipted, and stored. Each detainees identification documents must be secured in the detainees A-file. Medical screening protects the health of the detainee and others in the facility, and the detainee must be given an opportunity to shower and be issued clean clothing, bedding, towels, and personal hygiene items. All detainees must be screened upon admission, ordinarily including: screening with a metal detector, a thorough pat search, and a search of his or her clothing (or the issuance of institutional clothing). Staff must permit the detainee to change clothing and shower in a private room, without being visually observed by staff, unless there is reasonable suspicion to search the detainee in accordance with the section below on Strip Searches and the Detention Standard on Searches of Detainees. A staff member of the same gender must be present immediately outside the room where the detainee changes clothing and showers, with the door ajar to hear what transpires inside. The staff member must be prepared to intervene or provide assistance if he or she hears or observes any indication of a possible emergency or contraband smuggling.
PAGE
AR-1
10

(b)(7)e
44
ICE.11.5082.000654
DETENTION STANDARD
AR-2
AR-3
Admission and Release Funds and Personal Property
AR-4
F&PP-2
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Admission and Release, section (V)(F), the FOD must ensure, following the video, staff conducts a question-andanswer session. Staff must respond to the best of their ability. Under no circumstances may staff give advice about a legal matter or recommend a professional service. In accordance with the ICE PBNDS, Admission and Release, section (V)(H)(9), the FOD must ensure, before returning the property to the detainee, the officer explains the form and requires the detainee to sign his or her name on the bottom of Form I-77, or on a separate piece of paper. The officer must compare this signature with the signature on the back of the top portion of Form I-77 that is attached to the property. If the signatures appear the same, the officer must return the items to the detainee. In accordance with the ICE PBNDS, Admission and Release, section (V)(B)(5), and Funds and Personal Property, section (V)(I), the FOD must ensure each facility has a procedure for the inventory and receipt of detainee funds and valuables. The personal property inventory form must contain, at a minimum, signatures of the officer completing the inventory and of the detainee.
PAGE
11
11
11
22
Classification System
CS-1
(b)(7)e
12

(b)(7)e
ICE.11.5082.000655
DETENTION STANDARD
C&OM-1
C&OM-2
Detainee Handbook
DH-2
Detainee Handbook
DH-1
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Correspondence and Other Mail, section (V)(D), the FOD must ensure incoming mail is distributed to detainees on the day it is received by the facility. Incoming priority, overnight, and certified mail, and deliveries from a private package delivery service, etc., must be recorded in a logbook maintained by the facility, with detainee signatures. In accordance with the ICE PBNDS, Correspondence and Other Mail, section (V)(C)(8), the FOD must notify detainees of rules on correspondence and other mail through the detainee handbook. The notification must specify that identity documents, such as passports, birth certificates, etc., in a detainees possession are contraband and may be used by ICE/DRO as evidence against the detainee or for other purposes authorized by law; however, upon request, the detainee will be provided a copy of each document, certified by an ICE/DRO officer to be a true and correct copy. In accordance with the ICE PBNDS, Detainee Handbook, section (V)(2), the FOD must ensure, while all applicable topics from the ICE National Detainee Handbook must be addressed, it is particularly important that each local supplement notify each detainee of the procedures for requesting interpretive services for essential communication.
PAGE
13
13
14
14

(b)(7)e
ICE.11.5082.000656
DETENTION STANDARD
Detainee Handbook
DH-3
Food Service
FS-4
Detainee Handbook
DH-4
F&PP-1
Detainee Handbook
DH-5
Marriage Request
MR-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Food Service, section (V)(G)(5), the FOD must ensure, if a facility has a nopork menu, in order to alleviate any 15 confusion for those who observe no-pork diets for religious reasons, this information should be included in the facilitys handbook and in the facility 21 orientation. If the facility has a Chaplain, he or she should also be made aware of the policy. In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must ensure the detainee handbook or equivalent notifies 15 detainees of facility policies and procedures concerning personal property, including: the procedures for filing a claim for lost or damaged 22 property, and the procedures for accessing detainee personal funds to pay for legal services. In accordance with the ICE PBNDS, Marriage Requests, section (V)(B)(F), the FOD must ensure the National Detainee Handbook and local facility supplement provided each detainee 15 upon admittance advise detainees of the facilitys marriage request procedures. The AFOD may revoke approval of a 28 marriage request for good cause in writing to the detainee. In those instances, the detainee may file an appeal.

(b)(7)e
ICE.11.5082.000657
DETENTION STANDARD
Detainee Handbook
DH-6
Law Library and Legal Materials
LL&LM-1
Detention Files
DF-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Law Libraries and Legal Material, sections (V)(O)(2, 3, 5-8), the FOD must ensure the detainee handbook or supplement provides detainees with the rules and procedures governing access to legal materials, including the following information: that a law library is available for detainee use; the procedures for requesting access to the law library; the procedures for requesting additional time in the law library (beyond the five hours per week 15 minimum); the procedures for requesting legal reference materials not maintained in the law library; the procedures for notifying a designated employee that library material is missing or damaged; required access to computers, printers, and other supplies; and Lexis-Nexis is used at the facility, and instructions for its use are available. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with the ICE PBNDS, Detention Files, section (V)(E)(3), the FOD must ensure closed detention files are not transferred with the detainee to another facility. However, staff may forward copies of file documents at the 16 request of supervisory personnel at the receiving facility or office. When forwarding requested documents, staff at the sending office must update the archived file, noting the document request, and the name and title of the requester.

(b)(7)e
48
ICE.11.5082.000658
DETENTION STANDARD
Detention Files
DF-2
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Detention Files, section (V)(F)(3), the FOD must ensure staff accommodate all requests for detainee detention files from other departments that require the material for official purposes, such as disciplinary hearings. Unless the Chief of Security (or equivalent) determines otherwise, each borrowed file must be returned by the end of the administrative workday. A representative of the department requesting the file is responsible for obtaining the file, logging it out, and ensuring its return. At a minimum, a logbook entry recording the files removal from the cabinet must include: the date and time returned; and the signature of the person returning the file. Upon request by the detainee, the detention file must be provided to the detainee, or his or her designated attorney of record.
PAGE
16
Emergency Plans
EP-1
17
(b)(7)e
Emergency Plans
EP-2
17

(b)(7)e
49
ICE.11.5082.000659
DETENTION STANDARD
PAGE
Emergency Plans
EP-3
(b)(7)e
17
EH&S-1
EH&S-2
Environmental Health and Safety, section (VI)(E), the FOD must ensure the Maintenance Supervisor compiles: a master index of all hazardous substances in the facility and their locations; a master file of Material Safety Data Sheets; and a comprehensive, upto-date list of emergency telephone numbers (fire department, poison control center, etc.). The Maintenance Supervisor must maintain this information in the safety office (or equivalent), and ensures a copy is sent to the local fire department. In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(C), the FOD must ensure every area maintains a current inventory of the hazardous substances (flammable, toxic, or caustic) used and stored there. Inventory records must be maintained separately for each substance. Entries for each must be logged on a separate card (or equivalent) filed alphabetically by substance. The entries must contain relevant data, including purchase dates and quantities, use dates and quantities, and quantities on hand.
18
18

(b)(7)e
50
ICE.11.5082.000660
DETENTION STANDARD
FS&C-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Facility Security and Control, section (V)(C)(1)(c)(3), the FOD must ensure the Facility Administrator establishes procedures for issuing colorcoded visitor passes to all visitors entering the facility at the main gate/front entrance. The visitor must prominently display this pass on an outer garment, 19 where staff can see it at a glance. Orange visitor passes (or color-code equivalent) must be used for contractual construction service personnel, including: representatives of the Corps of Engineers; contractors, including subcontractors; employees; laborers; supervisors; etc.

(b)(7)e
ICE.11.5082.000661
DETENTION STANDARD
FS&C-2
Food Service
FS-1
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Facility Security and Control, section (V)(B)(5), the FOD must ensure the facility maintains a list of the current home and cellular telephone numbers of every officer, administrative/support services staff, SRTs, HNTs, and law enforcement agencies. (If any staff member is inaccessible by telephone, other means of off-duty contact approved by the Facility Administrator, such as a pager number or e-mail address, may be listed.) The list must: be on file in both the Control Center and the shift supervisors office; be maintained in a secure file; comply with the Privacy Act; be used for emergency recall or urgent business only; and be updated at least quarterly. The list must prominently feature the following notice: This information must be safeguarded. Use is restricted to those needing the information in the performance of their official duties. Misuse will subject the user to criminal liability. This agency will view any misuse of this information as a serious violation of the Employee Code of Conduct, which may result in disciplinary action, including removal. In accordance with the ICE PBNDS, Food Service, section (V)(B)(4)(b), the FOD must ensure all facilities have procedures for handling food items that pose a security threat, including sugar. Purchase orders must specify specialhandling requirements for delivery; the item must be stored and inventoried in a secure area in the Food Service Department; and staff must directly supervise use.
PAGE
19
20

(b)(7)e
ICE.11.5082.000662
DETENTION STANDARD
Food Service
FS-2
Food Service
FS-3
Food Service
FS-5
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Food Service, section(V)(K)(1), the FOD must ensure, on the purchase requests for potentially dangerous items (knives, mace, yeast, nutmeg, cloves and other items considered contraband if found in a detainee's possession), the Food Service Administrator (FSA) marks them "hot, signaling the need for special handling. In accordance with the ICE PBNDS, Food Service, section (V)(D)(2)(g), the FOD must ensure food is delivered from one place to another in covered containers. These may be individual containers, such as pots with lids, or larger conveyances that can move objects in bulk, such as enclosed, satellite-meals carts. Food carts must have locking devices. In any facility, if food carts are delivered to housing units by detainees, they must be locked unless they are under constant supervision of staff. In accordance with the ICE PBNDS, Food Service, section (V)(G)(1), the FOD must ensure ICE/DRO requires the facilities to provide detainees requesting a religious diet a reasonable and equitable opportunity to observe their religious dietary practice within the constraints of budget limitations, and the security and orderly running of the facility by offering a Common Fare menu. The detainee must provide a written statement articulating the religious motivation for participation in the Common Fare program. To participate in the religious diet program, a detainee must initiate an Authorization for Common Fare Participation form for consideration by the Chaplain.
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20
21

(b)(7)e
ICE.11.5082.000663
DETENTION STANDARD
Food Service
FS-6
Grievance System
GS-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Food Service, sections (V)(G)(1)(9)(10), the FOD must ensure detainees whose religious beliefs require adherence to particular dietary laws or generally accepted religious guidelines and practices are referred to the Chaplain. The Chaplain must verify the religious diet requirement by reviewing files and consulting with religious representatives. The Chaplain and FSA must collectively verify the requirement and issue specific written instructions for the implementation of the diet as soon as practicable, but within ten business days of verification. The Facility Administrator, in consultation with the Chaplain, must be the approving official 21 for a detainee's removal from the Common Fare program. A detainee who has been approved for a Common Fare menu must notify the Chaplain, in writing, if he or she wishes to withdraw from the religious diet. The Chaplain, in consultation with local religious leaders if necessary, must develop the ceremonial meal schedule for the following calendar year and provide it to the Facility Administrator. This schedule must include the date, religious group, estimated number of participants, and special foods required. Ceremonial and commemorative meals must be served in the food service facility, unless otherwise approved by the Facility Administrator. In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure the facility devises a method for documenting detainee grievances; at a minimum, a Detainee 23 Grievance Log. The documentation must include the date of the grievance; nature of the grievance, in detail; and the date the grievance was resolved.

(b)(7)e
ICE.11.5082.000664
DETENTION STANDARD
HR-1
HR-2
HR-3
HR-4
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(6), the FOD must ensure each hold room is equipped with stainless steel, combination lavatory/toilet fixtures, with modesty panels, in compliance with the Americans with Disabilities Act of 1990. Consistent with International Plumbing Code, each large hold room, holding 15 to 49 detainees, must have at least two combination units. The Hold Room Design Standards A-E, HDR Architecture, recommends a third combination unit for a Hold Room with 30 or more detainees, or one combination unit for every 15 detainees. In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(A)(7), the FOD must ensure that each hold room has a floor drain(s). In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(C), the FOD must ensure, before placing a detainee in a room, staff does a pat down search for weapons or contraband. The pat down search must be done by a staff member of the same gender as the detainee, unless one is not available. A pat down search is required, even if another section or agency claims to have completed one. In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(D)(5), the FOD must ensure officers closely supervise hold rooms through direct supervision that includes: continuous auditory monitoring, even when the hold room is not in the officers direct line of sight.
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24
24
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24

(b)(7)e
ICE.11.5082.000665
DETENTION STANDARD
LRGP-1
LRGP-2
Marriage Requests
MR-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(F), the FOD must ensure the requestor provides a one-page poster (no larger than 8.5 by 11 inches) to inform detainees of the general nature and contents of the presentation, the 27 intended audience, and the language(s) in which it will be conducted. The poster should instruct detainees to contact the housing officer if they wish to sign up to attend. For poster text in languages other than English, an English translation must be provided. In accordance with the ICE PBNDS, Legal Rights Group Presentations, section (V)(J), the FOD must ensure the request for approval of a presentation lists any published or unpublished materials proposed for distribution. The requestor must provide a copy of any unpublished material, with a cover page, 27 that: identifies the submitter and the preparer of the material; includes the date of preparation; and states clearly that ICE/DRO did not prepare, and is not responsible for, the contents of the material. If any material is provided in a language other than English, an English translation must be provided. In accordance with the ICE PBNDS, Marriage Requests, section (V)(G), the FOD must ensure, once the marriage has taken place, the Facility 28 Administrator forwards original copies of all documentation to the detainees Afile, and maintains copies in the facilitys detention file.

(b)(7)e
56
ICE.11.5082.000666
DETENTION STANDARD
Medical Care
MC-1
News Media Interviews and Tours
NMI&T
Population Counts
PC-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE PBNDS, Medical Care, section (lll)(I)(J), the FOD must ensure the clinical medical authority is responsible for reviewing all health screening forms within 24 hours or the next business day to assess the 29 priority for treatment (for example, Urgent, Today, or Routine). The clinical medical authority must be responsible for reviewing all health appraisals to assess the priority for treatment. In accordance with the ICE PBNDS, News Media Interviews and Tours, section (V)(A)(1), the FOD must ensure, by regulating interviews in the detention setting, the Facility Administrator ensures the secure, orderly and safe operation of the facility. Interviews by reporters, other news media 30 representatives, academics and parties not included in other visitation categories in the Detention Standard on Visitation must be permitted access to facilities only by special arrangement, and with prior approval of the respective ICE/DRO FOD. In accordance with the ICE PBNDS, Population Count, section (V)(A)(2)(C), the FOD must ensure counting officers 31 remain in the count area until the facility Control Center verifies and clears the
Post Orders
PO-1
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(b)(7)e
ICE.11.5082.000667
DETENTION STANDARD
PAGE
Post Orders
PO-2
(b)(7)e
32
Post Orders
PO-3
32
Recreation
R-1
Religious Practices
RP-1
Religious Practices
RP-2
Recreation, section (V)(A), the FOD must ensure each outdoor exercise area provides a minimum of 750 square feet of unencumbered space, or 1,500 square feet of unencumbered space if 100 or more detainees are expected to use the space at the same time. In accordance with the ICE PBNDS, Religious Practices, section (V)(B), the FOD must ensure, in the interest of maintaining the security and orderly running of the facility and to prevent abuse or disrespect by detainees of religious practice or observance, the Chaplain monitor patterns of changes in declarations of religious preference. In accordance with the ICE PBNDS, Religious Practices, section (V)(C), the FOD must ensure the Chaplain possesses minimum qualifications of clinical pastoral education or equivalent specialized training, and endorsement by the appropriate religious-certifying body.
33
34
34

(b)(7)e
ICE.11.5082.000668
DETENTION STANDARD
Religious Practices
RP-3
Searches of Detainees
SD-1
SDC-1
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Religious Practices, section (V)(E), the FOD must ensure detainees in the SMU have regular access to the Chaplain or other religious service providers. The Chaplain must provide pastoral care in the SMUs and hospital units at least weekly. In accordance with the ICE PBNDS, Searches of Detainees, section (V)(D)(2)(c), the FOD must ensure staff conduct a strip search only where there is reasonable suspicion that contraband may be concealed on the person. Officers must obtain supervisory approval before conducting strip searches. It must be based on specific and articulable facts, along with reasonable inferences that may be drawn from those facts, that the officer should document in Form G-1025 (or contractor equivalent). In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. At a minimum, the logbook must record the date the request, with staff response and action, was returned to the detainee.
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34
35
36
Tool Control
TC-1
(b)(7)e
37

(b)(7)e
59
ICE.11.5082.000669
DETENTION STANDARD
PAGE
Tool Control
TC-2
(b)(7)e
37
TD-1
Transfer of Detainees, section (V)(B)(3), the FOD must ensure, at the time of the transfer, ICE/DRO provides the detainee, in writing, with the name, address and telephone number of the facility to which he or she is being transferred, using the Detainee Transfer Notification form. Staff must place a copy of the form in the detainees
38
Transportation
T-1
39
(b)(7)e
UOF&R-1
40

(b)(7)e
ICE.11.5082.000670
DETENTION STANDARD
PAGE
UOF&R-2
(b)(7)e
40
Visitation
V-1
Visitation
V-2
In accordance with the ICE PBNDS, Visitation, section (V)(D) and section (V)(J)(15), the FOD must ensure each facility maintains a log of all general visitors, and a separate log of legal visitors as described below. Staff must record in the general visitors log: the name and alien-registration number (Anumber) of the detainee visited, and the visitors name and address. In accordance with the ICE PBNDS, Visitation, section (V)(J)(8), the FOD must ensure, once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitation reception area. Staff must collect completed forms and forward them to ICE/DRO. Each completed Form G-28 becomes a permanent part of the detainees A-file, and it remains valid until ICE/DRO receives written notice of the relationships termination from the detainee or the legal representative. Staff must place such notices in the Afile on top of the Form G-28.
41
41

(b)(7)e
61
ICE.11.5082.000671
DETENTION STANDARD
Visitation
V-3
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE PBNDS, Visitation, section (V)(N)(4), the FOD must ensure volunteers read and sign a waiver of liability that releases ICE/DRO of all responsibility in case of injury during the visit before being admitted to any secure portion of the facility, or a location where detainees are present.
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41

(b)(7)e
ICE.11.5082.000672
APPENDIX C
DETENTION STANDARD RECOMMENDATIONS ODO was informed the Safety Officer has not completed any Occupational Safety and Health Administration (OSHA) training. ODO recommends completion of the 10-hour OSHA Outreach Program for General Industry. Written resolved informal grievance forms should be acknowledged with a signature by the detainee before being placed in the detention file. PAGE
18
Grievance System
23
ODO recommends the FOD discuss the possibility of more library space and more computers for 26 Lexis-Nexis accessibility. ODO recommends the FOD discuss with GEO the possibility of updating the detainee handbook, page12, and/or the GEO policy 5.2.3 (III)(G)(2), to reflect the same attorney visitation hours.
Visitation
42
Visitation
ODO recommends the FOD discuss the possibility of documenting reasons for terminating or 42 suspending an attorneys visitation privileges.

(b)(7)e
63
ICE.11.5082.000673
ICE.11.5082.000674
ICE.11.5082.000675
ICE.11.5082.000676
(b)(7)e
(b)(7)e
ICE.11.5082.000677
(b)(7)e
ICE.11.5082.000678
(b)(7)e
ICE.11.5082.000679
(b)(7)e
ICE.11.5082.000680
(b)(7)e
(b)(7)e
ICE.11.5082.000681
(b)(7)e
(b)(7)e
ICE.11.5082.000682


Detention and Removal Operations Denver Field Office Park County Jail Fairplay, Colorado
May 19-20, 2010
ICE.11.5082.000683
ICE.11.5082.000684
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization. Inspection Team Members. OVERVIEW .. AREAS OF CONCERN . ICE NATIONAL DETENTION STANDARDS Access to Legal Material Admission and Release............................................................ Detainee Grievance Procedures... Detention Files. Disciplinary Policy... Environmental Health and Safety.. .. Food Service Funds and Personal Property Medical Care Special Management Unit.. Suicide Prevention and Intervention. Terminal Illness, Advance Directives, and Death Use of Force. 1 1 2 3
4 4 5 5 6 7 8 9 10 10 11 11 13
ICE.11.5082.000685
INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Detention and Removal Operations (DRO) Headquarters and DRO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. In July 2009, ODO, formerly the Detention Facilities Inspection Group, conducted a Focus Review of the Park County Jail (PCJ), located in Fairplay, Colorado. The Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Focus Review.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Focus Review report submitted to DRO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Assistant Director, Office of Professional Responsibility.

(b)(6), (b)(7)(C)
Management & Program Analyst (Team Lead) ODO, Headquarters Detention & Deportation Officer ODO, San Diego Contract Inspector MGT of America
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000686
Park County Jail DRO Denver
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material; Admission and Release; Detainee Classification System; Detainee Grievance Procedures; Detainee Handbook; Detention Files; Disciplinary Policy; Environmental Health and Safety; Food Service; Funds and Personal Property; Medical Care; Special Management Unit; Staff-Detainee Communication; Suicide Prevention and Intervention; Terminal Illness, Advance Directives, and Death; and Use of Force. ODO staff identified 77 deficiencies during the Focus Review conducted in July 2009. During this Follow-up Inspection, ODO staff found 31 (40%) repeated deficiencies. ODO and DRO staff found corrective actions were taken on all deficiencies revisited in the following standards: Detainee Classification System, Detainee Handbook, and Staff-Detainee Communication. Deficiencies revisited in the following standards were not corrected and were found by ODO, along with DRO management at PCJ, to be noncompliant with the ICE NDS: Access to Legal Material; Admission and Release; Detainee Grievance Procedures; Detention Files; Disciplinary Policy; Environmental Health and Safety; Food Service; Funds and Personal Property; Medical Care; Special Management Unit; Suicide Prevention and Intervention; Terminal Illness, Advanced Directives and Death; and Use of Force.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000687
AREAS OF CONCERN
ODO conducted a Focus Review in July 2009. The ICE Supervisory Detention and Deportation Officer (SDDO) and PCJ staff informed ODO they did not submit a comprehensive Plan of Action because ODO submitted few recommendations to improve effectiveness and efficiency of operations at PCJ. The SDDO and PCJ management were informed by ODO an action plan should have been submitted to DRO in response to the 77 deficiencies found during the Focus Review. In response, PCJ management stated the final report was not provided by DRO in a timely manner and expressed frustration over the lack of opportunity to review the final report and address the deficiencies identified prior to the arrival of the Follow-up Inspection team. Upon review of the Medical Care standard, ODO found the sick call request form is only provided in English. There is no evidence assistance in filling out the request slip is provided to illiterate or non-English speaking detainees when necessary.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000688

During the initial ODO inspection, seven deficiencies were identified. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Access to Legal Material, section (III)(L), the FOD must ensure unrepresented, or illiterate or non-English speaking detainees who wish to pursue a legal claim related to their immigration proceedings or detention, and indicate difficulty with legal materials, are provided with more assistance than access to a set of English-language law books. ODO Follow-up Finding: Unrepresented detainees, and illiterate or non-English speaking detainees, are not provided with access to more than a set of English-language law books. The facility does not possess law books written in the Spanish-language. ODO Initial Finding: In accordance with the ICE NDS, Access to Legal Material, section (III)(Q)(4-6), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including: the procedure for requesting additional time in the law library (beyond the five hours per week minimum); the procedure for requesting legal reference materials not maintained in the law library; and the procedure for notifying a designated employee that library material is missing or damaged. Law library polices and procedures must be posted in the law library, along with a list of the librarys holdings. ODO Follow-up Finding: The PCJ detainee handbook does not include procedures for: requesting additional time in the law library beyond five hours a week, requesting legal reference materials not maintained in the law library, or notifying designated employees that library materials are missing or damaged.

During the initial ODO inspection, six deficiencies were identified. During this Follow-up Inspection, the following three deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Admission and Release, section (III)(A)(1), the FOD must ensure the orientation process, supported by a video (ICE) and handbook, informs new arrivals about facility operations, programs, and services. Covered subjects must include prohibited activities and the associated sanctions. ODO Follow-up Finding: An ICE officer and a PCJ staff member both stated PCJs admission process is not supported by a video.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000689
ODO Initial Finding: In accordance with the ICE NDS, Admission and Release, section (III)(C), the FOD must ensure the classification process determines the appropriate level of custody for each detainee. Once this is established, staff can issue the detainee clothing or a wristband in the appropriate color for his or her classification level. ODO Follow-up finding: After completing the classification process, and determining the level of custody for each detainee, PCJ does not issue detainees clothing or wristbands in the appropriate color based upon the detainees classification level. Except for female detainees and workers, all ICE detainees are dressed in white clothing with black stripes. ODO Initial Finding: In accordance with the ICE NDS, Admission and Release, section (III)(I), the FOD must ensure the officer completes a Report of Detainees Missing Property (Form I-387) when any newly-arrived detainee claims his or her property has been lost or left behind. Intergovernmental Service Agreement (IGSA) facilities must forward the completed Form I-387s to ICE. ODO Follow-up Finding: PCJ does not have Form I-387s available for newly-arrived detainees to file a claim when their property has been lost or left behind.

During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure the facility implements procedures for identifying and handling an emergency grievance. An emergency grievance involves an immediate threat to a detainees safety or welfare. Once the receiving staff member, approached by a detainee, determines the detainee is in fact raising an issue requiring urgent attention, emergency grievance procedures must apply. ODO Follow-up Finding: ODO reviewed the PCJ policies and procedures that describe the process for handling, investigating and responding to grievances filed by detainees. The policy does not mention the procedures for identifying and handling emergency procedures. The Sergeant stated procedures will be developed to identify and handle emergency grievances.
DETENTION FILES
During the initial ODO inspection, four deficiencies were identified. During this Followup Inspection, the following deficiency was found not corrected.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000690
ODO Initial Finding: In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office with IGSA-facility jurisdiction creates and maintains detention files on all detainees admitted to IGSA facilities. ODO Follow-up Finding: An ICE SDDO stated detention files are not maintained at the Denver field office.
DISCIPLINARY POLICY
During the initial ODO inspection, nine deficiencies were identified. During this Follow-up Inspection, the following three deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Disciplinary Policy, section (III)(C), the FOD must ensure detention facilities have procedures in place to ensure that all incident reports are investigated within 24 hours of the incident. ODO Follow-up Finding: ODO reviewed local policies. The facility does not have written policies and procedures to ensure all incident reports are investigated within 24 hours of the incident. ODO Initial Finding: In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(1-4), the FOD must ensure the detention facilitys disciplinary policies and procedures clearly define detainee rights and responsibilities; disciplinary actions are not capricious or retaliatory; staff do not impose or allow imposition of the following sanctions: corporal punishment, deviations from normal food services, deprivation of clothing, bedding, or items of personal hygiene, deprivation of correspondence privileges, or deprivation of physical exercise, unless such activity creates an unsafe condition; and staff do not hold a detainee accountable for his or her conduct if a medical authority finds the detainee mentally incompetent. ODO Follow-up Finding: ODO reviewed local policies and found they do not clearly define detainee rights and responsibilities as they relate to the disciplinary process. Policies do not include: detainee rights and responsibilities, that disciplinary actions will not be capricious or retaliatory, and that staff will not hold a detainee accountable for his or her conduct if a medical authority finds the detainee mentally incompetent. Local policies also do not state that staff will not impose or allow imposition of the following sanctions: corporal punishment; deviations from normal food services; deprivation of clothing, bedding, or items of personal hygiene; deprivation of correspondence privileges; or deprivation of physical exercise, unless such activity creates an unsafe condition. ODO Initial Finding: In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5), the FOD must ensure the detention facilitys detainee handbook or equivalent provides notice of the facilitys rules of conduct and of the sanctions imposed for violations of the rules. The handbook must advise detainees of the following: 1) The right to protection from personal abuse, corporal punishment, unnecessary or excessive
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000691
use of force, personal injury, disease, property damage, and harassment; 2) The right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs; 3) The right to pursue a grievance in accordance with written procedures; 4) The right to correspond with persons or organizations, consistent with safety, security, and the orderly operation of the facility; and 5) The right to due process, including the prompt resolution of a disciplinary matter (in accordance with the rules, procedures, and sanctions provided In the handbook). ODO Follow-up Finding: The PCJ detainee handbook does not address detainee rights to protection from abuse and discrimination, or a prompt resolution of a disciplinary matter. It also does not address the procedures for pursuing a grievance, corresponding with persons or organizations, or receiving due process.

During the initial ODO inspection, nine deficiencies were identified in this area. During this Follow-up Inspection, the following three deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3), the FOD must ensure every institution develops a fire prevention, control, and evacuation plan, to include the following: 1) provisions for occupant protection from fire and smoke; 2) inspection, testing, and maintenance of fire protection equipment, in accordance with National Fire Protection Association (NFPA) codes; 3) monthly fire inspections; 4) accessible, current floor plans (buildings and rooms), prominently posted evacuation maps/plans, exit signs and directional arrows for traffic flow, and a copy of each revision filed with the local fire department; and 5) conspicuously posted exit diagrams in each area. ODO Follow-up Finding: ODO reviewed the Fire Prevention, Control, and Evacuation Plan, and determined it does not include and/or require documentation of: monthly fire inspections; provisions for occupant protection from fire and smoke; inspections, testing, and maintenance of fire protection equipment; or accessible and current floor plans, copies of evacuation maps/plans posted in the facility, and locations of exit signs and directional arrows for traffic flow. Facility staff stated a copy of the plan has not been sent to the local fire department. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD must ensure, in addition to general area diagrams, the following information is provided on existing signs: 1) English and Spanish instructions; 2) You are here markers; and 3) emergency equipment locations. New signs and sign replacements must also identify and explain Areas of Safe Refuge. ODO Follow-up Finding: The PCJ Lieutenant stated exit diagrams located throughout the facility do not include "You are here" markers in English and Spanish. Signs to locate emergency equipment or areas of safe refuge are also not identified.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000692
ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1-4), the FOD must ensure the following sanitation of barbering operations is kept due to possible transfer of diseases through direct contact by towels, combs, and clippers: 1) the operation must be located in a separate room not used for any other purpose; 2) each barbershop must be provided with all equipment and the facilities necessary for maintaining sanitary procedures of hair care; 3) between detainees, all hair care tools coming into contact with detainees must be cleaned and effectively disinfected; and 4) each barbershop must have detailed hair care sanitation regulations posted in a conspicuous location for use by all hair care personnel and detainees. ODO Follow-up Finding: Facility staff stated the facility does not have a designated barbershop. The same conditions exist: PCJ sets up a chair outside Central Control and has a county inmate (when available) use clippers and other equipment to groom local inmates and ICE detainees. Hair care tools that come in contact with detainees are not cleaned or disinfected. Hair care sanitation regulations are not posted conspicuously where hair care equipment, tools, and materials are used.
FOOD SERVICE
During the initial ODO inspection, nine deficiencies were identified in this area. During this Follow-up Inspection, the following three deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(C)(2)(g), the FOD must ensure food is delivered from one place to another in covered containers. These may be individual containers, such as pots with lids, or larger conveyances that can move objects in bulk, such as enclosed, satellite-feeding carts. Food carts must have locking devices. ODO Follow-up Finding: The Food Service Manager stated PCJ delivers food in covered containers during their satellite feeding, but delivery carts are not locked after food is loaded. ODO visited the kitchen and observed all food delivery carts are not lockable. ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(H)(5)(k), the FOD must ensure facility food storage premises are maintained in a condition that precludes the harboring or feeding of insects and rodents. Outside openings must be protected by tight-fitting screens, windows, and doors that are selfclosing with controlled air curtains. ODO Follow-up Finding: ODO visited a food storage area located in a sally port. ODO observed the space under the door that leads outside is large enough to allow insects and rodents to gain entry into the food storage area to feed.
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(b)(7)e
ICE.11.5082.000693
ODO Initial Finding: In accordance with the ICE NDS, Food Service, section (III)(H)(11)(c)(1), the FOD must ensure all toxic, flammable, and caustic materials are segregated from food products, and stored in a locked and labeled cabinet or room. Cleaning and sanitizing compounds must be stored apart from food products. ODO Follow-up Finding: ODO observed containers of cleaning and sanitizing compounds stored with food products on shelves in the sally port area, rather than stored in a locked and labeled cabinet or room.

During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must ensure all IGSA facilities have, and follow, a policy for loss of, or damage to, properly-receipted detainee property, as follows: 1) all procedures for investigating and reporting property loss or damage must be implemented as specified in this standard; 2) supervisory staff must conduct the investigation; 3) the senior facility contract officer must process all detainee claims for lost or damaged property promptly; 4) the official deciding the claim must be at least one level higher in the chain of command than the official investigating the claim; 5) the official must promptly reimburse detainees for all validated property losses caused by facility negligence; 6) the official must not arbitrarily impose a ceiling on the amount to be reimbursed for a validated claim; and 7) the senior contract officer must immediately notify the designated ICE officer of all claims and outcomes. The FOD must also ensure the facility has written policies and procedures for detainee property reported missing or damaged. ODO Follow-up Finding: The PCJ Sergeant stated the facility does not have a policy addressing the loss of, or damage to, properly-receipted detainee property, and does not have policies and procedures for handling detainee property reported missing or damaged. ODO Initial Finding: In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: 1) which items detainees may retain in their possession; 2) that, upon request, detainees must be provided an ICE-certified copy of any identity document, such as a passport or birth certificate, placed in their A-files; 3) the rules for storing or mailing property not allowed in their possession; 4) the procedure for claiming property upon release, transfer, or removal; and 5) the procedures for filing a claim for lost or damaged property.
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(b)(7)e
ICE.11.5082.000694
ODO Follow-up Finding: ODO reviewed the PCJ detainee handbook and found it does not notify detainees of: how to request ICE-certified copies of identity documents; facility policies and procedures concerning the rules for storing or mailing property not allowed in their possession; the procedures for claiming property upon release; and the procedures for filing a claim for lost or damaged property.
MEDICAL CARE
During the initial ODO inspection, seven deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure initial screening of detainees includes observation and interview items related to possible mental disabilities, including mental illness and mental retardation, and evaluation for use of, or dependence on, mood and mind-altering substances. ODO Follow-up Finding: Upon review of 30 randomly selected medical records, ODO was unable to verify whether initial screening addressed possible mental disabilities, including mental illness and mental retardation, or evaluation for use of, or dependence on, mood and mind-altering substances. ODO Initial Finding: In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure the health care provider conducts a health appraisal and physical examination on each detainee within 14 days of arrival at the facility. If there is documented evidence of a health appraisal within the previous 90 days, the facility health care provider may determine that a new appraisal is not required. Health appraisals must be performed according to the National Commission on Correctional Healthcare and the Joint Commission on Accreditation of Healthcare organizations standards, to include dental screening. ODO Follow-up Finding: A review of 30 randomly selected medical records revealed detainees did not receive health appraisals or physical examinations within 14 days of arrival. There was no evidence health appraisals had been completed within the previous 90 days, or documentation the health care provider determined a new appraisal was not required. The Lead Nurse informed ODO, health appraisals are not routinely conducted on all detainees. When conducted, health appraisals do not include dental screenings unless a dental problem exists.
SPECIAL MANAGEMENT UNIT

During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected.
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SUICIDE PREVENTION AND INTERVENTION

During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Finding: In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(A), the FOD must ensure all facility staff receives training during orientation and periodically in the following: recognizing signs of suicidal thinking, including suspect behavior; facility referral procedures; suicide prevention techniques; and responding to an in-progress suicide attempt. All training must include the identification of suicide risk factors and the psychological profile of a suicidal detainee. ODO Follow-up Finding: A review of training records revealed not all facility staff members receive suicide prevention and intervention training during orientation. Annual training does not include responding to an in-progress suicide attempt.
TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH

During the initial ODO inspection, seven deficiencies were identified in this area. During this Follow-up Inspection, six deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (l), the FOD must ensure all facilities have policies and procedures addressing the issues of terminal illness, fatal injury, and advance directives. ODO Follow-up Finding: PCJ does not have a policy or procedure addressing terminal illness, fatal injury, advance directives, and death. ODO was informed detainees to whom this standard may apply are transferred from PCJ custody. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lII)(A)(4), the FOD must ensure the facility notifies ICE immediately when a detainee is seriously injured or ill. Additionally, the FOD must ensure the Health Services Administrator (HSA) notifies the Officer in Charge (OIC) of
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the detainees condition, and documents the detainees condition in a memorandum, briefly describing the illness and prognosis, if possible. ODO Follow-up Finding: PCJ does not have a policy addressing notification of ICE when a detainee is seriously injured or ill. Additionally, there is no policy requiring the HSA to notify the OIC of the detainees condition, or to document the condition in a memorandum describing the illness and the prognosis. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lII)(B), the FOD must ensure each medical facility uses the State Advance Directive Form for implementing living wills and advance directives. ODO Follow-up Finding: PCJ does not utilize the State Advance Directive Form for implementing living wills and advance directives. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lII)(C), the FOD must ensure each facility holding ICE detainees establishes and implements, through written procedure, policy governing Do Not Resuscitate orders. ODO Follow-up Finding: PCJ does not have a written policy addressing Do Not Resuscitate orders. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lII)(I), the FOD must ensure the OIC specifies in post orders the designated officers responsibility for proper distribution of the death certificate. ODO Follow-up Finding: The OIC has not specified in post orders the designated officers responsibility for proper distribution of the death certificate. ODO Initial Finding: In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lII)(J), the FOD must ensure the OIC develops and implements written procedures for making autopsy arrangements. ODO Follow-up Finding: The OIC has not developed and implemented written procedures for making autopsy arrangements.
USE OF FORCE
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, all three deficiencies were found not corrected.
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Focus Review Phoenix Field Office Pinal County Adult Detention Center Florence, Arizona
January 11 13, 2011
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FOCUS REVIEW PINAL COUNTY ADULT DETENTION CENTER PHOENIX FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY ........................................................................................... 1 INSPECTION PROCESS Report Organization ............................................................................................ 4 Inspection Team Members ................................................................................... 4 OPERATIONAL ENVIRONMENT Internal Relations ................................................................................................ 5 Detainee Relations ............................................................................................... 5 ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed ............................................................................ 6 Access to Legal Material ..................................................................................... 7 Detention Files .................................................................................................... 8 Environmental Health and Safety....................................................................... 10 Key and Lock Control ....................................................................................... 12 Recreation ......................................................................................................... 13 Security Inspections ........................................................................................... 14 Special Management Units ................................................................................ 15 Staff-Detainee Communication .......................................................................... 18 Tool Control ...................................................................................................... 20 Use of Force ...................................................................................................... 21 Visitation ........................................................................................................... 22 LIST OF ACRONYMS ............................................................................................... 24
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EXECUTIVE SUMMARY
The Immigration and Customs Enforcement (ICE), Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO), conducted a Focus Review of the Pinal County Adult Detention Center (PCADC), in Florence, Arizona, on January 11 13, 2011. A Focus Review was conducted at the facility to best ensure PCADC and ICE Enforcement and Removal Operations (ERO) personnel were providing ample oversight with respect to ICE detainees and the applicable detention standards. ODO evaluates multiple criteria prior to its selection of detention facilities to be inspected, including significant event notifications from ERO staff and complaints submitted to the DHS Joint Intake Center. The selection of PCADC for an ODO Focus Review was made based on an analysis of the totality of criteria and circumstances related to the facility, including an elevated number of incidents and complaints in comparison to other detention facilities across the country. ICE, under an intergovernmental service agreement (IGSA), uses PCADC to house male detainees of all classification levels requiring detention for more than 72 hours. The Pinal County Sheriffs Office (PCSO), Florence, Arizona, operates and has jurisdiction over the PCADC, which houses ICE detainees as well as serves as the county jail for prisoners received from area law enforcement jurisdictions. During the Focus Review, ODO examined processes employed at PCADC to determine compliance with ICE policies and the ICE National Detention Standards (NDS). PCADC compliance with ICE policies and the ICE NDS is the responsibility of the ERO Field Office Director (FOD), Phoenix, Arizona An ERO Assistant Field Office Director (AFOD) stationed at the Service Processing Center, Florence, Arizona (Florence SPC), supervises ICE staff at the PCADC. The ICE personnel who monitor detention conditions and serve as liaisons with PCADC staff are permanently assigned to the Detention Compliance Unit, Florence SPC, and work with PCADC on regular business days, excluding weekends and holidays,. Additionally, Deportation Officers from FOD/Phoenix conduct scheduled weekly detainee visits at the PCADC regarding detained docket control duties related to immigration court proceedings.
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In August 2008, Creative Corrections, LLC, conducted an annual review of PCADC. The review resulted in a deficient rating. Consequently, a plan of action was submitted to ERO by PCSO to address the deficiencies. In February 2009, the former OPR Management Inspections Unit, Detention Facilities Inspection Group (DFIG) conducted a Quality Assurance Review (QAR) of the PCADC. DFIG staff recorded a total of 63 deficiencies among the 21 NDS reviewed. In February 2010, ODO conducted a Follow-up Review of the PCADC to ascertain whether the PCADC had addressed
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the deficiencies noted in the 2009 QAR. Reviewers documented five (8%) repeated deficiencies among four of the NDS reviewed. During the Focus Review, ODO reviewed a total of 26 NDS finding that 15 were in full compliance, while 11 had deficiencies. During the review of those 11 standards, ODO identified a total of 22 deficiencies: Access to Legal Materials (1); Detention Files (2); Environmental Health and Safety (3); Key and Lock Control (1); Recreation (1); Security Inspections (1); Special Management Unit (Administrative Segregation) (6); Staff-Detainee Communication (3); Tool Control (1); Use of Force and Restraints (2); and Visitation (1). A majority of these deficiencies were minor with minimal impact regarding life safety issues and the overall operational readiness of the facility. OPR interviewed detainees, who stated they are able to send and receive mail and have adequate access to legal materials and a law library. In addition, none of the detainees interviewed complained about personal hygiene or recreation. All of the detainees were familiar with the procedures for contacting their Deportation Officers, pro bono legal services, and consular officers.
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PCADC personnel made several on-site corrections to eliminate deficiencies during the Focus Review. Of particular note, PCADC is in the process of building a barber facility that will comply with the Environmental Health and Safety standard of the ICE NDS. Construction is expected to be completed by spring 2011.
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This Focus Review report includes descriptions of 22 identified deficiencies, and refers to the 11 relevant NDS. A copy of the final report will be provided to ERO to assist in developing and implementing corrective actions.

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INSPECTION PROCESS
The Office of Professional Responsibilitys (OPR) Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards or the Performance Based National Detention Standards (PBNDS), as applicable. In addition, focus may be applied to the inspection with information provided on detention management by ERO HQ and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at PCADC to determine compliance with current policies and detention standards. This Focus Review was predicated on many different criteria, including incoming allegations and complaints to the JIC. Prior to the inspection, ODO collected and analyzed relevant allegations and detainee information from multiple ICE databases, including the Joint Integrity Case Management System (JICMS), the ENFORCE Alien Booking Module (EABM) and Alien Removal Module (EARM). ODO also gathered facility facts and inspectionrelated information from ERO headquarters staff to best prepare for the site visit at PCADC.
REPORT ORGANIZATION
This Focus Review contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies were not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. The report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and generate useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding findings should be forwarded to the OPR Deputy Division Director for the Office of Detention Oversight.

Special Agent (Team Leader) Special Agent (Section Chief) Special Agent Special Agent Special Agent Detention & Deportation Officer Contract Inspector Contract Inspector Contract Inspector OPR/ODO, Phoenix OPR/ODO, Phoenix OPR/ODO, Phoenix OPR/ODO, Phoenix OPR/ODO, San Diego OPR/ODO, San Diego MGT of America MGT of America MGT of America
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INTERNAL RELATIONS
ODO interviewed supervisory and non-supervisory PCSO staff at the PCADC, as well as ICE staff from FOD/Phoenix. Personnel interviewed stated morale is high at the facility. PCADC staff indicated they were satisfied with the relationship with ICE officials. ICE staff stated the facility has adequate resources to fulfill its contractual obligations. PCADC staff stated executive management at FOD/Phoenix is supportive of operational needs at PCADC.
DETAINEE RELATIONS
ODO interviewed 20 randomly-selected ICE detainees to assess their perspective of the detention conditions at the PCADC. The majority of detainees interviewed stated they were treated with dignity and respect. Detainees stated they are able to send and receive mail and have adequate access to legal materials and a law library. In addition, none of the detainees interviewed complained about personal hygiene or recreation. All of the detainees were familiar with the procedures for contacting their Deportation Officers, pro bono legal services, and consular officers. Three detainees complained about the 20-minute restriction imposed on telephone calls. This restriction is clearly explained in the detainee handbook and is compliant with the NDS. Ten detainees complained that the food served at the facility was not fully cooked, portions were small, and food was served cold. One detainee stated he got sick from a bad meal served to him around Christmas. Review of the Food Service standard during this ODO review found PCADC to be 100% compliant with the NDS. During the interviews, ODO observed that two detainees did not possess identification wristbands, and two detainees had broken identification wristbands that could not be worn on their wrists. The facilitys local detainee handbook states all detainees are required to wear their identification wristbands at all times. ODO brought the issue to the attention of PCADC officials, who initiated immediate corrective action. One detainee expressed concerns with his personal medical care, stating he had been scheduled for non-emergency hernia repair surgery on January 12, 2011, the same day he was scheduled to appear in court, where he anticipated being released from custody or removed from the U.S. The detainee chose not have the surgery and refused to consent to rescheduling the procedure. Another detainee praised the facilitys medical staff and stated the medical service was excellent. Review of the Medical standard during this ODO review found PCADC to be 100% compliant with the NDS.

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DETENTION STANDARDS REVIEWED
A total of 26 National Detention Standards were reviewed during the ODO inspection. The following 11 areas were found to be deficient with respect to adherence to the ICE NDS, as required: Access to Legal Material Detention Files Environmental Health and Safety Key and Lock Control Recreation Security Inspections Special Management Unit (Administrative Segregation) Staff-Detainee Communication Tool Control Use of Force and Restraints Visitation The following 15 standards were found to be well-managed: Admission and Release Classification System Detainee Handbook Disciplinary Policy Food Service Funds and Personal Property Grievance Procedures Hunger Strikes Issuance and Exchange of Clothing, Bedding, and Towels Medical Care Special Management Unit (Disciplinary Segregation) Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Voluntary Work Program As these 15 standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ODO reviewed the Access to Legal Material standard at the PCADC to determine whether detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed policy, observed procedures, inspected the library, and conducted interviews with staff and detainees. The law library is sufficient in size, with adequate equipment to facilitate legal research and document preparation. Four computers are available for use and have the latest version of LexisNexis. There are printers, a typewriter, a copier, and paper all readily available. Writing implements are provided upon request. Detainees in the Special Management Unit (SMU) can request library access by filling out a request form. If additional legal materials are needed, there is a procedure in place for detainees to make a formal request. The PCADC facilitates notary public, certified mail, and other services necessary to pursue legal matters. Pro bono attorneys can be accessed via the telephone system. The detainee handbook describes the procedure for requesting additional time in the library, requesting legal reference materials not maintained in the law library, and notifying a designated employee of missing or damaged library material. The policies and procedures related to use of the law library are in the detainee handbook and have been posted in the law library; however, a list of the law librarys holdings is not posted (Deficiency ALM-1).

DEFICIENCY ALM-1 In accordance with the ICE National Detention Standard, Access to Legal Material, section (III)(Q), the FOD must ensure that these policies and procedures shall also be posted in the law library with a list of the law librarys holdings.

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ODO reviewed the Detention Files standard at PCADC to determine if files are created and maintained containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the NDS. ODO reviewed detention files, logbooks, and interviewed staff. The facility maintains its active and archived detention files in a secure part of the admissions and intake processing area. Staff must record the removal and return of detention files in a logbook. The logbook contains columns recording the detainees name and alien file number, the date and time the file was removed, the reason for the files removal, the signature of the person removing the file, the date and time the file was returned, and the signature of the person returning the file. ODO reviewed the logbook and found all detention files signed out by staff were returned by the end of the working day. ODO reviewed 20 randomly-selected active detention files located at PCADC and verified they contained the Alien Booking Record (Form I-385), a photograph of the detainee, the acknowledgement form documenting receipt of the detainee handbook, and the classification worksheet. None of the files reviewed contained the detainee housing identification card, as required by the NDS (Deficiency DF-1). The facility does not process or store detainee property and valuables at PCADC. Detainee property and valuables are processed and secured at the Florence Service Processing Center (SPC). Therefore, ODO reviewed the corresponding detention files located at Florence SPC for the 20 randomly-selected detention files from PCADC. Although all 20 corresponding detention files located at Florence SPC contained the Personal Property Inventory Sheet and the Property Receipt (Form G-589), 17 of the 20 detention files did not contain the Baggage Check tag (Form I-77), as required by the ICE NDS (Deficiency DF-2). The Baggage Check tags for these 17 files were located at the main control center of the Florence SPC. Since PCADC does not process or store detainee property and valuables at PCADC and all detainees are released through Florence SPC, ODO reviewed 15 inactive detention files located at Florence SPC and observed they contained completed release documents, closed-out receipts for detainee property and valuables (Form G-589), and closed-out Alien Booking Records (Form I-385).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B)(1)(d), the FOD must ensure the detainee detention file will, at a minimum, contain the following: Housing Identification Card.

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DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(B)(1)(f), the FOD must ensure the detainee detention file will, at a minimum, contain the following: I-77, Baggage Check(s).

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ENVIRONMENT HEALTH & SAFETY (EH&S)

ODO reviewed the Environmental Health and Safety standard at PCADC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. The ODO inspection verified all chemicals and flammable and combustible materials were stored and issued as required. Procedures for handling caustic and toxic substances are in place and followed. Hazardous substances are strictly controlled and when used, personal safety equipment is worn. Monthly fire drills were conducted on each shift and documentation is on file in the Safety Officers office. Pest control services are under contract and monthly inspections are conducted. The facility maintained a high level of sanitation. At the time of the initial review, a running inventory of hazardous substances stored in the laundry was not maintained (Deficiency EH&S-1). This issue was corrected on-site during the inspection, and an inventory was established. As control of hazardous substances is a critical life safety issue, ODO recommended that the Safety Officer monitor continued compliance. Hair care is conducted in a hallway outside of housing units. There is no lavatory, or hot and cold running water (Deficiency EH&S-2). Hair care sanitation regulations are not posted (Deficiency EH&S-3). Postings help ensure all detainees are aware of sanitation requirements. Adherence to sanitation regulations is critical to minimizing the risk of cross-contamination related to the use of shared hair care equipment. PCADC is in the process of building a barber facility that will be comply with the standard. Construction is expected to be completed by spring 2011.

DEFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure that every area will maintain a running inventory of the hazardous (flammable, toxic, or caustic) substances used and stored in that area. Inventory records will be maintained separately for each substance, with entries for each logged on a separate card (or equivalent). That is, the account keeping will not be chronological, but filed alphabetically, by substance (dates, quantities, etc.). DEFICIENCY EH&S-2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the operation will be located in a separate room not used for any other purpose. The floor will be smooth, nonabsorbent and easily cleaned. Walls and ceilings will be in good repair and painted a light color. Artificial lighting of at least 50-foot candles will be provided. Mechanical ventilation of 5 air changes per hour will be provided if there are no operable windows to provide fresh air. At least one lavatory will be provided. Both hot and cold water will be available, and the hot water will be capable maintaining a constant flow of water between 105 degrees and 120 degrees.
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DEFICIENCY EH&S-3 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(4), the FOD must ensure each barber shop will have detailed hair care sanitation regulations posted in a conspicuous location for the use of all hair care personnel and detainees.

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ODO reviewed the Key and Lock Control standard at the PCADC to determine if facility safety and security is maintained by requiring keys and locks to be controlled and maintained, in accordance with the ICE NDS. ODO toured the facility and observed use, accountability, and maintenance of keys and locks. Additionally, ODO interviewed staff and reviewed all available documentation and local policies.
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RECREATION (R)
ODO reviewed the Recreation standard at PCADC to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO toured the recreation areas, reviewed local policies, and interviewed staff and detainees. Detainees in the general population and in segregation at PCADC are provided recreation at least one hour a day, seven days a week. Detainees in the general population do not participate in recreational activities in the same location as detainees in segregation. During recreation time, detainees can choose to participate in physical activities such as hacky sack, volleyball, soccer, and basketball; or sedentary activities such as board games, checkers, dominos, chess, playing cards, viewing television, and reading books. According to facility staff, PCADC does not deny recreation as a disciplinary sanction. The facilitys recreation officer issues all recreation equipment to detainees. Equipment is inspected for alteration or damages by the recreation officer before it is issued, and after it has been returned. PCADC recreation policy requires the facilitys recreation areas to be searched for contraband or security breaches before and after each use. According to the compliance officer and the recreation officer, the recreation areas are searched hourly, regardless of whether detainees or inmates have used the area for recreation. An electronic sensor verifies and records the hourly searches of the recreational areas. The facility does not have a policy established concerning television viewing (Deficiency R-1).
STANDARD/ POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

DEFICIENCY R-1 In accordance with the ICE NDS, Recreation, section (III)(G)(10), the FOD must ensure the OIC shall establish facility policy concerning television-viewing in dayrooms. All television-viewing schedules shall be subject to the OICs approval.

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ODO reviewed the Security Inspections standard at the PCADC to determine if the facility security is maintained, and events posing a risk of harm are prevented, in accordance with NDS. ODO reviewed logbooks and policies, observed operations, and interviewed staff. The PCADC has a comprehensive security inspection system covering all areas of the facility. The front entrance of the facility has a sally port with electronic interlocking doors to prevent unauthorized entry or exit. PCADC staff control and document vehicular traffic entering and exiting the facility. The PCADC has procedures in place for issuing visitor passes to all visitors, as well as area and personal searches. ODO identified a best practice, PCADCs use of the Key Watcher System, an electronic key management program that ensures accountability of facility keys. Keys are secured to unique fobs with memory chips, which are assigned and programmed to designated key numbers. Staff access and return keys by entering the key ring number and their unique user code and password. Key fobs store key transactions in memory, which generate a daily inventory for review by the Key Control Officer. The Key Watcher System has features that support key control, including real-time alerts to possible security issues such as illegal entry, doors left open, invalid key return, etc., serving to enhance the overall security of the facility. There were no written procedures addressing the requirement that officers take precautions to ensure that an individual requesting entry or exit to a Special Management Unit (SMU) is not doing so under duress (Deficiency SI-1). This issue was corrected on-site. The policy was revised during the inspection to require necessary and appropriate precautions before allowing entry to the SMU in accordance with the standard.

DEFICIENCY SI-1 In accordance with the ICE NDS, Security Inspections, section (III)(D)(4)(a), the FOD must ensure that in accordance with written procedures established by the OIC, these officers will take precautions to ensure that the person requesting entry or exit is not doing so under duress.

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The ODO review determined whether procedures exist to provide formal and informal contact between detainees and key ICE and PCADC staff; and whether ICE detainees are able to submit written requests to ICE staff and receive responses in an acceptable timeframe, in accordance with the Staff/Detainee Communication standard, and the applicable Change Notice(s) both dated June 15, 2007. ODO reviewed policies, logbooks, and reports, observed procedures, and interviewed detainees as well as ICE and PCADC staff. The standard calls for ICE department heads to conduct regularly unannounced visits to the facility. ODO noted visits are being conducted and documented by ICE line staff. ICE officers conducted a minimum of one scheduled and one unscheduled visit to detainee housing units every week. However, PCADC management staff interviews indicated that the ICE FOD, DFOD and AFOD only visited the facility on one occasion in 2010 (Deficiency SDC-1). The housing units have schedules posted with the days visits are scheduled and names of ICE staff responsible. ICE officers are required to sign the housing unit logbooks to prove they were onsite. ICE officers are also completing the required Telephone Serviceability Worksheet as required in the Change Order dated June 15, 2007. The detainee handbook describes procedures for detainees to contact an ICE officer. ICE officers collect and log the detainee request forms and provide answers within 72 hours. However, ODO noted the log does not document the name of the ICE Officer logging the request, and staffs response and action are not included in the log (Deficiency SDC-2). Copies of completed detainee request forms are placed in detention files for a minimum of three years. ODO noted there were detainees currently in administrative segregation for more than 30 days. PCADC and ICE are conducting weekly reviews. However, ICE is not forwarding the reviews to the FOD as required in the Change Notice, National Detention Standards, Staff/Detainee Communication dated June 15, 2007, Model Protocol (Deficiency SDC-3).

DEFICIENCY SDC-1 In accordance with the ICE National Detention Standard, Staff Detainee Communication, section (IIII)(A)(1), the FOD must ensure policy and procedures shall be in place to ensure and document that the ICE Officer in Charge (OIC), the Assistant Officer in Charge (AOIC) and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and informally observing living and working conditions. DEFICIENCY SDC-2 In accordance with the ICE National Detention Standard, Staff Detainee Communication, section (III)(B)(2), the FOD must ensure all requests shall be recorded in a logbook specifically designed for that purpose. The log, at a minimum, shall contain: a) the date the detainee request was received; b) detainees name; c) A-number; d) nationality; e) officer logging the request; f) the
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date that the request, with staff response and action, is returned to the detainee; and g) any other site-specific pertinent information. DEFICIENCY SDC-3 In accordance with the Change Notice, National Detention Standards, Staff/Detainee Communication, Model Protocol, dated June 15, 2007, DRO Officer Facility Liaison Visits, section (D)(1), the FOD must ensure assigned DRO officers shall: review the reason for placement in the SMU and the projected length of stay. Determine that ICE was notified regarding any ICE detainee placed into segregation for 30 days or more and the Field Office Director has reviewed the detainees status.

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TOOL CONTROL (TC)
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USE OF FORCE (UOF)
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VISITATION (V)
ODO reviewed the Visitation standard at PCADC to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the NDS. ODO observed visitation practices, reviewed written policies, and interviewed staff. PCADC maintains separate logs for documenting general and legal visitors. General visitations are documented electronically while legal visitations are recorded in a logbook. General visitors can leave money for detainees but must do so by depositing funds into the account of a detainee via an electronic kiosk located within the facility. Visitors wanting to leave property and valuables for detainees must do so through the Florence SPC. PCADC does not process or accept property for detainees. All visitors are subject to a personal search at PCADC. A search includes an overall visual inspection and a bag and/or purse search, if applicable. Once positive identification is confirmed, visitors are escorted by facility staff to the visitation room. ODO toured the visitation room and found it to be adequately furnished. ODO witnessed that visitations are conducted in a quiet and orderly manner. Contact visits are not allowed at the facility for general visitors. General visitors conduct visitation with detainees through the use of video teleconferencing equipment located in the facilitys visitation room. Legal visitors are allowed to exchange documents with detainees. Legal visitations are subject to visual monitoring by facility staff, but auditory monitoring is not permitted. The facility allows legal visitation seven days a week, including holidays. Copies of Form G-28 (Notice of Entry of Appearance as Attorney or Accredited Representative) are available in the visitors reception area. Completed forms are collected by facility staff and forwarded to ICE. PCADC encourages visits from consular officers and facilitates visits from law enforcement officials and members of the news media. Members of the news media must obtain prior approval from the Sheriff and the Chief Deputy of detention in order to conduct visitations and interviews of detainees at PCADC. Once the approval is obtained, a Media Interview Release Form must be signed by the detainee consenting to be interviewed. The member of the news media conducting the interview must also sign this form. PCADC has no established policy pertaining to procedures governing circumstances where animals may accompany a visitor into the facility (Deficiency V-1).

DEFICIENCY V-1 In accordance with the ICE NDS, Visitation, section (III)(O)(4), the FOD must ensure each facility shall establish and disseminate a policy and implementing procedures governing whether

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22
ICE.11.5082.000722
and, if so, under what circumstances animals may accompany human visitors onto or into facility property.

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ICE.11.5082.000723
LIST OF ACRONYMS
ACA AFOD CDF DFIG ERO EABM FOD HQ ICE IHS IGSA JIC JICMS NDS OIC ODO OPR PBNDS SIR SMU American Corrections Association Assistant Field Office Director Contract Detention Facility Detention Facilities Inspection Group Enforcement and Removal Operations ENFORCE Alien Booking Module Field Office Director Headquarters Immigration and Customs Enforcement ICE Health Service Corps Intergovernmental Service Agreement Joint Intake Center Joint Integrity Case Management System National Detention Standards Officer in Charge Office of Detention Oversight Office of Professional Responsibility Performance Based National Detention Standards Significant Incident Report Special Management Unit

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ICE.11.5082.000724


Detention and Removal Operations Phoenix Field Office Pinal County Adult Detention Center Florence, Arizona
February 24-26, 2010
ICE.11.5082.000725
ICE.11.5082.000726
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW. ICE NATIONAL DETENTION STANDARDS Detention Files....... Environmental Health and Safety Medical Care.. Security Inspections. 1 1 2
3 3 4 4
ICE.11.5082.000727
INSPECTION PROCESS
The Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Detention and Removal Operations (DRO) Headquarters and DRO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. In February 2009, ODO, formerly the Detention Facilities Inspection Group, conducted a Quality Assurance Review of the Pinal County Adult Detention Center (PCADC) Florence, Arizona. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to DRO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Director, Office of Professional Responsibility.

DDO / Team Leader Special Agent Contract Inspector ODO, OPR San Diego ODO, OPR San Diego MGT of America, Inc.
(b)(6), (b)(7)(C)
_____________________________________________________________________________________________
Office of Detention Oversight February 2010

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Pinal County Adult Detention Center DRO Phoenix
ICE.11.5082.000728
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material, Admission and Release, Detainee Classification System, Detainee Grievance Procedure, Detainee Handbook, Detention Files, Emergency Plans, Environmental Health and Safety, Food Service, Hold Rooms in Detention Facilities, Key and Lock Control, Medical Care, Population Counts, Security Inspections, Special Management Unit, Staff Detainee Communications Suicide Prevention and Intervention, Telephone Access, Tool Control, Use of Force, and Visitation. ODO staff identified 63 deficiencies during the Quality Assurance Review conducted in February 2009. During this Follow-up Inspection, ODO staff found five (8%) repeated deficiencies. ODO and DRO staff found corrective actions were taken on all deficiencies revisited in the following standards: Access to Legal Material, Admission and Release, Detainee Classification System, Detainee Grievance Procedure, Detainee Handbook, Emergency Plans, Food Service, Hold Rooms in Detention Facilities, Key and Lock Control, Population Counts, Special Management Unit, Staff Detainee Communications Suicide Prevention and Intervention, Telephone Access, Tool Control, Use of Force, and Visitation. Deficiencies revisited in the following standards were not corrected and were found by ODO, along with DRO management at the PCADC, to be noncompliant with the ICE NDS: Detention Files, Environmental Health and Safety, Medical Care, and Security Inspections.
_____________________________________________________________________________________________

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ICE.11.5082.000729

DETENTION FILES
During the initial ODO inspection, four deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure PCADC maintains a detention file logbook for controlling access to detention files. ODO Follow-up Finding: The facility maintains a logbook to record the removal and return of detention files from the intake area; however, the logbook does not contain a block or column to record the reason the detention file was removed. The logbook also does not have separate blocks or columns to record the signature of the person removing the file and the signature of the person returning the file. The title and department of the person removing and returning the detention file are not recorded in the logbook. The logbook does have columns to record the date and time a file was removed and the date and time a file was returned. During the inspection, corrective action was taken by adding the missing blocks and columns in the logbook.

During the initial ODO inspection, six deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barber operation is located in a separate room not used for any other purpose. At least one lavatory must be provided. Hot and cold water must be available, and the hot water must be capable of maintaining a constant flow of water between 105 and 120 degrees Fahrenheit. ODO Follow-up Finding: The facility does not have a dedicated room for barbershop services and operations. A small area near the housing unit officers table is used to conduct barbershop services and operations on Saturdays. This area does not have a lavatory with running hot and cold water. This is a structural deficiency and the facility is making efforts to build a dedicated room to be used for barbershop services and operations.
_____________________________________________________________________________________________

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ICE.11.5082.000730
MEDICAL CARE
During the initial inspection, five deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Findings: In accordance with the ICE National Detention Standard, Medical Care, section (III)(D), the FOD must ensure all new arrivals receive initial medical and mental health screening immediately upon their arrival by a health care provider or an officer trained to perform this function. ODO Follow-up Finding: In two of 25 medical records reviewed, ODO was unable to verify initial screening was conducted immediately upon the detainees arrival. The Intake Screening Form (Form DIHS-795A) did not document the time of arrival or initial screening. ODO Initial Findings: In accordance with the ICE National Detention Standard, Medical Care, section (III)(D), the FOD must ensure the health care provider conducts a health appraisal and physical examination on each detainee within 14 days of arrival at the facility. If there is documented evidence of a health appraisal within the previous 90 days, the facility health care provider may determine that a new appraisal is not required. ODO Follow-up Finding: In two of 30 medical records reviewed, the detainees did not receive health appraisals or physical examinations within 14 days of arrival. Additionally, there was no evidence health appraisals had been completed within the previous 90 days, or documentation the health care provider determined a new appraisal was not required.
During the initial ODO inspection, three deficiencies were identified in this area. During this Follow- up Inspection, the following deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE National Detention Standard, Security Inspections, section (III)(D)(3)(1)(a), the FOD must ensure the facility has policies and procedures to control and document all vehicular traffic entering the facility.
ODO Follow-Up Finding: The parking area resembles what ICE considers as a sallyport. The PCADC has procedures in place to electronically observe and control vehicle traffic in and out of this area. Cameras are strategically placed throughout, and are used for observation purposes. A door accessing the booking and processing areas of the PCADC is present within this secured area. PCADC does not thoroughly search vehicles immediately before entering and prior to exiting the loading area. An armed officer does not closely monitor this area. However, the facility fails to document all vehicular traffic entering and exiting this area.
_____________________________________________________________________________________________

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ICE.11.5082.000731


Enforcement and Removal Operations Boston Field Office Plymouth County Correctional Facility Plymouth, Massachusetts September 14-15, 2010
ICE.11.5082.000732
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members OVERVIEW. ICE NATIONAL DETENTIONSTANDARDS Environmental Health and Safety ............ Post Orders.. Staff Detainee Communications. Use of Force 1 1 2
3 3 3 4
ICE.11.5082.000733
INSPECTION PROCESS
The Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. In September 2009, ODO conducted a Quality Assurance Review of the Plymouth County Correctional Facility (PCCF) Plymouth, Massachusetts. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to ERO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the ODO Deputy Division Director, Office of Professional Responsibility.

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DDO / Team Leader Contact Inspector
ODO, OPR San Diego MGT of America, Ink.
_____________________________________________________________________________________________

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Plymouth County Correctional Facility ERO Baltimore
ICE.11.5082.000734
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed Access to Legal Material, Admission & Release, Correspondence & Other Mail,
Detention Files, Detainee Handbook, Environmental Health & Safety, Food Service, Funds & Personal Property, Hold Rooms, Key & Lock Control, Medical Care, Post Orders, Special Management Unit, Staff-Detainee Communication, Suicide Prevention and Intervention Tool Control, Use of Force, and Visitation.
ODO staff identified 42 deficiencies during the Quality Assurance Review conducted in September 2009. During this Follow-up Inspection, ODO staff found 4 (10%) repeated deficiencies. ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards Access to Legal Material, Admission and Release, Correspondence and Other Mail, Detention Files, Detainee Handbook, Food Service, Funds and Personal Property, Hold Rooms, Key and Lock Control, Medical Care, Special Management Unit, Suicide Prevention and Intervention, Tool Control, Visitation, Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at the PCCF, to be noncompliant with the ICE NDS: Environmental Health and Safety Post Orders, Staff Detainee Communication, and Use of Force.
_____________________________________________________________________________________________

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ICE.11.5082.000735

During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barber operation is located in a separate room not used for any other purpose. At least one lavatory must be provided. Hot and cold water must be available, and the hot water must be capable of maintaining a constant flow of water between 105 and 120 degrees Fahrenheit. ODO Follow-up Finding: Each housing unit maintains its own haircut equipment and haircuts are done on the main floor next to the officers station.
POST ORDERS
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ODO Initial Finding: In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file and will remain in the detainees detention file for at least three years.
_____________________________________________________________________________________________

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ICE.11.5082.000736
ODO Follow-up Finding: ERO retains completed detainee request forms in the field office. However, a copy of the request is not stored within the applicable detention file.
USE OF FORCE
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_____________________________________________________________________________________________

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ICE.11.5082.000737


Quality Assurance Review Enforcement and Removal Operations St. Paul Field Office Polk County Jail Des Moines, Iowa
May 25-27, 2010
________________________________
FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law enforcement, management, and employee information. It has been written for the express use of the Department of Homeland Security to identify and correct management and operational deficiencies. In reference to OPR Directive 7006.1 issued 09/22/05, any disclosure, dissemination, or reproduction of this document, or any segments thereof, is prohibited without the approval of the Director, Office of Professional Responsibility.
ICE.11.5082.000738
ICE.11.5082.000739
FOCUS REVIEW POLK COUNTY JAIL St. PAUL FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Access to Legal Material Admission and Release. Detainee Grievance Procedures.. Detainee Handbook Detention Files. Disciplinary Policy Funds and Personal Property Hunger Strike... Medical Care Recreation Staff-Detainee Communication..... Suicide Prevention and Intervention. Telephone Access .. Terminal Illness, Advance Directives and Death Use of Force. Visitation... 1 1
5 5
8 9 10 11 13 15 16 18 19 21 22 24 25 26 28 30
ICE.11.5082.000740
ICE.11.5082.000741
INSPECTION PROCESS
The Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. ODO conducted an inspection of the Polk County Jail (PCJ) in Des Moines, Iowa, on May 25-27, 2010. ODO reviewed the processes employed at PCJ to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from ENFORCE, ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION

Team Leader Special Agent Management and Program Analyst Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America, Inc. MGT of America, Inc.
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ICE.11.5082.000742
Polk County Jail ERO Des Moines

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ICE.11.5082.000743
BACKGROUND
HISTORY
On October 1, 1984, PCJ entered into an Intergovernmental Service Agreement (IGSA) with the United States Marshals Service (USMS) to house prisoners and Immigration and Naturalization Service (INS) detainees over 72 hours. The agreement was last modified November 1, 2005 to allow for a rate increase. PCJ was opened and began receiving INS detainees in November 1984, and continues to hold ICE detainees. Adult male and female detainees of all classification levels are housed at PCJ. Juvenile detainees are not housed at the facility. PCJ is owned and operated by the Polk County Sheriffs Office. PCJ has not received any special accreditations. Medical services are provided to detainees through Prison Health Services. Food Service is provided by Polk County. The total PCJ housing capacity for ICE detainees is 40. ICE employs a full-time staff of five employees, to include a supervisory detention and deportation officer, deportation officers (DO), and immigration enforcement agents (IEA), at an ERO sub-office in Des Moines. The total number of facility staff (non-ICE) employed at PCJ is 293. The ERO Detention Standards Compliance Unit contractors, MGT of America, Inc. conducted an annual review of the ICE NDS at PCJ in September 2009; the facility received an Acceptable rating.

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ICE.11.5082.000744

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ICE.11.5082.000745
INTERNAL RELATIONS
ODO interviewed numerous ICE and PCJ management staff, correctional officers, DOs, and IEAs. All staff stated morale was very good. Both ICE and PCJ staff stated they share a good working relationship. The PCJ Chief stated Electro-Muscular Disruptive Devices (EMDD), commonly referred to as Tasers, are used at the facility as part of the PCJ Use of Force Continuum. ICE staff does not utilize space at PCJ. However, the ERO Des Moines office is equipped with adequate office equipment and supplies to carry out ICEs mission. Several ICE employees expressed concerns that ERO office space is too close to the holding cells, and there is a lack of space to process detainees.
DETAINEE RELATIONS
ODO interviewed nine ICE detainees at PCJ, consisting of six male detainees and three female detainees, to ascertain detainees concerns and to identify areas of possible noncompliance with the ICE NDS. ODO encouraged detainees to express their feelings about the facility, its staff, ICE staff, and the progress of their case. This often results in examples and anecdotes. In addition, in some cases detainees view these interviews as a self-serving opportunity. ODO cautions, due to the nature of the information obtained, it is not possible to verify each statement. Nonetheless, it is important to obtain information from the detainees point of view. The detainees had no complaints regarding food service, and were generally satisfied with the medical care provided by PCJ. Several detainees expressed concerns about the fresh air exchange in the recreation yards attached to the pods. PCJ staff explained, while the air conditioning is running, the louvers which allow for air exchange cannot be operated due to an electrical interlock.

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ICE.11.5082.000746

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ICE.11.5082.000747

This quality assurance review was based on the 2000 ICE NDS. The following standards were reviewed: Access to Legal Material; Admission and Release; Detainee Grievance Procedures; Detainee Handbook; Detention Files; Disciplinary Policy; Food Service; Funds and Personal Property; Hunger Strike; Medical Care; Recreation; StaffDetainee Communication; Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives and Death; Use of Force; and Visitation. No deficiencies were noted in the Food Service standard. As this standard was compliant at the time of the review, a synopsis for this area was not prepared for this report.

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ICE.11.5082.000748

ODO reviewed the Access to Legal Material standard at PCJ to determine if detainees have access to a law library, legal materials, courts, counsel and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed local policies, procedures, and the detainee handbook; inspected the law library; and interviewed staff and detainees. At the time of the inspection, ODO observed the only computer available for detainee use for legal research was not functioning properly. ICE staff was made aware of the malfunctioning computer, and made arrangements for its repair. The law library does not have writing implements, paper or other office supplies available to enable detainees to prepare documents for legal proceedings (Deficiency ALM-1). The PCJ detainee handbook does not address the rules and procedures governing access to legal materials. The information is also not posted in the law library (Deficiency ALM-2 and DH-1).

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare documents for legal proceedings. The facility must designate an employee with responsibility to inspect the equipment at least weekly to ensure it is in good working order, and to stock sufficient office supplies. DEFICIENCY ALM-2 and DH-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

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ICE.11.5082.000749

ODO reviewed the Admission and Release standard at PCJ to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO observed the intake area, reviewed the detainee handbook and facility policies, and interviewed staff and detainees. The Property Officer stated identity documents are kept in the detainees property rather than given to ICE to be placed into the detainees A-file (Deficiency AR-1). According to facility policies and the detainee handbook, detainees are issued two sets of socks and underwear, and laundry is exchanged twice a week. Therefore, detainees are unable to have a clean set of socks and underwear on a daily basis (Deficiency AR-2).

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(E), the FOD must ensure identity documents, such as passports and birth certificates, are inventoried, then given to a deportation officer or ICE official for placement in the detainees A-file. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(E), and Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure staff issues detainees clothing and bedding in quantities and weights appropriate for the facility environment and local weather conditions. Detainees must be provided with clean clothing, linen, and towels on a regular basis to ensure proper hygiene. Socks and undergarments must be exchanged daily.

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ICE.11.5082.000750

ODO reviewed the Detainee Grievance Procedures standard at PCJ to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff, and reviewed detainee grievance procedures and the PCJ detainee handbook. Based on ODOs interviews with PCJ and ICE staff, detainee grievances alleging staff misconduct are not forwarded to ICE by the facility (Deficiency DGP-1). The grievance section of the detainee handbook does not address the opportunity to file a complaint of staff misconduct directly with U.S. Department of Homeland Securitys Office of Inspector General (Deficiency DGP-2 and DH-7).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(F), the FOD must ensure staff forwards all detainee grievances containing allegations of officer misconduct to a supervisor or higher-level official in the chain of command. Facilities must forward detainee grievances alleging officer misconduct to ICE. ICE must investigate every allegation of officer misconduct. DEFICIENCY DGP-2 and DH-7 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the opportunity to file a complaint about officer misconduct directly with the U.S. Department of Homeland Securitys Office of Inspector General.
Office of Detention Oversight May 2010 Moines

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Polk County Jail ERO Des
ICE.11.5082.000751

ODO reviewed the Detainee Handbook standard at PCJ to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO reviewed the detainee handbook, and interviewed staff and detainees. The detainee handbook does not include information regarding: access to legal materials (Deficiency DH-1 and ALM-2); classification levels, including conditions and restrictions applicable to each (Deficiency DH-2); general and special correspondence, including access to identity documents (Deficiency DH-3); personal property (Deficiency DH-4 and F&PP-6); or visitation hours (Deficiency DH-5 and V-1). The detainee handbook also does not provide information regarding a detainees right to freedom from discrimination (Deficiency DH-6 and DP-1); the opportunity to file a complaint about officer misconduct to the U.S. Department of Homeland Securitys Office of Inspector General (Deficiency DH-7 and DGP-2); or the opportunity to submit written questions, requests, or concerns to ICE staff, or the procedures for doing so (Deficiency DH-8 and SDC-5).

DEFICIENCY DH-1 and ALM-2 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. DEFICIENCY DH-2 In accordance with the ICE NDS, Detainee Classification System, section (III)(I)(1), the FOD must ensure the detainee handbooks section on classification includes an explanation of the classification levels, with the conditions and restrictions applicable to each. DEFICIENCY DH-3 In accordance with the ICE NDS, Correspondence and Other Mail, sections (III)(B)(3)(5) and (7), the FOD must ensure the facility notifies detainees of its policies on correspondence and other mail through the detainee handbook provided to each detainee upon admittance. At a minimum, the notification must specify: that general correspondence and other mail addressed to detainees must not be opened and
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11
ICE.11.5082.000752
inspected in the detainees presence, unless the Officer in Charge authorizes inspection without the detainees presence for security reasons; and the definition of special correspondence, including instructions on the proper labeling for special correspondence, without which it will not be treated as special mail. The notification must clearly state that it is the detainees responsibility to inform senders of special mail labeling requirements. The notification must state that identity documents, such as passports and birth certificates, are contraband and may be used by ICE as evidence or as otherwise appropriate. The notification must state that if detainees are not allowed to keep an identity document in their possession, they will be provided with a copy of the document, certified by an ICE officer to be a true and correct copy. DEFICIENCY DH-4 and F&PP-6 In accordance with the ICE NDS, Funds and Personal Property, sections (III)(J)(2) and (4-5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: that, upon request, they will be provided an ICE-certified copy of any identity document, such as a passport or birth certificate, placed in their A-files; the procedures for claiming property upon release, transfer, or removal; and the procedures for filing a claim for lost or damaged property. DEFICIENCY DH-5 and V-1 In accordance with the ICE NDS, Visitation, section (III)(B), the FOD must ensure the facility provides written notification of visitation rules and hours in the detainee handbook or equivalent given each detainee upon admittance. DEFICIENCY DH-6 and DP-1 In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(b), the FOD must ensure the handbook advises detainees of the right of freedom of discrimination based on race, religion, national origin, sex, handicap, or political beliefs. DEFICIENCY DH-7 and DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the opportunity to file a complaint about officer misconduct directly to the U.S. Department of Homeland Securitys Office of Inspector General. DEFICIENCY DH-8 and SDC-5 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook must state the detainee has the opportunity to submit written questions, requests, or concerns to ICE staff, and the procedures for doing so, including the availability of assistance in preparing the request.

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12
ICE.11.5082.000753

ODO reviewed the Detention Files standard at PCJ to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed active and inactive detention files, as well as facility policies, and interviewed staff. Detention files do not include classification worksheets (Deficiency DF-1), or documents generated during the detainees time in the facility (Deficiency DF-2). Documents such as requests and disciplinary forms are put into a master file created for the detainee, and are not included in the detention file once the detainee is released and the file is closed. The ERO St. Paul field office does not create and maintain detention files for all detainees admitted to IGSA facilities within the field offices jurisdiction (Deficiency DF-3). The facility does not maintain a logbook to record when detention files are removed from the storage cabinets (Deficiency DF-4).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III), the FOD must ensure the detention file contains the classification level and any copies of receipts for items issued to or surrendered by the detainee. It must also document adverse behavior, special requests and complaints, and other information considered appropriate for the record facility officials. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, sections (III)(B)(2) and (C)(1), the FOD must ensure the detainees detention file contains documents generated during the detainees time at the facility. During the course of the detainees stay at the facility, staff must add documents associated with normal operations to the detainees detention file without prior approval: special requests; any property receipts or baggage checks closed-out during the detainees stay; disciplinary forms; grievances, complaints, and the dispositions of the same; all forms associated with disciplinary and or administrative segregation; strip search forms; and other approved documents, such as staff reports about detainees behavior or attitude. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office with IGSA-facility jurisdiction creates and maintains detention files on all detainees admitted to IGSA facilities. These files must contain the same materials, such as forms and other documents, as service processing center and contract detention facility detention files to the extent possible, given that they are created by the field office. For example, if the field office takes and holds detainee property, the detention file must contain the baggage check and property receipt. The file must also
(b)(7)e
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ICE.11.5082.000754
contain copies of all Orders to Detain or Release, and the Alien Booking Records related to the alien. The facility must forward all documents relating to the individuals detention to the ICE field office of jurisdiction for inclusion in the detention file. DEFICIENCY DF-4 In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-file number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

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ICE.11.5082.000755

ODO reviewed the Disciplinary Policy standard at PCJ to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO reviewed the disciplinary policy, the detainee handbook, and disciplinary files; and interviewed detainees and staff. The detainee handbook does not advise detainees of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DP-1 and DH-6). The facility does not investigate incident reports. Incident reports are written and forwarded to a supervisor, who reviews and forwards the reports to the disciplinary panel for adjudication (Deficiency DP-2).

DEFICIENCY DP-1 and DH-6 In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(b), the FOD must ensure the handbook advises detainees of the right of freedom of discrimination based on race, religion, national origin, sex, handicap, or political beliefs. DEFICIENCY DP-2 In accordance with the ICE NDS, Disciplinary Policy, section (III)(C), the FOD must ensure facilities have procedures in place to investigate all incident reports within 24 hours of the incident. The investigating officer must have a supervisory rank, or higher (unless prevented by personnel shortages), and must have no prior involvement in the incident, either as a witness or the officer at the scene. If an officer below supervisory rank conducts the investigation, the shift supervisor must review his/her reports for accuracy and completeness, and sign them.

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ICE.11.5082.000756

ODO reviewed the Funds and Personal Property standard at PCJ to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with ICE NDS. ODO observed the property room, reviewed detention files and facility policies, and interviewed staff. According the Property Officer, identity documents are kept in the detainees property, rather than in the detainees A-file (Deficiency F&PP-1). The Property Officer also stated the facility does not turn-over property abandoned by detainees to ICE (Deficiency F&PP-2). The facility does not have policies or standard operating procedures regarding: obtaining forwarding addresses from every detainee (Deficiency F&PP-3), auditing detainee funds and property (Deficiency F&PP-4), or processing claims for lost or damaged detainee property (Deficiency F&PP-5). The detainee handbook does not notify detainees of facility policies and procedures concerning: obtaining a certified copy of identity documents, claiming property upon release, or filing a claim for lost or damaged property (Deficiency F&PP-6 and DH-4).

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(B)(3), the FOD must ensure identity documents, such as passports and birth certificates, are held in the detainees A-file. Upon request, staff must provide the detainee with a copy of the document, certified by an ICE official to be a true and correct copy. DEFICIENCY F&PP-2 In accordance with the ICE NDS, Funds and Personal Property, section (III)(I), the FOD must ensure all facilities report and turn over to ICE all detainee abandoned property. DEFICIENCY F&PP-3 In accordance with the ICE NDS, Funds and Personal Property, section (III)(C), the FOD must ensure standard operating procedures include obtaining a forwarding address from every detainee who has personal property that could be lost or forgotten in the facility after the detainees release, transfer or removal. DEFICIENCY F&PP-4 In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must ensure each facility has written procedures for inventorying and auditing detainee funds, valuables, and personal property.

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ICE.11.5082.000757
DEFICIENCY F&PP-5 In accordance with the ICE NDS, Funds and Personal Property, sections (III)(H)(2)(3) and (5-7), the FOD must ensure all facilities have and follow a policy for loss of or damage to properly-receipted detainee property as follows: supervisory staff must conduct the investigation; the senior facility contract officer must process all detainee claims for lost or damaged property promptly; the facility must promptly reimburse detainees for all validated property losses caused by facility negligence; the facility must not arbitrarily impose a ceiling on the amount to be reimbursed for a validated claim; and the senior contract officer must immediately notify the designated ICE officer of all claims and outcomes. DEFICIENCY F&PP-6 and DH-4 In accordance with the ICE NDS, Funds and Personal Property, sections (III)(J)(2) and (4-5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: that, upon request, they will be provided an ICE-certified copy of any identity document, such as a passport or birth certificate, placed in their A-files; the procedures for claiming property upon release, transfer, or removal; and the procedures for filing a claim for lost or damaged property.

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ICE.11.5082.000758
HUNGER STRIKES (HS)

ODO reviewed the Hunger Strikes standard at PCJ to determine whether the facility protects detainees health and well-being by monitoring, counseling, and treating detainees on hunger strike, in accordance with the ICE NDS. ODO interviewed the Director of Nursing and reviewed the hunger strike policy. There have been no hunger strikes for the past year. The local policy does not require ICE notification of a detainee hunger strike (Deficiency HS-1) or refusal of treatment (Deficiency HS-2), and does not address a detainees release from treatment (Deficiency HS-3).

DEFICIENCY HS-1 In accordance with the ICE NDS, Hunger Strike, section (lll)(A), the FOD must ensure ICE is notified of any hunger-striking detainee housed in a facility. DEFICIENCY HS-2 In accordance with the ICE NDS, Hunger Strike, section (lll)(D), the FOD must ensure the Officer in Charge of the facility notifies ICE that a detainee is refusing treatment. DEFICIENCY HS-3 In accordance with the ICE NDS, Hunger Strike, section (lll)(E), the FOD must ensure the Clinical Director may order a detainee be released from hunger strike evaluation and treatment. The FOD must ensure the order is documented in the detainees medical record.

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ICE.11.5082.000759
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at PCJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined medical records of all 31 detainees housed at PCJ, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by Prison Health Services and holds no accreditations. Review of 31 medical records revealed physical examinations (PE) were not performed on two detainees, and PEs of four detainees were not completed within fourteen days (Deficiency MC-1). PEs are performed by registered nurses; however, there was no documentation of appropriate training provided or approved by the Medical Director. The Medical Director did not document the review of three completed PEs (Deficiency MC-2). The PCJ Nurse Practitioner informed ODO, ICE detainees are not given Tuberculosis (TB) medications in the event of a positive skin test. While ODO was onsite, TB medications were discontinued on a detainee when the detainees custody was transferred from the U.S. Marshal Service to ICE. While this is not a deficiency, it is a concern.

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure the health provider conducts a PE within 14 days of a detainees arrival at the facility. DEFICIENCY MC-2 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure health appraisals are performed according to National Commission on Correctional Health Care, and Joint Commission on Accreditation of Healthcare Organizations standards. National Commission on Correctional Health Care Standard J-E-04 allows the hands-on portion of the health assessment to be performed by a registered nurse when the nurse completes appropriate training, approved or provided by the responsible physician; and the responsible physician documents his or her review of all health assessments.

The PCJ Nurse Practitioner informed ODO, ICE detainees are not given Tuberculosis (TB) medications in the event of a positive skin test. While ODO was on-site, TB medications were discontinued on a detainee when the detainees custody was transferred from the U.S. Marshal Service to ICE. While this is not a deficiency, it is a concern. According to medical literature, if taken for six to 12 months, medications will prevent TB from turning into an active infection. Furthermore, stopping the medication
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ICE.11.5082.000760
too early or skipping doses may allow the bacteria to continue to grow, which may result in a return of the infection and cause the infection to be more difficult to treat. To support control of communicable disease, ODO recommends PCJ reconsider its policy against treating detainees for TB.

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ICE.11.5082.000761
RECREATION (R)
ODO reviewed the Recreation standard at PCJ to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO reviewed local policies and procedures, observed recreation areas, and interviewed staff and detainees. PCJ does not have a Recreation Specialist who is responsible for the development and oversight of the recreation program (Deficiency R-1).

DEFICIENCY R-1 In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure the facility has an individual responsible for the development and oversight of the recreation program.

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ICE.11.5082.000762

ODO reviewed the Staff-Detainee Communication standard at PCJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed local policies and procedures, reviewed logbooks, and interviewed staff and detainees. There are no policies or procedures in place to ensure and document the Field Office Director (FOD), Assistant Field Office Director (AFOD), and designated department heads conduct regular unannounced visits of PCJ (Deficiency SDC-1). Observations of detainee housing units revealed there are no written schedules posted for weekly detainee visits by ICE staff (Deficiency SDC-2). PCJ does not have written policies or procedures to route detainee requests to appropriate ICE officials (Deficiency SDC-3). A review of the detainee request logbook, which documents requests made to ICE, did not contain the detainees nationality, or name of the ICE officer logging the request. The dates of when PCJ forwards detainee requests to ICE, and the dates they are returned, are not documented (Deficiency SDC-4). The PCJ detainee handbook does not advise that ICE detainees have the opportunity to submit written questions, requests, or concerns to ICE staff, or the procedures for doing so (Deficiency SDC-5 and DH-8).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure policy and procedures are in place to ensure and document that the ICE FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and observe living and working conditions. Each facility must develop a method to document the unannounced visits, and ICE must document visits to facilities. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(2)(b), the FOD must ensure facilities devise a written schedule and procedure for weekly visits by district ICE deportation staff. Written schedules must be developed and posted in the detainee living areas, as well as other areas with detainee access. DEFICIENCY SDC-3 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must ensure all facilities that house ICE detainees have written procedures to route detainee requests to the appropriate ICE official.
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ICE.11.5082.000763
DEFICIENCY SDC-4 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. The logbook, at a minimum, must contain: a) the date the detainee request was received; b) detainees name; c) A-number; d) nationality; e) officer logging the request; f) the date the request, with staff response and action, is returned to the detainee; and g) any other site-specific pertinent information. DEFICIENCY SDC-5 and DH-8 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook must state the detainee has the opportunity to submit written questions, requests, or concerns to ICE staff, and the procedures for doing so, including the availability of assistance in preparing the request.

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ICE.11.5082.000764

ODO reviewed the Suicide Prevention and Intervention standard at PCJ to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO reviewed the suicide prevention policy, interviewed staff, and examined ten medical and ten contract staff training records. There have been no suicides in the past year. The local policy does not address notification of ICE when a detainee is diagnosed as suicidal or requires special housing (Deficiency SP&I-1).

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure the Officer in Charge reports to ICE any detainees clinically diagnosed as suicidal or requiring special housing for suicide risk.

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ICE.11.5082.000765

ODO reviewed the Telephone Access standard at PCJ to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the ICE NDS. ODO reviewed local policies and procedures, tested telephones in detainee housing units, and interviewed staff and detainees. Telephone access rules were not posted in the housing units or in other areas where detainees may easily see them (Deficiency TA-1). The PCJ telephone policies and procedures do not provide guidance on how to obtain an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation (Deficiency TA-2).

DEFICIENCY TA-1 In accordance with the ICE NDS, Telephone Access, section (III)(B), the FOD must ensure the facility provides telephone access rules in writing to each detainee upon admittance, and posts these rules where detainees may easily see them. DEFICIENCY TA-2 In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure the facility has a written policy on the monitoring of detainee telephone calls. If telephone calls are monitored, the facility must notify detainees in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each monitored telephone stating: that detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

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ICE.11.5082.000766

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donations, at PCJ to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO reviewed policies and interviewed the Director of Nursing. There have been no deaths in the past year. The facility does not have a policy on organ donation (Deficiency TIADD-1). The End of Life Decision Making policy does not require use of the State Advance Directive Form for implementing living wills and advanced directives, or notification of ICE (Deficiency TIADD-2). The section of the policy governing the decision to withhold resuscitative services does not address the detainee being unconscious (Deficiency TIADD-3) or terminally injured (Deficiency TIADD-4). Documentation validating the Do Not Resuscitate order is not required for inclusion in the detainees medical file (Deficiency TIADD-5). The inmate death policy does not address the requirement to follow written procedures when notifying ICE officials of a detainee death (Deficiency TIADD-6).

DEFICIENCY TIADD-1 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(D), the FOD must ensure specified procedures govern organ donations. DEFICIENCY TIADD-2 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(B), the FOD must ensure each facility uses the State Advance Directive Form for implementing living wills and advance directives. When the medical professional responsible for the detainees care determines the terms and conditions of the detainees medical directive should be implemented, he/she must contact the Clinical Director or Health Services Administrator, as well as the ICE General Counsel, providing the name, condition, and circumstances of the detainee. DEFICIENCY TIADD-3 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C)(3)(a), the FOD must ensure, if the detainee is unconscious or otherwise unable or incompetent to participate in the decision to withhold resuscitative services, staff must attempt to obtain the written concurrence of an immediate family member. DEFICIENCY TIADD-4 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C)(3)(b), the FOD must ensure the decision to withhold resuscitative services is considered only under specified conditions that include diagnosis with a terminal injury.

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ICE.11.5082.000767
DEFICIENCY TIADD-5 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C)(4)(a)(b)(1-9), the FOD must ensure the detainees medical file includes documentation validating the Do Not Resuscitate order, including a standard stipulation at the front of the in-patient record, and explicit directions: Do Not Resuscitate or DNR, and forms and memoranda recording: diagnosis and prognosis; express wishes of the detainee (living will, advance directive, or other signed document); immediate familys wishes; consensual decisions and recommendations of medical professionals, identified by name and title; mental competency (psychiatric evaluation), if detainee concurred in, but did not initiate, the Do Not Resuscitate decision; informed consent evidenced, among other things, by the legibility of the Do Not Resuscitate order, signed by the ordering physician and Clinical Director; a detainee with a Do Not Resuscitate order may receive all therapeutic efforts short of resuscitation; the facility must follow written procedures for notifying attending medical staff of the Do Not Resuscitate order; the medical facility must notify the DIHS Medical Director and governing body, and the ICE General Counsel, of the name and basic circumstances of any detainee for whom a Do Not Resuscitate order has been filed in the medical record. DEFICIENCY TIADD-6 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(E), the FOD must ensure the facility follows written procedures when notifying ICE officials, immediate family members, and consulate offices of a detainees death.

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ICE.11.5082.000768
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at PCJ to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a detainee, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed policies and use-of-force documentation, and inspected equipment and inventories. Staff was interviewed to determine their level of knowledge and understanding of the circumstances warranting
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(b)(7)e

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ICE.11.5082.000769
VISITATION (V)
ODO reviewed the Visitation standard at PCJ to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO observed visitation areas and housing units, reviewed the detainee handbook and facility policies, and interviewed staff and detainees. The facility does not provide visitation hours in the detainee handbook, and does not post visitation rules where detainees can easily see them (Deficiency V-1 and DH-5). Visitation is not provided on Saturdays and Sundays and most visits are scheduled for 20 minutes (Deficiency V-2). Legal representatives do not fill out a Notice of Appearance as Attorney form (Deficiency V-3). The facility does not document pre-representational meetings in the legal visitation logbook (Deficiency V-4). According to the Lieutenant, when legal visitations proceed through scheduled meal periods, detainees are not provided with a sack lunch (Deficiency V-5). The facilitys written legal visitation procedures do not provide for the exchange of documents between detainee and legal representative (Deficiency V-6). The facility does not have written procedures to allow legal service providers to call the facility in advance of a visit to determine whether a particular individual is detained at the facility (Deficiency V-7). The facility also does not have a policy governing under what circumstances animals may accompany human visitors onto or into facility property (Deficiency V-8). According to the Lieutenant, requests by non-governmental organizations to visit the facility are not submitted to ICE in writing (Deficiency V-9).

DEFICIENCY V-1 and DH-5 In accordance with the ICE NDS, Visitation, section (III)(B), the FOD must ensure the facility provides written notification of visitation rules and hours in the detainee handbook or equivalent, given each detainee upon admittance. The facility must also post these rules and hours where detainees can easily see them. DEFICIENCY V-2 In accordance with the ICE NDS, Visitation, section (III)(H)(1), the FOD must ensure visits are permitted during set hours on Saturdays, Sundays, and holidays. The facilitys written rules must specify time limits for visits: 30 minutes minimum, under normal conditions.

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ICE.11.5082.000770
DEFICIENCY V-3 In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure, once an attorney-client relationship has been established, the legal representative completes and submits a Notice of Appearance as Attorney (Form G-28) form, available in the legal visitors reception area. Staff must collect completed forms and forward them to ICE. DEFICIENCY V-4 In accordance with the ICE NDS, Visitation, section (III)(I)(7), the FOD must ensure the facility documents pre-representation meetings in the logbook for legal visitation. DEFICIENCY V-5 In accordance with the ICE NDS, Visitation, section (III)(I)(2), the FOD must ensure, on regular business days, legal visitations may proceed through a scheduled meal period. In such cases, the detainee must receive a tray or sack meal after the visit. DEFICIENCY V-6 In accordance with the ICE NDS, Visitation, section (III)(I)(10), the FOD must ensure the facilitys written legal visitation procedures provide for the exchange of documents between detainee and legal representative, or legal assistant, even when contact visitation rooms are unavailable. DEFICIENCY V-7 In accordance with the ICE NDS, Visitation, section (III)(I)(6), the FOD must ensure each facility establishes a written procedure to allow legal service providers and legal assistants to telephone the facility in advance of a visit to determine whether a particular individual is detained in that facility. The request must be made to the on-site ICE staff or, where there is no resident staff, to the ICE office with jurisdiction over the facility. DEFICIENCY V-8 In accordance with the ICE NDS, Visitation, section (III)(O)(4), the FOD must ensure each facility establishes and disseminates a policy and implementing procedures governing whether, and, if so, under what circumstances animals may accompany human visitors onto or into facility property. DEFICIENCY V-9 In accordance with the ICE NDS, Visitation, section (III)(L), the FOD must ensure all requests by non-governmental organizations and other organizations to send representatives to visit detainees are submitted in writing to the ICE Officer in Charge or ICE district office supervising the contract, state, or local facility.

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ICE.11.5082.000771
APPENDIX A
Acronyms
TAR

TB UDC

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ICE.11.5082.000772
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare 8 documents for legal proceedings. The facility must designate an employee with responsibility to inspect the equipment at least weekly to ensure it is in good working order, and to stock sufficient office supplies. In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the 8 law library; 4) the procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.
ALM-1
ALM-2 and DH-1

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ICE.11.5082.000773
DETENTION STANDARD
AR-1
AR-2
DGP-1
DGP-2 and DH-7
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(E), the FOD must ensure identity documents, such as passports and birth 9 certificates, are inventoried, then given to a deportation officer or ICE official for placement in the detainees A-file. In accordance with the ICE NDS, Admission and Release, section (III)(E), and Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure staff issues detainees clothing and bedding in quantities and weights appropriate for 9 the facility environment and local weather conditions. Detainees must be provided with clean clothing, linen, and towels on a regular basis to ensure proper hygiene. Socks and undergarments must be exchanged daily. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(F), the FOD must ensure staff forwards all detainee grievances containing allegations of officer misconduct to a supervisor or higher10 level official in the chain of command. Facilities must forward detainee grievances alleging officer misconduct to ICE. ICE must investigate every allegation of officer misconduct. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the 10 opportunity to file a complaint about officer misconduct directly with the U.S. Department of Homeland Securitys Office of Inspector General.

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ICE.11.5082.000774
DETENTION STANDARD
Detainee Handbook
DH-1 and ALM-2
Detainee Handbook
DH-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of 11 access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. In accordance with the ICE NDS, Detainee Classification System, section (III)(I)(1), the FOD must ensure the detainee handbooks section on 11 classification includes an explanation of the classification levels, with the conditions and restrictions applicable to each.

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ICE.11.5082.000775
DETENTION STANDARD
Detainee Handbook
DH-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Correspondence and Other Mail, sections (III)(B)(3)(5) and (7), the FOD must ensure the facility notifies detainees of its policies on correspondence and other mail through the detainee handbook provided to each detainee upon admittance. At a minimum, the notification must specify: that general correspondence and other mail addressed to detainees must not be opened and inspected in the detainees presence, unless the Officer in Charge authorizes inspection without the detainees presence for security reasons; and the definition of special correspondence, including instructions 11 on the proper labeling for special correspondence, without which it will not be treated as special mail. The notification must clearly state that it is the detainees responsibility to inform senders of special mail labeling requirements. The notification must state that identity documents, such as passports and birth certificates, are contraband and may be used by ICE as evidence or as otherwise appropriate. The notification must state that if detainees are not allowed to keep an identity document in their possession, they will be provided with a copy of the document, certified by an ICE officer to be a true and correct copy.

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ICE.11.5082.000776
DETENTION STANDARD
Detainee Handbook
DH-4 and F&PP-6
Detainee Handbook
DH-5 and V-1
Detainee Handbook
DH-6 and DP-1
Detainee Handbook
DH-7 and DGP-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, sections (III)(J)(2) and (4-5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: that, upon request, they will be provided an ICE12 certified copy of any identity document, such as a passport or birth certificate, placed in their A-files; the procedures for claiming property upon release, transfer, or removal; and the procedures for filing a claim for lost or damaged property. In accordance with the ICE NDS, Visitation, section (III)(B), the FOD must ensure the facility provides written 12 notification of visitation rules and hours in the detainee handbook or equivalent given each detainee upon admittance. In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(b), the FOD must ensure the handbook advises detainees of the right of 12 freedom of discrimination based on race, religion, national origin, sex, handicap, or political beliefs. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the 12 opportunity to file a complaint about officer misconduct directly to the U.S. Department of Homeland Securitys Office of Inspector General.

(b)(7)e
36
ICE.11.5082.000777
DETENTION STANDARD
Detainee Handbook
DH-8 and SDC-5
Detention Files
DF-1
Detention Files
DF-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook 12 must state the detainee has the opportunity to submit written questions, requests, or concerns to ICE staff, and the procedures for doing so, including the availability of assistance in preparing the request. In accordance with the ICE NDS, Detention Files, section (III), the FOD must ensure the detention file contains the classification level and any copies of receipts for items issued to or surrendered by the detainee. It must 13 also document adverse behavior, special requests and complaints, and other information considered appropriate for the record facility officials. In accordance with the ICE NDS, Detention Files, sections (III)(B)(2) and (C)(1), the FOD must ensure the detainees detention file contains documents generated during the detainees time at the facility. During the course of the detainees stay at the facility, staff must add documents associated with normal operations to the detainees detention file without prior approval: special requests; any 13 property receipts or baggage checks closed-out during the detainees stay; disciplinary forms; grievances, complaints, and the dispositions of the same; all forms associated with disciplinary and or administrative segregation; strip search forms; and other approved documents, such as staff reports about detainees behavior or attitude.

(b)(7)e
37
ICE.11.5082.000778
DETENTION STANDARD
Detention Files
DF-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office with IGSAfacility jurisdiction creates and maintains detention files on all detainees admitted to IGSA facilities. These files must contain the same materials, such as forms and other documents, as service processing center and contract detention facility detention files to the extent possible, given that they are created by the field 13 office. For example, if the field office takes and holds detainee property, the detention file must contain the baggage check and property receipt. The file must also contain copies of all Orders to Detain or Release, and the Alien Booking Records related to the alien. The facility must forward all documents relating to the individuals detention to the ICE field office of jurisdiction for inclusion in the detention file.
In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-file number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.
Detention Files
DF-4
14
Disciplinary Policy
DP-1 and DH-6
In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(b), the FOD must ensure the handbook advises detainees of the right of freedom of discrimination based on race, religion, national origin, sex, handicap, or political beliefs.
15

(b)(7)e
38
ICE.11.5082.000779
DETENTION STANDARD
Disciplinary Policy
DP-2
F&PP-1
F&PP-2
F&PP-3
F&PP-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Disciplinary Policy, section (III)(C), the FOD must ensure facilities have procedures in place to investigate all incident reports within 24 hours of the incident. The investigating officer must have a supervisory rank, or higher (unless prevented by personnel 15 shortages), and must have no prior involvement in the incident, either as a witness or the officer at the scene. If an officer below supervisory rank conducts the investigation, the shift supervisor must review his/her reports for accuracy and completeness, and sign them. In accordance with the ICE NDS, Funds and Personal Property, section (III)(B)(3), the FOD must ensure identity documents, such as passports and birth certificates, are held in the detainees A16 file. Upon request, staff must provide the detainee with a copy of the document, certified by an ICE official to be a true and correct copy. In accordance with the ICE NDS, Funds and Personal Property, section (III)(I), the FOD must ensure all facilities report 16 and turn over to ICE all detainee abandoned property. In accordance with the ICE NDS, Funds and Personal Property, section (III)(C), the FOD must ensure standard operating procedures include obtaining a forwarding address from every 16 detainee who has personal property that could be lost or forgotten in the facility after the detainees release, transfer or removal. In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must ensure each facility has 16 written procedures for inventorying and auditing detainee funds, valuables, and personal property.

(b)(7)e
39
ICE.11.5082.000780
DETENTION STANDARD
F&PP-5
F&PP-6 and DH-4
Hunger Strike
HS-1
Hunger Strike
HS-
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, sections (III)(H)(2)(3) and (5-7), the FOD must ensure all facilities have and follow a policy for loss of or damage to properlyreceipted detainee property as follows: supervisory staff must conduct the investigation; the senior facility contract officer must process all detainee claims for lost or damaged property promptly; 17 the facility must promptly reimburse detainees for all validated property losses caused by facility negligence; the facility must not arbitrarily impose a ceiling on the amount to be reimbursed for a validated claim; and the senior contract officer must immediately notify the designated ICE officer of all claims and outcomes. In accordance with the ICE NDS, Funds and Personal Property, sections (III)(J)(2) and (4-5), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: that, upon request, they will be provided an ICE17 certified copy of any identity document, such as a passport or birth certificate, placed in their A-files; the procedures for claiming property upon release, transfer, or removal; and the procedures for filing a claim for lost or damaged property. In accordance with the ICE NDS, Hunger Strike, section (lll)(A), the FOD must ensure ICE is notified of any 18 hunger-striking detainee housed in a facility. In accordance with the ICE NDS, Hunger Strike, section (lll)(D), the FOD must ensure the Officer in Charge of the 18 facility notifies ICE that a detainee is refusing treatment.

(b)(7)e
40
ICE.11.5082.000781
DETENTION STANDARD
Hunger Strike
HS-
Medical Care
MC-1
Medical Care
MC-2
Recreation
R-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Hunger Strike, section (lll)(E), the FOD must ensure the Clinical Director may order a detainee be released from 18 hunger strike evaluation and treatment. The FOD must ensure the order is documented in the detainees medical record. In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure the health provider 19 conducts a PE within 14 days of a detainees arrival at the facility. In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure health appraisals are performed according to National Commission on Correctional Health Care, and Joint Commission on Accreditation of Healthcare Organizations standards. National Commission on Correctional Health 19 Care Standard J-E-04 allows the handson portion of the health assessment to be performed by a registered nurse when the nurse completes appropriate training, approved or provided by the responsible physician; and the responsible physician documents his or her review of all health assessments. In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure the facility has an 21 individual responsible for the development and oversight of the recreation program.

(b)(7)e
41
ICE.11.5082.000782
DETENTION STANDARD
SDC-1
SDC-2
SDC-3
SDC-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(A)(1), the FOD must ensure policy and procedures are in place to ensure and document that the ICE FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys 22 living and activity areas to encourage informal communication between staff and detainees, and observe living and working conditions. Each facility must develop a method to document the unannounced visits, and ICE must document visits to facilities. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(A)(2)(b), the FOD must ensure facilities devise a written schedule and procedure for weekly visits by district 22 ICE deportation staff. Written schedules must be developed and posted in the detainee living areas, as well as other areas with detainee access. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B), the FOD must ensure all 22 facilities that house ICE detainees have written procedures to route detainee requests to the appropriate ICE official. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. The logbook, at a minimum, must contain: a) the date the detainee 23 request was received; b) detainees name; c) A-number; d) nationality; e) officer logging the request; f) the date the request, with staff response and action, is returned to the detainee; and g) any other site-specific pertinent information.
42 Polk County Jail ERO Des

(b)(7)e
ICE.11.5082.000783
DETENTION STANDARD
SDC-5 and DH-8
SP&I-1
Telephone Access
TA-1
Telephone Access
TA-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook 23 must state the detainee has the opportunity to submit written questions, requests, or concerns to ICE staff, and the procedures for doing so, including the availability of assistance in preparing the request. In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure the Officer in Charge reports to ICE any 24 detainees clinically diagnosed as suicidal or requiring special housing for suicide risk. In accordance with the ICE NDS, Telephone Access, section (III)(B), the FOD must ensure the facility provides telephone access rules in writing to 25 each detainee upon admittance, and posts these rules where detainees may easily see them. In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure the facility has a written policy on the monitoring of detainee telephone calls. If telephone calls are monitored, the facility must notify detainees in the detainee handbook or equivalent provided upon 25 admission. The facility must also place a notice at each monitored telephone stating: that detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

(b)(7)e
43
ICE.11.5082.000784
DETENTION STANDARD Terminal Illness, Advance Directives and Death
TIADD-1
Terminal Illness, Advance Directives and Death
TIADD-2
TIADD-3
TIADD-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(D), the FOD 26 must ensure specified procedures govern organ donations. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(B), the FOD must ensure each facility uses the State Advance Directive Form for implementing living wills and advance directives. When the medical professional responsible for the detainees care determines the terms 26 and conditions of the detainees medical directive should be implemented, he/she must contact the Clinical Director or Health Services Administrator, as well as the ICE General Counsel, providing the name, condition, and circumstances of the detainee. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C)(3)(a), the FOD must ensure, if the detainee is unconscious or otherwise unable or 26 incompetent to participate in the decision to withhold resuscitative services, staff must attempt to obtain the written concurrence of an immediate family member. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C)(3)(b), the FOD must ensure the decision to 26 withhold resuscitative services is considered only under specified conditions that include diagnosis with a terminal injury.

(b)(7)e
44
ICE.11.5082.000785
DETENTION STANDARD
TIADD-5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(C)(4)(a)(b)(1-9), the FOD must ensure the detainees medical file includes documentation validating the Do Not Resuscitate order, including a standard stipulation at the front of the in-patient record, and explicit directions: Do Not Resuscitate or DNR, and forms and memoranda recording: diagnosis and prognosis; express wishes of the detainee (living will, advance directive, or other signed document); immediate familys wishes; consensual decisions and recommendations of medical professionals, identified by name and title; mental competency (psychiatric 27 evaluation), if detainee concurred in, but did not initiate, the Do Not Resuscitate decision; informed consent evidenced, among other things, by the legibility of the Do Not Resuscitate order, signed by the ordering physician and Clinical Director; a detainee with a Do Not Resuscitate order may receive all therapeutic efforts short of resuscitation; the facility must follow written procedures for notifying attending medical staff of the Do Not Resuscitate order; the medical facility must notify the DIHS Medical Director and governing body, and the ICE General Counsel, of the name and basic circumstances of any detainee for whom a Do Not Resuscitate order has been filed in the medical record.
In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (lll)(E), the FOD must ensure the facility follows written procedures when notifying ICE officials, immediate family members, and consulate offices of a detainees death.
TIADD-6
27

(b)(7)e
45
ICE.11.5082.000786
DETENTION STANDARD
PAGE
Use of Force
UOF-1
28
Use of Force
UOF-2
28
(b)(7)e
Use of Force
UOF-3
28
Visitation
V-1 and DH-5
Visitation
V-2
Visitation, section (III)(B), the FOD must ensure the facility provides written notification of visitation rules and hours in the detainee handbook or equivalent, given each detainee upon admittance. The facility must also post these rules and hours where detainees can easily see them. In accordance with the ICE NDS, Visitation, section (III)(H)(1), the FOD must ensure visits are permitted during set hours on Saturdays, Sundays, and holidays. The facilitys written rules must specify time limits for visits: 30 minutes minimum, under normal conditions.
30
30

(b)(7)e
46
ICE.11.5082.000787
DETENTION STANDARD
Visitation
V-3
Visitation
V-4
Visitation
V-5
Visitation
V-6
Visitation
V-7
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure, once an attorney-client relationship has been established, the legal representative completes and 31 submits a Notice of Appearance as Attorney (Form G-28) form, available in the legal visitors reception area. Staff must collect completed forms and forward them to ICE. In accordance with the ICE NDS, Visitation, section (III)(I)(7), the FOD must ensure the facility documents pre31 representation meetings in the logbook for legal visitation. In accordance with the ICE NDS, Visitation, section (III)(I)(2), the FOD must ensure, on regular business days, legal visitations may proceed through a 31 scheduled meal period. In such cases, the detainee must receive a tray or sack meal after the visit. In accordance with the ICE NDS, Visitation, section (III)(I)(10), the FOD must ensure the facilitys written legal visitation procedures provide for the 31 exchange of documents between detainee and legal representative, or legal assistant, even when contact visitation rooms are unavailable. In accordance with the ICE NDS, Visitation, section (III)(I)(6), the FOD must ensure each facility establishes a written procedure to allow legal service providers and legal assistants to telephone the facility in advance of a 31 visit to determine whether a particular individual is detained in that facility. The request must be made to the onsite ICE staff or, where there is no resident staff, to the ICE office with jurisdiction over the facility.

(b)(7)e
47
ICE.11.5082.000788
DETENTION STANDARD
Visitation
V-8
Visitation
V-9
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Visitation, section (III)(O)(4), the FOD must ensure each facility establishes and disseminates a policy and implementing procedures governing 31 whether, and, if so, under what circumstances animals may accompany human visitors onto or into facility property. In accordance with the ICE NDS, Visitation, section (III)(L), the FOD must ensure all requests by nongovernmental organizations and other organizations to send representatives to 31 visit detainees are submitted in writing to the ICE Officer in Charge or ICE district office supervising the contract, state, or local facility.

(b)(7)e
48
ICE.11.5082.000789
APPENDIX C
DETENTION STANDARD RECOMMENDATIONS The PCJ Nurse Practitioner informed ODO, ICE detainees are not given Tuberculosis (TB) medications in the event of a positive skin test. While ODO was on-site, TB medications were discontinued on a detainee when the detainees custody was transferred from the U.S. Marshal Service to ICE. While this is not a deficiency, it is a concern. According to medical literature, if taken for six to 12 months, medications will prevent TB from turning into an active infection. Furthermore, stopping the medication too early or skipping doses may allow the bacteria to continue to grow, which may result in a return of the infection and cause the infection to be more difficult to treat. To support control of communicable disease, ODO recommends PCJ reconsider its policy against treating detainees for TB. PAGE
Medical Care
19

(b)(7)e
49
ICE.11.5082.000790


Enforcement and Removal Operations San Antonio Field Office Port Isabel Detention Center Los Fresnos, Texas
December 7-9, 2010
ICE.11.5082.000791
ICE.11.5082.000792
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization ... Inspection Team Members OVERVIEW.. ICE NATIONAL DETENTION STANDARDS Emergency Plans. Environmental Health and Safety............ Facility Security and Control.. Medical.. 1 1 2
3 3 3 4
ICE.11.5082.000793
INSPECTION PROCESS
The OPR, Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE Performance Based National Detention Standards (PBNDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives include the evaluation of the welfare, safety, and living conditions of detainees, and compliance with applicable laws, policies, regulations, and procedures. In January 2010, ODO, formerly the Detention Facilities Inspection Group, conducted a Quality Assurance Review of the Port Isabel Detention Center (PIDC) in Los Fresnos, Texas. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review report.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to ERO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE Performance Based National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Deputy Division Director, Office of Professional Responsibility.

(b)(6), (b)(7)(C)
Special Agent (Team Leader) Special Agent Medical Subject Matter Expert
ODO, OPR Houston ODO, OPR Houston MGT, Washington, DC
_____________________________________________________________________________________________

(b)(7)e
Port Isabel Detention Center ERO San Antonio
ICE.11.5082.000794
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Admission and Release; Detainee Handbook; Emergency Plans; Environmental Health and Safety; Facility Security and Control; Food Service; Funds and Personal Property; Grievance System; Key and Lock Control; Law Libraries and Legal Material; Medical Care; Post Orders; Special Management Unit; Staff-Detainee Communication; Telephone Access; Tool Control; and Visitation. ODO staff identified 41 deficiencies during the Quality Assurance Review conducted in January 2010. During this Follow-up Inspection, ODO staff found 5 (8%) repeated deficiencies. Deficiencies revisited in the following standards were not corrected and were found by ODO, along with ERO management at PIDC, to be noncompliant with the ICE PBNDS: Emergency Plans Environmental Health and Safety Facility Security and Control Medical Care ODO and ERO staff found corrective actions were taken on all deficiencies revisited in the following standards: Admissions and Release Correspondence and Other Mail Detainee Handbook Food Service Funds and Personal Property Grievance System Key and Lock Control Law Libraries and Legal Material Post Orders Special Management Units Staff Detainee Communication Telephone Access Tool Control Visitation
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000795

EMERGENCY PLANS
During the initial ODO inspection, one deficiency was identified in this area. During this Follow-up Inspection, the following deficiency was found uncorrected.
(b)(7)e

During the initial ODO inspection, two deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found uncorrected. ODO Initial Finding: In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(G)(1), the FOD must ensure any liquid or aerosol labeled Flammable or Combustible must be stored and used as prescribed on the label required by the Federal Hazardous Substances Labeling Act. ODO Follow-up Finding: ODO observed 16 five gallon containers of paint marked Flammable stored in an open area of the maintenance building. It is required that all items labeled flammable be kept in storage lockers approved for flammable materials. The PIDC has secure storage lockers designated for flammable materials; however, these 16 containers were not stored in those lockers.
FACILITY SECURITY AND CONTROL

During the initial ODO inspection, four deficiencies were identified in this area. During
(b)(7)e
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000796
(b)(7)e
MEDICAL CARE
During the initial ODO inspection, six deficiencies were identified in this area. During the follow-up inspection, one deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE PBNDS, Medical Care, section (V)(X)(1), the FOD must ensure the administrative health authority shall convene a meeting at least quarterly and include other facility and medical staff as appropriate. The meeting agenda shall include, at a minimum: an account of the effectiveness of the facility health care program; discussions of health environment factors that may need improvement; review and discussion of communicable disease and infectious control activities; changes effected since the previous meetings; and recommended corrective actions, as necessary. ODO Follow-up Finding: ODO reviewed weekly meeting minutes. All required items were addressed with the exception of recommended corrective actions. ODO was informed the missing item would be added to agendas and minutes for future meetings.
_____________________________________________________________________________________________

(b)(7)e
ICE.11.5082.000797



Washington Field Office Rappahannock Regional Jail Stafford, Virginia
December 6-8, 2010
________________________________
ICE.11.5082.000798
QUALITY ASSURANCE REVIEW RAPPAHANNOCK REGIONAL JAIL WASHINGTON FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY.. INSPECTION PROCESS Report Organization Inspection Team Members OPERATIONAL ENVIRONMENT Internal Relations........ Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed Access to Legal Material Admission and Release. Detainee Grievance Procedures.. Detainee Handbook.... Detention Files. Disciplinary Policy Environmental Health and Safety.. Food Service. Funds and Personal Property. Hold Rooms in Detention Facilities Medical Care Staff-Detainee Communication..... Suicide Prevention and Intervention. Telephone Access... Terminal Illness, Advance Directives, and Death... Tool Control.. Use of Force 1
3 3
4 4
5 6 7 8 9 10 11 13 15 16 17 18 21 22 23 24 25 26
ICE.11.5082.000799
EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO) conducted a Quality Assurance Review (QAR) of the Rappahannock Regional Jail (RRJ), Stafford, Virginia, on December 6-8, 2010. The review was the first completed at RRJ by ODO. The facility was opened in June 2000 and serves as a regional jail for males and females arrested by local law enforcement. RRJ is owned and operated by the Rappahannock Regional Jail Authority. In February 2008, ICE began to place male and female detainees of all classification levels at RRJ through an intergovernmental service agreement (IGSA). The facility accommodates ICE detainees for periods in excess of 72 hours. Medical care is provided by Rappahannock Health Services and food service is contracted under Aramark. RRJ has not received any accreditations. ICE staff assigned to RRJ consists of two immigration enforcement agents (IEAs) who are associated with the ERO Washington, DC field office. The Assistant Field Office Director (AFOD) overseeing the facility is located at the ERO Washington, DC field office. The total number of staff (non-ICE) employed at RRJ is 323. (b)(7)e
(b)(7)e
ERO contractors, MGT of America, Inc., conducted an annual review of the ICE NDS at RRJ in August 2010. The facility received an overall rating of acceptable, and was found to be in compliance with all 36 standards reviewed. ODO reviewed a total of 25 NDS; 9 areas were found to be fully compliant, while 16 had a total of 33 deficiencies, including the following: Access to Legal Material (2); Admission and Release (2); Detainee Grievance Procedures (2); Detainee Handbook (1); Detention Files (2); Disciplinary Policy (4); Environmental Health and Safety (3); Food Service (2); Funds and Personal Property (1); Hold Rooms in Detention Facilities (1); Medical Care (5); Staff-Detainee Communication (2); Suicide Prevention and Intervention (1); Terminal Illness, Advance Directives, and Death (3); Tool Control (1); and Use of Force (1). Overall, ODO found RRJ to be in compliance with the standards areas inspected; however, inadequacies in the facilitys detainee handbook and a general lack of staff-detainee interaction/communication is negatively affecting many critical detainee-centric areas that could be in full compliance. Those include Access to Legal Material, Detainee Grievance Procedures, Disciplinary Policy, and Funds and Personal Property. ODO did fully address these issues and concerns during the Closeout Brief on December 8th to best ensure that the facility and ERO staff would have the opportunity to initiate actions to expeditiously correct the deficiencies. At the time of the review, RRJ was providing ICE detainees with a 2006 version of its detainee handbook. During the review of several standards, ODO noticed a recurring theme of required items missing from the handbook. The handbook was missing substantial information regarding access to legal materials, grievance appeal procedures, disciplinary process, filing claims for lost or missing property, and procedures for contacting ICE. Additionally, several deficiencies were of a clerical nature, such as the incorrect placement of, or missing, grievances and detainee requests from their proper locations. The detainee handbook is one of the primary means to
(b)(7)e
Rappahannock Regional Jail ERO Washington
ICE.11.5082.000800
ensure that all detainees, regardless of their language, clearly understand their rights and expectations while in ICE custody at detention facilities. ICE staff conduct daily regular and irregular visits to housing units to address detainee concerns and inquiries. RRJ has processes in place to ensure detainees have the opportunity to file grievances and appeal the decisions of grievances. During the review, ODO found that not all detainees are issued hygiene supplies upon admission. No major deficiencies were found in security, environmental health and safety, and food service standards. RRJ has a fully functioning medical unit to address detainee health care. Four deficiencies were identified with two of a critical nature. ODO discovered that Licensed Practical Nurses (LPNs) are conducting health appraisals, which is beyond the scope of their practice and not in accordance with the National Commission on Correctional Health Care (NCCHC) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. Additionally, the facility could not produce documentation of certification in cardio-pulmonary resuscitation (CPR) and first aid for eight of twenty-eight medical staff (28%). In the absence of documentation and the verbal uncertainty regarding the completion of the required CPR and first aid training, it can only be concluded that the eight staff members are not in compliance with the medical detention standards. Fourteen of twenty-four medical staff members (58%) had not completed suicide prevention and intervention training. This report includes descriptions of all the deficiencies and refers to the specific, relevant NDS. The report will be provided to ERO to develop corrective actions to resolve the 33 deficiencies.

(b)(7)e
ICE.11.5082.000801
INSPECTION PROCESS
The ODO primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS) or the Performance Based National Detention Standards (PBNDS), as applicable. In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at RRJ to determine compliance with current policies and detention standards. Prior to the inspection, ODO collected and analyzed relevant
(b)(7)e (b)(7)e (b)(7)e
ff to best prepare for the site visit at RRJ.
REPORT ORGANIZATION

Special Agent (Team Leader) Detention and Deportation Officer Management and Program Analyst Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector
3
(b)(7)e
(b)(6), (b)(7)(C)
ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America, Inc MGT of America, Inc. MGT of America, Inc.
ICE.11.5082.000802
INTERNAL RELATIONS
ODO interviewed supervisory ICE and RRJ staff, including the RRJ Superintendent, Assistant Superintendent, Captains, and the ERO AFOD. ODO also interviewed non-supervisory staff, including Immigration Enforcement Agents and Corrections Officers. RRJ personnel stated that ICE staff conduct daily visits to the facility and its detainee housing units. One concern raised by RRJ staff was that RRJ is subjected to a significant number of inspections each year by federal, state, and local entities. Staff noted that the number of reviews can negatively impact operations at the facility because it is disruptive to constantly have to prepare for inspections and difficult to make ongoing corrections at the facility based on varying standards. ICE staff indicated that they have the necessary resources to carry out their duties and responsibilities. Overall, RRJ and ICE staff expressed good morale levels and a good working relationship between the two entities.
DETAINEE RELATIONS
ODO randomly selected 15 detainees to interview to assess the detention conditions of RRJ. Detainees stated they receive daily recreation, can send and receive mail, use the telephones, and have access to grievance forms. Since Deportation Officers (DOs) do not normally visit RRJ, most detainees stated they have not met their DO; however, RRJ detainees have access to ICE staff (IEAs) who handle inquiries involving their removal cases. A review of the Admission and Release NDS revealed several detainees did not receive hygiene supplies. This was confirmed by a review of detention files and detainee interviews. Several detainees complained about food portions and a lack of variety. ODO verified during a review of the Food Service NDS that a master-cycle menu is used and a registered dietitian certifies the menu. Overall, the majority of the detainees stated they were treated with dignity and respect.

(b)(7)e
ICE.11.5082.000803

A total of 25 National Detention Standards were reviewed during the ODO inspection. The following 17 areas were found to be deficient with respect to adherence to the ICE NDS, as required: Access to Legal Material Admission and Release Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Medical Care Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Use of Force The following eight standards were found to be well-managed: Hunger Strikes Issuance and Exchange of Clothing, Bedding, and Towels Population Counts Recreation Religious Practices Special Management Unit (Administrative Segregation) Special Management Unit (Disciplinary Segregation) Visitation As these eight standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e
ICE.11.5082.000804

ODO reviewed the Access to Legal Material standard at RRJ to determine if detainees have access to a law library, legal materials, courts, counsel and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed local policies, procedures, and the detainee handbook; inspected the law library; and interviewed staff and detainees. RRJ houses ICE detainees in four locations: housing units C-1, C-2, B-4, and the segregation unit. The segregation unit and housing area B-4 are assigned individual designated law libraries; however, housing units C-1 and C-2 do not maintain a designated law library for their detainees. Housing units C-1 and C-2 maintain a desk and a chair, with a computer that is equipped with Lexis-Nexis; however, the desk and computer is located in the day room of the housing unit, not in a quiet area, and does not allow for use by multiple detainees (Deficiency ALM-1). The RRJ detainee handbook does not provide rules and procedures for detainees on the following: how to request additional law library time, how to request legal reference materials not maintained in the law library, and how to notify a facility employee that library material is missing or damaged (Deficiency ALM-2). Interviews with detainees did not reveal any issues relating to these omissions from the detainee handbook. ODO recommends RRJ make a revision of the detainee handbook to include the required information found in this standard.

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(A), the FOD must ensure the facility shall provide a law library in a designated room with sufficient space to facilitate detainees legal research and writing. The law library shall be large enough to provide reasonable access to all detainees who request its use. It shall contain a sufficient number of tables and chairs in a well-lit room, isolated from noisy areas. DEFICIENCY ALM-2 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent, shall provide detainees with the rules and procedures governing access to legal materials, including the following information: (1) that the law library is available for detainee use; (2) the scheduled hours of access to the law library; (3) the procedures for requesting access to the law library; (4) the procedure for requesting additional time in the law library [beyond the 5 hours per week minimum]; (5) the procedure for requesting legal reference materials not maintained in the law library; (6) the procedure for notifying a designated employee that library material is missing or damaged. These policies and procedures shall also be posted in the law library along with a list of the law librarys holdings.
Office of Detention Oversight December 2010

(b)(7)e
ICE.11.5082.000805

ODO reviewed the Admission and Release standard at RRJ to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed policies and files, observed the admission process, and interviewed staff and detainees. ODO identified a systemic recordkeeping issue involving required contents of detention files. ODO reviewed 30 detention files to determine if all documents during the duration of detainees custody are enclosed in their respective files. None of the files reviewed contained personal property inventory sheets, grievances, or classification forms. Twenty detention files reviewed did not contain proof of hygiene item issuance. Of 15 detainees interviewed, 6 stated they did not receive hygiene supplies during the admission and intake process (Deficiency AR-1). . RRJ staff stated ICE does not provide RRJ documentation to properly identify and classify arriving detainees (Deficiency AR-2). This could be problematic if a detainee is not classified properly, potentially resulting in the commingling of detainees of different classification levels, which is prohibited per the NDS, Detainee Classification System. Detainees must be properly classified to maintain the safety and security of themselves, staff, and visitors.

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(A)(2), the FOD must ensure every arriving detainee personal-hygiene items, clothing, sheets and blankets appropriate for local weather conditions (see the "Issuance of Clothing, Bedding, and Towels" Standard). DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(B), the FOD must ensure admission staff use the documentation accompanying each new arrival for identification and classification purposes. If the classification officers are not ICE employees, ICE will provide only the information needed for classification processing.

(b)(7)e
ICE.11.5082.000806

ODO reviewed the Detainee Grievance Procedures standard at RRJ to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff, and reviewed detainee grievance procedures and the RRJ detainee handbook. RRJ has a system in place for detainees to file both informal and formal grievances; however, no policies or procedures were identified by ODO which address handling and filing emergency grievances (Deficiency DGP-1). An appeal process is in place for detainees to appeal grievance decisions to the RRJ Superintendent; however, no procedures exist for detainees to appeal the RRJ grievance appeal decision to ICE. The grievance section of the detainee handbook does not address the grievance appeal procedures to ICE, or the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Securitys Office of Inspector General (Deficiency DGP-2). ODO recommends RRJ revise the detainee handbook to address grievance appeal procedures, and to draft policy to address the identification and handling of emergency grievances, consistent with the ICE NDS.

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(B), the FOD must ensure procedures are implemented for identifying and handling an emergency grievance. An emergency grievance involves an immediate threat to a detainees safety or welfare. Once the receiving staff member, approached by a detainee, determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures must apply. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(G)(2), (3), (4) and (6), the FOD must ensure the grievance section of the detainee handbook provides notice of the following: the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance; procedures for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved; the procedure for contacting ICE to appeal the decision of the OIC of the facility; and the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Securitys Office of Inspector General.

(b)(7)e
ICE.11.5082.000807

ODO reviewed the Detainee Handbook standard at RRJ to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, in accordance with the ICE NDS. Additionally, an examination of the handbook was conducted to determine if the following exist, in accordance with the NDS: a description of the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care. ODO interviewed staff and detainees, and reviewed the detainee handbook. RRJ detainee handbooks are available in both English and Spanish. A review of the ICE ENFORCE Alien Removal Module (EARM) database showed the majority of detainees housed at RRJ are from Mexico and Central America. RRJ staff stated if a non-English or non-Spanish speaking detainee requests assistance with translation of the detainee handbook, translation services are available to assist those detainees. RRJ stated this has not been an issue in the past. Fourteen of fifteen detainees interviewed stated they received a detainee handbook in the appropriate language. RRJ does not have a process to review the handbook on an annual basis (Deficiency DH-1). RRJ staff stated there is a revision under review, but was unable to provide a draft copy. The most recent version of the detainee handbook provided to ODO was dated January 2006.

DEFICIENCY DH-1 In accordance with the ICE NDS, Detainee Handbook, section (III)(I), the FOD must ensure an appointed committee will conduct annual reviews of the handbook, after the annual reviews and revisions by facility department heads and the OIC.

(b)(7)e
ICE.11.5082.000808

ODO reviewed the Detention Files standard at RRJ to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files, logbook, policies, and procedures, toured the admissions and release area, and interviewed staff. ODO reviewed 30 random detention files to determine if required documentation was present. ODO found missing required documentation such as housing identification cards, personal property inventory sheets, grievances, and classification work sheets (Deficiency DF-1). The logbook for recording the removal of detention files from the assigned cabinets does not include the following information: the detainees name, the detainees Alien File number, the time the file is removed, and the reason for removal (Deficiency DF-2).

DEFICIENCY DF-1 In accordance with the ICE NDS Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file will contain either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-File. The file will, at a minimum, contain the following: classification work sheet, personal property inventory sheet, and housing identification card. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(F)(2)(a), (b), (c), (d) and (e), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet will include: the detainees name and A-number; time removed; and reason for removal.

(b)(7)e
ICE.11.5082.000809

ODO reviewed the Disciplinary Policy standard at RRJ to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO interviewed staff and reviewed policy, disciplinary records, and the detainee handbook. The facility uses graduated severity scales of prohibited acts and disciplinary consequences, and minor transgressions are informally settled whenever possible. ODO review revealed incidents were objectively and impartially investigated and reported by a person of supervisory rank. The facility uses a Unit Disciplinary Committee to further investigate incidents and an Institutional Disciplinary Panel to conduct formal hearings. Detainees are advised of their rights during a hearing, to include appeal rights. The handbook does not advise detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment (Deficiency DP-1); and the right to freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DP-2). Additionally, the handbook does not address the right to pursue a grievance in accordance with written procedures (Deficiency DP-3); or the right to due process, including the prompt resolution of a disciplinary matter (Deficiency DP-4). ODO recommends revision of the detainee handbook to include these fundamental rights.

DEFICIENCY DP-1 In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(a), the FOD must ensure the detainee handbook or equivalent advises detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force personal injury, disease, property damage and harassment. DEFICIENCY DP-2 In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(b), the FOD must ensure the detainee handbook or equivalent advises detainees of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs. DEFICIENCY DP-3 In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(c), the FOD must ensure the detainee handbook or equivalent advises detainees of the right to pursue a grievance in accordance with written procedures.

(b)(7)e
ICE.11.5082.000810
DEFICIENCY DP-4 In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(e), the FOD must ensure the detainee handbook or equivalent advises detainees of the right to due process, including the prompt resolution of a disciplinary matter.

(b)(7)e
ICE.11.5082.000811

ODO reviewed the Environmental Health and Safety standard at RRJ to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical management, and fire drills. Overall, ODO found compliance with the standard. Material Safety Data Sheets (MSDS) are maintained as required. Monthly fire drills were conducted on each shift and documentation is maintained by the safety officer. Reports for water testing and pest control were current. Facility sanitation is maintained at a high level. A total of three deficiencies were cited. Inventory logs for flammable materials stored in cabinets in the maintenance shop were inaccurate (Deficiency EH&S-1). Maintaining strict accountability of all hazardous substances protects detainees, staff, and visitors. Facility exit diagrams were not written in Spanish and do not identify You are Here markers or emergency equipment locations (Deficiency EH&S-2); however, ODO observed lighted Exit signs in place throughout the facility in accordance with NFPA. Hair care is conducted in the hallway near housing unit control centers. The areas do not have a lavatories with hot and cold water, and hair care sanitation regulations were not posted (Deficiency EH&S-3). Adherence to sanitation regulations is critical to minimizing the risk of cross-contamination related to use of shared hair care equipment, and posting the regulations ensures all detainees are aware of sanitation requirements. This area was found deficient during the August 2010 ERO annual inspection. In addition to the three cited deficiencies, ODO identified one additional deficiency which was corrected during the inspection. In the maintenance shop, ODO observed 20 gallons of paint labeled highly flammable and numerous cans of aerosol paint and adhesive not stored in flammable cabinets. Proper storage and control of toxic and flammable items is a critical lifesafety requirement. ODO recommends that the facility ensure ongoing compliance with storage requirements by way of routine and thorough inspections.

DEFICIENCY EH&S-1 In accordance with ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of the hazardous (flammable, toxic, or caustic) substances used and stored in that area. DEFICIENCY EH&S-2 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a), (b) and (c), the FOD must ensure exit diagrams include instructions in English and Spanish, You are Here markers, and emergency equipment locations.
(b)(7)e
ICE.11.5082.000812
DEFICIENCY EH&S-3 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), (2), (3) and (4), the FOD must ensure the sanitation of barber operations is maintained.

(b)(7)e
ICE.11.5082.000813
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at RRJ to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed policy and relevant documentation. The facility contracts with Aramark, Inc., for management of the food service operation. Review of required inspections, production sheets, and temperature logs supported compliance with the standard. All menus, to include medical and religious, were certified by a registered dietitian. A total of two deficiencies were cited. ODO inspection revealed the food service area was not cleaned regularly. ODO observed trash, food, and other debris on the floors, and missing or broken floor tiles (Deficiency FS-1). This area was found deficient during the August 2010 ERO annual inspection. A walk-in freezer located in the warehouse had broken and damaged pallets (Deficiency FS-2). These conditions pose a risk to both health and safety. ODO recommends that the facility institute a sanitation and inspection program to ensure sanitation standards are met. Additionally, ODO noted the food service areas three-compartment sink was not labeled when first inspected. This deficiency was corrected during the review. ODO recommends that the inspection program include verification that labels remain in place.

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section (III)(H)(5)(a)(c), the FOD must ensure facility food service areas meet environmental standards. Walls, floors, and ceilings in all areas must be routinely cleaned. DEFICIENCY FS-2 In accordance with ICE NDS, Food Service, section (III)(J)(3)(b), the FOD must ensure damaged pallets are promptly replaced.

(b)(7)e
15
ICE.11.5082.000814

ODO reviewed the Funds and Personal Property standard at RRJ to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed policies and detention files and interviewed staff. The detainee handbook does not provide procedures for filing a claim for lost or damaged property or rules for storing or mailing property (Deficiency F&PP-1).

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, notifies the detainees of facility policies and procedures concerning personal property, including: the rules for storing or mailing property not allowed in their possession; and the procedures for filing a claim for lost or damaged property.

(b)(7)e
ICE.11.5082.000815

ODO reviewed the Hold Rooms in Detention Facilities standard at RRJ to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure and comfortable environment, and not confined in hold rooms for over 12 hours, in accordance with the ICE NDS. ODO inspected the hold rooms, interviewed staff, and reviewed policy and documentation. ODO review of documentation confirmed detainees are not confined in hold rooms more than 12 hours. The rooms are clean, well lit, and have adequate seating and lavatory/toilet fixtures. Basic hygiene items are provided, and a detention log is maintained. ODO review of policy and logs revealed officers conduct visual checks of hold rooms every 30 minutes (Deficiency HR-1). Monitoring hold rooms every 15 minutes is required by the standard and assures optimal detainee supervision.

DEFICIENCY HR-1 In accordance with ICE NDS, Hold Rooms In Detention Facilities, section (III)(D)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which involves "irregular" visual monitoring every 15 minutes.

(b)(7)e
ICE.11.5082.000816
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at RRJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical infirmary, reviewed policies and procedures, examined 30 medical records, verified medical staff credentials, and interviewed staff and the licensed practical nurse (LPN) who serves as the Medical Director. RRJ medical services are provided by Rappahannock Health Services. The facility holds no accreditations. Clinic staffing is sufficient to meet detainee health needs. ODO verified intake and tuberculosis screening, medications, treatment for special and chronic needs, and follow-up care are provided in accordance with the standard. Detainees access care by submitting written medical request forms or by direct request to officers to attend sick call. Detainees in the Special Management Unit (SMU) have the same access to health care services as detainees in the general population. Four deficiencies were identified, two of a critical nature. According to the National Commission on Correctional Health Care (NCCHC) standard J-E-04, compliance with which is required by the NDS, health assessments may be performed by RNs provided they complete training approved or provided by the responsible physician. The standard also requires physician review of health appraisals performed by RNs. At RRJ, LPNs perform health appraisals, a function beyond the scope of their expertise (Deficiency MC-1). According to the Medical Director, LPNs are trained in conducting health appraisals by viewing a video tape; however, the tape has not been approved by a physician and ODO discovered four LPNs had not viewed it prior to completing health appraisals. ODO further learned health appraisals conducted by LPNs are not reviewed by a physician. ODO recommends RRJ immediately discontinue use of LPNs for performance of health appraisals, and commence completion of physician-approved training by any RNs assigned to the function, and review of RNs health appraisals by the physician. Training in responding to health emergencies is required by the standard and facility policy for all RRJ personnel; however, there was no documentation of certification in cardio-pulmonary resuscitation (CPR) and first aid for eight of twenty-eight medical staff (Deficiency MC-2). The Medical Director was unable to confirm whether seven of the eight staff completed training, indicating she does not track providers compliance with training requirements. Documentation of certification for the eighth, an LPN, was not found in training records. ODO recommends completion of CPR and first aid by any staff members not currently certified, and implementation of an improved system ensuring training requirements are met. RRJ medical infirmary maintains current and retired medical records for ICE detainees in a locking file cabinet. ODO found this file cabinet unlocked several times during the inspection (Deficiency MC-3). ODO recommends that file cabinets consistently be secured to protect against unauthorized access to detainee health records. RRJ correctional officers are responsible for completing Intake Screening and Advisements forms which include consent for treatment. ODO medical record review revealed three of thirty forms were not signed (Deficiency MC-4). This area was found deficient during the August
(b)(7)e
18
ICE.11.5082.000817
2010 ERO annual inspection. ODO recommends the facility establish a system of review to ensure consent forms are consistently signed during the intake process, and ongoing verification as part of the facilitys quality assurance program. ODO verified written authorization is obtained before a detainee medical record is released; however, notification of ICE is not required by policy and does not occur in practice (Deficiency MC-5). Notification when a medical record has been released serves as an alert to possible issues relating to care. ODO also noted envelopes containing the medical records of detainees being transferred are sealed and marked Confidential; however, detainees A-numbers are not documented on the envelopes as required by the standard. The Medical Director agreed to include A-Numbers on the envelopes to fully comply with the standard requirement.

DEFICIENCY MC-1 In accordance with ICE NDS, Medical Care, section (III)(D), the FOD must ensure health appraisals are performed according to NCCHC and JCAHO standards. According to NCCHC standard J-E-04, Initial Health Assessment, the hands-on portion of health assessments may be performed by a registered nurse (RN) only when the nurse completes appropriate training approved or provided by the responsible physician. Health assessments performed by RNs must be reviewed by the physician. DEFICIENCY MC-2 In accordance with ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure staff is trained to respond to health-related emergencies within a 4-minute response time. The training provided by a responsible medical authority in cooperation with the OIC will include the administration of first aid and cardio-pulmonary resuscitation. DEFICIENCY MC-3 In accordance with ICE NDS, Medical Care, section (III)(B), the FOD must ensure all medical records are kept separate from detainee records and stored in a securely locked area within the medical unit. DEFICIENCY MC-4 In accordance with ICE NDS, Medical Care, section (III)(L), the FOD must ensure facility health care providers obtain signed and dated consent forms from all detainees before any medical examination or treatment, except in emergency circumstances.

(b)(7)e
ICE.11.5082.000818
DEFICIENCY MC-5 In accordance with ICE NDS, Medical Care, section (III)(M), the FOD must ensure IGSA facilities notify ICE each time detainee medical records are released.

(b)(7)e
ICE.11.5082.000819
STAFF DETAINEE COMMUNICATIONS (SDC)

ODO reviewed the Staff-Detainee Communication standard at RRJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed policies, documentation, and interviewed detainees and staff. ODO found that ICE staff makes daily regular and irregular visits in response to ICE detainee requests and concerns. ODO has historically observed that facilities in which ICE has a permanent or a part-time daily presence, detainee requests and concerns are addressed in a more timely manner, thereby resulting in a general climate of decreased detainee anxiety levels and negativity, including fewer behavioral issues. Along with a thorough and universally available detainee handbook, vibrant and healthy staff-detainee communications is a key component to a well-maintained detention environment. A review of logbooks and interviews with staff indicates the FOD, AFOD, and department heads do not conduct regular unannounced (unscheduled) visits to RRJ. There are no policies and procedures in place for ERO management to conduct unannounced contacts with detainees (Deficiency SDC-1). It is vitally important for ERO management staff to conduct regular visits to detention facilities to observe and monitor conditions of confinement for detainees. The detainee handbook lacks the procedures for detainees to contact ICE staff (Deficiency SDC2).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff Detainee Communication, section (III)(A)(1), the FOD must ensure that a policy and procedure shall be in place to ensure and document that the ICE Officer in Charge (OIC), the Assistant Officer in Charge (AOIC) and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and informally observing living and working conditions. These unannounced visits shall include but not be limited to: Housing Units, Food Service preferably during lunch meal; Recreation Area; Special Management Units (Administrative and Disciplinary Segregation), and Infirmary rooms. While visiting the Special Management Unit, the detainees shall be interviewed, living conditions will be observed and detainee-housing records will be reviewed. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff Detainee Communication, section (III)(B)(3), the FOD must ensure the facility shall provide each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook shall state that the detainee has the opportunity to submit written question, requests, or concerns to ICE staff and the procedures for doing so, including the availability of assistance.
(b)(7)e
ICE.11.5082.000820

ODO reviewed the Suicide Prevention and Intervention standard at RRJ to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO reviewed the policy, inspected medical and facility staff training records, and interviewed staff and the LPN who serves as Medical Director. There have been no suicides in the past year. ODO verified screening for suicide potential occurs as part of intake screening. Detainees determined at risk for suicide are immediately referred to medical and mental health staff for further evaluation, and are housed and monitored in accordance with the standard. ODO review indicated RRJ policies on suicide prevention, mental illness, and depression cover elements required by the standard, including recognizing signs of suicidal thinking; facility referral procedures; suicide-prevention techniques; responding to an in-progress suicide attempt; identification of suicide risk factors; and the psychological profile of a suicidal detainee. ODO inspection of training records and interview of the Medical Director revealed 14 of 24 medical staff members had not completed suicide prevention and intervention training as required by the standard and RRJ policy (Deficiency SP&I1). The Medical Director indicated five of the twenty-four were newly hired nurses; however, ODO found the nurses were hired one to three months prior to the inspection. Whereas suicide is a leading cause of death in correctional institutions, and suicide prevention and intervention are life-safety issues, ODO recommends that the 14 untrained staff members complete training as soon as possible. ODO further recommends the facility retain copies of all staff training records and improve its tracking of compliance with training requirements.

DEFICIENCY SP&I -1 In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(A), the FOD must ensure all staff is trained during orientation and periodically in the following: recognizing signs of suicide thinking, including suspect behavior; facility referral procedures; suicideprevention techniques; and responding to an in-progress suicide attempt. All training will include the identification of suicide risk factors and the psychological profile of a suicidal detainee.

(b)(7)e
ICE.11.5082.000821

ODO reviewed the Telephone Access standard at RRJ to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the ICE NDS. ODO inspected all telephones accessed by detainees, and reviewed all telephone worksheet orders from ICE and facility staff. ODO observed that detainees have access to the required ratio between telephones and detainees, and determined all phones were in good working order. ODO observed during the inspection that the telephone access rules are posted, but not where detainees may easily see them. RRJ corrected this deficiency before completion of the inspection; therefore, this is not cited as a deficiency but rather noted as an area of concern.

(b)(7)e
ICE.11.5082.000822

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donation, at RRJ to determine if the facilitys policies and practices are in accordance with ICE NDS requirements. ODO reviewed policies and interviewed the Medical Director and staff. There have been no deaths in the past year. RRJ has policies addressing detainee death; however, there are no policies addressing terminal illness, fatal injury, or advance directives (Deficiency TIADD-1); Do Not Resuscitate orders (Deficiency TIADD-2); or organ donation (Deficiency TIADD-3). Two of these areas (Deficiency TIADD-2 and 3) were found deficient during the August 2010 ERO annual inspection. ODO also notes RRJ policies do not include reference to ICE responsibilities for notification of next of kin in the event of a detainees serious illness or injury, or case closure. Whereas these requirements are addressed in the standard, ODO recommends referencing them in facility policies.

DEFICIENCY TIADD-1 In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure facilities have policies and procedures addressing the issues of terminal illness, fatal injury, advance directives, and detainee death. DEFICIENCY TIADD-2 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(C), the FOD must ensure facilities establish and implement through written procedure policy governing DNR orders. DEFICIENCY TIADD-3 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(D), the FOD must ensure specified procedures govern organ donations by detainees.

(b)(7)e
ICE.11.5082.000823
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at RRJ to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO reviewed policy, interviewed staff, and inspected tools and areas where tools are stored and maintained.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.000824
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at RRJ to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO interviewed staff and reviewed local policy, training records, and use of force documentation.
(b)(7)e
(b)(7)e

(b)(7)e
26
ICE.11.5082.000825
APPENDIX A
Acronyms

(b)(7)e
ICE.11.5082.000826
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS In accordance with the ICE NDS, Access to Legal Material, section (III)(A), the FOD must ensure the facility shall provide a law library in a designated room with sufficient space to facilitate detainees legal research and writing. The law library shall be large enough to provide reasonable access to all detainees who request its use. It shall contain a sufficient number of tables and chairs in a well-lit room, isolated from noisy areas. In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent, shall provide detainees with the rules and procedures governing access to legal materials, including the following information: (1) that the law library is available for detainee use; (2) the scheduled hours of access to the law library; (3) the procedures for requesting access to the law library; (4) the procedure for requesting additional time in the law library [beyond the 5 hours per week minimum]; (5) the procedure for requesting legal reference materials not maintained in the law library; (6) the procedure for notifying a designated employee that library material is missing or damaged. These policies and procedures shall also be posted in the law library along with a list of the law librarys holdings. In accordance with the ICE NDS, Admission and Release, section (III)(A), the FOD must ensure staff open a detainee detention file as part of the admissions process. This file must contain all paperwork generated by the detainees stay at the facility. PAGE
ALM-1
ALM-2
Admission And Release
AR-1

(b)(7)e
ICE.11.5082.000827
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE NDS, Admission and Release, section (III)(B), the FOD must ensure admission staff use the documentation accompanying each new arrival for identification and classification purposes. If the classification officers are not ICE employees, ICE will provide only the information needed for classification processing. In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(B), the FOD must ensure procedures are implemented for identifying and handling an emergency grievance. An emergency grievance involves an immediate threat to a detainees safety or welfare. Once the receiving staff member, approached by a detainee, determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures must apply. In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(G)(2)(3)(4)and(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the following: the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance; procedures for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved; the procedure for contacting ICE to appeal the decision of the OIC of the facility; and the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Securitys Office of Inspector General. In accordance with the ICE NDS, Detainee Handbook, section (III)(I), the FOD must ensure an appointed committee will conduct annual reviews of the handbook, after the annual reviews and revisions by facility department heads and the OIC.
29
PAGE
Admission And Release
AR-2
DGP-1
DGP-2
Detainee Handbook
DH-1

(b)(7)e
ICE.11.5082.000828
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE NDS Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file will contain either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-File. The file will, at a minimum, contain the following: classification work sheet, personal property inventory sheet, and housing identification card. In accordance with the ICE NDS, Detention Files, section (III)(F)(2)(a)(b)(c)(d)and(e), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet will include: the detainees name and A-number; time removed; and reason for removal. In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(a), the FOD must ensure the detainee handbook or equivalent advises detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force personal injury, disease, property damage and harassment. In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(b), the FOD must ensure the detainee handbook or equivalent advises detainees of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs. In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(c), the FOD must ensure the detainee handbook or equivalent advises detainees of the right to pursue a grievance in accordance with written procedures.
PAGE
Detention Files
DF-1
10
Detention Files
DF-2
10
Disciplinary Policy
DP-1
11
Disciplinary Policy
DP-2
11
Disciplinary Policy
DP-3
11

(b)(7)e
ICE.11.5082.000829
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS In accordance with ICE NDS, Disciplinary Policy section (III)(A)(5)(e), the FOD must ensure the detainee handbook or equivalent advises detainees of the right to due process, including the prompt resolution of a disciplinary matter. In accordance with ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of the hazardous (flammable, toxic, or caustic) substances used and stored in that area. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a)(b)(c), the FOD must ensure exit diagrams include instructions in English and Spanish, You are Here markers, and emergency equipment locations. In accordance with ICE NDS, Food Service, section (III)(H)(5)(a)(c), the FOD must ensure facility food service areas meet environmental standards. Walls, floors, and ceilings in all areas must be routinely cleaned. In accordance with ICE NDS, Food Service, section (III)(J)(3)(b), the FOD must ensure damaged pallets are promptly replaced. In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, notifies the detainees of facility policies and procedures concerning personal property, including: the rules for storing or mailing property not allowed in their possession; and the procedures for filing a claim for lost or damaged property. In accordance with ICE NDS, Hold Rooms In Detention Facilities, section (III)(D)(4), the FOD must ensure officers closely supervise the detention hold rooms through direct supervision, which involves "irregular" visual monitoring every 15 minutes.
PAGE
Disciplinary Policy
DP-4
12
Environmental Health And Safety
EH&S-1
13
EH&S-2
13
Food Service
FS-1
15
Food Service
FS-2
15
Funds And Personal Property
F&PP-1
16
HR-1
17

(b)(7)e
31
ICE.11.5082.000830
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS In accordance with ICE NDS, Medical Care, section (III)(D), the FOD must ensure health appraisals are performed according to NCCHC and JCAHO standards. According to NCCHC standard J-E-04, Initial Health Assessment, the hands-on portion of health assessments may be performed by a registered nurse (RN) only when the nurse completes appropriate training approved or provided by the responsible physician. Health assessments performed by RNs must be reviewed by the physician. In accordance with ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure staff is trained to respond to health-related emergencies within a 4-minute response time. The training provided by a responsible medical authority in cooperation with the OIC will include the administration of first aid and cardio-pulmonary resuscitation. In accordance with ICE NDS, Medical Care, section (III)(B), the FOD must ensure all medical records are kept separate from detainee records and stored in a securely locked area within the medical unit. In accordance with ICE NDS, Medical Care, section (III)(L), the FOD must ensure facility health care providers obtain signed and dated consent forms from all detainees before any medical examination or treatment, except in emergencies circumstances. In accordance with ICE NDS, Medical Care, section (III)(M), the FOD must ensure IGSA facilities notify ICE each time detainee medical records are released.
PAGE
Medical Care
MC-1
19
Medical Care
MC-2
19
Medical Care
MC-3
19
Medical Care
MC-4
19
Medical Care
MC-5
20

(b)(7)e
ICE.11.5082.000831
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE NDS, Staff Detainee Communication, section (III)(A)(1), the FOD must ensure that a policy and procedure shall be in place to ensure and document that the ICE Officer in Charge (OIC), the Assistant Officer in Charge (AOIC) and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and informally observing living and working conditions. These unannounced visits shall include but not be limited to: Housing Units, Food Service preferably during lunch meal; Recreation Area; Special Management Units (Administrative and Disciplinary Segregation), and Infirmary rooms. While visiting the Special Management Unit, the detainees shall be interviewed, living conditions will be observed and detaineehousing records will be reviewed. In accordance with the ICE NDS, Staff Detainee Communication, section (III)(B)(3), the FOD must ensure the facility shall provide each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook shall state that the detainee has the opportunity to submit written question, requests, or concerns to ICE staff and the procedures for doing so, including the availability of assistance. In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(A), the FOD must ensure all staff is trained during orientation and periodically in the following: recognizing signs of suicide thinking, including suspect behavior; facility referral procedures; suicide-prevention techniques; and responding to an in-progress suicide attempt. All training will include the identification of suicide risk factors and the psychological profile of a suicidal detainee. Area of Concern
33
PAGE
SDC-1
21
SDC-2
21
SP&I-1
22
Telephone Access
(b)(7)e
TA-1
23
ICE.11.5082.000832
DETENTION STANDARD
DEFICIENCIES AND REQUIREMENTS In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure facilities have policies and procedures addressing the issues of terminal illness, fatal injury, advance directives, and detainee death. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(C), the FOD must ensure facilities establish and implement through written procedure policy governing DNR orders. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(D), the FOD must ensure specified procedures govern organ donations by detainees.
PAGE
TIADD-1
24
TIADD-2
24
TIADD-3
24
Tool Control
TC-1
25
(b)(7)e
Use Of Force
UOF-1
26

(b)(7)e
34
ICE.11.5082.000833


Enforcement and Removal Operations Dallas Field Office Rolling Plains Regional Detention Center
July 27-29, 2010
FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law enforcement, management and employee information. It has been written for the express use of the Department of Homeland Security to identify and correct management and operational deficiencies. In reference to OPR Directive 08006.1, issued 09/22/05; any disclosure, dissemination, or reproduction of this document, or any segments thereof, is prohibited without the approval of the Assistant Director, Office of Professional Responsibility.
ICE.11.5082.000834
OFFICE OF PROFESSIONAL RESPONSIBILITY MISSION STATEMENT The Office of Professional Responsibility (OPR) is responsible for investigating allegations of employee misconduct impartially, independently, and thoroughly. OPR prepares timely and comprehensive reports of investigations for judicial or management action. OPR inspects and reviews Immigration and Customs Enforcement (ICE) field offices, operations, and processes in order to provide executive management with an independent review of the agencys organizational health, and assesses the effectiveness and efficiency of the overall ICE mission.
ICE.11.5082.000835
QUALITY ASSURANCE REVIEW ROLLING PLAINS REGIONAL DETENTION CENTER DALLAS FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. Area of Concern.. OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE NATIONAL DETENTION STANDARDS National Detention Standard Reviewed... Access to Legal Material Admission and Release. Detainee Classification System Detainee Grievance Procedures.. Detainee Handbook Detainee Transfers. Detention Files. Food Service. Funds and Personal Property Medical Care. Post Orders.. Staff-Detainee Communication..... Suicide Prevention and Intervention. Terminal Illness, Advanced Directives and Death . Visitation.... 1 1
3 3
4 4
7 8 9 10 11 12 14 15 17 19 20 21 22 23 24 25
ICE.11.5082.000836
ICE.11.5082.000837
INSPECTION PROCESS
The ICE, Office of Professional Responsibilitys (OPR), Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of the Rolling Plains Regional Detention Center (RPRDC) in Haskell, Texas, on June 22-24, 2010. ODO reviewed the processes employed at RPRDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the Department of Homeland Security (DHS), the Joint Interagency Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Director, Office of Professional Responsibility.

DDO (Team Leader) Special Agent Detention and Deportation Officer Special Agent Detention and Deportation Officer Contract Inspector Contract Inspector Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Houston, TX ODO, Headquarters ODO, Houston, TX ODO, San Diego, CA MGT of America, Inc. MGT of America, Inc. MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
(b)(6), (b)(7)(C)
Office of Detention Oversight June 2010

(b)(7)e
Rolling Plains Regional Detention Center ERO Dallas, TX
ICE.11.5082.000838

(b)(7)e
ICE.11.5082.000839
BACKGROUND
HISTORY
RPRDC is an ICE-dedicated intergovernmental service agreement (IGSA) detention facility which opened in February 2002. ERO began using the facility to house ICE detainees in 2003. RPRDC is authorized to house adult male and female ICE detainees over 72 hours. . (b)(7)e RPRDC is owned by the c members. Emerald Correctional Management (ECM) manages RPRDC, and Emerald Health Care operates the medical clinic. In 2009 and 2010, ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted annual reviews of the 2000 ICE NDS at RPRDC. The final overall rating was Good in both years. The facility holds American Correctional Association accreditation since 2007. AREA OF CONCERN During the interview process, concerns over shower water temperature and allegations of burned skin and hair loss due to the water issue were raised to ODO staff. ODO tested the hot water temperature of the showers in the female detainees housing unit and found it to be 111 degrees Fahrenheit. The shower is not properly mixing hot and cold water.
3
(b)(7)e
ICE.11.5082.000840

(b)(7)e
ICE.11.5082.000841
INTERNAL RELATIONS
ODO interviewed ICE personnel: three Immigration Enforcement Agents (IEAs) assigned to the RPRDC and a Deportation Officer (DO) serving as the Contracting Officer Technical Representative (COTR). Several RPRDC staff were interviewed including the Warden, Deputy Warden, and correction officers. Based on the interviews, ICE and RPRDC officials share a positive working relationship. ICE personnel stated morale is excellent; however, training would improve job performance. Communication from ICE management is inadequate, including a lack of email updates and staff meetings. When asked about logistical issues, IEAs reported not having access to basic ICE systems, including IDENT, TECS, and CIS, nor having the required skills to use the computer programs. The IEAs seemed overwhelmed with the various duties, including coordinating all activities with the Dallas field office, and obtaining sufficient training, guidance, and oversight because of the lack of supervision. RPRDC management stated there is a good working relationship with ICE. Recent permanent assignment of IEAs at the facility has improved interactions with the detainees. The facility management does not have direct communication with the Dallas field office. All communication is made through IEAs and/or the COTR. The RPRDC correction officers were familiar with local policies and procedures, and appeared to have very high morale. However, none of the officers had received specific training in the ICE NDS. All officers identified the need for additional training related to ICE detainees.
DETAINEE RELATIONS
ODO selected and interviewed 20 ICE detainees housed at RPRDC. Two major complaints were the facilitys food service and inadequate ICE presence in the housing units. Detainees stated their food was bland, lacked variety and quality, and served in small portions. All detainees stated ICE officers do not visit the housing units as often as needed to answer questions regarding detainee cases. Detainees also stated they have noticed an increased ICE presence since the regular visits of the Detention Service Manager (DSM) in the housing units. Two detainees stated several corrections officers consistently display bad attitudes and do not treat the detained population with respect.

(b)(7)e
ICE.11.5082.000842

(b)(7)e
ICE.11.5082.000843

This inspection was based on the 2000 ICE NDS. The following 25 standards were reviewed: Access to Legal Material; Admission and Release; Detainee Classification System; Detainee Grievance Procedures; Detainee Handbook; Detainee Transfers; Detention Files; Disciplinary Policy; Emergency Plans; Environmental Health and Safety; Food Service; Funds and Personal Property; Hold Rooms in Detention Facilities; Hunger Strikes; Key and Lock Control; Medical Care; Post Orders; Security Inspections; Special Management Units; Staff-Detainee Communication; Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives, and Death; Tool Control; and Visitation. No deficiencies were noted in the following 11 standards: Disciplinary Policy, Emergency Plans, Environmental Health and Safety, Hold Rooms in Detention Facilities, Hunger Strikes, Key and Lock Control, Security Inspections, Special Management Units, Telephone Access, and Tool Control. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e
ICE.11.5082.000844

ODO reviewed the Access to Legal Material standard at RPRDC to determine if detainees have access to a law library, legal materials, courts, counsel and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO inspected the law library, interviewed staff and detainees, and reviewed policies, detainee handbook, and special management unit logs. The six rules and procedures governing access to legal materials are not posted, nor are they all included in the handbook (Deficiency ALM-1).

DEFICIENCY ALM-1 and DH-3 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

(b)(7)e
ICE.11.5082.000845

ODO reviewed the Admission and Release standard at RPRDC to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed policies, procedures, and detention files, interviewed staff, and observed the admission and release processes. The supervisor in charge of baggage and personal property stated that identity documents, such as passports and birth certificates, are not always inventoried and forwarded to an ICE Deportation Officer for placement in the detainees Alien File (Deficiency AR-1). Facility staff assigned to intake and processing are not aware of the process to report detainees missing property, including the Report of Detainees Missing Property (Form I-387) (Deficiency AR-2).

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(E), the FOD must ensure each facility has a procedure for inventory and receipt of detainee baggage and personal property (other than funds and valuables). Identity documents such as passports and birth certificates will be inventoried and then given to an ICE deportation officer for placement in the detainees A-File. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(E), the FOD must ensure officers complete a Form I-387, Report of Detainees Missing Property, when any newly arrived detainee claims his/her property has been lost or left behind. IGSA facilities must forward the completed I-387s to ICE.

(b)(7)e
ICE.11.5082.000846

ODO reviewed the Detainee Classification System standard at RPRDC to determine if there is a formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE NDS. ODO toured the processing area and interviewed an officer and a supervisor assigned to classify detainees upon their arrival.
(b)(7)e
(b)(7)e

(b)(7)e
10
ICE.11.5082.000847

ODO reviewed the Detainee Grievance Procedures standard at RPRDC to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff and reviewed files, policies, procedures, and logs. ODO reviewed six detention files to determine if copies of grievances were placed in the files. Two files did not contain the required copies (Deficiency DGP-1).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance remains in the detainees detention file for at least three years.
11
(b)(7)e
ICE.11.5082.000848

ODO reviewed the Detainee Handbook standard at RPRDC to determine if the facility provides each detainee with a handbook, written in English, and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO reviewed the handbook and interviewed staff. The handbook did not cover restricted areas (Deficiency DH-1), or grievance appeal procedures (Deficiency DH-2). ODO also observed the handbook does not include the following procedures for requesting additional time in the law library, requesting legal reference materials not maintained in the law library, and notifying a designated employee that library material is missing or damaged (Deficiency DH-3). ODO staff review of the facilitys detainee handbook revealed it does indicate that upon request, detainees will be provided an ICE-certified copy of any identity document taken from their property, the rules for storing or mailing property not allowed in their possession, the procedure for claiming property upon release, transfer or removal, and the procedure for filing a claim for lost or damaged property (Deficiency DH-4).

DEFICIENCY DH-1 In accordance with the ICE NDS, Detainee Handbook, section (III)(C), the FOD must ensure the detention facility handbook specifies detailed rules, regulations, policies, and procedures which every detainee must follow, including, but not limited to: smoking policy, restricted areas, and contraband. DEFICIENCY DH-2 In accordance with the ICE NDS, Detainee Handbook, section (III)(C), the FOD must ensure the detention facility handbook lists detainee rights and responsibilities. It must also list and classify prohibited actions/behavior, along with disciplinary procedures and sanctions. This section will include grievance and appeals procedures. DEFICIENCY DH-3 and ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.
Office of Detention Oversight Rolling Plains Regional Detention Center ERO Dallas, TX
12
(b)(7)e
ICE.11.5082.000849
DEFICIENCY DH-4 and F&PP 1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: 1) which items they may retain in their possession; 2) that, upon request, they will be provided an ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files; 3) the rules for storing or mailing property not allowed in their possession; 4) The procedure for claiming property upon release, transfer, or removal; and 5) The procedures for filing a claim for lost or damaged property.

(b)(7)e
13
ICE.11.5082.000850
DETAINEE TRANSFERS (DT)

ODO reviewed the Detainee Transfers standard at RPRDC to determine if transfers of detainees from one facility to another are responsibly managed in regard to notification, detention records, safety and security, and protection of detainees funds and property, in accordance with the ICE NDS. ODO reviewed policies and documents pertaining to the transfer of detainees to other facilities. Detainee Transfer Notification forms are not used to provide detainees with required information concerning their transfers (Deficiency DT-1). Detainee Transfer Checklists are not completed prior to transferring detainees from RPRDC (Deficiency DT-2).

DEFICIENCY DT-1 In accordance with the ICE NDS, Detainee Transfers, section (III)(A)(3), the FOD must ensure at the time of the transfer, ICE provides the detainee in writing, the name, address, and telephone number of the facility he/she is being transferred to. The Detainee Transfer Notification Sheet must be used for this purpose. DEFICIENCY DT-2 In accordance with the ICE NDS, Detainee Transfers, section (III)(D), the FOD must ensure the Detainee Transfer Checklist is filled out, insuring that all procedures are completed, and it is placed in the detainees A-file or work folder.
14
(b)(7)e
ICE.11.5082.000851

ODO reviewed the Detention Files standard at RPRDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed ten active and ten archived detention files. Original booking cards (Form I-385) are not placed in active files (Deficiency D-1), nor maintained, with an original photograph, in archived detention files (Deficiency DF-2). Not all staff members have access to detention files. The log used for recording removal of detention files from the records area is missing required information, including: reason for removal; signature, title, and department of person removing the file; and the signature of person returning the file (Deficiency DF-3). The ERO Dallas field office does not create and maintain detention files on all detainees admitted to the facility (Deficiency DF-4). ICE staff receives written requests from detainees and responds within 72 hours, but the requests are not maintained in the detention file for at least three years (Deficiency DF-5).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admissions process. The detention file may include copies of material contained in the detainees A-File. The file, at a minimum, must contain the I-385, Alien Booking Record, with one or more original photographs attached. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(E)(2), the FOD must ensure staff inserts copies of completed release documents, the original closed-out receipts for property and valuables, and the original I-385 into the released detainees detention file. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F), the FOD must ensure all staff has access to the detention files, and at a minimum, a logbook entry recording the files removal from the cabinet will include: a) detainees name and A-File number; b) date and time removed; c) reason for removal; d) signature of person removing the file, including title and department; e) date and time returned; and f) signature of person returning the file.

(b)(7)e
15
ICE.11.5082.000852
DEFICIENCY DF-4 In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office with IGSA-facility jurisdiction creates and maintains detention files on all detainees admitted to IGSA facilities. These files must contain the same material (forms and other documents) as SPC/CDF detention files to the extent possible, given that they are created by the field office. For example, if the field office takes and holds detainee property, the detention file must contain the G-589 and I-77. The file must also contain copies of all I-203s and the G-385 related to the alien. The IGSA must forward all documents relating to the detainee to the ICE field office of jurisdiction for inclusion into the detention file. DEFICIENCY DF-5 and SDC-3 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and remain in the detainees detention file for at least three years.

(b)(7)e
16
ICE.11.5082.000853
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at RPRDC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed policies, interviewed staff, observed meal service, and inspected food storage and preparation areas. There is no documentation of annual review of detainee job descriptions (Deficiency FS-1). Food is not delivered to housing areas in covered containers or enclosed carts (Deficiency FS-2). ODO observed serving pans containing leftovers were not labeled to ensure utilization within 24 hours (Deficiency FS-3). Documentation of refrigerator, freezer, and dishwasher temperature checks were missing for June 16, 2010 (Deficiency FS-4). Daily chemical inventory logs were not current (Deficiency FS-5). The fire suppression system was last inspected by an outside contractor in September 2009, outside the required six-month timeframe (Deficiency FS-6).

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section(III)(B)(11), the FOD must ensure the Food Service Director reviews detainee job descriptions annually to ensure they are accurate and up to date. DEFICIENCY FS-2 In accordance with ICE NDS, Food Service, section (III)(C)(2)(g), the FOD must ensure food is delivered from one place to another in covered containers, such as enclosed, satellite feeding carts. DEFICIENCY FS-3 In accordance with ICE NDS, Food Service, section (III)(1)(8), Food Preparation, the FOD must ensure leftover food items are retained for no more than 24 hours, and are labeled to identify the product and preparation date and time. DEFICIENCY FS-4 In accordance with ICE NDS, Food Service, section (III)(H)(13)(a), the FOD must ensure staff check refrigerator and water temperatures daily and record the results. DEFICIENCY FS-5 In accordance with ICE NDS, Food Service, section (III)(H)(11)(b), the FOD must ensure staff members know where and how much toxic, flammable, or caustic material is on hand, and be aware that their use must be controlled and accounted for daily.
17
(b)(7)e
ICE.11.5082.000854
DEFICIENCY FS-6 In accordance with ICE NDS, Food Service, section (III)(H)(12)(f), the FOD must ensure the approved, fixed, fire-suppression system is inspected by a qualified contractor every six months.

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ICE.11.5082.000855

ODO reviewed the Funds and Personal Property standard at RPRDC to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with ICE NDS. ODO reviewed policies and the detainee handbook. ODO staff review of the facilitys detainee handbook revealed it does indicate that upon request, detainees will be provided an ICE-certified copy of any identity document taken from their property, the rules for storing or mailing property not allowed in their possession, the procedure for claiming property upon release, transfer or removal, and the procedure for filing a claim for lost or damaged property (Deficiency F&PP-1).

DEFICIENCY F&PP-1 and DH-4 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: 1) which items they may retain in their possession; 2) that, upon request, they will be provided an ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files; 3) the rules for storing or mailing property not allowed in their possession; 4) The procedure for claiming property upon release, transfer, or removal; and 5) The procedures for filing a claim for lost or damaged property.
19
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ICE.11.5082.000856
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at RPRDC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 30 medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. At the time of the review, RPRDC did not have a written plan in place to deliver 24-hour emergency care (Deficiency MC-1). The HSA has developed a new policy entitled, Emergency Health Care; however, it has not been approved and implemented. Review of training records revealed one out of eleven detention staff and one out of eighteen medical staff did not have current first aid and cardiopulmonary resuscitation (CPR) training (Deficiency MC-2).

DEFICIENCY MC-1 In accordance with ICE NDS, Medical Care, section (III)(G), the FOD must ensure the facility has a written plan to deliver 24-hour emergency health care when no medical personnel are on duty at the facility, or when immediate outside medical attention is required. DEFICIENCY MC-2 In accordance with ICE NDS, Medical Care, section (III)(H), the FOD must ensure staff is trained to respond to health-related emergencies within a 4-minute timeframe. Training must include the administration of first aid and CPR.

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ICE.11.5082.000857
POST ORDERS (PO)

ODO reviewed the Post Orders standard at RPRDC to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies and all post orders.
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ICE.11.5082.000858

ODO reviewed the Staff-Detainee Communication standard at RPRDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed logbooks and interviewed staff. Although ICE department heads conduct regular unannounced visits, they do not visit the facilitys living and activity areas: housing, food service, recreation, segregation, and medical (Deficiency SDC-1). ICE staff conducts scheduled visits to address detainees personal concerns and to monitor living conditions, but no schedule is posted in detainee access areas (Deficiency SDC-2). ICE staff receives written requests from detainees and responds within 72 hours, but the requests are not maintained in the detention file for at least three years (Deficiency SDC-3).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure the ICE Officer in Charge, Assistant Officer in Charge, and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and observe living and working conditions. Each facility will develop a method to document the visits. ICE will develop a method to document the visits independent of the facilitys documentation. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. DEFICIENCY SDC-3 and DF-5 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and remain in the detainees detention file for at least three years.
22
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ICE.11.5082.000859

ODO reviewed the Suicide Prevention and Intervention standard at RPRDC to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO reviewed the suicide prevention and intervention policy, interviewed the HSA and staff, and reviewed training records. There have been no suicides in the past year. Training records indicate one of eleven detention staff, and seven of eighteen medical staff, did not receive suicide prevention and intervention training during orientation (Deficiency SP&I-1).
STANDARD POLICY REQUIREMENT FOR DEFICIENT FINDINGS

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention & Intervention, section (III)(A), the FOD must ensure all staff receive training, during orientation and periodically, in the following: recognizing signs of suicidal thinking, including suspect behavior; facility referral procedures; suicide-prevention techniques; and responding to an in-progress suicide attempt.

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ICE.11.5082.000860

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donation, at RPRDC to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO reviewed policies and procedures and interviewed the HSA. There have been no deaths in the past year. Local policy H-73, Terminal Illness, Advance Directives, and Do-Not-Resuscitate, does not address fatal injury (Deficiency TIADD-1).
STANDARD POLICY REQUIREMENT FOR DEFICIENT FINDINGS

DEFICIENCY TIADD1 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure the facility has policies and procedures addressing the issues of terminal illness, fatal injury, advance directives, and detainee death.

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ICE.11.5082.000861
VISITATION (V)
ODO reviewed the Visitation standard at RPRDC to determine if authorized persons, including legal representatives, are able to visit detainees within security and operational constraints, in accordance with ICE NDS. ODO observed the visiting areas, interviewed staff and detainees, and reviewed policies, the detainee handbook, and the visitor logbooks. Notice of Entry of Appearance as Attorney or Representative (Form G-28) is not available in the legal visitors reception area (Deficiency V-1).

DEFICIENCY V-1 In accordance with ICE NDS, Visitation, section (III)(I)(8), The FOD must ensure once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitors reception area.
25
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ICE.11.5082.000862
APPENDIX A Acronyms
ACA COTR CXR DIHS DOS DSCU EABM EADM EOIR ERO FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU
TAR
American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Enforcement and Removal Operations Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit

TB UDC

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ICE.11.5082.000863
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law 7 library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional 11 time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with the ICE NDS, Admission and Release, section (III) (E), the FOD must ensure each facility has a procedure for inventory and receipt of detainee baggage and personal property (other than funds and 8 valuables). Identity documents such as passports and birth certificates will be inventoried and then given to an ICE deportation officer for placement in the detainees A-file.
Access to Legal Material Detainee Handbook
ALM-1
DH-3
AR-1

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ICE.11.5082.000864
DETENTION STANDARD
AR-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE National Detention Standard, Admission and Release, section (III)(E), the FOD must ensure Officers complete a Form I-387, Report of Detainees Missing Property, 8 when any newly arrived detainee claims his/her property has been lost or left behind. IGSA facilities must forward the
DCS-1
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DGP-1
Detainee Handbook
DH-1
Detainee Handbook
DH-2
Detainee Grievance Procedures, section (III) (E), the FOD must ensure a copy of the grievance remains in the detainees detention file for at least three years. In accordance with the ICE NDS, Detainee Handbook, section (III)(C), the FOD must ensure the detention facility handbook specifies detailed rules, regulations, policies, and procedures which every detainee must follow, including, but not limited to: smoking policy, restricted areas, and contraband. In accordance with the ICE NDS, Detainee Handbook, section (III) (C), the FOD must ensure the detention facility handbook lists detainee rights and responsibilities. It must also list and classify prohibited actions/behavior, along with disciplinary procedures and sanctions. This section will include grievance and appeals procedures.
10
11
11

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ICE.11.5082.000865
DETENTION STANDARD
Detainee Handbook
DH-4
F&PP-1
Detainee Transfers
DT-1
Detainee Transfers
DT-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies detainees of facility policies and procedures concerning personal property, including: 1) which items they 11 may retain in their possession; 2) that, upon request, they will be provided an ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files; 3) the rules 18 for storing or mailing property not allowed in their possession; 4) The procedure for claiming property upon release, transfer, or removal; and 5) The procedures for filing a claim for lost or damaged property. In accordance with the ICE NDS, Detainee Transfers, section (III)(A)(3), the FOD must ensure at the time of the transfer, ICE provides the detainee in writing, the name, address, and 13 telephone number of the facility he/she is being transferred to. The Detainee Transfer Notification Sheet must be used for this purpose. In accordance with the ICE NDS, Detainee Transfers, section (III) (D), the FOD must ensure the Detainee Transfer Checklist is filled out, insuring that all 13 procedures are completed, and it is placed in the detainees A-file or work folder.

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ICE.11.5082.000866
DETENTION STANDARD
Detention Files
DF-1
Detention Files
DF-2
Detention Files
DF-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admissions 14 process. The detention file may include copies of material contained in the detainees A-file. The file, at a minimum, must contain the I-385, Alien Booking Record, with one or more original photographs attached. In accordance with the ICE National Detention Standard, Detention Files, section (III)(E)(2), the FOD must ensure staff inserts copies of completed release 14 documents, the original closed-out receipts for property and valuables, and the original I-385 into the released detainees detention file. In accordance with the ICE NDS, Detention Files, section (III)(F), the FOD must ensure all staff has access to the detention files, and at a minimum, a logbook entry recording the files removal from the cabinet will include: a) detainees name and A-File number; b) 14 date and time removed; c) reason for removal; d) signature of person removing the file, including title and department; e) date and time returned; and f) signature of person returning the file.
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ICE.11.5082.000867
DETENTION STANDARD
Detention Files
DF-4
Detention Files DF-5 Staff-Detainee Communication
SDC-3
Food Service
FS-1
Food Service
FS-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office with IGSAfacility jurisdiction creates and maintains detention files on all detainees admitted to IGSA facilities. These files must contain the same material (forms and other documents) as SPC/CDF detention files to the extent possible, given that they are created by the field 14 office. For example, if the field office takes and holds detainee property, the detention file must contain the G-589 and I-77. The file must also contain copies of all I-203s and the G-385 related to the alien. The IGSA must forward all documents relating to the detainee to the ICE field office of jurisdiction for inclusion into the detention file. In accordance with the ICE NDS, StaffDetainee Communication, section 14 (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and remain 21 in the detainees detention file for at least three years. In accordance with ICE NDS, Food Service, section(III)(B)(11), the FOD must ensure the Food Service Director 16 reviews detainee job descriptions annually to ensure they are accurate and up to date. In accordance with ICE NDS, Food Service, section (III)(C)(2)(g), the FOD must ensure food is delivered from one 16 place to another in covered containers, such as enclosed, satellite feeding carts.
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ICE.11.5082.000868
DETENTION STANDARD
Food Service
FS-3
Food Service
FS-4
Food Service
FS-5
Food Service
FS-6
Medical Care
MC-1
Medical Care
MC-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Food Service, section (III)(1)(8), Food Preparation, the FOD must ensure leftover food items are retained for no 16 more than 24 hours, and are labeled to identify the product and preparation date and time. In accordance with ICE NDS, Food Service, section (III)(H)(13)(a), the FOD must ensure staff check refrigerator and 16 water temperatures daily and record the results. In accordance with ICE NDS, Food Service, section (III)(H)(11)(b), the FOD must ensure staff members know where and how much toxic, flammable, or 16 caustic material is on hand, and be aware that their use must be controlled and accounted for daily. In accordance with ICE NDS, Food Service, section (III) (H) (12) (F), the FOD must ensure the approved, fixed, 16 fire-suppression system is inspected by a qualified contractor every six months. In accordance with ICE NDS, Medical Care, section (III)(G), the FOD must ensure the facility has a written plan to deliver 24-hour emergency health care 19 when no medical personnel are on duty at the facility, or when immediate outside medical attention is required. In accordance with ICE NDS, Medical Care, section (III) (H), the FOD must ensure staff is trained to respond to health-related emergencies within a 19 4-minute timeframe. Training must include the administration of first aid and CPR.
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ICE.11.5082.000869
DETENTION STANDARD
PAGE
Post Orders
PO-1
20
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PO-2
20
SDC-1
SDC-2
Detainee Communication, section (III)(A)(1), the FOD must ensure the ICE Officer in Charge, Assistant Officer in Charge, and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and observe living and working conditions. Each facility will develop a method to document the visits. ICE will develop a method to document the visits independent of the facilitys documentation. In accordance with the ICE NDS, StaffDetainee Communication, section (III) (B) (2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose.
21
21
33
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ICE.11.5082.000870
DETENTION STANDARD
SP&I-1
TIADD-1
Visitation
V-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Suicide Prevention & Intervention, section (III) (A), the FOD must ensure all staff receive training, during orientation and periodically, in the 22 following: recognizing signs of suicidal thinking, including suspect behavior; facility referral procedures; suicideprevention techniques; and responding to an in-progress suicide attempt. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure the facility has policies and 23 procedures addressing the issues of terminal illness, fatal injury, advance directives, and detainee death. In accordance with ICE NDS, Visitation, section (III)(I)(8), The FOD must ensure once an attorney-client relationship has been established, the legal 24 representative completes and submits a Form G-28, available in the legal visitors reception area.
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ICE.11.5082.000871


Enforcement and Removal Operations Los Angeles Field Office Santa Ana Jail Santa Ana, California
ICE.11.5082.000872
QUALITY ASSURANCE REVIEW SANTA ANA JAIL LOS ANGELES FIELD OFFICE TABLE OF CONTENTS
EXECUTIVE SUMMARY ................................................................................ 1 INSPECTION PROCESS Report Organization. ... 3 Inspection Team Members ......... 3 BACKGROUND .................................................................................................. OPERATIONAL ENVIRONMENT Internal Relations....... ..4 Detainee Relations ......... .4 ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed. ........................ .5 Detention Files. ............... 6 Environmental Health and Safety. .............. 7 Food Service.. .............. 9 Medical Care.. ........... 10 Recreation.............. 12 Staff-Detainee Communication.. ............... 13 Suicide Prevention and Intervention.. ............... 15 Terminal Illness, Advance Directives, and Death... .............. 16 Tool Control.. ............ 17 Use of Force.. ........ 19 LIST OF ACRONYMS 21
ICE.11.5082.000873
EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO) conducted a Quality Assurance Review (QAR) of the Santa Ana Jail (SAJ) in Santa Ana, California, November 16-18, 2010. The review was the first completed at the facility by ODO. ICE houses detainees in SAJ under an intergovernmental service agreement (IGSA). SAJ is
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ice is contracted by Aramark. ERO contractors, MGT of America, Inc., conducted an annual review of the ICE NDS at SAJ in 2009. The facility received an overall rating of good. ODO reviewed the processes employed at SAJ to determine compliance with current policies and detention standards. The review covered 20 National Detention Standards (NDS). No deficiencies were noted in the following ten standards: Access to Legal Material; Admission and Release; Detainee Grievance Procedures; Detainee Handbook; Funds and Personal Property; Hold Rooms in Detention Facilities; Hunger Strike; Special Management Unit; and Issuance and Exchange of Clothing, Bedding and Towels. The review revealed 29 total deficiencies related to the remaining ten NDS: Detention Files (1); Environmental Health and Safety (4); Food Service (2); Medical Care (6); Recreation (1); StaffDetainee Communication (3); Suicide Prevention and Intervention (2); Terminal Illness, Advance Directives, and Death (2); Tool Control (5); and Use of Force (3). Of these deficiencies, 2 were corrected before the end of the review; the addressed deficiencies included medical consent forms (Medical Care), and the facility liaison visit checklist and telephone serviceability worksheet (Staff-Detainee Communication). Overall, ODO found SAJ to be in compliance with the standards areas inspected; however, deficiencies cited in half of the areas reviewed, including medical care, are of concern. Thorough staff-detainee interaction/communication is typically considered a key component and best practice of well run ICE detention facilities. Additionally, many of the identified deficiencies are within detention standards relating to security, health and safety. ODO did address these issues and concerns during the Closeout Brief on November 18th to best ensure that the facility and ERO staff would have the opportunity to initiate actions to expeditiously correct the deficiencies. Several deficiencies noted during this inspection warrant special mention. Under the Medical Care standard, concerns about maintaining detainee privacy, the cardiopulmonary resuscitation training of facility staff, and the communication of appropriate medical clearances for release, transfer, or removal, were of particular note. Five deficiencies identified regarding Tool Control raise security issues due to the potential use of tools as weapons, or as a means to facilitate escape. Further, under the Staff-Detainee Communication standard, there are two change orders from ERO HQ, dated June 2007, that have not been implemented by ICE Staff at SAJ. The
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Santa Ana Jail ERO Los Angeles, CA
ICE.11.5082.000874
change orders, which were intended to reduce and/or mitigate exposure to civil liability claims, ensure that medical, special management unit, and staff-detainee communication issues are not neglected. ODO reviewed local policies, food service logs, and inventory sheets, inspected storage areas, observed meal preparation and plating and delivery of food trays, and interviewed the Food Service Director. Overall the food service complied with the NDS; however, there were deficiencies regarding religious diet requests and medical examinations for food service employees. No detainees raised concerns or issues with regard to food quality and quantity. All deficiencies identified in this QAR refer to specific, relevant sections of the ICE NDS. Enforcement and Removal Operations (ERO) will be provided a copy of the report to assist in developing corrective actions to resolve the 24 identified deficiencies.

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ICE.11.5082.000875
INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS) or Performance Based National Detention Standards, as applicable. In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO reviewed the processes employed at SAJ to determine compliance with current policies and detention standards. Prior to the inspection, ODO collected and analyzed relevant allegations and detainee information from multiple ICE databases, including the Joint Integrity Case Management System (JICMS), the ENFORCE Alien Booking Module (EABM) and Alien Removal Module (EARM). ODO also gathered facility facts and inspection-related information from ERO headquarters staff to best prepare for the site visit at SAJ.
REPORT ORGANIZATION

Special Agent (Team Lead) Special Agent (A) Section Chief Special Agent Special Agent Contract Inspector Contract Inspector Contract Inspector ODO, Phoenix, AZ ODO, Phoenix, AZ ODO, Phoenix, AZ ODO, Houston, TX MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
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ICE.11.5082.000876
INTERNAL RELATIONS
ODO interviewed ICE and SAJ personnel. Facility management and assigned officers familiar with the ICE NDS reported SAJ met the level of care required by the ICE NDS, and reported a low number of detainee complaints and grievances. SAJ staff indicated they maintain a positive relationship with ICE, and morale is good. ICE supervisory personnel described the relationship with SAJ as good and positive. ICE management expressed concern about a lack of sufficient ICE ERO personnel and office space at the SAJ. SAJ and ICE management stated the current AFOD has too many tasks and additional DOs are needed because IEAs are doing jobs normally assigned to a DO. ICE personnel stated a lack of sufficient computers, scanners, printers, and ink hinders their ability to perform assigned duties.
DETAINEE RELATIONS
ODO randomly selected 20 detainees to interview to assess the detention conditions of RRJ. ODO encouraged detainees to express their opinions about the facility, staff, ICE personnel, and the progress of their cases. Some detainees stated they did not know their Deportation Officer or how to access the telephone system to make telephone calls. Female detainees complained about being confined to their rooms except when participating in recreation or self-help classes. One male detainee complained the facility does not have full-time dental staff. Another detainee expressed concerns with his personal medical care. No concerns or issues were expressed with regard to food quality and quantity, or recreation. ODO provided information to the detainees on how to contact ICE personnel. Overall, the majority of the detainees stated they were treated with dignity and respect.

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ICE.11.5082.000877

A total of 20 National Detention Standards were reviewed during the ODO inspection. The following 10 areas were found to be deficient with respect to adherence to the ICE NDS, as required: Detention Files Environmental Health and Safety Food Service Medical Care Recreation Staff-Detainee Communication Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death Tool Control Use of Force The following 10 standards were found to be well-managed: Access to Legal Material Admission and Release Detainee Grievance Procedures Detainee Handbook Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strike Issuance and Exchange of Clothing, Bedding and Towels Special Management Unit (Administrative Segregation) Special Management Unit (Disciplinary Segregation) As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.
Office of Professional Responsibility 5

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ICE.11.5082.000878

ODO reviewed the Detention Files standard at SAJ to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed 20 detention files and interviewed staff. SAJ retains the original documentation of the acknowledgement form indicating that the detainees received both the ICE and SAJ Detainee Handbooks; however, the required documentation is filed in the SAJ Classification Unit and not within the detention file (Deficiency DF-1). Otherwise, the files examined by ODO were in good order and complied with the NDS and ICE policies.

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B)(1)(g), the FOD must ensure the detainee detention file contains either originals or copies of forms and other documents generated during the admissions process. The file will also contain the following original documents, if used in the facility: Acknowledgment form, documenting receipt of handbook, orientation, locker key, etc.

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ICE.11.5082.000879

ODO reviewed the Environmental Health and Safety standard at SAJ to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical management, and fire drills. Overall, ODO found compliance with the standard. Material Safety Data Sheets (MSDS) are maintained as required. Monthly fire drills were conducted on each shift and documentation is maintained by the safety officer. Reports for water testing and pest control were current. Facility sanitation is maintained at a high level. Material Safety Data Sheets (MSDS) are up to date for all substances in all areas; however, running inventories of hazardous substances are not maintained in the housing units (Deficiency EH&S-1). Maintaining strict accountability of all hazardous substances protects detainees, staff and visitors. ODO observed lighted Exit signs in place throughout the facility in accordance with NFPA; however, exit diagrams and evacuation route instructions were posted only in stairwells and were not available in housing units and hallways (Deficiency EH&S-2). Barber operations are conducted in the dayrooms of living areas (Deficiency EH&S-3). Observation of barbering practices revealed clippers are not properly cleaned and sanitized between use on detainees (Deficiency EH&S-4). Adherence to sanitation regulations is critical to minimizing the risk of cross-contamination related to use of shared hair care equipment.

DEFICIENCY EH&S-1 In accordance with ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of hazardous substances used and stored in that area. DEFICIENCY EH&S-2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(3)(h), the FOD must ensure exit diagrams are conspicuously posted in each area. DEFICIENCY EH&S-3 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barber operation is located in a separate room not used for any other purpose.

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ICE.11.5082.000880
DEFICIENCY EH&S-4 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(3), the FOD must ensure all hair care tools coming into contact with the detainees are cleaned and effectively disinfected.

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FOOD SERVICE (FS)

ODO reviewed the Food Service standard at SAJ to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed local policies, food service logs, and inventory sheets, inspected storage areas, observed meal preparation and plating and delivery of food trays, and interviewed the Food Service Director. Overall the food service complied with the NDS; however, there were deficiencies regarding religious diet requests and medical examinations for food service employees. No detainees raised concerns or issues with regard to food quality and quantity. ODO noted there were no documented instances of complaints by detainees regarding religious diets, but the ODO inspection revealed that religious diet requests are not reviewed and approved by a Chaplain (Deficiency FS-1). SAJ does not employ inmates or ICE detainees in the Food Service Department. All work associated with preparing meals and sanitation in the kitchen is performed by contractor Aramark. There was no documentation of pre-employment medical examinations for food service employees, and Aramark was unaware of the requirement (Deficiency FS-2).

DEFICIENCY FS-1 In accordance with the ICE NDS, Food Service, section (III)(E)(1), the FOD must ensure detainees whose religious beliefs require adherence to particular dietary laws will be referred to the Chaplain. After verifying the religious dietary requirement by reviewing files and\or consulting with local religious representatives, the Chaplain will issue specific written instructions. Special diets will be kept simple, as much like the food served on the main line as possible. DEFICIENCY FS-2 In accordance with the ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel (both staff and detainee) shall receive a pre-employment medical examination. The purpose of this examination is to exclude those who have a communicable disease in any transmissible stage or condition. Detainees who have been absent from work for any length of time for reasons of communicable illness (including diarrhea) shall be referred to Health Services for a determination as to fitness for duty prior to resuming work.

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ICE.11.5082.000882
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at SAJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the clinic, observed intake screening, interviewed staff, and reviewed the medical policies and procedures, 23 medical records, and medical staff credentials. Healthcare is provided by Correctional Managed Care Medical Corporation and administered by a Director of Operations (DOO) who is not a clinician. The jail holds no accreditations. Overall, ODO found healthcare services to be adequate. The clinic is sufficiently staffed to meet detainee needs and staff holds proper credentials. Initial intake screening and physical examinations are performed in a timely manner and in accordance with the standard. Deficiencies in six components of the standard were identified. Initial intake screening is performed by correctional staff who have had specialized training to perform this function. ODO verified training in all cases reviewed. The screening interview is conducted in the hallway in the presence of other detainees or inmates (Deficiency MC-1). This practice allows virtually no privacy and may discourage disclosure of important medical information. Upon completion of the screening, the Santa Ana Jail Medical/Mental Pre-Screening form is filed in the detention file (Deficiency MC-2). Inclusion in the detention file allows access to medical information by non-medical personnel. Detainees access health care services by submitting sick call requests to housing unit officers, who enter the information from the requests in a computer system. The nursing staff then accesses this information on a daily basis, triages the complaint, and schedules the detainee for sick call. While ODO verified the sick call system allows for timely triage and follow-up, patient confidentiality is violated by correctional officers access to medical information as documented on the forms (Deficiency MC-3). ODOs review of ten detention staff training files found there was no documentation of current cardiopulmonary (CPR) certification in three of the ten, or 33% of the files. Per administrative staff, detention officers are not required to maintain CPR certification (Deficiency MC-4). Review of medical records revealed consent forms were missing or signed after medical treatment was rendered in seven of 23, or 30% of cases (Deficiency MC-5). In one case, the consent form was signed four months after the detainees arrival. Informed consent is required by the NDS to ensure medical treatment is not provided against a detainees will. ODO was informed the DDO has already put in place an improved admission process to correct this deficiency.

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ICE.11.5082.000883
A medical/psychiatric alert mechanism is not used when the medical staff determines a detainees medical or psychiatric condition requires medical clearance prior to release or transfer or to indicate the need for a medical escort during transfer or deportation (Deficiency MC-6). ODO recommends development of an alert mechanism to ensure continuity of care for detainees with special medical or mental health needs.

DEFICIENCY MC-1 In accordance with ICE NDS, Medical Care, section (III)(B), the FOD must ensure detention facilities provide adequate areas and equipment so that detainees are afforded privacy. DEFICIENCY MC-2 In accordance with ICE NDS Medical Care, section (III)(B), the FOD must ensure medical records are maintained separate from detainee records. DEFICIENCY MC-3 In accordance with ICE NDS, Medical Care, section (III)(M) the FOD must ensure medical providers protect the privacy of detainees medical information to the extent possible. DEFICIENCY MC-4 In accordance with ICE NDS, Medical Care, section (III)(H) the FOD must ensure detention staff receive CPR training. DEFICIENCY MC-5 In accordance with ICE NDS, Medical Care, section (III)(L) the FOD must ensure consent forms are signed and dated before any examination or treatment is rendered, except in emergency circumstances. DEFICIENCY MC-6 In accordance with ICE NDS, Medical Care, section (III)(N), the FOD must ensure the OIC is notified in writing when medical staff determines a detainees medical or psychiatric condition requires either clearance by the medical staff prior to release or transfer, or requires medical escort during deportation or transfer.

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ICE.11.5082.000884
RECREATION (R)
ODO reviewed the Recreation standard at SAJ to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO reviewed local policies and procedures, observed recreation areas, and interviewed staff and detainees. ODO observed that SAJ exceeds the requirements prescribed by the Recreation standard. Detainees have all day access to the recreation yard when they are in their assigned dorms as each dorm has its own outdoor recreation yard attached. Playing cards and board games are also available for detainee recreation. While no detainees raised concerns or issues with regard to recreation, ODO noted that SAJ does not have a staff member responsible for the development and oversight of the recreation program (Deficiency R-1).


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ICE.11.5082.000885

ODO reviewed the Staff-Detainee Communication (SDC) standard at SAJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed logbooks, detention files, the detainee handbook, local policy and procedures, and interviewed ERO officers and detainees. ODO has historically observed that facilities in which ICE has a permanent or a part-time daily presence, detainee requests and concerns are addressed in a more timely manner, thereby resulting in a general climate of decreased detainee anxiety levels and negativity, including fewer behavioral issues. Along with a thorough and universally available detainee handbook, vibrant and healthy staff-detainee communications is a key component to a wellmaintained detention environment. ERO has no permanent staff assigned to SAJ; however, ERO has an AFOD, a SDDO, two DOs, and three IEAs assigned to a sub-office located within two city blocks of SAJ. ERO department heads do not conduct regular unannounced visits to the facilitys living and activity areas. While ERO staff stated they conduct visits to the housing areas to address the personal concerns of detainees and to monitor living conditions, these visits are not documented by ICE staff (Deficiency SDC-1). Nothing is posted advising detainees of when to expect a scheduled visit by a Deportation Officer (DO) to the housing units, or which DO is assigned to their case (Deficiency SDC-2). The facility does not complete the Facility Liaison Visit Checklist and the Telephone Serviceability Worksheet as required in Change Orders, both dated June 15, 2007. SAJ and ERO management stated they were unaware of the Change Orders to the Staff-Detainee Communication Standard of the ICE NDS. SAJ management took immediate steps to implement the change orders (Deficiency SDC-3).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communications, section (III)(A)(1), the FOD must ensure policy and procedures shall be in place to ensure and document that the ICE Officer in Charge (OIC), the Assistant Officer in Charge (AOIC) and designated department heads conduct regular unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees and informally observing living and working conditions. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communications, section (III)(A)(2)(b), the FOD shall devise a written schedule and procedure for weekly detainee visits by District ICE
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ICE.11.5082.000886
detention and deportation staff. The ICE officer will also visit the facilitys Special Management Units (SMU) to interview any ICE detainees housed there, monitor housing conditions, review detainees classification and basis for placement in the SMU, and review all records in this regard. Written schedules shall be developed and posted in the detainee living areas and other areas with detainee access. The FOD must have specific procedures for documenting the visit. DEFICIENCY SDC-3 In accordance with the Change Notice to the ICE NDS, Staff-Detainee Communication, dated June 15, 2007, the FOD must ensure that in Inter-Governmental Service Agreements (IGSAs) facilities housing ICE Detainees the model protocol should be completed weekly for regularly used facilities and each visit for facilities that are used intermittently. In addition, all model protocol forms shall be submitted annually with the Annual Detention Reviews.

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ICE.11.5082.000887

ODO reviewed the Suicide Prevention and Intervention standard at SAJ to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO reviewed local Suicide Prevention policies and ten staff training records, and interviewed medical staff and the training manager. No detainee suicide watch medical records were available for review. Staff could not recall any detainees being placed on suicide watch and informed ODO archived records are stored off-site. ODO verified detainees are screened for suicide potential during the intake process. All staff receives initial and ongoing suicide prevention training which includes the identification of suicide risk factors, recognizing the signs of suicidal thinking and behavior, referral procedures, suicide prevention techniques, and responding to an in-progress suicide attempt. Deficiencies in two components of the standard were identified. There are two suicide prevention policies in place, a Health Services policy revised December 2009, and a jail policy dated February 12, 2003. Neither meets all ICE NDS requirements. The jail policy does not address ICE notification procedures in the event a detainee is diagnosed as suicidal or requires special housing for suicide risk (Deficiency SP&I-1). Additionally, the jail policy states the initiating discipline, detention or medical staff, may remove detainees from suicide watch (Deficiency SP&I-2). The DDO informed ODO the policy is inaccurate, indicating that in practice, medical staff is involved in the decision-making process to remove a detainee from suicide watch. Because there were no medical records available for review, ODO could not verify removal from suicide watch is consistently under sole authority of medical personnel. It is critical that the determination a detainee is no longer suicidal and may be removed from suicide watch is made by persons with proper clinical authority. ODO recommends revision of the SAJ policy accordingly.

DEFICIENCY SP&I-1 In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD must ensure the OIC reports to ICE any detainees clinically diagnosed as suicidal or requiring special housing for suicide risk. DEFICIENCY SP&I-2 In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD must ensure detainees on suicide watch are returned to general population written authorization from the Clinical Director.

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ICE.11.5082.000888

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donations, at SAJ to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO interviewed medical staff and reviewed policies and procedures. There have been no detainee deaths within the last year. ODO was informed SAJ does not accept terminally ill detainees, therefore, there is no policy addressing death by any means (Deficiency TIADD-1). Additionally, SAJ does not have a policy addressing notification of ICE when a detainee becomes seriously injured or ill (Deficiency TIADD-2). Though terminally ill detainees are not accepted by SAJ, ODO recommends development of policies addressing procedures to be followed in the event a detainee becomes seriously injured or ill, or in the event of a sudden death. Two local policies address Do Not Resuscitate (DNR) orders and organ donations. The DNR policy does not address notification of the ICE Health Services Corps medical director and the ICE General Counsel at the time a DNR order has been filed in the medical record (Deficiency TIADD-3). Because SAJ does not hold terminally ill detainees, these policies do not reference applicability to the ICE detainee population. ODO recommends revision to support compliance with the standard. STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS DEFICIENCY TIADD-1 In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure detention facilities have policies and procedures addressing the issues of terminal illness, fatal injury, advance directives and detainee death. DEFICIENCY TIADD-2 In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(A)(4), the FOD must ensure a detention facility immediately notifies ICE when a detainee is seriously injured or ill. DEFICIENCY TIADD-3 In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section (III)(C), the FOD must ensure detention facilities notify the IHS medical director and the ICE General Counsel if the name and circumstances of any detainee for whom a DNR order has been filed in the medical record.

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ICE.11.5082.000889
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at SAJ to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO observed all areas where tools are maintained, reviewed policies, and interviewed staff.
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ICE.11.5082.000890
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Office of Professional Responsibility November 2010

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ICE.11.5082.000891
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at SAJ to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO interviewed staff and reviewed local policy, training records, and use of force documentation.
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ICE.11.5082.000892
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ICE.11.5082.000893
LIST OF ACRONYMS
ACA COTR CXR DIHS DOS DSCU EABM ERO EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU TAR TB UDC American Correctional Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement and Removal Operations Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee

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ICE.11.5082.000894


Quality Assurance Review Enforcement and Removal Operations Detroit Field Office Seneca County Jail Tiffin, Ohio
July 20-22, 2010
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ICE.11.5082.000895
ICE.11.5082.000896
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QUALITY ASSURANCE REVIEW SENECA COUNTY JAIL DETROIT FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization.. 3 Inspection Team Members... 3 BACKGROUND History.. 5 OPERATIONAL ENVIRONMENT Internal Relations 7 Detainee Relations. 7 Area of Concern. 7 ICE NATIONAL DETENTION STANDARDS National Detention Standards Reviewed. 9 Access to Legal Material... 10 Admission and Release. 11 Detainee Grievance Procedures.. 13 Detainee Handbook 14 Detention Files 15 Disciplinary Policy.. 16 Environmental Health and Safety 17 Food Service.. 20 Funds and Personal Property. 21 Medical Care. 22 Population Counts 24 Special Management Unit 25 Staff-Detainee Communication.. 26 Suicide Prevention and Intervention.. 27 Terminal Illness, Advance Directives, and Death 28 Tool Control... 29 Use of Force. 30 Visitation 31 APPENDIX ACRONYMS SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS A B
ICE.11.5082.000898
ICE.11.5082.000899
INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of the Seneca County Jail (SCJ) in Tiffin, Ohio, on July 20-22, 2010. ODO reviewed the processes employed at DCDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION

Team Leader Special Agent Special Agent Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Houston ODO, Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
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ICE.11.5082.000900
Seneca County Jail ERO Detroit, MI

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ICE.11.5082.000901
BACKGROUND
HISTORY
ICE utilizes the SCJ under an ICE Intergovernmental Service Agreement (IGSA). SCJ opened in May 1994, and is owned and operated by the Seneca County Commissioners (SCC). SCJ is authorized to houses adult male and female detainees of all classification levels, over 72 hours. Juvenile detainees are not housed at the facility. The total SCJ housing capacity for ICE detainees is 150. Medical services are provided by two Licensed Practical Nurses (LPN) employed by the SCJ and two physicians employed by the SCC. Food Service is provided by the Seneca County Sheriff Department. The ERO Detroit field office does not have personnel located at SCJ. There is a Supervisory Detention and Deportation Officer (SDDO) and an Immigration Enforcement Agent (IEA) assigned to SCJ on a ninety-day rotation. The total number of facility staff (non-ICE) employed at SCJ is 54. The ERO Detention Standards Compliance Unit contractors, MGT of America, Inc. conducted an annual review of the ICE NDS at SCJ in November 2009; the facility received an Acceptable rating. SCJ does not hold any special accreditations.
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ICE.11.5082.000902
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INTERNAL RELATIONS
ODO interviewed supervisory and nonsupervisory ICE and SCJ personnel. ICE supervisory personnel described the positive working relationship exists between ICE and SCJ. Overall, ICE and SCJ staff expressed morale as high.
DETAINEE RELATIONS
ODO interviewed eleven ICE detainees at SCJ. The three common complaints focused on food service, medical services, and staff-detainee communication. Several detainees complained about the portion size and lack of variety of food. In many instances, detainees did not know the identity of, or how to contact the deportation officer handling their case. Some detainees stated the medical care at SCJ could be improved, but added that the medical staff is doing the best they can and that the previous nurse was unprofessional.
AREA OF CONCERN
Female detainees complained they are verbally harassed by county inmates during outdoor recreation. Female detainees stated they often bypass outdoor recreation to avoid being harassed. This issue was brought to the attention of the SCJ Warden.

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ICE.11.5082.000904

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ICE.11.5082.000905

This inspection was based on the 2000 NDS. The following 22 standards were reviewed: Access to Legal Material Admission and Release Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Medical Care Population Counts Recreation Special Management Unit Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Use of Force Visitation No deficiencies were noted in the following four standards: Hold Rooms in Detention Facilities Hunger Strikes Recreation Telephone Access As these standards were compliant at the time of this review, a synopsis for these areas was not prepared for this report.

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ICE.11.5082.000906

ODO reviewed the Access to Legal Material standard at SCJ to determine if detainees have access to a law library, legal materials, courts, counsel and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed policies, procedures, and the detainee handbook, inspected the law library, and interviewed staff and detainees. At the time of the inspection, ODO observed that one of the three computers detainees use for legal research had a malfunctioning CD drive and therefore, LexisNexis could not be updated on that computer. ICE was aware of the malfunctioning computer, and advised arrangements were made for its repair (Deficiency ALM-1). The SCJ detainee handbook does not address the rules and procedures governing access to legal materials. The information is also not posted in the law library (Deficiency ALM-2).

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare documents for legal proceedings. The facility must designate an employee with responsibility to inspect the equipment at least weekly to ensure it is in good working order, and to stock sufficient office supplies. DEFICIENCY ALM-2 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for detainee use; 2) scheduled hours of access to the law library; 3) procedures for requesting access to the law library; 4) procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) procedures for requesting legal reference materials not maintained in the law library; and 6) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

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ICE.11.5082.000907

ODO reviewed the Admission and Release standard at SCJ to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed policies and files, observed the admission process, and interviewed staff and detainees. Interview of SCJ staff revealed the facility orientation process did not include a video informing new arrivals about facility operations, programs, services, and prohibited activities and associated sanctions (Deficiency AR-1). Interviews with staff and detainees, and review of detention files revealed some detainees had not received the national detainee handbook upon their arrival as it was not available for a period of time. The national handbook was distributed to detainees on June 2, 2010, and thereafter (Deficiency AR-2 and DH-1). A review of detention files revealed two Order to Detain or Release (Form I-203) forms lacking appropriate official signatures. Several archived files also lacked Form I-203 with official signatures authorizing release (Deficiency AR-3) . Report of Detainees Missing Property (Form I-387) is not utilized to report claims of missing property to ICE (Deficiency AR-4). Fingerprints are not obtained prior to the release, removal, or transfer of detainees (Deficiency AR-5).

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(A)(1), the FOD must ensure the orientation process, supported by a video (ICE) and handbook, informs new arrivals about facility operations, programs, and services. Subjects covered will include prohibited activities and the associated sanctions. DEFICIENCY AR-2 and DH-1 In accordance with the ICE NDS, Admission and Release, section (III)(K), the FOD must ensure, upon admission, every detainee receives a detainee handbook. It will fully describe all policies, procedures, and rules in effect at the facility, in accordance with the Detainee Handbook standard. In accordance with the ICE NDS, Detainee Handbook, section (I), the FOD must ensure every OIC develops a site-specific handbook to serve as an overview of, and guide to, the detention policies, rules, and procedures in effect at the facility. The handbook will also describe the services, programs, and opportunities available through various sources, including the facility, ICE, private organizations, etc. Every detainee will receive a copy of this handbook upon admission to the facility.

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ICE.11.5082.000908
DEFICIENCY AR-3 In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an Order to Detain or Release (Form I-203 or I-203a) bearing the appropriate official signature accompanies the newly arriving detainee. DEFICIENCY AR-4 In accordance with the ICE NDS, Admission and Release, section (III)(I), the FOD must ensure officers complete a Report of Detainees Missing Property (Form I-387) when any newly arrived detainee claims his/her property has been lost or left behind. IGSA facilities will forward the completed Form I-387s to ICE. DEFICIENCY AR-5 In accordance with the ICE NDS, Admission and Release, section (III)(L), the FOD must ensure staff completes certain procedures before any detainees release, removal, or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting, returning personal property, and reclaiming facility-issued clothing, bedding, etc.

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ICE.11.5082.000909

ODO reviewed the Detainee Grievance Procedure standard at SCJ to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO visited housing areas, interviewed staff and detainees, and reviewed policies, procedures, the detainee handbook, detention files, and grievance logs. The facility has not implemented procedures for identifying and handling emergency grievances (Deficiency DGP-1).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure each facility implements procedures for identifying and handling emergency grievances. An emergency grievance involves an immediate threat to a detainees safety or welfare. Once the receiving staff member approached by a detainee determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures will apply.

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ICE.11.5082.000910

ODO reviewed the Detainee Handbook standard at SCJ to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO interviewed staff and detainees and reviewed the detainee handbook, detention files, policies, and training records. Interviews with staff and detainees, and review of detention files revealed that some detainees had not received the national detainee handbook upon their arrival. The national handbook was not available for a period of time, but it was distributed on June 2, 2010, and thereafter (Deficiency DH-1 and AR-2). The detainee handbook does not provide procedures for filing a claim for lost or damaged property or rules for storing or mailing property (Deficiency DH-2 and F&PP-2).

DEFICIENCY DH-1 and AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(K), the FOD must ensure, upon admission, every detainee receives a detainee handbook. It will fully describe all policies, procedures, and rules in effect at the facility, in accordance with the Detainee Handbook standard. In accordance with the ICE NDS, Detainee Handbook, section (I), the FOD must ensure every OIC develops a site-specific handbook to serve as an overview of, and guide to, the detention policies, rules, and procedures in effect at the facility. The handbook will also describe the services, programs, and opportunities available through various sources, including the facility, ICE, private organizations, etc. Every detainee will receive a copy of this handbook upon admission to the facility. DEFICIENCY DH-2 and F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, notifies the detainees of facility policies and procedures concerning personal property, including: rules for storing or mailing property not allowed in their possession, and procedures for filing a claim for lost or damaged property.

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ICE.11.5082.000911

ODO reviewed the Detention Files standard at SCJ to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files and policies, toured the admissions and release area, and interviewed staff. The officer completing the admissions portion of the detention file does not make a notation indicating the file has been activated (Deficiency DF-1). Releasing officers did not always add closed-out property and valuable receipt forms to the detention file prior to a detainees release (Deficiency DF-2). Releasing officers did not notate the detention file was complete and ready for archiving (Deficiency DF-3). Interviews with SCJ and ICE staff revealed the local ICE field office does not create and maintain detention files, and SCJ does not forward all documents relating to an individuals detention to ICE for inclusion in the detention file (Deficiency DF-4).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(A)(2), the FOD must ensure the officer completing the admissions portion of the detention file will note that the file has been activated. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(E)(2), the FOD must ensure staff inserts into the released detainees file copies of completed release documents, the original closed-out receipts for property and valuables, the original Form I-385, and other documentation. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(E)(3), the FOD must ensure the officer closing the detention file makes a notation (on the acknowledgement form, if applicable) that the file is complete and ready for archiving. DEFICIENCY DF-4 In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office with IGSA-facility jurisdiction creates and maintains detention files on all detainees admitted to IGSA facilities. These files must contain the same material (forms and other documents) as SPC/CDF detention files to the extent possible, given that they are created by the field office. For example, if the field office takes and holds detainee property, the detention file must contain the G-589s and I-77s. The file must also contain copies of all I-203s and the G-385 related to the alien. The IGSA must forward all documents relating to the individuals detention to the ICE field office of jurisdiction for inclusion in the detention file.
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ICE.11.5082.000912

ODO reviewed the Disciplinary Policy at SCJ to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO interviewed staff and reviewed policies, disciplinary records, and the SCJ detainee handbook. The disciplinary and appeal processes are not addressed in the SCJ detainee handbook (Deficiency DP-1).

DEFICIENCY DP-1 In accordance with ICE NDS, Disciplinary Policy, section (III)(L)(1)(3), the FOD must ensure the Detainee Handbook or equivalent, notifies detainees of the disciplinary process and the procedure for appealing disciplinary findings.

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ICE.11.5082.000913

ODO reviewed the Environmental Health and Safety standard at SCJ to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed chemical inventories, Material Safety Data Sheets (MSDS), master index of hazardous substances, and documentation of fire and safety inspections, fire drills, water and generator testing, and vermin and pest control. ODO found no inventory or MSDS for five 25-pound boxes of laundry detergent stored in a sanitation closet (Deficiency EH&S-1). Weekly fire and safety inspections are not conducted by a qualified staff member. ODO was informed the inspections are conducted by a firefighter; however, no documentation of training or certification was provided. Monthly and weekly fire and safety inspections are not properly documented and forwarded to the Officer in Charge (OIC) (Deficiency EH&S-2). The facilitys fire prevention, control, and evacuation policy does not address monthly inspections or exit signs with directional arrows (Deficiency EH&S-3). Emergency key drills are not conducted (Deficiency EH&S-4). Exit diagrams do not provide instructions in Spanish (Deficiency EH&S-5). The facility has no barbershop; instead, detainees are allowed the use of a barbers box within housing areas on designated days. Hair care sanitation regulations are not posted or observed (Deficiency EH&S-6). The sanitary conditions of the medical unit restroom were poor. There was no hand soap or sanitizer available in the medical unit restroom or the detainee restroom in food service (Deficiency EH&S-7). SCJ does not dispose of infectious and bio-hazardous waste in accordance with federal and state law (Deficiency EH&S-8). The locking devices on SCJs H-unit doors were not equipped to function when pressure is applied from inside the room. The locks functioned with keys only, preventing prompt egress in the event of an emergency (Deficiency EH&S-9).

DEFICIENCY EH&S -1 In accordance with ICE NDS, Environmental Health and Safety, section (III)(A)(B), the FOD must ensure facilities maintain a running inventory of the hazardous (flammable, toxic, or caustic) substances used and stored in that area. Every area using hazardous substances will maintain a self contained file of the corresponding MSDS.

(b)(7)e
17
ICE.11.5082.000914
DEFICIENCY EH&S-2 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure a qualified departmental staff member conducts weekly fire and safety inspections. Maintenance (safety) staff must conduct monthly inspections. Written reports of the inspection will be forwarded to the OIC for review, and if necessary, corrective action determinations. The Maintenance Supervisor or designate will maintain inspection reports and records of corrective action in the safety office. DEFICIENCY EH&S-3 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(3)(e)(g), the FOD must ensure every institution develops a fire prevention, control, and evacuation plan to include, among other things, monthly fire inspections, and exit signs and directional arrows for traffic flow. DEFICIENCY EH&S-4 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure monthly fire drills include timed emergency key drills. Emergency keys must be drawn and used by the appropriate staff to unlock one set of emergency exit doors not in daily use. National Fire Protection Association (NFPA) recommends a limit of four-and-one-half minutes for drawing keys and unlocking emergency doors. DEFICIENCY EH&S-5 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD must ensure existing exit signs provide instructions in English and Spanish. DEFICIENCY EH&S-6 In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1-4), the FOD must ensure the sanitation of barber operations is maintained by adhering to specified standards, including locating barber operations in a separate room not used for any other purpose; equipping the barbershop as necessary to maintain sanitary procedures of hair care; cleaning and disinfecting all hair care tools between use on detainees; and posting of hair care sanitation regulations in a conspicuous location for use by all hair care personnel and detainees. DEFICIENCY EH&S-7 In accordance with ICE NDS, Environmental Health and Safety, section (III)(R)(1)(2), the FOD must ensure environmental health conditions are maintained at a level that meets recognized standards of hygiene. Responsibility for ensuring the cleanliness of the medical facility lies with the Health Services Administer (HSA), or with the individual designated by the HSA or other health care provider. The HSA or designee must make a daily visual inspection of the medical facility, noting conditions of the floors, walls windows, horizontal surfaces, and equipment.
18
(b)(7)e
ICE.11.5082.000915
DEFICIENCY EH&S-8 In accordance with ICE NDS, Environmental Health and Safety, section (III)(R)(5), the FOD must ensure infectious and hazardous waste generated at a medical facility is stored and disposed of in accordance with all applicable federal and state regulations. DEFICIENCY EH&S-9 In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(1), the FOD must ensure facilities comply with standards issued by EPA and OSHA, ACA mandatory standards, and local and national fire and safety codes. In accordance with ICE NDS, Key and Lock Control, section (III)(B)(4)(f), the FOD must ensure entrance/exit door locks of housing units, work areas, chapels, gyms, and other areas with the room capacity of 50 or more people meet the standards specified in the Occupational Safety and Environmental Health Manual (chapter 3) and in the NFPA life safety code (#101). Specifically, doors must be equipped with prison-type locking devices modified to function when pressure is applied from inside the room. Panichardware is an acceptable alternative to the prison-type locking device.
19
(b)(7)e
ICE.11.5082.000916
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at SCJ to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed policies and relevant documentation. There is no documentation of pre-employment medical examinations for detainees assigned to work in food service (Deficiency FS-1). The detainee/inmate lavatory was not equipped with a soap dispenser (Deficiency FS-2 and EH&S-7). ODO discovered open dispensing units for chemicals used in the laundry area are stored in a room also used to store food items (Deficiency FS-3).

DEFICIENCY FS-1 In accordance with ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel (both staff and detainee) receive pre-employment medical examinations. DEFICIENCY FS-2 In accordance with ICE NDS, Food Service, section (III)(H)(9)(c), the FOD must ensure soap or detergent, and paper towels or a hand-drying device providing heated air, is available at all times in each lavatory. DEFICIENCY FS-3 In accordance with ICE NDS, Food Service, section (III)(H)(11)(c)(1), the FOD must ensure all toxic, flammable, and caustic materials are segregated from food products and stored in a locked and labeled cabinet or room. Cleaning and sanitizing compounds must be stored apart from food products.
20
(b)(7)e
ICE.11.5082.000917

ODO reviewed the Funds and Personal Property standard at SCJ to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed policies and detention files, and interviewed staff. The detainee handbook does not provide procedures for filing a claim for lost or damaged property or rules for storing or mailing property (Deficiency F&PP-1 and DH-2).

DEFICIENCY F&PP-1 AND DH-2 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, notifies the detainees of facility policies and procedures concerning personal property, including: rules for storing or mailing property not allowed in their possession, and procedures for filing a claim for lost or damaged property.
21
(b)(7)e
ICE.11.5082.000918
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at SCJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the clinic, interviewed staff, and reviewed 26 medical records, medical staff credentials, and medical policies and procedures. The clinic is operated by the SCJ and holds no accreditations. ODO found clinic staffing inadequate (Deficiency MC-1). Two physicians provide services once a week for four hours each. No mid-level providers are used. The clinic is administered by a Licensed Practical Nurse (LPN) who has held the position for 11 years and is National Commission on Correctional Healthcare certified. SCJ has one other medical staff member, also an LPN, who started on April 19, 2010. Responsibility for the clinic was delegated to the new LPN on May 24, 2010, when the administrator began an extended period of medical leave. The sole LPN has provided nursing coverage and handled administrative responsibilities without any time off during this period. An additional nurse position would allow coverage on the off-shifts, weekends, holidays, and during staff leave, ensuring there are no gaps in service. ODO discovered 31 percent of medical records reviewed did not contain signed consent for treatment forms (Deficiency MC-2). Completed sick call request forms are turned in to the nurse during medication pass, or given to correctional officers to forward to the clinic (Deficiency MC-3). There is no process to alert ICE and SCJ staff when medical staff determines a detainees medical or psychiatric condition requires either clearance by the medical staff prior to release or transfer, or a medical escort during deportation or transfer (Deficiency MC-4).

DEFICIENCY MC-1 In accordance with ICE NDS, Medical Care, section (lll)(A), the FOD must ensure detention facilities employ, at a minimum, a medical staff large enough to perform basic examinations and treatments for all detainees. DEFICIENCY MC-2 In accordance with ICE NDS, Medical Care, section (lll)(L), the FOD must ensure consent forms are signed prior to any medical examination or treatment, except in emergency circumstances. DEFICIENCY MC-3 In accordance with ICE NDS, Medical Care, section (lll)(M), the FOD must ensure the privacy of detainees medical information is maintained to the extent possible while permitting the exchange of health information required to fulfill program responsibilities and provide for the well being of detainees.
(b)(7)e
22
ICE.11.5082.000919
DEFICIENCY MC-4 In accordance with ICE NDS, Medical Care, section (lll)(N), the FOD must ensure the OIC is notified when medical staff determines that a detainees medical or psychiatric condition requires either clearance by medical staff prior to release or transfer, or medical escort during deportation or transfer.
23
(b)(7)e
ICE.11.5082.000920

ODO reviewed the Population Counts standard at SCJ to determine if the facility has an effective system of conducting population counts, which ensures detainee accountability, in accordance with the ICE NDS. ODO reviewed policies, inspected training records, and observed a formal count in a housing area and the control room. There was no documentation supporting verification by supervisors of count accuracy (Deficiency PC-1).

DEFICIENCY PC-1 In accordance with ICE NDS, Population Counts, section (III)(A), the FOD must ensure formal counts are conducted at specific times of day or night in a predetermined manner. A formal count should be conducted at least once per shift, with a supervisor verifying its accuracy.

(b)(7)e
24
ICE.11.5082.000921

ODO reviewed the Special Management Unit standard at SCJ to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. ODO interviewed staff, inspected the SMU, and reviewed policies, procedures, SMU logs, and pertinent documentation.
(b)(7)e
(b)(7)e
25
(b)(7)e
ICE.11.5082.000922

ODO reviewed the Staff-Detainee Communication standard at SCJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed policies, procedures, and logbooks, and interviewed staff and detainees. The detainee request logbook, which documents requests made to ICE, did not contain the detainees nationality, name of the officer logging the request, or the date ICE responded (Deficiency SDC-1). The ICE detainee request logbook showed that requests are not consistently responded to within 72 hours (Deficiency SDC-2).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all detainee requests are recorded in a logbook for that specific purpose. The logbook, at a minimum, must contain: a) date the detainee request was received; b) detainees name; c) A-number; d) nationality; e) officer logging the request; f) date the request, with staff response and action, is returned to the detainee; and g) any other site-specific, pertinent information. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communications, section (III)(B)(1)(b), the FOD must ensure detainee requests are forwarded to the ICE office of jurisdiction within 72 hours and answered as soon as possible and practicable, but not later than within 72 hours from receiving the request. If it is apparent that the request is serious in nature, procedures must be in place for an expedited review and response to the detainees request.
26
(b)(7)e
ICE.11.5082.000923

ODO reviewed the Suicide Prevention and Intervention standard at SCJ to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO reviewed the suicide prevention policy and ten staff training records, inspected the room used for suicide watch, and interviewed staff. No recent detainee suicide watches were documented. The suicide prevention policy is in place and current. The policy allows nurses to discontinue or change watch status (Deficiency SP&I-1).

DEFICIENCY SP&I-1 In accordance with ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure detainees under suicide watch are returned to general population upon written authorization by the Medical Director.

(b)(7)e
27
ICE.11.5082.000924

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do-Not-Resuscitate (DNR) orders and organ donations, at SCJ to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO interviewed medical staff and reviewed policies and procedures. No detainee deaths have occurred within the past year. A comprehensive local policy is in place and current. The policy limits the authority to the Seneca County Coroner to order an autopsy (Deficiency TIADD-1).

DEFICIENCY TIADD-1 In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section (llI)(J), the FOD must ensure facilities authorize the FBI, local coroner, or United States Public Health Service (USPHS) to order an autopsy in cases involving homicide, suicide, fatal illness, accident, or unexplained death; and authorize DIHS to order an autopsy for other cases, with the written consent of a person authorized under State law to give such consent.
28
(b)(7)e
ICE.11.5082.000925
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at SCJ to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with ICE NDS. ODO reviewed policies, interviewed staff, and inspected all areas where tools are stored and maintained.
(b)(7)e
(b)(7)e
29
(b)(7)e
ICE.11.5082.000926
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at the SCJ to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO interviewed staff and reviewed policies, training records, use of force documentation, and video recordings.
(b)(7)e
(b)(7)e

(b)(7)e
30
ICE.11.5082.000927
VISITATION (V)
ODO reviewed the Visitation standard at SCJ to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with ICE NDS. ODO observed the visiting areas, interviewed staff and detainees, and reviewed policies, detainee handbook, and visitor logs. Detainees housed in disciplinary segregation may only receive visits only from legal representatives (Deficiency V-1). The Notice of Entry of Appearance as Attorney or Representative, Form G-28, is not available in the legal visitors reception area (Deficiency V-2). SCJ policy does not address whether animals may accompany human visitors into the facility, and if so, under what circumstances (Deficiency V-3).

DEFICIENCY V-1 In accordance with ICE NDS, Visitation, section (III)(H)(5), the FOD must ensure a detainee ordinarily retains visiting privileges while in administrative or disciplinary segregation status. DEFICIENCY V-2 In accordance with ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitors reception area. DEFICIENCY V-3 In accordance with ICE NDS, Visitation, section (III)(O)(4), the FOD must ensure each facility establishes and disseminates a policy and implements procedures governing whether, and if so, under what circumstances animals may accompany human visitors onto or into facility property.

(b)(7)e
31
ICE.11.5082.000928
APPENDIX A
Acronyms
32
(b)(7)e
ICE.11.5082.000929
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare 10 documents for legal proceedings. The facility must designate an employee with responsibility to inspect the equipment at least weekly to ensure it is in good working order, and to stock sufficient office supplies. In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) a law library is available for detainee use; 2) scheduled hours of access to the law library; 3) procedures for requesting access to the law library; 10 4) procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) procedures for requesting legal reference materials not maintained in the law library; and 6) procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.
ALM-1
ALM-2
33
(b)(7)e
ICE.11.5082.000930
DETENTION STANDARD
AR-1
AR-2 and DH-1
AR-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(A)(1), the FOD must ensure the orientation process, supported by a video (ICE) and handbook, informs new 11 arrivals about facility operations, programs, and services. Subjects covered will include prohibited activities and the associated sanctions. In accordance with the ICE NDS, Admission and Release, section (III)(K), the FOD must ensure, upon admission, every detainee receives a detainee handbook. It will fully describe all policies, procedures, and rules in effect at the facility, in accordance with the Detainee Handbook standard. In accordance with the ICE NDS, Detainee Handbook, section (I), the FOD must 11 ensure every OIC develops a sitespecific handbook to serve as an 14 overview of, and guide to, the detention policies, rules, and procedures in effect at the facility. The handbook will also describe the services, programs, and opportunities available through various sources, including the facility, ICE, private organizations, etc. Every detainee will receive a copy of this handbook upon admission to the facility. In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an Order to Detain or Release (Form I-203 or 12 I-203a) bearing the appropriate official signature accompanies the newly arriving detainee.
In accordance with the ICE NDS, Admission and Release, section (III)(I), the FOD must ensure officers complete a Report of Detainees Missing Property (Form I-387) when any newly arrived detainee claims his/her property has been lost or left behind. IGSA facilities will forward the completed Form I-387s to ICE.
AR-4
12
34
(b)(7)e
ICE.11.5082.000931
DETENTION STANDARD
AR-5
DGP-1
DH-2 and Detainee Handbook F&PP-1
Detention Files
DF-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(L), the FOD must ensure staff completes certain procedures before any detainees release, removal, or transfer from the facility. Necessary steps 12 include completing and processing forms, closing files, fingerprinting, returning personal property, and reclaiming facility-issued clothing, bedding, etc. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD must ensure each facility implements procedures for identifying and handling emergency grievances. An emergency grievance involves an immediate threat to a 13 detainees safety or welfare. Once the receiving staff member approached by a detainee determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures will apply. In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, notifies the 14 detainees of facility policies and procedures concerning personal 21 property, including: the rules for storing or mailing property not allowed in their possession and the procedures for filing a claim for lost or damaged property. In accordance with the ICE NDS, Detention Files, section (III)(A)(2), the FOD must ensure the officer completing 15 the admissions portion of the detention file will note that the file has been activated.
35
(b)(7)e
ICE.11.5082.000932
DETENTION STANDARD
Detention Files
DF-2
Detention Files
DF-3
Detention Files
DF-4
Disciplinary Policy
DP-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detention Files, section (III)(E)(2), the FOD must ensure staff inserts into the released detainees file copies of 15 completed release documents, the original closed-out receipts for property and valuables, the original Form I-385, and other documentation. In accordance with the ICE NDS, Detention Files, section (III)(E)(3), the FOD must ensure the officer closing the detention file makes a notation (on the 15 acknowledgement form, if applicable) that the file is complete and ready for archiving. In accordance with the ICE NDS, Detention Files, section (IV), the FOD must ensure the field office with IGSAfacility jurisdiction creates and maintains detention files on all detainees admitted to IGSA facilities. These files must contain the same material (forms and other documents) as SPC/CDF detention files to the extent possible, given that they are 15 created by the field office. For example, if the field office takes and holds detainee property, the detention file must contain the G-589s and I-77s. The file must also contain copies of all I203s and the G-385 related to the alien. The IGSA must forward all documents relating to the individuals detention to the ICE field office of jurisdiction for inclusion in the detention file. In accordance with ICE NDS, Disciplinary Policy, section (III)(L)(1)(3), the FOD must ensure the Detainee Handbook or equivalent, notifies 16 detainees of the disciplinary process and the procedure for appealing disciplinary findings.

(b)(7)e
36
ICE.11.5082.000933
DETENTION STANDARD
EH&S-1
EH&S-2
EH&S-3
EH&S-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Environmental Health and Safety, section (III)(A)(B), the FOD must ensure facilities maintain a running inventory of the hazardous (flammable, toxic, or 17 caustic) substances used and stored in that area. Every area using hazardous substances will maintain a self contained file of the corresponding MSDS. In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure a qualified departmental staff member conducts weekly fire and safety inspections. Maintenance (safety) staff must conduct monthly inspections. 18 Written reports of the inspection will be forwarded to the OIC for review, and if necessary, corrective action determinations. The Maintenance Supervisor or designate will maintain inspection reports and records of corrective action in the safety office. In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(3)(e)(g), the FOD must ensure every institution develops a fire 18 prevention, control, and evacuation plan to include, among other things, monthly fire inspections, and exit signs and directional arrows for traffic flow. In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD must ensure month fire drills include timed emergency key drills. Emergency keys must be drawn and used by the appropriate staff to unloc 18 one set of emergency exit doors not in daily use. National Fire Protection Association (NFPA) recommends a limit o four-and-one-half minutes for drawing key and unlocking emergency doors.

(b)(7)e
37
ICE.11.5082.000934
DETENTION STANDARD Environmental Health and Safety
EH&S-5
EH&S-6
EH&S-7
EH&S-8
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD must ensure 18 existing exit signs provide instructions in English and Spanish. In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1-4), the FOD must ensure the sanitation of barber operations is maintained by adhering to specified standards, including locating barber operations in a separate room not used for any other purpose; 18 equipping the barbershop as necessary to maintain sanitary procedures of hair care; cleaning and disinfecting all hair care tools between use on detainees; and posting of hair care sanitation regulations in a conspicuous location for use by all hair care personnel and detainees. In accordance with ICE NDS, Environmental Health and Safety, section (III)(R)(1)(2), the FOD must ensure environmental health conditions are maintained at a level that meets recognized standards of hygiene. Responsibility for ensuring the cleanliness of the medical facility lies 18 with the Health Services Administer (HAS), or with the individual designated by the HSA or other health care provider. The HSA or designee must make a daily visual inspection of the medical facility, noting conditions of the floors, walls windows, horizontal surfaces, and equipment. In accordance with ICE NDS, Environmental Health and Safety, section (III)(R)(5), the FOD must ensure infectious and hazardous waste 19 generated at a medical facility is stored and disposed of in accordance with all applicable federal and state regulations.
38
(b)(7)e
ICE.11.5082.000935
DETENTION STANDARD
EH&S-9
Food Service
FS-1
Food Service
FS-2
Food Service
FS-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(1), the FOD must ensure facilities comply with standards issued by EPA and OSHA, ACA mandatory standards, and local and national fire and safety codes. In accordance with ICE NDS, Key and Lock Control, section (III)(B)(4)(f), the FOD must ensure entrance/exit door locks of housing units, work areas, chapels, gyms, and other areas with the room 19 capacity of 50 or more people meet the standards specified in the Occupational Safety and Environmental Health Manual (chapter 3) and in the NFPA life safety code (#101). Specifically, doors must be equipped with prison-type locking devices modified to function when pressure is applied from inside the room. Panic-hardware is an acceptable alternative to the prison-type locking device. In accordance with ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel 20 (both staff and detainee) receive preemployment medical examinations. In accordance with ICE NDS, Food Service, section (III)(H)(9)(c), the FOD must ensure soap or detergent, and 20 paper towels or a hand-drying device providing heated air, is available at all times in each lavatory. In accordance with ICE NDS, Food Service, section (III)(H)(11)(c)(1), the FOD must ensure all toxic, flammable, and caustic materials are segregated from food products and stored in a 20 locked and labeled cabinet or room. Cleaning and sanitizing compounds must be stored apart from food products.
39
(b)(7)e
ICE.11.5082.000936
DETENTION STANDARD
Medical Care
MC-1
Medical Care
MC-2
Medical Care
MC-3
Medical Care
MC-4
Population Counts
PC-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Medical Care, section (lll)(A), the FOD must ensure detention facilities employ, at a 22 minimum, a medical staff large enough to perform basic examinations and treatments for all detainees. In accordance with ICE NDS, Medical Care, section (lll)(L), the FOD must ensure consent forms are signed prior 22 to any medical examination or treatment, except in emergency circumstances. In accordance with ICE NDS, Medical Care, section (lll)(M), the FOD must ensure the privacy of detainees medical information is maintained to the 22 extent possible while permitting the exchange of health information required to fulfill program responsibilities and provide for the well being of detainees. In accordance with ICE NDS, Medical Care, section (lll)(N), the FOD must ensure the OIC is notified when medical staff determines that a detainees 23 medical or psychiatric condition requires either clearance by medical staff prior to release or transfer, or medical escort during deportation or transfer. In accordance with ICE NDS, Population Counts, section (III)(A), the FOD must ensure formal counts are conducted at specific times of day or 24 night in a predetermined manner. A formal count should be conducted at least once per shift, with a supervisor verifying its accuracy.

(b)(7)e
40
ICE.11.5082.000937
DETENTION STANDARD
PAGE
SMU-1
(b)(7)e
25
SDC-1
SDC-2
SP&I-1
Detainee Communication, section (III)(B)(2), the FOD must ensure all detainee requests are recorded in a logbook for that specific purpose. The logbook, at a minimum, must contain: a) date the detainee request was received; b) detainees name; c) A-number; d) nationality; e) officer logging the request; f) date the request, with staff response and action, is returned to the detainee; and g) any other site-specific, pertinent information. In accordance with the ICE NDS, StaffDetainee Communications, section (III)(B)(1)(b), the FOD must ensure detainee requests are forwarded to the ICE office of jurisdiction within 72 hours and answered as soon as possible and practicable, but not later than within 72 hours from receiving the request. If it is apparent that the request is serious in nature, procedures must be in place for an expedited review and response to the detainees request. In accordance with ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure detainees under suicide watch are returned to general population upon written authorization by the Medical Director.
26
26
27
41
(b)(7)e
ICE.11.5082.000938
DETENTION STANDARD
TIADD-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Terminal Illness, Advance Directives, and Death, section (llI)(J), the FOD must ensure facilities authorize the FBI, local coroner, or United States Public Health Service (USPHS) to order an autopsy in 28 cases involving homicide, suicide, fatal illness, accident, or unexplained death; and authorize DIHS to order an autopsy for other cases, with the written consent of a person authorized under State law
Tool Control
TC-1
29
Tool Control
TC-2
29
(b)(7)e
Tool Control
TC-3
29
Use of Force
UOF-1
30
Visitation
V-1
section (III)(H)(5), the FOD must ensure a detainee ordinarily retains visiting privileges while in administrative or disciplinary segregation status.
31

(b)(7)e
42
ICE.11.5082.000939
DETENTION STANDARD
Visitation
V-2
Visitation
V-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure once an attorney-client relationship has been established, the legal 31 representative completes and submits a Form G-28, available in the legal visitors reception area. In accordance with ICE NDS, Visitation, section (III)(O)(4), the FOD must ensure each facility establishes and disseminates a policy and implements 31 procedures governing whether, and if so, under what circumstances animals may accompany human visitors onto or into facility property.

(b)(7)e
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ICE.11.5082.000940


Enforcement and Removal Operations St. Paul Field Office Sherburne County Jail Elk River, MN
July 15-17, 2010 ________________________________

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QUALITY ASSURANCE REVIEW SHERBURNE COUNTY JAIL St. PAUL FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. Areas of Concern ICE NATIONAL DETENTION STANDARDS Detention Standards Reviewed Access to Legal Material Admission and Release. Detainee Grievance Procedures.. Detainee Handbook Detention Files. Disciplinary Policy Environmental Health and Safety. Food Service Funds and Personal Property Hold Rooms in Detention Facilities.. Hunger Strikes.... Medical Care Special Management Unit. Staff-Detainee Communication..... Suicide Prevention and Intervention. Terminal Illness, Advance Directives, and Death.. Tool Control.. Use of Force. Visitation... 1 1
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INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO inspected the Sherburne County Jail (SCJ), Elk River, Minnesota, on July 15-17, 2010. ODO reviewed the processes employed at DCDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, Joint Integrity Case Management System (JICMS), ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION

Management Analyst (Team Leader) ODO, Headquarters Special Agent ODO, Houston Special Agent ODO, Houston Special Agent ODO, Houston Contract Inspector MGT of America, Inc. Contract Inspector MGT of America, Inc. Contract Inspector MGT of America, Inc.
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Sherburne County Jail ERO St. Paul

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BACKGROUND
HISTORY
SCJ is an intergovernmental service agreement (IGSA) detention facility. SCJ opened in 1979. Since then, the facility has undergone multiple renovations and expansions, and now has the capacity to hold 667 inmates/detainees of all classification levels. The ERO St. Paul Field Office Director (FOD) utilizes SCJ to detain and process aliens who have been placed in removal proceedings. The current intergovernmental service agreement between ICE and SCJ was signed in 1999, allowing SCJ to house detainees over 72 hours. Medical care is provided by the Sherburne County Sheriffs Department and includes a contracted physician. Food service is contracted through Lancer Foods. The ERO St. Paul field office does not have staff permanently assigned at SCJ. There are two Deportation Officers (DO), at the field office, assigned to case management for detainees at SCJ. SCJ has 100 correctional officers, as well as management and administrative staff. The facility currently has six correctional officer vacancies and two certified medical assistant vacancies. In December 2009, ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the 2000 NDS at SCJ. The facility received an overall rating of Acceptable.

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INTERNAL RELATIONS
ODO interviewed supervisory and nonsupervisory ICE and DCDC staff, including the Assistant Field Office Director (AFOD) and Supervisory Detention and Deportation Officers (SDDO). ODO also interviewed non-supervisory ICE staff including Immigration Enforcement Agents and Deportation Officers (DO). Both ICE and facility staff expressed employees have good morale, and there is a good working relationship between ICE and SCJ. According to the Medical Director, the number of detainees present at the facility with psychiatric problems warrants the addition of on-site mental health staff. SCJ management stated the facility often receives inmates and detainees previously released from the Rochester Mental Health Center. When detainees are brought to the facility, ICE does not provide notification or medical files on the detainees mental health problems. SCJ does not have an on-site mental health professional. A local psychologist is utilized on referral, but only after a Treatment Authorization Request has been made and approved by the Division of Immigration Health Services (DIHS). According to SCJ staff, DIHS authorizations for treatment and payment are often delayed. SCJ management also stated SCJ has had medical billing issues, which caused SCJ to be delinquent on bill pays to outside labs. SCJ staff stated the food service provider was contracted in January, and is new to providing services to jails. Facility staff said they are satisfied with the food service provider.
DETAINEE RELATIONS
ODO interviewed 22 male and female detainees at SCJ to determine their concerns and to identify areas of possible noncompliance with the ICE NDS. ODO encouraged detainees to express their opinions about the facility, staff, ICE personnel, and the progress of their cases. This often results in examples and anecdotes, and in some cases detainees view these interviews as a self-serving opportunity. ODO cautions, due to the nature of the information obtained, it is not possible to verify each statement. Nonetheless, it is important to obtain information from the detainees point of view. Overall, detainees stated they were treated with dignity and respect by both ICE and SCJ staff. Most detainees did not know the name of their DO. Two detainees stated they have tried to reach their DO by calling and submitting written requests, but have not met with their DO. ODO called the DO, who acknowledged she had received several letters from the detainees; she said the letters and requests were the same each time.

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A detainee stated he received medical care from SCJ and was referred to an outside medical provider for his illness; he was billed twice by the outside service. ODO raised this issue with medical staff, who stated they would look into the issue. Several detainees stated their families had ordered bibles for them, and the books were confiscated the week before ODOs inspection. Officers interviewed regarding this matter stated the bibles were confiscated because they were leather bound. The Detention Manager mentioned the detainee handbook does not state, No soft, leather bound books are allowed. The Detention Manager stated this information would be included during the next handbook revision.
AREAS OF CONCERN
During the tour, ODO was informed all inmates and detainees are housed in a single housing unit during their first week at the facility. Inmates and detainees are not segregated by classification level during this week of orientation. Once detainees are properly oriented to the jail, they are placed into housing units according to their classification levels. According to the ICE NDS, Level 1 and Level 3 detainees cannot be housed together. SCJ issues a facility handbook to detainees during admission; however, detainees are not able to keep the handbook once they are moved into their assigned housing units. During the medical record review for detainees isolated on special watch, ODO discovered inconsistent documentation of regular assessments by medical staff. Extended periods of time passed between entries in the medical record. A detainee was put on a special watch status after being found with a rope around his neck on April 12, 2010, and there were no subsequent entries to the medical record until April 19, 2010, when nursing staff was asked by correctional staff to evaluate the detainee. On April 28, 2010, correctional staff again requested an assessment by nursing staff. When ODO asked the Nurse Manager about this issue, she said medical staff did not necessarily evaluate the detainee every day. The medical record did not include documentation of a mental health referral. The detainee was on a special watch status for 47 days.

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This inspection was based on the 2000 NDS. The following 22 standards were reviewed: Access to Legal Material Admission and Release Detainee Grievance Procedures Detainee Handbook Detention Files Disciplinary Policy Environmental Health and Safety Food Service Funds and Personal Property Hold Rooms in Detention Facilities Hunger Strikes Medical Care Population Counts Recreation Special Management Unit Staff-Detainee Communication Suicide Prevention and Intervention Telephone Access Terminal Illness, Advance Directives, and Death Tool Control Use of Force Visitation No deficiencies were noted in the following three standards: Population Counts Recreation Telephone Access As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ODO reviewed the Access to Legal Material standard at SCJ to determine if detainees have access to a law library, legal materials, courts, counsel and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed local policies, procedures, and the detainee handbook; inspected the law library; and interviewed staff and detainees. ODO observed the only computer available for detainee use is in a small holding room located in the booking area. The law library is equipped with one chair, one computer, a keyboard, and a mouse (Deficiency ALM-1). The law library does not have adequate equipment and/or writing implements, paper, or other office supplies available to enable detainees to prepare documents for legal proceedings (Deficiency ALM-2). The SCJ detainee handbook does not address the rules and procedures governing access to legal materials; the information is also not posted in the law library (Deficiency ALM-3 and DH-1).

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(A), the FOD must ensure the facility provides a law library in a designated room with sufficient space to facilitate detainees legal research and writing. The law library must be large enough to provide reasonable access to all detainees who request its use. It must contain a sufficient number of tables and chairs in a well-lit room, reasonably isolated from noisy areas. DEFICIENCY ALM-2 In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare documents for legal proceedings. The facility must designate an employee with responsibility to inspect the equipment at least weekly to ensure it is in good working order, and to stock sufficient office supplies. Equipment and office supplies must generally include: typewriters and/or computers, carbon paper (unless a copier is available), writing implements, writing tablets, and non-toxic liquid paper. DEFICIENCY ALM-3 and DH-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: that a law library is available for detainee use; the scheduled hours of access to the law library; the procedures for requesting access to the law library; the procedures for requesting additional time in the law library (beyond the five hours per week minimum); the procedures for requesting legal reference materials not maintained in the law library;
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and the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

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ODO reviewed the Admission and Release standard at SCJ to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed local policies and detention files, interviewed staff and detainees, and observed the admissions and release process. ODO reviewed ten active detention files. Nine of the files did not contain the Order to Detain or Release Alien (Form I-203) (Deficiency AR-1). According to facility staff, officers do not complete a report for newly-arrived detainees claiming their property has been lost or left behind, or forward the report to ICE (Deficiency AR-2).

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an order to detain or release (Form I-203 or I-203a), bearing the appropriate official signature, accompanies the newly-arriving detainee. The facility must forward the detainees A-file or temporary work file to the ICE office with jurisdiction. Staff must prepare specific documents in conjunction with each new arrival to facilitate timely processing, classification, medical screening, accounting of personal effects, and reporting of statistical data. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(I), the FOD must ensure officers complete a Report of Detainees Missing Property (Form I-387) when any newly-arrived detainee claims his or her property has been lost or left behind. The facility must forward the completed Form I-387s to ICE.

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ODO reviewed the Detainee Grievance Procedures standard at SCJ to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff, and reviewed detainee grievance procedures and the SCJ detainee handbook. Procedures are not in place for identifying and handling emergency grievances (Deficiency DGP-1). SCJ policy does not address appeals of grievances when the facilitys decisions are not accepted by the detainee (Deficiency DGP-2). This deficiency was corrected prior to the completion of the review. The grievance section of the detainee handbook does not address the availability of assistance in filing a grievance, the grievance appeal procedures, or the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Securitys Office of Inspector General (Deficiency DGP-3).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(B), the FOD must ensure procedures are implemented for identifying and handling an emergency grievance. An emergency grievance involves an immediate threat to a detainees safety or welfare. Once the receiving staff member, approached by a detainee, determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures must apply. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(C), the FOD must ensure, if the detainee does not accept the grievance committees decision, he/she may appeal it to the Officer in Charge (OIC). All facilities must implement procedures for addressing detainee appeals. DEFICIENCY DGP-3 In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(G)(2-4)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the following: the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance; procedures for resolving a grievance or appeal, including the right to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved; the procedure for contacting ICE to appeal the decision of the OIC of the facility; and the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Securitys Office of Inspector General.

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ODO reviewed the Detainee Handbook standard at SCJ to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO interviewed staff and detainees, and reviewed the detainee handbook. The SCJ detainee handbook is available in English and Spanish. The handbook is provided to detainees during admission; however, detainees are not able to keep the handbook once they are moved into their assigned housing units. The handbook does not address the rules and procedures governing access to legal materials (Deficiency DH-1 and ALM-3). The handbook does not advise detainees of the opportunity to submit written questions, requests, or concerns to ICE staff, or the procedures for doing so (Deficiency DH-2 and SDC-5). The detainee handbook also does not advise detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment; or of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DH-3 and DP-2). The handbook does not provide a written notification of visitation hours (Deficiency DH-4 and V-1).

DEFICIENCY DH-1 and ALM-3 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: that a law library is available for detainee use; the scheduled hours of access to the law library; the procedures for requesting access to the law library; the procedures for requesting additional time in the law library (beyond the five hours per week minimum); the procedures for requesting legal reference materials not maintained in the law library; and the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. DEFICIENCY DH-2 and SDC-5 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook must state the detainee has the opportunity to submit written questions, requests, or concerns to ICE staff, and the procedures for doing so, including the availability of assistance in preparing the request.

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DEFICIENCY DH-3 and DP-2 In accordance with the ICE NDS, Disciplinary Policy, section (lll)(A)(5)(a)(b), the FOD must ensure the detainee handbook advises detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment; and of the right of freedom from discrimination based on race, religion national origin, sex, handicap, or political beliefs. DEFICIENCY DH-4 and V-1 In accordance with the ICE NDS, Visitation, section (III)(B), the FOD must ensure written notifications of visitation rules and hours are provided in the detainee handbook, or equivalent, given each detainee upon admittance.

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ODO reviewed the Detention Files standard at SJC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files, toured the admission and release area, and interviewed staff. SCJ detention files do not contain Alien Booking Records (Form I-385), housing identification cards, property receipts (Form G-589), or baggage checks (Form I-77) (Deficiency DF-1). When forwarding documents for detainees transferred to another facility, staff does not update the archived file by noting the documents requested, or the name and title of the requester (Deficiency DF-2). The logbook, used to record the removal of detention files from the assigned cabinets, does not include the following information: the detainees A-number; the time the file is removed; the reason for removal; the signature of the person removing the file, along with the persons title and department; the time the file is returned; or the signature of the person returning the file (Deficiency DF-3).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B)(1), the FOD must ensure the detainees detention file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material contained in the detainees A-file. The file must, at a minimum, contain an Alien Booking Record (Form I-385), with one or more photographs attached; a housing identification card; property receipts (Form G-589); and baggage checks (Form I-77). DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(E)(5), the FOD must ensure, when forwarding documents, staff accordingly updates the archived file, noting the document request, and the name and title of the requester. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

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ODO reviewed the Disciplinary Policy standard at SCJ to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO interviewed staff and detainees; and reviewed the detainee handbook, policies, and reports. The disciplinary policy does not specify which sanctions may not be imposed on detainees (Deficiency DP-1). The detainee handbook does not advise detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment; or of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DP-2 and DH-3). The facility imposes time in disciplinary segregation exceeding 60 days for single incidents. Written justifications for segregation exceeding 60 days are not forwarded to the Assistant Director of ERO after the first 30 days (Deficiency DP-3 and SMU-2).

DEFICIENCY DP-1 In accordance with the ICE NDS, Disciplinary Policy, section (lll)(A)(3), the FOD must ensure the following sanctions are not imposed: corporal punishment; deviations from normal food services; deprivation of clothing, bedding, or items of personal hygiene; deprivation of correspondence privileges; or deprivation of physical exercise unless such activity creates an unsafe condition. DEFICIENCY DP-2 and DH-3 In accordance with the ICE NDS, Disciplinary Policy, section (lll)(A)(5)(a)(b), the FOD must ensure the detainee handbook advises detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive use of force, personal injury, disease, property damage, and harassment; and of the right of freedom from discrimination based on race, religion national origin, sex, handicap, or political beliefs. DEFICIENCY DP-3 and SMU-2 In accordance with the ICE NDS, Disciplinary Policy, section (lll)(H)(1), and Special Management Unit, Disciplinary Segregation, section (lll)(A), the FOD must ensure time in segregation after a hearing generally does not exceed 60 days. The FOD must ensure a maximum sanction of 60 days in disciplinary segregation applies to violations associated with a single incident. After the first 30 days, the OIC must send a written justification to the Assistant District Director for ERO. Considering the grounds for the OICs disciplinary action, the Assistant District Director may decide to transfer the detainee to a facility where security is such that he or she could be placed in the general population.

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ODO reviewed the Environmental Health and Safety standard at SCJ to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility; interviewed staff; and reviewed policies and documentation of inspections, hazardous chemical management, and fire drills. Exit diagrams are not available in the administration and visitation areas, and diagrams in detainee housing areas are posted at heights that make them difficult to read (Deficiency EH&S-1). Exit diagrams do not provide instructions in English and Spanish, and do not include emergency equipment locations (Deficiency EH&S-2). Barber operations are conducted in housing unit dayrooms (Deficiency EH&S-3). ODO recorded hot water supply temperatures for cleaning barber tools at 156.2 and 146.2 degrees Fahrenheit in the Gamma and Delta Units, respectively (Deficiency EH&S-4). This deficiency was corrected during the review.

DEFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(h), the FOD must ensure exit diagrams are conspicuously posted in each area. DEFICIENCY EH&S-2 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a)(c), the FOD must ensure English and Spanish instructions, and emergency equipment locations are provided on existing exit diagrams. DEFICIENCY EH&S-3 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure the barber operation is located in a separate room not used for any other purpose. DEFICIENCY EH&S-4 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure hot water in barber operations is capable of maintaining a constant flow between 105 degrees and 120 degrees Fahrenheit.

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FOOD SERVICE (FS)

ODO reviewed the Food Service standard at SCJ to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed available documentation; interviewed contract food service employees; inspected food, chemical, and utensil storage areas; and observed meal preparation and service. SCJ does not use detainee or inmate workers in the kitchen. There was no record of any religious or special diet requests. A new food service contract began on January 1, 2010, with Lancer Foods. Lancer Foods has not previously contracted with correctional facilities. Many employees were retained from the previous contractor (Aramark), so many food service procedures have been maintained. However, policies have not been established to replace those removed by Aramark upon termination of the contract. There are currently no policies governing the food service operation (Deficiency FS-1). Procedures are not in place for handling food items that pose a security threat (Deficiency FS-2). Signs requiring hand washing are not posted (Deficiency-FS-3). Staff pre-employment medical examinations are unavailable (Deficiency FS-4). Water temperatures in two wash basins in the food preparation area were recorded at 145 degrees Fahrenheit (Deficiency FS-5). Inspection of the kitchen area by the Food Service Administrator (FSA) is not documented or reported to the Jail Administrator (Deficiency FS-6). The FSA has not developed and posted a cleaning schedule (Deficiency FS-7), or established a written stock rotation schedule (Deficiency FS-8).

DEFICIENCY FS-1 In accordance with the ICE NDS, Food Service, section (III)(A), the FOD must ensure the food service program is under the direct supervision of a professional FSA. The FSA is responsible for planning, controlling, directing, and evaluating food service; establishing standards of sanitation, safety, and security; developing specifications for the procurement of food, equipment, and supplies; and establishing a training program which ensures operational efficiency and a quality food service operation. DEFICIENCY FS-2 In accordance with the ICE NDS, Food Service, sections (III)(B)(4) and (III)(J)(1), the FOD must ensure the facility has procedures for the handling of food items that pose a security threat. On purchase requests for potentially dangerous items, such as knives, mace, yeast, nutmeg, cloves and other items considered contraband if found in a detainees possession, the FSA must mark them hot, signaling the need for special handling. DEFICIENCY FS-3 In accordance with the ICE NDS, Food Service, section (III)(H)(2)(a), the FOD must ensure staff does not resume work after visiting the toilet facility without washing their hands with soap or detergent. The FSA must post signs to this effect.
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DEFICIENCY FS-4 In accordance with the ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel receive a pre-employment medical examination. DEFICIENCY FS-5 In accordance with the ICE NDS, Food Service, section (III)(H)(5)(i), the FOD must ensure all facilities meet environmental standards, including a ready water supply of hot water at a temperature of 105-120 degrees Fahrenheit. DEFICIENCY FS-6 In accordance with the ICE NDS, Food Service, section (III)(H)(13)(a)(b), the FOD must ensure the FSA or Cook Supervisor inspects the food service areas weekly. Personnel inspecting the Food Service Department must note needed corrective actions in a written report to the OIC. The OIC must establish dates by which identified problems must be corrected. DEFICIENCY FS-7 In accordance with the ICE NDS, Food Service, section (III)(H)(13)(d), the FOD must ensure the FSA develops and posts a cleaning schedule for each food service area. DEFICIENCY FS-8 In accordance with the ICE NDS, Food Service, section (III)(J)(5), the FOD must ensure the facility establishes a written stock rotation schedule.

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ODO reviewed the Funds and Personal Property standard at SJC to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed local policies and procedures, the detainee handbook, and detention files; observed the process for receiving and releasing personal property, as well as the secure storage area for detainee property; and interviewed staff and detainees. The facility does not have written policies or procedures for detainee property reported missing or damaged, and does not have procedures for investigating and reporting property loss or damage (Deficiency F&PP-1).

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must ensure the facility has written policies and procedures for detainee property reported missing or damaged. The facility must have and follow a policy for loss of or damage to properly receipted detainee property as follows: all procedures for investigating and reporting property loss or damage are implemented properly; supervisory staff must conduct the investigation; the senior facility contract officer must process all detainee claims for lost or damaged property promptly; the official deciding the claim must be at least one level higher in the chain of command than the official investigating the claim; the facility must reimburse detainees for all validated property losses caused by facility negligence; the facility must not arbitrarily impose a ceiling on the amount to be reimbursed for a validated claim; and the senior contract officer must immediately notify the designated ICE officer of all claims and outcomes.

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ODO reviewed the Hold Rooms in Detention Facilities standard at SCJ to determine if detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure and comfortable environment, and not held confined in hold rooms for over 12 hours, in accordance with the ICE NDS. ODO interviewed staff, reviewed local policies and logbooks, and inspected the hold rooms. Officers carry the chemical agent CS/OC Freeze PlusP; supervisors carry M-26 Tasers at all times while on duty, including when entering hold rooms (Deficiency HR-1).

DEFICIENCY HR-1 In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (lll)(C)(6), the FOD must ensure officers do not carry firearms, OC spray, batons or other non-deadly force devices into hold rooms.

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HUNGER STRIKES (HS)

ODO reviewed the Hunger Strikes standard at SCJ to determine if the facility protects detainees health and well-being by monitoring, counseling, and treating detainees on hunger strikes, in accordance with the ICE NDS. ODO reviewed the hunger strike policy and the medical record of one detainee on hunger strike, as well as interviewed medical staff. There were documented hunger strikes in the past year; however, staff was able to provide only one medical record for review. The facility was unable to provide the exact number of hunger strikes that occurred within the last year. A local policy on hunger strikes is in place; however, it is not dated or signed by the Medical Director. The policy does not require obtaining ICE approval before administering forced medical treatment (Deficiency HS-1).

DEFICIENCY HS-1 In accordance with the ICE NDS, Hunger Strikes, section (lll)(D), the FOD must ensure facilities do not administer forced medical treatment unless they are granted permission by ICE.

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ICE.11.5082.000968
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at SCJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the clinic; interviewed staff; and reviewed medical policies and procedures, 25 medical records, and medical staff credentials. The clinic is operated by the Sherburne County Sheriffs Office and holds no accreditations. The clinic is administered by a Registered Nurse (RN). According to the Jail Commander, staffing is at 100 percent for all allocated positions; however, the clinic has a need for two additional certified medical assistants. A review of staff credential files indicated all had copies of current licenses; however, none had been primary source-verified with the issuing agency (Deficiency MC-1). Initial intake screening is performed by correctional staff who have not had specialized training to perform this function (Deficiency MC-2). Nursing staff review the forms completed by the officers. The nurses role in documenting the screening process is not addressed in the policy (Deficiency MC-3). ODO was informed by the Nurse Manager, any medical or mental health issues identified by the officers are noted by the reviewing nurse on the booking sheet. The medical record review revealed the nurses documentation was inconsistent, and did not always include the date and signature of the reviewer. In one instance, the screening form indicated a follow-up mental health evaluation was needed for a detainee, but it was never completed. The medical record review verified physical examinations (PE) were performed within 14 days of arrival in all cases, with one exception. A new PE was not completed on a detainee who left SCJ custody, returning more than 90 days later (Deficiency MC-4). The Nurse Manager reported RNs previously performed PEs, but the physician took over this function after the first of the year. According to the medical record review, four out of the twenty-five PEs performed since the first of the year were completed by RNs with no documented training (Deficiency MC-5). Consent forms were not signed prior to rendering treatment in 48 percent of the records reviewed. Eight percent of the records did not contain consent forms (Deficiency MC-6). The ENFORCE system utilized by detention staff has a section where information may be entered, alerting ICE and detention personnel when a detainee has a medical or psychiatric condition requiring either clearance by medical staff prior to release or transfer, or a medical escort during deportation or transfer. ODO discovered the system is unused for this purpose; instead, the default Routine Medical Needs is left unaltered. ODO observed this to be true even in the case of a detainee with serious medical and psychiatric issues (Deficiency MC-7).

(b)(7)e
24
ICE.11.5082.000969

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (lll)(C), the FOD must ensure all medical staff at detention facilities have valid professional licenses and/or certifications. DEFICIENCY MC-2 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure correctional officers who perform initial intake screening have specialized training. DEFICIENCY MC-3 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure detention facilities have policy and procedures to ensure the initial health screening and assessment is documented. DEFICIENCY MC-4 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure health care providers conduct a health appraisal and physical examination on each detainee within 14 days of arrival. If there is documented evidence of a health appraisal within the previous 90 days, the health care provider may determine that a new appraisal is not required. DEFICIENCY MC-5 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure health appraisals are performed according to National Commission on Correctional Health Care (NCCHC) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. NCCHC standard J-E-04 allows the hands-on portion of the health assessment to be performed by an RN when the nurse completes appropriate training, approved or provided by the responsible physician; and the responsible physician documents his or her review of all health assessments. DEFICIENCY MC-6 In accordance with the ICE NDS, Medical Care, section (lll)(L), the FOD must ensure the health care provider obtains signed and dated consent forms from all detainees before any examination or treatment, except in emergency circumstances. DEFICIENCY MC-7 In accordance with the ICE NDS, Medical Care, section (lll)(N), the FOD must ensure the OIC is notified in writing when the medical staff determines a detainees medical or psychiatric condition requires either clearance by the medical staff prior to release or transfer, or requires medical escort during deportation or transfer.

(b)(7)e
ICE.11.5082.000970

ODO reviewed the Special Management Unit (SMU) standard at SCJ to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. ODO observed SMU operations, reviewed policies and logbooks, and interviewed staff.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.000971

ODO reviewed the Staff-Detainee Communication standard at SCJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed policies, procedures, logbooks, and interviewed staff and detainees. There are no policies or procedures in place to ensure and document the Field Office Director (FOD), Assistant Field Office Director (AFOD), and designated department heads conduct regular unannounced visits to SCJ (Deficiency SDC-1). Observations of detainee housing units revealed there are no written schedules posted for weekly detainee visits by ICE staff (Deficiency SDC-2). SCJ does not have written procedures to route detainee requests to appropriate ICE officials (Deficiency SDC-3). The facility does not have a logbook, used to document requests made to ICE, containing the detainees name, A-number, nationality, or name of the officer logging the request. The dates when SCJ forwards detainee requests to ICE, and the dates the requests are returned, are also not documented (Deficiency SDC-4). The SCJ detainee handbook does not advise that ICE detainees have the opportunity to submit written questions, requests, or concerns to ICE staff, or the procedures for doing so (Deficiency SDC-5 and DH-2).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1), the FOD must ensure policy and procedures are in place to ensure and document that the FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and observe living and working conditions. Each facility must develop a method to document the unannounced visits, and ICE must document visits to facilities. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(2)(b), the FOD must ensure facilities devise a written schedule and procedure for weekly visits by district ICE deportation staff. Written schedules must be developed and posted in the detainee living areas, as well as other areas with detainee access. DEFICIENCY SDC-3 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must ensure all facilities that house ICE detainees have written procedures to route detainee requests to the appropriate ICE official.

(b)(7)e
ICE.11.5082.000972
DEFICIENCY SDC-4 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. The logbook, at a minimum, must contain: the date the detainee request was received; detainees name; A-number; nationality; officer logging the request; the date the request, with staff response and action, is returned to the detainee; and any other site-specific pertinent information. DEFICIENCY SDC-5 and DH-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee handbook or equivalent. The handbook must state the detainee has the opportunity to submit written questions, requests, or concerns to ICE staff, and the procedures for doing so, including the availability of assistance in preparing the request.

(b)(7)e
28
ICE.11.5082.000973

ODO reviewed the Suicide Prevention and Intervention standard at SCJ to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO interviewed staff; and reviewed local policies, ten staff training records, and the medical record of three detainees on mental health observation status. The facility has two policies regarding suicide prevention and intervention. The jail policy is current; however, the medical policy is dated May 13, 2008, and is not signed by the Clinical Director. Terminology is not consistent between the jail and medical policies. The terms 15-minute suicide watch, 15 minute close watch, and 15 minute special watch are all used to describe the mental health observation status used to isolate and protect a detainee with suicidal ideations. The three terms are not clearly defined and are used interchangeably in the medical record. The inconsistency of the terminology makes it difficult to ascertain detainees exact clinical observation status. Neither policy requires ICE be notified of any detainee clinically diagnosed as suicidal or requiring special housing for suicide risk (Deficiency SP&I-1). The jail policy states, the jail nurse may discontinue the close watch. In two of the three medical records reviewed, an RN discontinued the special watch (Deficiency SP&I-2). Correctional staff receive suicide prevention training at the time of orientation, and subsequent training during daily briefings; however, the Training Manager was not able to provide documentation to verify the training, or support that staff in other disciplines receive suicide prevention training on a periodic basis (Deficiency SP&I-3).

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure detention facilities include in policy ICE reporting procedures for any detainee clinically diagnosed as suicidal or requiring special housing for suicide risk. DEFICIENCY SP&I-2 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure detainees under suicide watch are returned to general population upon written authorization from the Clinical Director. DEFICIENCY SP&I-3 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(A), the FOD must ensure all staff receives suicide prevention training during orientation and periodically.

(b)(7)e
29
ICE.11.5082.000974

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders and organ donations, at SCJ to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO interviewed medical staff, and reviewed policies and procedures. There have been no detainee deaths within the last year. Local policy consists of a medical directive addressing terminal illness, advance directives, and Do Not Resuscitate orders; and a jail policy regarding death. The medical policy is dated August 25, 2008, and is signed by the Medical Director; the jail policy is current. Neither policy addresses the authority to order an autopsy (Deficiency TIADD-1).

DEFICIENCY TIADD-1 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (llI)(J), the FOD must ensure the OIC develops and implements written procedures for making autopsy arrangements, including: contacting the local coroner, scheduling the autopsy, identifying the person who will perform the autopsy, obtaining the official death certificate, and transporting the body to the coroners office.

(b)(7)e
ICE.11.5082.000975
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at SCJ to determine if tools are properly classified, identified, inventoried, stored and issued, in accordance with the ICE NDS. ODO reviewed policies and inventories, interviewed staff, and inspected areas where tools are stored and maintained.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.000976
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at the SCJ to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO interviewed staff; inspected equipment and inventories; and reviewed policies, use of force documentation, and video recordings.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.000977
(b)(7)e

(b)(7)e
33
ICE.11.5082.000978
VISITATION (V)
ODO reviewed the Visitation standard at SCJ to determine if authorized persons, including legal representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO observed the visiting process; interviewed staff; and reviewed logbooks, schedules, policies, and the facility handbook. The detainee handbook does not provide a written notification of visitation hours (Deficiency V-1 and DH-4).

DEFICIENCY V-1 and DH-4 In accordance with the ICE NDS, Visitation, section (III)(B), the FOD must ensure written notifications of visitation rules and hours are provided in the detainee handbook, or equivalent, given each detainee upon admittance.

(b)(7)e
34
ICE.11.5082.000979
APPENDIX A
Acronyms
TAR

TB UDC

(b)(7)e
ICE.11.5082.000980
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(A), the FOD must ensure the facility provides a law library in a designated room with sufficient space to facilitate detainees legal research and writing. 10 The law library must be large enough to provide reasonable access to all detainees who request its use. It must contain a sufficient number of tables and chairs in a well-lit room, reasonably isolated from noisy areas. In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare documents for legal proceedings. The facility must designate an employee 10 with responsibility to inspect the equipment at least weekly to ensure it is in good working order, and to stock sufficient office supplies. Equipment and office supplies must generally include: typewriters and/or computers, carbon paper (unless a copier is available), writing implements, writing tablets, and non-toxic liquid paper.
ALM-1
ALM-2

(b)(7)e
ICE.11.5082.000981
DETENTION STANDARD
Access To Legal Material Detainee Handbook
ALM-3
DH-1
AR-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: that a law library is available for detainee use; the scheduled hours of access to the law library; the 10 procedures for requesting access to the law library; the procedures for requesting additional time in the law 14 library (beyond the five hours per week minimum); the procedures for requesting legal reference materials not maintained in the law library; and the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an order to detain or release (Form I-203 or I-203a), bearing the appropriate official signature, accompanies the newlyarriving detainee. The facility must forward the detainees A-file or 12 temporary work file to the ICE office with jurisdiction. Staff must prepare specific documents in conjunction with each new arrival to facilitate timely processing, classification, medical screening, accounting of personal effects, and reporting of statistical data.

(b)(7)e
37
ICE.11.5082.000982
DETENTION STANDARD
AR-2
DGP-1
DGP-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(I), the FOD must ensure officers complete a Report of Detainees Missing Property (Form I-387) when any newly-arrived 12 detainee claims his or her property has been lost or left behind. The facility must forward the completed Form I-387s to ICE. In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(B), the FOD must ensure procedures are implemented for identifying and handling an emergency grievance. An emergency grievance involves an immediate threat to a 13 detainees safety or welfare. Once the receiving staff member, approached by a detainee, determines that he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures must apply. In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(C), the FOD must ensure, if the detainee does not accept the grievance committees decision, he/she 13 may appeal it to the Officer in Charge (OIC). All facilities must implement procedures for addressing detainee appeals.

(b)(7)e
38
ICE.11.5082.000983
DETENTION STANDARD
DGP-3
Detainee Handbook
DH-2
SDC-5
Detainee Handbook Disciplinary Policy
DH-3 DP-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Detainee Grievance Procedures, section (lll)(G)(2-4)(6), the FOD must ensure the grievance section of the detainee handbook provides notice of the following: the procedures for filing a grievance and appeal, including the availability of assistance in preparing a grievance; procedures for resolving a grievance or appeal, including the right 13 to have the grievance referred to higher levels if the detainee is not satisfied that the grievance has been adequately resolved; the procedure for contacting ICE to appeal the decision of the OIC of the facility; and the opportunity to file a complaint about officer misconduct directly with the Department of Homeland Securitys Office of Inspector General. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(3), the FOD must ensure the facility provides each detainee, upon admittance, a copy of the detainee 14 handbook or equivalent. The handbook must state the detainee has the opportunity to submit written questions, 28 requests, or concerns to ICE staff, and the procedures for doing so, including the availability of assistance in preparing the request. In accordance with the ICE NDS, Disciplinary Policy, section (lll)(A)(5)(a)(b), the FOD must ensure the detainee handbook advises detainees of the right to protection from 15 personal abuse, corporal punishment, unnecessary or excessive use of force, 17 personal injury, disease, property damage, and harassment; and of the right of freedom from discrimination based on race, religion national origin, sex, handicap, or political beliefs.

(b)(7)e
39
ICE.11.5082.000984
DETENTION STANDARD Detainee Handbook Visitation DH-4
V-1
Detention Files
DF-1
Detention Files
DF-2
Detention Files
DF-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Visitation, section (III)(B), the FOD must 15 ensure written notifications of visitation rules and hours are provided in the 34 detainee handbook, or equivalent, given each detainee upon admittance. In accordance with the ICE NDS, Detention Files, section (III)(B)(1), the FOD must ensure the detainees detention file contains either originals or copies of forms and other documents generated during the admissions process. If necessary, the detention file may include copies of material 16 contained in the detainees A-file. The file must, at a minimum, contain an Alien Booking Record (Form I-385), with one or more photographs attached; a housing identification card; property receipts (Form G-589); and baggage checks (Form I-77). In accordance with the ICE NDS, Detention Files, section (III)(E)(5), the FOD must ensure, when forwarding documents, staff accordingly updates 16 the archived file, noting the document request, and the name and title of the requester. In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the files removal from the cabinet includes: the detainees name and A-number; date 16 and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

(b)(7)e
40
ICE.11.5082.000985
DETENTION STANDARD
Disciplinary Policy
DP-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Disciplinary Policy, section (lll)(A)(3), the FOD must ensure the following sanctions are not imposed: corporal punishment; deviations from normal food services; deprivation of clothing, 17 bedding, or items of personal hygiene; deprivation of correspondence privileges; or deprivation of physical exercise unless such activity creates an unsafe condition.
Disciplinary Policy Special Management Unit
DP-3
(b)(7)e
17
SMU-2
26
EH&S-1
EH&S-2
Environmental Health and Safety, section (III)(L)(3)(h), the FOD must ensure exit diagrams are conspicuously posted in each area. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a)(c), the FOD must ensure English and Spanish instructions, and emergency equipment locations, are provided on existing exit diagrams.
18
18

(b)(7)e
ICE.11.5082.000986
DETENTION STANDARD
EH&S-3
EH&S-4
Food Service
FS-1
Food Service
FS-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure 18 the barber operation is located in a separate room not used for any other purpose. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure hot water in barber operations is 18 capable of maintaining a constant flow between 105 degrees and 120 degrees Fahrenheit. In accordance with the ICE NDS, Food Service, section (III)(A), the FOD must ensure the food service program is under the direct supervision of a professional FSA. The FSA is responsible for planning, controlling, directing, and evaluating food service; 19 establishing standards of sanitation, safety, and security; developing specifications for the procurement of food, equipment, and supplies; and establishing a training program which ensures operational efficiency and a quality food service operation. In accordance with the ICE NDS, Food Service, sections (III)(B)(4) and (III)(J)(1), the FOD must ensure the facility has procedures for the handling of food items that pose a security threat. On purchase requests for potentially 19 dangerous items, such as knives, mace, yeast, nutmeg, cloves and other items considered contraband if found in a detainees possession, the FSA must mark them hot, signaling the need for special handling.

(b)(7)e
42
ICE.11.5082.000987
DETENTION STANDARD
Food Service
FS-3
Food Service
FS-4
Food Service
FS-5
Food Service
FS-6
Food Service
FS-7
Food Service
FS-8
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Food Service, section (III)(H)(2)(a), the FOD must ensure staff does not resume work after visiting the toilet facility without 19 washing their hands with soap or detergent. The FSA must post signs to this effect. In accordance with the ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all food service personnel 20 receive a pre-employment medical examination. In accordance with the ICE NDS, Food Service, section (III)(H)(5)(i), the FOD must ensure all facilities meet environmental standards, including a 20 ready water supply of hot water at a temperature of 105-120 degrees Fahrenheit. In accordance with the ICE NDS, Food Service, section (III)(H)(13)(a)(b), the FOD must ensure the FSA or Cook Supervisor inspects the food service areas weekly. Personnel inspecting the 20 Food Service Department must note needed corrective actions in a written report to the OIC. The OIC must establish dates by which identified problems must be corrected. In accordance with the ICE NDS, Food Service, section (III)(H)(13)(d), the FOD must ensure the FSA develops and 20 posts a cleaning schedule for each food service area. In accordance with the ICE NDS, Food Service, section (III)(J)(5), the FOD 20 must ensure the facility establishes a written stock rotation schedule.

(b)(7)e
43
ICE.11.5082.000988
DETENTION STANDARD
F&PP-1
Hold Rooms In Detention Facilities
HR-1
Hunger Strikes
HS-1
Medical Care
MC-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must ensure the facility has written policies and procedures for detainee property reported missing or damaged. The facility must have and follow a policy for loss of or damage to properly receipted detainee property as follows: all procedures for investigating and reporting property loss or damage are implemented properly; supervisory staff must conduct the investigation; the senior facility contract officer must 21 process all detainee claims for lost or damaged property promptly; the official deciding the claim must be at least one level higher in the chain of command than the official investigating the claim; the facility must reimburse detainees for all validated property losses caused by facility negligence; the facility must not arbitrarily impose a ceiling on the amount to be reimbursed for a validated claim; and the senior contract officer must immediately notify the designated ICE officer of all claims and outcomes. In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (lll)(C)(6), the FOD must ensure officers 22 do not carry firearms, OC spray, batons, or other non-deadly force devices into hold rooms. In accordance with the ICE NDS, Hunger Strikes, section (lll)(D), the FOD must ensure facilities do not administer 23 forced medical treatment unless they are granted permission by ICE. In accordance with the ICE NDS, Medical Care, section (lll)(C), the FOD must ensure all medical staff at 25 detention facilities have valid professional licenses and/or certifications.

(b)(7)e
ICE.11.5082.000989
DETENTION STANDARD
Medical Care
MC-2
Medical Care
MC-3
Medical Care
MC-4
Medical Care
MC-5
Medical Care
MC-6
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure correctional officers who 25 perform initial intake screening have specialized training. In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure detention facilities have 25 policy and procedures to ensure the initial health screening and assessment is documented. In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure health care providers conduct a health appraisal and physical examination on each detainee within 14 25 days of arrival. If there is documented evidence of a health appraisal within the previous 90 days, the health care provider may determine that a new appraisal is not required. In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure health appraisals are performed according to National Commission on Correctional Health Care (NCCHC) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. 25 NCCHC standard J-E-04 allows the hands-on portion of the health assessment to be performed by an RN when the nurse completes appropriate training, approved or provided by the responsible physician; and the responsible physician documents his or her review of all health assessments. In accordance with the ICE NDS, Medical Care, section (lll)(L), the FOD must ensure the health care provider obtains signed and dated consent forms 25 from all detainees before any examination or treatment, except in emergency circumstances.

(b)(7)e
45
ICE.11.5082.000990
DETENTION STANDARD
Medical Care
MC-7
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Medical Care, section (lll)(N), the FOD must ensure the OIC is notified in writing when the medical staff determines a detainees medical or 25 psychiatric condition requires either clearance by the medical staff prior to release or transfer, or requires medical escort during deportation or transfer.
SMU-1
(b)(7)e
26
SDC-1
SDC-2
Detainee Communication, section (III)(A)(1), the FOD must ensure policy and procedures are in place to ensure and document that the FOD, AFOD, and designated department heads conduct regular, unannounced (not scheduled) visits to the facilitys living and activity areas to encourage informal communication between staff and detainees, and observe living and working conditions. Each facility must develop a method to document the unannounced visits, and ICE must document visits to facilities. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(A)(2)(b), the FOD must ensure facilities devise a written schedule and procedure for weekly visits by district ICE deportation staff. Written schedules must be developed and posted in the detainee living areas, as well as other areas with detainee access.
27
27

(b)(7)e
46
ICE.11.5082.000991
DETENTION STANDARD
SDC-3
SDC-4
SP&I-1
SP&I-2
SP&I-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B), the FOD must ensure all 27 facilities that house ICE detainees have written procedures to route detainee requests to the appropriate ICE official. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure all requests are recorded in a logbook specifically designed for that purpose. The logbook, at a minimum, must contain: the date the detainee request 28 was received; detainees name; Anumber; nationality; officer logging the request; the date the request, with staff response and action, is returned to the detainee; and any other site-specific pertinent information. In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure detention facilities include in policy ICE 29 reporting procedures for any detainee clinically diagnosed as suicidal or requiring special housing for suicide risk. In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(C), the FOD must ensure detainees under suicide watch are 29 returned to general population upon written authorization from the Clinical Director. In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(A), the FOD must ensure all 29 staff receives suicide prevention training during orientation and periodically.

(b)(7)e
ICE.11.5082.000992
DETENTION STANDARD
TIADD-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (llI)(J), the FOD must ensure the OIC develops and implements written procedures for making autopsy arrangements, 30 including: contacting the local coroner, scheduling the autopsy, identifying the person who will perform the autopsy, obtaining the official death certificate, and transporting the body to the
Tool Control
TC-1
31
Tool Control
TC-2
31
Tool Control
TC-3
(b)(7)e
31
Tool Control
TC-4
31
Tool Control
TC-5
31

(b)(7)e
48
ICE.11.5082.000993
DETENTION STANDARD
PAGE
Use Of Force
UOF-1
32
Use Of Force
UOF-2
(b)(7)e
32
Use Of Force
UOF-3
32

(b)(7)e
ICE.11.5082.000994
DETENTION STANDARD
PAGE
Use Of Force
UOF-4
33
(b)(7)e
Use Of Force
UOF-5
33

(b)(7)e
ICE.11.5082.000995
ICE.11.5082.000996
ICE.11.5082.000997
ICE.11.5082.000998
(b)(7)e (b)(6), (b)(7)(C)
ICE.11.5082.000999
(b)(7)e
ICE.11.5082.001000
(b)(7)e
ICE.11.5082.001001


Enforcement and Removal Operations Juvenile and Family Residential Management Unit T. Don Hutto Residential Center Taylor, TX June 8-10, 2010 ________________________________
ICE.11.5082.001002
ICE.11.5082.001003
ICE.11.5082.001004
QUALITY ASSURANCE REVIEW T. DON HUTTO RESIDENTIAL CENTER JUVENILE AND FAMILY RESIDENTIAL MANAGEMENT UNIT TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE RESIDENTIAL STANDARDS Admission and Release... Discipline and Behavior Management... Emergency Plans... Funds and Personal Property. Law Libraries and Legal Material Medical Care .. Personal Hygiene.. Post Orders. Recreation... Residential Files..... Sexual Abuse and Assault Prevention Intervention.. Staff-Resident Communication.. Transfer of Residents. Transportation.. Visitation....... 1 1
4 4
6 7 8 9 10 11 12 13 14 15 16 18 19 20 21
ICE.11.5082.001005
ICE.11.5082.001006
INSPECTION PROCESS
This inspection, conducted by the Office of Detention Oversight (ODO), primarily focused on areas of noncompliance with the ICE Residential Standards (RS). In addition, focus may be applied to the inspection with information provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of residents, and to determine compliance with applicable laws, policies, regulations and procedures. ODO conducted an inspection of the T. Don Hutto Residential Center (TDHRC), Taylor, Texas, on June 8-10, 2010. ODO reviewed 29 of the standards under the ICE RS. ODO reviewed the processes employed at TDHRC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from ERO Headquarters, the Joint Integrity Case Management System, and pertinent media reports.
REPORT ORGANIZATION

Special Agent (Team Leader) Special Agent Special Agent Special Agent Detention and Deportation Officer Management and Program Analyst Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Houston, TX ODO, Houston, TX ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
(b)(6), (b)(7)(C)

(b)(7)e
T. Don Hutto Residential Center ERO Juvenile and Family Residential ICE.11.5082.001007 Management Unit

(b)(7)e
BACKGROUND
HISTORY
TDHRC opened in January 1997, and began receiving ICE residents in May 2006. On February 1, 2010, TDHRC entered into an intergovernmental service agreement (IGSA) with ICE to house adult female residents over 72 hours. TDHRC is owned and operated by Corrections Corporation of America (CCA). TDHRC houses female residents who are generally classified as Level one and low-Level two residents. Only ICE residents are housed at TDHRC. TDHRC was accredited by the American Correctional Association in 2004. Medical services are provided to residents by the Division of Immigration Health Services (DIHS). Food service is contracted through Canteen Services, Inc. The total capacity for ICE residents is 512. ICE personnel are assigned to TDHRC on a permanent basis and maintain a constant presence at the facility, to include a midnight shift. ICE employs a full-time staff of 73 employees, 43 of whom are DIHS employees. ICE staff includes the acting Assistant Field Office Director (AFOD), an acting Supervisory Detention and Deportation Officer (SDDO), Deportation Officers (DO), Supervisory Immigration Enforcement Agents, and Immigration Enforcement Agents (IEA). The total number of facility staff (non-ICE) employed at TDHRC is 151. The food service provider employs a total of eight employees. As TDHRC is a residential center, individuals housed at this facility will be referred to as residents rather than detainees.

(b)(7)e
INTERNAL RELATIONS
ODO interviewed seven supervisory and eight non-supervisory ICE and CCA staff. Several issues occurred recently which have negatively affected morale of CCA staff. These issues included a recent allegation of misconduct that occurred involving a CCA staff member, resulting in a sense of uncertainty of the future of TDHRC, and the recent deaths of two CCA employees. Additionally, morale has also been negatively affected by issues concerning employee salaries. CCA employees were scheduled to receive a raise in salary last year; due to budgetary constraints, the raise did not take effect. Overall, CCA staff stated morale is fair and there is a positive working relationship with ICE. Based on interviews with ICE personnel, morale levels amongst ICE staff is fair. Several IEAs stated maintaining a high level of morale has been difficult to achieve. A recent transition from a family residential center to a female-only detention facility, as well as learning a new set of policies and procedures, has affected morale. Many of the IEAs interviewed stated they do not feel respected by management and are spoken to in a derogatory manner at times. One common complaint encountered during staff interviews involved an ICE employee who has occupied an assignment for approximately three years. The position was supposed to be a temporary assignment. IEAs expressed concern that other employees are not given the opportunity to work temporarily in this assignment. ICE staff stated this issue has been brought to the attention of ICE management and has not been addressed.
RESIDENT RELATIONS
ODO interviewed 24 residents at THDRC. ODO did not receive any complaints from residents relating to food or medical services. One resident complained about experiencing difficulty in contacting her consulate and claimed she did not receive a resident handbook upon arrival to THDRC. One resident explained difficulty in contacting her DO. Several other residents complained to ODO about an ICE staff member who was rude and not helpful to residents when conducting visits to resident housing units. This issue was brought to the attention of ICE management by ODO. Overall, residents felt they were treated with dignity and respect.

(b)(7)e

This inspection was based on the 2008 ICE RS. The following 28 standards were reviewed: Admission and Release; Discipline and Behavior Management; Emergency Plans; Environmental Health and Safety; Escorted Trips for Non-Medical Emergencies; Food Service; Funds and Personal Property; Grievance System; Housekeeping and Voluntary Work Program; Hunger Strikes; Key and Lock Control; Law Libraries and Legal Material; Legal Rights Group Presentations; Marriage Requests; Medical Care; Personal Hygiene; Post Orders; Recreation; Religious Practices; Residential Files; Sexual Abuse, Assault Prevention and Intervention; Staff-Resident Communication; Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives, and Death; Tool Control; Transfer of Residents; Transportation; and Visitation No deficiencies were noted in the following 14 standards: Environmental Health and Safety; Escorted Trips for Non-Medical Emergencies; Food Service; Grievance System; Housekeeping and Voluntary Work Program; Hunger Strikes; Key and Lock Control; Legal Rights Group Presentations; Marriage Requests; Religious Practices; Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives, and Death; and Tool Control. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e

ODO reviewed the Admission and Release standard at TDHRC to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE RS. ODO reviewed local policies and resident files, interviewed staff and residents, and observed the admissions and release process. ODO reviewed seven resident admission records. Four records did not contain the Order to Detain or Release Alien (Form I-203). All seven records did not contain the Alien Booking Record (Form I-385) (Deficiency AR-1). There was no acknowledgement of receipt of a resident handbook by residents in three of the seven records reviewed (Deficiency AR-2). Of the six resident release records ODO reviewed, none contained the Form I-385 (Deficiency AR-3).

DEFICIENCY AR-1 In accordance with the ICE RS, Admission and Release, section (V)(4), the FOD must ensure an order to detain or release the resident (Form I-203 or I-203a), bearing the appropriate official signature, accompany each newly arriving resident. Forms requiring completion include, but are not limited to, the Alien Booking Record (Form I-385); the medical questionnaire; the housing assignment card, and any others used by the booking entity. DEFICIENCY AR-2 In accordance with ICE RS, Admission and Release, section (V)(6), the FOD must ensure in accordance with the Detention Standard on Resident Handbook, each facility must issue to each newly admitted resident a handbook (or equivalent) that fully describes all policies, procedures, and rules in effect at the facility. DEFICIENCY AR-3 In accordance with ICE RS, Admission and Release, section (V)(7), the FOD must ensure staff complete certain procedures before any residents release, removal, or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting; returning personal property; and reclaiming facility issued clothing bedding, etc. ICE/ERO must approve release procedures.

(b)(7)e
DISCIPLINE AND BEHAVIOR MANAGEMENT (DBM)

ODO reviewed the Discipline and Behavior Management standard at TDHRC to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE RS. ODO interviewed staff and residents, and reviewed the local policy, resident handbook, and available documentation. The Management Review Committee reviewed one disciplinary incident in the past year. The incident report did not document initiation of the investigation within 24 hours (Deficiency DBM-1).

DEFICIENCY DBM-1 In accordance with ICE RS, Discipline and Behavior Management, section (VI)(3), the FOD must ensure all incident reports are investigated within 24 hours of the incident.

(b)(7)e

ODO reviewed the Emergency Plans standard at TDHRC to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with ICE RS. ODO interviewed staff, inspected the command center, and reviewed local policies, emergency plans, and memoranda of understanding.
(b)(7)e
(b)(7)e

(b)(7)e

ODO reviewed the Funds and Personal Property standard at TDHRC to determine if controls are in place to inventory, receipt, store, and safeguard residents personal property, in accordance with ICE RS. ODO reviewed local policies, the resident handbook, and resident files. ODO also observed the process for receiving and releasing personal property, as well as the secure storage area for residents property; and interviewed staff and residents. TDHRCs handbook does not notify residents of policies and procedures on how to obtain a certified copy of identity documents, claiming property upon release, or filing a claim for lost or damaged property (Deficiency F&PP-1).

DEFICIENCY F&PP-1 In accordance with the ICE RS, Funds and Personal Property, section (V)(3), the residents handbook or equivalent must notify the residents of facility policies and procedures concerning personal property, including: (a) the certain items that they may retain in their possession; (b) the procedure for requesting a certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files; (c) the rules for storing or mailing property not allowed to be in their possession at the facility; (d) the procedure for claiming their property upon release, transfer or removal; (e) the procedures for filling a claim for lost or damaged property. Please note that a claim for lost property needs to include documentation (such as the property receipt) that the property was stored or deposited with the facility and that the process for adjudicating a claim requires that the facility retain the receipt books and property storage logs; (f) the procedure for recovering information contained on electronic media such as personal cell phones or computers belonging to the resident.

(b)(7)e

ODO reviewed the Law Libraries and Legal Material standard at TDHRC to determine if residents have access to a law library, legal materials, courts, counsel and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE RS. ODO observed the law library, reviewed policies and the detainee handbook, and interviewed staff and detainees. TDHRCs handbook does not include the procedures for requesting additional time in the law library, requesting legal reference materials not maintained in the law library, or notifying staff that library materials are missing or damaged. These rules and procedures, along with the law librarys holdings, are not posted in the library (Deficiency LL&LM-1).

DEFICIENCY LL&LM-1 In accordance with the ICE RS, Law Libraries and Legal Material, section (V)(14), the FOD must ensure the resident handbook or equivalent provides residents with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for resident use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting additional time in the law library (beyond the five-hour per week minimum); 4) the procedures for requesting legal reference materials not maintained in the law library; and 5) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

(b)(7)e
10
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at TDHRC to determine if residents have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE RS. ODO toured the medical clinic, reviewed policies and procedures, examined 30 medical files, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by the Division of Immigration Health Services (DIHS) and is staffed by both DIHS and contract personnel. TDHRC does not maintain an accreditation with the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) (Deficiency MC-1). A review of staff credential files verified all contained copies of current professional licenses; however, 54 percent had not been primary source-verified with the issuing agency (Deficiency MC-2). The Assistant Health Services Administrator (AHSA) corrected this deficiency during the review by providing documentation of verification for all licenses. The medical record review revealed all residents referred for mental health treatment were seen within 14 days, with one exception. A mental health treatment referral was made on May 14, 2010 and as of the date of the review (27 days later), the resident had not been assessed (Deficiency MC-3). When this was brought to the attention of the AHSA, mental health staff promptly evaluated the resident.

DEFICIENCY MC-1 In accordance with ICE RS, Medical Care, section (V)(1), the FOD must ensure residential facilities are accredited and maintain compliance with the standards of Joint Commission on the Accreditation of Health Care Organizations (JCAHO). DEFICIENCY MC-2 In accordance with ICE RS, Medical Care, section (V)(7), the FOD must ensure health care staff have valid professional licenses and/or certifications. DEFICIENCY MC-3 In accordance with ICE RS, Medical Care, section (V)(9)(e), the FOD must ensure any resident referred for mental health treatment receives a comprehensive evaluation by a licensed mental health provider as soon as possible and no later than14 days.

(b)(7)e
PERSONAL HYGIENE (PH)

ODO reviewed the Personal Hygiene standard at TDHRC to determine if the facility provides clean clothing, bedding, linens and towels to every resident upon arrival; and to ascertain if the facility provides residents with regular exchanges of items for the duration of their stay, in accordance with the ICE RS. ODO reviewed local policies and the resident handbook; interviewed staff and residents; inspected living areas; and observed the inventorying, issuance, and exchange of clothing, linens, and towels. White uniforms are not issued for resident food service workers (Deficiency PH-1).

DEFICIENCY PH-1 In accordance with ICE RS, Personal Hygiene, section (V)(3), the FOD must ensure each adult resident assigned to a special work area must be clothed in accordance with the requirements of the job, including any appropriate protective clothing and equipment. Residents employed as food service workers must be issued white uniforms.

(b)(7)e
12
POST ORDERS (PO)

ODO reviewed the Post Orders standard at TDHRC to determine if the facility has established post orders and has ensured those orders are updated timely. Each set of orders must also specify the duties, procedures, and responsibilities of each post, in accordance with the ICE RS. ODO interviewed staff, reviewed local policies, and inspected all security posts and post orders.
(b)(7)e
(b)(7)e

(b)(7)e
RECREATION (R)
ODO reviewed the Recreation standard at the TDHRC to determine if residents are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE RS. ODO observed the indoor and outdoor recreation areas, reviewed policies and the detainee handbook, and interviewed staff and detainees. The facility has a general recreation policy listing television viewing as one of the indoor recreational activities. The policy fails to provide specific guidance regarding television viewing and does not state that all viewing schedules are subject to the Facility Administrators approval (Deficiency R-1).

DEFICIENCY R-1 In accordance with the ICE RS, Recreation, section (V)(5)(i), the FOD must ensure the Facility Administrator establishes facility policy concerning television viewing in the dayrooms. All television viewing schedules must be subject to the Facility Administrators approval.

(b)(7)e
14
RESIDENTIAL FILES (RF)

ODO reviewed the Residential Files standard at THDRC to determine if files are created containing all significant information relating to residents who are housed at the facility for 24 hours or more, in accordance with the ICE RS. ODO reviewed resident files, toured the admissions and release area, and interviewed staff. The resident files do not contain Form I-385, Alien Booking Record. (Deficiency RF-1).

DEFICIENCY RF-1 In accordance with the ICE RS, Residential Files, section (2)(a), the FOD must ensure the resident file contains Form I-385, Alien Booking Record.

(b)(7)e
15
SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (SAAPI)

ODO reviewed the Sexual Abuse and Assault Prevention and Intervention standard at TDHRC. In accordance with the ICE RS, facilities must implement appropriate policies and procedures to prevent sexual abuse and assaults on detainees, provide prompt and effective intervention and treatment for victims of sexual abuse and assault, and control, discipline, and prosecute the perpetrators. ODO reviewed local policies, the resident handbook, and interviewed staff and residents. The facility does not maintain separate general and investigative files for cases of sexual abuse or assault as required by the ICE RS (Deficiency SAAPI-1).

DEFICIENCY SAAPI-1 In accordance with the ICE RS, Sexual Abuse and Assault Prevention and Intervention, section (V)(M), all case records associated with claims of sexual abuse, including incident reports, investigative reports, offender information, case disposition, medical and counseling evaluation findings, and recommendations for post-release treatment and/or counseling are maintained in appropriate files in accordance with other Residential Standards and applicable policies and retained in accordance with established schedules. Monitoring and evaluation are essential to assess both sexual assault levels and agency effectiveness in reducing sexually abusive behavior. Accordingly, the facility administrator must maintain two types of files. General files include: the victim(s) and assailant(s) or a sexual assault; crime characteristics; and formal or informal action taken. Investigative files include all reports; medical forms; supporting memos and videotapes; any other evidentiary materials pertaining to the allegation. The facility administrator must maintain these files chronologically in a secure location. Each facility administrator must maintain a listing of the names of sexual assault victims and assailants along with the dates and locations of all sexual assault incidents occurring with the institution on his or her computerized incident reporting system. In Residential Centers, the facility administrator must give resident assault assailant(s) and victim(s) involved in a ICE/ERO sexual assault incident a specific designator as required in the official reporting system (SIR, SEN, Other). Access to this designation must be limited to those staff that are involved on the treatment of the victim or the investigation of the incident. The authorized designation will allow administrative, treatment, and facility administrator staff to track the resident across the system who have been involved in sexual assault either as a victim or as an assailant. Based on the designated reporting data, the ICE/ERO program office must

(b)(7)e
report annually the number of sexual assaults occurring within the secure detention facilities utilized by ICE/ERO. Data will be provided through the SEN system.

(b)(7)e
17
STAFF-RESIDENT COMMUNICATION (SRC)

ODO reviewed the Staff-Resident Communication standard at THDRC to determine if procedures are in place to allow formal and informal contact between residents and key ICE and facility staff; and, if residents are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE RS. ODO reviewed procedures and logbooks, and interviewed staff and detainees. THDRC staff complete weekly unscheduled inspection worksheets; however, worksheets are not organized by month and several weekly visits are not documented (Deficiency SRC-1).

DEFICIENCY SRC-1 In accordance with the ICE RS, Staff-Resident Communication, section (V)(1)(a), the FOD must ensure facility must have policy and procedures to ensure and document that the ICE/ERO department heads conduct frequent unannounced, unscheduled visits to the facility's living and activity areas to informally observe living and working conditions and encourage informal communication among staff and residents. Such unannounced visits must include but not be limited to: Housing Units; Food Service preferably during the lunch meal; Recreation Area; Infirmary rooms. These unannounced visits must be conducted at least weekly. Each facility must develop a method to document the unannounced visits, and ICE/ERO staff must document their visits to Facilities.

(b)(7)e
18
TRANSFER OF RESIDENTS (TR)

ODO reviewed the Transfer of Residents standard at TDHRC to determine if transfers of residents from one facility to another are responsibly managed with regard to notification, resident records, safety and security, and protection of resident funds and property, in accordance with the ICE RS. ODO reviewed local policies, ENFORCE reports, Resident Alien Files, Resident Files, and interviewed staff. ODO also observed the admission and release of residents. ODO reviewed two Alien Files of residents who were recently transferred to another facility. Both files did not contain the Resident Transfer Checklist (Deficiency TR-1).

DEFICIENCY TR-1 In accordance with the ICE RS, Transfer of Residents, section (V)(4), the FOD must ensure the sending facility staff must complete the Resident Transfer Checklist to ensure all procedures are complete. The sending facility must place a copy of the checklist in the residents Alien File or work folder. The records must accompany the resident to the receiving facility. If any procedure cannot be completed prior to transfer, the resident may be transferred only if the authorizing Field Office official has expressly waived that procedure, and the sending facility staff must not any such waivers on the checklist.

(b)(7)e
19
TRANSPORTATION (T)
ODO reviewed the Transportation standard at TDHRC to determine if vehicles are properly equipped, maintained and operated, and if residents are transported in a safe, secure and humane manner under supervision of trained and experienced staff, in accordance with the ICE RS. ODO reviewed local policies, maintenance logs, driver records, and training records; and observed vehicle maintenance checks, as well as the arrival and departure of residents.
(b)(7)e
(b)(7)e

(b)(7)e
VISITATION (V)
ODO reviewed the Visitation standard at THDRC to determine if authorized persons, including legal and media representatives, are able to visit residents within security and operational constraints, in accordance with the ICE RS. ODO interviewed staff, reviewed local policies and resident handbook, and observed the visitation area. Staff interviews revealed visitors immigration status are not requested or documented in the visitors log. The visitors log does not include the visited residents name and full alien registration number. Only the last three digits of the residents alien registration number are recorded (Deficiency V-1).

DEFICIENCY V-1 In accordance with the ICE RS, Visitation (V)(4), the FOD must ensure each facility must maintain a log of all general visitors, and a separate log of legal visitors, as described below. Facility staff must record the following information in the general visitors log: (a) name and alien registration number (A-number) of the resident visited; (b) visitors name and address; (c) visitors immigration status; (d) visitors relationship to the resident; and (e) date and time in and time out.

(b)(7)e
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DSCU EABM EADM EOIR ERO FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU
TAR
American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Enforcement and Removal Operations Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit

TB UDC

(b)(7)e
22
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Admission and Release, section (V)(4), the FOD must ensure an order to detain or release the resident (Form I-203 or I203a), bearing the appropriate official signature, accompany each newly arriving resident. Forms requiring 6 completion include, but are not limited to, the Alien Booking Record (Form I385); the medical questionnaire; the housing assignment card, and any others used by the booking entity. In accordance with ICE RS, Admission and Release, section (V)(6), the FOD must ensure in accordance with the Detention Standard on Resident Handbook, each facility must issue to each newly admitted resident a handbook (or equivalent) that fully describes all policies, procedures, and rules in effect at the facility. In accordance with ICE RS, Admission and Release, section (V)(7), the FOD must ensure staff complete certain procedures before any residents release, removal, or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting; returning personal property; and reclaiming facility issued clothing bedding, etc. ICE/ERO must approve release procedures.
AR-1
AR-2
AR-3

(b)(7)e
23
DETENTION STANDARD
Discipline and Behavior Management
DBM-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE RS, Discipline and Behavior Management, section (VI)(3), the FOD must ensure all 7 incident reports are investigated within 24 hours of the incident.
Emergency Plans
EP-1
(b)(7)e

(b)(7)e
DETENTION STANDARD
F&PP-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Funds and Personal Property, section (V)(3), the residents handbook or equivalent must notify the residents of facility policies and procedures concerning personal property, including: (a) the certain items that they may retain in their possession; (b) the procedure for requesting a certified copy of any identity document (passport, birth certificate, etc.) placed in their A-files; (c) the rules for storing or mailing property not allowed to be in their possession at the facility; (d) the procedure for claiming their property 9 upon release, transfer or removal; (e) the procedures for filling a claim for lost or damaged property. Please note that a claim for lost property needs to include documentation (such as the property receipt) that the property was stored or deposited with the facility and that the process for adjudicating a claim requires that the facility retain the receipt books and property storage logs; (f) the procedure for recovering information contained on electronic media such as personal cell phones or computers belonging to the resident.

(b)(7)e
DETENTION STANDARD
LL&LM-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Law Libraries and Legal Material, section (V)(14), the FOD must ensure the resident handbook or equivalent provides residents with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for resident use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting additional time in the law library 10 (beyond the five-hour per week minimum); 4) the procedures for requesting legal reference materials not maintained in the law library; and 5) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with ICE RS, Medical Care, section (V)(1), the FOD must ensure residential facilities are accredited and maintain compliance with the standards of Joint Commission on the Accreditation of Health Care Organizations (JCAHO). In accordance with ICE RS, Medical Care, section (V)(7), the FOD must ensure health care staff have valid professional licenses and/or certifications. In accordance with ICE RS, Medical Care, section (V)(9)(e), the FOD must ensure any resident referred for mental health treatment receives a comprehensive evaluation by a licensed mental health provider as soon as possible and no later than14 days.
Medical Care
MC-1
11
Medical Care
MC-2
11
Medical Care
MC-3
11

(b)(7)e
DETENTION STANDARD
Personal Hygiene
PH-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with ICE RS, Personal Hygiene, section (V)(3), the FOD must ensure each adult resident assigned to a special work area must be clothed in accordance with the requirements of the 12 job, including any appropriate protective clothing and equipment. Residents employed as food service workers must be issued white uniforms.
Post Orders
PO-1
(b)(7)e
13
Recreation
R-1
Recreation, section (V)(5)(i), the FOD must ensure the Facility Administrator establishes facility policy concerning television viewing in the dayrooms. All television viewing schedules must be subject to the Facility Administrators approval. In accordance with the ICE RS, Residential Files, section (2)(a), the FOD must ensure the resident file contains I-385, Alien Booking Record.
14
Residential Files
RF-1
15

(b)(7)e
27
DETENTION STANDARD
Sexual Abuse and Assault Prevention and Intervention
SAAPI-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Sexual Abuse and Assault Prevention and Intervention, section (V)(M), all case records associated with claims of sexual abuse, including incident reports, investigative reports, offender information, case disposition, medical and counseling evaluation findings, and 16 recommendations for post-release treatment and/or counseling are maintained in appropriate files in accordance with other Residential Standards and applicable policies and retained in accordance with established schedules. In accordance with the ICE RS, StaffResident Communication, section (V)(1)(a), the FOD must ensure facility must have policy and procedures to ensure and document that the ICE/ERO department heads conduct frequent unannounced, unscheduled visits to the facility's living and activity areas to informally observe living and working conditions and encourage informal communication among staff and residents. Such unannounced visits must include but not be limited to: Housing Units; Food Service preferably during the lunch meal; Recreation Area; Infirmary rooms. These unannounced visits must be conducted at least weekly. Each facility must develop a method to document the unannounced visits, and ICE/ERO staff must document their visits to Facilities.
Staff-Resident Communication
SRC-1
18

(b)(7)e
DETENTION STANDARD
TR-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE RS, Transfer of Residents, section (V)(4), the FOD must ensure the sending facility staff must complete the Resident Transfer Checklist to ensure all procedures are complete. The sending facility must place a copy of the checklist in the residents Alien File or work folder. The records must 19 accompany the resident to the receiving facility. If any procedure cannot be completed prior to transfer, the resident may be transferred only if the authorizing Field Office official has expressly waived that procedure, and the sending facility staff must not any
Transportation
T-1
20
(b)(7)e
Transportation
T-2
20
Visitation
V-1
Visitation (V)(4), the FOD must ensure Each facility must maintain a log of all general visitors, and a separate log of legal visitors, as described below. Facility staff must record the following information in the general visitors log: (a) name and alien registration number (A-number) of the resident visited; (b) visitors name and address; (c) visitors immigration status; (d) visitors relationship to the resident; and (e) date and time in and time out.
21

(b)(7)e
ICE.11.5082.001036
ICE.11.5082.001037
ICE.11.5082.001038
(b)(6), (b)(7)(C)
(b)(7)e
ICE.11.5082.001039
(b)(7)e
ICE.11.5082.001040
(b)(7)e
ICE.11.5082.001041
(b)(7)e
(b)(7)e
ICE.11.5082.001042


Enforcement and Removal Operations Chicago Field Office Tri-County Justice and Detention Center Ullin, Illinois
June 15-17, 2010
ICE.11.5082.001043
ICE.11.5082.001044
ICE.11.5082.001045
ODO QUALITY ASSURANCE REVIEW TRI-COUNTY JUSTICE AND DETENTION CENTER CHICAGO FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History..................... OPERATIONAL ENVIRONMENT Internal Relations Detainee Relations.. Area of Concern.. ICE NATIONAL DETENTION STANDARDS National Detention Standards Reviewed... Access to Legal Material... Admission and Release . . Detainee Classification System.. Detainee Handbook ........ Detention Files.. Disciplinary Policy. Environmental Health and Safety. . Food Service .... Funds and Personal Property.... Issuance and Exchange of Clothing, Bedding, and Towels. . Key and Lock Control.. Medical Care. Recreation . Security Inspections Special Management Units Staff-Detainee Communication. Suicide Prevention and Intervention Tool Control .. Use of Force.. Visitation................................................ 1 1
3 5 5 5
7 8 9 11 12 13 14 15 17 18 19 20 21 22 23 24 25 26 27 28 29
APPENDIX
ACRONYMS SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS A B
ICE.11.5082.001046
ICE.11.5082.001047
INSPECTION PROCESS
The Office of Professional Responsibility, Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO inspected the Tri-County Justice and Detention Center (TCJDC), a contract detention facility located in Ullin, Illinois, on June 15-17, 2010. In performing this inspection, ODO reviewed current policies and detention standards, and applied them against the processes employed at TCJDC. Prior to the inspection, ODO gathered and analyzed relevant data from the Enforce Alien Detention Module (EADM), ERO Headquarters, the Joint Integrity Case Management System, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report and are encoded sequentially according to a detention standard designator. This report documents inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards, and useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Assistant Director, Office of Professional Responsibility.

Det. & Deportation Officer (Team Lead) Management Program Analyst Senior Special Agent Det. & Deportation Officer Management Program Analyst Contract Inspector Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Houston, TX ODO, Headquarters ODO, Headquarters MGT of America MGT of America MGT of America MGT of America
(b)(6), (b)(7)(C)

(b)(7)e
Tri-County Justice and Detention Center ERO Chicago
ICE.11.5082.001048

(b)(7)e
ICE.11.5082.001049
BACKGROUND
HISTORY
TCJDC is utilized by ICE under an intergovernmental service agreement (IGSA). The facility, which opened on October 16, 1998, is owned by Pulaski County, Illinois, and is operated by the Paladin Eastside Psychological Services, Inc. The facility currently has the contractual capacity to house 215 detainees, with an emergency capacity of 230 detainees. TCJDC houses male and female detainees of all classification levels. TCJDC food services are provided by Paladin Eastside Psychological Service, Inc. TCJDC medical care is provided by the Cairo Community Health Services. ICE/ERO does not maintain a permanent presence at TCJDC. A Detention Service Manager (DSM) is assigned by ERO Headquarters for standards compliance at the facility. The total number of facility staff (non-ICE) employed at the TCJDC is 64. In March 2010, the ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the 2000 ICE NDS at TCJDC. The facility received an overall rating of Acceptable.

(b)(7)e
ICE.11.5082.001050

(b)(7)e
ICE.11.5082.001051
INTERNAL RELATIONS
ODO conducted interviews with the Acting Assistant Field Office Director (AFOD), a Supervisory Detention and Deportation Officer (SDDO), an Immigration Enforcement Agent (IEA), the DSM, and facility staff. Facility staff expressed good morale levels and a positive relationship with ICE ERO. The DSM expressed a positive relationship with the facility.
DETAINEE RELATIONS
ODO interviewed 18 detainees at TCJDC. Overall, detainees stated they were treated with respect and dignity by both ICE and facility staff. Detainees had no complaints regarding the medical care. Two detainees stated food portions are too small. Detainees complained they did not receive a free initial telephone call when they arrived at the facility; however free telephone calls are available to detainees through a TCJDC request form. Detainees stated they did not know the name of their DO; however, a list of case management DOs, along with their telephone numbers is posted in every housing unit.
AREA OF CONCERN
TCJDC female detainee housing units are located in close proximity of the admissions area. Female detainees are free to roam anywhere within the admissions area where there is access to sensitive facility computer databases and documents relating to other detainees and facility operations. ODO observed on occasion during the night shift, there is only one male contract staff member within the admissions area monitoring the female detainees and performing admissions and release duties.

(b)(7)e
ICE.11.5082.001052

(b)(7)e
ICE.11.5082.001053

This inspection was based on the 2000 ICE NDS. The following 29 standards were reviewed: Access to Legal Material; Admission and Release; Correspondence and Other Mail; Detainee Classification System; Detainee Grievance Procedures; Detainee Handbook; Detention Files; Disciplinary Policy; Environmental Health and Safety; Food Service; Funds and Personal Property; Hold Rooms in Detention Facilities; Hunger Strikes; Issuance and Exchange of Clothing, Bedding, and Towels; Key and Lock Control; Medical Care; Population Counts; Post Orders; Recreation; Security Inspections; Special Management Units; Staff-Detainee Communication; Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives, and Death; Tool Control; Use of Force; and Visitation. No deficiencies were noted in the following eight standards: Correspondence and Other Mail; Detainee Grievance Procedures; Hold Rooms in Detention Facilities; Hunger Strikes; Population Counts; Post Orders; Telephone Access; and Terminal Illness, Advance Directives, and Death. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

(b)(7)e
ICE.11.5082.001054

ODO reviewed the Access to Legal Material standard at TCJDC to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed local policies and the detainee handbook, observed procedures and the law library, and interviewed staff and detainees. The rules and procedures governing access to the law library were not in the detainee handbook and were not posted in the law library (Deficiency ALM-1).

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings.

(b)(7)e
ICE.11.5082.001055

ODO reviewed the Admission and Release standard at TCJDC to determine if procedures are in place to protect the health, safety, security, and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO interviewed staff and detainees, and reviewed detention files and admission process. ODO reviewed 15 detention files to determine if all documents during the duration of detainees custody are enclosed in their detention files. None of the files reviewed contained classification forms; five files did not contain documentation the detainee viewed the orientation video; one file did not contain documentation the detainee received a handbook; and three files did not contain proof of hygiene items issuance (Deficiency AR-1). Staff interviews revealed ICE does not provide documentation to properly identify and classify arriving detainees (Deficiency AR-2). Files reviewed contained the Order to Detain or Release, Form I-203, but they were not signed by the appropriate ICE official (Deficiency AR-3). Four of the files reviewed were for detainees that were released. The four files did not contain fingerprints, documentation of returned clothing and bedding to the facility, and documentation the detainees property was returned upon release (Deficiency AR-4). ODO detainee interviews revealed newly arrived detainees were not offered a free phone call once the initial booking process was completed (Deficiency AR-5).

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(A), the FOD must ensure the staff opens a detainee detention file as part of the admissions process. This file must contain all paperwork generated by the detainees stay at the facility. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(B), the FOD must ensure admission staff use the documentation accompanying each new arrival for identification and classification purposes. If the classification officers are not ICE employees, ICE will provide only the information needed for classification processing. DEFICIENCY AR-3 In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an Order to Detain or Release (Form I-203 or Form I-203a), bearing the appropriate official signature, arrives with each new detainee.

(b)(7)e
ICE.11.5082.001056
DEFICIENCY AR-4 In accordance with the ICE NDS, Admission and Release, section (III)(L), the FOD must ensure staff completes certain procedures before any detainee's release, removal, or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting, returning personal property, and reclaiming facility-issued clothing, bedding, and towels. ICE will approve the IGSA release procedures. DEFICIENCY AR-5 In accordance with the Headquarters ERO Taskings letter, from Marc J. Moore, Assistant Director for Operations to permit all ICE detainee one free domestic phone call. Until a phone system and processes are identified and standardized, the FOD must ensure that detainees are provided the opportunity to complete one free phone call once the initial booking process is completed. The free call is not to exceed 3 minutes and can only be placed within the United States and its territories.

(b)(7)e
ICE.11.5082.001057

ODO reviewed the Detainee Classification System standard at TCJDC to determine if there is a requirement for a formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE NDS. ODO interviewed staff and detainees, and reviewed detention files and admission process.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.001058

ODO reviewed the Detainee Handbook standard at TCJDC to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees housed at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO reviewed the detainee handbook. The TCJDC handbook neither notifies detainees on facility rules, regulations, and restricted areas (Deficiency DH-1), nor informs detainees of their rights (Deficiency DH-2).

DEFICIENCY DH-1 In accordance with the ICE NDS, Detainee Handbook, section (III)(C), the FOD must ensure the handbook specifies, in greater detail, the rules, regulations, policies, and procedures with which every detainee must comply, including, but not limited to: smoking policy, restricted areas, and contraband. DEFICIENCY DH-2 and DP-2 In accordance with the ICE NDS, Detainee Handbook, section (III)(D), the FOD must ensure the handbook lists detainee rights and responsibilities. It must also list and classify prohibited actions/behavior, along with disciplinary procedures and sanctions. This section must also include grievance and appeals procedures.

(b)(7)e
12
ICE.11.5082.001059

ODO reviewed the Detention Files standard at TCJDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files and their handling procedures. Detention files reviewed by ODO did not contain classification worksheets and work assignment sheets (Deficiency DF-1). Detention files reviewed of released detainees did not have completed release documents (Deficiency DF-2). ODO observed the cabinet where detention files were kept, and no sign-in/sign-out logbook was present (Deficiency DF-3).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file will contain either originals or copies of forms and other documents generated during the admission process. If necessary, the detention file may include copies of material contained in the detainees A-File. The file will, at a minimum, contain the following: I-385, Alien Booking Record, one or more original photograph(s) attached; classification work sheet; personal property inventory sheet; housing identification card; G-589, Property Receipt; and an I-77, Baggage Check(s). DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(E)(2), the FOD must ensure staff inserts pertinent documentation into the released detainees detention file including: copies of completed release documents, the original closed-out receipts for property and valuables, and the original form I-385. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure staff accommodates all requests for detainee detention files from other departments who may need the material for disciplinary hearings or other proceedings. A representative of the department requesting the file is responsible for obtaining the file, logging it out, and ensuring its return. Unless the ICE staff or equivalent determines otherwise, borrowed file(s) must be returned by the end of the administrative workday. At a minimum, a logbook entry recording the files removal from the cabinet will include: the detainees name and A-File number; date and time removed; reason for removal; signature of person removing the file, including title and department; and signature of person returning the file.

(b)(7)e
ICE.11.5082.001060

ODO reviewed the Disciplinary Policy standard at TCJDC to determine if sanctions imposed on detainees who violate facility rules are appropriate, and if the discipline process includes due process requirements, in accordance with the ICE NDS. ODO interviewed staff and detainees, reviewed policies and detainee handbook, and examined disciplinary files. The facility policy does not address or disallow specified sanctions for rule violations (Deficiency DP-1). The detainee handbook does not advise detainees of the right of protection from personal abuse, corporal punishment, unnecessary or excessive force, personal injury, disease, property damage, and harassment, or of the right of freedom from discrimination based on race, religion, national origin, sex, handicap, or political beliefs (Deficiency DP-2).

DEFICIENCY DP-1 In accordance with ICE NDS, Disciplinary System, section (lll)(A)(3), the FOD must ensure staff does not impose or allow imposition of the following sanctions: corporal punishment; deviation from normal food service; deprivation of clothing, bedding, or items of personal hygiene; deprivation of correspondence privileges; or deprivation of physical exercise unless such activity creates an unsafe condition. DEFICIENCY DP-2 and DH-1 In accordance with ICE NDS, Disciplinary System, section (lll)(A)(5)(a)and(b), the FOD must ensure the handbook advises detainees of the right to protection from personal abuse, corporal punishment, unnecessary or excessive force, personal injury, disease, property damage, and harassment, and freedom from discrimination based on race, religion, national origin, sex, handicap or political beliefs.

(b)(7)e
ICE.11.5082.001061

ODO reviewed the Environmental Health and Safety standard at TCJDC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed chemical inventories, Material Safety Data Sheets (MSDS), master index of hazardous substances, and documentation of fire and safety inspections, fire drills, water and generator testing, and vermin and pest control. The chemical inventory of Apex dishwashing detergent in the food service area was inaccurate (Deficiency EH&S-1). A qualified staff member does not conduct weekly fire and safety inspections (Deficiency EH&S-2). Monthly inspections of the facility are not conducted by a licensed pest-control professional (Deficiency EH&S-3). The emergency electrical power generator is tested weekly by facility staff; however, it is tested for only 20 minutes instead of one hour as required. Additionally, the emergency generator is not tested and serviced quarterly by an external generator service company (Deficiency EH&S-4).

DEFICIENCY EH&S-1 and FS-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(4), the FOD must ensure inventory records for hazardous substances are kept current before, during, and after each use. DEFICIENCY EH&S-2 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure a qualified departmental staff member conducts weekly fire and safety inspections. The maintenance (safety) staff must conduct monthly inspections. Written reports of the inspections must be forwarded to the OIC for review and, if necessary, corrective action determinations. The Maintenance Supervisor or designate will maintain inspection reports, and records of corrective action, in the safety office. DEFICIENCY EH&S-3 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(M), the FOD must ensure the OIC has a contract with a licensed pest-control professional to perform monthly inspections. During these routine inspections, they will identify and eradicate rodents, insects, and vermin. The contract will include a preventative spraying program for indigenous insects.

(b)(7)e
15
ICE.11.5082.001062
DEFICIENCY EH&S-4 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure power generators are tested at least every two weeks. Other emergency equipment and systems will undergo quarterly testing, with follow-up repairs or replacement as necessary. The biweekly test of the emergency electrical generator will last one hour. During that time, the oil, water, hoses, and belts will be inspected for mechanical readiness to perform in an emergency situation. The emergency generator will also receive quarterly testing and servicing from an external generator-service company. Among other things, the technicians will check starting battery voltage, generator voltage, and amperage output.

(b)(7)e
16
ICE.11.5082.001063
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at TCJDC to determine if detainees are provided with a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed policies, observed meal preparation and service, interviewed contract food service employees, and inspected food, chemical, and utensil storage areas. The inventory for dishwashing detergent was inaccurate (Deficiency FS-1).

DEFICIENCY FS-1 and EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(4), the FOD must ensure inventory records for hazardous substances are kept current before, during, and after each use.

(b)(7)e
17
ICE.11.5082.001064

ODO reviewed the Funds and Personal Property standard at TCJDC to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with ICE NDS. ODO reviewed policies, procedures, logbooks, and detainee handbook, and interviewed facility staff. The facilitys has a written procedure for inventory and receipt of detainee funds and valuables, but does not include written procedures for lost or damaged property (Deficiency F&PP-1). ODO observed detainee identity documents are kept in facility property area instead of forwarding the documents to ICE for placement in the A-Files (Deficiency F&PP-2). ODO observed the detainee handbook does not include detainee request procedures for copies of identity documents in their A-Files; procedures for claiming property upon release, transfer or removal; and the procedure for filing a claim for lost or damaged property (Deficiency F&PP-3).

DEFICIENCY F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must ensure each facility has written policy and procedures for detainee property reported missing or damaged. DEFICIENCY F&PP-2 In accordance with ICE NDS, Funds and Personal Property, section (III)(B)(3), the FOD must ensure identity documents are held in detainees A-Files. DEFICIENCY F&PP-3 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, must notify the detainees they will be provided, upon request, an ICE-certified copy of any identity document taken from their property, the rules for storing or mailing property not allowed in their possession, the procedure for claiming property upon release, transfer, or removal, and the procedure for filing a claim for lost or damaged property.

(b)(7)e
18
ICE.11.5082.001065
ISSUANCE AND EXCHANGE OF CLOTHING, BEDDING AND TOWELS (I&ECTB)

ODO reviewed the Issuance and Exchange of Clothing, Bedding, and Towels standard at TCJDC to determine if the facility provides clean clothing, bedding, linens, and towels to every detainee upon arrival; and to ascertain if the facility provides ICE detainees with regular exchanges of clothing, linens, and towels for as long as they remain in detention, in accordance with the ICE NDS. ODO reviewed the detainee handbook and interviewed staff. A review of the detainee handbook and the posted laundry schedule revealed detainees do not receive daily exchanges of socks and undergarments (Deficiency I&ECB&T-1).

DEFICIENCY I&ECB&T-1 In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure detainees must be provided with clean clothing, linen, and towels on a regular basis to ensure proper hygiene. Socks and undergarments must be exchanged daily, outer garments at least twice weekly, and sheets, towels, and pillowcases at least weekly.

(b)(7)e
19
ICE.11.5082.001066

ODO reviewed the Key and Lock Control standard at TCJDC to determine if facility safety and security is maintained by requiring keys and locks to be controlled and maintained, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, reviewed policies, logbooks and other available documentation, and observed use, accountability, and maintenance of keys and locks.
(b)(7)e
(b)(7)e

(b)(7)e
20
ICE.11.5082.001067
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at TCJDC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined 25 detainee medical records, verified medical staff credentials, inspected staff clinical files, and interviewed staff. The clinic is operated by medical detention staff and holds no accreditations. The majority of physical examinations are performed by the Health Services Administrator, a registered nurse. There was no documentation of appropriate training provided or approved by the Medical Director (Deficiency MC-1).

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (lll)(D), the FOD must ensure health appraisals are performed according to National Commission on Correctional Health Care (NCCHC) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. NCCHC standard J-E-04 allows the hands-on portion of the health assessment to be performed by a registered nurse when the nurse completes appropriate training, approved or provided by the responsible physician, and the responsible physician documents his or her review of all health assessments.

(b)(7)e
21
ICE.11.5082.001068
RECREATION (R)
ODO reviewed the Recreation standard at TCJDC to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO reviewed policies and recreation schedules, and observed recreation periods. Detainees in general population have access to indoor and outdoor recreation, while detainees assigned to the Special Management Unit (SMU) may only recreate indoors and do not have access to natural light (Deficiency R-1).

DEFICIENCY R-1 and SMU-1 In accordance with ICE NDS, Recreation, section (lll)(B)(2), the FOD must ensure if only indoor recreation is available, detainees have at least one hour each day with access to natural light.

(b)(7)e
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ICE.11.5082.001069
SECURTY INSPECTIONS (SI)

ODO reviewed the Security Inspections standard at TCJDC to determine if the facility security is maintained, and events posing risk and harm are prevented, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed policies, logbooks, and other documents pertaining to the security inspection process.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.001070

ODO reviewed the Special Management Unit (SMU) standard at TCJDC to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. ODO observed SMU operations, interviewed staff, and reviewed policies, logbooks, and detention files.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.001071

ODO reviewed the Staff-Detainee Communication standard at TCJDC to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed logbooks, local policies, and procedures, and interviewed staff and detainees. An ODO review of the logbook indicates ICE does not always respond to detainee requests within the required 72 hours (Deficiency SDC-1). ODO observed completed detainee request are not maintained in the detainees detention file (Deficiency SDC-2).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(1)(b), the FOD must ensure IGSA facilities without an ICE on-site presence forward detainee requests to the ICE office of jurisdiction within 72 hours and respond as soon as possible and practicable, but not later than within 72 hours from receiving the request. If it is apparent that the request is serious in nature, procedures must be in place for an expedited review and response to the detainees request. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure that all completed Detainee Requests are filed in the detainees detention file and remain in the detainees detention file for at least three years.

(b)(7)e
ICE.11.5082.001072

ODO reviewed the Suicide Prevention and Intervention standard at TCJDC to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO reviewed the suicide prevention policy, interviewed staff, and examined medical and detention staff training records. There have been no suicides in the past year. Required training of medical staff in suicide prevention and intervention could not be verified (Deficiency SP&I-1).

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(A), the FOD must ensure all staff receive training during orientation, and periodically, in the following: recognizing signs of suicidal thinking, including suspect behavior; facility referral procedures; suicide prevention techniques; and responding to an in-progress suicide attempt. All training will include the identification of suicide risk factors and the psychological profile of a suicidal detainee.

(b)(7)e
26
ICE.11.5082.001073
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at TCJDC to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO reviewed policies and inventories, interviewed staff, and inspected areas where tools are stored and maintained.
(b)(7)e
(b)(7)e

(b)(7)e
27
ICE.11.5082.001074
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at TCJDC to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed policies and use of force documentation, inspected equipment and inventories, and interviewed staff to determine their level of knowledge and understanding of the circumstances warranting immediate and calculated uses of force.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.001075
VISITATION (V)
ODO reviewed the Visitation standard at TCJDC to determine if authorized persons, including legal representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO reviewed the detainee handbook, logbooks, policies, and procedures, observed the visiting area, and interviewed facility staff. ODO observed the facility visitation rules and hours were not posted in the visitors waiting area (Deficiency V-1). The visitors reception area does not maintain any Notice of Entry of Appearance as Attorney or Accredited Representative, Form G-28, on hand for visiting attorneys (Deficiency V-1).

Deficiency V-1 In accordance with the ICE NDS, Visitation, section (III)(B), the FOD must ensure the visitation rules and hours are posted in the visitors waiting area. Deficiency V-2 In accordance with the ICE NDS, Visitation, section (III)(l)(8), the FOD must ensure once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitors' reception area.

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ICE.11.5082.001076
APPENDIX A Acronyms
ACA COTR CXR DIHS DOS DRO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU
TAR
American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit

TB UDC

(b)(7)e
ICE.11.5082.001077
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must ensure the detainee handbook or equivalent provides detainees with the rules and procedures governing access to legal materials, including the following information: 1) that a law library is available for detainee use; 2) the scheduled hours of access to the law library; 3) the procedures for requesting access to the law library; 4) the 8 procedures for requesting additional time in the law library (beyond the five hours per week minimum); 5) the procedures for requesting legal reference materials not maintained in the law library; and 6) the procedures for notifying a designated employee that library material is missing or damaged. These policies and procedures must also be posted in the law library, along with a list of the law librarys holdings. In accordance with the ICE NDS, Admission and Release, section (III)(A), the FOD must ensure the staff opens a detainee detention file as part of the 9 admissions process. Files must contain all paperwork generated by the detainees stay at the facility. In accordance with the ICE NDS, Admission and Release, section (III)(B), the FOD must ensure admission staff use the documentation accompanying each new arrival for identification and 9 classification purposes. If the classification officers are not ICE employees, ICE will provide only the information needed for classification processing.
ALM-1
AR-1
AR-2

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ICE.11.5082.001078
DETENTION STANDARD
AR-3
AR-4
AR-5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an Order to Detain or Release (Form I-203 or Form 9 I-203a), bearing the appropriate official signature, arrives with each new detainee. In accordance with the ICE NDS, Admission and Release, section (III)(L), the FOD must ensure staff completes certain procedures before any detainee's release, removal, or transfer from the facility. Necessary steps 9 include completing and processing forms, closing files, fingerprinting, returning personal property, and reclaiming facility-issued clothing, bedding, and towels. ICE will approve the IGSA release procedures. In accordance with the Headquarters ERO Taskings letter, from Marc J. Moore, Assistant Director for Operations to all ERO field offices, dated January 16, 2009, stating, the FOD must ensure that detainees are 9 provided the opportunity to complete one free phone call once the initial booking process is completed. The free call is not to exceed 3 minutes and can only be placed within the United States and its territories.

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ICE.11.5082.001079
DETENTION STANDARD
PAGE
DCS-1
(b)(7)e
11
Detainee Handbook
DH-1
Detainee Handbook
DH-2
Disciplinary Policy
DP-2
Detention Standard, Detainee Handbook, section (III)(C), the FOD must ensure the handbook specifies, in greater detail, the rules, regulations, policies, and procedures with which every detainee must comply, including, but not limited to: smoking policy, restricted areas, and contraband. In accordance with the ICE National Detention Standard, Detainee Handbook, section (III)(D), the FOD must ensure the handbook lists detainee rights and responsibilities. It must also list and classify prohibited actions/behavior, along with disciplinary procedures and sanctions. This section must also include grievance and appeals procedures.
12
12
14

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ICE.11.5082.001080
DETENTION STANDARD
Detention Files
DF-1
Detention Files
DF-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE National Detention Standard, Detention Files, section (III)(E)(2), the FOD must ensure staff inserts pertinent documentation into the released detainees detention 13 file including: copies of completed release documents, the original closedout receipts for property and valuables, and the original form I-385. In accordance with the ICE National Detention Standard, Detention Files, section (III)(F)(2), the FOD must ensure staff accommodates all requests for detainee detention files from other departments who may need the material for disciplinary hearings or other proceedings. A representative of the department requesting the file is responsible for obtaining the file, logging it out, and ensuring its return. Unless the ICE staff or equivalent 13 determines otherwise, borrowed file(s) must be returned by the end of the administrative workday. At a minimum, a logbook entry recording the files removal from the cabinet will include: the detainees name and A-File number; date and time removed; reason for removal; signature of person removing the file, including title and department; and signature of person returning the file.

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34
ICE.11.5082.001081
DETENTION STANDARD
Detention Files
DF-3
Disciplinary Policy
DP-1
Environmental Health And Safety Food Service
EH&S-1
FS-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE National Detention Standard, Detention Files, section (III)(B)(1), the FOD must ensure the detainee detention file will contain either originals or copies of forms and other documents generated during the admission process. If necessary, the detention file may include copies of material contained in the detainees A13 File. The file will, at a minimum, contain the following: I-385, Alien Booking Record, one or more original photograph(s) attached; classification work sheet; personal property inventory sheet; housing identification card; G589, Property Receipt; and an I-77, Baggage Check(s). In accordance with ICE NDS, Disciplinary System, section (lll)(A)(3), the FOD must ensure staff does not impose or allow imposition of the following sanctions: corporal punishment; deviation from normal food 14 service; deprivation of clothing, bedding, or items of personal hygiene; deprivation of correspondence privileges; or deprivation of physical exercise unless such activity creates an unsafe condition. In accordance with the ICE NDS, Environmental Health and Safety, 15 section (III)(E)(4), the FOD must ensure inventory records for hazardous 17 substances are kept current before, during, and after each use.

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35
ICE.11.5082.001082
DETENTION STANDARD
EH&S-2
EH&S-3
EH&S-4
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(2), the FOD must ensure a qualified departmental staff member conducts weekly fire and safety inspections. The maintenance (safety) staff must conduct monthly inspections. 15 Written reports of the inspections must be forwarded to the OIC for review and, if necessary, corrective action determinations. The Maintenance Supervisor or designate will maintain inspection reports, and records of corrective action, in the safety office. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(M), the FOD must ensure the OIC has a contract with a licensed pest-control professional to perform monthly inspections. During these 15 routine inspections, they will identify and eradicate rodents, insects, and vermin. The contract will include a preventative spraying program for indigenous insects. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure power generators are tested at least every two weeks. Other emergency equipment and systems will undergo quarterly testing, with follow-up repairs or replacement as necessary. The biweekly test of the emergency electrical generator will last one hour. 15 During that time, the oil, water, hoses, and belts will be inspected for mechanical readiness to perform in an emergency situation. The emergency generator will also receive quarterly testing and servicing from an external generator-service company. Among other things, the technicians will check starting battery voltage, generator voltage, and amperage output.

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36
ICE.11.5082.001083
DETENTION STANDARD
F&PP-1
F&PP-2
F&PP-3
I&ECB&T-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must ensure each facility has 18 written policy and procedures for detainee property reported missing or damaged. In accordance with ICE NDS, Funds and Personal Property, section (III)(B)(3), the FOD must ensure identity 18 documents are held in detainees Afiles. In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook, or equivalent, must notify the detainees they will be provided, upon request, an ICE-certified copy of any identity document taken from their 18 property, the rules for storing or mailing property not allowed in their possession, the procedure for claiming property upon release, transfer, or removal, and the procedure for filing a claim for lost or damaged property. In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure detainees must be provided with clean clothing, linen, and towels on a regular basis to ensure proper hygiene. Socks and undergarments must be exchanged daily, outer garments at least twice 19 weekly, and sheets, towels, and pillowcases at least weekly. More frequent exchanges of outer garments may be appropriate, especially in hot and humid climates. Individual facilities may institute their own clothing, linen, and towel exchange policy and procedures, provided the standards in this policy are met.

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37
ICE.11.5082.001084
DETENTION STANDARD
PAGE
K&LC-1
20
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K&LC-2
20
Medical Care
MC-1
Medical Care, section (lll)(D), the FOD must ensure health appraisals are performed according to National Commission on Correctional Health Care (NCCHC) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards. NCCHC standard J-E-04 allows the hands-on portion of the health assessment to be performed by a registered nurse when the nurse completes appropriate training, approved or provided by the responsible physician, and the responsible physician documents his or her review of all health assessments.
21
Recreation Special Management Units
R-1
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22 24
SMU-1

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38
ICE.11.5082.001085
DETENTION STANDARD
SI-1
23
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SI-2
23

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ICE.11.5082.001086
DETENTION STANDARD
PAGE
SMU-2
24
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SMU-3
24

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ICE.11.5082.001087
DETENTION STANDARD
SDC-1
SDC-2
SP&I-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(1)(b), the FOD must ensure IGSA facilities without an ICE on-site presence forward detainee requests to the ICE office of jurisdiction within 72 hours and respond as soon as possible 25 and practicable, but not later than within 72 hours from receiving the request. If it is apparent that the request is serious in nature, procedures must be in place for an expedited review and response to the detainees request. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure that all completed Detainee Requests are filed 25 in the detainees detention file and remain in the detainees detention file for at least three years. In accordance with the ICE NDS, Suicide Prevention and Intervention, section (lll)(A), the FOD must ensure all staff receive training during orientation, and periodically, in the following: recognizing signs of suicidal thinking, including suspect behavior; facility 26 referral procedures; suicide prevention techniques; and responding to an inprogress suicide attempt. All training will include the identification of suicide risk factors and the psychological profile
Tool Control
TC-1
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27

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ICE.11.5082.001088
DETENTION STANDARD
Use Of Force
UOF-1
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28
Visitation
V-1
Visitation
V-2
Visitation, section (III)(B), the FOD must ensure the visitation rules and hours are posted in the visitors waiting area. In accordance with the ICE NDS, Visitation, section (III)(l)(8), the FOD must ensure once an attorney-client relationship has been established, the legal representative completes and submits a Form G-28, available in the legal visitors' reception area.
29
29

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ICE.11.5082.001089

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43
ICE.11.5082.001090


Detention and Removal Operations San Antonio Field Office Willacy Detention Center Raymondville, Texas
April 27-29, 2010
________________________________
ICE.11.5082.001091
ICE.11.5082.001092
ICE.11.5082.001093
QUALITY ASSURANCE REVIEW WILLACY DETENTION CENTER SAN ANTONIO FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. Areas of Concern OPERATIONAL ENVIRONMENT Internal Relations..... Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Admission and Release Detention Files Emergency Plans.. Environmental Health and Safety Medical Care.. Post Orders. Suicide Prevention and Intervention.. Tool Control Use of Force...... 1 1
3 3
5 5
8 9 10 11 12 13 14 15 16
ICE.11.5082.001094
ICE.11.5082.001095
INSPECTION PROCESS
The Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided by the Office of Detention and Removal Operations (DRO) Headquarters and DRO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of the Willacy Detention Center (WDC) in Raymondville, Texas on April 27-29, 2010. ODO reviewed 29 standards. ODO reviewed the processes employed at WDC to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from ENFORCE, the Joint Intake Case Management System, DRO Headquarters, and pertinent media reports.
REPORT ORGANIZATION
This report contains a detailed analysis of the significant areas inspected. Instances where detention standards and/or policies are not met are reported as deficiencies. Deficiencies are highlighted in bold throughout the report, and are encoded sequentially according to a detention standard designator. Recommendations are provided to improve the effectiveness, efficiency and overall living conditions at the detention center. This report documents inspection results, serves as an official record and is intended to provide senior management with a concise evaluation of compliance with policies and detention standards, and provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Director, Office of Professional Responsibility.

DDO (Team Leader) Detention and Deportation Officer Management and Program Analyst Special Agent Special Agent Detention and Deportation Officer Special Agent Management and Program Analyst Contract Inspector Contract Inspector Contract Inspector Contract Inspector ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Headquarters ODO, Chicago ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America MGT of America MGT of America MGT of America
Willacy Detention Center DRO San Antonio
(b)(6)

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ICE.11.5082.001096

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ICE.11.5082.001097
BACKGROUND
HISTORY
WDC is an ICE-dedicated intergovernmental service agreement detention facility which
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. WDC medical care is provided by the DIvision of Immigration Health Services (DIHS).
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ICE employs a full-time staff of 87 officers, to include an Assistant Field Office Director (AFOD), 6 supervisory detention and deportation officers (SDDO), 26 deportation officers (DO), 8 supervisory immigration enforcement agents (SIEA), 46 immigration enforcement agents (IEA) and 28 support staff, consisting of 4 mission support specialists, 1 student aide and 23 detention and removal assistants. ICE currently has 19 positions vacant. The total number of facility staff (non-ICE) employed at the WDC is 575. In March 2010, the DRO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the WDC. The final overall rating for the review was Acceptable.
AREAS OF CONCERN
It was reported through ODO interviews with detainees, a MTC officer refuses to allow female homosexual detainees to use the toilet or shower facilities if another detainee is in the area. This matter was brought to the attention of the MTC management and appropriate measures were taken before the conclusion of the review.

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ICE.11.5082.001098

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ICE.11.5082.001099
INTERNAL RELATIONS
ODO conducted interviews with the AFOD, SDDOs, SIEAs, DOs, and IEAs, as well as MTC contract staff. A positive working relationship exists between ICE and MTC. Overall, ICE and MTC staff expressed morale was good amongst employees.
DETAINEE RELATIONS
ODO interviewed 38 male and female detainees at WDC. Overall, detainees stated they were treated with respect and dignity by both ICE and MTC staff. Some detainees claimed to have no knowledge of who their DO is and claimed to have never seen their DO. Some detainees complained about the food. The major complaints were: the majority of meals contain the same items, too much starch, not enough protein, and had a poor taste. ODO determined the food served was compliant with the approved 3,000 calorie a day menu, which was approved by a registered dietitian. One detainee stated he was not allowed to attend religious services because the unit he is in is a bit problematic. Therefore, he was not allowed to attend service. ODO spoke with the Chaplain and he stated everyone is invited to attend service but some religious services are early in the morning and detainees prefer to sleep instead of attending. The Chaplain additionally stated he had heard of no problems in any units preventing detainees from attending worship services. One detainee claimed MTC staff used force on him during an altercation in which he was sent to the SMU for disciplinary reasons. ODO reviewed the detention file of the detainee, and no incident reports, segregation orders, segregation log, or disciplinary reports were found. ODO reviewed the Use of Force procedures at WDC and verified the above mentioned incident. The incident was reported through official channels to ICE/DRO.

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ICE.11.5082.001100

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ICE.11.5082.001101

Out of the 29 NDS reviewed by ODO, no deficiencies were noted in the following 20 standards: Access to Legal Materials, Detainee Classification System; Contraband; Detainee Handbook; Disciplinary Policy; Food Service; Funds and Personal Property; Detainee Grievance Procedures; Hold Rooms in Detention Facilities; Hunger Strikes; Issuance and Exchange of Clothing, Bedding and Towels; Key and Lock Control; Population Counts; Religious Practices; Security Inspections; Special Management Units (Administrative and Disciplinary); Staff and Detainee Communication; Telephone Access; Terminal Illness, Advanced Directives and Death; and Visitation. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ICE.11.5082.001102

ODO reviewed the Admission and Release standard at WDC to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed detention files and local policies, interviewed staff, and observed the admission and release process. An Order to Detain or Release (Form I-203 or I-203a), bearing an appropriate official signature, does not accompany any of the newly-arriving detainees (Deficiency AR-1). A review of detention files revealed fingerprints are not taken before releasing, removing, or transferring a detainee from the facility (Deficiency AR-2).

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an Order to Detain or Release (Form I-203 or Form I-203a), bearing the appropriate official signature, must accompany the newly-arriving detainee. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(L), the FOD must ensure a facilitys staff completes certain procedures before any detainees release, removal or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting, returning personal property and reclaiming facility-issued clothing, bedding, etc.

None

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ICE.11.5082.001103

ODO reviewed the Detention Files standard at WDC to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed active and inactive detention files, and interviewed facility staff responsible for the maintenance, completion and storage of the files. After forwarding requested documents from an inactive detention file, staff does not update the archived file by noting the document request, or the name, title and location of the requester (Deficiency DF-1). The logbook recording removal of detention files does not notate all dates and times the files are returned, or signatures of persons returning the files (Deficiency DF-2).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(E)(5), the FOD must ensure, when forwarding documents, staff accordingly updates the archived file, noting the document request, and the name and title of the requester. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure the detention file logbook contains, at a minimum, the following fields: detainees name and A number; date and time removed; reason for removal; signature, title and department of the person removing the file; date and time returned; and signature of the person returning the file.

None

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ICE.11.5082.001104

ODO reviewed the Emergency Plans standard at WDC to determine if a contingency plan has been developed to quickly and effectively respond to any emergency situations and minimize their severity, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed emergency plans.
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None

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ICE.11.5082.001105

ODO reviewed the Environmental Health and Safety standard at WDC to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices, and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility, interviewed staff, and reviewed chemical inventories, Material Safety Data Sheets (MSDS), and the master index of hazardous substances. Additionally, documentation of fire and safety inspections, fire drills, water and generator testing, and vermin and pest control were reviewed. Fire drills are not conducted in all areas of the facility. There was no documentation that fire drills are conducted in the gymnasium, which was confirmed by the Recreation Supervisor (Deficiency EH&S-1).

DEFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4), the FOD must ensure monthly fire drills are conducted and documented separately in each department.

None

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11
ICE.11.5082.001106
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at WDC to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the clinic, interviewed staff, and reviewed 30 medical records, including the record of one detainee who registered complaints during detainee interviews. Policies, medical staff credentials, and staff clinical files were also reviewed. The clinic is operated by DIHS, and is staffed by both DIHS and contract personnel. The facility currently does not hold any accreditations. The current DIHS Staffed Facility Profile indicated the vacancy rate is 34 percent. There is no on-site Clinical Director, and positions for another physician, psychiatrist, and psychologist have not been filled (Deficiency MC-1). Health appraisals and physical examinations (PE) were completed within the 14-day requirement; however; a review of medical records revealed 16 percent of PEs completed by registered nurses were not reviewed in a timely manner or had not been reviewed altogether (Deficiency MC-2). A review of staff training records revealed ICE staff has not been trained on cardiopulmonary resuscitation (CPR) (Deficiency MC-3).

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (III)(A), the FOD must ensure detention facilities employ, at a minimum, a medical staff large enough to perform basic exams and treatments for all detainees. DEFICIENCY MC-2 In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure the health appraisals are performed according to the National Commission on Correctional Health Care (NCCHC), and Joint Commission on Accreditation of Healthcare Organizations standards. NCCHC standard, J-E-05, requires the responsible physician to review all health assessments performed by registered nurses. DEFICIENCY MC-3 In accordance with the ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure staff are trained to respond to health-related emergencies within a 4-minute response time, to include training in the administration on CPR.

None
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ICE.11.5082.001107
POST ORDERS (PO)

ODO reviewed the Post Orders standard at WDC to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE NDS. ODO reviewed post orders and interviewed staff.
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None

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ICE.11.5082.001108

ODO reviewed the Suicide Prevention and Intervention standard at WDC to determine if the health and well-being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO inspected the suicide watch rooms in the short stay unit, interviewed staff, and reviewed suicide prevention policies, ten staff training records, and medical records of two detainees on suicide watch. There have been five suicide watches in the past year. The medical record review supported suicide prevention management is consistent with policy requirements. A review of staff training records supported full compliance by MTC security staff for suicide prevention training; however, ICE staff had not received training (Deficiency SP&I-1).

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(A), the FOD must ensure all staff receives suicide prevention and intervention training during orientation and annually.

None

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ICE.11.5082.001109
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at WDC to determine if tools are properly classified, identified, inventoried, stored and issued in accordance with the ICE NDS. ODO reviewed policies, toured the facility, inspected inventories and documentation, and interviewed staff.
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None

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ICE.11.5082.001110
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at WDC to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a subject, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed policies and use-of-force documentation, and inspected equipment and inventories. Staff was interviewed to determine their level of knowledge and understanding of the circumstances warranting immediate and calculated uses of force.
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None

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16
ICE.11.5082.001111
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DRO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS PBNDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU TAR TB American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets Performance Based National Detention Standards National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis
UDC
Unit Disciplinary Committee

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ICE.11.5082.001112
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure an Order to Detain or Release (Form I-203 or Form I-203a), bearing the appropriate official signature, must accompany the newly arriving detainee. In accordance with the ICE NDS, Admission and Release, section (III)(L), the FOD must assure a facilitys staff completes certain procedures before any detainees release, removal or transfer from the facility. Necessary steps include completing and processing forms, closing files, fingerprinting, returning personal property and reclaiming facility-issued clothing, bedding, etc. In accordance with the ICE NDS, Detention Files, section (III)(E)(5), the FOD must ensure when forwarding documents, staff will accordingly update the archived file, noting the document request, and the name and title of the requester. In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure the detention file logbook must contain, at a minimum, the following fields: detainees name and A-file number; date and time removed; reason for removal; signature, title and department of person removing the file; date and time returned and signature of the person returning the file. PAGE
AR-1
AR-2
Detention Files
DF-1
Detention Files
DF-2

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ICE.11.5082.001113
DETENTION STANDARD
PAGE
Emergency Plans
EP-1
10
Emergency Plans
EP-2
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10
Emergency Plans
EP-3
10
EH&S-1
Medical Care
MC-1
Medical Care
MC-2
Environmental Health and Safety, section (III)(L)(4), monthly fire drills must be conducted and documented separately in each department. In accordance with the ICE NDS, Medical Care, section (III)(A), the FOD must ensure detention facilities employ, at a minimum, a medical staff large enough to perform basic exams and treatments for all detainees. In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure the health appraisals are performed according to NCCHC and Joint Commission standards. NCCHC standard J-E-05 requires the responsible physician to review all health assessments performed by registered nurses.
11
12
12

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ICE.11.5082.001114
DETENTION STANDARD
Medical Care
MC-3
DEFICIENCIES AND REQUIREMENTS In accordance with the ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure staff are trained to respond to health-related emergencies within a 4-minute response time, to include training in
PAGE
12
Post Orders
PO-1
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13
SP&I-1
Suicide Prevention and Intervention, section (III)(A) the FOD must ensure all staff receives suicide prevention and intervention training during
14
Tool Control
TC-1
15
Tool Control
TC-2
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15
Tool Control
TC-3
15

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ICE.11.5082.001115
DETENTION STANDARD
PAGE
Use of Force
UOF-1
16
Use of Force
UOF-2
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Use of Force
UOF-3
16
Use of Force
UOF-4
16

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ICE.11.5082.001116


Detention and Removal Operations Philadelphia Field Office York County Prison York, PA
April 14 - 15, 2010
ICE.11.5082.001117
ICE.11.5082.001118
TABLE OF CONTENTS
INSPECTION PROCESS Report Organization. Inspection Team Members. OVERVIEW .. AREA OF CONCERN .... ICE NATIONAL DETENTION STANDARDS Admission and Release Disciplinary Policy....................................................................... Environmental Health and Safety Funds and Personal Property .. Hold Rooms in Detention Facilities . Issuance and Exchange of Clothing, Bedding and Towels .. Key and Lock Control. Security Inspections ... 1 1 2 3
4 4 5 5 6 6 6 7
ICE.11.5082.001119
INSPECTION PROCESS
The Office of Detention Oversight (ODO) inspection primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the level of management provided by the Office of Detention and Removal Operations (DRO) Headquarters and DRO field offices on detention management, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations and procedures. In March 2009, ODO, formerly the Detention Facilities Inspection Group, conducted a Quality Assurance Review of the York County Prison (YCP) located in York, Pennsylvania. This Follow-up Inspection was conducted to determine the corrective actions taken on the deficiencies identified in the Quality Assurance Review.
REPORT ORGANIZATION
This report documents corrective actions taken on deficiencies identified in the Quality Assurance Review report submitted to DRO. A summary of findings is provided in the Overview, and uncorrected deficiencies are detailed in the ICE National Detention Standards section. This report documents the Follow-up Inspection results, serves as an official record, and is intended to provide senior management with a concise evaluation of compliance with policy and detention standards. It also provides useful feedback on the effectiveness and efficiency of the areas inspected. Comments and questions regarding the report findings should be forwarded to the Director, Office of Professional Responsibility.

(b)(6), (b)(7)(C)
Det. & Deportation Officer (Team Leader) ODO, OPR Headquarters Management and Program Analyst ODO, OPR Headquarters
_____________________________________________________________________________________________

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ICE.11.5082.001120
York County Prison DRO Philadelphia
OVERVIEW
Deficiencies identified in the following standards during the initial inspection were reviewed: Access to Legal Material; Admission and Release; Disciplinary Policy; Environmental Health and Safety; Food Service; Funds and Personal Property; Hold Rooms in Detention Facilities; Issuance and Exchange of Clothing, Bedding, and Towels; Key and Lock Control; Medical Care; Population Counts; Post Orders; Recreation; Security Inspections; Staff-Detainee Communication; Telephone Access; and Tool Control. ODO staff identified 60 deficiencies during the Quality Assurance Review conducted in March 2009. During this Follow-up Inspection, ODO staff found 13 (22%) repeated deficiencies. ODO and DRO staff found corrective actions were taken on all deficiencies revisited in the following standards: Access to Legal Material, Food Service, Medical Care, Population Counts, Post Orders, Recreation, Staff-Detainee Communication, Telephone Access, and Tool Control. Deficiencies revisited in the following standards were not corrected and were found by ODO, along with DRO management at YCP, to be noncompliant with the ICE NDS: Admission and Release; Disciplinary Policy; Environmental Health and Safety; Funds and Personal Property; Hold Rooms in Detention Facilities; Issuance and Exchange of Clothing, Bedding, and Towels; Key and Lock Control; and Security Inspections.
_____________________________________________________________________________________________

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ICE.11.5082.001121
AREA OF CONCERN
ODO conducted a Quality Assurance Review of YCP in March 2009. In May 2009, the Philadelphia Field Office Director (FOD) prepared and submitted a plan of action (POA) to DRO Headquarters. The POA was in response to the ODO preliminary findings, sent to DRO preceding the release of the final report. The POA documented corrective actions taken or actions to be taken to address areas identified in the report as needing improvement. DRO staff informed ODO that no feedback had been received from DRO Headquarters concerning the POA. In April 2010, the POC advised ODO staff the FOD had not received a copy of the final report. However, after being notified of the Follow-up Inspection, the FOD obtained a copy of the final report from DRO Headquarters. YCP management staff expressed disappointment over the lack of opportunity to review and address the deficiencies in the final report before the inspection.
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ICE.11.5082.001122

During the initial ODO inspection, eight deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE National Detention Standard, Detainee Classification System, section (III)(B), the FOD must ensure the officer assigned to intake/processing reviews the detainees A-file, work-folder and/or information provided by ICE to identify and classify each new arrival, according to the Detention Classification System (DCS). The officer must place all original paperwork related to the detainees assessment and classification in his or her A-file (right side), with a copy in the detention file. ODO Follow-up Finding: The Deputy Warden of Treatment and the Records Custodian Captain stated ICE provides sufficient information to identify and classify each newly-arriving detainee. The classification sheets are filed in a separate folder and not maintained in the detention files. ODO Initial Finding: In accordance with the ICE National Detention Standard, Detention Files, section (III)(B)(1)(g), the FOD must ensure the detention files contain an acknowledgement form, documenting receipt of the detainee handbook. ODO Follow-up Finding: The Deputy Warden of Treatment and the Records Custodian Captain stated the facility does not have acknowledgment paperwork documenting detainees receipt of the detainee handbook.
DISCIPLINARY POLICY
During the initial ODO inspection, two deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE National Detention Standard, Disciplinary Policy, section (III)(A)(3), the FOD must ensure detention facilities local policy does not impose or allow imposition of the following sanctions: corporal punishment; deviations from normal food services; deprivation of clothing, bedding, or items of personal hygiene; deprivation of correspondence privileges; or deprivation of physical exercise unless such activity creates an unsafe condition. ODO Follow-up Finding: ODO staff and YCP Deputy Warden of Treatment reviewed the YCP local disciplinary policy and determined it does not indicate the facility is not allowed to impose sanctions, including: corporal punishment; deviations from normal food services; deprivation of clothing, bedding, or items of personal hygiene; deprivation of correspondence privileges; or deprivation of physical exercise unless such activity creates an unsafe condition.
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ICE.11.5082.001123

During the initial ODO inspection, five deficiencies were identified in this area. During this Follow-up Inspection, the following two deficiencies were found not corrected. ODO Initial Finding: In accordance with the ICE National Detention Standard, Environmental Health and Safety, sections (III)(F)(3)(a),(b),(c) and (d), the FOD must ensure every hazardous material storage room is of fire-resistant construction and properly secured, has self-closing doors at each opening, is constructed with either a four-inch sill or a four-inch depressed floor, and has a ventilation system within twelve inches of the floor. ODO Follow-up Finding: The hazardous material storage room is not of fire-resistant construction, and does not have self-closing doors at each opening. ODO Initial Finding: In accordance with the ICE National Detention Standard, Environmental Health and Safety, section (III)(P)(1), the FOD must ensure both hot and cold water will be available, and the hot water will be capable of maintaining a constant flow of water between 105 degrees and 120 degrees. ODO Follow-up Finding: The Deputy Warden for Operations informed ODO staff, contract barbering services are available at the facility in the multi-purpose room. However, the barbershop does not have a lavatory equipped with hot and cold water. Hot and cold water is available in another room within close proximity.

During the initial ODO inspection, two deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Finding: In accordance with the ICE National Detention Standard, Funds and Personal Property, section (III)(J)(2), the FOD must ensure the detainee handbook, or equivalent, notifies the detainees of facility policies and procedures concerning personal property, including, upon request, the detainee will be provided an ICEcertified copy of any identity document placed in their A-files. ODO Follow-up Finding: ODO staff reviewed the YCP detainee handbook and determined it does not notify detainees of facility policies and procedures concerning personal property, including, that upon request, detainees will be provided with an ICEcertified copy of any identity documents placed in their A-files.
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ICE.11.5082.001124

During the initial ODO inspection, three deficiencies were identified in this area. During this Follow-up Inspection, the following deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE National Detention Standard, Hold Rooms in Detention Facilities, section (III)(C)(6), the FOD must ensure no officer enters a hold room unless another officer is stationed outside the door, ready to respond as needed. Officers must not carry firearms, OC sprays, batons, or other non-deadly force devices into the hold room. ODO Follow-up Finding: The Deputy Warden for Operations and a Supervisory Detention and Deportation Officer (SDDO) assigned to YCP stated the facilitys local policy permits officers to carry Oleoresin Capsicum (OC) spray within the facility, including in the hold rooms.
ISSUANCE AND EXCHANGE OF CLOTHING, BEDDING AND TOWELS

During the initial ODO inspection, a deficiency was identified in this area. During this Follow-up Inspection, the deficiency was found not corrected. ODO Initial Findings: In accordance with the ICE National Detention Standard, Issuance and Exchange of Clothing, Bedding and Towels, section (III)(E), the FOD must ensure socks and undergarments are exchanged daily. ODO Follow-up Finding: Facility staff informed ODO staff detainees are not issued enough socks to exchange them on a daily basis.

During the initial ODO inspection, nine deficiencies were identified in this area. During this Follow-up Inspection, two deficiencies were found not corrected.
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ICE.11.5082.001125
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During the initial ODO inspection, six deficiencies were identified in this area. During this Follow-up Inspection, two deficiencies were found not corrected.
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ICE.11.5082.001126


Enforcement and Removal Operations San Francisco Field Office Yuba County Jail Marysville, CA
May 18-20, 2010
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ICE.11.5082.001127
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QUALITY ASSURANCE REVIEW YUBA COUNTY JAIL SAN FRANCISCO FIELD OFFICE TABLE OF CONTENTS
INSPECTION PROCESS Report Organization Inspection Team Members BACKGROUND History.. Areas of Concern OPERATIONAL ENVIRONMENT Internal Relations........ Detainee Relations.. ICE NATIONAL DETENTION STANDARDS Access to Legal Material Admission and Release. Correspondence and Other Mail.. Detainee Classification System Detainee Grievance Procedures.. Detainee Handbook Detention Files. Environmental Health and Safety. Food Service Funds and Personal Property Issuance and Exchange of Clothing, Bedding, and Towels. Key and Lock Control. Medical Care Population Counts.. Post Orders.. Recreation.... Security Inspections Special Management Unit (Administrative and Disciplinary) Staff-Detainee Communication..... Suicide Prevention and Intervention. Telephone Access... Terminal Illness, Advance Directives, and Death... Tool Control.. Use of Force. Visitation 1 1
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INSPECTION PROCESS
The Office of Detention Oversight (ODO) primarily focuses on areas of noncompliance with the ICE National Detention Standards (NDS). In addition, focus may be applied to the inspection with information provided on detention management by the Office of Enforcement and Removal Operations (ERO) Headquarters and ERO field offices, and to issues of high priority or interest to ICE executive management. Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and to determine compliance with applicable laws, policies, regulations, and procedures. ODO conducted an inspection of Yuba County Jail (YCJ) in Marysville, California on May 18-20, 2010. ODO reviewed the processes employed at YCJ to determine compliance with current policies and detention standards. Prior to the inspection, ODO gathered and analyzed relevant data from the ENFORCE Alien Booking Module, ERO Headquarters, and pertinent media reports.
REPORT ORGANIZATION

Special Agent (Team Leader) Special Agent Detention and Deportation Officer Detention and Deportation Officer Contract Inspector Contract Inspector Contract Inspector Contract Inspector ODO, San Diego ODO, Headquarters ODO, Headquarters ODO, Headquarters MGT of America, Inc. MGT of America, Inc. MGT of America, Inc. MGT of America, Inc.
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Yuba County Jail ERO San Francisco

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BACKGROUND
HISTORY
YCJ was opened in 1962 and completed a major structural addition to the facility in 1994. The U.S. Border Patrol began using YCJ in 1994 to house aliens. On December 15, 2008, YCJ entered into an Inter-Governmental Services Agreement (IGSA) with ICE to house er (b)(7)e immigration proceedings.
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ICE does not have staff located at YCJ. Deportation officers (DO) and immigration enforcement agents (IEA) from the ERO San Francisco field office conduct scheduled and unannounced visits to the facility on a regular basis. YCJ employs one captain, five sergeants, three corporals, fifty-five deputies, two clerical employees, three commissary personnel, one food service manager, three cooks, and medical staff. The ERO Detention Standards Compliance Unit contractors, MGT of America, Inc., conducted an annual review of the ICE NDS at YCJ in December 2009, in which the facility received an Acceptable overall rating.
AREAS OF CONCERN
Through detainee interviews, it was discovered YCJ charges detainees 50 cents for requested over-the-counter medications, such as Tylenol. This practice is authorized by YCJ policy, Order #D-218, which states, a non-prescription medication log must be filled out and all drugs or treatments signed for by the inmate. A copy of the nonprescription log will be forwarded to the Jail Clerk. The Jail Clerk will debit inmates accounts 50 cents for each dosage of the non-prescription medication received. The Executive Assistant (EA) to the Medical Director confirmed this practice applies to ICE detainees as well as inmates. Per INS memorandum, entitled Fees for Services, Reimbursement Under Intergovernmental Service Agreements, dated May 18, 2001, this practice is prohibited for federally-housed detainees. The memorandum states, pill fees or co-payments sometimes charged for preparing or dispensing medications, prescriptions, or over-the-counter items directed by a medical authority cannot be charged to INS detainees regardless of any authority the facility may have to charge other non-Federal detainees or prisoners.

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ICE.11.5082.001134

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INTERNAL RELATIONS
ODO interviewed six supervisory and five non-supervisory ICE and YCJ staff. Based on the interviews conducted, ICE and YCJ maintain an excellent working relationship. All ICE and YCJ staff interviewed said morale is very high. The Captain expressed concerns regarding frequent audits and inspections, stating they can negatively impact the daily operations of the facility and reduce its operational efficiency. The Captain said he believes a facility should be audited and inspected less frequently if it is initially found to be compliant. Several YCJ staff stated the audit and inspection results from the annual compliance reviews conducted by the ERO Detention Standards Compliance Unit led them to believe the facility was fully compliant with the ICE NDS. One deputy advised ERO should provide more background information on ICE detainees in order to classify the detainees more accurately. An IEA stated ERO could benefit from hiring more support staff. Specifically, more detention and removal assistants should be hired to handle the work load in the district. The Field Office Director (FOD) and the Assistant FOD (AFOD) both said they would like to acquire and purchase more IDENT terminals for their area of responsibility. Both the FOD and the AFOD also expressed concerns the location between the field office and the facility, along with the traffic congestion encountered within the San Francisco and Sacramento metropolitan areas, affect the amount of time spent on the road by ICE officers transporting detainees.
DETAINEE RELATIONS
ODO interviewed 17 ICE detainees at YCJ, consisting of 11 male detainees and 6 female detainees, to ascertain detainees concerns and to identify areas of possible noncompliance with the ICE NDS. ODO encouraged detainees to express their feelings about the facility, its staff, ICE staff, and the progress of their case. This often results in examples and anecdotes. In addition, in some cases detainees view these interviews as a self-serving opportunity. ODO cautions, due to the nature of the information obtained, it is not possible to verify each statement. Nonetheless, it is important to obtain information from the detainees point of view. Most detainees interviewed sated they did not know who their deportation officers were. Despite not knowing the names of their deportation officers, several detainees acknowledged ICE officers do visit the housing units on a regular basis. The detainees expressed minor concerns with the medical care offered at YCJ. One detainee alleged she did not receive a physical examination until one month after her

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arrival at YCJ, and was charged 50 cents for each Tylenol she received. One male detainee said it took him almost three weeks to see a dentist. Four female detainees stated they were offered outdoor recreation only four times a week while three male detainees complained they were offered outdoor recreation too early, at 5:00am, a couple of times per week. Nine male detainees stated the quality of the food served at the facility is very good; however, five male detainees said the portions served were very small and inadequate.

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ICE.11.5082.001137

This inspection was based on the 2000 ICE NDS. The following standards were reviewed: Access to Legal Material, Admission and Release, Correspondence and Other Mail, Detainee Classification System, Detainee Grievance Procedures, Detainee Handbook, Detention Files, Disciplinary Policy, Environmental Health and Safety, Food Service, Funds and Personal Property, Hold Rooms in Detention Facilities, Hunger Strike, Issuance and Exchange of Clothing, Bedding, and Towels, Key and Lock Control, Medical Care, Population Counts, Post Orders, Recreation, Security Inspections, Special Management Unit (Administrative Segregation and Disciplinary Segregation), Staff-Detainee Communication, Suicide Prevention and Intervention, Telephone Access, Terminal Illness, Advance Directives, and Death, Tool Control, Use of Force, and Visitation. No deficiencies were noted in the following standards: Disciplinary Policy, Hold Rooms in Detention Facilities, and Hunger Strike. As these standards were compliant at the time of the review, a synopsis for these areas was not prepared for this report.

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ICE.11.5082.001138

ODO reviewed the Access to Legal Material standard at YCJ to determine if detainees have access to a law library, legal materials, courts, counsel, and document copying equipment to facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed policies and procedures, inspected the library, and conducted interviews with staff. ODO found only one laptop computer was available for 257 detainees housed at YCJ (Deficiency ALM-1).

DEFICIENCY ALM-1 In accordance with the ICE NDS, Access to Legal Material, sections (III)(B) and (G), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare documents for legal proceedings. The FOD must devise a flexible schedule to permit all detainees, regardless of housing or classification, to use the law library on a regular basis. Each detainee must be permitted to use the law library for a minimum of five hours per week.

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ICE.11.5082.001139

ODO reviewed the Admission and Release standard at YCJ to determine if procedures are in place to protect the health, safety, security and welfare of each person during the admission and release process, in accordance with the ICE NDS. ODO reviewed detention files, forms, policies, and procedures; and interviewed detainees and staff assigned to admission and release processing duties. YCJ does not have a method for providing detainees with an orientation to the facility other than through the detainee handbook (Deficiency AR-1). Not all newly-arrived detainees receive a medical intake screening from medical staff during the admissions process (Deficiency AR-2). YCJ non-medical correctional staff screens all newlyarrived detainees during the booking process using a questionnaire; however, only detainees who are deemed as needing further evaluation are recommended for a medical screening by medical staff.

DEFICIENCY AR-1 In accordance with the ICE NDS, Admission and Release, sections (III)(J) and (A)(1), the FOD must ensure the facility has a medium to provide detainees with an orientation to the facility. The orientation process must be supported by an approved ICE video and handbook, which must inform new arrivals about the facility operations, programs, and services. DEFICIENCY AR-2 In accordance with the ICE NDS, Admission and Release, section (III)(A)(3), the FOD must ensure a medical screening is conducted during the admissions process for all newly-arrived detainees, in order to protect the health of the detainees and others in the facility.

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ICE.11.5082.001140

ODO reviewed the Correspondence and Other Mail standard at YCJ to determine if the facility provides detainees the opportunity to send and receive correspondence, in a timely manner, subject to limitations required for the safe and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed facility policies and procedures, interviewed staff, and observed the distribution of mail to detainees. ODO observed YCJ staff issue special correspondence to a detainee without first inspecting it. The envelope identified the sender as the U.S. District Court, and remained sealed when given to the detainee (Deficiency C&OM-1). Detainees are not notified and do not receive a receipt when mail has been confiscated or withheld (Deficiency C&OM-2).

DEFICIENCY C&OM-1 In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(E)(2), the FOD must ensure facilities implement procedures for inspecting special correspondence for contraband. Any such inspection must be in the presence of the detainee. Special correspondence includes written communication from courts. DEFICIENCY C&OM-2 In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(G), the FOD must ensure all facilities implement policies and procedures addressing the issue of acceptable and non-acceptable mail. The affected detainees must be notified when incoming or outgoing mail is confiscated or withheld. The detainee must receive a receipt for the confiscated or withheld item(s).

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ICE.11.5082.001141

ODO reviewed the Detainee Classification System standard at YCJ to determine if there is a formal classification process for managing and separating detainees based on verifiable and documented data, in accordance with the ICE NDS. ODO interviewed staff assigned to classify detainees; and reviewed detention files, forms, policies, and procedures.
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ICE.11.5082.001142

ODO reviewed the Detainee Grievance Procedures standard at YCJ to determine if a process to submit formal or emergency grievances exists, and responses are provided in a timely manner, without fear of reprisal. In addition, the review was conducted to determine if detainees have an opportunity to appeal responses, and if accurate records are maintained, in accordance with the ICE NDS. ODO interviewed staff and detainees, and reviewed local policies and logbooks. ODO found copies of completed grievance forms are not placed in the detainees detention file (Deficiency DGP-1). YCJ does not forward all detainee grievances alleging officer misconduct to ICE (Deficiency DGP-2).

DEFICIENCY DGP-1 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance remains in the detainees detention file for at least three years. DEFICIENCY DGP-2 In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(F), the FOD must ensure facilities forward detainee grievances alleging officer misconduct to ICE.

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ICE.11.5082.001143
DETAINEE HANDBOOK
ODO reviewed the Detainee Handbook standard at YCJ to determine if the facility provides each detainee with a handbook, written in English and any other languages spoken by a significant number of detainees at the facility, describing the facilitys rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in accordance with the ICE NDS. ODO interviewed staff, and reviewed the detainee handbook and detention files. The detainee handbook does not notify detainees of facility policies and procedures concerning personal property (Deficiency DH-1 and F&PP-1). Notifications regarding recorded telephone calls are not mentioned in the detainee handbook (Deficiency DH-2 and TA-2).

DEFICIENCY DH-1 and F&PP-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies detainees of the facility policies and procedures concerning personal property. DEFICIENCY DH-2 and TA-2 In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure, if telephone calls are monitored, the facility notifies detainees in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each monitored telephone stating: that detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

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ICE.11.5082.001144

ODO reviewed the Detention Files standard at YCJ to determine if files are created containing all significant information on detainees housed at the facility for over 24 hours, in accordance with the ICE NDS. ODO reviewed detention files, logbooks, policies and procedures, and interviewed staff. ODO reviewed 30 detention files and found YCJ does not keep required documentation in detention files, such as special requests, disciplinary forms, and grievances (Deficiency DF-1). The facility does not keep detention files in a secured area. Detention files are located in a high-traffic processing area, and the door to the processing area is not locked (Deficiency DF-2). YCJ does not keep a logbook documenting the removal of detention files from the processing area (Deficiency DF-3).

DEFICIENCY DF-1 In accordance with the ICE NDS, Detention Files, section (III)(C), the FOD must ensure, during the course of the detainees stay at the facility, staff adds documents associated with normal operations to the detainees detention file without prior approval. DEFICIENCY DF-2 In accordance with the ICE NDS, Detention Files, section (III)(D), the FOD must ensure detainee detention files are located and maintained in a secured area. DEFICIENCY DF-3 In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the detention files removal from the cabinet includes the detainees name and A-file number; date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

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ICE.11.5082.001145

ODO reviewed the Environmental Health and Safety standard at YCJ to determine if the facility maintains high standards of cleanliness and sanitation, safe work practices and control of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility; interviewed staff; and reviewed chemical inventories, Material Safety Data Sheets (MSDS), and the master index of hazardous substances. Additionally, documentation of fire and safety inspections, fire drills, water and generator testing, and vermin and pest control were reviewed. Although YCJ has an inventory of hazardous substances, items were not listed in an easily-identifiable sequence, and the inventory list did not include all storage areas (Deficiency EH&S-1). YCJ maintains MSDS on a computer system; however, ODO observed not all sheets were accessible in the main storage area near the hazardous substances (Deficiency EH&S-2). This issue was resolved by the end of the inspection. The Maintenance Supervisor does not maintain a master index of all hazardous substances in the facility (Deficiency EH&S-3). Hazardous substances are not issued in single-day increments (Deficiency EH&S-4), and all inventories are not kept current before, during and after use (Deficiency EH&S-5). ODO observed numerous spray bottles throughout the facility which were not labeled correctly or were without labels (Deficiency EH&S-6). There are no exit/evacuation diagrams conspicuously posted in each area (Deficiency EH&S-7). The emergency generator is tested monthly, not bi-weekly (Deficiency EH&S-8). The facilitys barbershop does not contain appropriate cabinets, covered metal waste containers, laundered towels, or hair cloths (Deficiency EH&S-9). Hair care sanitation regulations are not posted in the barbershop (Deficiency EH&S-10).

DEFICIENCY EH&S-1 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of the hazardous (flammable, toxic, or caustic) substances used and stored in that area. Inventory records must be maintained separately for each substance, with entries for each logged on a separate card (or equivalent). That is, the account keeping must not be chronological, but filed alphabetically, by substance (dates, quantities, etc.). DEFICIENCY EH&S-2 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(B), the FOD must ensure every area using hazardous substances maintains a self-contained file of the corresponding MSDS.
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DEFICIENCY EH&S-3 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the Maintenance Supervisor or designate compiles a master index of all hazardous substances in the facility, including locations, along with a master file of MSDS. He/she must maintain this information in the safety office (or equivalent), with a copy to the local fire department. DEFICIENCY EH&S-4 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(2), the FOD must ensure the Maintenance Supervisor or designate issues hazardous substances in single-day increments. DEFICIENCY EH&S-5 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(4), the FOD must ensure the Maintenance Supervisor or designate maintains current inventory records for hazardous substances before, during and after each use. DEFICIENCY EH&S-6 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(J)(4), the FOD must ensure the Maintenance Supervisor or designate places correct labels on all smaller containers when only the larger shipping container bears the manufactureraffixed label. DEFICIENCY EH&S-7 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(g), the FOD must ensure the facility develops: a fire prevention, control, and evacuation plan, to include accessible, current floor plans (buildings and rooms); prominently posted evacuation maps/plans; and exit signs and directional arrows for traffic flow; with a copy of each revision filed with the local fire department. DEFICIENCY EH&S-8 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure power generators are tested at least every two weeks. DEFICIENCY EH&S-9 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(2), the FOD must ensure each barbershop provides all equipment and facilities necessary for maintaining sanitary procedures of hair care. Each shop must be provided with appropriate cabinets, covered metal containers for waste, disinfectants, dispensable headrest covers, laundered towels and haircloths.

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DEFICIENCY EH&S-10 In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(4), the FOD must ensure each barbershop has detailed hair care sanitation regulations posted in a conspicuous location for the use of all hair care personnel and detainees.

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ICE.11.5082.001148
FOOD SERVICE (FS)

ODO reviewed the Food Service standard at YCJ to determine if detainees are provided a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed policies and documentation; interviewed staff; inspected equipment, as well as food and chemical storage areas; observed meal preparation and satellite feeding; and verified food temperatures. A sign reminding staff to wash hands after using the toilet facility was not posted in the kitchen restroom (Deficiency FS-1). A three-compartment sink used for washing, rinsing, and sanitizing utensils and equipment was not labeled (Deficiency FS-2). Both of these deficiencies were corrected prior to the conclusion of the review.

DEFICIENCY FS-1 In accordance with the ICE NDS, Food Service, section (III)(H)(2)(a), the FOD must ensure staff and detainees not resume work after visiting the toilet facility without first washing their hands with soap or detergent. The Food Service Administrator must post signs to this effect. DEFICIENCY FS-2 In accordance with the ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least three labeled compartments is present for manually washing, rinsing, and sanitizing utensils and equipment.

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ICE.11.5082.001149

ODO reviewed the Funds and Personal Property standard at YCJ to determine if controls are in place to inventory, receipt, store, and safeguard detainees personal property, in accordance with the ICE NDS. ODO reviewed policies and procedures, and interviewed staff regarding the control and safeguarding of detainees personal property, funds, and valuables. Detainees do not arrive at YCJ with baggage or valuable personal property. Baggage or valuable personal property is kept at either the ERO San Francisco field office or the Sacramento sub-office. The detainee handbook does not notify detainees of facility policies and procedures concerning personal property (Deficiency F&PP-1 and DH-1).

DEFICIENCY F&PP-1 and DH-1 In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies detainees of the facility policies and procedures concerning personal property.

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ICE.11.5082.001150

ODO reviewed the Issuance and Exchange of Clothing, Bedding and Towels standard at YCJ to determine if the facility provides clean clothing, bedding, linens, and towels to every detainee upon arrival; and to determine if the facility provides ICE detainees with regular exchanges of clothing, linens and towels for as long as they remain in detention, in accordance with the ICE NDS. ODO observed the intake and admissions process, interviewed YCJ staff, and reviewed policies and procedures. ODO interviewed two clothing officers at YCJ. Both officers stated the facility issues socks and underwear to detainees on Mondays, Wednesdays, and Fridays (Deficiency IECB&T-1).

DEFICIENCY IECB&T-1 In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), the FOD must ensure socks and undergarments are exchanged daily.

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ICE.11.5082.001151

ODO reviewed the Key and Lock Control standard at YCJ to determine if facility safety and security is maintained by requiring keys and locks to be controlled and maintained, in accordance with the ICE NDS. ODO toured the facility, and observed accountability, use, and maintenance of keys and locks. ODO also interviewed staff, and reviewed local policies and documentation.
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ICE.11.5082.001153
MEDICAL CARE (MC)

ODO reviewed the Medical Care standard at YCJ to determine if detainees have access to healthcare and emergency services to meet health needs in a timely manner, in accordance with the ICE NDS. ODO toured the clinic, interviewed staff, and reviewed 25 medical records, including the records of three detainees who registered complaints during detainee interviews. Policies, medical staff credentials, and staff clinical files were also reviewed. The Yuba County Health Department operates the facilitys clinic; it holds no accreditations. The clinic is small, but secure, and is administered by the Executive Assistant (EA) to the Medical Director. According to the EA, staffing is at 100 percent for all disciplines. According to the EA, at the time of admission, detainees are interviewed and asked health-related questions by a booking officer who has not been trained to perform this function. If the booking officer determines the detainee should be seen by medical staff the same day, due to a chronic condition or medication requirements, medical staff is alerted by a notation on the booking questionnaire routed to the clinic for review. A review of medical records revealed screening by medical staff occurred between three and eleven days after the detainees arrival (Deficiency MC-1). Health appraisals and physical examinations (PE) were not completed within 14 days on two records reviewed: one appraisal was completed 20 days after arrival, and the other was completed 41 days after arrival (Deficiency MC-2). Detainees obtain health care services by completing sick call slips. Slips are collected by nursing staff during the distribution of medication, or are given to correctional officers to be forward to the clinic (Deficiency MC-3). A review of staff training records revealed full compliance by the security staff for annual cardiopulmonary resuscitation (CPR) training; however, the EA reported medical staff is not required to maintain CPR certification (Deficiency MC-4). There is no Medical/Psychiatric Alert process in place to ensure clearance by medical staff for special medical or psychiatric conditions prior to transfer or release (Deficiency MC-5). The EA stated a transfer list is generated by ICE, and faxed to the clinic for review and clearance; however, this system does not ensure special conditions are flagged. The EA reported a detainee with a communicable disease was transferred, and then returned upon discovering he was contagious. During the medical record review, ODO discovered a sick call slip from an insulindependent diabetic requesting a snack. Medical staff documented on the form no indications for a bedtime snack. Policy CMS-002-023, Diabetes, dated August 21, 2006, states: Evening snacks should be provided for all inmates who are treated with either oral or injectable hypoglycemic agents. Snacks may consist of milk, sandwich, crackers, or fruit. A review of the whiteboard in the Food Service Managers office
(b)(7)e
ICE.11.5082.001154
revealed only three out of the twenty patients on diabetic diets were authorized evening snacks. This low number may be reflective of marginal application of the policy.

DEFICIENCY MC-1 In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure detention facilities perform initial medical and mental health screening immediately upon arrival by a health care provider or an officer trained to perform this function. DEFICIENCY MC-2 In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure all physical examinations are performed within 14 days of arrival. DEFICIENCY MC-3 In accordance with the ICE NDS, Medical Care, section (III)(M), the FOD must ensure medical providers protect the privacy of detainees medical information to the extent possible, while permitting the exchange of health information required to fulfill program responsibilities and to provide for the well being of detainees. DEFICIENCY MC-4 In accordance with the ICE NDS, Medical Care, section (III)(H), the FOD must ensure detention facilities require staff training in the administration of CPR. DEFICIENCY MC-5 In accordance with the ICE NDS, Medical Care, section (III)(N), the FOD must ensure detention facilities utilize a mechanism to guarantee clearance by medical staff for special medical or psychiatric conditions prior to the transfer or release of a detainee.

(b)(7)e
ICE.11.5082.001155

ODO reviewed the Population Counts standard at YCJ to determine if the facility has an effective system of conducting population counts, which ensures detainee accountability, in accordance with the ICE NDS. ODO reviewed policies, observed the count process, and interviewed staff.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.001156
POST ORDERS (PO)

ODO reviewed the Post Orders standard at YCJ to determine if the facility has established post orders for each post that are available to all officers and specify the duties, procedures, and responsibilities of each post, in accordance with the ICE NDS. ODO interviewed staff, reviewed training files, inspected post order binders on posts, and verified the availability of post orders to all staff via the facilitys intranet.
(b)(7)e
(b)(7)e

(b)(7)e
26
ICE.11.5082.001157
RECREATION (R)
ODO reviewed the Recreation standard at YCJ to determine if detainees are provided access to recreational programs and activities within the constraints of a safe and secure environment, in accordance with the ICE NDS. ODO inspected the recreation area, reviewed local policies, interviewed staff and inmates, and reviewed documentation. The facility does not have a designated individual responsible for the recreation program (Deficiency R-1). YCJ has one outdoor recreation area accessed by detainees for two-hour periods, four days a week (Deficiency R-2).

DEFICIENCY R-1 In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure facilities have an individual responsible for the development and oversight of the recreation program. DEFICIENCY R-2 In accordance with the ICE NDS, Recreation, section (III)(B)(1), the FOD must ensure, if outdoor recreation is available at the facility, each detainee has access for at least one hour daily, at a reasonable time of day, five days a week, weather permitting.

(b)(7)e
ICE.11.5082.001158

ODO reviewed the Security Inspections standard at YCJ to determine if the facility security is maintained, and events posing a risk of harm are prevented, in accordance with the ICE NDS. ODO toured the facility; interviewed staff; and reviewed local policies, logbooks and other documents pertaining to the security inspection process.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.001159

ODO reviewed the Special Management Unit (SMU) standard at YCJ to determine if the facility has procedures in place to temporarily segregate detainees for disciplinary and administrative reasons, in accordance with the ICE NDS. ODO observed SMU operations; reviewed policies, logbooks, and relevant documentation; and interviewed staff.
(b)(7)e
(b)(7)e

(b)(7)e
29
ICE.11.5082.001160

ODO reviewed the Staff-Detainee Communication standard at YCJ to determine if procedures are in place to allow formal and informal contact between detainees and key ICE and facility staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses in a timely manner, in accordance with the ICE NDS. ODO reviewed logbooks, observed interaction between ERO and detainees, and interviewed staff and detainees. ODO found detainee requests are not placed in the detainees detention file (Deficiency SDC-1), and written schedules of ICE visits are not posted in all living areas (Deficiency SDC-2).

DEFICIENCY SDC-1 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and remain in the detainees detention file for at least three years. DEFICIENCY SDC-2 In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(2)(b), the FOD must ensure written schedules are developed and posted in the detainee living areas and other areas with detainee access.

(b)(7)e
ICE.11.5082.001161

ODO reviewed the Suicide Prevention and Intervention standard at YCJ to determine if the health and well being of detainees are protected by training staff in effective methods of suicide prevention, in accordance with the ICE NDS. ODO inspected the suicide watch rooms in the booking area; interviewed staff; and reviewed ten staff training records, the medical records of two detainees on suicide watch, the Suicide Prevention Handbook, and the Suicide Prevention and Intervention Manual. The Suicide Prevention Handbook, and Suicide Prevention and Intervention Manual serve as YCJ policy. Both meet ICE NDS requirements, with one exception. Neither addresses ICE reporting requirements for detainees who are suicidal or require special housing for suicide risk (Deficiency SP&I-1). YCJ does not maintain a log of detainees placed on suicide watch during the year; however, ODO was able to identify two detainees who had recently been on suicide watch. A review of the medical records for these two detainees revealed suicide prevention management was consistent with YCJ written procedures and ICE NDS requirements.

DEFICIENCY SP&I-1 In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD must ensure detention facilities include, in policy, ICE reporting procedures regarding detainees who are suicidal or require special housing for suicide risk.

(b)(7)e
ICE.11.5082.001162

ODO reviewed the Telephone Access standard at YCJ to determine if the facility provides detainees with reasonable and equitable access to telephones to maintain ties with family and others in the community, in accordance with the ICE NDS. ODO interviewed staff and detainees; reviewed facility policies, procedures, and the detainee handbook; and tested the telephones in detainee housing units. YCJ records all telephone conversations, including privileged calls; there is no privacy for detainees making legal calls (Deficiency TA-1). Detainees are not notified telephone calls are recorded. Notifications regarding recorded telephone calls are not mentioned in the detainee handbook, or posted on the telephones or on housing unit bulletin boards (Deficiency TA-2 and DH-2). The telephone service does not allow free or direct calls to special designated groups (Deficiency TA-3). Detainees are not able to contact the DHS Office of the Inspector General (OIG) directly (Deficiency TA-4).

DEFICIENCY TA-1 In accordance with the ICE NDS, Telephone Access, section (III)(J), the FOD must ensure the facility ensures privacy for detainees telephone calls regarding legal matters. For this purpose, the facility must provide a reasonable number of telephones on which detainees can make such calls without being overheard by officers, other staff or other detainees. Facility staff must not electronically monitor detainee telephone calls for legal matters, absent a court order. DEFICIENCY TA-2 and DH-2 In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure, if telephone calls are monitored, the facility notifies detainees in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each monitored telephone stating: that detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation. DEFICIENCY TA-3 In accordance with the ICE NDS, Telephone Access, section (III)(E), the FOD must ensure, even if telephone service is generally limited to collect calls, the facility permits the detainee to make direct calls: to the local immigration court and the Board of Immigration Appeals; to Federal and State courts where the detainee is or may become involved in a legal proceeding; to consular officials; to legal service providers, in pursuit of legal representation or to engage in consultation concerning his/her expedited removal case; to a government office, to obtain documents relevant to his/her immigration case; and in a personal or family emergency, or when the detainee can otherwise demonstrate a compelling need (to be interpreted liberally).

(b)(7)e
32
ICE.11.5082.001163
DEFICIENCY TA-4 In accordance with the ERO memorandum, entitled Change Notice National Detention Standards Staff-Detainee Communication Standard, dated June 15, 2007, the FOD must ensure detainees are able to directly communicate with the DHS OIG from any detainee telephone system at all facilities housing ICE detainees.

(b)(7)e
33
ICE.11.5082.001164

ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not Resuscitate orders, and organ donations, at YCJ to determine if the facilitys policies and practices are in accordance with the ICE NDS. ODO interviewed medical staff. There have been no detainee deaths at the facility within the last year. According to the EA to the Medical Director, YCJ does not have policies addressing terminal illness, advance directives, do not resuscitate orders, or death (Deficiency TIADD-1).

DEFICIENCY TIADD-1 In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure detention facilities have policies and procedures addressing the issues of terminal illness, fatal injury, advance directives, and detainee death.

(b)(7)e
34
ICE.11.5082.001165
TOOL CONTROL (TC)

ODO reviewed the Tool Control standard at YCJ to determine if tools are properly classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO observed all areas maintaining tools, reviewed policies, and interviewed staff.
(b)(7)e
(b)(7)e

(b)(7)e
ICE.11.5082.001166
USE OF FORCE (UOF)

ODO reviewed the Use of Force standard at YCJ to determine if necessary use of force is utilized only after all reasonable efforts have been exhausted to gain control of a detainee, while protecting and ensuring the safety of detainees, staff, and others, preventing serious property damage, and ensuring the security and orderly operation of the facility, in accordance with the ICE NDS. ODO reviewed policies and use of force documentation, and inspected equipment and inventories. Staff was interviewed to determine their level of knowledge and understanding of the circumstances warranting immediate and calculated uses of force.
(b)(7)e
(b)(7)e

(b)(7)e
36
ICE.11.5082.001167
(b)(7)e

(b)(7)e
37
ICE.11.5082.001168
VISITATION (V)
ODO reviewed the Visitation standard at YCJ to determine if authorized persons, including legal and media representatives, are able to visit detainees within security and operational constraints, in accordance with the ICE NDS. ODO observed visitation practices, reviewed written policies, and interviewed staff. YCJ does not maintain separate logbooks for general and legal visitors (Deficiency V-1). Detainees are allowed to visit privately with their legal representatives during normal visitation hours, but not during meal times (Deficiency V2). There were no copies of Notice of Entry of Appearance as Attorney or Accredited Representative (Form G-28) available in the visitors reception area (Deficiency V-3). This deficiency was corrected prior to the prior to the conclusion of the review.

DEFICIENCY V-1 In accordance with the ICE NDS, Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all general visitors, and a separate log of legal visitors. DEFICIENCY V-2 In accordance with the ICE NDS, Visitation, section (III)(I)(2), the FOD must ensure, on regular business days, legal visitations may proceed through a scheduled meal period. In such cases, the detainee must receive a tray or sack meal after the visit. DEFICIENCY V-3 In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure copies of Form G-28 are readily available in the legal visitors reception area.

(b)(7)e
38
ICE.11.5082.001169
APPENDIX A
Acronyms
ACA COTR CXR DIHS DOS DRO DSCU EABM EADM EOIR FOD FSA HSA HQ ICE IDP IEA JIC JPATS KOP LVN MOU MRT MSDS NDS NP OB OIC ODO OPR ORR OTC PE PHS POA PPD R&D RN SIR SMU TAR TB UDC American Corrections Association Contracting Officer Technical Representative Chest X-ray Division of Immigration Health Services Detention Operations Supervisor Detention and Removal Operations Detention Standards Compliance Unit Enforce Alien Booking Module Enforcement Detention Module Executive Office of Immigration Review Field Office Director Food Service Administrator Health Services Administrator Headquarters Immigration and Customs Enforcement Institution Disciplinary Panel Immigration Enforcement Agent Joint Intake Center Justice Prisoner and Alien Transport System Keep on Persons Licensed Vocational Nurse Memorandum of Understanding Medical Records Technician Material Safety Data Sheets National Detention Standards Nurse Practitioner Obstetric Officer in Charge Office of Detention Oversight Office of Professional Responsibility Office of Refugee Resettlement Over the Counter Physical Education Public Health Service Plan of Action Purified Protein Derivative Receiving and Discharge Registered Nurse Significant Incident Report Special Management Unit Treatment Authorization Request Tuberculosis Unit Disciplinary Committee

(b)(7)e
39
ICE.11.5082.001170
APPENDIX B
DETENTION STANDARD DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Access to Legal Material, sections (III)(B) and (G), the FOD must ensure the law library provides an adequate number of typewriters and/or computers, writing implements, paper, and office supplies to enable detainees to prepare documents for legal 9 proceedings. The FOD must devise a flexible schedule to permit all detainees, regardless of housing or classification, to use the law library on a regular basis. Each detainee must be permitted to use the law library for a minimum of five hours per week. In accordance with the ICE NDS, Admission and Release, sections (III)(J) and (A)(1), the FOD must ensure the facility has a medium to provide detainees with an orientation to the 10 facility. The orientation process must be supported by an approved ICE video and handbook, which must inform new arrivals about the facility operations, programs, and services. In accordance with the ICE NDS, Admission and Release, section (III)(A)(3), the FOD must ensure a medical screening is conducted during 10 the admissions process for all newlyarrived detainees, in order to protect the health of the detainees and others in the facility.
ALM-1
AR-1
AR-2

(b)(7)e
40
ICE.11.5082.001171
DETENTION STANDARD
C&OM-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(E)(2), the FOD must ensure facilities implement procedures for inspecting special correspondence for 11 contraband. Any such inspection must be in the presence of the detainee. Special correspondence includes written communication from courts.
In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(G), the FOD must ensure all facilities implement policies and procedures addressing the issue of acceptable and non-acceptable mail. The affected detainees must be notified when incoming or outgoing mail is confiscated or withheld. The detainee must receive a receipt for the
C&OM-1
11
DCS-1
(b)(7)e
12
DGP-1
DGP-2
Detainee Grievance Procedures, section (III)(E), the FOD must ensure a copy of the grievance remains in the detainees detention file for at least three years. In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(F), the FOD must ensure facilities forward detainee grievances alleging officer misconduct to ICE.
13
13

(b)(7)e
ICE.11.5082.001172
DETENTION STANDARD
Detainee Handbook
DH-1 and F&PP-1
Detainee Handbook
DH-2 and TA-2
Detention Files
DF-1
Detention Files
DF-2
Detention Files
DF-3
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies 13 detainees of the facility policies and procedures concerning personal property. In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure, if telephone calls are monitored, the facility notifies detainees in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each 13 monitored telephone stating: that detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation. In accordance with the ICE NDS, Detention Files, section (III)(C), the FOD must ensure, during the course of the detainees stay at the facility, staff 14 adds documents associated with normal operations to the detainees detention file without prior approval. In accordance with the ICE NDS, Detention Files, section (III)(D), the FOD must ensure detainee detention 14 files are located and maintained in a secured area. In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, at a minimum, a logbook entry recording the detention files removal from the cabinet includes the detainees name and A-file number; 14 date and time removed; reason for removal; signature of person removing the file, including title and department; date and time returned; and signature of person returning the file.

(b)(7)e
42
ICE.11.5082.001173
DETENTION STANDARD
EH&S-1
EH&S -2
EH&S -3
EH&S -4
EH&S -5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Environmental Health and Safety, section (III)(A), the FOD must ensure every area maintains a running inventory of the hazardous (flammable, toxic, or caustic) substances used and stored in that area. Inventory records 16 must be maintained separately for each substance, with entries for each logged on a separate card (or equivalent). That is, the account keeping must not be chronological, but filed alphabetically, by substance (dates, quantities, etc.). In accordance with the ICE NDS, Environmental Health and Safety, section (III)(B), the FOD must ensure 16 every area using hazardous substances maintains a self-contained file of the corresponding MSDS. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must ensure the Maintenance Supervisor or designate compiles a master index of all hazardous substances in the facility, 17 including locations, along with a master file of MSDS. He/she must maintain this information in the safety office (or equivalent), with a copy to the local fire department. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(2), the FOD must ensure 17 the Maintenance Supervisor or designate issues hazardous substances in single-day increments. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(4), the FOD must ensure the Maintenance Supervisor or 17 designate maintains current inventory records for hazardous substances before, during and after each use.

(b)(7)e
ICE.11.5082.001174
DETENTION STANDARD
EH&S -6
EH&S -7
EH&S -8
EH&S -9
EH&S -10
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Environmental Health and Safety, section (III)(J)(4), the FOD must ensure the Maintenance Supervisor or 17 designate places correct labels on all smaller containers when only the larger shipping container bears the manufacturer-affixed label. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(g), the FOD must ensure the facility develops: a fire prevention, control, and evacuation plan, to include accessible, current floor 17 plans (buildings and rooms); prominently posted evacuation maps/plans; and exit signs and directional arrows for traffic flow; with a copy of each revision filed with the local fire department. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must ensure 17 power generators are tested at least every two weeks. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(2), the FOD must ensure each barbershop provides all equipment and facilities necessary for maintaining sanitary procedures of hair care. Each 17 shop must be provided with appropriate cabinets, covered metal containers for waste, disinfectants, dispensable headrest covers, laundered towels and haircloths. In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(4), the FOD must ensure each barbershop has detailed hair care 18 sanitation regulations posted in a conspicuous location for the use of all hair care personnel and detainees.

(b)(7)e
44
ICE.11.5082.001175
DETENTION STANDARD
Food Service
FS-1
Food Service
FS-2
F&PP-1 and DH-1
IECB&T-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Food Service, section (III)(H)(2)(a), the FOD must ensure staff and detainees not resume work after visiting the toilet 19 facility without first washing their hands with soap or detergent. The Food Service Administrator must post signs to this effect. In accordance with the ICE NDS, Food Service, section (III)(H)(7)(f)(1), the FOD must ensure a sink with at least 19 three labeled compartments is present for manually washing, rinsing, and sanitizing utensils and equipment. In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must ensure the detainee handbook or equivalent notifies 20 detainees of the facility policies and procedures concerning personal property. In accordance with the ICE NDS, Issuance and Exchange of Clothing, Bedding, and Towels, section (III)(E), 21 the FOD must ensure socks and undergarments are exchanged daily.
K&LC-1
22
K&LC-2
(b)(7)e
22
K&LC -3
22

(b)(7)e
ICE.11.5082.001176
DETENTION STANDARD
K&LC-4
(b)(7)e
22
K&LC-5
23
Medical Care
MC-1
Medical Care
MC-2
Medical Care
MC-3
Medical Care
MC-4
Medical Care, section (III)(D), the FOD must ensure detention facilities perform initial medical and mental health screening immediately upon arrival by a health care provider or an officer trained to perform this function. In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure all physical examinations are performed within 14 days of arrival. In accordance with the ICE NDS, Medical Care, section (III)(M), the FOD must ensure medical providers protect the privacy of detainees medical information to the extent possible, while permitting the exchange of health information required to fulfill program responsibilities and to provide for the well being of detainees. In accordance with the ICE NDS, Medical Care, section (III)(H), the FOD must ensure detention facilities require staff training in the administration of CPR.
25
25
25
25

(b)(7)e
46
ICE.11.5082.001177
DETENTION STANDARD
Medical Care
MC-5
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Medical Care, section (III)(N), the FOD must ensure detention facilities utilize a mechanism to guarantee clearance by 25 medical staff for special medical or psychiatric conditions prior to the transfer or release of a detainee.
Population Counts
PC-1
26
Population Counts
PC-2
(b)(7)e
26
Post Orders
PO-1
27
Recreation
R-1
Recreation
R-2
Recreation, section (III)(F), the FOD must ensure facilities have an individual responsible for the development and oversight of the recreation program. In accordance with the ICE NDS, Recreation, section (III)(B)(1), the FOD must ensure, if outdoor recreation is available at the facility, each detainee has access for at least one hour daily, at a reasonable time of day, five days a week, weather permitting.
28
28
SI-1
(b)(7)e
29

(b)(7)e
47
ICE.11.5082.001178
DETENTION STANDARD
SI-2
29
(b)(7)e
SI-3
29
SMU-1
SDC-1
In accordance with the ICE NDS, Special Management Unit, Administrative Segregation, section (E)(1), and Disciplinary Segregation, section (E)(1), the FOD must ensure a permanent log is maintained in the SMU. The log must record all activities concerning the SMU detainees; e.g., meals served, recreation, visitors, etc. In accordance with the ICE NDS, StaffDetainee Communication, section (III)(B)(2), the FOD must ensure all completed detainee requests are filed in the detainees detention file, and remain in the detainees detention file for at least three years.
30
31

(b)(7)e
48
ICE.11.5082.001179
DETENTION STANDARD
SDC-2
SP&I-1
Telephone Access
TA-1
Telephone Access
TA-2 and DH-2
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, StaffDetainee Communication, section (III)(A)(2)(b), the FOD must ensure 31 written schedules are developed and posted in the detainee living areas and other areas with detainee access. In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD must ensure detention facilities include, in policy, ICE 32 reporting procedures regarding detainees who are suicidal or require special housing for suicide risk. In accordance with the ICE NDS, Telephone Access, section (III)(J), the FOD must ensure the facility ensures privacy for detainees telephone calls regarding legal matters. For this purpose, the facility must provide a reasonable number of telephones on 33 which detainees can make such calls without being overheard by officers, other staff or other detainees. Facility staff must not electronically monitor detainee telephone calls for legal matters, absent a court order. In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure, if telephone calls are monitored, the facility notifies detainees in the detainee handbook or equivalent provided upon admission. The facility must also place a notice at each 33 monitored telephone stating: that detainee calls are subject to monitoring; and the procedures for obtaining an unmonitored call to a court, legal representative, or for the purposes of obtaining legal representation.

(b)(7)e
49
ICE.11.5082.001180
DETENTION STANDARD
Telephone Access
TA-3
Telephone Access
TA-4
TIADD-1
DEFICIENCIES AND REQUIREMENTS PAGE In accordance with the ICE NDS, Telephone Access, section (III)(E), the FOD must ensure, even if telephone service is generally limited to collect calls, the facility permits the detainee to make direct calls: to the local immigration court and the Board of Immigration Appeals; to Federal and State courts where the detainee is or may become involved in a legal proceeding; to consular officials; to legal 33 service providers, in pursuit of legal representation or to engage in consultation concerning his/her expedited removal case; to a government office, to obtain documents relevant to his/her immigration case; and in a personal or family emergency, or when the detainee can otherwise demonstrate a compelling need (to be interpreted liberally). In accordance with the ERO memorandum, entitled Change Notice National Detention Standards StaffDetainee Communication Standard, dated June 15, 2007, the FOD must 34 ensure detainees are able to directly communicate with the DHS OIG from any detainee telephone system at all facilities housing ICE detainees. In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death, section (I), the FOD must ensure detention facilities have policies 35 and procedures addressing the issues of terminal illness, fatal injury, advance
Tool Control
TC-1
(b)(7)e
36

(b)(7)e
ICE.11.5082.001181
DETENTION STANDARD
Tool Control
TC-2
36
Tool Control
TC-3
36
(b)(7)e
Use of Force
UOF-1
37

(b)(7)e
51
ICE.11.5082.001182
DETENTION STANDARD
Use of Force
UOF-2
37
Use of Force
UOF-3
38
(b)(7)e
Use of Force
UOF-4
38
Visitation
V-1
Visitation
V-2
Visitation
V-3
Visitation, section (III)(C), the FOD must ensure the facility maintains a log of all general visitors, and a separate log of legal visitors. In accordance with the ICE NDS, Visitation, section (III)(I)(2), the FOD must ensure, on regular business days, legal visitations may proceed through a scheduled meal period. In such cases, the detainee must receive a tray or sack meal after the visit. In accordance with the ICE NDS, Visitation, section (III)(I)(8), the FOD must ensure copies of Form G-28 are readily available in the legal visitors reception area.
39
39
39

(b)(7)e
52
ICE.11.5082.001183

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U.S.

Department of Homeland Security

Office of Detention Oversight

August 25-26, 2010

INSPECTION TEAM MEMBERS

Office of Detention Oversight Augu OPR (b)(7)e

Atlanta City Detention Center ERO Atlanta

Office of Detention Oversight August 2010 OPR (b)(7)e

Atlanta City Detention Center ERO Atlanta

ICE NATIONAL DETENTION STANDARDS

DETAINEE CLASSIFICATION SYSTEM

Office of Detention Oversight August 2010 OPR (b)(7)e

Atlanta City Detention Center ERO Atlanta

ENVIRONMENTAL HEALTH AND SAFETY

Office of Detention Oversight August 2010 OPR (b)(7)e

Atlanta City Detention Center ERO Atlanta

Office of Detention Oversight August 2010 OPR (b)(7)e

Atlanta City Detention Center ERO Atlanta

Office of Detention Oversight August 2010 OPR 200901313

Atlanta City Detention Center ERO Atlanta

U.S. Department of Homeland Security

Office of Detention Oversight

July 27-29, 2010 ________________________________

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APPENDIX ACRONYMS SUMMARY OF REQUIREMENTS FOR DEFICIENT FINDINGS A B

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INSPECTION TEAM MEMBERS

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

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Baker County Detention Center ERO Miami

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

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Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

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Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

ICE NATIONAL DETENTION STANDARDS

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

ADMISSION AND RELEASE (AR)

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

Office of Detention Oversight July OPR (b)(7)e

Baker County Detention Center ERO Miami

DETAINEE GRIEVANCE PROCEDURES (DGP)

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

DETENTION FILES (DF)

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami

ENVIRONMENTAL HEALTH AND SAFETY (EH&S)

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS

Office of Detention Oversight July 2010 OPR (b)(7)e

Baker County Detention Center ERO Miami