U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Management Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Quality Assurance Review

Enforcement and Removal Operations
Phoenix Field Office
Eloy Detention Center
Eloy, Arizona

April 26 – 28, 2011

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 ICE Policy 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.

 QUALITY ASSURANCE REVIEW
ELOY DETENTION 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 PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................ 5
Correspondence and Other Mail .......................................................................... 6
Detainee Handbook ............................................................................................. 7
Detention Files .................................................................................................... 8
Environmental Health and Safety......................................................................... 9
Key and Lock Control ....................................................................................... 10
Law Libraries and Legal Material ...................................................................... 11
Medical Care ..................................................................................................... 13
Suicide Prevention and Intervention .................................................................. 15
Terminal Illness, Advance Directives, and Death ............................................... 16
Use of Force and Restraints ............................................................................... 17
LIST OF ACRONYMS ............................................................................................... 18

 EXECUTIVE SUMMARY

From April 26 lmtil April 28, 2011, the Of?ce of Professional Responsibility (OPR), Of?ce of
Detention Oversight (ODO) conducted a Quality Assru?ance Review (QAR) of the Eloy
Detention Center (EDC), Eloy, Arizona. EDC, which opened in May 1994, is owned and
operated by Corrections Corporation of America (C A) for the City of Eloy, Arizona. The City
of Eloy has an Intergovernmental Service Agreement (IGSA) with ICE. EDC accommodates
ICE detainees of all classi?cation levels for periods in excess of 72 how's. Medical care is
provided by the ICE Health Service Corps (IHSC), and food service is provided under contract
by Canteen Correctional Services. EDC maintains accreditation through the American
Correctional Association (AC A) .

Dru?ing the QAR, ODO examined processes employed at EDC to determine compliance with ICE

policies and the 2008 ICE Performance Based National Detention Standards EDC

compliance is the responsibility of the Of?ce of Enforcement and Removal Operations (ERO),

Field Of?ce Director (FOD), Phoenix, Arizona (FOD/Phoenix). An Assistant Field Of?ce

Director (AFOD) physically located at EDC oversees ICE detention operations at the facility.

Onsite ICE staff consists Supervisory Detention and Deportation Of?cer (SDDO (7) (E)
positions, with. vacancres; Deportation Of?cer (DO) positions, with one vacanc (7) (E)
Supervisory Enforcement Agent (SIEA) positions, with no vacancies; and (7) (3)
Immigration Enforcement Agent IEA) positions, with vacancies. The total number 0 staff (7) E)
(non-ICE) employed at EDC is . The ICE detainee capacity is 1,550. At the time of the

ODO review, EDC housed 1,462 ICE detainees (1,035 males and 427 females).

 
 

 

Compliance with the ICE 2008 became mandatory when ICE modi?ed the current
IGSA effective February 17, 2010. ERO contractors, MGT of America, Inc., conducted the ?rst
annual review of the ICE 2008 at the EDC on February 1 3, 2011. The facility
received an overall rating of ?Meets Standards.? This QAR is the ?rst review
completed at EDC by ODO. Previously, the OPR Detention Facilities Inspection Group (DFIG)
conducted a QAR of 21 detention standards rmder the 2000 ICE National Detention Standards on
February 10 12, 2009, and noted 28 de?ciencies. The Follow-11p Inspection conducted by
ODO on June 29 30, 2010, recorded one repeat de?ciency in the area of Suicide Prevention
and Intervention.

Dru?ing this QAR, ODO reviewed a total of 24 14 areas were found to be fully
compliant, while 10 areas had a total of 13 de?ciencies, including the following: Correspondence
and Other Mail (1 de?ciency); Detainee Handbook Detention Files Environmental
Health and Safety Key and Lock Control Law Libraries and Legal Material Medical
Care Suicide Prevention and Intervention Terminal Illness, Advance Directives and
Death and Use of Force and Restraints (1).

Overall, ODO found EDC to be in compliance with the reviewed dru'ing the 
however, 11 of the 75 detainees interviewed by ODO stated they were reluctant to ?le grievances
because they felt intimidated when they were required by a Correctional Of?cer (C O) to
articulate their complaints prior to being provided grievance forms. Fluther inquiry by ODO

 

Of?ce of Detention Oversight Eloy Detention Center
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OPR 201106000

established this questioning by a CO was intended as a preliminary assessment prior to the
submission of a formal grievance; the PBNDS requires that detainee grievances be resolved at
the lowest level possible before elevating the issue to a formal grievance. ODO recommended to
the Warden that each CO be provided training to clarify the intent of questioning regarding
detainee requests for grievance forms.
In compliance with the Staff-Detainee Communication standard, ICE personnel conduct daily
scheduled and unscheduled visits to housing units to address detainee concerns and respond to
inquiries.
Of the 75 detainees interviewed by ODO regarding the Food Service standard, 23 complained
that food portions were too small. ODO found that a master-cycle menu is used and a registered
dietitian certifies the menu. EDC is in full compliance with the PBNDS regarding food portions.
EDC has a fully-functioning medical unit to address detainee health care. The ODO inspection
of 30 medical records revealed detainees are screened upon arrival by a Nurse Practitioner (NP),
a Physician’s Assistant (PA), or a Registered Nurse (RN). However, none of the 30 records for
the detainee’s initial screening had been reviewed by the clinical medical authority to assess
priority for treatment as required by the PBNDS. Additionally, ODO determined the clinical
medical authority had reviewed only three of the 30 health appraisals audited by ODO. The
PBNDS requires all health appraisals to be completed and reviewed by the clinical medical
authority within 14 days of the detainee’s arrival.
This report includes descriptions of all deficiencies and refers to the specific, relevant PBNDS.
The report will be provided to ERO to develop corrective actions to resolve the 13 identified
deficiencies.

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 INSPECTION PROCESS
ODO primarily focuses on areas of noncompliance with the ICE National Detention Standards
(NDS) or the ICE 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 ERO Headquarters (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.
ODO reviewed the processes employed at EDC 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 HQ staff to fully prepare for the site visit at EDC.

REPORT ORGANIZATION
This report contains a detailed synopsis of those PBNDS areas ODO found to be deficient in at
least one aspect of the standard. Instances in which detention standards 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 nationwide 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.

INSPECTION TEAM MEMBERS
Special Agent (Team Leader)
Special Agent
Special Agent
Detention and Deportation Officer
Contract Inspector
Contract Inspector
Contract Inspector

ODO, Phoenix, AZ
ODO, Phoenix, AZ
ODO, Phoenix, AZ
ODO, San Diego, CA
MGT of America, Inc
MGT of America, Inc.
MGT of America, Inc.

(b)(6), (b)(7)(C)
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 OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed supervisory ICE and CCA staff, to include the Warden, Assistant Warden,
AFOD, and the Detention Operations Supervisor (DOS). ODO also interviewed a DO and a CO.
CCA command staff and the AFOD expressed interest in the outcome of the review and were
committed to achieving compliance with the PBNDS. All ERO and CCA interview subjects
were cooperative and provided assistance throughout the inspection process. Staff interviewed
by ODO stated that ICE personnel conduct daily visits to the detainee housing units and
throughout the facility.
ERO management stated that despite human resource limitations, morale among EDC and ICE
staff is good, and the working relationship is mutually beneficial. Both entities described the
work environment at EDC as professional.

DETAINEE RELATIONS
ODO interviewed 75 randomly-selected detainees to assess the detention conditions at EDC. All
of the detainees interviewed stated they receive daily recreation, can send and receive mail, use
the telephones, and have access to the law library. All detainees stated they were treated with
dignity and respect. All expressed satisfaction with the quality of the food; however 23 detainees
felt the food portions were too small. ODO verified during the review of the Food Service
PBNDS that a master-cycle menu is used and a registered dietitian certifies the menu. EDC is in
full compliance with the PBNDS regarding food portions.
During detainee interviews, 11 detainees stated they were reluctant to file grievances because
they were required by a CO to articulate their grievances prior to being provided with a
grievance form. Further inquiry by ODO established this questioning by a CO was intended as a
preliminary assessment prior to the submission of a formal grievance; the PBNDS requires that
detainee grievances be resolved at the lowest level possible before elevating the issue to a formal
grievance. ODO recommended to the Warden that each CO be provided training to clarify the
intent of questioning regarding detainee requests for grievance forms.

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 ICE PERFORMANCE BASED NATIONAL
DETENTION STANDARDS
A total of 24 PBNDS were reviewed during the ODO inspection. Deficiencies were found in the
following ten areas:
Correspondence and Other Mail
Detainee Handbook
Detention Files
Environmental Health and Safety
Key and Lock Control
Law Libraries and Legal Material
Medical Care
Suicide Prevention and Intervention
Terminal Illness, Advance Directives and Death
Use of Force and Restraints
ODO found EDC fully compliant with the following 14 standards:
Admission and Release
Disciplinary System
Food Service
Funds and Personal Property
Grievance System
Hold Rooms in Detention Facilities
Hunger Strikes
Personal Hygiene
Post Orders
Recreation
Special Management Unit
Staff-Detainee Communication
Telephone Access
Tool Control
As these 14 standards were compliant at the time of the review, a synopsis for these areas was
not prepared for this report.

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 CORRESPONDENCE AND OTHER MAIL (C&OM)
ODO reviewed the Correspondence and Other Mail standard at EDC 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 PBNDS. ODO interviewed EDC staff members and reviewed local policies, logbooks
and the detainee handbook.
The EDC detainee handbook does not notify detainees that incoming general correspondence
will be opened and inspected in the detainee’s presence. Awareness of what to expect during
mail delivery can alleviate detainee concerns about mail tampering. Additionally, written
instructions on how to obtain writing supplies are directed only at indigent detainees (Deficiency
C&OM-1). All detainees should be made aware of how to access correspondence materials for
legal and general correspondence.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY C&OM-1
In accordance with the ICE PBNDS, Correspondence and Other Mail, section (V)(C)(3) and (9),
the FOD must ensure that the facility shall notify 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 shall specify: 3. That general correspondence and
other mail addressed to detainees will be opened and inspected in the detainee’s presence, unless
the facility administrator authorizes inspection without the detainee’s presence for security
reasons; and 9. The procedure to obtain writing implements, paper, and envelopes.

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 DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at EDC 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 facility’s rules and
sanctions, disciplinary system, mail and visiting procedures, grievance system, services,
programs, and medical care, in accordance with the PBNDS. ODO interviewed staff and
detainees, and reviewed the detainee handbook.
Upon admission to the EDC, as part of the orientation program, EDC provides detainees with a
copy of the ICE National Detainee Handbook. EDC detainee handbooks are available in English
and Spanish. A review of the detainee roster revealed the majority of detainees at EDC are from
Mexico. The EDC detainee handbook was last updated in March 2011.
While the detainee handbook contained most of the required information, ODO determined that
it did not list procedures for requesting interpretive services for essential communication
(Deficiency DH-1). It is vital for detainees to be aware of the opportunity to request interpretive
services, especially for medical or legal matters. Ensuring ICE detainees have clear and
comprehensive ICE and facility detainee handbooks is an essential element of a well-run facility.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE PBNDS, Detainee Handbook, section (V)(2), the FOD must ensure
that 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 rules,
regulations, policies, and procedures with which every detainee must comply; Detainee rights
and responsibilities; Procedures for requesting interpretive services for essential communication;
Prohibited acts categorized by severity (Greatest, High, High Moderate or Low Moderate); The
disciplinary system, procedures, and sanctions; The detainee Grievance System, including
medical grievances; Law library access; Telephone access; The availability of Legal Orientation
Programs; and How to contact ICE (Local ICE Field Office).

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 DETENTION FILES (DF)
ODO reviewed the Detention Files standard at EDC to determine if files are created containing
all significant information on detainees housed at the facility for over 24 hours, in accordance
with the PBNDS. ODO reviewed detention files, logbooks, and policies and procedures; toured
the admissions and release area and property room; and interviewed staff.
ODO reviewed 20 active and 15 archived detention files to determine if required documentation
was present. In all files reviewed ODO found staff members create a detention file as part of
admissions processing when a detainee is admitted to EDC, but officers completing the
admissions portion of the detention file fail to note that the file had been activated (Deficiency
DF-1). All 35 files reviewed by ODO were missing housing identification cards, and 10 of the
35 files did not contain I-77 baggage check forms (Deficiency DF-2).
Six of 15 archived files reviewed by ODO contained incomplete Orders to Detain or Release
Alien (Form I-203); one contained an incomplete Alien Booking Card (Form I-385). ODO noted
the I-203s did not reflect the date and time an official ordered the detainee released, nor the
signature of the officer receiving the detainee. The Form I-385 was missing information
pertaining to where the detainee was released, who released the detainee, the release date, and a
right index fingerprint for both book-in and book-out (Deficiency DF-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DF-1
In accordance with the ICE PBNDS, Detention Files, section (V)(A)(2), the FOD must ensure
the officer completing the admissions portion of the Detention File shall note that the file has
been activated. The note may take the form of a generic statement in the Acknowledgment form.
DEFICIENCY DF-2
In accordance with the ICE PBNDS, Detention Files, section (V)(B)(1), the FOD must ensure
the detainee Detention File shall 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 detainee’s A-File. The file shall, at a minimum, contain: Housing
Identification Card, and I-77 Baggage Checks.
DEFICIENCY DF-3
In accordance with the ICE PBNDS, Detention Files, section (V)(E)(1), the FOD must ensure
that upon the detainee’s release from the facility, staff shall add final documents to the file before
closing and archiving it after inserting: Detention file copies of completed release documents;
The original closed-out receipts for property and valuables; and The original I-385 and other
documentation.

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 ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at EDC 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 PBNDS. ODO toured the facility,
interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical
management, generator testing, and fire drills.
The ODO inspection revealed all chemicals, flammables and combustible materials are stored
and issued as required. Hazardous substances are strictly controlled. Material Safety Data
Sheets, a master index of chemicals, and documentation of reviews are available and complete.
Monthly fire drills are conducted on each shift, and documentation is on file. Pest control
invoices and reports for water testing are current. Barbering services are conducted in a
designated area, and hair care sanitation regulations are posted. Sanitation is maintained at a
high level throughout the facility.
The facility’s emergency generators are tested by an external generator servicing company on a
quarterly basis. Internal testing of the facility’s emergency generators is conducted weekly for
30 minutes rather than every two weeks for 60 minutes as required by the PBNDS (Deficiency
EH&S-1). ODO discussed with maintenance personnel that not all generators reach their
operating temperature within 30 minutes. Testing generators for one hour ensures there is
sufficient time to reach operating temperature, verify the engine’s ability to provide the required
power over time, and identify any fuel or oil leaks.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE PBNDS, Environmental Health and Safety, section (V)(F), the FOD
must ensure that at least every two weeks , emergency power generators shall be tested for one
hour, and the oil, water, hoses and belts of these generators shall be inspected for mechanical
readiness to perform in an emergency situation.

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 KEY AND LOCK CONTROL 

ODO reviewed the Key and Lock Control standard at EDC to determine if facility safety and
security is maintained by requiring keys and locks to be controlled and maintained in
accordance with the ODO interviewed the Security Officer and staff. observed key and
lock issuance. and reviewed facility policies, inventories. storage. and available records.

EDC has a comprehensive written policy governing key and lock control. Responsibility for the
key control program is assigned to a designated full-time Security Of?cer. who successfully
completed a locksmith training program in October 2010. All facility staff is trained and
accountable for key control. Keys are issued from the control center using a photo chit system
which facilitates accountability by prominently displaying a photo facsimile in the place of a key
that is in use.

(7) (E)

No corrective action was ta ?en prior to comp etion is revrew.

 

REQUIRMENTS FOR DEFICIENT FINDINGS

DEFICIENCY (7) (E)
I11 accordance with the ICE Ke and Lock Control. section 4 .

 

 

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LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)
ODO reviewed the Law Libraries and Legal Material standard at EDC 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 PBNDS. ODO observed the
law library, interviewed staff, and reviewed policies and the detainee handbook.
There are two main libraries in the facility, located on the North and South sides. Detainees in
the Special Housing Units (SHU) also have access to the law library. The main libraries are
under the supervision of CCA staff law librarians. The libraries are large enough to
accommodate access for all detainees and are sufficiently equipped with adequate seating and
workspace. All areas are well lit and reasonably isolated from noisy areas.
ODO examined the computers in the law libraries and determined the Lexis-Nexis legal resource
software was current as of April 2011. In addition, the law libraries are equipped with
typewriters. A notary public, certified mail, and other such services to pursue legal matters are
available to detainees. A listing is posted indicating all law books available via Lexis-Nexis.
When equipment is damaged, work orders are prepared to have the equipment repaired. ODO
found adequate office supplies and writing materials are available to detainees. EDC staff
continuously supervises detainees while at the libraries to prevent vandalism.
The law libraries are open Monday through Friday from 7:30 am to 4:00 pm. A schedule is
posted in each housing unit indicating designated times for each specific unit, to include the
SHU. Detainees can request additional time in the law library beyond the 5-hour minimum time
limit by submitting a request through the Housing Unit Manager.
The detainee handbook contains the rules and procedures governing access and use of the law
library and legal materials in the facility. However, these rules and procedures, as well as the
procedures for requesting additional law library access, are not posted in the law libraries as
required by the PBNDS (Deficiency LL&LM-1). EDC management corrected this deficiency
before completion of the inspection.

STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
DEFICIENCY LL&LM-1
In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(O), the FOD
must ensure that the Detainee Handbook or supplement shall provide 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 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; 7. Required access
to computers, printers, and other supplies; 8. If applicable, that Lexis/Nexis is being used at the

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 facility and that instructions for its use are available. These policies and procedures shall also be
posted in the law library along with a list of the law library’s holdings.

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 MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at EDC to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the PBNDS. ODO toured the medical unit, reviewed policies and procedures, examined
30 medical records, verified medical staff credentials, and interviewed the Health Services
Administrator (HSA), Assistant Health Services Administrator (AHSA), and staff.
The facility holds current accreditation from the American Correctional Association. Medical
services are provided by the IHSC and contract groups STG International and SDI. Staffing
consists of full-time, part-time, and full-time equivalent positions, including a Medical (b)(7)(E)
Director (designated clinical medical authority), a staff physician, Nurse Practitioners (NP),
Physician Assistants (PA), mental health and dental providers, Registered Nurses (RN) and
Licensed Practical Nurses (LPN), and pharmacy and support positions. At the time of the
review, the staff physician was fulfilling the duties of clinical medical authority as the Medical
Director position was vacant. ODO found staffing comprehensive and sufficient to meet the
standard.
ODO verified detainees are consistently tested for tuberculosis upon intake by way of chest
x-ray, read immediately by a tele-radiology service. Medications; treatment for mental health,
special, and chronic needs; and follow-up care are provided as required. Detainees request
health care services by submitting sick call request forms available in English and Spanish.
ODO verified request forms are efficiently and expediently triaged to determine priority for care,
and detainees are seen for sick call in a timely manner. Sick call request forms are not
maintained in detainees’ medical records, but are maintained permanently in another location.
ODO recommends inclusion of sick call requests in detainees’ medical records so that all
documentation relating to access to health care is present.
Detainees are screened upon arrival by an NP, a PA, or an RN. ODO’s review of 30 medical
records revealed that none of the 30 completed screening forms was reviewed by the clinical
medical authority (Deficiency MC-1). Intake screenings conducted by an NP or PA were not
reviewed at all, and screenings performed by an RN were reviewed by another RN. Though this
practice is consistent with EDC clinical guidelines, which state review may be accomplished “by
the clinical medical authority or his/her designee and may be assigned to RN, midlevel, or
physician categories,” the PBNDS specifies intake screening forms must be reviewed by the
clinical medical authority. The HSA informed ODO that IHSC HQ approved this EDC practice,
but was unable to produce documentation for verification.
ODO verified detainees receive health appraisals within 14 days of arrival; however, ODO
observed documentation of clinical medical authority reviews in only three of 30 records
(Deficiency MC-2). One of four appraisals conducted by an RN was not reviewed, and none of
the 26 appraisals conducted by an NP or PA was reviewed. ODO notes the PBNDS exceeds
National Commission on Correctional Health Care (NCCHC) standard J-E-04 which does not
require physician review of health appraisals conducted by an NP or a PA. The NCCHC
standard does, however, require physician review of appraisals conducted by an RN.
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 STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE PBNDS, Medical Care, section (V)(I), the FOD must ensure the
clinical medical authority shall be responsible for review of all health screening forms within 24
hours or next business day to assess the priority for treatment (for example, Urgent, Today, or
Routine).
DEFICIENCY MC-2
In accordance with the ICE NDS, Medical Care, section (V)(J), the FOD must ensure the clinical
medical authority shall be responsible for review of all health appraisals to assess the priority for
treatment.

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 SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at EDC to determine if the
health and well-being of detainees is protected by training staff in effective methods of suicide
prevention, in accordance with the PBNDS. ODO reviewed facility policy, medical and facility
staff training records, the medical records of 15 detainees who had been on suicide watch; and
interviewed the HSA, AHSA, the Detention Training Manager, and staff.
The HSA reported 48 suicide watches between January 1, 2010, and April 28, 2011, with no
suicides or suicide attempts. However, ERO staff at the EDC reported an attempted suicide to
ICE Headquarters on March 12, 2011. When questioned concerning the conflicting information,
the HSA stated she did not consider the actions of the detainee in question to constitute a true
suicide attempt. ODO reviewed the case pursuant to a referral from the Joint Intake Center (JIC)
and determined the facts presented were inconclusive to substantiate that the detainee in question
actually attempted suicide.
ODO verified that the EDC suicide prevention training curriculum covers all 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. Inspection of training
records and interviews of the HSA, AHSA, and Detention Training Manager revealed all facility
staff completed required training.
Two of 15 medical records pertaining to detainees previously on suicide watch did not include
forms documenting 15-minute checks by security officers (Deficiency SP&I-1). In the other 13
cases, ODO verified 15-minute checks were documented on “Medical/Suicide Observation
Checklists” as required by the standard.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with the ICE PBNDS, Suicide Prevention and Intervention, section (V)(F), the
FOD must ensure suicidal detainees will be monitored by assigned security officers who
maintain constant one-to-one visual observation, 24 hours a day, until the detainee is released
from suicide watch. The assigned security officer makes a notation every 15 minutes on the
behavioral observation checklist.

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 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 EDC to determine if the facility’s policies and
practices are in accordance with the PBNDS. ODO examined policies and interviewed the HSA,
AHSA, and staff.
There have been no deaths in the past year. ODO was informed the facility does not have an
infirmary, and all seriously or terminally ill detainees are transferred to an appropriate outside
facility. EDC policies do not address case closure (Deficiency TIADD-1). Additionally, EDC
policy does not address the disposition of remains. Though the standard does not expressly
require written procedures for disposition of remains, and ICE and CCA staff stated both case
closure and disposition of remains would be properly addressed in the event of a detainee death,
ODO recommends inclusion of specific procedures in policy to ensure compliance.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TIADD-1
In accordance with the ICE PBNDS, Terminal Illness, Advance Directives and Death, section
(V)(H), the FOD must ensure procedures for closing the case of a deceased detainee include the
following: Sending the detainee’s fingerprint card to the FBI stamped “Deceased” and
identifying the place of death; Placing the detainee’s death certificate or medical examiner’s
report (original or certified copy) in the subject’s A-file; Placing a copy of the gravesite title in
the A-file (indigent burial only); and Closing any electronic files on the detainee (EARM, for
example).

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 USE OF FORCE AND RESTRAINTS (UOF&R)
ODO reviewed the Use of Force and Restraints standard at EDC 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 PBNDS. ODO toured the facility, inspected equipment, and
reviewed local policies, training records, and other pertinent documentation.
EDC has a comprehensive written policy governing the use of force. The facility does not use
four-point restraints, a restraint chair, or any Electro-Muscular Disruption Device. The Chief of
Security informed ODO there were five calculated and 15 immediate use-of force incidents
between April 2010 and April 2011. ODO’s review of documentation on the 15 immediate useof-force incidents supported compliance with both the standard and facility policy. Review of
documentation on the five calculated use-of-force incidents revealed audiovisual recordings are
maintained no fewer than 30 months as required by the standard, but are not cataloged
(Deficiency UOF&R-1). Cataloging audiovisual recordings supports accountability and ensures
they may be easily located and retrieved when necessary.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF&R-1
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(K), the FOD must
ensure each audiovisual record shall be catalogued and preserved until no longer needed, but
shall be kept no less than 30 months after its last documented use. In the event of litigation, the
facility shall retain the relevant audiovisual record a minimum of six months after the litigation
has concluded or been resolved. The audiovisual records may be catalogued electronically or on
3" x 5" index cards, provided that the data can be searched by date and detainee name. A log
shall document audiovisual record usage.

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Eloy Detention Center
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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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Eloy Detention Center
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