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
Atlanta Field Office
Stewart Detention Center
Lumpkin, Georgia

August 16-18, 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
STEWART DETENTION CENTER
ATLANTA 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 PERFORMANCE BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ................................................................................6
Admission and Release ............................................................................................7
Detention Files .........................................................................................................9
Environmental Health and Safety ..........................................................................10
Food Service ..........................................................................................................11
Funds and Personal Property .................................................................................12
Grievance System ..................................................................................................14
Medical Care ..........................................................................................................15
Personal Hygiene ...................................................................................................16
Staff-Detainee Communication .............................................................................17
Suicide Prevention and Intervention ......................................................................19
Use of Force and Restraints ...................................................................................20
Visitation ................................................................................................................22

 EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Quality Assurance Review (QAR) of the Stewart Detention Center (SDC) in
Lumpkin, Georgia, on August 16 - 18, 2011. The facility is owned by Stewart County and
operated by the Corrections Corporation of America (CCA). SDC accommodates ICE detainees
of all classification levels for periods in excess of 72 hours. In October 2006, ICE began housing
male detainees at SDC under an intergovernmental service agreement (IGSA). SDC does not
accommodate female ICE detainees. The facility is a dedicated IGSA. ICE Health Service
Corps (IHSC) provides medical care and Canteen Correctional Services provides food service.
SDC attained American Correctional Association accreditation in October 2008.
The Enforcement and Removal Operations (ERO), Field Office Director in Atlanta, Georgia
(FOD/Atlanta) is responsible for ensuring SDC is in compliance with ICE policies and the ICE
Performance Based National Detention Standards (PBNDS). The ERO Assistant Field Office
Director (AFOD/Atlanta) who oversees the facility is physically located at SDC. The permanent
ICE staff at SDC consists of (b) (7) Supervisory Detention and Deportation Officers (SDDO),
(E)
(b)
Supervisory Immigration Enforcement Agents (SIEA) (b) Deportation Officers (DO), (b)
(7)
(7)
(7)
Immigration Enforcement Agents (IEA), (b) Detention and Removal Assistants (DRA), and one
(7)
Mission Support Specialist. The total number of staff (non-ICE) employed at SDC is (b) . The
(7)
total bed capacity is 1,924, with an emergency bed capacity of 2,000. At the time of the review,
SDC housed 1,619 male ICE detainees of all three classification levels, ranging in age from 18 to
69 years old. The average length of stay is 38 days.
ERO Detention Standards Compliance Unit contractor MGT of America, Inc. conducted an
annual review of the PBNDS at SDC in April 2011. The facility received an overall rating of
“Meets Standards,’’ and was found to be in compliance with all 41 standards reviewed.
ODO conducted a QAR of SDC in November 2008, using the then-applicable ICE National
Detention Standards, and conducted a Follow-up Inspection in June 2010. ODO found 25
deficiencies during the QAR within the following 12 standards: Access to Legal Material;
Correspondence and Other Mail; Detainee Grievance Procedures; Environmental Health and
Safety; Food Service; Medical Care; Security Inspections; Staff-Detainee Communication;
Suicide Prevention and Intervention; Telephone Access; Terminal Illness, Advance Directives,
and Death; and Visitation. During the Follow-up Inspection, ODO found two repeated
deficiencies, one in Medical Care and one in Staff-Detainee Communication. ODO found one
detainee had not received a physical examination within 14 days of arrival; and not all detainee
requests sent to ICE were responded to within 72 hours of receipt by ICE, if they were responded
to at all.
A detainee death occurred at SDC on March 11, 2009. ODO conducted a detainee death review,
in which ODO noted three discrepancies. A physical examination, performed by a registered
nurse, was not reviewed or signed by the physician. Additionally, ODO found a discrepancy
regarding the time an EKG was performed at SDC; there was a 45 minute difference between the
time listed on the EKG printout and the time noted on the medical record. Overall, ODO found
SDC administered and provided proper medical care and treatment to the detainee. The
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 Department of Homeland Security, Of?ce for Civil Rights and Civil Liberties reviewed the death
and detainee death report, and provided recommendations to the ICE Director and
Principal Legal Advisor on September 30, 2011, which are under review.

Dru'ing this review, ODO reviewed 26 SDC was fully compliant with 14 standards,
while ODO formd a total of 25 de?ciencies in the following 12 standards: Admission and
Release (3 de?ciencies), Detention Files (2), Environmental Health and Safety (1), Food Service
(2), and Personal Property (3), Grievance System (1), Medical Care (1), Personal Hygiene
(2), Staff-Detainee omnnmication (2), Suicide Prevention and Intervention (2), Use of Force
and Restraints (3), and Visitation (3).

Overall, ODO found few de?ciencies in the standards reviewed at however, some of the
de?ciencies forurd were signi?cant. This report includes descriptions of all de?ciencies and
refers to the speci?c, relevant The report will be provided to ERO to develop
corrective actions to resolve identi?ed de?ciencies. All de?ciencies were discussed with SDC
personnel on?site dining the inspection, as well as dining the close?out brie?ng conducted on
August 18, 2011.

 

(7) (E)

The food service chemical log for August 15, 2011, did not document the quantities issued,
received, or retruned of ?ve cleaning solvents, as required by the Food Service standard.

According to the Fluids and Personal Property standard, a secru?ed locker for holding large
valuables is to be accessed only by a designated supervisor. During the inspection, ODO
observed that access to the locker was controlled by a non-supervisory SDC staff member. The
SDC detainee handbook does not notify detainees of facility policies and procedru'es concerning
personal property or of procedures for accessing personal funds to pay for legal services.
Additionally, SDC policy arbitrarily limits the maximrml claim for lost personal property to $50,
despite the mandate for reimbru'sement of all valid claims without regard to dollar
amorurts.

SDC has no written policy or established procedru?es to ensru'e that medical grievances are
received by the administrative health authority within 24 hours, or by the next business day, as
required under the Grievance System standard.

Intake health screening forms are not reviewed by the Clinical Director within 24 hours, or by
the next business day, to assess the priority for treatment as prescribed wider the Medical Care
standard.

ERO staff members do not respond within 72 hours to detainee requests, either in person or in
writing, as required by the Staff-Detainee Communication standard.

 

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Review of documentation on five calculated (planned) and six immediate use-of force incidents
between July 2010 and August 2011 confirmed the examinations and debriefings were not audiovisually recorded as required by the Use of Force standard.

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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, ODO may focus its inspection based on detention management information provided
by the ERO Headquarters (HQ) and ERO field offices, and on 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 SDC to determine compliance with current policies
and detention standards. The PBNDS apply to SDC. 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) and 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 prepare for the site visit at SDC.

REPORT ORGANIZATION
This report contains a detailed synopsis of those PBNDS areas reviewed by ODO that were
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
provides the reader with contextual and quantitative information 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
on-going 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
(b)(6)(b)(7)(C)

Special Agent (Team Lead)
Special Agent
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

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ODO, Houston
ODO, Houston
ODO, Houston
ODO, Chicago
MGT of America, Inc.
MGT of America, Inc.
MGT of America, Inc.

Stewart Detention Center
ERO Atlanta

 OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the SDC Warden, Assistant Warden, one Correctional Officer (CO), and the
Assistant Chief of Security, as well as the ERO AFOD, one SDDO, and the SIEA who serves as
the Contracting Officer’s Technical Representative (COTR) at the facility.
ERO management stated ICE staff at SDC has been reduced from 101 to 78. Of the 78
employees, 6 are assigned full-time to the Criminal Alien Program, further reducing the staff
necessary to carry out the duties and responsibilities related to SDC. ERO staff stated that
morale is low due to a lack of personnel resources. At the time of the inspection, one SDDO,
one SIEA, and six DRA positions were vacant.
SDC staff interviewed stated morale is good. SDC and ERO staff stated the working relationship
between them is excellent.

DETAINEE RELATIONS
ODO interviewed 30 detainees randomly-selected from all classification levels to assess
detention conditions at SDC. All detainees interviewed stated they participate in outdoor
recreation, can send and receive mail, are permitted to use telephones, have access to a law
library, possess required handbooks, and voiced no complaints regarding food service and
medical care.
Five (17%) detainees complained that after their initial issuance of hygiene supplies, they were
required to pay for additional hygiene products if they had funds in their accounts. According to
the ICE PBNDS, supplies must be replenished as needed.
Eleven (37%) detainees were interviewed in Spanish and all were able to name their Deportation
Officer (DO). Seven (23%) detainees said they had met their DO at least once; four (13%) had
never met their DO; and six (20%) did not know how to contact their DO.

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 ICE PERFORMANCE BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 26 PBNDS and found SDC fully compliant with the following 14
standards:
Detainee Handbook
Disciplinary System
Facility Security and Control
Hunger Strikes
Key and Lock Control
Population Counts
Post Orders
Recreation
Religious Practices
Sexual Abuse and Assault Prevention and Intervention
Special Management Units
Telephone Access
Terminal Illness, Advance Directives, and Death
Tool Control
As these standards were compliant at the time of the review, a synopsis for these areas was not prepared
for this report. Even though no deficiencies were found in the Detainee Handbook standard,

Deficiency F&PP-2 (in Funds and Personal Property) relates to omission of required material in
the detainee handbook.
ODO found deficiencies in the following 12 standards:
Admission and Release
Detention Files
Environmental Health and Safety
Food Service
Funds and Personal Property
Grievance System
Medical Care
Personal Hygiene
Staff-Detainee Communication
Suicide Prevention and Intervention
Use of Force and Restraints
Visitation
Findings for each of these standards are presented in the remainder of this report.

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 ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at SDC 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 and files,
interviewed staff and detainees, and observed the admission and release process.
SDC has written policies and procedures for admission and release. ODO reviewed 15 detention
files and verified that detainees undergo medical screenings and are properly classified. Personal
property is categorized, inventoried, and safeguarded. However, none of the reviewed files
contained an Order to Detain or Release (Form I-203 or I-203a) (Deficiency AR-1), recording
ICE’s authorization to the facility to detain the individuals.
During the admissions process, ODO observed a male detainee in a holding cell changing clothes
and undergarments in full view of a female CO (Deficiency AR-2). The supervisory CO
confirmed the CO was not following policy regarding detainee privacy, and stated that corrective
actions would be taken immediately.
ODO reviewed release procedures and examined 15 archived detention files. ODO found none
of the reviewed files contained fingerprints or verifications that wants and warrants had been
checked (Deficiency AR-3). SDC facility staff stated they do not routinely receive these items
from ERO. ODO confirmed through interviews with ERO staff that these documents are not
provided to the facility. Fingerprints and record checks help facility staff ensure that detainees
are properly classified and identify criminal affiliations.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
In accordance with the ICE PBNDS, Admission and Release, section (V)(E), the FOD must
ensure an Order to Detain or Release the detainee (Form I-203 or I-203a), bearing the
appropriate ICE/[ERO] Authorizing Official signature, must accompany each newly arriving
detainee. Staff shall 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 PBNDS, Admission and Release, section (V)(B)(2), the FOD must
ensure staff shall 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 shall 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-3
In accordance with the ICE PBNDS, Admission and Release, section (V)(H), the FOD must
ensure staff must complete 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,
checking wants and warrants, etc. ICE/[ERO] shall approve IGSA release procedures.

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 DETENTION FILES (DF)
ODO reviewed the Detention Files standard at SDC 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 examined 10 detention files, and reviewed logbooks, policies and
procedures.
ODO found none of the files reviewed contained housing identification cards (Deficiency DF-1).
Facility staff advised this issue would be corrected.
The logbook used to record entry and removal of detainee detention files from the storage
cabinet did not contain the date and time files are removed or returned, the reason for removal, or
the title and department of the person removing the file (Deficiency DF-2). Detention file
contents are subject to Privacy Act regulations. Personnel accessing detention files are
accountable for securing personally identifiable information.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DF-1
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 [among other
items] a housing identification card.
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 file’s removal from the cabinet shall include: The
detainee’s 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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 ENVIRONMENTAL HEALTH AND SAFETY 

ODO reviewed the Environmental Health and Safety standard at SDC to detennine 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 ODO toured the
facility, interviewed staff and reviewed policies and documentation of inspections, hazardous
chemical management. and fn'e drills.

Facility sanitation is generally maintained at a high level. ODO veri?ed fire drills were
conducted on each shift. and documentation was maintained by the SDC Safety Of?cer. Repo?s

for water uali testin and est control were current.
ty (E)

eficienc 1 .

 

FOR DEFICIENT FINDINGS

DEFICIENCY -1

In accordance with the ICE Enviromnental Health and Safet section VI 4 .

       

 

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at SDC to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE PBNDS. ODO
reviewed available documentation, interviewed food service staff, inspected storage areas, and
observed meal preparation and service.
All work associated with food preparation and service is performed by Canteen Correctional
Services. ODO verified all food service workers received pre-employment medical screenings.
Sanitation in the food service department was good.
Logs of chemicals revealed running inventories of hazardous substances were complete and
accurate for all days between June 15 and August 15, with the exception of one day. Food
Service chemical logs for August 15, 2011, did not record quantities issued, received, or returned
of five cleaning solvents (Deficiency FS-1). This deficiency was corrected during the QAR.
ODO found dishwasher temperatures were not recorded for August 15, and the morning of
August 16, 2011 (Deficiency FS-2). Temperature readings were recorded for all other days
between June 15 and the date the review commenced. Taking temperatures daily ensures
cooking equipment is washed at temperatures high enough to kill bacteria and prevent food
borne illness.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE PBNDS, Food Service, section (V)(J)(11), the FOD must ensure only
those toxic and caustic materials required for sanitary maintenance of the facility, equipment,
and utensils shall be used in the food service department. All food service staff shall 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.
DEFICIENCY FS-2
In accordance with the ICE PBNDS, Food Service, section (V)(J)(13), the FOD must ensure all
of the food service department equipment (ranges, ovens, refrigerators, mixers, dishwashers,
garbage disposal, etc.) require frequent inspection to ensure their sanitary and operable
condition. Staff shall check refrigerator and water temperatures daily and record the results. The
FSA or designee will verify and document requirements of food and equipment temperatures.
Checks of equipment temperatures shall follow this schedule: Dishwashers: every meal.

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 FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at SDC to determine if controls are in
place to inventory, issue receipts for, store, and safeguard detainees’ personal property, in
accordance with the ICE PBNDS. ODO interviewed staff, reviewed policies and procedures,
and observed the admissions and release process.
SDC has written policies and procedures for funds and personal property, which account for and
safeguard detainee property from the time of the detainee’s admission until the time of release.
Funds and valuables are properly inventoried and logged by the facility’s accounting department.
The dedicated safe for cash is maintained in a secure area and is only accessible to supervisory
staff. However, ODO observed SDC non-supervisory staff accessing the facility’s secure locker
used for holding large valuables (Deficiency F&PP-1). By restricting the staff allowed into
detainee property areas, the facility will be better able to protect detainee property from loss or
damage.
The SDC detainee handbook does not provide detainees with the procedures for filing a claim for
lost or damaged property, or for accessing personal funds to pay for legal services (Deficiency
F&PP-2). Ensuring ICE detainees have clear and comprehensive ICE and facility detainee
handbooks is an essential element in ensuring detainees are made well aware of rules, policies,
and procedures.
SDC policy states a detainee that has a loss of property proven to be due to facility negligence is
limited to a maximum claim of $50 (Deficiency F&PP-3). A facility may not place an arbitrary
ceiling on the amount of money a detainee may claim for loss of property. Therefore, it is in the
facility’s interest to maintain proper records and to provide for the strict protection and security
of detainee property.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(A), the FOD must
ensure all facilities, at a minimum, shall provide a secured locker for holding large valuables that
can be accessed only by designated supervisor(s). Both the safe and the large-valuables locker
should be kept in either the shift supervisor’s office or otherwise secured in an area accessible
only by the shift supervisor.
DEFICIENCY 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 shall notify the detainees of facility policies and
procedures concerning personal property, including: The rules for storing or mailing property
not allowed in their possession; the procedures for filing a claim for lost or damaged property;
and access to detainee personal funds to pay for legal services.

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 DEFICIENCY F&PP-3
In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(L)(3), the FOD
must ensure all CDFs and IGSA facilities shall have and follow a policy for loss of or damage to
properly receipted detainee property, as follows: The facility shall promptly reimburse detainees
for all validated property losses caused by facility negligence; the facility may not arbitrarily
impose a ceiling on the amount to be reimbursed for a validated claim.

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 GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at SDC to determine if a process exists to submit
formal or emergency grievances, without fear of reprisal; if responses are provided in a timely
manner; if detainees have an opportunity to appeal responses; and if accurate records are
maintained, in accordance with the ICE PBNDS. ODO reviewed policies and procedures, formal
grievances, emergency grievances, and the appeals process; ODO also interviewed staff and
detainees.
SDC has policies and procedures for detainees to file informal and formal grievances, emergency
grievances, and appeals. A notice for filing a grievance is provided in the SDC detainee
handbook. Grievances, responses, and appeals are properly logged. ODO reviewed ten active
and ten inactive detention files, and found all files contained the required grievance
documentation. However, SDC does not have written procedures to ensure medical grievances
are received by the Administrative Health Authority or Health Services Administrator (HSA)
within 24 hours, or by the next business day, as required by the standard (Deficiency GS-1).
Timely reviews and responses ensure detainees receive the necessary care, are treated fairly, and
receive notification of the basis for the decision.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE PBNDS, Grievance System, section (V)(A), the FOD must ensure
each facility shall have written policy and procedures for a 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.

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 MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at SDC 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
32 medical records, verified medical staff credentials, and interviewed the HSA, Assistant HSA,
Quality Assurance Monitor, and staff.
According to the HSA, five positions are vacant including the Clinical Director (CD),
psychiatrist, a second social worker, one full-time Registered Nurse (RN), and one part-time RN.
ODO was informed the CD from the Krome Special Processing Center is available around-theclock for telephonic consults, and teleconferences with an offsite psychiatrist are available when
needed. ODO determined staffing is sufficient to meet detainee health needs.
ODO verified tuberculosis screenings, medications, treatments for special and chronic needs, and
follow-up care are provided in accordance with the standard, and consent for treatment is
consistently obtained. Detainees access care by submitting written medical requests, “sick call
slips,” available in English and Spanish, which they place in the secure “Sick Call” box located
in the main hallway outside the cafeteria. Medical staff collects sick call slips seven days a week
and triage them on a timely basis to determine priority for care. Detainees in the short stay unit
have access to sick call slips and are seen daily by medical staff. Detainees with chronic issues
are seen within 24 hours of intake.
Physical examinations (PE) are conducted by mid-level providers and RNs trained in the
function. A random review of 32 medical records revealed all PEs were completed within the
required 14-day timeframe. ODO notes seven PEs completed by RNs were co-signed by a
physician as required; however, they were signed between one and four months later. Though no
timeframe for review of PEs conducted by RNs is set in the standard, ODO notes one to four
months is excessive given the purpose of the physician review is to assure the RN properly
assessed health needs. ODO recommends the facility take steps to assure every PE is reviewed
on a timely basis by a physician.
Intake health screenings are conducted by nurses and triaged by other nurses to determine if
chronic conditions such as diabetes and hypertension exist, requiring the detainee to be seen by a
mid-level provider within 24 hours. However, none of the intake health screening forms was
reviewed by the CD (Deficiency MC-1). The clinical medical authority should review all health
screening forms to ensure detainees are accurately and promptly assessed.

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).

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 PERSONAL HYGIENE (PH)
ODO reviewed the Personal Hygiene standard at SDC 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 items for as long as they remain in
detention, in accordance with the ICE PBNDS. ODO interviewed staff and detainees, reviewed
policies and procedures, and observed laundry schedules and required postings.
ODO verified that the facility has policies and procedures in place to provide regular exchanges
of clothing, bedding, and towels. The laundry schedule was posted in the housing areas. During
interviews with ICE staff, ODO confirmed that detainees are permitted to shave, but razors are
issued only three times a week, not daily (Deficiency PH-1). Providing detainees with daily
access to razors promotes a greater level of personal hygiene.
The hot water temperature in the detainee shower area fell below the required 100 degrees
Fahrenheit. The water temperature averaged 95 degrees as measured by ODO as well as facility
maintenance personnel (Deficiency PH-2). Adequate hot water temperatures within the showers
ensure detainees are able to thoroughly wash and clean themselves in a comfortable
environment.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY PH-1
In accordance with the ICE PBNDS, Personal Hygiene, section (V)(D), the FOD must ensure
razors must be strictly controlled. Disposable razors will be provided to detainees on a daily
basis. Razors will be issued and collected daily by staff. Detainees will not be permitted to
share razors.
DEFICIENCY PH-2
In accordance with the ICE PBNDS, Personal Hygiene, section (V)(E), the FOD must ensure
operable showers that are thermostatically controlled to temperatures between 100 and 120
degrees Fahrenheit, to ensure safety and promote hygienic practices.

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 STAFF-DETAINEE COMMUNICATIONS (SDC)
ODO reviewed the Staff-Detainee Communication standard at SDC 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 logs, and interviewed
ICE and SDC staff, as well as detainees.
Scheduled visits by ICE staff are conducted in each housing unit once per week. During the
scheduled visits, ICE staff limits interaction to detainees within a specified A-number range.
This process limits informal access by other detainees within the housing units and the ability for
detainees to address personal concerns (Deficiency SDC-1). Often detainees are unaware of or
do not comprehend the immigration removal process and have personal needs; ICE staff should
be readily available to explain the general process without providing specific legal advice on
individual cases.
ICE staff presented ODO with a copy of the staff-detainee communication electronic logbook of
written detainee requests received by ICE from February 15 - August 15, 2011, containing 6,762
written requests. ODO randomly-selected the period of June 1, 2011 thru July 28, 2011 to
review, accounting for 2,451 requests. Of those reviewed, 301 entries (12%) indicated the
requests were not responded to within 72 hours. Of these, 139 had a late response date recorded,
while 162 lacked a response date entirely (Deficiency SDC-2). Detainees must be able to
receive a response to a written request within 72 hours; when detainee requests and concerns are
met in a timelier manner, it can result in less anxiety and behavioral issues on the part of
detainees.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(A), the FOD
must ensure ICE/[ERO] detainees shall have frequent informal access to and interaction with key
facility staff members, as well as key ICE/[ERO] staff, in a language they can understand. As
detailed below, Field Office Directors shall assign Deportation Officers, Immigration
Enforcement Agents (IEA), and Supervisory Immigration Enforcement Agents (SIEA) to visit
detention facilities. Detainees will be advised how to contact local ICE personnel.
Often detainees in ICE/[ERO] custody are unaware of or do not comprehend the immigration
removal process, and staff should explain the general process without providing specific legal
advice on individual cases. Staff should provide general information to detainees pertaining to
the immigration court process. At a minimum, this information should include the types of
hearings such as master calendar and merits hearings. Legal advice will not be provided by ERO
staff.

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 DEFICIENCY SDC-2
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.

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 SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at SDC 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 PBNDS. ODO reviewed facility policies; interviewed
the Assistant HSA, Quality Assurance Monitor, and facility staff; and reviewed medical and
facility staff training records. Additionally, ODO reviewed the medical records of eight
detainees who had been on suicide watch.
Screening for suicide potential occurs as part of intake screening. Detainees at risk for suicide
are referred to medical staff, housed, and monitored in accordance with the standard. A review
of the SDC Suicide Prevention Awareness training curriculum confirmed it covers required
elements: 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 for 22 SDC medical facility staff and ten SDC non-medical facility
staff confirmed that all had received training during orientation and on an annual basis. ODO
could not verify training for assigned ICE officers, because ICE management was unable to
provide documentation to ODO at the time of the inspection (Deficiency SP&I-1).
ODO reviewed the records of eight detainees on suicide watch. One of the eight records did not
contain a copy of the suicide observation checklist documenting one-on-one visual observation
by the assigned officer (Deficiency SP&I-2); however, the logbook confirmed that one-on-one
observation of the detainee had occurred, despite the missing checklist.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I -1
In accordance with the ICE PBNDS, Suicide Prevention and Intervention, section (V)(A), the
FOD must ensure all facility staff who interact with and/or are responsible for detainees shall be
trained, during orientation and at least annually, on: recognizing verbal and behavioral cues that
indicate potential suicide; demographic, cultural, and precipitating factors of suicidal behavior;
responding to suicidal and depressed detainees; effective communication between correctional
and health care personnel; necessary referral procedures; constant observation and suicide-watch
procedures; follow-up monitoring of detainees who have already attempted suicide, and
reporting and written documentation procedures.
DEFICIENCY SP&I -2
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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 USE OF FORCE AND RESTRAINTS (UOF&R)
ODO reviewed the Use of Force and Restraints standard at SDC to determine if necessary use of
force and the use of restraints is employed 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, inspected equipment,
and reviewed policies, training records, and other pertinent documentation.
SDC 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 devices. The Chief of
Security informed ODO there were five calculated use-of-force incidents and six immediate useof-force incidents between July 2010 and August 2011.
A review of documentation on the six immediate use-of-force incidents supported compliance
with both the standard and facility policy. Review of documentation on the five calculated useof-force incidents revealed post-incident medical examinations and incident debriefings were
conducted; however, the examinations and debriefings were not audio-visually recorded
(Deficiency UOF&R-1). Video-recording of detainees during medical examinations provides
evidence of the presence or absence of injuries. Video-recording the debriefing provides staff
accounts and critiques of the incident, as well as descriptions of any injuries to staff. The audiovisual recordings, although missing medical examinations or debriefings, were maintained for
the timeframe required by the standard; however, none was catalogued (Deficiency UOF&R-2).
Cataloging audio-visual recordings supports accountability, and ensures they may be easily
located and retrieved when necessary.
Copies of the use-of-force and application of restraints documentation was placed in the
detainees’ detention files, but was not placed in the detainees’ A-Files (Deficiency UOF&R-3).
The AFOD informed ODO all future use-of-force documentation will be placed in the detainees’
A-Files.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF&R-1
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(I)(2)(5-6), the
FOD must ensure, while ICE/[ERO] requires that all use-of-force incidents be documented and
forwarded to ICE/[ERO] for review, for calculated use of force it is required that the entire
incident be audio visually recorded. The facility administrator or designee is responsible to
ensure that use of force incidents are audio visually recorded. Calculated use-of-force incidents
shall be audio-visually recorded in the following order: Faces of all team members should
briefly appear (with helmets removed and heads uncovered), one at a time, identified by name
and title; take close-ups of the detainee's body during a medical exam, focusing on the
presence/absence of injuries. Staff injuries, if any, are to be described but not shown; debrief the
incident with a full discussion/analysis/assessment of the incident.

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 DEFICIENCY UOF&R-2
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.
DEFICIENCY UOF&R-3
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(O)(1), the FOD
must ensure all facilities shall have an ICE/[ERO]-approved form to document all uses of force.
Within two working days, copies of the report shall be placed in the detainee’s A-File and sent to
the Field Office Director.

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 VISITATION (V)
ODO reviewed the Visitation standard at SDC 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 logbooks are properly maintained. Detainees are provided daily one-hour access to
visitation with family members, including minor children, friends, clergy, and consular
representatives. Visitation is available seven days per week. Attorney visits are unrestricted.
The facility does not have a written procedure to allow legal representatives and their assistants
to telephone the facility in advance of a visit to determine if someone is detained there
(Deficiency V-1). ODO confirmed no reported instances of legal representatives being denied
information regarding the presence of detainees; however, having a policy in place complies with
the standard, and ensures attorneys and their assistants have the opportunity to call the facility in
advance thereby avoiding complaints, unnecessary trips, and loss of time.
The facility does not have the Form G-28 (Notice of Entry of Appearance as Attorney or
Representative) available in the visitors’ area (Deficiency V-2). The form authorizes an attorney
to legally represent a detainee during immigration proceedings.
There is no written procedure for visitation by law enforcement officers conducting official
investigations (Deficiency V-3). ICE staff stated that no law enforcement officers requested
visitation in 2011, and no documentation was available for verification. A clear, written
procedure for law enforcement visitation would allow the facility and outside law enforcement
agencies to properly document these events.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY V-1
In accordance with the ICE PBNDS, Visitation, section (V)(J)(6), the FOD must ensure each
facility shall establish a written procedure to allow legal representatives and assistants to
telephone the facility in advance of a visit to determine whether a particular individual is
detained there. The request must be made to the on-site ICE/[ERO] staff or, where there is no
resident staff, to the ICE/[ERO] office with jurisdiction over the facility.
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 shall complete and
submit a Form G-28, available in the legal visitation reception area. Staff shall collect completed
forms and forward them to ICE/[ERO].

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 DEFICIENCY V-3
In accordance with the ICE PBNDS, Visitation, section (V)(O)(1), the FOD must ensure facility
visitation procedures shall cover law enforcement officials requesting interviews with detainees.
Facilities will notify and seek approval from ICE/[ERO] of any proposed law enforcement
officer visit with a detainee.

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