U.S. Immigration ;) and Customs ,/ Enforcement (.: Be Safe, UNITED STATES DEPARTMENT OF HOMELAND SECURITY IMMIGRATION AND CUSTOMS ENFORCEMENT OFFICIAL DETAIL- Karnes County Residential Center VEHICLE H: 33 0-i (b)(6),(b)(7)(C) TO: GEO TninspurIen ASSIGNMENT: Tmnsport(Jflee attached 1-216) BEGINNING AT 0600 hours June 08,2015 YOU ARE DIRECTED TO PERFORM TRANSPORT DUTIES AS SET FOR THE BELOW. PICK UP AT: KCRC DELAYER TO: Motel 6 5522 N Interstate 35 Rittiman Rd. San Antonio, TX 782 Ili OTHER INSTRIICTIONS. PICRCP retool co v or or. oinal hark SIFA POC's: SDDI (b)(6),(b)(7)( at 202-5 IBM. IE MOM 9s6-5 lid S 11-110-) • • at 830-20 /I 1,171/ ; Universal Precautions during all transports'. A copy oldie 1-216 or I-203(a) must accompany . tItisform. ANY QUESTIONS, CONTACT SIEA ON DUTY. UPON CONCLUSION OF THIS DETAIL YOU ARE REQUIRED TO COMPLETE YOUR REPORT IN ALL THE SPACES PROVIDED BELOW. AFTER GASSING UP YOUR VEHICLE, RETURN THIS ORDER AND VAN KEYS TO THE DUTY SUPERVISOR IMMEDIATELY. BEGINNING MILEAGE: (-1/5a/ ENDING MILEAGE: 1-/ ©Pf, 7 (b)(6),(b)(7)(C) D SIG 'ATURE OF SUPERVISOR REPORT DATE: June 08, 2015 I HEREBY CERTIFY I HAVE COMPLIED WITH THE ABOVE ORDER EXACTLY AS DIRECTED (IF NOT, EXPLAIN EXCEPTIONS TIME ACCOUNTING: EOD FOR THIS DEFAIL 0730 RETURNED FROM DETAIL / hours 300 hours TIME CHARGED TO: CONVEYANCE, PRODUCT! E CONVEYANCE, LOXI"EIME 3 (b)(6),(b)(7)(C) Page 1 of 740 ' J. 'IOTA! NCR IRS CIE TH l IIPTA II G-391 75 7: OD HRS DRS US. Immigration and Customs Enforcement Be Safe' UNITED STATES DEPARTMENT OF HOMELAND SECURITY IMMIGRATION AND CUSTOMS ENFORCEMENT OFFICIAL DETAIL- Karnes County Residential Center VEHICLE SI: -2 TO: CEO Transporter: Transpor (b)(6),(b)(7)(C) ASSIGNMENT: Transport' (b)(6),(b)(7)(C) hours June 08, 2015 YOU ARE DIRECTED TO PERFORM TRANSPORT DUTIES AS SET BEGINNING AT FOR TB E BELOW: PICK UP AT: KCRC (b)(b)abninl--) I: at 6811 Austin Center Blvd 1-07)(6),( (Far West Medical lower) Austin, TX 78731 Phone 512DELIVER TOI 3460Enand back to KCRC. OTHER INSTRIICTIONS- Please robin) Copy or oricinal bark In SJFA [Universal PrCeautio* during all transports': A copy ofth 1-216 or 1-203(a) mast accompany [ilyWornkAVY QUESTIONS,.CONTACT SIEA, ON DUTY., UPON CONCLUSION OF THIS DETAIL YOU ARE REQUIRED TO COMPLETE YOUR REPORT IN ALL THE SPACES 1 ' A ..7 1" 1"%71..-r THE PROVIDED BELOW. AFTER GASSING UP YOUR VEHICLE, RETURN THIS ORDE"a^ DUTY SUPERVISOR IMMEDIATELY. (b)(6),(b)(7)(C) BEGINNING MILEAGE: 41 °Li 1E,11(b)(6),(bi ENDING MILEAGE: q SIGNATURE OF SUPERVISOR REPORT DATE: June 05, 2015 I HEREBY CERTIFY I HAVE COMPLIED WITH THE ABOVE ORDER EXACTLY AS DIRECTED (IF NOT, EXPLAIN EXCEPTIONS TIME ACCOUNTING: EOD FOR THIS DETAIL 073 0 RETURNED FROM DETAIL hours I1 100 hours TIME CHARGED TO: CONVEYANCE, PRODUCTIVE S • .2 C HIES CONVEYANCE, LOST TIME Tren I 'inn Tic fir1-141t 1117TA II 1. a s G. 5 (b)(6),(b)(7)(C) G-39I Page 2 of 740 HRS U.S. Immigration and Customs Enforcement Be Safe UNITED STATES DEPARTMENT OF HOMELAND SECURITY IMMIGRATION AND CUSTOMS ENFORCEMENT OFFICIAL DETAIL- Karnes County Residential Center VEHICLE 0: (b)(6),(b)(7)(C) 10: CEO Transporter: ASSIGNMENT: Transport (.10 see attached 1-216) BEGINNING AT 0600 hours June 08,2015 YOU ARE DIRECTED TO PERFORM TRANSPORT DUTIES AS SET FORTH E BELOW: PICK UP AT: KCRC DELIVER TO: Motel 6 5522 N Interstate 35 Rahman Rd. San Antonio, TX 78218 OTHER INSTRI ICTIONS• Please whim ropy nr otinal bark In STFA POC's: SDDO (b)(6),(b)(7)( I 202 5011010..1EA wow ,56.53 (b)( and SIEA (b)(6) ( 830-200- . (h)(7) r nivertal Precautions 4uring all transports'. A copy of the 1-216 or I-2(13(a) must accornlin fornA 4INTY QUMTI9NS, COIVTACT S1EA OP/DUTY UPON CONCLUSION OF THIS DETAIL YOU ARE REQUIRED TO COMPLETE YOUR REPORT IN ALL THE SPACES PROVIDED BELOW. AFTER GASSING UP YOUR VEHICLE, RETURN THIS ORDER AND VAN KEYS TO THE DUTY SUPERVISOR IMMEDIATELY. EA BEGINNING MILEAGE: 4472/02_. ENDING MILEAGE: 73a G 1 REPORT DATE: June 08,2015 I HEREBY CERTIFY I HAVE COMPLIED WITH THE ABOVE ORDER EXACTLY AS DIRECTED (IF NOT, EXPLAIN EXCEPTIONS (b)(6),(b)(7)(C) SIGNATURE OF SUPERVISOR TIME ACCOUNTING: EOD FOR THIS DETAIL 0 -2/ 3----- hours RETURNED FROM DETAIL /3 V S--- hours TIME CHARGED TO: CONVEYANCE, PRODUCTIVE 3, 013 CONVEYANCE, LOST TIME HRS C7 (b)(6),(b)(7)(C) G-391 Page 3 of 740 HRS (b)(6),(b)(7)(C) frnia"; April I , 2014 sasc. _ The GEO Group, Inc. (b)(6),(b)(7)(C) Contracting Officer's Representative Karnes County Residential Center 409 FM 1144 Karnes City, Texas 78118 Karnes County Residential Center 409 FM 1144 Karnes City. TX 78118 Re: GEO Response to CDR Report Number: CDR 15-0006 (b)(6),(b)(7)(C) I am in receipt of CDR 15-006 and following corrective actions are provided in response to your noted concerns. Finding: On March 6, while conducting dining hall and kitchen checks, ICE staff encountered no Kitchen Manager present during breakfast. Corrective Action: GPO Central Region approved a request for two Assistant Food Service Managers. I expect to have these positions in place no later than May 1,2015. In the interim, I have assigned a Security Supervisor to the Kitchen during peak feeding times to provide supervisory oversight. Finding: On March 7, 2015, while conducting dining hall and kitchen checks, ICE staff encountered kitchen personnel with little or no control of the dining hall, with one staff member completely surrounded by residents and unable to move and fulfill her regular duties of filling the self-serve cereal bar. In the walk in cooler a can of biscuits dated 3-4-15. Corrective Action: Video footage revealed to the COR, GEO staff had control of the dining hall. The kitchen personnel were refilling the "fruit-loops" for the children. The children were excited because it was a new cereal and ran to look and get more. It is unclear as to what is meant by a can of biscuits dated 03/04/15. Finding: On March 11, ICE staff encountered no supervisor for the breakfast service and the cleanliness of the grill and oven was not being maintained. Corrective Action: GEO Central Region approved a request for two Assistant Food Service Manager's. I expect to have these positions in place no later than May 1,2015. In the interim,! have assigned a Security Supervisor to the Kitchen during peak feeding times to provide supervisory oversight. During the weekly ICE meeting it was noted that the grill was clean but was displaying discoloration on the surface. Also, the ovens were being used at the time to prepare for the evening meal. When the meal preparation was completed the ovens were inspected and cleaned. Page 4 of 740 Finding: On March 12, ICE staff encountered 3 containers of prepared food not labeled with a date or identified as to what it was supposed to be. Corrective Action: During the weekly ICE meeting, it was explained that the containers were the three days of "dead man" trays required to be kept. The trays were placed in a drop box that is specifically designed for this purpose. The Food Service Manager was counseled the day of the inspection to verify the dates are placed on the trays. Refresher training for Food Services staff on the proper dating of food and other topics was initially provided 3-13-15. Written instruction was included in the Opening & Closing Checklist Packet on 3-28-15. (See Attachment A) Finding: On March 13, ICE encountered the kitchen log book with pages falling out, breakfast meal temperatures not logged at approximately 1130 and when checked again at approximately 1215 the log was filled out, the substitution of bread for the bun listed on the menu was not annotated, 1 container of potatoes dated 3-14-15, an unlabeled container of prepared beans, a white container of opened dill pickles with an arrival date of 12-11-14 but no opened date, an unopened container of cultured sour cream arrival date of 12-1-14, personal food items in a plastic grocery bag (a lime, frozen meat, and a tomato), tortillas in boxes dated 1-15-15 and more in banana boxes without a date with some in bags not properly tied or closed. Corrective Action: The Kitchen log book was replaced 011 03/18/2015 to correct this issue. Kitchen staff documents the food temperatures on two separate forms, Quality Assessment and the Opening and Closing Checklist. When ICE conducted their inspection on 03/13/15, M. Kordus observed that the temperature was not logged on the Quality Assessment form. The kitchen staff did fail to notate on that specific form; however, staff was able to obtain temperatures from the breakfast meal from the Opening and Closing Checklist and update the Quality Assessment form. "The Food Service Manager counseled kitchen staff on documentation of temperatures, substitutions, and on the correct procedure for labeling food items. The beans, pickles and sour cream were disposed of immediately upon notification by the Food Service Manager. Unopened sour cream has a shelf life of one year from the manufacturer date. The staff member responsible for placing personal food in the cooler was counseled and the food was immediately removed. Finding: On March 17, ICE staff encountered kitchen personnel serving under cooked rice to residents, and it was not replaced until ICE staff informed the contractor and requested a replacement item. Corrective Action: The Food Service Manager was notified by ICE M. Barcenas and mashed potatoes were substituted in place of the rice. The Food Service Manager counseled the morning kitchen staff on the procedure of preparing rice. Finding: On March 18, ICE staff encountered no Kitchen Manager or supervisor during breakfast service. Food thawing procedures were not followed as meat was not submerged under Page 5 of 740 running water. Most employees and resident voluntary workers were not wearing approved rubber soted safety shoes. Moist cloths were not cleaned between uses using a sanitation solution, and were not free of food debris. Manual cleaning procedures were not being followed, as the 3 part sink in the kitchen does not have a functioning drain. During breakfast the sausage patttes weighed 1.4oz instead of the 2oz required by the menu, and the orange slices were being served at 4oz instead of 8oz as required by the menu. The dayroom refrigerators had excessive buildup of dirt and debris on the shelves and food was placed in direct contact with it. Corrective Action: GEO Central Region approved a request for two Assistant Food Service Manager's. I expect to have these positions in place no later than May 1, 2015. In the interim, I have assigned a Security Supervisor to the Kitchen during peak feeding times to provide supervisory oversight. A review of this matter found the use of improper methods to thaw meat was an isolated incident. The proper procedure to thaw frozen meat is to place it into the cooler a day or two prior to the intended use so that it is properly thawed by the time it is to be used. Non-slip rubber shoe covers have been ordered and are scheduled for delivery no later than Tuesday, April 7. The referenced cleaning rags were being held in the sink until they were to be taken to laundry after the completion of the meal. All dishes are cleaned and sanitized using the Dish Machine. The three compartment sink was repaired by maintenance on 03/27/15. The scale was determined to be faulty and replaced. The food portions are now in accordance with menu specifications. The kitchen staff gave residents two 4 oz. scoops of the oranges instead of one 8 oz. scoop. ICE Barcenas advised kitchen staff and the 4 oz. scoop was replaced with an 8 oz. scoop immediately. Kitchen staff has been instructed to wipe down all dayroom refrigerators when restocking. Follow up inspections have verified compliance. Finding: On March 20. ICE staff encountered kitchen staff not following food thawing procedures and did not have meat submerged under running water. Most kitchen staff and resident voluntary workers were not wearing approved rubber soled safety shoes. Moist cloths being used to clean and sanitize were not being properly cleaned and sanitized between uses. The dayroom refrigerators had excessive buildup of dirt and debris on the shelves and food was placed in direct contact with it. Corrective Action: It is my understanding that the reference to thawing of the meat is the same as was noted on March 18. The proper procedure to thaw frozen meat is to place it into the cooler a day or two prior to the intended use so that it is properly thawed by the time it is to be used. Non-slip rubber shoe covers have been ordered and are scheduled for delivery no later than Tuesday, April 7. Page 6 of 740 Staff was instructed on March 19, 2015 and again on March 20, 2015 to utilize the green buckets, which are filled with sanitizing solution, when cleaning in the kitchen area. This issue has not reoccurred. Kitchen staff has been instructed to wipe down all dayroom refrigerators when restocking. Finding: On March 23, ICE staff encountered a 4 oz scoop not annotated on the log for he kitchen tool control. Corrective Action: This issue was corrected immediately and the responsible staff was disciplined. Finding: On March 24, ICE staff encountered 1 container of prepared salad and 1 container of prepared corn salad that were out over 24 hrs old. Corrective Action: A review into this matter found that the referenced items were dated incorrectly. Food Service staff promptly disposed of the referenced items. Finding: On March 25, ICE staff encountered a can opener not annotated on the kitchen tool log. The 3 part sanitation sinks were not being properly utilized with dirty pans placed into the rinse station instead of the soaking station. Corrective Action: The issue concerning the tool log was corrected immediately and the responsible staff was disciplined. All dishes were cleaned and sanitized using the dish machine. The Food Service Manager followed up with Maintenance on the status of the work order for the rinse compartment of the three compartment sink. Maintenance repaired the damaged seal on 03/27/15. Finding: On March 27, ICE staff encountered, at approximately 0730 hrs, 2 containers of prepared rice, I container prepared potatoes dated 3-27-15 and time placed in the cooler was labeled 1000. One item with hand written Use by Date of prepackaged shredded cabbage with 37-15. Corrective Action: A review into this matter found that the referenced items were dated incorrectly. Food Service staff promptly disposed of the referenced items. Refresher training for Food Services staff on the proper dating of food and other topics was initially provided 3-13-15. Written instruction was included in the Opening & Closing Checklist Packet 011 3-28-15. Finding: On March 29, ICE staff encountered a 4 oz. scoop not logged on the tool log, both voluntary workers and GEO kitchen staff was not wearing approved safety shoes, and only 2 oz of salsa was being served instead of the 4 oz required by the menu. Corrective Action: The tool log was corrected on the spot and the responsible staff was disciplined. Page 7 of 740 Non-slip rubber shoe covers have been ordered and are scheduled for delivery no later than luesciay, April 7. With regards to the serving of salsa, the menu calls for a 'A cup, which is equivalent to 2 oz. Please advise if additional information is needed. (b)(6),(b)(7)(C) Facility Administrator Enclosures CC: (b)(6),(b)(7)(C) Executive Vice President, Contract Compliance ce President of Operations, Central Region Page 8 of 740 Attachment A 1. Sign log book/ log anything that needs to be logged in the book. 2. Check sample trays (DO NOT USE SYTROFOAM FOR SAMPLE TRAY) 3. Check for 24 hr. left over food. If any throw it away 4. Label & Date your food for today. MAKE SURE TO FINISH PAPERWORK BEFORE MEAL IS OVER. S. Only 2 people to go stock refrig. Take a wet rag to wipe down refrig. 6. Double check your tools and chit sign out. 7. Clean your work area after you are finish. 8. Do Not do paperwork if your are not cooking OIC/Helping Masters Stock refrigs (b)(6),(b)(7)(C) HELP EACH OTHER WHERE HELP IS NEEDED. Page 10 of 740 KARNES COUNTY CIVIL DETENTION CENTER TRAINING ATTENDANCE RECORDS GEO CENTRAL REGION Date 3/13/15 Food Service Training NAME (PRINT) EMPLOYEE ti CIC.NATIIPF DEPARTMENT (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) f.c F5 9. 10. [ SUBJECTS Train; Hours Refrigerators stock 3 times a day. Only 2 persons to stock. Do Not stock refrigerators during meal time. Food Service needs to stock refrigerator) don't just leave products on counter. Check sample box, need to use correct tray not Styrofoam tray. Check for 24 hr. leftovers. If any throw it away. Sign Post Order book Any open products, use that 1". If you get something out put it back in the correct place. When getting call from intake ask if residents are already there. If resident not there yet, wait to make trays until residents are there. Clean after yourself and work area. (b)(6),(b)(7)(C) Page 11 of 740 (b) (6),(b 30 KARNES COUNTY CIVIL DETENTION CENTER TRAINING ATTENDANCE RECORDS GEO CENTRAL REGION Date 3/13/1S rood Service Training NAME (PRINT) EMPLOYEE # DEPARTMENT f15 )x, _ (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) 7ze, scent, c lipoar carov F0ac7J_. (b)(6), (b)(7) (C) 8. bI Ecco cc) 9. 10. SUBJECTS Train Hours Refrigerators stock 3 times a day. Only 2 persons to stock. Do Not stock refrigerators during meal time. Food Service needs to stock refrigerator, don't just leave products on counter. Check sample box, need to use correct tray not Styrofoam tray. Check for 24 hr. leftovers. If any throw it away. Sign Post Order book Any open products, use that ft. If you get something out put it back in the correct place. When getting call from intake ask if residents are already there. If resident not there yet, wait to make trays until residents are there. Clean after yourself and work area. (b)(6),(b)(7)(C) Page 12 of 740 (b)(6), (b)(7) (C) 3 ICE CONTINUATION SHEET 1 CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERO-IGSA-11-0004 Date: 04/15/2015 Report Number: CDR-15-0007 7c 5c0n1r4r(gr and Manager Name) 00),(10 A )(U.IFacilin/ Administrator 01005eig )1(1*7rd2IMA CEO Group Inc DHS/ILE DATES CONTRAC1OR NOTIFICATION 04.15 2015 CONTRACTOR RESPONSE RETURNED BY CONTRACTOR DUE BY ACTION COMPLETE C4, 1712015 4 DISCREPANCY OR PROBI FM rfleisc. Abe Derpei Inplude rureyence PWS Allan CO !hearten sheet e necessary ) Contractor Violations: Contract: GUN 0001 Housing and care of Family Rescrentral. Family Residential Facility Statement of Work 2 a The purpose of tins contract is to facilitate the provisions for the necessary physical structures, equipment recall:es, personnel and services to provide a program of temporary shelter care in a staff secure environment and other related services to alien family groups who are currently held in the legal I custody of ICE e SIGNATURE OF CONTRACTING OFFICERS TECHNICAL REPRESENTA` (b)(6),(b)(7)(C) 7 FROM (Confrai E TO (COS) 8 CONTRACTOR RESPONSE AS TO CAUSE CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE ATTACH CONTINUATION SHEET IF NECESSARY Wile app'eceb e 0 A wogram proCedUre5 0 , nen) A W prsCodures ) (b)(6),(b)(7)(C) 10 pATE 1—)11-1 11 GOVERNMENT EVALUATION OF CONTRACTOR RESPONSERESOLUTION. PLAN (Acceptable tespcnse/plan.panda! 3CC prance al responselp0A tejeChOn attach corProuabon heel II necessary) GOVERNMENT ACT:ONS (Pa tri"” Cd SC CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIEO COP CONTRACTING OFFICER Page 13 of 740 SIGNATURE DATE Issues: During a routine check, conducted on April 7, 2015, of the Central Control area and log books revealed that numerous cameras were not operational or had video degradation to the point where individuals were not identifiable. A Plan of Action was requested for how future maintenance was to be performed and a request for all documentation on previous maintenance performed on the affected cameras, due to the fact that CDR-KCRC-14-0004 had been submitted for similar issues. This Plan of Action request was sent on April 8, 2015 and the Plan of Action was due no later than April 13, 2015, and was not received. Cameras known to need maintenance: 1-10; 19-20; 22, 24 and 66 do not have a picture, and 32, 35, 36, 49, 51, 53, 55 and 68 have a blurry picture. In CDR KCRC-14-0004 it was mentioned that a previous Plan of Action from August 22, 2014 had received a plan for a Preventative Maintenance Schedule. This schedule should have been included with this last request for a Plan of Action as we requested for all past maintenance records, it was not received and can only be concluded that it has not been adhered to. Contract Stipulations: Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary," A Contract Discrepancy Report that cites violations of FRS, PREA, and SOW (contract) sections that protect the community, staff contractors, volunteers, and residents from harm, permits the Contract Officer to withhold or deduct up to 15% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section" Page 14 of 740 April 17.2015 (b)(6),(b)(7)(C) Karnes County Residential Center Contracting Officer's Representatis'e Karnes County Residential Center 409 FM 1144 Karnes City. Texas 78118 409 FM 1104 Karnes City . TX 7B118 WWW geo.rcup corn Re: GEO Response to CDR Report Number CDR 15-0007 (b)(6),(b)(7)(C) 1 am in receit t of CDR 15-007 and the following corrective actions are provided in response to your noted concerns. Finding:During a routine check, conducted on April 7.2015. or the Central Control area and log books resealed that numerous cameras were not operational or had video degradation to the point where individuals were not identifiable. A Plan of Action was requested for how future maintenance was to be performed and a request for all documentation on previous maintenance performed on the affected cameras, due to the fact that CDR-KCRC-14-0004 had been submitted for similar issues. This Plan of Action request was sent on April 8. 2015 and the Plan of Action was due no later than April 13,2015. and was not received. Cameras known to need maintenance: 1-10i 19-20: 22-24 and 66 do not have a picture, and 32, 35. 36.49. 51. 53. 55 and 68 have a blurry picture. In CDR KCRC-14-0004 it was mentioned that a previous Plan of Action from August 22. 2014 had received a plan for a Preventative Maintenance Schedule. This schedule should have been included with this last request for a Plan of Action as we requested for all past maintenance records, it was not received, and can only be concluded that it has not been adhered to. Corrective Action: The facility's preventative maintenance program for cameras entails the Central Control staff conducting a daily inspection of all cameras to verify their functionality. The outcome of the daily camera inspections is documented in the Camera Log Book. After an issue with a camera is documented in the Log. the Security Clerk generates a maintenance work order to adjust and or repair the equipment. A sample of those work orders is provided lin' your review and record (Attachment A). On January 19. 2015 Facility Administrator verbally informed AFOD (b)(6),(b)(7)(C) that many cameras would be disconnected due to site excavation of the facility expansion (Attachment B). The cameras that are currently disconnected are: 1-3 NW Site Exterior: 4-7 N Site Exterior: 8-10 NE Site Exterior: 19-20 E Site Exterior: and 66 S Exterior Admin. A work order was generated April I. 2015 requesting the surveillance cameras to be evaluated (Attachment C). On April 15. 2015 a lift was rented and all cameras noted as out of focus and Page 15 of 740 not disconnected due to construction were repaired The following cameras were adjusted: • 22 Rec I Site • 23 Rec I Site • 24 Rec 1 Site • 32 S HI Roof • 35 E PI Roof • 36 S PI Roof • 49 SW Rec • 51 NW Rec • 53 SW Rec 2 • 55 NW Fxt HI • 68 S Ext Admin eN aluated and The referenced work order was completed April 16, 2015. As a matter of follow-up after the repair work, the Deputy Eacilit), Administrator. (b)(6),(b)(7)(C) inspected the surveillance cameras and, with the exception of those temporarily disconnected to accommodate the current construction project. found them Rill), operational. Please advise if additional information is needed. (b)(6),(b)(7)(C) Facility Administrator Enclosures CC: (b)(6),(b)(7)(C) 'Executive Vice President. Contract Compliance I Vice President of Operations. Central Region Page 16 of 740 Attachment A &Geo rffir7!!N Work Order Cre ted By Cre led 154526 Facility Camera Scheduled Start Scheduled End Date Status (b)(ba (b)(/)(U) 0919/2014 09/19/2014 09/26/2014 Closed Reprint WO Type BRKD Breakdown Project Parent WO Class Priority Warranty Safety Equipment Criticality Assigned To Reported By Assigned By Multiple Equipment Campaign Standard WO Campaign Event Date Started Department DEFAULT ALL DEoARTMENTS PM Schedule Cost Code Problem Code Equipment 200-FACILITY 200-Facility Manufacturer Model Serial Number Location 200-FACILITY 200-Facility Reliability Ranking (09/19/2014 10:54 Cameras 2, 8 17 & 23 need to be checked [09/24/2014 08.28]. 2-8-17 ok 23 needs some trouble shooling Page 18 of 740 (b)(6), (bAlC ,1)(f)(C) Nu 09/22/2014 11.15 Date Completed 09/22/2014 Time Completed 11:30 Reliability Ranking Score Reliability Ranking Index ELECTRNS 3 rd. ..r•Vi.71PM?"771‘11171irti tr. Work Order Activity Trade MAINT TECH Estimated Hours 1 fr0R-0710 Employee/Crew GENERAL MAINTENANCE 154526 10 Activity Start Date Activity End Date People Required , Time On Time Off Route Page 19 of 740 Total Time 09/1912014 09/2612014 1 /3/V 2i4Pi•froiTri+L(4::,•,,,- E :.. 5,..iy.,c...„,....,:-.;fip.4...0,-..?,. ,.., . . Work Order Created By 214765 CAMERAS (b)(6),(b)(7)(C) Created 12/0 /2014 : ;satia :. .—seal .f.T.,1-;s?,[7,777.,....-.73,,,,,,t-, , r,-.11.F..7.,Fsm-FATs:7 . -.!:_ Scheduled Start Scheduled End Date Status - 12/01/2014 12/0812014 Closed Repent WO Type BRKD Breakdown Parent WO Class Priority Warranty Safety Equipment Criticality Assigned To Reported By Assigned By Multiple Equipment Campaign Campaign Event Date Started Department DEFAL1L° ' ALL DEPARTMENTS PM Schedule Cost Code Problem Code Project Standard WO Equipment 200-PERIMETER Manufacturer Model Serial Number LOC3ti011 200-PERIMETER Reliability Ranking (b)(6),(b)(7)(C) No 12/01/2010 16 15 Date Completed 12/01/2014 Time Completed 16.30 200-Perimeter 200-Perimeter Reliability Ranking Score Reliability Ranking Index PRIMISSEMEZIZZMEM I E011en 12/01/2014 14:24): S- #17 NOT WORKING (12/03/2014 08:44]. re mere-Compton Page 20 of 740 _ ,211W ._!.4fraje 7r3. Work Order Activity Trade MAINT Estimated Hours C 5 GENERAL MAINTENANCE e 717.T71777 214765 10 Activity Star! Date Activity End Date People Required 12(01.20 4 12,08.2014 2 gia,W5.13 • Employee/Crew Date Time On Time Off Total Time Type of Hours { Route Page 21 of 740 _ Work Order Created By Created 214913 CAMERAS Scheduled Start Scheduled End Date Status 11015311011 12/01/2014 12k/1/2014 12/0812014 Ctosed Reprint WO Type BRKD Breakdown Parent WO Class Priority Warranty Safety Equipment Criticality Assigned To Reported By Assigned By Multiple Equipment Campaign Campaign Event Date Started Department DEFAU. I ALL DEPARTMENTS PM Schedule Cost Code Problem Code Project Standard WO * eC 2/tanF2AW jate%akC; Agr 1 Ki Equipment 200-FACILITY Manufacturer Model Serial Number Location 200-FACILITY Reliability Ranking NO PROBLEM FOUND-COMPTON Page 22 of 740 No 12/01/2014 15 45 Time Completed 15 55 200-Facility tIJIwIu 112./03/2014 09.46) (b)(6),(b)(7)(C) 12/01/2014 Reliability Ranking Score 4a .W ' Ste l. n 1 'nekl '- tt 3‘ / 12/01/2014 14:42]: ream CAMERA 18 DARK (b)(6),(b) Date Completed 200-Fac ittv Reliability Ranking Index SURVIEt Work Order Activity Trade MAIN"' TECH Estimated Hours 05 GENERAL MAINTENANCE 214913 10 Activity Start Date Activity End Date People Required 12;0'12014 12(08'2014 2 tw'mk,f,;-. 7:-',r'r"rrcnrAfl'kr9mNTglArt9.9gst,'''" Date Time On Time Off FOf r Route Page 23 of 740 Total Time Type of Hours +:4-4tr• 1, ji itirWork Order Cre ted By Cre ted 333341 wr 77-77255 COMPOUND 1 CAMERAS Scheduled Start Scheduled End Date Status 04/0 i2015 04/06/2015 04/13/2016 Open Repro' WO Type BRKD Breakdown Parent WO Class Priority Warranty Safety Equipment Criticality Assigned To Reported BY Assigned By Multiple Equipment Campaign Campaign Event Date Started Department DEFAULT ' ALL DEPARTMENTS PM Schedule Cost Code Problem Code Project Standard WO SURVIEL 3 (b)(6),(b)(7)(C) INC Date Completed Time Completed WINNESTIT.itifflafftaILEIMENIRMIEW Equipment Manufacturer Model Serial Number Location 200-COMPOUND 1 200-COMPOUND 1 Reliability Ranking 200-Compound 1 200-Compound 1 Reliability Ranking Score Reliability Ranking Index (b)(6),(b) [04/06/2015 08.51]. ,ifiO/PlkonivineA COMPOUND 1 CAMERAS 22123 ARE OUT Page 24 of 740 .17117T .r.,%417 Thldridf?.1 ,71!TPdr?;:npriidtd . , Work Order Activity Trade MAINT TECH Estimated Hours 1 5 F. ,— Employee/Cre tatty GENERAL MAINTENANCE '741,-"reck17." Date Time On Time Off 7 1077d Route Page 25 of 740 333341 10 Activity Start Date Activity End Date People Required . Total Time 04/06,2015 04.13/2015 2 .,,t.AM/fffre.TW Type of Hours Attachment clia20 ,5 T re Geo Gr ClJr. 1'10' Ka SLYVein Carre:as (b)(6),(b)(7)(C) Karnes Surveillance Cameras (b)(6),(b)(7)(C) Wed Apr 15, 2015 at 11 22 AM (b)(6),(b)(7)(C) (b)(6),(b)(7)(C] As we discuss earlier today, we are working to reconnect any that had to be taken out of service do to the site excavation of the new expansion. These cameras will be placed back online as the construction progresses Please let us know that this is acceptable. Thank you, (b)(6),(b)(7)(C) Project Executive White Construction Company General Contracting Construction Management Design/Build 613 Crescent Circlel(b)(6) (bIRidgeland MS 31;157 Tel 1601) 85F1(b)(6) Fax 601 fr 8 0 8 1 cD Annw vedniteconst corn OP 1 IttFi I Wing a Greener loloGrc (b)(7)(E) Page 27 of 740 1:1 Attachment - Work Work Order Created By Created 339011 Order FACILITY CAMERAS Scheduled Start Scheduled End Date Status ROIOX01 04115'2615 04/01/2015 04/16/2015 Open Reprint WO Type BRKD Breakdown Parent WO Class Priority Warranty Safety Equipment Criticality Assigned To Reported By Assigned By Multiple Equipment Campaign Campaign Event Date Started Department DEFAULT ALL DEPARTMENTS PM Schedule Cost Code Problem Code Project Standard WO Date Completed Time Completed Equipment Equipment 200-FACILITY Manufacturer Model Serial Number Location 200-FACII ITV 200-Faci 20D-Fac lity Reliability Ranking Reliability Ranking Score Reliability Ranking Index 04/15/2015 14:37): THE LISTED SECURTIV CAMERAS BELOW NEEDS SOME MAINTENANCE CAMERAS 19-20 22,24 AND 66 HAVE NO PICTURE CAMERAS 32 35 36, 49 5' 53 55 AND 68 HAVE A BLURRY PICTURE Page 29 of 740 SURVIEL (b)(6),(b)(7)(C) No an 5b 5 WthIls ullsos 0130 1100 Gee :oder! comprehensive Work Order Activity Trade MAINT TECH Estimated Hours 12 339011 10 GENERAL fAAIWIENANCE Activity Start Date Activity End Date People Required 04z01/2015 04/0912015 Hooked Hours Employee/Grew Date Time On lishs 09 bp (b)(6),(b)(7)(C) iShS OquID q11015 0V3 9114115 °Bee Time Off I 7 GO I 700 093D 0930 Total Time Type of Hours 1 .0 -7 .0 G22g 12,VD. RR 6-- f\b)-kAST OfenlarS ccervz LENS a- RX(RIPAP -soVVag CO rare C1SS C_I-113/41sg.g triA)106)•) C_AMAT:aS CZ) Route Route Page 30 of 740 ICE CONTINUATION SHEET 1 CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERO-IGSA-11-0004 Date: 07/15/2015 Report Number: CDR-15-0008 CR OL )aziodo 690 2M 100)( 2 TQ (Contractor and Manager Name) (b)(b),07J)(/)( i Facility Administrator CEO Group. Inc DHS/ICE DATES CONIRACTOR NOTIFICATION 0/D5124115. ACHON COMPLETE CONTRACTOR RESPONSE RETURNED BY CONTRACTOR DUE BY 071 H2015 4 DISCREPANCY OR PROBLEM (Descrebe a Detail Inpude tense ,r( ?WS/ arectwe Alum conenuation sheet it necessary Contractor Violations: Contract: CLIN 0001 Housing and care of Family Residential Family Residential Facility Statement of Work 2 a. The purpose of this contract is to facHtete the provisions for the necessary physical structures, equipment, facilities, personnel and services, to provide a program of temporary shelter cam in a staff secure environment and other related services to alien family groups who are currently held in the legal custody of ICE." 5 SIGNATURE OF CONTRACTING OFFIC S TECHNICAL REPRESENTATIVE (COED L, 7 FROM IC 6 TO (DOR) 8 CONTRACTOR RESPONSE AS TO CAUSE CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE ATTACH CONTINUATION SHEET IF NECESSARY (Cite apohcable 0 A program procedures or new A V/ aroceoures 9 SIGNATURE OF CONTRACTOR REPRESENTATIVE (b)(6),(b)(7)(C) 10 DATE s 11 GOVERNMENT EVALUATION OF CONTRACTOR R SPONSERESOLUTION PLAN (A Ceptable reSporise/Man Partat acceptance of response/plan rejection attach contrnuato sheet if (Mensal)/ 12 GOVERNMENT ACTIONS (Payment (vothholchng cure norms show cause otner CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COP CONTRACTING OFFICER Page 31 of 740 SIGNATURE DATE Issues: During a routine check, conducted on June 14, 2015 and July 13, 2015 of the Central Control area it was discovered that numerous cameras and monitors were not operational or had video degradation to the point where individuals were not identifiable. Previous Plans of Action and CDRs KCRC-15-0007 and KCRC-14002 have addressed this area and while the maintenance was performed at that time to immediately address the discrepancies nothing appears to have been done to prevent the same issues from reoccurring. It is understood the facility will have issues due to the current construction but most of the cameras referenced below are not part of the affected areas we were told about nor are the monitors located in Central Control. Cameras known to need maintenance: 8,9, 10,19. 20, 41, 56, 57, 58, and 66 do not have a picture, and 22, 24, 25, 27, 47, 48, 49, 53, 54, 62, and 75 have a blurry picture. In CDR KCRC-14-0004 it was mentioned that a previous Plan of Action from August 22, 2014 had received a plan for a Preventative Maintenance Schedule. This schedule is in a form of a log book that the Security Clerk is responsible for checking and generating Work Orders that the staff in Central Control have no way of recording when they were submitted to ensure accountability. Contract Stipulations: Per ERO-IGSA-11-0009, Attachment 6.4, Performance Requiremenis Summary," A Contract Discrepancy Report that cites violations of FRS, PREA, and SOW (contract) sections that protect the community, staff contractors, volunteers, and residents from harm, permits the Contract Officer to withhold or deduct up to 15% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Page 32 of 740 GOO July 17, 2015 The GEO Group, Jilt. ih7hs (b)(6),(b)(7)(C) Contracting Officers Representative Karnes County Residential Center 409 FM 1144 Karnes City, Texas 78118 Karnes County Residential Center 009 FM 1144 Karnes City . TX '8'18 Re: GPO Response to CDR Report Number: CDR 15-0008 Dea4(b)(6),(b)(7)(C) 1 am in receipt of CDR 15-008 and the following corrective actions are provided in response to your noted concerns. Finding: During a routine check, conducted on June 14, 2015 and July 13. 2015 of the Central Control area it was discovered that numberous cameras and monitors were not operational or had video degradtion to the point where individuals were not identifiable. Previous Plans of Action and CDRs KCRC-15-007 and KCRC-14002 have addressed this area and while the maintenance was performed at that time to immediately address the discrepancies nothing appears to have been done to prevent the same issues from reoccurring. It is understood the facility will have issues due to the current construction but most of the cameras referenced below are not part of the affected areas we were told about nor are the monitors located in Central Control. Cameras known to need maintenance 8, 9, 10, 19. 20, 41, 56,57, 58, and 66 do not have a picture, and 22, 24, 25, 27, 47, 48. 49, 53 54, 62. and 75 have a bluff>. picture In CDR KCRC-14-004 it was mentioned that a previous Plan of Action from August 22, 2014 had received a plan for a Preventative Maintenance Schedule. .1-his schedule is in a form of a log book that the Security Clerk is responsible for checking and generating Work Orders that the staff in Central Control have no way of recording when they were submitted to ensure accountability. Facility Response: Daily checks of the cameras are made by the Shift Supervisor who turns the documentation into the Chief of Resident Advisors, Program Director, Deputy Program Director, and Maintenance. There is an open work order on the surveillance cameras until the construction is completed and all cameras are restored to operational status. The attached e-mail was sent to the CUR on 5-20-15 listing the status of the following cameras as inoperative due to construction Camera 8: NE Site PTZ Camera 9: NE Site Camera 10: NE Site Camera 19: W Site Camera 20: W Site Out due to Construction Out due to Construction Out due to Construction Out due to Construction Out due to Construction Page 33 of 740 Camera 41 Admin Roof Out due to Construction Camera 56 EXT PI Out due to Construction Camera 57 N EXT PI Out due to Construction Camera 58. NE Ext P2 Out due to Construction Camera 66: .[his is a spare camera, there is no picture The reference to blurry camera images was investigated and the cameras and monitors were found to be in working order. I have enclosed pictures of the monitoring screens for cameras 22, 24. 25, 27, 47, 48, 49, 53, 54, 62, and 75 The facility administration respectfully disagrees with the COR's assertion that monitors are not located in Central Control. In addition to Central Control, surveillance monitors are located in the Main Control Room and Program Directors office. With regards to your concern over the tracking and accountability of the facility's preventative maintenance for surveillance cameras, this activity is tracked hy the Chief of Resident Advisors for consistency due to the rotation of staff in Central Control. Please advise if additional information is required Sincerely, The GEO Grou (b)(6),(b)(7)(C) minis rato Faci Enclosures CC I (b)(6),(b)(7)(C) Executive Vice President. Contract Compliance (b)(6),(b)(7)(C) Vice President of Operations. Central Region Page 34 of 740 Camera 022 Camera 024 .-I-J tr: nil-z} m? Cam?ra page 35 of 740 Camera 027' Hi?li?i??f? :Jr'?L'j Camera 047 Camera 043 Page 35 of T40 -E 'fr' 14' Camera 049 21:1] arr 4'1: . . Camera 033 Camera 054 Page 3? of T40 [i155] ii-Iu? (Tamara 062 Camera 0?:3 Page 38 of T40 (b)(6),(b)(7)(C) From Date May 20 2015 4 59 PM Su ject Update on Surveillance To (b)(6),(b)(7)(C) Cc Here is a lisl of the cameras that are not showing as operaconal due to constriction 8. NE Site PTZ 9. NE Site 10 NE Site 14 E Site 19 W Site 20 VV Site 30 NW H1 Roof 31. Sw H1 Roof 66. Camera was renumbered 71 Sw Ext. H1 72. SW Ext. H1 73 NVV Ext H1 181 706 C Corridor White Construction has installed several new cameras around the perimeter of the facility 10 alleviate blind spots These new cameras have taken the place of cameras 8.9.10.71,72, and 73 I will keep you updated. Page 39 of 740 1 CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERO-IGSA-11-0004 Date: 0711512015 Report Number: CDR-15-0009 2 TO (Contractor and Manager Name) (b)(5)),(3)(F)( racthly Administrator GEC Group, Inc 3 FROM Name of CUR) CORTIEA DATES CONTRACTOR NOTIFICATION 071150015 CONTRACTOR RESPONSE RETURNED BY DUE BY CONTRACTOR ACTION COMPLETE 07 /17;2015 4 DISCREPANCY OR PROBLEM fLescrobe on Delaol Include ref erence PILS /DEANNA Attach conimualson slicer it necessary ) Contractor Violations: Contract: CON 0001 Housing and Care of Family Residential Family Residential Facility Statement of Work 2. a. The purpose of this contract is to facilitate the provisions for the necessary physrcal structures. equipment, facilities, personnel and services. to provide a program of temporary shelter care in a stall secure environment and other related services to alien family groups who are currently held in the legal custody of ICE." 4. b. 2. c The Service Provider shall furnish sufficient vehicles in good repair and suitable as approved by the ICE, to safely provide the required transportation service " 5 SIGNATURE OF CONTRACTING OFFICERS TECHNICAL REPRESENTATIVE (CORI (b)(6),(b)(7)(C) 7 FROM (Contra log 6 TO (COR) 8 CONTRACTOR RESPONSE AS TO CAUSE CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE ATTACH CONTINUATION SHEET IF NECESSARY (Ole appocapoe 0A program procedures or new A Sto procedures ) 9 SIGNATURE OF CONTRACTOR REPRESENTAT 10 (b)(6),(b)(7)(C) 11 GOVERNMENT EVALUATION OF CONTRACT° acceptance of respoaseipfan. rejectoon attach conlona loon sheet P tIece3sary DATE Platte response/pfan. pagoal 12 GOVERNMENT ACTIONS (Payment oholdong. cure not, CLOSE OUT NAME AND I FILE CONTRACTOR NOTIFIED COR friniTOACTINa' Page 40 of 740 SIGNATURE DATE ICE CONTINUATION SHEET Issues: During an emergency medical run conducted on June 8, 2015, the facility had to use the perimeter vehicle to conduct the transportation, which left the facility without a roving patrol for an indeterminate amount of time. All other available vehicles were being used for a prior scheduled and approved event. 'During the facility provided field trip on June 26, 2015, it was noted that the facifity was not capable of transporting in one trip all of the students on the provided list. Contract Stipulations: Per ERO-IGSA-11-0004, Attachment 6.,1, Performance Requirements Summary," A Contract Discrepancy Report that cites violations of FRS, PREA, and SOW (contract) sections that protect the community, staff contractors, volunteers, and residents from harm, permits the Contract Officer to withhold or deduct up to 15% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Page 41 of 740 Geo The GEO Group, Inc. July 17, 2015 Ka nes County Residential Center 409 FM 1144 Karnes City. TX 78110 (b)(6),(b)(7)(C) Contracting Officer's Representative Karnes County Residential Center 409 FM 1144 Karnes City, Texas 78118 Re GE() Response to CDR Report Number CDR 15-0009 Deal k444,444, (c.) I am in receipt of CDR 15-009 and the following corrective actions are provided in response to your noted concerns. Concern: During an emergency medical run conducted on June 8. 2015, the facility had to use the perimeter vehicle to conduct the transportation, which left the facility without a roving patrol for an indeterminate amount of time. All other available vehicles were being used for a prior scheduled and approved event. Response: The enclosed log documents Vehicle 421134 was used for Mobile Patrol on June 8, 2015 and was not out of commission. Vehicle 421137 was used to transport a detainee to to a medical appointment in Austin and Vehicle 421133 was used for morning and afternoon transports. Concern: During the facility provided field trip on June 26, 2015, it was noted that the facility was not capable of transporting in one trip all of the students on the provided list. Response: The referenced trip was within 2 miles from the facility and the participating juveniles were transported in two trips as noted. Jam unaware of any requirement mandating the use of one trip to transport juveniles for a field trip. The facility's intent was to afford the opportunity to as many juveniles as possible, so the decision was made to take two trips The Juveniles participating in the trip were properly supervised at all times. Please advise if additional information is required. Sincerely, The CFO Grim in Inc (b)(6),(b)(7)(C) Facility Administrator Enclosures Page 42 of 740 cc: 'Executive Vice President, Contract Compliance Vice President of Operation, Central Region I gol)i go?V)cC) (r.) Page 43 of 740 Tr 0/15/70 GEO Tranopert Inc. Karnes County Residential Center 409 FM 1144 Karnes City, Texas 78118 TEL 830-254-2000 FAX' WWW.GEOGROUP.COM MEMORANDUM To (b)(6),(b)(7)(C) Facility Administrator From (b)(6),(b)(7)(C) Transportation Superviso (b)(6),(b) (7)(C) Date: July 15, 2015 Re: Synopsis of KCRC Transportation Operations- June 8, 2015 0600 hours- #21134-Officer (b)(6)(b)(7)(c) begins Perimeter Patrol Post.. vehicle 21134 remains assigned to Perimeter patrol continuously until 0600 hours On June 9, 2015. Officerj (b)(6) (b)(7)(c)Dast driver 0200-0600 hours. 0715 hours-#61501 with officer (b)(6),(b)(7)(C) depart sallyport enroute to San Antonio Tx with 9 residents being transported to Motel Six with 24 hour ICE security detail. Vehicle # 61501 arrives back at KCRC At 1345 hours. (b)(6),(b)(7)(C) 0730 hours-#21133 with Drivers depart th with one (1) resident enroute to Motel Six in San Antonio. I onboard as active ICE security for the transport. Vehicle #211 back at KCRC at 1300 hours. • S.' (b)(6),(b)(7)(C) arrives 0730 hours-#21137 with drivers (b)(6),(b)(7)(C) 'departs the Sallyport with one (1) resident for medical appointment in Austin, Tx. Vehicle #21137 arrives back at KCRC at 1400 hours. (b)(6),(b)(7)(C) 1315 hours-#21133 with officers departs the sallyport with two (2) residents enroute Otto Kaiser Hospital. #21133 returns to KCRC at 1600 hours Page 44 of 740 11 t iF I 1 I L' i I i !L i.I ; L 121 ' L !IL- L14' ES .Li "If 54 .. 2&) WC,A-C.Y\ DCS 0 ..._ bcy...t1 IN&tSNN EX e \-0/ \. jj I (.) . -1---a-N (*) tO I 01 I • .......----- -Claa0 • ab. •. 1- r 3A \. akar (b)(6),(b 7C -- --.1-- I ----(b)(6),(b)(7)(C) C11_ C.,teor (b)(6),(b)(7 ) C) ( ( . 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I' _ - . 1/31) _ow it' I ' age 7 • k' i_on 2 -/p6 2 /ye: 4,40 Wlifiterra I Itf , km J1 11. 0 f. /41/ 1 if/ 4(1 Ate e tat a. Order ii •;. ini/ j f/d t (b) (b)( F1/77 (b)(6).(b)(7)(C) jflgj A pi/ Sp• /I /1 (b)(6).(b)(7)(C) (b)(6).(b) (7)(C) 56 crf Sall Av. a it (6) (b) et_Z - i./z72/ nA - ,-, ior own i A, 'cthnievi ,/,2n . ey , 2 I in e f1 (b)(6),(b)(7)(C) kJ A03 / d • (b)(6). (b)(7) (C) ar .1 4., cfl2 I/ JO 'A / , 1 ber lied" of-i- •A f (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) itelii-- • f WSW " 1 41i ratirairS (6) (b) 7) I I ,-- • al , .111 (b)(6),(b)(7)(C) CO dr/ tilde- le 17 5 oPa6 4 (b)(6).(b)(7) (C) I /ail* f ki (b)(6).(b) ( 7)(C) (6). (b)(7 / tiesomlati/ / al Lil Winn nAe / lanc. (b)(6).(b) ( 7)(C) NOD (b)(6).(b) ( 7)(C) (b)(6).(b) ( 7)(C) .(b)(7)(C) (b)(6).(b) ( 7)(C) (b)( 6) (b)( 7) (b)(7)(C Page 47 of 740 KARNES COUNTY RESIDENTIAL CENTER TRA DATE: /C FUEL ADDED: VEHICLES!: P-1,133 STARTING MILEAGE: Li DESTINATION t g :p i Transport, NSPORTATION DETAIL RECEIPT TURNED IN: YES 70 DVIR COMPLETED: DEPART BEGINNING TIME MILEAGE /3 15 4/57C 15q5— 4 IS] S a TRANSPORT OFFICERS:I (b)(6()C) (b)(7) NO SF OF RESIDENTS ENDING MILEAGE: ARRIVAL TIME OUT ,lai-e•--- YES 3 3b 162 00 Pg-- I 41677 ENDING MILEAGE St OF RESIDENTS IN / ,C---- q/ 2(2.- -7q NOTE: ANYTIME YOU HAVE AN EMERGENC Y OR ANY OTHER ISSUE PERATAIN1NG TO THE SAFE AND SECURE TRANSPORT OF RESID THE TRANSPORTATION SUPERVISOR OR SUPE ENTS CALL RVISOR ON DUTY IMMEDIA TELY FOR INSTRUCTIONS. IF!? IS AN ISSU E THAT IS NOT /DENTS PLEASE RECORD THE ISSUES IN THE COMMENTS SECTION ABOVE. (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) 1 TRANSPORTATION SUPERVISOR Frage 48 of 740 6, f-,1 DATE KARNES COUNTY RESIDENTIAL CENTER TRANSPORT DATE: !9 ATION DETAIL te7 VEHICLE*: q 1(11/4 DESTINATION an 4-7-kro, ardent o(-A--e_ i e Sot n FUEL ADDED: 9 //33 STARTING MILEAGE: Prinirm to ICC, IZt eeTraC fc nsport. ,- r DEPART TIME NO RECEIPT TURNED IN: NO TRANSPORT OFFICERS: DVIR COMPLETED: NO ENDING MILEAGE: BEGINNING MILEAGE it OF RESIDENTS OUT ARRIVAL TIME Li 5-70 ENDING MILEAGE 0-730 c4M7 o1 oglis q/5-0,6 os co -Fr Oc/ IT 14 I 5-10 era' /300 4 icio LH `-10 6 I I I6- --fl5'O 51 0 (b)(6) ,(b)(7)(C) _ 31 OF RESIDENTS IN a1 -0— NOTE: ANYTIME IME YOU HAVE AN EMERGENCY OR ANY OTHE R ISSUE PERATA/NING TO THE SAFE AND SECU RE TRANSPORT OF RESIDENTS CALL THE TRANSPORTATION SUPERVISOR OR SUPE RVISOR ON DUTY IMMEDIATELY FOR INSTRUCTI ONS. IF IT IS AN ISSUE THAT IS NOT PERTAINING TO THE SAFF AND crruns: 'FDA al !calf". am •• SIDENTS PLEASE RECORD THE ISSUES IN THE COMMENTS SECTION ABOVE. (b)(6),(b)(7)(C) nn.) Lu-umupeR's SIGNATURE (b)(6),(b)(7)(C) 4-/sc TRANSPORTATION SUPERVISOR (b)(6),(b)(7)(0)I l Page 49 of 740 DATE ra, Transport, KARNES COUNTY RESIDENTIAL CENTER TRANSPORTATION DETAIL SHEET DATE: 06: 06' IY FUEL ADDED: VEHICLE#: c:2//37 RECEIPT TURNED IN NO TRANSPORT OFFICERS STARTING MILEAGE: DVIR COMPLETED: NO ENDING MILEAGE: DESTINATION De e),,,„ ch. A‘,5+;,, DEPART TIME BEGINNING MILEAGE 0730 z/// bei 1 1 LIS 14 # OF RESIDENTS OUT I I (a-13 ARRIVAL TIME /033 ,1#00 (b)(6),(b)(7)(C) gig ap-ENDING MILEAGE # OF RESIDENTS IN ft2, i3 1 (113010,- 1 t COMMENTS: NOTE t IF YOU HAVE AN EMERGENCY OR ANY OTHER ISSUE PERTAIN TRANSPO T fl IN g ortrincrt ING TO THE SAFE AND SECURE TRANSPORT OF RESIDEN TS CALL THE DIATELY FOR INSTRUCTIONS. IF IT /S AN ISSUE THAT IS NOT PERTAINING RD THE ISSUEr ENTS SECTION ABOVE. (b)(6),(b)(7)(C) TR/ Page 50 of 740 (b)(6),(b)(7) (C) N SUPERVISOR 0- 6DATE Oa) Karnes County Residential Center 409 FM 11 DAILY VEHICLE INSPECTION REPORT e Date: -IS Time Out: 0(arn0 Karnes City, TX 78118 Tel 830 250-2000 Fax: 830 254-2296 Unit #: 2(134 Time In: /bir.3 DETAIL: If there is no vehicle damage initial OK in the appropriate blank, If there is visible damage to the vehicle using the diagram above circle the damaged area and note the area below. FRONT OF VEHICLE: drIc OL REAR OF VEHICLE: LEFT FRONT: obi-, LEFT SIDE DOORS: og. LEFT REAR: Pa.+ RIGHT FRONT: bit RIGHT SIDE DOORS: (tic RIGHT REAR: oK WIPERS: ofri. TIRES: bbC BATTERY: OK LIGHTS: MA TURN SIGNALS: BRAKE LIGHTS: int< OiC SANITATION LEVEL: GOOD IN NEED OF CLEANING 1 /4/e5 ALL EQUIPMENT PRESENT: Y / N Gas Added: Y / ati) GOOD FUEL LEVEL(vHEN CHECKED OUT) [ 1/4 1/2 3/4 START MILEAGE: END MILEAGE: LOW OIL LEVEL TRANSMISSION FLUID 3c3b411- 3.608 SEARCHED FOR CONTRABAND: sie-S (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) DRIVER'S NAME ;NATURE (b)(6),(b) (7)(C) Page 51 of 740 eee (1:200 Karnes County Residential Center 409 FM DAILY VEHICLE INSPECTION REPORT Date: Co- F Time Out: /043 Karnes City, TX 78118 Tel: 830 254-2000 Fax: 830 254-2296 Unit #: 21/34 Time In: NOD DETAIL: Pa40-ekar If there is no vehicle damage initial OK in the appropriate blank if there is visible damage to the vehicle using the diagram above circle the damaged area and note the area below. FRONT OF VEHICLE: REAR OF VEHICLE: OAek LEFT FRONT: I* LEFT SIDE DOORS: ak LEFT REAR: h047-7/ RIGHT FRONT: rA RIGHT SIDE DOORS: ak RIGHT REAR: oft WIPERS: ok TIRES: BATTERY: ni LIGHTS: ek TURN SIGNALS: ok BRAKE LIGHTS: ok SANITATION LEVEL: GOOD, ,:ti IN NEED OF CLEANING ALL EQUIPMENT PRESENT: Y / N Gas Added: Y a GOOD LOW FUEL LEVEL(w 1/4 1/2 't ow) OIL LEVEL FULL TRANSMISSION FLUID ED 3/4 START MILEA END MILEAGE: I-IFn PflD rONTRABAND: (b)(6),(b)(7)(C) DRIVER'S NAME (b)(6),(b)(7)(C) SIGNATURE (b)(6), (b)(7) (C) Page 52 of 740 see ert99'- Karnes County Residential Car:6,409 FM I DAILY VEHICLE INSPECTION REPORT Date: (J(flç Time Out: /c100 Karnes City, TX 78118 Tel: 830 254-2000 Fax 830 254-2296 Unit #: 7 13t/ Time In: 2/S5 DETAIL: gr-pytetter If there is no vehicle damage initial OK in the appropriate blank, if there is visible damage to the vehicle using the diagram above circle the damaged area and note the area below. FRONT OF VEHICLE:0REAR OF VEHICLE: 01( LEFT FRONT: DL LEFT SIDE DOORS:Or LEFT REAR: nleRIGHT FRONT:01' RIGHT SIDE DOORS: CRRIGHT REAR:(ic WIPERS:ft TIRES:aBATTERY:0V LIGHTS: pkTURN SIGNALS:Ob.BRAKE LIGHTS: be. SANITATION LEVEL: GOODOK-, IN NEED OF CLEANING •I ALL EQUIPMENT PRESENT: 5".)/ N Gas Added: Y / N 1— ,,,,,.. ......._. ruCL LCV CL(WHEN CHECKED OUT) 1/4 -17-2) 3/4 FULL START MILEAGE::WYS •U END MILEAGE:c36(0 4-1.5(b)(6),(b)(7)(C) OIL LEVEL TRANSMISSION FLUID GOOD LOW / / SEARcHFn FnI4 CONTRABAND: (b)(6),(b)(7)(C) DRIVER'S NAME t'S SIGNATURE Page 53 of 740 (b)(6), (b)(7) (C) Gee Karnes County Residential ne 409 FM 11 DAILY VEHICLE INSPECTION REPORT Date: gt,-8--/sTime Out: ogiscr Karnes City, Tx 78118 Tell 830 254-2000 Fax: 830 254-2296 Unit #: (;)/3, -1 Time In: enss DETAIL: P-rinticic_ If there is no vehicle damage initial QK in the appropriate blank, if there is visible damage to the vehicle using the diagram above circle the damaged area and note the area below. FRONT OF VEHICLE: _se-4204REAR OF VEHICLE: o 4_ LEFT FRONT: (2/-- LEFT SIDE DOORS:o4 LEFT REAR: Akna tRIGHT FRONT:QC RIGHT SIDE DOORS: e> 1-RIGHT REAR: cp C WIPERS: CA TIRES: Ott._ BATTERY: 0 C LIGHTS: o4 TURN SIGpALS: ct BRAKE LIGHTS: 0/ SANITATION LEVEL: GOOD IN NEED OF CLEANING ALL EQUIPMENT PRESENT: (10 N Gas Added: V AIL) GOOD LOW FUEL LEVEL(wHEN CHECKED OUT) 1/4 3/4 START MILEAGE: 3 if 0614,5 END MILEAGE: -;t0tre4 7 (b)(6),(b)(7)(C) OIL LEVEL to I TRANSMISSION FLUID SEARCHED FOR CONTRABAND: ?re,s(b)(6),(b)(7)(C) DRIVERS NAME DRIVER'S SIGNATURE (b)(6),(b) (7)(C) Page 54 of 740 SG0 Karnes County Residential Cerio: 409 FM DAILY VEHICLE INSPECTION REPORT ci-/ Date: Time Out:at Unit #:c0itsAk Time In: Oztai) Karnes City, TX 78118 Tel: 830 254-2000 Fax: 830 254-2296 DETAIL: aria If there is no vehicle damage initial QA in the appropriate blank, if there is visible damage to the vehicle using the diagram above circle the damaged area and note the area below. FRONT OF VEHICLE: 41/ REAR OF VEHICLE: OIL LEFT FRONT:,.goirlas LEFT SIDE DOORS: 42)c, LEFT REAR :7Y-A-K RIGHT FRONT:0k , RIGHT SIDE DOORS: Lk RIGHT REAR: 404° WIPERS: A4. TIRES: oh,, BATTERY :CL____ LIGHTS: bite TURN SIGNALS: elk,' BRAKE LIGHTS: Mc-, SANITATION LEVEL: GOOD V IN NEED OF CLEANING &L-) ALL EQUIPMENT PRESENT: Y / N Gas Added: Y / N FUEL LEVEL(wHEN CHECKED OUT) OIL LEVEL 1/4 1/2 3/4 FULL TRANSMISSION FLUID START MILEAGE: .3i1)0.7 END MILEAGE: a&n S7 GOOD LOW , L2 t./ SEARCHED FOR CONTRABAND: (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) DRIVER'S NAME DRIVER'S SIGNATURE (b)(6), (b)(7) (C) Page 55 of 740 1 CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERC-IGSA-11-0004 Page 1 of 3 Date: 08/29/2014 Report Number: KCRC-14-0001 2. TO: (Contractor and Manager Name) I (b)(b),(b)(f)( 'Facility Administrator CEO Group, Inc. I IDWan ne of "R) COR(lEA CHS(ICE DATES CONTRACTOR NOTIFICATION CONTRACTOR RESPONSE DUE BY 08/29/2014 09/05/2014 RETURNED BY CONTRACTOR ACTION COMPLETE 4. DISCREPANCY OR PROBLEM (Describe on Detail - Include reference in PWS / Direcave. Attach continuation sheet of necessary ) Violations: Per ERO-IGSA-11-004, Statement of Work (SOW) Section ix: Recreation and Leisure Time- "The Service Provider shall provide a separate space for indoor and outdoor age appropriate recreation activities. The Service Provider shall develop a program allowing for off-site field trips by juveniles at least monthly." Section x Library Services — "The Service Provider shall make leisure library services available to all residents " Section xv: Daily Program Activity Schedule — "The Service Provider shall develop a weekly schedule of all program activities. The schedule shall show on a daily basis (Sunday- Saturday) the activity, location, supervisor, and any limitation on the number of participants." Section Yu: Acculturation/Adaptation —"The Service Provider shall provide a program, which includes, but is not limited to, information regarding personal health and hygiene, human sexuality, and the development of social and inter-personal skills, which contribute to those abilities necessary to live independently and responsibly." Per the Family Residential Standards, Recreation, Section V:2, 'Residents shall be provided with access to structured activities and programs. In particular, these programs and activities should be structured towards growth, development and healthy living." Section V:5:6, "Recreation areas shall be under continuous supervision by staff equipped with radios or other communication devices, to ensure the safety of the residents. Per the Family Residential Standards, Food Service, Section V:S:4, "Determining inventory levels and properly receiving, storing, and issuing goods are critical to controlling costs and maintaining quality. While the FSA shall base inventory levels on facility needs, each facility shall, at all times, stock a 15-day-minimum food supply." Issues: The Service Provider has failed to fellow the Activity Schedule which was submitted to the COR and JERMU that stated a variety ol programs would be provided to the residents. There were 119 scheduled activities on the activity schedule for August, ICE is only aware of Zumba 8 Sidewalk Chalk classes that were given, and possibly Story Time and some Computer Classes. The Rec Specialist who was conducting the Computer Classes does not speak Spanish The majority of the 119 scheduled program activities were not provided to the residents during the month of August At best, possibly 34 of the 119 scheduled activities were conducted. In addition. ICE continued to find the gymnasium closed before the scheduled closing time. and ICE found the gymnasium unlocked and unstaffed on multiple occasions. ICE also observed the leisure and law library closed before posted hours as well The Dining Hall has also been found to have no CEO security staff directly observing the residents. See attachment for a list of specified dates of findings. The Service Provider has also not provided any Field Trips for the residents, as specified in the SOW ICE has also received a few complaints about residents not being able to get lormu la after the kitchen closes, being directed to give their infant milk out of the boxes (vitamin Lli milk) instead of formula, and one report of the facility running out of formula. Continued on attachment... 5. SIGNATURE OF CONTRACTING OFFICER'S TECHNICAL REPRESENTATIVE (COR) 7. FROM: (Contractor ) B. TO: (COR) 8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE, PLEASE ATTACH CONTINUATION SHEET. (Cite applicable 0.A program procedures or new 4W procedures.) 9. SIGNATURE OF CONTRACTOR REPRESENTATIVE 10, DATE 11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan. rejection: attach continuation sheet if necessary) 12. GOVERNMENT ACTIONS (Payment withholding,re notice, show cause. other. CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER Page 56 of 740 SIGNATURE DATE Page 2 of 3 ICE has submitted 4 Plan of Action requests to GEO this month concerning chemicals, child safety, facility safety & security and the formula issue. ICE is not satisfied with the answers received on the Plan of Action requests. We would like to request a 20-30% monetary deduction for the month of August 2014 for the Service Provider failing to supply the goods and services as specified above and in the Statement of Work and for failing to comply with all of the Family Residential Standards. Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary, ''A Contract Discrepancy Report that cites violations of cited PBNDS and PWS (contract) sections that provide a safe work environment for staff, volunteers, contractors and detainees, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary ''A Contract Discrepancy Report that cites violations of PBNDS and PWS Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that provide for the basic needs and personal care of detainees, permits the Contract Officer to withhold of deduct up to 20% of a monthly invoice until the contract Officer determines there is full compliance with the standard or section.' Per ERO-IGSA-11-0004, Attachment 6A, Performance Requirements Summary, ''A Contract Discrepancy Report that cites violations of PONDS and PWS (contract) sections that reduce the negative effects of confinement permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the contract Officer determines there is full compliance with the standard or section." Facility Findings Reported to GEO Management via Compliance/COR Reports August 2014: "These are just a highlight of the most serious findings for the month of August. We had a total of 9 pages of observed facility findings/safety concerns On 8/5/2014 Tribase multi-purpose cleaner was found unsecured in the gym. There was also no rec specialist in the gym; they were all outside on the soccer field. On 8/7/2014 ICE observed the Dining Hall at 0747hrs; no GEO staff were monitoring the residents. ICE observed one small toddler who was left in a high chair (unbuckled) while the mom went to return her tray. Yesterday ICE also observed no GEO security staff present in the Dining Hall during meal time, and there were two children under 5 years old whom were left at a table unattended while the mother went to get food for them. This is a huge safety concern. Per the new Statement of Work, -Service Provider shall ensure: Staffing ratio is to be at most stringent state licensing requirement level, specifically, at a ratio at the lowest age group in the facility." On 8/7/2014 Residents were informing ICE Officers that their babies are not drinking the Semilac Formula. The mothers are giving them milk or juice instead. Does the facility have alternative formula to give the mothers to try? Juice is not a healthy alternative to formula and milk can cause stomach upset, gas and acid reflux. • On 8/12/2014 the gym was left unattended at 0813hrs. The rec specialist was in the daycare, then went to the gym, then was called to intake. • On 8/12/2014 Resident in Elm 118 stated that she is not receiving enough formula for her two month old baby. When she requests more, she alleged that GEO staff tell her to drink the milk out of the box. On 8/12/2014 Elm 118 had a resident with a 9 month old ROIOXONA and a resident with a 2 month 0100)(6)200ff7) they only have one crib in their room. Also 4 more rooms were found to not have cribs in their rooms: Oak 101, 11 month old, no crib, Oak 105, playpen, but no crib. Oak 107 play pen, no crib (8 months old). Oak 109 9 month old no crib. On 8/13/2014, there were only 10 high chairs available in the dining hall. We currently have 14 babies, 22 one year olds and 34 two year olds. During dining hours, there are not enough high chairs for everyone to use. On 8/14/2014 around 0815hrs, the gym was found unstaffed again, there were three minor children inside the gym unsupervised. Two of the children had hall passes; one of the children was only 8 years old and was not with his mother. On 8/14/2014 during the breakfast hours a 3 year old and 5 year old were left alone at a table. Also an infant and a toddler were left alone at another table. Who is going to assist the young mothers with getting and returning their trays and not leaving the children unattended? On 8/18/2014 the gym was found locked around 0846hrs. On 8/20/2014 one boy broke his clavicle bone when he was allegedly 'playing tag with his feet". ICE requested a copy of the video surveillance of the incident and it was never provided. On 8/22/2014 1109hrs the gym was locked and not available for the residents. Page 57 of 740 Page 3 of 3 On 8/22/2014 when surveillance video was requested this week, it was blurry and dark; you cannot clearly make out images or actions of the residents. On 8/24/2014 Library was closed by 1500hrs. Gym was closed by 2000hrs. The signs on the doors say gym will be opened from 0600hrs — 2200hrs. On 8/27/2014 the gym was closed by 2000hrs On 8/28/2014 at 0811hrs there were no GEO staff found to be observing the Dining Hall operations, On 8/28/2014 at 0830hrs the gymnasium was found unlocked, there were no CEO staff present. The gym office was also found unlocked. I looked inside an unlocked cupboard in the office and found multiple bottles of chemicals, including but not limited to: Granberry Ice, Mold & Mildew Remover & Tribase cleaner. Page 58 of 740 1 CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERO-IGSA-11-0004 Date: 08/29/2014 Report Number: KCRC-14-0002 • sir (b)(6),(b)(7)( • 3. FROM ame of COR) Mining] COR/lEA DHS/ICE a d Ma age Na e) Facility Administrator louP, no. DATES CONTRACTOR NOTIFICATION CONTRACTOR RESPONSE DUE BY 08/29/2014 09/05/2014 RETURNED BY CONTRACTOR ACTION COMPLETE 4. DISCREPANCY OR PROBLEM (Describe in Detail - Include reference in PWS /Directive: Attach continuation sheet if necessary.) Violations: ERO-IGSA-11-004 The Service Provider shall ensure that video cameras monitor hallways, exits, and common areas. A qualified individual shall be responsible for monitoring this system inside and outside the building. Considering that the videos will be recordings of residents who may be seeking asylum or other considerations under U.S. immigration law, the Service Provider is required to maintain the tapes and may not release them to anyone, unless approved by DRS. The Service Provider shall develop a plan for keeping the videos for the duration of the project period and destruction of them upon completion of the program. Issues: During two recent significant incidents that occurred in the facility we were not provided with a valuable surveillance system recording to support the final conclusion of the incidents: • On 8/18/2014 at approximately 0823hrs ICE observed a young bay hitting and kicking another child near the soccer field. The video security/surveillance camera did not record the incident clearly. ICE requested video tape of the incident. When the video tape was reviewed the images were very dark and blurry, despite the incident having happened during the day time. When viewing the images you cannot distinguish one resident from another and you are unable to distinguish what exactly the residents are doing • On 8/20/2014 a child was /playing tag with his feet' with a group of kids near the soccer field. The child 202 008 236) fell and sustained a fractured clavicle. ICE requested the video surveillance of this incident and did not receive it. GEO Management slated that they had tried to view the incident, but were unable to see a clear picture of what happened. This facility is characterized by the indirect supervision and the freedom of movement and this is the reason why it is essential for us that the Service Provider possess a surveillance system capable of covering certain areas that might not be covered by Resident Advisors. ICE requested a formal Plan of Action from GEO on 8/22/2014. GEO provided a response stating that they will implement a Preventative Maintenance Schedule for all camera systems GEO also put in a maintenance request for a maintenance employee to check out the surveillance system. This task has not been completed yet, and that is unacceptable. ICE is requesting a 20% deduction or withholding for this contract deficiency for the month of August 2014. Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary, Safety, "A Contract Discrepancy Report that cites violations of cited PBNDS and PWS (contract) sections that provide a safe work environment for staff, volunteers, contractors and detainees, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.'' Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary, Security, "A Contract Discrepancy Report that cites violations of PBNDS and MS (contract) sections that protect the community. staff, contractors, volunteers, and detainees from harm, permits the Contract Oft cer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer 5. SIGNATURE OF CONTRACTING OFFICER'S TECHNICAL REPRESENTATIVE (COR) 7. FROM: (Contractor ) 6. TO: (COR) 8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE, PLEASE ATTACH CONTINUATION SHEET, (Cite applicable 0.A program procedures or new 4W procedures.) 9. SIGNATURE OF CONTRACTOR REPRESENTATIVE 10, DATE 11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan. rejection: attach continuation sheet if necessary) 12. GOVERNMENT ACTIONS (Payment withholding re notice, show cause, other. CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER Page 59 of 740 SIGNATURE DATE Page 60 of T40 ICE CONTINUATION SHEET 1. CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERO-IGSA-11-0004 Date: 11/12/2015 Report Number: CDR-16-0002 7 MA MinticoefRI COR) C 2. TO: (Contractor and Manager Name) i(b)(b),(b)(/)(CI Program Director SEC Group, Inc. I DHSLICE DATES CONTRACTOR NOTIFICATION CONTRACTOR RESPONSE DUE BY RETURNED BY CONTRACTOR ACTION COMPLETE 11/12/2015 11/16/2015 4 DISCREPANCY OR PROBLEM (Describe in Detail: Include reference in PW. S / Thrective Attach continuation sheet of necessary ) Contractor Violations: Change Family Program SOW: Program Services, xiii Translators to include the following: Should the facility encounter individuals who only speak languages such as Kiche and Mam or other oral and indigenous languages and/ or in instances when commercially available telephone services are insufficient to provide meaningful access to services, the Service Provider must arrange for consistent regular interpretive services through on-site interpreters or unavailable via televideo. Issues; On September 14, 2015 an interpreter began employment at Karnes County Residential Center with no background or knowledge of Khche or Marn ICE cannot request a formal Plan of Action due service not provided will not be resolved on the spot by GEO management. The COR is declining payment of this service not rendered. 5 SIGNATURE OF CONTRACTING OFFICERS TECHNICAL REPRESENTATIVE (COR) Marco A. Barcena Jr. 7. FROM: (Contractor) 6 TO: (COM 8 CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE ATTACH CONTINUATION SHEET IF NECESSARY. (CA. applicable QA program procedures or new A W procedures.) 9 SIGNATURE OF CONTRACTOR REPRESENTATIVE 10. DATE 11 GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, Parhal acceptance of response/plan, rejection: attach continuation sheet it- necessary) 12 GOVERNMENT ACTIONS (Payment wothheidong. cure notice, show cause, Other) CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER Page 61 of 740 SIGNATURE DATE Contract Stipulations: Per ERG-/GSA-11-0004„4iluchm nt 73, Staff Hiring and Training," A Contract Diwrepancy Report that cites violationv of FRS or SOW sections that require the Contractor's admini,smition and ntanugeinein of the Jacilio• in a nal and Key fmcihh, 01(11111er, aml Inalnienance of WOrkli»re integrity, permits the Contract Officer to withhold up to 10% qf a mrmthly invoice until the Contract Officer deteimines theteb 'tell compliance with the 'SC( il()12 Page 62 of 740 I. CONTRACT NUMBER CONTRACT DISCREPANCY REPORT EROAGSA-11 -0004 Page lot 3 Date: 08129/2014 Report Number: KCRC-14-0001 12. (cpiliraclor and Manager Name) 3. FROM: Name Of COR) Itallnitall CORDEA I ( WOO, ( DR i )( (Facility Administrator GEO Group, Inc. DHSACE DATES CONTRACTOR NOTIFICATION CONTRACTOR RESPONSE DUE BY 08/29/2014 09/05/2014 RETURNED BY CONTRACTOR ACTION COMPLETE 4. DISCREPANCY OR PROBLEM (DesCnbe in Detail: Include reference in PWS / 0/teary : Attach continuation sheet if necessary.) Violations. Per ERO-IGSA-1l,004. Statement of Work (SOW) Section ix: Recreation and Leisure Time- The Service Provider shall provide a separate space for indoor and outdoor age appropriate recreation activities. The Service Provider shall develop a program allowing for off-site field trips by juveniles at least monthly.' Section A Library Services - The Service Provider shall make leisure library services available to all residents.' Section xv: Daffy Prograin Activity Schedule - 'The Service Provider shall develop a weekly schedule of all program activities. The schedule shall show on a daily basis (Sunday- Saturday) the activity. location. supervisor, and any limitation on the number of participants.' Section vii: AcculturatIon/Adaptagen - The Service Provider shall provide a program, which includes, but is not limited to, information regarding personal health and hygiene, human sexuality, and the developmental social and inter-personal skills, which contribute lo those abilities necessary to live independently and responsibly.' Per the Family Residential Standards, Recreation, Section V:2, 'Residents shall be provided with access to structured activities and programs In particular, these programs and activities should be structured towards growth, development and healthy living? Section V:5:0, 'Recreation areas shall be under continuous supervision by staff equipped with radios or other communication devices, to ensure the safety of the residents.' Per the Family Residential Standards, Food Service, Section V:SA, 'Determining inventory levels and properly receiving, sic:ding, and issuing goods are critical to controlling costs and maintaining quality. While the FSA shall base inventory levels on facility needs, each facility shall, at all times, stack a 15-datminimum food supply.' (Magi The Service Provider has failed to follow the Activity Schedule which was submitted to the COR and JERMU that slated a variety of programs would be provided to the residents. There were 119 scheduled activities on the activity schedule for August ICE is only aware of zumba 8 Sidewalk Chalk classes that were given, and possibly Story Time and some Computer Classes, The Rec Specialist who was conducting the Computer Classes does not speak Spanish. The majority o the 119 scheduled program activibes were not provided to the residents dining the month of August. At best. possibly 30 of the 119 scheduled activities were conducted. In addition. ICE continued to find the gymnasium closed before the scheduled closing lime, and ICE found the gymnasium unlocked and un taffed on multiple occasions. ICE also observed the leisure and law library closed before posted hours as well. The Dining Hall has also been found to have no CEO security taff directly Observing the residents See attachment for a list of specified dates of findings. The Service Provider has also not provided any Field Trips for the residents, as specified in the SOW. ICE has also received a few complaints about residents not being able to get formula after the kitchen closes, being directed to give their infant milk out of the boxes (vitamin D milk) Instead of formula, and one report of the facility running out of formula. Continued on attachment... 5. SIGNATURE OF CONTRACTING OFFICER'S TECHNICAL REPRESENTATIVE (COR F ()(b)( b)(6, 7)( C) 7. FROM: (Contractor) 13.TO: (COR) B. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. PLEASE. ATTACH CONTINUATION SHEET (Cite applicable Q.A. program procedures or new A.W, procedures) 9 SIGNATURE OF CONTRACTOR REPRESENTATIVE 10. DATE 11.GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan, rejection: attach continuation sheet it necessary) 12.GOVERNMENT ACTIONS (Payment withholding, cure notice, show cause, other.) CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER Page 63 of 740 SIGNATURE DATE Page 2 of 3 ICE has submitted 4 Plan of Action requests to GEO this month concerning chemicals, child safety, facility safety 8 security and the formula issue. ICE is not satisfied with the answers received on the Plan of Action requests. We would like to request a 20-30% monetary deduction for the month of August 2014 for the Service Provider failing to supply the goods and services as specified above and in the Statement of Work and for failing to comply with all of the Family Residential Standards. Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary, "A Contract Discrepancy Report that cites violations of cited PBNDS and PWS (contract) sections that provide a safe work environment for staff, volunteers, contractors and detainees, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary "A Contract Discrepancy Report that cites violations of PBNDS and PWS Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that provide for the basic needs and personal care of detainees, permits the Contract Officer to withhold of deduct up to 20% of a monthly invoice until the contract Officer determines there is hill compliance with the standard or section." Per ERO-IGSA-11-0004. Attachment 6.A, Performance Requirements Summary, "A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that reduce the negative effects of confinement permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the contract Officer determines there is full compliance with the standard or section." Facility Findings Reported to GEO Management via Compliance/COR Reports August 2014: *These are just a highlight of the most serious findings for the month of August. We had a total of 9 pages of observed facility findings/safety concerns. On 8/5/2014 Tdbase multi-purpose cleaner was found unsecured in the gym. There was also no rec specialist in the gym; they were all outside on the soccer field. On 8/7/2014 ICE observed the Dining Hall at 0747hrs; no GEO staff were monitoring the residents. ICE observed one small toddler who was left in a high chair (unbuckled) while the mom went to retum her tray. Yesterday ICE also observed no GEO security staff present in the Dining Hall during meal time, and there were two children under 5 years old whom were left at a table unattended while the mother went to get food for them. This is a huge safety concem. Per the new Statement of Work, °Seivice Provider shall ensure: Staffing ratio is to be at most stringent state licensing requirement level, specifically, at a ratio at the lowest age group in the facility." On 8/7/2014 Residents were informing ICE Officers that their babies are not drinking the Semilac Formula. The mothers are giving them milk or Juice instead. Does the facility have alternative formula to give the mothers to try? Juice is not a healthy alternative to formula and milk can cause stomach upset, gas and acid reflux. On 8/12/2014 the gym was left unattended at 0813hrs. The rec specialist was in the daycare, then went to the gym, then was called to intake. On 8/12/2014 Resident in Elm 118 stated that she is not receiving enough formula for her two month old baby. When she requests more, she alleged that GEO staff tell her to drink the milk out of the box. On 8/122014 Elm 118 had a resident with a 9 month old EtaItaital• and a resident with a 2 month oldrellillieln they only have one crib in their room. Also 4 more rooms were found to not have cribs in their rooms: Oak 101,11 month old, no crib, Oak 105, playpen, but no crib, Oak 107 play pen, no crib (8 months old), Oak 109 9 month old no crib. On 8/13/2014, there were only 10 high chairs available in the dining hall. We currently have 14 babies, 22 one year olds and 34 two year olds. During dining hours, there are not enough high chairs for everyone to use. On 8/14/2014 around 0815hrs, the gym was found unstaffed again, there were three minor children inside the gym unsupervised. Two of the children had hall passes; one of the children was only 8 years old and was not with his mother. • On 8/14/2014 during the breakfast hours a 3 year old and 5 year old were left alone at a table. Also an infant and a toddler were left alone at another table. Who is going to assist the young mothers with getting and returning their trays and not leaving the children unattended? On 8/18/2014 the gym was found locked around 0846hrs. On 8/20/2014 one boy broke his clavicle bone when he was allegedly "playing tag with his feet". ICE requested a copy of the video surveillance of the incident and it was never provided. On 8/22/2014 1109hrs the gym was locked and not available for the residents. Page 64 of 740 Page 3 of 3 On 812212014 when surveillance video was requested this week, it was blurry and dark; you cannot clearly make out images or actions of the residents. On 8/24/2014 Library was closed by 1500hrs. Gym was closed by 2000his. The signs on the doors say gym will be opened from 0800hrs — 2200hrs. On 8/27/2014 the gym was closed by 2000hrs. On 8/28/2014 at 0811hrs there were no CEO staff found to he observing the Dining Hall operations. On 8/28/2014 at 0830hrs the gymnasium was found unlocked, there were no CEO staff present. The gym office was also found unlocked. I looked inside an unlocked cupboard in the office and found multiple bottles of chemicals, including but not limited to: Cranberry Ice, Mold & Mildew Remover & Tribase cleaner. Page 65 of 740 1.1.1thi I KAts I Llibtatt 1"/IPIL•T KtYLIK I ERO-IGSA-11-0004 Date: 08/2912014 Report Number: KCRC-14-0002 3. FROM: Warne Of COR) 2 TO: (Contractor and Manager Name) teagiewn Faddy AdMiniStratOr tellilliell COFUIEA GEO Group, Inc. DHS/ICE DATES CONTRACTOR NOTIFICATION CONTRACTOR RESPONSE DUE BY 08/29/2014 09/05/2014 RETURNED BY CONTRACTOR ACTION COMPLETE 4. DISCREPANCY OR PROBLEM (Oescnbe in Detait Include reference in PWS / Defective Attach continuation sheer if necessary) Violations: ERO-IGSA-11.004 The Service Provider shall ensure that video cameras monitor hallways, ethts, and common areas. A qualified individual shall be responsible for monitoring this system inside and outside the building. Considering that the videos will be recordings of residents who may be seeking asylum or other considerations under U.S. immigration law, the Service Provider is required to maintain the tapes and may not release them to anyone, unless approved by DRS. The Service Provider shall develop a plan for keeping the videos for the duration of the project period and destruction of them upon completion of the program LIMOS Dining two recent significant Incidents that occurred in the facility we were not provided with a valuable surveillance system recording to support the final conclusion of the incidents: • On 0/18/2014 at approximately 0823hrs ICE observed a young boy hitting and kicking another child near the soccer field. The wdeo security/surveillance camera did not recoil] the incident clearly. ICE requested video tape of the kidded. VVhen the video tape was reviewed the images were very dark and blurry, despite the incident haying happened during the day time. when viewing the images you cannot distinguish one resident from another and you are unable to distinguish what exactly the residents am doing, • On 13(20/2014 a child was 'playing lag with his feet' with a group of kids near the xi/Irv-Pr field. The child requested the video surveillance of this incident and did not receive it. GEO Management stated that they tad Ut dear picture of what happened. thil and sustained a fractured clavicle ICE view the incident, but were unable to see a This facility is characterized by the indirect supervision and the freedom of movement and this is the reason why it is essential for us that the Service Provider possess a surveillance system capable of covering certain areas that might not be covered by Resident Advisors. ICE requested a formal Plan of Action from GEO on 6/22/2014. GEO provided a response stating that they will implement a Preventative Maintenance Schedule for all camera systems. GEO also put in a maintenance request for a maintenance employee to check out the surveillance system. This task has not been completed yet, and that is unacceptable. ICE is requesting a 20% deduction or withhotding for this contract deficiency for the month of August 2014, Per ERO4GSA-11-13004, Attachment 6.A, Performance Requirements Summary. Safety. 'A Contract Discrepancy Report that cites violations of cited KINDS and PWS (contract) sections that provide a safe wort environment for staff. volunteers, contractors and detainees, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section.' Per ERNGSA-11-0004. Attachment 6.A, Performance Requirements Summary. Security, 'A Contract Discrepancy Report that cites violations of KINDS and PWS (contract) sections that protect the oommunity, staff, contractors, volunteers. and detainees frorn harm, permits the Contract Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer 5. SIGNATURE OF CONTRACTING OFFICERS TECHNICAL REPRESENTATIVE (COR) (b)(6),(b)(7)(C) . 6.To. (COR) 8- z 9- ( 4 8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. PLEASE ATTACH CONTINUATION SHEET. (Cite applicable Q.A. diagram procedures or new AW procedures) 10.DATE 9. SIGNATURE OF CONTRACTOR REPRESENTATIVE 11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan, rejection: attach continuation sheet if necessary) 12.GOVERNMENT ACTIONS (Payment withholding, cure notice, show cause, other.) CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COR ,,,...,,-...,-, Page EE of 740 SIGNATURE DATE Page 1 of 2 1. CONTFtACT NUMBER ERO-IGSA-11-0004 CONTRACT DISCREPANCY REPORT Date: 10/27/2014 Report Number: KCRC-14-0003 3. FROM: (Name of COR) 2.10: (Contractor and Manager Name) ItERDINI1 COFUIEA I (b)(6) (10)(/)(1 Facility Administrator DHS/ICE GEO Group, Inc. DATES CONTRACTOR NOTIFICATION CONTRACTOR RESPONSE DUE BY 10/27)2014 10/29/2014 RETURNED BY CONTRACTOR ACTION COMPLETE 4.DISCREPANCY OR PROBLEM (Descnbe in Detail: Include reference in PWS/Direcavez Mach continuation sheet if necessary.) Contract Violations: Per ERO4GSA-11-004. Statement of Work (SOW), Section 4:B:1, The Service Provider will correct all identified defidencles within 30 days: Sedon lx: Recreation and Leisure Time..'The Service Provider shall provide a separate space for Indoor and outdoor age appropriate recreation activities. The Service Provider shall develop a program allowing for off-site field trips by juveniles at least monthly' Section x: Library Services — The Service Provider shall make leisure library services available to all residents.' Secton V:5:G. -Recitation areas shall be under continuous supervision by staff equipped with radios or other communication der/roes. to ensure the safety of the residents.' Per the Family Residential Standards, Food Service, Section VS:4, 'Determining inventory levels and ProPedY receiving. storing, and issuing goods are Meal to controlling costs and maintaining quatiry. Mile the FSA shall base Inventory levels on faddy needs, each featly shall, at all times, stock a 15-day4minirnum food supply: &SEIM The followng issues have been brought to the attention of the Service Provider on multiple occasions. and the deficiencies have not been corrected The issues are as follows: The gym continues to be found unsupervised or dosed before the posted open hours on the following dates: 9)27, 10/4, 10/6. 1017,10/8, 10/9, 10/11, 10/14. 10/15. 8 11120. The Law Library/Leisure Library has also been found to be dosing before the sdieduled open hours on the follcnving dates: 9/8, 10/1, 1014,10/5, 10/9. 10/16.10/17. 10/18 8 10/20. A Plan of Acton was requested for these Items on 9/5/2014. The Dining Hall continues to be found unsupervised by Security Staff. The Facility Administrator has been assignng the Chaplain or the Food Serwce staff to supervise the residents. Those staff members are not equipped with radios or the proper training for conducting security supervision. The Dining Hall has been found to be unsupervised by GEO slat? (or only have non security staff supervising the meals) on the following dates: 8/28. 9/29 8 10/21. This issue was already addressed In a request for Plan or Action on 9/29/2014 with no improvement The facility also has been found to not be In compliance of keeping the required minimum amount of formula on hand for the residents. The inventory of formula has been found defident on: 8/29, 9/22& 10/23. A request for a Plan of Acton on this issue was sent on 8/27/2014. The residents contnue to be observed sting and lingering on the upper tiers. and leaning on the railings, blocking the walkway. They also continue to et and dimb on the railings under the stairs. This has been repeatedly brought up and addressed in a request for a Plan of Acton on 9)2512014 with no improvement. This is also a serious safety concern and OSHA violation which has been observed and documented on 8127, a/Zeta 1WO. 10,20 8 10/22. In addition, ICE has observed children lobe unattended by their mothers on multiple octasions,Induding but not !Mated to: 9/8. 9/19, 9/29, 10/10, 10/20. ICE also found that on 9/25/2014, there were 3 resident children (all under 7 years old) they were unacoompanied In an unlocked mom in medical. Their mothers were at the hospital, so they required one to one supervision. GEO provided no one-to-one supeMslon for these 3 unaccompanied minor children from Welters - 0612hrs on 9128. ICE has also observed resident voluntary workers unsupervised in the gyrn and medical areas on multiple occasions including 9/28,9/20 8 10/20. Many of these issues concern the supervision and basic needs (formula, gym 8 library) to be provided to the residents, which the Service Provider Is not fully providing. Field Trips were also not provided, until 10/22. ICE has made 3 formal requests for a Plan of Adio on these items, and some of these items were involved in the previous CDR. The COR is recommending a 20% deduction or withholding until the majority of the deficienaes are corrected and found to be in compliance. Continued on attachment.. 5.SIGNATURE OF CONTRACTING OFFICER'S TECHNICAL REPRESENTATIVE (COR) (b)(6),(b)(7)(C) I. I MVIVP. 6.TO: (COR) , V 0 -27 • tt-A lifil..W) 8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. PLEASE, ATTACH CONTINUATION SHEET (Cite applicable QA. program procedures or new A.W. procedures.) 9.SIGNATURE OF CONTRACTOR REPRESENTATIVE 10.DATE 11.GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptab)e response/plan, partial acceptance of response/plan. rejection: attach continuation sheet if necessary) 12.GOVERNMENT ACTIONS (Payment wahholding, care notice, snow cause. Met) CLOSE OUT NAME AND TOLE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER Page 67 of 740 SIGNATURE DATE Page 2 of 2 Family Residential Standard Deficiencies: Food Service, Section V:4:B, The facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents' Law Libraries 8 Legal Material, Section V:3:13. "Each Facility Administrator shall devise a flexible schedule that: Enables the maximum use possible, without interfering with the orderly operation of the facility. Generally law library hours of operation are to be scheduled between 8:00am and 8:00pm daily." Recreation, Section V:3:G, "Every resident shall have daily access to indoor and outdoor recreation from 8:00am to dusk.... Recreation areas shall be under continuous supervision by staff equipped with radios and other communication devices, to ensure the safety of the residents.' Housekeeping 8 Voluntary Work Program, Section V:3, "Each adult resident has a primary responsibility to care for and supervise his or her minor child (or children)." OSHA Violations: 1926.34(a) General, "In every building or structure, exits shall be so arranged and maintained as to provide free and unobstructed egress from all pads of the building or structure at all times when it is occupied." 1926.34(c) "Means of egress shall be continually maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Contract Stipulations: Per ERO4GSA-11-0004, Attachment 6.A, Performance Requirements Summary, "A Contract Discrepancy Report that cites violations of cited PBNDS and PWS (contract) sections that provide a safe work environment for staff, volunteers, contractors and detainees, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is kill compliance with the standard or section." Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary "A Contract Discrepancy Report that cites violations of PBNDS and PWS Contract Discrepancy Report that cites violations of RENDS and PWS (contract) sections that provide for the basic needs and personal care of detainees, permits the Contract Officer to withhold of deduct up to 20% of a monthly invoice until the contract Officer determines there is full compliance with the standard or section? Page 68 of 740 ICE CONTINUATION SHEET 1. CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERO- IGSA- 11- 0004 Date: 03/30/2015 Report Number: CDR-15-0006 3. FROM (Name of COR) COR/LEA DHS/ICE 2, TO: Contractor and Manager Name) Facility Administrator oEo Group, Inc. flog61(b)(/)(U DATES 03/30/2015 RETURNED BY I CONTRACTOR CONTRACTOR RESPONSE DUE BY CONTRACTOR NOTIFICATION I ACTION COMPLETE ' l 04/1/2015 4 DISCREPANCY OR PROBLEM (Describe in DeraiL Include reference in PWS/ Directive Attach continuation sheet if necessary.) Contractor Violations: Contract: CON 0001 Housing and care of Family Residential Family Residential Facility Statement of Work 4 Program Scope and Services a (I) The design and the administration of the program shall be in accordance with the requirements of ICE Family ReSIdellrlal Standards (FRS) It is the Service PrOvider s responsibility to assume adequate and appropriate management oversight for the implementation and successful performance of this contract Family Residential standards: Food Service, Section V: 4: a:' Meals shall always be prepared. delivered, and served under staff (or contractor) supervision ' Food Service, Section V: 4: a:Before and during the meal the CS in charge shall inspect the hue lo ensure All menu items are ready for consumption and food is appropriately presented ' Food Service, Section V: 0: b The facility shall assign a supd visor to be responsible for supewrsing the dining room arra for ensunrad the safety and welfare of the residents' 5. SIGNATURE OF CONTRACTING OFFICER'S TECIINIC I ra/sPr 212 "T ' TIVF , OR, 5. (b)(6),(b)(7)(C) 6. TO. (COP) (b)(6),(b)(7)(C) 1... i , (b)(6),(b)(7)(C) 8 CONTRACTOR RESPONSE AS TO CAUSE. coRREcTivii ACTI/ N AND ACTIONS TO PREVENT RE URRENCE ATTACH CONTINUATION SHEET IF NECESSARY (Cite applicable CA /Yard -an procedures or new A Mir proceclin es) 9. SIGNATURE OF CONTRACTOR REPRESENTATIVE 10, DATE 11 GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN- (Acceptable response/plan. partial acceptance of response/plan, rejection attach continuation sheet if necessary) 11GOVERNMENT ACTIONS (Payment withholding, cure norwe. show cause other) CLOSE OUT NAME AND TITLE SIGNATURE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER • Paae 69 of 740 1 DATE Family Residential Standards Continued: Food Service, Section V. 9: b, 5: 'Approved rubber soled safety shoes Shall be provided and used by all food service personnel working in food service." Food Service, Section V, 9: J, a and b: 'a) Moist cloths for wiping food spins on kitchenware and food-contact surfaces on equipment shall be clean, rinsed (requenffy in sanitizing solution, and used solely for this purpose. They shall soak in the sanitizing solution between uses. b) Moist cloths used for non-food-contact surfaces, such as counters, dining table lops and shelves, shall be cleaned, rinsed, and stored In the same way as the moist cloths used on food-oontact surfaces. They shall be used on non-food-contact surfaces only? Food Service, Section V, 9: Ic a: "A sink with at least three labeled compartments is required for manually washing, rinsing, and sanitizing utensils and equipment Each compartment shall have the capacity to accommodate the Items to be cleaned. Each shall be supplied with hot and cold water' Family Residential Standard Deficiencies: Issues' On March 8, while conducting dining hall and kitchen checks. ICE staff encountered no Kitchen Manager present during breakfast On March 7, while conducting dining hall and kitchen checks. ICE staff encountered kitchen personnel with little or no control of the dining hall, with one staff member completely surrounded by residents and unable to move and full fill her regular duties of filling the self-serve cereal bar. In the walk in cooler a pan of biscuits dated 3/4/15, On March II. ICE staff encountered no supervisor for the breakfast service and the cleanliness of the grill and oven was not being maintained_ On March 12, ICE Staff encountered 3 containers of prepared food not labeled with a date or identified as to what it was supposed to be, On March 13, ICE staff encountered the kitchen log book with pages falling out, breakfast meal temperatures not logged at approximately 1130 and when checked again at approximately 1215 the log was filled out, the substitution of bread for the bun listed on the menu was not annotated. 1 container of potatoes dated 3-14-15, an unlabeled container of prepared beans, a white container of opened dill pickles with an arrival date of 12-11-19 but no opened date, an unopened container or cultured sour cream arrival date of 12-01-14, personal food items in a plastic grocery bag (a lime, frozen meat, and a tomato), tortillas in boxes dated 1-15-15 and more in banana boxes without a date with some in bags not properly tied or closed. On March 17, ICE staff encountered kitchen personnel serving under cooked rice to residents, and it was not replaced until ICE staff informed the contractor and requested a replacement item. On March 18, ICE staff encountered no Kitchen Manager or supervisor dunng breakfast service. Food thawing procedures were not followed as meat was not submerged under running water. Most employees and resident voluntary workers were not wearing approved tubber soled safety shoes. Moist cloths were not cleaned between uses using a sanitation solution, and were not free of food debris. Manual cleaning procedures were not being followed, as the 3 part sink in the kitchen does not have a hindering drain. Dunn° breakfast the sausage patties weighed 1.001 instead of the 2oz required by the menu, and the orange slices were being served at 401 instead of Etoz as required by the menu. The dayroom refrigerators had excessive buildup of dirt and debris on the shelves and food was placed in direct contact with it. On March 2e ICE staff encountered kitchen stall not following food thawing procedures and did nol have meat submerged under running water. Most kitchen sly* and resident voluntary workers were not wearing approved rubber soled safety shoes. Moist cloths being used to clean and sanitize were not being properly cleaned and sanitized between uses. The dining area had food strewn on the floor, tables, and chairs and was not being cleaned between uses. The dayroom refrigerators had excessive buildup of dirt and debris on the shelves and food was placed in direct contact with R. On March 23, ICE staff encountered a tloz scoop not annotated on the log for the kitchen tool control. On March 24, ICE Staff encountered I container of prepared salad and 1 container of prepared corn salad that were out over 29nrs old. On March 25, ICE staff encountered a can opener not annotated on the kitchen tool log. The 3 part sanitation sinks were not being properly Utilised with dirty pans placed Into the rinse station instead of the soaking station. On March 27. ICE staff encountered, at approximately 0730hrs. 2 containers of prepared rice, I container of prepared beans, and 1 container prepared potatoes dated 3/27/15 and time placed in the cooler was labeled 1000. One item with hand written Use by Dale of prepackaged shredded cabbage with 3-7-15. On March 29, ICE staff encountered a 901 scoop not logged on the tool log, both voluntary workers and GEO kitchen staff was not wearing approved sarely shoes, and only 201 of salsa was being served instead of the 402 required by the menu. Contract Stipulations: Per ERO-IGSA-11-0004, Attachment 6A, Performance Requirements Summaty," "A Contract Discrepancy Report that cites violations of FRS and SOW (contract) sections that provide for the basic needs and personal care of residents, pennits the Contract Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is hill compliance with the standard or section." Per ERO-IGSA-I -004, Attachment 6.A. Performance Requirements Summary, "A Contract Discrepancy Report that cites violations of cited FRS and SOW (contract) sections that provide a safe work environment for staff, volunteers, contractors and residents, permits the Contract Officer to withhold or deduct up to 15% of a month invoice until the Contract Officer determines there is full compliance with the standard or section. Page 70 of 740 ICE CONTINUATION SHEET 1. CONTRACT NUMBER ERO-IGSA-11-0004 CONTRACT DISCREPANCY REPORT Date: 10/_/2015 Report Number: CDR-16-0001 2. TO: (Contractor and Manager Name) II (WWI (bH /I( I Facility Administrator SEC Group, Inc. I ?ID cn i DHS/ICE n COR) CFC IDR D).0. DATES CONTRACTOR NOTIFICATION 10/ /2015 CONTRACTOR RESPONSE DUE BY RETURNED BY CONTRACTOR ACTION COMPLETE 10/ . 17/2015 4 DISCREPANCY OR PROBLEM (Describe in Detail: Include reference in PW. S / Thrective: Attach continuation sheet of necessary.) Contractor Violations: Contract: CLIN 0001 Housing and care of Family Residential. Family Residential Facility Statement of Work 2. a. "The purpose Of this contract is to facilitate the provisions for the necessary physical structures, equipment, facilities, personnel and services, to provide a program of temporary shelter care in a staff secure environment and other related services to alien family groups who are currently held in the legal custody of ICE." 5. SIGNATURE OF CONTRACTING OFFICERS TECHNICAL REPRESENTATIVE (COR) 7 FROM (Contractor) 6. TO: (CORI 8. CONTRACTOR RESPONSE AS TO CAUSE. CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. ATTACH CONTINUATION SHEET IF NECESSARY. (Cite applicable aA program procedures or new A W procedures-) 9. SIGNATURE OF CONTRACTOR REPRESENTATIVE 10, DATE 11, GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan, rejection: attach continuation sheet if necessary) 12. GOVERNMENT ACTIONS (Payment withholding, cure no e. show cause. other) CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER Prin 71 nf 74n SIGNATURE DATE Issues: During a routine check, conducted on October 18, 2015 of the Central Control area it was discovered that numerous cameras and monitors were not operational or had video degradation to the point where individuals were not identifiable. Some monitors have little white squares in the middle of the frames, which forces staff to look at the cameras one by one on the bigger monitor rather than panning across several views at once. Previous Plans of Action and CDRs KCRC-150007, KCRC 15-0008, and KCRC-14002 have addressed this area and while the maintenance was performed at that time for KCRC 15-0007 and KCRC 14-0002 to immediately address the discrepancies nothing appears to have been done to prevent or correct the issues from KCRC 15-0008 with most of the same equipment being affected. It is understood the facility will have issues due to the current construction and the cameras listed within this CDR are not on the most current list provided to the COR(s). Cameras known to need maintenance: 17, 23, 29, 30, 31, 37, 47, 52, 55, 59, 62, 64, 67, 68, 70, 71, 72, 73, and 172 do not have a picture. In CDR KCRC-14-0004 it was mentioned that a previous Plan of Action from August 22, 2014 had received a plan for a Preventative Maintenance Schedule. This schedule is in a form of a log book that the Security Clerk is responsible for checking and generating Work Orders that the staff in Central Control have no way of recording when they were submitted to ensure accountability. In addition Central Control does not have a list of cameras known to be impacted by the ongoing construction, hence the staff in Central Control do not know which cameras need to have work orders placed. Contract Stipulations: Per ERG-/GSA-I 1-0004, Attachment 6.4, Performance Requirements Summary," A Contract Discrepancy Report that cites violations uf FRS, PREA, and SOW (contract) seclions that ;doted the community, staff cpntractors, volunteen, and residentsfrom harm, perm itS the Conti-cal Officer to withhold or deduct lip to /5% (Wu monthly invoice until the Contracl Officer determines there iv fidl compliance with the standard or section. Page 72 of 740 Enforcement anti Removal U.S. Depot-tine 'It or Ho inelainl Security 1777 NE 1 nop 410 San Antonio exas 78217 IQIWII U.S. Immigration and Customs Enforcement November 12, 2015 (b)(6),(b)(7)(C) MEMORANDUM FOR: Contracting officer Office of Acquisition Management FROM: SUBJECT: I (b)(6),(b)(7)(C) Contracting Officer Representative Karnes County Residential Center (KCRC) Memorandum for KCRC-16-0002 (memo #2) This is the formal memorandum for Contract Discrepancy Report KCRC-16-0002, in reference to the facility failing to provide an Interpreter under, ERO-IGSA-11-004 Quality Assurance Surveillance Program 7.3. "A Contract Discrepancy Report that cites violations a/ IRS or SOW sections that require the Contractor's administration and management of the facility in a professional and responsible manner, and maintenance of ww-kfiwce integrity permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there isffill compliance with the standard or section." GEO was notified of CDR KCRC-16-0002 in reference to an interpreter not provided as per Change Family Program SOW: Program Services, xi ii Translators to include the following: "Should the facil4y encounter individuals who only speak languages such as K'iche and Mom or other oral and indigenous languages and/or in instances when annmercially available telephone services are insufficient to provide meaningfid access to services. the Service Provider must arrange for consistent regular interpretive services through oil-site interpreters or unavailable via televideo." On November 12, 2015, I requested translation services from CEO Interpreteil (b)(6),(b for K' iche to explain the release process to the Alternative to Detention (ATD) with the GPS to one of the mothers e 7 f who spoke limited Spanish. The mother informed us she was a K' iche speaker and whenWalni 1 came to assist us I asked her to please translate for us in K'iche, howeverl(b)(6),(b (7)( 'began speaking to her in Spanish and tasked her we need the translation in K' iche I (b)(6),(b)(7)( informed us the resident speaks Spanish and I informed her the resident speaks limited Spanish and we prefer the translation in K'iche. (6)(6),(6)(7) persisted in translating in Spanish and 1 asked her not to translate in Spanish since I can speak Spanish as well. This is the second time (b)(6),(b)(7)( avoids translating for us in K'iche. I have (b)(6),(b)(7)(C) as my witnesses when this incident occurred. Page 73 of 740 SUBJECT: CDR Page 2 Page T4 of T40 Enforcement clad Removal U.S. Departintott or Homeland Sccurity 1777 NE L000 41{) ttiJIGJxtiJII San Antomo exas 782 I 7 U.S. Immigration and Customs Enforcement October 23, 2015 MEMORANDUM FOR: (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management FROM: (b)(6),(b)(7)(C) Contracting Officer Representative Karnes County Residential Center (KCRC) SUBJECT: Memorandum for KCRC-16-0002 This is the formal memorandum for Contract Discrepancy Report ICCRCT 6-0002, in reference to the facility failing to provide an Interpreter under, ERO-IGSA- 11-004 Quality Assurance Surveillance Program 7.3. "A Contract Discrepancy Report that cites violations a/ IRS or SOW sections that require the Contractor's administration and management of the facility in a professional and responsible manner, and maintenance of ww-kfiwce integrity permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there is compliance with the standard or section." GEO was notified of CDR KCRC-16-0002 in reference to an interpreter not provided as per Change Family Program SOW: Program Services, xi ii Translators to include the following: "Should the facility encounter individuals who only speak languages such as K'iche and Mani or other oral and indigenous languages and/or in instances when commercially available telephone services are insufficient to provide ineaningfid access to services, the Service Provider must arrange for consistent regular interpretive services through on-site interpreters or unavailable via televideo." During an informal interview the individual hired as the K'iche speaker for Karnes County Residential Center by GEO administration it was found that this individual had no K'iche background and GEO informed her she will be able to pick up this dialect during her time at KCRC. After completing this interview it was determined by ICE this translation service will not be available for our immediate use. At this time I am recommending a no payment for this service due to GEO management not promptly hiring an adequate translator for our CDR concerns. In addition, I am recommending a 10% deduction from our monthly invoice for failure to maintain workforce integrity that is crucial in providing ICE staff legal translation services. Page 75 of 740 Elston em cot a at/ /tsarina/ Opener ion U.S. Departintott or Homeland Sccurity 1777 NE 1 nop 410 EU 015311101M San Antomo lexas 78217 U.S. Immigration and Customs Enforcement April 24, 2015 MEMORANDUM FOR: (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management FROM: (b)(6),(b)(7)(C) Contracting Officer Representative Karnes County Residential Center SUBJECT: Close Out Memorandum for KCRC-16-0003 This is the formal close out memorandum for Contract Discrepancy Report KCRC-16-0003, in reference to the facility failing to maintain a safe and secure environment by not providing adequate protection during construction which caused a resident to be struck by construction fencing, as per the contract, EROAGSA-11-004 Family Residential Statement of Work, 6. a. "Performance Requirements Summary," A Contract Discrepancy Report that cites violations of cited FRS and SOW (contract) sections that provide a sale work environment /Or stall volunteers, contractors and residents, permits the Contract Officer to withhold or deduct up to 15% of a rnonth ilIVOICe until the Contract Officer determines there is full compliance with the standard or section," GEO was notified of a request for a Plan of Action on October I, in reference to the temporary construction fencing that was put in place on or about September 27. GEO's response to the POA was to only put in the place the items specifically requested in the POA: the placing of sand bags. orange construction fencing to help block gaps at the bottom of the fencing, and warning signs. At no time did compliance staff see additional staffing to assist in the blind spots created by the fencing, nor did we witness GEO staff attempt to keep walk areas clear of residents or away from the fencing when in more open areas, like the soccer field. In GEO's response is found an Attachment 2, which is an email from Inc and in the second paragraph I wrote that the current level of visible staff was not adequate to prevent children from climbing the fence. This item was never addressed by GEO management in writing. On October 21 a resident was struck by a fence that was blown over by wind and the only report produced to the COR was the standard Significant Incident Report, which did not have any additional supporting documentation from any witnesses to the incident. No report was ever received from GEO's on-site Fire and Safety Manager (b)(6),(b)(7)(C) stating how the fencing had failed or how it was to be corrected going forward, as more storms were forecasted that weekend. The next day. October 22, Supervisory Detention and Deportation Officeil tr4 v1A 1 called me out to the outdoor recreation area of Compound One because other sections of the fencing had started to collapse in the higher wind gusts. At this time SDDO (b)(6),( and I spoke withl(b)(6),(b)(7Iand asked him if it was a requirement to have Page 76 of 740 SUBJECT: CDR Ka2C- I 6-0003 Page 2 the black mesh on the fencing, as it seemed to be the item causing the wind to push the fencing over. He stated he did not know and would look into this. The next walk through conducted on October 25 found the mesh had been partially removed, but was still attached at the bottom of the fencing potentially becoming more a trip hazard and severely restricted the walking spaces in certain areas as it draped on the ground. It is unknown if any one actually tripped over these items as this is not a reportable incident, but as for reporting to medical for injuries, GEO is correct that no slip or trip injuries were reported. A second POA was issued on October 22 that specifically requested a response for keeping residents away from the fence. GEO management's response was a reiteration of a practice that did not keep a resident away from the fence line. By only using weekly orientations and no follow through by line staff to enforce that policy or rule to keep away from the fence most residents chose to ignore the rule and continued to loiter around the fencing, often allowing their children to put hands on the fencing with active construction work being conducted on the opposite side. GEO management's assertion that the weather is what delayed the original one week time line, provided in the email from October I, is false. Most of the early part of October saw clear or cloudy days but very little rain. ICE compliance team did witness that only one Bobcat was being used to haul items to and from the work site, and for long stretches of time no progress was seen, with only three construction workers working one compound at a time most days. At one point the Bobcat was reported to have been in operational for a few days. but no formal notice was given to the COR of this item not working. It is unclear as to why GEO choose to allow both outdoor areas to be fenced off and ground torn up at the same time. Given the amount of work required; to haul away top soil, place rock and sand, pack it down and level it. and then place artificial turf, it was difficult to understand how a company can believe that the one week time frame was feasible with the amount of square footage being worked on. At this time I am recommending a one time deduction of 15% for the month of October, due to GEO management's inability to mitigate the harmful impact of the construction fencing on a resident. GEO management failed to show proactive planning in connection with the fencing, and only put in place specific items recommended to them by ICE ERO staff, and only one of whom has had 40 hours of OSHA certification training for Collateral Duty Safety Officer. It does fall on GEO management to assist in finding and correcting other deficiencies that may alleviate concerns brought to them by the CORs. Supporting documentation will be submitted in this CDR packet in the form of emails and photographs. The construction fencing has been removed as of the time of this memo being written, and no further incidents are anticipated in connection to the current construction plan. Per ERO-!GSA-11-0004, Attachment 6.A, Peribrmance Requirements Summary," A Contract Discrepancy Report that cites violations of FRS, PREA, and SOW (contract) sections that protect the community, staff contractors, volunteers, and residents from harm, permits the Contract Officer to withhold or deduct up to 15% 0/a month1v invoice until the Contract Officer determines there is All compliance with the standard or section." Page 77 of 740 [111(11Vel (1pciamms 1- .5. Department alkali:10nd Security 1777 N11 I .nop 410 EIBTOIRR San Antiiit'lcxtis 78217 US. Immigration , 2i,_ and Customs 410A Enforcement April 24, 2015 MEMORANDUM FOR• I (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management (b)(6),(b)(7)(C) FROM: SUBJECT: gI Contracting Officer Representative Karnes County Residential Center Close Out Memorandum for KCRC-I 6-0003 -0003, in This is the formal close out memorandum lel Contract Discrepancy Report KURC-16 adequate providing not by nt environme secure and safe a maintain to reference to the facility failing as per the fencing. on constructi by struck be to resident a protection during construction which caused ents Requirem ance "Perform a. 6. contract, ERO-IGSA-I I -004 Family Residential Statement of Work, of cited FRS and SOW (contract) Summary, ":1 Contract Discrepancy Report that cites viohaions teers. colaracton and residents. permits sections that provide a safe wiwk elldrallIllellt,fin. stall volui the C'ontract Officer to withhold or deduct up to 15% oft' month invoice until the Contract Officer determines there is full compliance with the standard or section. - the temporary GEO was notified of a request for a Plan of Action on October I. in reference to to the POA was response s . r 27. GEO construction fencing that N‘ as put in place on or about Septembe sand bans. orange to only put in the place the items specOka11y requested in the 'OA: the placinp of g signs. At no time did construction fencing to help block gaps at the bottom of the fencing. and w ant in fencing. nor did we the by created spots blind the in assist to cornpliance staff see additional staffing fencing when in In Ore the from away or itesidents of clear areas keep walk kv i mess GEO staff anew Pt to is an email from which 2, open areas. like the soccer field. In GEO's response is found an At to adequate not was staff me and in the second paragraph I rote that the current level of is in ent managem GEO prevent children from climbing the fence..Fhis item was never addressed by \ lit 11g. the only report On October 21 a resident "as struck by a fence that was blown over by wind and any additional have not did which Report. In t Shmitican produced to the COR was the standard from GEO's received ever was report No incident. the to supporting documentation from any witnesses was to be it how or railed had fencing the how 6 on-site Fire and Safety Managed (b)( ),(b)(7)(C)Istating 22, October day. next The weekend. corrected going forward, as more storms were forecasted that area recreation outdoor Supervisory Detention and DeportatMn Officer (b)(6) (b)( called ine out to the wind in the higher ousts. of Compound One because other sections of the fencing had started to collapse have to nt him requireme lilt a asked 'as and ( tvill b)(6),(b)(7 spoke I and (ba(6),( SDDO At this time www.ice.trov Page 78 of 740 SUBJECT: CDR KCRC-16-0003 Page 2 the black mesh on the fencing, as it seemed to be the item causing the wind to push the fencing over. He stated he did not know and would look into this. The next walk through conducted on October 25 found the mesh had been partially removed, but was still attached at the bottom of the fencing potentially becoming more a trip hazard and severely restricted the walking spaces in certain areas as it draped on the ground. It is unknown if any one actually tripped over these items as this is not a reportable incident, but as for reporting to medical for injuries, GEO is correct that no slip or trip injuries were reported. A second POA was issued on October 22 that specifically requested a response for keeping residents away from the fence. GEO management's response was a reiteration of a practice that did not keep a resident away from the fence line. By only using weekly orientations and no follow through by line staff to enforce that policy or rule to keep away from the fence most residents chose to ignore the rule and continued to loiter around the fencing, often allowing their children to put hands on the fencing with active construction work being conducted on the opposite side. GEO management's assertion that the weather is what delayed the original one week time line, provided in the email from October 1, is false. Most of the early part of October saw clear or cloudy days but very little rain. ICE compliance team did witness that only one Bobcat was being used to haul items to and from the work site, and for long stretches of time no progress was seen, with only three construction workers working one compound at a time most days. At one point the Bobcat was reported to have been in operational for a few days, but no formal notice was given to the COR of this item not working. It is unclear as to why GEO choose to allow both outdoor areas to be fenced off and ground torn up at the same time. Given the amount of work required; to haul away top soil, place rock and sand, pack it down and level it, and then place artificial turf, it was difficult to understand how a company can believe that the one week time frame was feasible with the amount of square footage being worked on. At this time lam recommending a one time deduction of 15% for the month of October, due to GEO management's inability to mitigate the harmful impact of the construction fencing on a resident. GEO management failed to show proactive planning in connection with the fencing, and only put in place specific items recommended to them by ICE ERO staff, and only one of whom has had 40 hours of OSHA certification training for Collateral Duty Safety Officer. It does fall on GEO management to assist in finding and correcting other deficiencies that may alleviate concerns brought to them by the CORs. Supporting documentation will be submitted in this CDR packet in the form of emails and photographs. The construction fencing has been removed as of the time of this memo being written, and no further incidents are anticipated in connection to the current construction plan. Per ERO-IGSA-I 1-0004, Attachment 6.A, Performance Requirements Summary," A Contract Discrepancy Report that cites violations of FRS, PREA, and SOW (contract) sections that protect the community, staff contractors, volunteers, and residents from harm, permits the Contract Officer to withhold or deduct up to 15% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section" Page 79 of 740 ICE CONTINUATION SHEET 1, CONTRACT NUMBER ERO-IGSA-11-0004 CONTRACT DISCREPANCY REPORT Date: 11/17/2015 Report Number: CDR-16-0003 3 . FROM: Name of COR) 100)(5),(b)( i HUICOR/D.0. DHS/ICE cilitMyaAndamgienrisNtraani toer) I 101-WilDnII rFacility SEC Group, Inc. DATES CONTRACTOR NOTIFICATION 11/17/2015 CONTRACTOR RESPONSE DUE BY RETURNED BY CONTRACTOR ACTION COMPLETE 11/19/2015 4 DISCREPANCY OR PROBLEM (Describe in DefeoInclude reference in PW. S / Thrective: Attach continuation sheet of necessary.) Contractor Violations: Contract: CLIN 0001 Housing and care of Family Residential. Family Residential Facility Statement of Work 2, a. "The purpose of this contract is to facilitate the provisions for the necessary physical structures, equipment, facilities, personnel and services, to provide a program of temporary shelter care in a staff secure environment and other related services to alien family groups who are currently held in the legal custody of ICE." a SIGNATURE OF CONTRACTING OFFICERS TECHNICAL REPRESENTATIVE (COR) 7 FROM (Contractor) 6. TO: (CORI 8. CONTRACTOR RESPONSE AS TO CAUSE. CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. ATTACH CONTINUATION SHEET IF NECESSARY. (Cite apphcable cm program procedures or new A W procedures-) 9. SIGNATURE OF CONTRACTOR REPRESENTATIVE 10, DATE 11, GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan, rejection: attach continuation sheet if neCeSSWW 12. GOVERNMENT ACTIONS (Payment withholding, cure notice, show se, other) CLOSE OUT NAME AND TITLE CONTRACTOR NOTIFIED COR CONTRACTING OFFICER Page 80 of 740 SIGNATURE DATE Issues: On or about September 27, 2015 temporary construction fencing was used to cordon off most of the outdoor recreational and sitting spaces for the purpose of removing sod and replacing it with artificial turf. It was estimated at that time to have taken away approximately 70% of the outdoor space, all but two tables for the outdoor seating area, and severely limited the use of the soccer field and the playground. Due to the school's use of the indoor gym during the daytime this left residents with small children few options for basic interactions and play. On October 1, 2015 the compliance team conducted a general safety check of the fencing and found numerous deficiencies and safely concerns, and a Plan of Acfion was requested to assist in mitigating the possible safety impact to our residents and recreation opportunities. GEO responded on October 1 and 2 with responses to the concerns raised, which included a statement that there were sufficient staff to watch over the safety and care of the residents. In an email received from Facility Administrator (FA)I (b)(6),(b)(7)(C) Ion October lit was staled that the project would only take one week to complete. On October 21, 2015 a resident was struck by a fence that had been supposedly blown over by wind. A Plan of Action was requested to address the lack oversite to resident behavior in being too close to the fence and the lack of mitigafion of the safety concerns originally communicated on October 1. The response signed by F , included a statement of "Staff will continue to orientate residents concerning fence safety?The compliance team had previously determined that the standard staffing levels of GEO couldn't adequately maintain line of sight of the entire fencing and attend to their basic duties of resident daily activities. The resident being struck by the fence was an example of GEO staff's inability to properly orientate residents to the potential hazards posed by the fencing especially in high wind. On October 23, 2015 a formal request of all video footage of the fence collapsing and incident reports generated, including medical reports, w s made, and a packet was received via an email from Compliance Administratoi (b)(6),(b)(7)(C) Ion October 26 that stated there wasn't a camera with a view of the incident. In fact there was one camera with a very poor view of the incident but it clearly showed the whole section of fencing the length of the soccer field falling, but it was not clear enough to identify individual people. The incident reports provided by GEO were not generated by GEO staff but by contracted construction staff and written on loose leaf lined paper. No incident reports from GEO staff assigned to that area were received, only the Significant Incident Report generated by the shift supervisor on duty and not in the area at the time of the incident was provided for CEO's formal report. At the time of this writing the fencing has now been in place approximately five weeks. GEO management has not been able to adequately mifigate the trip hazards, with additional trip hazards now being found by the black fabric laying on the ground almost half way into the walkway and one area near the east side classroom entrances being cut almost in half by fencing being pushed away from active construction. It now appears the fencing is slowing being bent down and the sand bags are showing excessive wear with torn corners and sand spilling out. Many places the fencing has been poorly reinforced with plastic zip ties to prevent gaps from forming between sections, and these zip ties often fail and the fence will be found with gaps within a day or two. In addition the weather forecast has predicted more rain storms to pass through the area this weekend. November 6-7, 2015, and this presents another chance of the fence being affected negatively. Page 81 of 740 Contract Stipulations: Per ERO-IG54-11-0004„4ilachmeni 6.A, Performance Requirements Summary," A Contrail Discrepancy Report that cites violations nf cited FRS and SOW Pontracpsec lions that provide a sok 1vw-k environmenrfim staff volunteers, on a tut residents, permits the Contract Officer to it ,ithhold or deduct up to 15% of a month in until the Contract Officur determines there is fill compliance with the standard or .vection. Page 82 of 740 Enfinremeni and Remora/ Opercilion.‘ U.S. Department of Homeland Security 409 FM 1144 Karnes City, TX 78118 U.S. Immigration tepie and Customs ar ,/, Enforcement t September 5th, 2014 MEMORANDUM FOR: FROM: Oon6),(n)(7nC) Contracting Officer Office of Acquisition Management (OAQ) (b)(6),(b)(7)(C) Contracting Officer's Representative Karnes County Residential Center SUBJECT: Request for Monetary Deduction and/or Withholding for Contract Discrepancy Report KCRC-14-001 As the Contracting Officer's Representative (COR), I am respectfully requesting a monetary deduction or withholding in pay to the Service Provider of 20-30°A for the Month of August 2014 due to non-deliverance of goods and services as specified in the Statement of Work and outlined in the Contract Discrepancy Report (CDR), KCRC-I 4-001. Specifically. the Service Provider failed to adhere to the August Activity Schedule. When the Assistant Field Office Director (AFOD) and the COR both requested documentation regarding the actual amount of activities completed for the month of August, the requested documentation was not provided. In addition, the gymnasium was found closed before the scheduled closing time on at least 6 different days. The Service Providers response that the gymnasium operating hours have changed is incorrcct. GEO has proposed a schedule change, but the schedule change has not been approved and signed off by the AEOD and IFRMU, so it should not have been implemented without approval and notification to ICE. Additionally, throughout the month of August there were numerous other compliance issues and concerns including but not limited to: inadequate number of high chairs, inadequate number of cribs, issues with mothers receiving formula, and lack of supervision in the gymnasium and dining hall. Page 1 of 2 Page 83 of 740 There were four Plan of Actions submitted to the Service Provider in regards to these items before the CDR was issued. ICE continued to see lack of improvement primarily to the lack of staff supervision in the Dining I Ia11 & gymnasium and formula issue, so a CDR was issued. Taking into consideration the totality of goods and services not provided for the month of August in the above annotated items, a deduction of at least 20 0/ for the 2' half of the month of August is being requested; an approximate deduction of $198,040 is recommended. Per ERO-IGSA-I 1-0004, Attachment 6.A, Performance Requirements Summary "A Contract Discrepancy Report that cites violations of PBNDS and PWS Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that provide for the basic needs and personal care of detainees, permits the Contract Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Per ERO-ICSA-11-0004, Attachment 6.A. Performance Requirements Summary, "A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that reduce the negative effects of confinement permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the contract Officer determines there is full compliance with the standard or section." Page 2 of 2 Page 84 of 740 Enforcement and Removal Operations U.S. Department of Homeland Security 1777 NE Loop 410.1(b)(6),(b)l San Antonio, Texas /821 U.S. Immigration and Customs Enforcement November 12. 2015 MEMORANDUM FOR: (b)(6),(b)(7)(C). 1 Contracting Of icor Office of Acquisition Management FROM: (b)(6),(b)(7)(C) l.ontracting (Juicer Representative Karnes County Residential Center (KCRC) SUBJECT: Memorandum for KCRC-I 6-0002 (memo #2) This is the formal memorandum for Contract Discrepancy Report KCRC-I 6-0002, in reference to the facility failing to provide an Interpreter under, ERO-IGSA-I I -004 Quality Assurance Surveillance Program 73. "A Contract Dkcrepancy Report that cites violations of FRS or SOW sections that require the Contractor's administration and management of the facility in a professional and responsible Incliner, and maintenance of workforce integrity permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section," GEO was notified of CDR KCRC-I 6-0002 in reference to an interpreter not provided as per Change Family Program SOW: Program Services, xiii Translators to include the following: "Should the facility encounter individuals who only speak languages such as K'iche and Mani or other oral and indigenous languages and/ or in instances when commercially available telephone services are insufficient to provide meaningful access to services, the Service Provider must arrange for consistent regular interpretive services through on-site inteipreters or unavailable via televideo." On November 12. 2015,! requested translation services from GEO Interpreter or ICiche to explain the release process to the Alternative to Detention (AID) with the GPS to one of the mothers who spoke limited Spanish. The mother informed LIS she was a !Cliche speakei and when came to assist us I asked her to please translate for us in K'iche. however (b)(6),(b)(7)( began speaking to her in Spanish and I asked her we need the translation In K iche. (b)(6),(b)(7)( informed us the resident speaks Spanish and I informed her the resident speaks limited Spanish and we prefer the translation in Knrche. (b)(6),(b)(7)( persisted in translating in Spanish and I asked her not to translate in Spanish since I can speak Spanish as well. This is the second time 1(b)(61(b)(71flavoids translatino for us in K'iche. I have (b)(6),(b)(7)(C) as my witnesses )vhen this incident occurred. www.ice.gov Page 85 of 740 ICE CONTINUATION SHEET 1 CONTRACT NUMBER CONTRACT DISCREPANCY REPORT ERO-IGSA-11-0004 Date: 11/12/2015 Report Number: CDR-16-0002 3 FROM (Name of COR) 2 TO (Contractor and Manager Name) I (b)(b),(b)( /)( IProgram Director NICT(b),(bn M I COR/DO DH/ICE GEO Group Inc DATES CONTRACTOR NOTIFICATION CONTRACTOR RESPONSE RETURNED BY CONTRACTOR DUE BY 4 DISCREPANCY OR PROBLEM (Describe iii Sera ACTION COMPLETE PrVS 0 leC:1.0 A:EdCh corit,'niiat,' on sireetif ner t Contractor violations: Change Family Program SOW: Program Services. xiii Translators to Include the following: and Maru or other oral and indigenous languages Should the faculty encounter individuals who only speak languages s,Jch as K and; or in instances when commercially available telephone services are insuff lc not to provide rueanrogrul access to services Inc Coyne Provider must arrange for consistent regular oterpretwe sersces thr000 Ii on. site interpreters or unavailable vta televideo Issues: On September 14, 2015 an interpreter began employment at Karnes County Ressiential Center with no background or Soon:ledge of K' :ohe or Mom ICE cannot request a formal Plan of Action due service not provided will not be resorved on the spot by GEO maeasement Tire COR is declining payment of this service Ii Dl reeneron 5 SIGNATURE OF CONTRA TING OFFICER'S TECHNICAL REPRESENTATIVE (CORI (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) 7 FRORI (CCOrran400 6 TO (COP) 2 CONTRACTOR RESPONSE AS TO CAUSE CORRECTIVE ACTION AND ACTIONS I U PREVEN 1 RECURRENCE AlEACH CONTINUATION SHEET IF NECESSARY f denapplicable C A mowden Grocer/cies or Ire C. A LL' procedures I 9 SIGNATURE OF CONTRACTOR REPRESENTATiVE Id DATE II GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE RESOLUTION PLAN ccep acceptance of response/plan retechon attach conheuareon street if necessary. •2 GOVERNmENT ACTIONS {Payment Other:ono pile noose Vow cause orfrer I CLOSE Our NAME AND TI I I CONTRACTOR NOTIFIED COP I CONTRACTING OFFICER Page 86 of 740 SIGNATURE DATE Contract Stipulations: Per ERO-IGSA-11-0004, Attachment 7.3, Staff Hiring and miming, "A Contract Discrepancy Report that cites violations of FRS or SOW sections that require Ow Contractor's administration and management of the facility in a professional and responsible manner. and maintenance ofivorkforce integrity, permits the Contract Officer tolvithhold or deduct up to 10% of a monthly invoice until the Contract Officer determines there is Ad, compliance with the standard or section." Page 87 of 740 AGE SEFERENCENOOFOOCUMENTBEINGCONTNUED CONTINUATION SHEET 2 EROIGSA-11-0004/P00018 Or I 2 NAMEOFOFF aosoftcomnfic OR KARNES COUNTY OF OuANTITY UNIT SuPPeESISEAviCES ITEIANO (C) (B) (A) (0) UNIT PRICE • AMOUNT (F) (El Interpreter services will be fiiçiclod on the task order as CLIN 0007 at a rate of (b)(4) I?" month. Change Family Program SON: b.Pr gram Services ,xiii Translators to include th . following: Should the facility encounter individuals who only speak languages such as Kliche. and Nam or other oral and indigenous lango des and/or in instances when commercially ava'lable telephonic services are insufficient fo piovide meaningful access to services, the Service Provider must arrange for consistent regular interpretive services through on-site interpreters or if unavailable via televideo. AtIaclurient 1 EROIGSA-11-0004 Karnes Family Program SOW 1-26-15 wild replace the previous Attachment 1 Family Program SOW. 2) Change the COR and ALT. COR Information. COR Changed: FROM - naltgilOIM 5(830)254-U01El] 830/25 114151 00)(6),00)(7)(C) W ALT. COR changed: From: N/A TO: (b)(b),(b)(f)(C) 830/454 (b)(6),( Except as provided herein, all other terms and conditions of said TGSA remain the same. Exempt Action: Y Period of Performance: 12/07/2010 to 12/06/2015 callow& FOIOA 3M @spo.nomdby0SA 16 C.,R)S3 110 FARM Page 88 of 740 JOB DESCRIPTION Job Title: Exemption Status: Reports To: RevICW Date: K'ichc interpreter Non-Exempt Programs Manager April, 201 5 Position Code: Department: Division: Supervises: Facility: Summary This position is responsible for listening understanding an statements and translate them into English.. 2.0074I Programs Residential lien:mem None Karnes County Residential Center inslating spoken or written Primary Duties and Responsibilities • Facilitates effective communication between two parties that do not speak a similar language by converting one spoken or written language to another to mediate discussions. • Attends conferences and meetings and act as official translaior • Translates for residents so they can understand center officials. • Relays concepts and ideas between languages. or COriVersS written materials from one language into another, such as books, publications, o web pages. • Creates a new text that reproduces the content and style of the original . • Edits and proofreads text to accurately reflect language. • Receives and submits assignments 6u:ironically • Uses dictionaries and glossaries ihr references • Utiliges computer-assisted translation. • Facilitates communication for residents with Inuited English ;vie ficiency. • Translates at meetings such as attorney-client meetings, preliminary hearings, arraignments, depositions and trials. • Interprets both legal terminology and colloquial language. • Reads aloud documents :n a language other than Ma: in which they were written. • Provides language services to healthcare residents with limited English protkieney. E Translates resident materials and informational nrochures issued ht.- medical facility. ▪ Accompanies resident and facilitates communication between receiving party and visitors. • Other duties as assigned. Minimum Requirements • High School Diploma Or equivalent or greater. • Experience as an interpreter or translator working with ch:ldren or adolescents in a social services setting is highly preferred. mid English . • Demonstrated ability to interpret and nans121t! between Spanish, I;:lche, with all levels effectively communicate to able be Must skills. interpe:sona! • Above average interests varying Wi!h within the facility, in addition to a varietv of outside Customers • Excellent writing skills. Must be able to thoroughly and effectively document all work performed in the position. NOTE. Job dessopons MC 1101 ostsrp but suss irteoCed to accurately refle:st pn lus ex:sou:soy!: Lists oiiI sesponsiEur • +al job elQussru Page 89 of 740 Is ung condi LnnSLid lailirronew and Pommel Oirnitrer kern:land Security Ilepnrithent 1777 NI% I oop 41( ttiJIGJxtiJI San Anioni.p. I CNOS 782 I riirgt,, U.S. Immigration t and Customs Iitta Enforcement October 23.2015 MEMORANDUM FOR: (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management FROM; (b)(6),(b)(7)(C) L ornracting ut tee]. RepresenTau VC Karnes County Residential Cente (KCRC) SUBJECT: Memorandum for KCRC-16-0002 This is the formal memorandum for Contract Discrepancy Report KCRC-I6-0002. in reference to the facility failing to provide an Interpreter under. ERO-IGSA-11-004 Quality Assurance Surveillance Program 7.3. "4 Contract Discrepancy &rift that cites 'whiff is o[ FRS or 80117 sections that require the Contractor's administrcition and management of the .facility ill a professional and roponsifile manner, and maintemmte of worAlbrce integrity permits the Contract Officer to withhold or ilechwi itp to 10% ola monthly invoice until the Contract Officer determines there is full compliance with the standard OP .cection.GEO was notified of CDR KCRC-I 6-0002 in reference to an interpreter not provided as per Change Family Program SOW: Program Services. NHI ITtrislators to include the following: -Should the filed»r encounter individuals gho war .speak languages such (IN Au he and Ham or other oral and indigenous languages and/ UI fit insicmces when conunerchiqv available telephone se/-vitS are insufficient to provide meaningful access in services, the Service Provider must arrange for cfmsistent regular hileipretive services through on-site imethreters or uninvilable via ielevideo.During an informal interview the individual hired as the Kliche speaker for Karnes County Residential Center by GEO administration it was found that this individual had no 'kta ---2, 1, 49) I (b)(6),(b)(7)(C) -10 ifkat-M1/ CR (b)(6),(b)(7)(C) 2/4-4,„ 174-ce--eak_21 +_••• 7 Et 29 10\_) O (b)(6),(b)(7)(C) Pu r) Jr-Liz& \A \rn \D 06:1E-c te- eciA-a)\-rn-\ Th(.,pnr\ po4 ICD 6 V-249_ (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) (b)(6),(b) (7)(C) (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) OLeark120 (b)(6),(b)(7)(C) ) A_GCL, StiOe-P • _4- —at 1/43-`(1 A A -a C (IS ) r‘ rn ces O fl rf cn — 1(-, uT cy Lile. arv-11 on ) av n — (b)(6),(b)(7)(C) •iy-) (b)(6),(b)(7)(C) e o--)A- Mein Nc\re,tren (b)(6),(b)(7)(C) e,Thi ciiied n Let rtovh n bee At, /4tp_ m pick ' (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) gm. sLio .5;c2 117;g' (b)(6),(b)(7)(C) 32 lb- iq (b)(6),(b)(7)(C) (b)(6), (b)(7)( Carl /giniconiS -S (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) vLk Cer 1. 5 n ociejrt RALiksikeldfi (b)(6),(b)(7) (C) \c•Ok'\ (b)(6),(b)(7)(C) , of-\ eC-1-Cn-D1 • 10 (b)(6),(b)(7)(C) L)Wk tc.)_ -1-ep.2z\ex_24A p(D'S4 — __LeLtacel Ftnr. Locepiia itakylnl-mAl 6750 _- , q1 (b)(6),(b)(7)(C) tjae_tr4, it 0) 5 eq-e-rLS / Conrvounal 1 +3 De_ci-bs Sr— cArr-ut (b)(6),(b)(7) (C) Department of Homeland Security FOR THE ATTACHED MATERIALS CONTAIN DEPARTMENT OF HOMELA D URITY INFORMATION THAT IS "FOR OFFICIAL USE ONLY' R OT TYPES OF SENSITIVE BUT UNCLASSIFIED INFO ATION REQUIRING ' zOTECTION AGAINST UNAUTHORIZED D OSURE. THE ATTACHED MI - RIALS WILL BE HANDLED AND t- s FEGUARDED IN ACCORDANCE W 'HS MANAGEMENT DI TIVES GOVERNING PROTECTION AND I EMINATION I UCH INFORMATION. AT A MI i f UM, THE ATTACHED MAT ' LS WILL BE DISSEMI D ONLY ON A "NEED-TO-KNOW" SAND WHEN UN NDED, WILL BE STORED IN A LOCKED CO ER OR EA OFFERING SUFFICIENT PROTECTION AGAINST T T, COMPROMISE, INADVERTENT ACCESS AND UNAUTHORIZE DISCLOSURE. Page 218 of 740 Te Nakana n alp., Inc. Compliance Review Summary Report Karnes County Residential Center December, 2014 Reviewer: Robert Manville, Compliance Reviewer Between December 27 through December 31, 2014 Nakamoto Group, Inc. Inspector/Compliance Review (CR) personnel and .1FRMU Coordinators toured and observed the operation of the Karnes Residential Center. The methodologies used were observations, resident and staff interview and review of program documentation. During this review, the Nakamoto Group provided training for JFRMU coordinators. Observations and findings for the current reporting period are summarized in this report and are documented in the Monitoring Worksheet. The findings and observations were discussed with Karnes County Residential Center staff during daily and end of the review period briefings. Several Endings were minor in nature and were corrected by staff during the review. Standards of greatest concern or value are as follows: General Finding Overall impression of the ccntcr's operations is positive. Residents were observed interacting with staff. Finding Environmental Health and Safely During the review, a gas operated leaf blower was discovered in the shift supervisor's office. The supervisor's administrative support staff indicated it was brought to the office sometime the previous day. Gas operated tools and machinery should never be kept inside the center overnight. It should be used and then removed from the center's perimeter. Food Service The food service area was not in compliance with the accepted sanitation and management of the Food Service program and the Food Service Family Residential standards; The below list is the finding for this area. o Sanitation § Dirty griddle (flat top); not cleaned from previous meal. § Dirty grease traps in griddle. Traps were full of water, grease and food particles (odorous). Page 2 of 3 "FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)" Page 219 of 740 § Dirty floor drains/trough. Food from previous meal was found in floor troughs. The food was at least from previous meal. § High chairs had not been cleaned. Food was found on high chairs between meal services. o Food storage § Food was found uncovered in the kitchen's walk in cooler/freezers (eggs, open bag- of cheese). § Weekly inspection logs were inconsistent; appeared to be photocopied from previous inspections. o Meal service § Only one food service worker serving food for at least two meal services (lunch service 12/29 and 12/30) § Staffing levels remain low (including voluntary workers/stewards). § Overall supervision was inadequate. Cook Supervisors (CS) were not identifiable Recommended action plan: Provide kitchen sanitation schedule Provide staffing module to identify FSA/CS and additional kitchen staff Provide deadline to meet adequate staffing levels Page 3 of 3 "FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)" Page 220 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement Frequency Residential Standard Rating A/D/ or N/O Corrective Action Required / Comments Due Date 1. Admission and Release 1111 X X X X X X X ICE i ) int tion is available for initial placement Medical screening taking place within timeframes Inventory resident personal effects Resident funds accountability in place for admin/release All searches are completed according to policy and are documented. Appropriate clothing and bedding issued —Residents are allowed to retain personal clothing including undergarments. Orientation material in English, Spanish or most prevalent second language. All orientations are conducted in person. A A A Inventory was reviewed and found to be correct. A A A A Residents had appropriate clothing. The center has an orientation program including daily information sharing by ICE and Karnes' Staff 2. Contraband I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 221 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement IIII X X X I Poli •y . ri pace for handlin_ con raband Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband A A A 3. Correspondence and Other Mail ii X X X X X X In .omfin, m il . creened (but not read and del‘e ed dai y Outgoing mail screened for contraband Legal mail opened in front of resident A S af de i er nal to th residei t ach cl. y A A Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or common areas, and resident handbook Facility has a system for residents to purchase stamps Staff deliver legal mail to residents each day. A A A Stamps are available in the center's commissary. 4. Resident Handbook I St w' re of ha dbook ontents and xr 0 low procedure - A 2 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 222 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary A A Orientation material available to illiterate residents A X Res•dei t file created for ea h new •r iv. I A X Resident files contain documents generated during custody A X Resident files maintained in a secure area A X Resident intake and orientation were observed. All information was provided to residents. 5. Resident Files Q Files are maintained in a secure location 6. Disci I linary and Behavior Manaement Folic INI X X Rul s of condu t/s-ti c ions p ovided in wr. ting Incident reports investigated within 24 hours A D All incident reports were not completed within appropriate timelines. 3 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 223 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement Disciplinary panel adjudicate infractions X Disciplinary sanctions are in accordance with standards Staff representation available X X A The center has policy in place. The behavior management incidents for the last 3 months were reviewed. Each intervention was appropriate. A A 7. Emer ency Plans W St ff trained A X X X X X Written plans Evacuation routes primary and secondary A complete set of emergency plans is available Staff work stoppage plan is available Staff r e ye tr in ng on the emeig ncy )Ian d inng y ar y in service. A A A A A 8. Environmental Health and Sa ety INI X System fo . u ring i. sui g/ n tin a fling hazardou materials D A ga lea blower via. found ii th hi t 'up rv so o Tic . The blower had been in th area rom the p evious d y. 4 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 224 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X X X X X X X X X Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents Fire prevention; control/evacuation plan Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested hiweekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations A A A A A A All staff are trained on taking universal precautions. N/A A N/O A The safety officer was not at the center during the review. The center was very clean and well maintained A 9. Non-Medical EmergencEscorted r Tn s IN 5 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 225 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards N/O 10. Security Ins ections (Criteria Only—No S andard) I W Al Ti it( r. of icial y recorded in a X X X X X X X X vi. i o og book Front entrance staff inspect ID of everyone entering/exiting Maintain a log of all incoming and departing vehicles Housing unit searches occur only as allowed by the standard. Area searches documented in log book Facility administrator or designee and department heads visit housing units and activity areas weekly Staff monitor all vehicular traffic entering and leaving the facility Tools being taken into the secure area of the facility arc inspected and inventoried A Vi, ito s I( g On ain d all required inform. tion. A A Center staff inspects all vehicles coming inside the center. A A A A A 6 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 226 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X Staff are positioned in or immediately adjacent to resident living areas to permit them to see or hear and respond promptly to emergency A 11. Food Service X X Appropreit s• f ty measures for .harp. • re in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a Melt level of sanitation A Residents receive safety and appropriate equipment training prior to beginning work in department A A Dirty griddle (flat top); not cleaned from previous meal. rty grease traps in griddle. Traps te full of water, grease and food tides (odorous). Dirty floor drains/trough. Food from previous meal was found in floor troughs. The food was at least from previous meal. -lid chairs not been cleaned. Food was found on high chairs between meal services. X X The centei doe, rut hat e harps. 7 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 227 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X X A minimum of two hot meals served daily, snacks are provided for children and special needs are accommodated. Facility has a standard 35 day cycle menu . Appropriate supervision is provided during each meal period. A A D Only one food service worker serving food for at least two meals (lunch servicel 2/29 and 12/30) Staffing levels remain low (including voluntary workers/stewards). Overall supervision was inadequate. Cook Supervisors (CS) were not identifiable. The Food Service Administrator (FSA) indicated there were 19 staff assigned to food service. The Center Administrator indicated there were 28 positions in food service with one FSA, and no cook supervisors. This results in cooks preparing meals with no supervision. There was a manual with recipes for all food items that had not been precooked. However, the manual was not provided to the line staff preparing the meal. 8 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 228 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X X X A registered dietician conducts nutritional analysis A A All menu changes documented Common fare menu for authorized residents A Weekly inspections conducted and documented r The center is implementing a new menu on January 1,2014 that has been reviewed by a registered dietician. Weekly inspection reports for the last two months appear to be copied from the previous report. There was not corrective action plan for the one discrepancy noted on each report. Each report since October 20 indicates there is a box on the floor. I) 12. Funds and Personal Proert .r X X X X Inv n ory per on-il p oper y/ unds is m int ii d Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff A Pe sona property wa invei tn da id app ( p iat ly maint med. A A A 9 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 229 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X X Resident funds are deposited into the cash box Staff secure every container used to store property with a tamper-proof numbered strap Quarterly audits of resident baggage & luggage are conducted, verified, and logged A A A Audit was completed during the review. 13. Resident Grievance Procedures Q Gi ievance p oc du es in pl ce X X X X X A Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances alleging staff misconduct to ICE Informal resolution to a resident grievance documented in resident l Sy. tern in place. There were no ..trievan e. iled during the review. A A A A 14. Hold Rooms in Residen Fociflies 111 Res.dent • are not kei t in holding X areas long r than 12 hours. X Maintain location log for each resident in holding rooms A A The - n er has a ho ding area with roon s adja en to thi area. Logs are maintained. 10 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 230 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement Written evacuation plan posted for each hold room Hold rooms contain sufficient seating for the number of residents held Residents are provided with basic personal hygiene items such as water. soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes Staff closely supervises the residential hold rooms. Holding rooms are irregularly monitored every 15 minutes. Hold room doors are not locked. X X X X A A A Residents are closely supervised in the intake area. A 15. Hii uni er Strikes Q X X X X Procedur . o - efer ng resident to medt a 'f v rbal y r f . ed o obser Ted retu ing to eat beyond 72 hours Procedures for referring resident to medical if visually observed not eating consecutive meals or in any instance where a minor is observed not consuming meals Staff receive training in identification of hunger strike Process for determining reason for hunger strike A A A A 11 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 231 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement 16. Key i and Lock Control I I I M i tan in cnto ies of II key. /locks lo k•ng devi es Emergency keys are available for all areas of the facility Chit system used to issue security equip./keys/radios Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried X X X X X X 17. Access to L A The enter has a fulltin e k y aidto lento' ta . A A A A A al Material i W X X X X Adeqm t cc uipment i. vailable )r re. idents Legal materials/law library current and available for residents. ICE staff inspect law library weekly Denials documented Schedule for use implemented 5 hours weekly per resident A A A A Center added required postings during the review. 12 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 232 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters X X 18. Grou Presentations on Ler al Ri A A ts I CE/DRO approved ideos p ayed for all in oming esidents Posters announcing presentation appear in common areas at least 48 hours prior to presentation Facility ensures adequate presentations so all residents wanting to attend have the opportunity X X X A A A 19. Marriage Requests r I Mani re w ten q sts approved by POD / Chief JERMU A Poi y i. in p ace. 20. Medical Care • X I ri ak proce • in lude - medi al al d mental health screening Sick call procedures established A A The center provides a daily sick call. 13 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 233 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X X X X X X X X X Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area All residents receive physical examination/assessment within 14 days of arrival. All minor residents physical examination/assessment within 48 hours of arrival, Sick call slips available in English, Spanish and/or most prevalent second language The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability A sharps container is used to dispose of used sharps The medical department is maintained at a high level of sanitation A A A N/A A review of records showed that residents received examinations within 2 working days of arriving at the center. Center allows residents to report to medical for sick call on a continuous basis. A A A A A A 21. Personal Hy Liene 4 I) = Daily; W = Week y M = Mon hly; Q = Quarterly; A = Accep able; D = Deficien ; N/O = Not Obse v d; N/A = No Applicable Page 234 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement Clothing provided upon intake and exchanged weekly A X Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily X X X X X X Residents may exchange clothing a minimum of one time a day. Parents can change out clothing on their children more often if needed. A A A A Temperatures were within the established limits. A A 22. Residential Census X X X X MI St .ondu t .ens s at lea:t twice daily Recount conducted when incorrect census is reported Face to photo count conducted as necessary Each resident positively identified during census A A Census was conducted within 40 minutes. A A 23. Post Orders 15 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 235 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement IIIII X X X X X I E e y post ha a pos order ur ent & igned by he .acili y administ ator Housing unit officers record all resident activity in a log Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty A A A A N/A (b)(7)(E) 24. Recreation W X X X X X 111 Outdoor/indoor recreation is p ovid d A c 510 ecieat. on act. or e • provided daily be ween SAM and 8PM or as requir d by the standard Staff conduct daily safety checks of recreation areas In unit activities are available including activities related to acculturation Where cover is not provided to mitigate inclement weather, residents are provided weather-appropriate equipment and attire A A A A A 16 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 236 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement 25. Reli 'ous Practices i Reside] t are -Mowed to ng ge in ielitious services Authoriz d re igious items are allowed in resident possession X X S - cral d no nina lei s provide s rvi es a h center. A A 26. Sexual Abuse and Assault Prevention and Intervention Q N w e ident: are in ormed of the S x Abu e and As a il P e ,ention and Intervention policies during the initial orientation. X X X The Resident Handbook contains information on the Sexual Abuse and Assault Prevention and Intervention program. All new employees, volunteers and contract personnel will receive an initial training and annual refresher thereafter. I A The • n e p ovi les info nation du i ig h orientatio i p ocess. Residen s sign an acknow edgeme it statement that they have received information. A A Staff received training as required. 17 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 237 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X The center policies on Sexual Abuse and Assault prevention and intervention and ICE Sexual assault awareness notice shall be posted in all resident living areas. The center has a designated Sexual Abuse and Assault Prevention and Intervention program coordinator. A A The center has a sex abuse and assault program coordinator. 27. Staff-Resident Communication X X X X X X X X IN Hous.ng unit rounds conducted daily by s • ff Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours ICE visit schedules are posted in housing unit Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement A A A Resident request were answered in a timely manner. A A A A 18 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 238 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement 28. Suicide Prevention and Intervention X MI The f cil ty has a written uicide preve f( n aid •nterven i n pr )gram X approv d and signed by the heal h autho i y and facility administrator which is reviewed annually Every new staff member receives suicide-prevention training. SuicideX prevention training occurs during the employee orientation program and annually thereafter The facility has a designated and X approved isolation room for evaluation and treatment Staff observes and documents the status of a suicide-watch resident at least once every 15 minutes A Training is provided as required by the standard. A A A 29. Telephone Access X X X II. Upon intake re idents are m de awa e of phone policies Out of order phones reported to service provider Telephones inspected regularly by staff A A Phones were found in good repair. A 19 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 239 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement Telephone access rules posted in each housing unit A X X The number for the ICE OIG is posted in housing units A X The pro bono list is posted in housing units A X Emergency phone call messages delivered to residents A Special access calls are available to residents Notification of telephone monitoring posted by unit phones where applicable X X There are telephones in each apartment which houses up to 8 persons. Other phones are available throughout the center. A A 30. Terminal Illness, Advanced Directives and Death 111 X Res.dent who ar hroni ally o te minally ill -ire rai s e red o an app opriate o f-si cility A X The facility has written plans for addressing organ donations A X There is a policy addressing Do Not Resuscitate Orders A X The facility has written procedures detailing the proper notifications A 31. Tool Control 20 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 240 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement IIIII I Tool inventorie • •ondu ted as specified X X X X X X X X Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to ensure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard A All tool, were on . nv ntor , and o -1 rol ed a ieq i ed by the standard. A A A A A A A 32. Resident Transfer . 21 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 241 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X X X Resident provided with resident transfer notification form Health records/transfer summary accompany resident Funds and personal property accompany resident A-File/work folder accompany resident A A A A 33. Trans-tortation (Land Trans ortation IN X X X X Documentalon indi ating a e y ep i sae completed .mm d tely and vehicles are not ii, ed unt 1 they hay been repaired and inspected, is available for review Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour 1 period when transporting residents (bX7) I officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place X addressing the use of restraining equipment on transportation vehicles Cent ha app op 'iat polict s in place A A Checklist is conducted by staff prior to any trips. A A A 22 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 242 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X X X Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Minors are transported in accordance with child safety laws using appropriate safety restraints and seats A A A 34. Use of Force M W X X X X X X X X Poli y govern ng . i nn ed•a e/c ilculated use of fore All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques 4 point restraints are never used Medical staff consulted prior to calculated use of force incidents A A A A A A A A 35. Visitation 23 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 243 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement IIIII I W i ten vi. i a M I s .hedule po. t d and ac s ible o the publi General visitation log book maintained Visitor dress code enforced Legal visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and identified per standards Current list of Pro Bono services posted in resident housing X X X X X X X A Vi. ita ion i 'n co npliance with the s andards A A A A A A 36. Voluntary Work Pro ram IN Facili y has a volui tary wo k program A X X X X X Maintain a written chart with work assignments Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Residents receive propel training and safety equipment The en er has d e op d seve a job oppo [unities for resid nt . A A A A 24 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 244 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center December, 2014 U.S. Immigration and Customs Enforcement X Resident housekeeping meets standards for neatness, cleanliness and sanitation A 37. Juvenile Education X 111 CI s owns a e equipped, in luding de ks hal , g ade-app op iate t x book., a tiv ty . uppli s, chalk boards and audio/visua equipmen Lesson plans are in place and have X clearly stated objectives and measures for student performance. Curricula and materials meet US X Dept. of Education, state and county requirements. At least one hour of daily gradeappropriate instruction is provided in the following core subjects: Science, X Social Studies, Math, Language Arts (Reading/Writing), and Physical Education. Teacher credentials meet state X English as Second Language (ESL) requirements. Teachers identify, address and refer X counseling and special needs of students. A The educa ion program wa not ope -ating during the review. N/0 N/0 A N/0 A 25 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 245 of 740 Compliance Review Summary Report Karnes County Family Residential Program February 22 - 24, 2015 Reviewers (b)(6),(b)(7)(C) A compliance review of the Karnes County Family Residential Program was conducted February 20, 23 and 24, 2015, by Nakamoto Group compliance inspectors (b)(6),(b)(7)(C) (b)(6),(b)(7)(C) All thirty-seven of the Juvenile and Family Residential Management Units Family Residential Standards were inspected. Upon arrival at the facility on February 20, an entrance conference was held with the facility administrator and other administrative staff to discuss the purpose of the visit and make introductions. The compliance officer for the facility was out that day on temporary duty at another facility; however another staff member who serves as a backup compliance officer was available and facilitated the inspector's review. The lead compliance officer was back at the facility on February 23 and 24 to facilitate the inspection. Both of the Nakamoto inspectors had been in the facility for previous inspections so there was no need for a tour. As mentioned above, the compliance team inspected the facility in relation to all thirty-seven Family Residential Standards. One area of concern was noted during the review. Changes to the menu are not consistently documented and justified. Menu changes should also be forwarded to the facility administrator who in turn would notify ICE of the change and the justification for the change. The food service area of this facility has struggled for some time. Although the nutritional needs of the residents are being met and meals are served according to established schedules; the operational structure of the area appears weak. It should be noted that the food service manager position is vacant, and currently filled with an interim food service manager. The position has been advertised and a replacement has been identified and is awaiting final approval. It is anticipated the food service program will stabilize with the hiring of the new food service manager. The facility has developed additional schedules for volunteer resident food service workers. Scheduling of these workers has been problematic because the workers cannot work Page 246 of 740 when their children are not in school. The workers first responsibility is to supervise their children; therefore on the weekends they are unable to work. Written policy, procedures and clinical protocols for the, response to and management of hunger strikers. The facility provides timely access to medical, dental and mental health services through appropriately trained and/or licensed GEO health care staff for routine care and chronic and emergency conditions. Medical personnel are on site 24 hours a day, seven days a week. Per review of 25 resident medical records, medical intake screenings are consistently completed in a timely manner. The resident medical record review indicated the physical assessments are consistently completed within 24 hours for the adult residents as well as the minor residents. Residents requesting sick call appointments received appropriate medical care in a timely manner. Tuberculosis screening is completed on all residents during the intake process. The facility has two negative airflow/ respiratory isolation rooms located in the medical department. Written medical treatment consent is consistently obtained prior to treatment. Residents with chronic illnesses are medically monitored and provided appropriate medical treatment. Prescription medication is provided through a contract pharmacy and medications are distributed by nursing staff. The facility has a current Clinical Laboratory Improvement Amendment (CLIA) waiver for limited on-site testing. All needed health care not available on site is provided through the use of community healthcare providers and services. JFRMU/ ICE is notified if the medical condition of a detainee already housed in the facility deteriorates and requires a level of medical care beyond the capabilities of this facility. Initial mental health screening is performed by nursing personnel during intake. Suicide prevention and intervention policies, procedures and training programs are in place to protect residents at risk for suicide and to intervene appropriately if the situation warrants. Adult residents who may be placed on suicide watch are housed in one of two designated single occupancy medical observation rooms located within the medical department. The rooms are free of objects and structural elements that could facilitate a suicide attempt. An adult resident placed on suicide watch is given a tear-resistant gown and blanket. A minor Page 247 of 740 resident who is diagnosed as suicidal will be transferred to an outside care facility for observation and treatment. Policy and procedures are in place for the completion of advanced directives, living wills and DNR orders. This facility does not accept or continue to house severely or terminally ill residents. It is established practice to notify JFRMU/ ICE if the medical condition of a resident already housed in the facility deteriorates and requires a level of medical care beyond the onsite health care capabilities. The resident would be transported to an outside medical facility for emergency and/or inpatient medical care as needed, pending transfer or removal by ICE. As confirmed per a review of policies and facility and personnel interviews, procedures for appropriately responding to the death of a resident while in custody are in place. With this said, the facility appears to be operating effectively. Residents are provided basic services, programming, medical services and general guidance in a manner that mirrors the standards. Personal observation of the residents indicated their needs were being met. They have access to religious and recreation programming and were observed participating in those programs during the inspection. (b)(6),(b)(7)(C) February 24, 2015 Page 248 of 740 U.S. Immigration and Customs Enforcement Frequency Hutto Residential Standard Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Rating A/D/ or N/0 Corrective Action Required / Comments Due Date 1. Admission and Release MI X X ICE prom a iiy with ac hi. tory for new arriv I ' initial placement. Medical screening taking place within timeframes Inventory resident personal effects X Resident funds accountability in place for admin/release All searches are completed according to policy and are documented. Ca. e hi:tory of new r iva resident • comp. nie ' he resident to he fac. lity. A A X X A Personal effects, valuables and funds are inventoried upon arrival. Residents are provided a receipt for their personal effects and valuables. A A I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 249 of 740 U.S. Immigration and Customs Enforcement Hutto Appropriate clothing and bedding issued Residents are allowed to retain personal clothing including undergarments. X Orientation material is in English, Spanish or most prevalent second language. All orientations are conducted in person to ensure that illiterate residents understand facility policies and procedures. X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A A Residents are allowed to retain their personal clothing after it has been inventoried and washed. Residents are issued six sets of clothing, including under garments when they arrive at the facility. Orientation materials are provided to residents in English and Spanish. Spanish speaking personnel conduct the intake process with residents and provide a personal orientation to each resident. 2. Contraband IN Poli y in p ace or hand ing contrab nd Contraband disposed of properly and documented X Facility s aft make a concerted effort to control contraband X 3. Correspondence and Other Mail X v. A A A Facility personnel dl gently work to control contraband. Q 2 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 250 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Incoming mail is screened (hut not read) and delivered daily X X A Outgoing mail is screened for contraband Legal mail is opened in front of the resident A X A Incoming funds processed according to the standard, X A Rules for correspondence and other mail posted in housing unit or common areas, and resident handbook X X Facility has a system for residents to purchase stamps Incoming mail is screened in the presence of the residents and delivered daily Monday through Friday. This process was observed during the inspection. A A Legal mail is opened in front of the resident. This process was observed during the inspection. Residents sign for the receipt of all mail and packages. Funds received in the mail are processed according to policy. The resident is provided a receipt for any funds received in the mail. Rules for correspondence and other mail are posted in the dayrooms and are included in the resident handbook. Stamps are furnished to indigent residents and are also available for purchase in the commissary. 4. Resident Handbook 111 3 I) = Daily; W = Week y M = Mon hly; Q = Quarterly; A = Accep able; D = Deficien ; N/0 = Not Ohs rved; N/A = Not Applicable Page 251 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Staff receives training on standards and contents of site handbook, X A Handbooks are available in both English and Spanish. Other prevalent language versions are made available if required. X X A Facility personnel receive training on the handbook and its contents during the orientation basic training program and each year afterwards during annual inservice training. The handbook is available in English and Spanish. An interpreter service is used if the resident does not speak either of those languages. Handb« k is updated as ne es, a y 5. Residential Files MI Resident Iles are created for each new arrival X X X A Resident files contain documents venerated during custody Resident files maintained in a secure arca A A Re id nt file are Cr a d for each r sident du ing th intake p ( cess. The process was obse ved during the inspection. A review of resident files indicated they contain pertinent information generated during custody. Resident files are securely maintained in the administration area of the facility. 6. Disciplinary and Behavior Management Policy 4 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 252 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 IIIII I Rul s of condu t s. nc ions p ovided ii wr. ting X A Incident reports investigated within 24 hours X A Disciplinary panel adjudicate XA infractions Disciplinary sanctions are in accordance with standards X X Staff representation available The ules of on luct and d s iplii a y pro ess for Vo atio s of thee rue arc ii c uded in the ha dbook and po. ted i 1 the da room on each hall. A process is in place for a disciplinary panel to adjudicate infractions. To date, since this facility has housed mothers and children, no disciplinary panels have been convened. A A Detainees may be represented by staff if they request such representation. A Facility p rsonnel receive [lain ng in h m rgency p an.. 7. Emer ency Plans W i Sri trained X X Written plans A 5 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 253 of 740 U.S. Immigration and Customs Enforcement Hutto Evacuation routes primary and secondary X A complete set of emergency plans is available X Staff woik s opp ge pan is available 8. Environmental Health and Safe X W X X X M Systems are in place for . u ring i. suinghn tin a n•ng ha rdou materi. I.. Complete inventories of hazardous materials are maintained A complete list of MSDS is readily accessible to staff and residents Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A A A A The aci i y has a ystem for so inh, 's 'flint_ and ma.nt ini v hazardous ma erial '. This system was observed during the inspection. A A Updated fire prevention; control/evacuation plans are in place. X Primary and secondary evacuation routes are posted throughout the facility. A A complete list of MSDS is maintained in the Fire/Safety Managers offices as well as the Medical offices. The fire prevention, control and evacuation plan is reviewed by a Certified Fire Executive on an annual basis. This review and approval was examined during the inspection. The local fire authority is the Karnes County Volunteer Fire Department. 6 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 254 of 740 U.S. Immigration and Customs Enforcement Hutto Fire/evacuation drills are conducted according to schedule/standard X X X X Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested biweekly Employees and residents using flammable, toxic, or caustic materials receive advance training in their use, storage, and disposal Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A A A A Safety Office maintains files of inspection reports; Including corrective actions taken X X X A Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations Fire drills are conducted and documented monthly. The documentation was reviewed during the inspection. Emergency generators are run tested weekly and tested under load every other week. Facility personnel receive training in the use, storage and disposal of hazardous materials during the orientation basic training program. The topic is also covered in annual refresher training. Files of inspection reports are maintained by the Fire/Safety Manager and include any corrective action which was required as a result of the inspection. These reports were reviewed during the inspection. A A Hazardous materials were observed stored and used according to label recommendations. 7 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 255 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 9. Non-Medical Emergiencr Escorted Trrs nil The Field 0 fic Din tor considers and approve e. ch individual XA resident', request to vis't an immedia e fami y member. 10.Security Insection (Criteria 0th —No Standard) I Al i •itor ate recorded in a vi log book X o '. Front entrance staff inspect ID of everyone entering/exiting X X X X X Maintain a log of all incoming and departing vehicles Housing unit searches occur only as allowed by the standard. Area searches documented in log book Facility administrator or designee and department heads visit housing units and activity areas weekly A A P tinent .nfonnation i recod dintheNtio' og b )( k Th book w . e Ti wed durn g the inspection. Everyone entering the facility have to produce ID and sign in. A A Four suites (housing areas) are searched randomly each day on each shift. These searches are documented. A A 8 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 256 of 740 U.S. Immigration and Customs Enforcement X Hutto Staff monitor all vehicular traffic entering and leaving the facility Tools being taken into the secure area of the facility arc inspected and inventoried X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A A X Staff are positioned in or immediately adjacent to resident living areas to permit them to see or hear and respond promptly to emergency Tools brought into the facility are inventoried out of the maintenance area by maintenance personnel and inventoried upon entering and exiting the facility by counselor staff. These inventories are documented. The documentation was reviewed during the inspection. A 11. Food Service Appropri it s• f ty measures for .harp. • re in place A Kitchen u en. i s a -e maait ined in • lo .ked cabinet and in‘ en oried daily. 9 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 257 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Appropriate food temperatures are maintained for both hot and cold food X A Food Service department is maintained at a high level of sanitation Residents receive safety and appropriate equipment training prior to beginning work in department X X A A X X X X X A minimum of two hot meals served daily, snacks are provided for children and special needs are accommodated. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis Food items are maintained at appropriate temperatures, both hot and cold. Temperatures are taken and recorded during the preparation and serving of all food items. The food service area was observed to be clean. Resident voluntary workers receive training on safety rules and safe equipment handling prior to beginning a work assignment in the food service area. The documentation of this training was reviewed during the inspection. A A A All menu changes documented D Common fare menu for authorized residents A All menu changes have not been properly documented. 10 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 258 of 740 U.S. Immigration and Customs Enforcement Hutto Weekly inspections conducted and documented X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A Weekly inspections of the food service program are completed and documented. The documentation was reviewed during the inspection. 12. Funds and Personal Pro erty MI An in entory o person. I prope ly/fund is maintained Funds/valuables documented on receipt X X Residents property searched for contraband Staff forward arriving residents medication to medical staff X X A A A A Resident funds are deposited into the cash box X The process of inventorying and receipting funds and valuables was observed. A Medical personnel are present when detainees arrive for intake processing and take possession of any medication a detainee has in their possession. Resident funds are deposited in a safe in the intake area after they have been inventoried and receipted in front of the detainee. 11 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 259 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Staff secure every container used to store property with a tamper-proof numbered strap X A X Quarterly audits of resident baggage & 1 ggage are conducted, verified, and logged Every container used to store resident property is sealed with a tamper-proof numbered strap. This strap is only removed in the presence of the resident. This process was observed during the inspection. Audits are not current. D 13. Resident Grievance Procedures 111 X Grier-ince proc dures in phce Staff awarene s of proc dures for en e gency grievances X X X A Grievance logs are maintained. Staff forward any grievances alleging staff misconduct to ICE Fail ty p rsonnel receive train ng for the awa enes of erne gency grievan e dining the orientation basi tr thing prog am as well as annual refresher training. A A Any grievance filed alleging staff misconduct would be processed in the facility's grievance system. ICE personnel on-site would be notified when the grievance is filed. 12 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 260 of 740 U.S. Immigration and Customs Enforcement Hutto Informal resolution to a resident grievance documented in resident file X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A 14. Hold Rooms in Resident Facilities I III Res.dent are not kept in holding areas ong r than 12 hour . X X X X X A Maintain location log for each resident in holding rooms Written evacuation plan posted for each hold room Hold rooms contain sufficient seating for the number of residents held Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes A A A A Re id fits a e logged in and o it of the int ke wa Ung a eas. A review o these ogs ii dicated resident. o no spend more than twelve hours in those waiting areas. Logs are maintained for each resident held in a waiting room. Evacuation plans are posted in each waiting area. There is sufficient seating for the residents held in each waiting area. Basic personal hygiene items are made available to residents. These items include but are not limited to the items listed in this component. 13 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 261 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Staff closely supervises the residential hold rooms. Holding rooms are irregularly monitored every 15 minutes. Hold room doors arc not locked. X A Residents in the waiting area are under constant supervision and monitored irregularly every fifteen minutes. The monitoring rounds are documented. Waiting area doors are halfdoors and are not locked. A Poll y and pi ocedures are in p a .e to addr ss wh an a lul residen has declared a h Inger strike o ' has r fused n eals for 72 hours, staff members refer the de ainee to the medical department. Training is provided o all employees, volunteer , and contract staff in the identification and referral of hunger striking residents. 15. Hun d i er Strikes INI Procedure o e errn g resident to m dica if v rbal y r fu. el o observed refu. ing to eat beyond 72 hours X 14 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 262 of 740 U.S. Immigration and Customs Enforcement X Hutto Procedures for referring resident to medical if visually observed not eating consecutive meals or in any instance where a minor is observed not consuming meals Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A Staff receive training in identification of hunger strike X A Per policy, when an adult resident has declared a hunger strike or has refused meals for 72 hours or when a minor is observed or is known to have missed three consecutive meals or four meals in two days, staff members refer the detainee to the medical department. Residential counselors and other staff members receive hunger-strike training during employee orientation and annually thereafter during refresher training. Medical personnel receive additional hunger-strike training. A resident identified on hunger strike will be moved to an observation cell in the medical department for monitoring and treatment. 15 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 263 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Process for determining reason for hunger strike X A Medical policy and procedures provide direction for the treatment of a hunger striker and include initial medical assessment and mental health status evaluation when a resident has declared or been identified as being on hunger strike. 16. Key and Lock Control 1111 Maintdn invent° ies of II key Rocks locking devices X X X X A Emergency keys are available for all areas of the facility Chit system used to issue security equipment/keys/radios Policy regarding restricted keys present and followed by staff A A maste key cont -el inv fiery i maintai i d by the key control office The do ument was rev ewed durn g the inspection. Emergency keys are maintained in sets applicable to each department. A A The facility utilizes an automated key manager system which controls all restricted keys, allowing them to be issued only to authorized personnel. By policy, all keys at this facility are restricted. 16 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 264 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Facility has policy and procedures in place to ensure key accountability. The keys are physically counted daily X A Locks and locking devices are continually inspected, maintained, and inventoried X Keys can be inventoried and counted at any time any day. This is a feature of the key manager system. A 17. Access to Leal pi Material 0 X A lequate equipment i re idents vaih ble for A Legal materials/law library current and available for residents. ICE staff inspect law library weekly Denials documented X A X X X X Adequate equipm nt 's a T. ilabl o r sidents who wi, h to w )rk on their cases in the law ibra y. A Schedule for use implemented 5 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters Any denial of a resident's access to the law library is documented. There have been no denials. A A All residents are provided free A postage and envelopes for legal mail. 18. Group Presentations on Legal Rights 17 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 265 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto IIIII I CE/DRO pproved ideos p ayed for all in oming re idents X Posters announcing presentation appear in common areas at least 48 hours prior to presentation Facility ensures adequate presentations so all residents wanting to attend have the opportunity X X A Th CE ' Know Your R.gh s' and h Spe k Up" video are shown to each resident. A A 19. Marriage Re i uests I Mar i he w tei requ sts appr w d by POD / Chief SERMU A Mar ' g qu s are approved by he Clie o FRMU. Thi is addressed in policy. 20. Medical Care W MI 18 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 266 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Intake process includes medical and mental health screening X A All residents transferred to this facility receive a medical and mental health screening conducted by nursing staff during the intake process. Policy requires that a signed and dated medical treatment consent form be completed before medical treatment is administered, minor children must have a consent form signed by their mother or legal guardian. General medical treatment consent forms are signed during the intake screening process. Each resident is screened for tuberculosis during the intake process by chest x-ray. The chest x-ray results are obtained, through contract agreement with the University of Maryland, prior to the resident leaving the intake area. Review of 25 random adult and minor resident medical records indicated the initial medical and mental health screening is consistently completed. 19 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 267 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Sick call procedures established X A The medical department has a 24 hour "walk in" policy for sick call. In addition, sick call request slips arc available to residents in English and Spanish. The submitted requests are taken daily by medical staff and triaged for appropriate response or appointment. Health care interviews, examinations and procedures are conducted in designated exam or interview rooms in a manner that provides privacy for the residents. Minors receiving medical evaluation or treatment must be accompanied by their parent or guardian. Sick call is held seven days per week. 20 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 268 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Adequate medical staff available proportionate to population A X Pharmaceuticals stored in a secure area X A Staffing is sufficient to meet the health services mission, consistent with this standard. Medical, dental and mental health services are provided by GEO and contract staff. Medical coverage is provided 24 hours a day, seven days a week. Health care personnel who provide services to residents are appropriately credentialed in accordance with state licensure, certification and/or registration requirements. Pharmaceuticals are stored within the designated secure pharmacy room within the medical department. Access is limited to authorized medical personnel. Pharmaceuticals are provided through a contract with Correct Rx, 21 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 269 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 All residents receive physical examination/assessment within 14 days of arrival. All minor residents physical examination/assessment within 48 hours of arrival, X A Physical assessments are completed by the full time physician or nurse practitioner within 24 hours of arrival at the facility for both the adult resident and the minor residents. Pediatric physical assessments are age appropriate. Per review of 25 random resident medical records the physical assessments were usually completed during the intake process, following the intake screening and TB clearance and prior to a housing assignment. This is within the standard's requirement of 7 days for adults and 24 hours for minors. 22 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 270 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Sick call slips available in English, Spanish and/or most prevalent second language X A Sick call requests slips are available continuously to residents in English and Spanish. The submitted requests are received daily by medical staff and triaged for appropriate response or appointment. Interpretation services are provided when required, and assistance in completing request forms is available. 23 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 271 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 The facility has a written plan fir 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required X A The medical department provides 24-hour coverage. The written plan for the delivery of 24-hour emergency health care includes procedures for response by personnel, the provision of emergency treatment on site and ambulance transport to a hospital emergency room if clinically indicated. All staff and medical personnel receive first aid training and are certified in cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use The Otto Kaiser Memorial Hospital and Methodist Children's Hospital were identified by the HSA for providing emergency and inpatient care. 24 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 272 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Medical records are available and transferred with the resident X A The resident's medical records are maintained in locking filing cabinets, in a designated locked room, within the medical department. Access to the records is restricted to health care staff and practitioners for the provision of health care. Minor resident's medical records are filed with their parent's medical record. When a resident is transferred, a Medical Summary of Federal Prisoner/Alien in Transit form is completed for each resident and accompanies the resident being transferred. Medical records transferred with a resident are placed in a sealed envelope and labeled "Medical Confidential". 25 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 273 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Records are maintained of medication distribution X A All sharps are under strict control and accountability X A A sharps container is used to dispose of used sharps X A Medications are distributed by medical personnel in accordance with procedures established by the HS A and physician. Medication administration records (MAR) are utilized to document medications given to detainees. The completed MAR's become a part of the permanent medical record. Medications are distributed by medical personnel in accordance with procedures established by the USA and physician. Medication administration records (MAR) are utilized to document medications given to detainees. The completed MAR's become a part of the permanent medical record. Sharps containers for disposal of sharps and biomedical waste are utilized at all treatment locations and exam rooms within the medical department. Disposal of biomedical waste and sharps containers is handled under a contract with Stericycle. 26 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 274 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto The medical department is maintained at a high level of sanitation A X As observed, the medical department including all exam rooms, treatment areas, aid observation rooms is maintained at a high level of sanitation. 21. Personal Hy'me 0 Clo higp (bided upon intake and x hang d w ekly X X X A Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Ea h residen i p ovided six h nges o . clothes II luding undergarmen s, during the nt• ke pro •es . L• undry ser ices a e provided multiple imes weekly by the facility. In addition, washers and lryers are available in the day oom of each living hall for he residents use at any time. A A X Facility provides and replenishes personal hygiene items as needed, at no cost to resident A X Showers operate between 100 degrees and 120 degrees A During the inspection, residents were observed in clothing appropriate for the cold weather. Showers temperatures are maintained to industry standard. 27 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 275 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Showers meet ADA standards and requirements Food Service resid nt volunteers exch, ng garment. da I , X X A A 22. Resident Census w111 S nt - condu t census at lea t twice X daily Recount conducted when incorrect X census is reported Face to photo count conducted as X necessary Each resident positively identified during census Ce isu 's condu ted Iree time. ea 11 & y A A X A Residents are required to produce their facility iden ification documents at each census. Residents are positively identified at that time. A Po t ordeis exist for a h of seve teen po t •n the a iiy A . a nple of he, e pa t orders wa eviewed during he inspection and found to be Cuff in and signed by the facility administrator. 23. Post Orders IN Eve y pos has a pos order urrei t & . igned by he -' c'li y dmini, trator X 28 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 276 of 740 U.S. Immigration and Customs Enforcement Hutto Housing unit officers record all resident activity in a log X Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due to an emergency X X Anyone assigned to an armed post qualifies with the post weapons before assuming post duty X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A A A N/A Out of the ordinary resident activity is recorded in a log. It is important to note, in a facility with open movement it is virtually impossible to record all resident activity. Shift supervisors are visible in the facility at all times. Post orders are signed by assigned personnel, even when the assignment is temporary. There are no armed posts in this facility. 24. Recreation 1111 Outdoor/indoor re reation is p ovid A X X X Access to recreation activities provided daily between 8AM and 8PM or as required by the standard Staff conduct daily safety checks of recreation areas A Indoo . nd out loor recreation i provided a w ll as acces to a gymnasium. Recreation opportunities are available to residents between the hours of 8am and 8pm Sunday through Thursday and Sam until lOpm Friday and Saturday. A 29 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 277 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto In unit activities are available including activities related to acculturation Where cover is not provided to mitigate inclement weather, residents are provided weather-appropriate equipment and attire X X A A Although the gymnasium is available for recreational activities during periods of inclement weather, residents are provided weatherappropriate attire as needed. A Re, id n s are allowed to engage in r I. vim services/ac i iti s. Thee act. v.tie a e scheduled daily Monday th ough Friday. 25. Religious Practices . i Resident are all( wed to ngage in e kious services X Authoriz d religious items are allowed in r sident possession X A 26. Sexual Abuse and Assault Prevention and Intervention Q 30 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 278 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 New residents are informed of the Sex Abuse and Assault Prevention and Intervention policies during the initial orientation, A X X The Resident Handbook contains information on the Sexual Abuse and Assault Prevention and Intervention program. A Residents are informed about the sexual abuse and assault prevention and intervention program and the zerotolerance policy regarding sexual abuse and assault through the orientation video, the residential handbook and a sexual abuse and assault prevention information video. The videos and handbook are available in English and Spanish. Information about the sexual abuse and assault prevention and intervention program and the zero-tolerance policy regarding sexual abuse and assault is provided in the resident handbook. 31 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 279 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto All new employees, volunteers and contract personnel will receive an initial training and annual refresher thereafter, X A The center policies on Sexual Abuse and Assault prevention and intervention and ICE Sexual assault awareness notice shall be posted in all resident living areas, X A As confirmed per review of training files, all employees, volunteers and contract personnel are trained during pre-service and annual training in all of the topics required by the detention standard. Policy requires that any personnel who becomes aware of an alleged assault immediately follows the reporting requirements as outlined in established procedure. Prompt notification is made through the chain of command to IFRMU/ICE and the appropriate law enforcement agency. The Sexual Assault Awareness Notice poster, along with the name of the program coordinator and national organizations that can assist detainees, is posted on all housing unit bulletin boards. The ICE Sexual Assault Awareness notice is also posted in all resident living areas. 32 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 280 of 740 U.S. Immigration and Customs Enforcement X Hutto The center has a designated Sexual Abuse and Assault Prevention and Intervention program coordinator. Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A The warden has a designated Sexual Abuse and Assault Prevention and Intervention (SAAPI) Compliance Administrator and a Program Coordinator. 27. Staff-Resident Communication MI X X X X X X X Housini, unit rounds conducted daily by st ff Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours ICE visit schedules are posted in housing unit Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis Unannounced ICE staff housing unit visits occur weekly A F Hay personnel con( u I round and ins )ections dai y. A A A These schedules are posted in the dayrooms of each hall. A A A ICE personnel were observed in the unit each day. Facility personnel report ICE personnel are in the facility, interacting with residents daily. 33 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 281 of 740 U.S. Immigration and Customs Enforcement Hutto Visiting staff observe, document and communicate current climate and conditions of confinement X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A 28. Suicide Prevention and Intervention IN X The facil ty has a written suicide preven ion and 'n erven ion program approv d and signed by the health authori y and faclity ad ninistrator which is reviewed annually A Every new staff member receives suicide-prevention training. Suicideprevention training occurs during the employee orientation program and annually thereafter X A The wit n suicide p ev ntion and inteivei ['on p og a in i ' reviewe and approved by the clinic. I health authority, the health services administrator (HSA) and the warden. The p ogram is reviewed annually. All facility employees are trained during orientation and annually thereafter on the facility's suicide prevention and intervention program. Training addresses the recognition, referral and management of potentially suicidal detainees. Contract staff and volunteers also receive training on this program. Training logs reviewed confirmed the provision of this training. 34 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 282 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 The facility has a designated and approved isolation room for evaluation and treatment X A Residents who may be placed on suicide watch are housed in one of two designated single occupancy medical observation rooms located within the medical department. The rooms are free of objects and structural elements that could facilitate a suicide attempt. Policy is in place for the provision of short-term care for the minor children of an adult resident who is placed on suicide watch. Per the USA, a minor resident who is determined to be suicidal will be referred and transferred for outside care at the Laurel Ridge Psychiatric Hospital. All appropriate notifications will be made through the chain of command. 35 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 283 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Staff observes and documents the status of a suicide-watch resident at least once every 15 minutes X A Per policy, any adult resident placed on suicide watch are housed in a designated isolation room for evaluation and receive continuous oneto-one monitoring, documented every 15 minutes or more frequently if necessary. 29. Telephone Access X X X X 01 Upc n intake ie idents are m• de awa e of phone poli ies Out of order phones reported to service provider Telephones inspected regularly by staff Telephone access rules posted in each housing unit A A A A X The number for the ICE OIG is posted in housing units A X The pro bono list is posted in housing units A X Emergency phone call messages delivered to residents Telephone access rules and information are posted in the dayrooms on each hall of the housing areas. The number for the ICE OIG is posted in the dayrooms on each hall of the housing areas. The pro bono list is posted in the dayrooms on each hall of the housing areas A 36 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 284 of 740 U.S. Immigration and Customs Enforcement Hutto Special access calls are available to residents NotTcation of telephone monitoring X pos ed by unit phones where app icable 30. Terminal Illness, Advanced Directives and Death X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A A MI Res•dei t wh r .hroni lly or te minally ill re tr nsferred to an app op iate olf-si fad ity X X A The facility has written plans for addressing organ donations A P i po i y, when ' re. iden '. med. c I condition dete ior te, to th point that approl rate care cannot be provided with•n the faci ity, the detainee will b transferred to an appropriate off-site medical facility. A resident who is chronically ill but is under managed care in a chronic care clinic status shall remain at the facility until such time the illness may not be managed or becomes lifethreatening. Policy provides procedures and guidelines addressing oruan donation by residents. 37 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 285 of 740 U.S. Immigration and Customs Enforcement Hutto Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 There is a policy addressing Do Not Resuscitate Orders X A The facility has written procedures detailing the proper notifications X A Written policy and procedures addressing DNR orders are in accordance with the laws of the state. Per policy, the detainees medical file would include documentation validating the DNR order. Per policy, when the terms of an advance directive must be implemented or a DNR order placed in a resident's medical record, the health services administrator (HSA) will notify the warden, and through the chain of command, the JFRMU and the AFOD or designee. 31. Tool Control w X X X X 111 Too inventorie onducted as . pe ified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit A Tool are invent° t d by maint n nc p r onnel A A A Tools of contractors are inventoried in and out of the facility. 38 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 286 of 740 U.S. Immigration and Customs Enforcement X Hutto There is an individual who is responsible for developing a tool control procedure and an inspection system to ensure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board X X X Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 A A Tools are maintained on a shadow board. Tools are issued to maintenance personnel utilizing a chit system. The chit is visible when the tool is missing. A A 32. Resident Transfer 111 W X ResBent p ovBed with esid nt tran ter notifi •ation form Health records/transfer summary accompany resident A X X A Funds and personal property accompany resident ICE pi ovides residents with a transfer notific tion f ) n. Health records accompany the resident when they are transferred. These records are sealed and marked "Medical Confidential." A 39 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 287 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto A-File/work folder accompany resident X A 33. Trannortation (Land Trans arta:ton IIII Documei talon indi ating :a e y ep i's are corn )Ie ed 'min d . tely and vehicles are not used u til they hay beei rep i ed and inspected, is available for review X Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour period when transporting residents rin tr tp officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents X X X X X A Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard A The facili y on y provides t ansportation o ' medi al t ips. Safety che ks are n ade on vehi les pri ) t) use nd after us . Safety checks • re documented and available for review. The checklist was reviewed during the inspection. A N/A All facility personnel involved in the transportation of residents have a CDL. The facility does not use buses for transportation of residents to medical appointments. A A Transportation personnel carry cellular telephones with 2 way radio capabilities. 40 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 288 of 740 U.S. Immigration and Customs Enforcement X X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Vehicles have written contingency plans on board Minors are transported in accordance with child safety laws using appropriate safety restraints and seats A A 34. Use of Force w111 Poli y govern ng X i nn ed•ateic ilculated use of fore All use of force incidents documented and reviewed A X X X A Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident There have been no use of force incidents in the facility since it was converted to a Family Residential Center. Policy states, and facility personnel confirm, any use of force incident would be documented and reviewed. A A There have been no use of force incidents in the facility since it was converted to a Family Residential Center. Policy states, and facility personnel confirm, a resident involved in a use of force incident would be seen by medical personnel. 41 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 289 of 740 U.S. Immigration and Customs Enforcement X X X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques 4 point restraints are never used Medical staff consulted prior to calculated use of force incidents A A A X A There have been no use of force incidents in the facility since it was converted to Family Residential Center. Policy states medical personnel would be consulted prior to a calculated use of force. 35. Visitation M X X X X W i ten vi. i a MI :chedule po. t d and ac - s ibl to he pub i General visitation log book maintained Visitor dress code enforced Legal visitation available 7 days a week A A Vi. it ion rule, ar posted in the lobby whe e they a e accessible to the public A general visitation log and an attorney visitation log are maintained by facility in the lobby. A A Attorneys are allowed to visit seven days a week. 42 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 290 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Facility complies with visitation schedule A X Visitors are searched and identified per standards Current list of Pro Bono services posted in resident housing X X Visitation schedules are met. Additional visitation times or special visits are approved by the Facility Administrator on a case-by-case basis. A A A current list of pro hono services is posted in each dayroom on each of the four halls. 36. Voluntary Work Proram IN X X X Facility ha ' voluntary we k program Mai tam n a wet en hart wi h work assignments Facility complies with work hour and pay requirements for residents A A A Residents are medically screened to participate X A Voluntary resident workers work in accordance with hour and pay requirements of facility policy. Voluntary resident workers are screened and approved to participate in the program by medical personnel. Documentation of this screening is maintained and was reviewed during the inspection. 43 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 291 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Residents receive proper training and safety equipment A X Resident housekeeping meets standards for neatness, cleanliness and sanitation X Voluntary resident workers receive appropriate training for the positions they fill. This training is documented and was reviewed during the inspection. A 37. Juvemle Education X X X X Cla, s oom ie equipped, in Judi' g ( esks han, ade- pp op te ex book , a by ty upplies, chalk boards and audio/vi al equipment. Lesson plans are in place and have clearly stated objectives and measures for student performance. Curricula and materials meet US Dept. of Education, state and county requirements. At least one hour of daily gradeappropriate instruction is provided in the following core subjects: Science, Social Studies, Math, Language Arts (Reading/Writing), and Physical Education. A A A A Residents participating in the education program are provided one hour of instruction in the required core subjects. 44 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 292 of 740 U.S. Immigration and Customs Enforcement X X Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto Teacher credentials meet state English as Second Language (ESL) requirements. A Teachers identify, address and refer counseling and special needs of students. A 38. Searches of Residents Policies and procedures on searches are in X place to include all areas of the residential standard, Staff trained on appropriate search X procedures. Centers employ the least intrusive method of search practicable, as determined by the X type of contraband and the method of suspected introduction or concealment; X Al! searches conducted by the same gender as the resident A All teachers are certified by the State of Texas. There are eleven teachers, six are ESL endorsed, one holds a doctorate in ESL. and one is certified to teach ESL. The educational program contracts with a licensed school psychologist who interviews and provides services to students with special needs. Policy and the local handbook explain in detail the facility's search procedures. A A A Policy notes that all searches will be conducted by the same gender as the resident. 45 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 293 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto The facility has established procedures to ensure all housing units and work areas are searched at least daily All searches of residents and respective housing areas are documented, available, legible and secure X X A A 39. NEWS MEDIA INTERVIEWS AND TOURS News media representatives, academics and other parties are permitted access to the facility only by special arrangement and with prior approval of 1FRMU. X X X Guidelines are in place for media requesting personal interviews - to include receiving prior approval from JFRMU Guidelines are available regarding requests for tours, interviews and other requests for facility access. A Established policy notes that the organizations listed in the component must be obtain approval from JERMU prior to entering the facility. A A 40. STAFF HIRING AND TRAINING 46 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/O = Not Observed; N/A = Not Applicable Page 294 of 740 U.S. Immigration and Customs Enforcement Detention and Removal Operations Performance Monitoring Tool Berks _X Karnes South Texas Family Residential Center February 24, 2015 Hutto The policy and procedure manual includes a clear description of the organizational structure X X X All staff positions possess a current job description Regular staff meetings are conducted that involve all staff, A A A Job descriptions for all staff are current. Scheduled staff meetings are conducted weekly. Daily staff meetings occur on an as needed basis. Staff training and development is coordinated by at least one individual with XA specialized training. A facility training plan is available and reviewed and approved annually by the X facility administrator. X X A The employee initial training and orientation program includes all elements of the Family Residential Standards All completed training is clearly documented in personnel files. A A Files contain all required training documents. 47 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; D = Deficient; N/0 = Not Observed; N/A = Not Applicable Page 295 of 740 Department of Homeland Security —FO-Ft-OFFICIA-L—USEONLY— E ATTACHED MATERIALS CONTAIN DEPARTMENT OF HOMEL S RITY INFORMATION THAT IS "FOR OFFICIAL USE ON OR 0TH YPES OF SENSITIVE BUT UNCLASSIFIED INF* ATION REQUIRING P •TECTION AGAINST UNAUTHORIZED L OS U R E. THE ATTACHED MA t IALS WILL BE HANDLED A P AFEGUARDED IN ACCORDANCE WIT S MANAGEMENT 11 CTIVES GOVERNING PROTECTION AND DI MINATIO a SUCH INFORMATION. AT A I MUM, THE ATTACHED MAT LS WILL BE DISSE I ' ' TED ONLY ON A "NEED-TO-KNOW" IS AND WHEN U TENDED, WILL BE STORED IN A LOCKED CO &INER OR AREA OFFERING SUFFICIENT PROTECTION AGAINST FT, COMPROMISE, INADVERTENT ACCESS AND UNAUTHORIZ DISCLOSURE. Page 296 of 740 h i Te Nakana n alp., Inc. Compliance Review Summary Report Karnes Residential Center October, 2014 Reviewer: Robert Manville, Compliance Reviewer Between October 1 through October 3,2014 Nakamoto Group, Inc. Inspector/Compliance Review (CR) personnel toured and observed the operation of the Karnes Residential Center. The methodologies used were observations, resident and staff interviews and review of program documentation. Technical assistance was provided to the Education Staff on the Family Residential Education Standard. Observations and findings for the current reporting period are summarized in this report and are documented in the Monitoring Worksheet. The findings and observations were discussed with JFRMU personnel and Karnes Residential Center staff during daily and end of the review period briefings. Several finding were minor in nature and were corrected by staff during the review. Standards of greatest concern or value are as follows: General Finding Overall impression of the center's implementation of the Family Residential Standards is positive. The center is in compliance with all but one of the Family Residential Standards (Resident Census). Finding Resident Census The resident census procedure for the 4:00 P.M. census on October 3, 2014 was observed. The center allows residents up to two hours to report to staff while at. the same time providing an out count for residents in Visitation. During this two hour period, some residents left medical and reported for census while on the out count. Students that were in the school program remained in the gymnasium until their parent's picked them up from a teacher. Since staff did not know where thc parents wcre, it was over an hour before all students were picked up. It was discovered that the parent was in the medical waiting area. Some residents who were in the medical area were neither on the out count nor on the census. One resident refused to report for census. The shift supervisor indicated he had completed a prior behavior referral. However, there was no behavior report for refusing to report for census found in the behavior management log. Page 2 of 3 "FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)" Page 297 of 740 Food Service The center is in compliance with most of the food service standards. However, on the evening meal of October 2, 2014 the hot entree temperature was 90 degrees Fahrenheit. The logged temperature was 165 degrees Fahrenheit. Staff indicated they logged the warm box temperature. The warming box temperature is not an indication of the food temperature. Also during this time, trays were being prepared to be taken to the medical area. The center uses a tray that required it to be stacked and then ratcheted down in order to maintain the tray at an acceptable temperature. The snacks were checked several times throughout the visit. Each time, there were no drinks or nutritional snacks. There were some fruit on all checks. Also during tours of the living area, two milk cartons were found in the living area. Each container was felt to be at room temperature, which could pose a health risk. Page 3 of 3 "FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)" Page 298 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Frequency Residential Standard Rating A/D/ or N/O Corrective Action Required / Comments Due Date 1. Admission and Release 1111 X X X X X X X ICE i ) int tion is available for initial placement Medical screening taking place within timeframes Inventory resident personal effects Resident funds accountability in place for admin/release All searches are completed according to policy and are documented. Appropriate clothing and bedding issued —Residents are allowed to retain personal clothing including undergarments. Orientation material in English, Spanish or most prevalent second language. All orientations are conducted in person. A A A Inventory was reviewed and found to be correct. A A A A Residents had appropriate clothing. The center has an orientation program including daily information sharing by ICE and Karnes' Staff 2. Contraband I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 299 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October 2014 U.S. Immigration and Customs Enforcement IIII X X X I Poli •y . ri pace for handlin_ con raband Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband A A A 3. Correspondence and Other Mail ii X X X X X X In .omim, m il . creened (but not read and del% e ed dai y Outgoing mail screened for contraband Legal mail opened in front of resident A S af de i er: mail to the residei t ach d. y A A Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or common areas, and resident handbook Facility has a system for residents to purchase stamps Staff delivers legal mail to residents each day. A A Stamps are available in the center's commissary. 4. Resident Handbook I St w' re of ha dbook ontents and xr 0 low procedure - A 2 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 300 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X X Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary A A Orientation material available to illiterate residents A X Res•dei t file created for ea h new •r iv. I A X Resident files contain documents generated during custody A X Resident intake and orientation were observed. All information was provided residents. 5. Resident Files Q Resident files maintained in a secure area X A Files are located in case manager's office in locked file cabinet. 6. Disci 1 linary and Behavior Mana ement Folic i W X X Rules of condu t s nc ioi s p ovided in wr. ting Incident reports investigated within 24 hours A A 3 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 301 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Disciplinary panel adjudicate XA infractions Disciplinary sanctions are in accordance with standards Staff representation available X X The center has policy in place. The behavior management log was reviewed. There have been 6 rules violations that required staff intervention. Each intervention was appropriate. A A 7. Emer ency Plans A. Staff trained X A X A X X X Written plans Evacuation routes primary and secondary A complete set of emergency plans is available Staff work stoppage plan is available Staff r eve tr ining on the eme g ncy plan during y ar y in, ervice. A A A A 8. Environmental Heal h and Safe I X I Syste n f ) tonng i suing/main am g hazardou mate .a s A All ha ard( u material. were found o be u ider direct supervision of talk 4 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 302 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Complete inventories of hazardous materials maintained X X X X X X X X X X A complete list of MSDS readily accessible to staff and residents Fire prevention; control/evacuation plan Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested biweekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations D D A chemical was found in the visitation room closet with no MSDS or inventory. No MSDS inventory. A A A A All staff are trained on taking universal precautions. N/A A A A The center was very clean and well maintained A 9. Non-Medical Emergenc Escorted Tr' s W MI 5 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 303 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards N/O 10. Security Ins ections (Criteria Only—No S andard) I W X X X X X X X X Al Ti 'it( r. of icial y recorded in a vi. i o og book Front entrance staff inspect ID of everyone entering/exiting Maintain a log of all incoming and departing vehicles Housing unit searches occur only as allowed by the standard. Area searches documented in log book Facility administrator or designee and department heads visit housing units and activity areas weekly Staff monitor all vehicular traffic entering and leaving the facility Tools being taken into the secure area of the facility arc inspected and inventoried A Vi, ito s kg On ain d all required inform. tion. A A Center staff inspects all vehicles coming inside the center. A A A A A 6 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 304 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X Staff are positioned in or immediately adjacent to resident living areas to permit them to see or hear and respond promptly to emergency A 11. Food Service w111 X X X X X X X X X Appropreit s• f ty measures for .harp. • re in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a high level of sanitation Residents receive safety and appropriate equipment training prior to beginning work in department A minimum of two hot meals served daily, snacks are provided for children and special needs are accommodated. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A D A The cente cic e ' n t have sharps Temperatures were not within the required limits during the evening meal. Food service and dining area were clean. A D There were no nutritional snacks or drinks provided during the review period. A A All menu changes documented D Common fare menu for authorized residents A Menu changes for two meals were not documented. 7 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 305 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Weekly inspections conducted and documented X A 12. Funds and Personal Pro ert IIII Inv n ory per. on. I p oper y/funds i. maintained X X X X X X X A Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box Staff secure every container used to store property with a tamper-proof numbered strap Quarterly audits of resident baggage & luggage are conducted, verified, and logged Pe sona propert , wa. invent° i d and app 'op 'iat ly maintained. A A A A A A Audit was completed during the review. 13. Resident Grievance Procedures S's X I Gi ievance p oc du es in pl ce A Sy. tern in plac . There were no g ievai e dur.ng he rating p nod 8 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 306 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X X X X Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances alleging staff misconduct to ICE Informal resolution to a resident grievance documented in resident tile A A A A 14. Hold Rooms in Resident Facilities W 111 Res•clent are not kept in holding X areas ong r than 12 hour:. X X X X X A Maintain location log for each resident in holding rooms Written evacuation plan posted for each hold room Hold rooms contain sufficient seating for the number of residents held Residents are provided with basic personal hygiene items such as water. soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes Staff closely supervises the residential hold rooms. Holding rooms are irregularly monitored every 15 minutes. Hold room doors are not locked. A The n er has a ho ding area with a ( ms adja ent to thi. area. Logs are maintained. A A A Residents are closely supervised in the intake area. A 9 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 307 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement 15. Hunger Strikes MI X X X X Procedur -. o eferr ng resident to m dica if v rbal y r fuel i observed refusing to eat beyond 72 hours Procedures for referring resident to medical if visually observed not eating consecutive meals or in any instance where a minor is observed not consuming meals Staff receive training in identification of hunger strike Process for determining reason for hunger strike A A A A 16. Ke i and i Lock Control MI X X X X Main a. n in e no ies of II key /locks lo king devices Emergency keys are available for all areas of the facility Chit system used to issue security equip./keys/radios Policy regarding restricted keys present and followed by staff A The ente has a f Iltime k y and tool cont ol tat. A A A 10 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 308 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried X X A A 17. Access to Leal pi Material 0 X X X X X X A lequate equipment i vail• ble for re idents Legal materials/law library current and available for residents. ICE staff inspect law library weekly Denials documented Schedule for use implemented 5 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters A A Center added the required postings during the review. A A A A 18. Grou 8 Presentations on Le i al Rifts I ICE/DRO approved Tide( s p yed fo X " 11! all incomii g residents A 11 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 309 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Posters announcing presentation appear in common areas at least 48 hours prior to presentation Facility ensures adequate presentations so all residents wanting to attend have the opportunity X X A A 19. Marriage Requests 1 I Mairiah wr't e i r qu sts appioved by POD / Chic .IFRMU A Poll y i. ii p ace. 20. Medical Care II. X X X X X In ak pro es. in ludes medi .al and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area All residents receive physical examination/assessment within 14 days of arrival. All minor residents physical examination/assessment within 48 hours of arrival, A A The center provides a daily sick call. A A A A review of records showed that residents received examinations within 2 working days of arriving at the center. 12 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 310 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X X X X X X X Sick call slips available in English, Spanish and/or most prevalent second language The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability A sharps container is used to dispose of used shams The medical department is maintained at a high level of sanitation N/A Center allows residents to report to medical for sick call on a continuous basis. A A A A A A 21. Personal Hy' WA Ch h'ng p .( v•ded upon int ike and x tiling d w ekl , A X X X Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Re, id nts nay ex h nge • o h ng a minimum of one ime a d. y. Parent can xchang clothing on their children morc often if needed. A A 13 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 311 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily X X X X A A Temperatures were wit hin the established limits. A A 22. Residential Census W M X Stqf . condu t census a lea t twice daily Recount conducted when incorrect census is reported A D X X X Face to photo count conducted as necessary Each resident positively identified during census The center has policy and procedures to conduct census three times each day. The present system is not effective; requiring up to 4 hours to clear. D A 23. Post Orders I E e y post ha a pos order ur ent & X " 11$ igned by he .acili y administ ator A 14 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 312 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Housing unit officers record all resident activity in a log Supervisor visits each housing area once per shift X X Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty X X D D Staff do not record all resident activities. There was no documentation of the supervisor's review of all housing units. A (b)(7)(E) N/A 24. Recreation 1111 X X X X X Outdoor/indoor re reation is p ovid A c.su cc e. ton act vIe pro ided daily be wed n AAM and OM or as reqdred by th . tandard Staff conduct daily safety checks of recreation areas In unit activities are available including activities related to acculturation Where cover is not provided to mitigate inclement weather, residents are provided weather-appropriate equipment and attire A A D Staff makes rounds but do not document safety and security inspections. A N/A 25. Religious Practices 15 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 313 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October 2014 U.S. Immigration and Customs Enforcement li I Resident are llowed to engage in religious services Authorized relieious items are allowed in r sic ent possession X S veral denomina ions p ovid servi es a h center. A A 26. Sexual Abuse and Assault Preven ion and Intervention Q X X X X I N w e ident are ii brmed of the Sex Abu e and As. aul P even i m and Intervention policies during the initial orientation. A The Resident Handbook contains information on the Sexual Abuse and Assault Prevention and Intervention program. All new employees, volunteers and contract personnel will receive an initial training and annual refresher thereafter. The center policies on Sexual Abuse and Assault prevention and intervention and ICE Sexual assault awareness notice shall be posted in all resident living areas. The n e - pi ovides r quired ii f nmath n du ing h o ientation proces . Re iden s sign an a know edgement statement that they have received information. A A Staff received training as required. A 16 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 314 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X The center has a designated Sexual Abuse and Assault Prevention and Intervention program coordinator. A The center has a sex abuse and assault program coordinator. 27. Staff-Resident Communication X X X X X X X X 111 Hous.ng unit rounds conducted cl. ily by s f Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours ICE visit schedules are posted in housing unit Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement A A A Resident requests were answered in a timely manner. A A A A 28. Suicide Prevention and Intervention 111 17 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 315 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X X X X The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator which is reviewed annually Every new staff member receives suicide-prevention flaming. Suicideprevention training occurs during the employee orientation program and annually thereafter The facility has a designated and approved isolation room for evaluation and treatment Staff observes and documents the status of a suicide-watch resident at least once every 15 minutes A Training is provided as required by the standard. A A A 29. Tele 'hone Access MI X X X X Upon i take re idents are m. de awa e of phone po icies Out of order phones reported to service provider Telephones inspected regularly by staff Telephone access rules posted in each housing unit A A Phones were found in good repair. A A There are telephones in each apartment which house up to 8 persons. Other phones are available throughout the center. 18 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 316 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement The number fir the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones where applicable X X X X X A A A A A 30. Terminal Illness, Advanced D'rectives, and Death II. Resilent who r .hroni .ally or X te mi ally il ar transferred to an app opriate off-si facility The facility has written plans for X addressing organ donations There is a policy addressing Do Not X Resuscitate Orders The facility has written procedures X detailing the proper notifications A A A A 31. Tool Control Q X Too in 'entorie condu tcd as . p ified A All tool, were o n , i tory and on rol e I a. equi ed by the standard. 19 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 317 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X X X X X X X Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to ensure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard A A A A A A A 32. Resident Transfer MI X X X Res•dent p .( vided with es'd t Iran lei notific lion form Health records/transfer summary accompany resident Funds and personal property accompany resident A A A 20 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 318 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement A-File/work folder accompany resident X A 33. Trannortation (Land Trans arta:ton IIII X X X X X X X X Documei talon indi ating :a e y ep i's are corn )1e ed 'ram d . tely and vehicles are not used u til they hay bee i rep i ed and inspected, is available for review Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour eriod when transporting residents "officers with valid Commercial (F) Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Minors are transported in accordance with child safety laws using appropriate safety restraints and scats Cent i ha app -op i t polun s in] lace A A Checklist is conducted by staff prior to any trips. A A A A A A 21 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 319 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement 34. Use of Force MI Poli y gov n ng X i nn ed•ate/c ilculated use of fore All use of force incidents documented X and reviewed Video tapes of incidents X preserved/catalogued for 2 1/2 yrs Resident is seen by medical X immediately after incident Facility subscribes to prescribed X confrontation avoidance procedures Staff trained in use of force X techniques X 4 point restraints are never used Medical staff consulted prior to X calculated use of force incidents A A A A A A A A 35. Visitation X X X X 111 W i ten vi. i a Um :chedule po. ted and ac - s ible to he publi General visitation log book maintained Visitor dress code enforced Legal 1, Isitation available 7 days a week A Vi. ita ion i 'n co npliance with the s andards A A A 22 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 320 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement Facility complies with visitation schedule Visitors are searched and identified per standards Current list of Pro Bono services posted in resident housing X X X A A A 36. Voluntary Work Pro ram Q Facili y ha ' voluntary wok program A X X X X X X Maintain a written chart with work assignments Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Residents receive proper training and safety equipment Resident housekeeping meets standards for neatness, cleanliness and sanitation The en er has d ve ( p d seve a job oppo [unities for resident . A A A A A 37. Juvenile Education Q 23 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 321 of 740 Detention and Removal Operations Performance Monitoring Tool Karnes Residential Center October, 2014 U.S. Immigration and Customs Enforcement X X X X X X Classrooms are equipped, including desks, chairs, grade-appropriate text books, activity supplies, chalk boards and audio/visual equipment. Lesson plans are in place and have clearly stated objectives and measures for student performance. Curricula and materials meet US Dept. of Education, state and county requirements. At least one hour of daily gradeappropriate instruction is provided in the following core subjects: Science, Social Studies, Math, Language Arts (Reading/Writing), and Physical Education. Teacher credentials meet state English as Second Language (ESL) requirements. Teachers identify, address and refer counseling and special needs of students. A The education program was operational. Staff were observed to be involved in educating students. A A A A A 24 I) = Daily; W = Weekly; M = Monthly; Q = Quarterly; A = Acceptable; I) = Deficient; N/O = Not Observed; N/A = Not Applicable Page 322 of 740 Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M I. Emergency Plans Staff trained, and able to identify signs of detainee unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the E. year to test specific plans F. Staff work stoppage plan is available A. B. C. D. G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety Rating A/D/R/NA A A A A A A A A. System for storing/issuing/maintaining hazardous materials D B. Complete inventories of hazardous materials maintained D C. D. A complete list of MSDS readily accessible to staff and detainees Fire prevention/control/evacuation plan A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 323 of 740 Corrective Action Required/Comments A A The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. The current system is not an accurate inventory of chemicals on hand. There is no chemical inventory in the kitchen area. On 7/17/2014 a Plan of Action was requested. MSDS lists are kept in the Food Service Department Laundry Area, Programs Building and the Medical Department. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA E. Conduct fire/evacuation drills according to schedule/standard A F. Staff trained to prevent conlact with blood and bodily fluids A G. Emergency generators are tested bi-weekly Every employee and detainee using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations A H. I J. K. A. B. C. D. E. 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspedion Transporting officers limit driving time to 10 hours in any 15 hour •eriod when transporting detainees rffil•fficers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting detainees Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 324 of 740 A A A A A A A A A Corrective Action Required/Comments Fire Drills are scheduled quarterly which include all areas of the building & all shifts. The generators were tested on 1st, 81x ,i 5th & 22nd July Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. G. A. B. C. D. E. F. G. Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board 4. Admission and Release ICE information is available for initial classification Medical screening taking place within timeframes Inventory detainee personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All detainees classified appropriately upon arrival B. Reassessment and reclassificafion process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system Detainees are assigned color coded uniforms/wrist bands to reflect E. classification level 6. Contraband A. Policy in place for handling contraband B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 325 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A A A A NA A A A A Wrist bands are utilized to reflect classification level. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M A. B. n•C. D. E. F. G. H. • • I J. K. L. M. • N. Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exifing Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times Area searches documented in log book Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to detainee living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and detainees is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 326 of 740 Enforcement Rating AR/NA Corrective Action Required/Comments A A A A A A A A A A Current staffing percentage for the month of June 2014 is 78.92%. This is taking into account the new SOW that was effective as of 7/11/2014, and a new staffing analysis of 189 authorized employees. A A A N/A No perimeter alarm & the fence was taken down. Due Date Attachment 5.B. U.S . mmigration -• „.F. and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone P. surveillance, high profile detainees, visiting room activities, etc Q. The facility shares intelligence information with ICE S. Funds and Personal Property A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Detainees property searched for contraband D. Staff forward arriving detainees medication to medical staff E. Detainee funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of detainee baggage & luggage are conducted, G. verified, and logged 9. Hold Rooms in Detention Facilities A. Detainees are not held in hold rooms longer than 12 hours B. All detainees pat searched prior to placement in hold room C. Maintain detention log for each detainee in hold room !D. Written evacuation plan posted for each hold room Hold rooms contain sufficient seating for the number of detainees E. held F. The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses G. are permitted inside hold rooms 0. • • • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 327 of 740 Rating AR/NA A A A A A A A A A A A A A A A A A Corrective Action Required/comments Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M H. I J. A. B. •C. D. E. F. A. B. C. D. E. A. B. C. Male and females are segregated from each other at all times Detainees are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes Officers closely supervise the detention hold rooms. Hold rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices Emergency keys are available for all areas of the facility Chit system used to issue security equip/keys/radios Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts Staff conduct formal count at least once per 8 hour shift/ 3x per day At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted Each detainee positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator Housing unit officers record all detainee activity in a log Supervisor visits each housing area once per shift A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 328 of 740 Enforcement Rating AR/NA A A A A A A A A A A A A A A A A A Corrective Action Required/comments No females were housed at the facility for the month of July. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M D. F. A. B. C. D. • •A. B. • •C. D. A. B. C. D. E. F. G. H. Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due loan emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Detainees Unit shakedowns are conducted Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of detainees. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and Intervention Program Detainees are advised of the program All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit bulletin boards 15. Special Management Units Written order accompany detainee placed in SMU SMU reviews are conducted in a timely manner (3,7,14,30,60) Admin SMU detainees enjoy same privileges as general population Detainees in SMU have access to legal materials Detainees in SMU retain visiting privileges Maintain a permanent log regarding detainee related activities Written order accompany detainee placed in disciplinary SMU Detainees in disciplinary SMU have access to legal materials A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 329 of 740 Rating A/D/R/NA Corrective Action Required/Comments Due Date A N/A A A A A A A A A N/A N/A N/A N/A N/A N/A N/A N/A (b)(7)(E) I Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M I J. K. L. M. N. 0. A. Detainees in disciplinary SMU retain visiting privileges Disciplinary SMU phone access limited to legal/consular calls Detainees in SMUs may shave and shower three times weekly and receive other basic services (laundry, hair care, barbering, clothing, bedding, linen) on the same basis as the general population The facility administrator (or designee) visits each SMU daily A health care provider visits every detainee in a SMU at least 3x week, and detainees are provided any medications prescribed for them Detainees in the SMU are offered at least one hour of recreation per day, scheduled at a reasonable time. Where cover is not provided to mifigate inclement weather, detainees are provided weather-appropriate equipment and attire When a detainee has been held in Admin Segregafion for more than 30 days, the facility administrator nofifies the Field Office Director, who notifies the ICE/DRO Deputy Assistant Director, DMD 16. Staff-Detainee Communication Housing unit rounds conducted daily by security staff Rating A/D/R/NA Corrective Action Required/Comments N/A N/A N/A N/A N/A N/A N/A A A B. Housing unit rounds conducted daily by Deportation Staff C. Detainee requests answered within 72 hours A A D. ICE SDC visit schedules are posted in housing unit E. F. Request forms are available to detainees There is a secure box available for detainees to place requests in for A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 330 of 740 A All dorm areas in the facility are scheduled to be visited by ICE Deportation Officers at least twice weekly. Request forms are available in Dayrooms and the Dining Hall. Due Date Attachment 5.B. S Immigration s.r and• Customs f U• Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating A/D/R/NA Corrective Action Required/Comments ICE staff that is checked on a daily basis A G. • H. • • A. B. C. D. E. F. G. H. A. B. C. D. E. F. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and detainees Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard IS. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Detainee is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 331 of 740 A A A A A A A A A A A A A A A ICE Officers conduct at least twice weekly visits to housing units. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M G. H. I A. B. C. D. E. Appropriate procedures in place for using 4 and/or 5 point restraints Medical staff consulted prior to deploying OC spray in calculated use of force situations All electronic stun devices inventoried and used by facility must be approved by ICE National Firearms and Tactical Training Unit 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Enforcement Rating AR/NA A N/A N/A A A A A A D. Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a high level of sanitation Detainees receive safety and appropriate equipment training prior to beginning work in department E. A minimum of two hot meals served daily A F. Facility has a standard 35 day cycle menu A G. H. I A registered dietician conducts nutritional analysis All menu changes documented Common fare menu for authorized detainees A A A A. B. C. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 332 of 740 Corrective Action Required/Comments Staff representation is available upon request. A A A A The facility has a 42 day cycle menu. The last nutritional analysis was completed on 1/31/2014. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M J. Rating A/D/R/NA A. B. C. D. Weekly inspections conducted and documented 21. Hunger Strikes Procedures for referring detainee to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All detainees receive physical examination/assessment within 14 days of arrival A F. Sick call slips available in English, Spanish and/or most prevalent second language A A. B. C. G. H. I J. K. L. A. B. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the detainee Records are maintained of medication distribution All sharps are under strict control and accountability A sharps container is used to dispose of used sharps The medical department is maintained at a high level of sanitation 23. Personal Hygiene Clothing provided upon intake and exchanged weekly Sheets and towels exchanged weekly A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 333 of 740 A A A A A A A A A A A A A A A A Corrective Action Required/Comments Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. F. F. G. A. B. C. D. • A. B. C. D. A. B. Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to detainee Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service detainee volunteers exchange garments daily 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator which is reviewed annually At Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program and annually thereafter The facility has a designated and approved isolation room for evaluation and treatment Staff observes and documents the status of a suicide-watch detainee at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Detainees who are chronically or terminally ill are transferred to an appropriate off-site facility The facility has written plans for addressing organ donations There is a policy addressing Do Not Resuscitate Orders The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail Incoming mail screened and delivered daily Outgoing mail screened for contraband A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 334 of 740 Rating AR/NA A A A A A A A A A A A A A A A Corrective Action Required/comments Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M C. D. E. F. G. • A. A. A. Legal mail opened in front of detainee Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or common areas, and detainee handbook Facility has a system for detainees to purchase stamps SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Rating AR/NA Corrective Action Required/Comments A A A A NA A A A B. C. D. Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available 30. Religious Practices A A A A. Detainees are allowed to engage in religious services A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 335 of 740 The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment fooseball tables, ping pong tables, Zumba classes and more. Scheduled Religious Services include: Catholic Mass 10am- Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M B. A. B. C. D. E. F. G. H. I A. B. C. D. E. F. G. Rating A/D/R/NA Authorized religious items are allowed in detainee possession 31. Telephone Access Upon intake, detainees are made aware of phone policies Out of order phones reported to service provider A Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to detainees Special access calls are available to detainees Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and idenfified per standards Current list of Pro Bono services posted in detainee housing 33. Voluntary Work Program A A A A A A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 336 of 740 Corrective Action Required/Comments 12pm Monday, Thursday, Friday, Saturday & Sunday. Catholic prayer time 8pm10pm everyday and Evangelical Services 2:30pm- 4:30pm and 8pm- 10pm everyday. A A A A A A A A A ICE staff conducts weekly telephone checks. Due Date Attachment 5.B. Enforcement and Removal Operations „.F. Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE A. B. C. D. E. • F. A. B. C. D. A. B. C. D. E. A. B. C. D. E. Facility has a voluntary work program Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for detainees Detainees are medically screened to participate Detainees receive proper training and safety equipment Detainee housekeeping meets standards for neatness, cleanliness and sanitation 34. Detainee Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate detainees 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a detainee grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for detainees Legal materials/law library current and available for detainees Detainee access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per detainee A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 337 of 740 Rating AR/NA S Immigration U• • Customs and Enforcement Corrective Action Required/comments A A A A A A A A A A A A A A A A A N/A A A No grievances were submitted for the month of July 2014. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. G. Access to legal material within 24 hours of written request Indigent detainees provided free stamps/envelopes for legal matters 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming detainees • Posters announcing presentation appear in common areas at least 48 B. hours prior to presentation C. Detainees in SMU receive separate presentation Facility ensures adequate presentations so all detainees wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with NDS 40. Staff Training !Thefacility conducts appropriate orientafion, inifial training, and A. annual training for all staff, contractors, and volunteers • B. A. B. C. Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance 41. Transfer of Detainees Detainee provided with detainee transfer notification form Health records/transfer summary accompany detainee Funds and personal properly accompany detainee A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 338 of 740 Rating A/D/R/NA A A Corrective Action Required/Comments A A N/A A A A A A A A A A A A refresher course of CPR & First Aid was given to ICE staff by CEO, per the contract requirements. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Frequenc D FZ! M Month/Year: 04/2014 PERFORMANCE MONITORING MEASURE D. A-File/work folder accompany detainee Rating A/D/R/NA A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 339 of 740 Corrective Action Required / Comments Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M I. Emergency Plans Staff trained, and able to identify signs of detainee unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the E. year to test specific plans F. Staff work stoppage plan is available A. B. C. D. G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety Enforcement Rating AR/NA A A A A A A A A. System for storing/issuing/maintaining hazardous materials D B. Complete inventories of hazardous materials maintained D C. A complete list of MSDS readily accessible to staff and detainees A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 340 of 740 Corrective Action Required/comments A The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. The current system is not an accurate inventory of chemicals on hand. There is no chemical inventory in the kitchen area. The chemical inventory in the laundry area was also noted to have multiple inaccuracies. MSDS lists are kept in the Food Service Department Laundry Area, Programs Building and the Medical Department. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE D. Rating A/D/R/NA A Fire prevention/control/evacuation plan E. Conduct fire/evacuation drills according to schedule/standard A F. Staff trained to prevent conlact with blood and bodily fluids A G. Emergency generators are tested bi-weekly Every employee and detainee using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations A H. I J. K. Corrective Action Required/Comments 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been A. repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspedion Transporting officers limit driving time to 10 hours in any 15 hour C.. peribd when transporting detainees 1(b)(71officers with valid Commercial Drivers Licenses, (CDL's) D. required in any bus transporting detainees Policies and procedures are in place addressing the use of E. restraining equipment on transportation vehicles A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 341 of 740 A A A A A A A A A Fire Drills are scheduled quarterly which include all areas of the building & all shifts. The generators were tested on th June 10th, 17th & 24 . Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. G. A. B. C. D. E. F. G. Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes Inventory detainee personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All detainees classified appropriately upon arrival B. Reassessment and reclassificafion process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system Detainees are assigned color coded uniforms/wrist bands to reflect E. classification level 6. Contraband A. Policy in place for handling contraband B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 342 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A A A A NA A A A A Wrist bands are utilized to reflect classification level. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M n A. B. C. D. E. F. G. • H. I J. K. L. M. • N. 0. Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exifing Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times Area searches documented in log book Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to detainee living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and detainees is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 343 of 740 Enforcement Rating AR/NA Corrective Action Required/Comments A A A A A A A A A A Current staffing percentage for the month of June 2014 is 92.05%. A A A A A No perimeter alarm Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M • • • The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone P. surveillance, high profile detainees, visiting room activities, etc Q. The facility shares intelligence information with ICE 8. Funds and Personal Property A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Detainees property searched for contraband D. Staff forward arriving detainees medication to medical staff E. Detainee funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of detainee baggage & luggage are conducted, G. verified, and logged 9. Hold Rooms in Detention Facilities A. Detainees are not held in hold rooms longer than 12 hours B. All detainees pat searched prior to placement in hold room C. Maintain detention log for each detainee in hold room ! D. Written evacuation plan posted for each hold room Hold rooms contain sufficient seating for the number of detainees E. held F. The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses G. are permitted inside hold rooms H. Male and females are segregated from each other at all times A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 344 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A A A A A A A No females are currently housed at the facility. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Detainees are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, I diapers and wipes Officers closely supervise the detention hold rooms. Hold rooms are J. irregularly monitored every 15 minutes 10. Key and Lock Control A. Maintain inventories of all keys/locks/locking devices B. Emergency keys are available for all areas of the facility C. Chit system used to issue security equip./keys/radios D. Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key E. accountability. The keys are physically counted daily F. A. B. C. D. E. A. B. C. Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts Staff conduct formal count at least once per 8 hour shift/ 3x per day At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted Each detainee positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator Housing unit officers record all detainee activity in a log Supervisor visits each housing area once per shift A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 345 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A D A D A A A A A A A A There are currently over 41 instances of problem keys which were utilized during the month of June. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M D. F. A. B. C. D. • •A. B. • •C. D. A. B. C. D. E. F. G. H. Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due loan emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Detainees Unit shakedowns are conducted Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of detainees. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and Intervention Program Detainees are advised of the program All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit bulletin boards 15. Special Management Units Written order accompany detainee placed in SMU SMU reviews are conducted in a timely manner (3,7,14,30,60) Admin SMU detainees enjoy same privileges as general population Detainees in SMU have access to legal materials Detainees in SMU retain visiting privileges Maintain a permanent log regarding detainee related activities Written order accompany detainee placed in disciplinary SMU Detainees in disciplinary SMU have access to legal materials A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 346 of 740 Rating A/D/R/NA Corrective Action Required/Comments A N/A A A A A A A A A N/A N/A N/A N/A N/A N/A N/A N/A No armed posts Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M I J. K. L. M. N. 0. A. Detainees in disciplinary SMU retain visiting privileges Disciplinary SMU phone access limited to legal/consular calls Detainees in SMUs may shave and shower three times weekly and receive other basic services (laundry, hair care, barbering, clothing, bedding, linen) on the same basis as the general population The facility administrator (or designee) visits each SMU daily A health care provider visits every detainee in a SMU at least 3x week, and detainees are provided any medications prescribed for them Detainees in the SMU are offered at least one hour of recreation per day, scheduled at a reasonable time. Where cover is not provided to mifigate inclement weather, detainees are provided weather-appropriate equipment and attire When a detainee has been held in Admin Segregafion for more than 30 days, the facility administrator nofifies the Field Office Director, who notifies the ICE/DRO Deputy Assistant Director, DMD 16. Staff-Detainee Communication Housing unit rounds conducted daily by security staff Rating A/D/R/NA Corrective Action Required/Comments N/A N/A N/A N/A N/A N/A N/A A A B. Housing unit rounds conducted daily by Deportation Staff D C Detainee requests answered within 72 hours A D. ICE SDC visit schedules are posted in housing unit A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 347 of 740 On 6/24 multiple GEO request forms were found which had not been andwered within the 72 hour timeframe. All dorm areas in the facility are scheduled to be visited by ICE Deportation Officers at least twice weekly. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA D E. F. G. • H. A. B. C. D. • E. F. G. H. A. B. C. Request forms are available to detainees There is a secure box available for detainees to place requests in for ICE staff that is checked on a daily basis Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and detainees Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 348 of 740 A A A A A A A A A A A A A A Corrective Action Required/Comments On 6/23 multiple locations in the facility were found to not have any staff resident requests available. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. G. • H. •I A. B. C. D. E. A. B. Detainee is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints Medical staff consulted prior to deploying OC spray in calculated use of force situations All electronic stun devices inventoried and used by facility must be approved by ICE National Firearms and Tactical Training Unit 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Rating A/D/R/NA A A A A N/A N/A A A A A A A A • C. D D. Food Service department maintained at a high level of sanitation Detainees receive safety and appropriate equipment training prior to beginning work in department E. A minimum of two hot meals served daily A Facility has a standard 35 day cycle menu A • F. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 349 of 740 Corrective Action Required/Comments On 6/23 the food service area was found to not have a sneeze guard in place. A The facility has a 42 day cycle menu. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc PERFORMANCE MONITORING MEASURE DWM •G. F. A registered dietician conducts nutritional analysis All menu changes documented Common fare menu for authorized detainees Weekly inspections conducted and documented 21. Hunger Strikes Procedures for referring detainee to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area All detainees receive physical examination/assessment within 14 days of arrival Sick call slips available in English, Spanish and/or most prevalent second language G. H. I J. K. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the detainee Records are maintained of medication distribution All sharps are under strict control and accountability A sharps container is used to dispose of used sharps H. I J. • A. B. C. A. B. C. D. E. • A s Acceptable D s Deficient R s At-Risk NA s Not Applicable Page 350 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A A A A A Corrective Action Required / Comments The last nutritional analysis was completed on 1/31/2014. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M L. A. B. C. D. E. F. G. A. B. C. D. • A. B. C. D. The medical department is maintained at a high level of sanitation 23. Personal Hygiene Clothing provided upon intake and exchanged weekly Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to detainee Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service detainee volunteers exchange garments daily 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator which is reviewed annually At Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientafion program and annually thereafter The facility has a designated and approved isolation room for evaluation and treatment Staff observes and documents the status of a suicide-watch detainee at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Detainees who are chronically or terminally ill are transferred loan appropriate off-site facility The facility has written plans for addressing organ donations There is a policy addressing Do Not Resuscitate Orders The facility has written procedures detailing the proper notifications A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 351 of 740 Enforcement Rating AR/NA A A A A A A A A A A A A A A A A Corrective Action Required/comments Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. • E. F. G. • A. • A. A. B. C. Rating A/D/R/NA 26. Correspondence and Other Mail Incoming mail screened and delivered daily Outgoing mail screened for contraband Legal mail opened in front of detainee Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or common areas, and detainee handbook Facility has a system for detainees to purchase stamps SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation A A NA Outdoor/indoor recreation is provided A Access to recreation activities Staff conduct daily searches of recreation areas A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 352 of 740 Corrective Action Required/Comments A A A A A A A A The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment, fooseball tables, ping pong tables, Zumba classes and more. Due Date Attachment 5.B. U.S.mmigration -• „F. and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. A. B. A. B. C. D. E. F. G. H. I A. B. C. D. E. In unit sedentary activities are available 30. Religious Practices Rating AR/NA A Detainees are allowed to engage in religious services Authorized religious items are allowed in detainee possession 31. Telephone Access Upon intake, detainees are made aware of phone policies Out of order phones reported to service provider A A Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to detainees Special access calls are available to detainees Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule A A A A A A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 353 of 740 Corrective Action Required/comments Scheduled Religious Services include: Catholic Mass 10am12pm Monday, Thursday, Friday, Saturday & Sunday. Catholic prayer time 8pm10pm everyday and Evangelical Services 2:30pm- 4:30pm and 8pm- 10pm everyday. A A A A A A A ICE staff conducts weekly telephone checks. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. G. A. B. C. D. E. • F. A. B. C. D. A. B. C. D. E. A. B. Visitors are searched and identified per standards Current list of Pro Bono services posted in detainee housing 33. Voluntary Work Program Facility has a voluntary work program Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for detainees Detainees are medically screened to participate Detainees receive proper training and safety equipment Detainee housekeeping meets standards for neatness, cleanliness and sanitation 34. Detainee Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate detainees 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a detainee grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for detainees Legal materials/law library current and available for detainees A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 354 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A A A A A A A A A A A No grievances were submitted for the month of June 2014. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. G. A. B. C. D. A. B. C. •A. A. B. Detainee access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per detainee Access to legal material within 24 hours of written request Indigent detainees provided free stamps/envelopes for legal matters 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming detainees Posters announcing presentation appear in common areas at least 48 hours prior to presentation Detainees in SMU receive separate presentation Facility ensures adequate presentations so all detainees wanting to attend have the opportunity 38. Detention Files Detention file created for each new arrival Detention files contain documents generated during custody Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and tours in accordance with NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 355 of 740 Rating A/D/R/NA Corrective Action Required/Comments N/A A A A A A A N/A A A A A A A D Per the contract, the Service Provider is required to provide CPR & First Aid Training for ICE Staff. We have not had CPR or First Aid training since Due Date Attachment 5.B. 1., Enforcement and Removal Operations ‘"Rrt41 Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. 41. Transfer of Detainees Detainee provided with detainee transfer notification form Health records/transfer summary accompany detainee Funds and personal property accompany detainee A-File/work folder accompany detainee A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 356 of 740 S.Immigration and Customs U. Enforcement Rating A/D/R/NA A A A A Corrective Action Required/Comments 6/7/2012. My CPR AFD card expired on 6/7/2014. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M I. Emergency Plans Staff trained, and able to identify signs of detainee unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the E. year to test specific plans F. Staff work stoppage plan is available A. B. C. D. A. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety System for storing/issuing/maintaining hazardous materials B. Complete inventories of hazardous materials maintained G. Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. A Kept in the Laundry Area. C. D. A complete list of MSDS readily accessible to staff and detainees Fire prevention/control/evacuafion plan A A A E. Conduct fire/evacuation drills according lo schedule/standard A F. Staff trained to prevent contact A h blood and bodily fluids A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 357 of 740 MSDS lists are kept in the Food Service Department, Laundry Area, Programs Building and the Medical Department. Fire Drills are scheduled quarterly which include all areas of the building & all shifts. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M G. H. I J. K. A. B. C. D. •E. F. G. A. B. Emergency generators are tested bi-weekly Every employee and detainee using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safely repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour period when transporting detainees (b)( officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting detainees Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 358 of 740 Enforcement Rating AR/NA A A A A A A A A A A A A A A Corrective Action Required/comments The generators were tested on may 6th, 13th, 20th & 27th, Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. G. Inventory detainee personal effects Rating A/D/R/NA Corrective Action Required/Comments A Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All detainees classified appropriately upon arrival B. Reassessment and reclassificafion process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system Detainees are assigned color coded uniforms/wrist bands to reflect E. classification level 6. Contraband A. Policy in place for handling contraband • B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A. Staff are required to conduct security check of assigned areas B. All visitors officially recorded in a visitor log book C. Front entrance staff inspect ID of everyone entering/exiting A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 359 of 740 A A A For the month of May, one resident was released without receiving all of his personal belongings. A A A A NA A A A A A A A Wrist bands are utilized to reflect classification level. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M D. E. F. G. • H. I J. K. L. M. • N. 0. Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times Area searches documented in log book Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to detainee living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and detainees is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 360 of 740 Enforcement Rating AR/NA Corrective Action Required/Comments A A A A A A A Current staffing percentage for the month of May 2014 is 91.02%. There were only 4 days this month the Service Provider was under a 90% staffing level. A A A A A No perimeter alarm Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M • • P. Q. A. B. C. D. E. F. G. A. B. The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile detainees, visiting room activities, etc The facility shares intelligence information with ICE S. Funds and Personal Property Inventory personal property/funds is maintained Funds/valuables documented on receipt Detainees property searched for contraband Staff forward arriving detainees medication to medical staff Detainee funds are deposited into the cash box Staff secure every container used to store property with a tamperproof numbered strap Quarterly audits of detainee baggage & luggage are conducted, verified, and logged 9. Hold Rooms in Detention Facilities Detainees are not held in hold rooms longer than 12 hours All detainees pat searched prior to placement in hold room A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 361 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A D D A On 5/20/2014 the Compliance Officer asked to see documentation of the quarterly inventory of the detainee baggage and luggage. Weekly audits are being conducted, but the detainee baggage/luggage inventory was not being documented. On 5/19/2014 there was a group of residents that were still in the hold room/intake area after the 12 hour threshold. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. G. H. I Enforcement Rating AR/NA Maintain detention log for each detainee in hold room Written evacuation plan posted for each hold room Hold rooms contain sufficient seating for the number of detainees held The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms A A Male and females are segregated from each other al all times Detainees are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items! diapers and wipes A Officers closely supervise the detention hold rooms. Hold rooms are irregularly monitored every 15 minutes 10. Key and Lock Control A. Maintain inventories of all keys/locks/locking devices B. Emergency keys are available for all areas of the facility C. Chit system used to issue security equip./keys/radios ! D. Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key E. accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and F. inventoried 11. Population Counts J. • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 362 of 740 Corrective Action Required/comments A A A No females are currently housed at the facility. A D A A A A A A Hold Room logs were observed on 5/30 & 5/31 which were being checked in exact 15 minute increments instead of staggered 15 minute Due Date Attachment 5.B. Enforcement and Removal Operations - Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M A. Staff conduct formal count at least once per 8 hour shift/ 3x per day B. At least two officers participate in count for each area C. Recount conducted when incorrect count is reported D. Face to photo count conducted E. Each detainee positively identified during count 12. Post Orders A. B. C. D. E. A. B. C. D. • •A. B. Every post has a post order, current & signed by the facility administrator Housing unit officers record all detainee activity in a log Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment s temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Detainees Unit shakedowns are conducted Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of detainees. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and Intervention Program Detainees are advised of the program A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 363 of 740 Rating AR/NA „.F. S Immigration U• • Customs and Enforcement Corrective Action Required/Comments A A A A A D A A The General Post Orders were observed to not be current. The last time they were reviewed/signed was on 10/1/2012. A N/A A A A A A A No armed posts Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE C. D. A. B. C. D. E. F. G. H. I J. K. L. M. N. 0. All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit bulletin boards 15. Special Management Units Written order accompany detainee placed in SMU SMU reviews are conducted in a timely manner (3,7,14,30,60) Admin SMU detainees enjoy same privileges as general population Detainees in SMU have access to legal materials Detainees in SMU retain visiting privileges Maintain a permanent log regarding detainee related activities Written order accompany detainee placed in disciplinary SMU Detainees in disciplinary SMU have access to legal materials Detainees in disciplinary SMU retain visiting privileges Disciplinary SMU phone access limited to legal/consular calls Detainees in SMUs may shave and shower three times weekly and receive other basic services (laundry, hair care, barbering, clothing, bedding, linen) on the same basis as the general population The facility administrator (or designee) visits each SMU daily A health care provider visits every detainee in a SMU at least 3x week, and detainees are provided any medications prescribed for them Detainees in the SMU are offered at least one hour of recreation per day, scheduled at a reasonable lime. Where cover is not provided to mitigate inclement weather, detainees are provided weather-appropriate equipment and attire When a detainee has been held in Admin Segregafion for more than 30 days, the facility administrator notifies the Field Office Director, A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 364 of 740 Rating AR/NA A A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Corrective Action Required/comments Due Date Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M who notifies the ICE/DRO Deputy Assistant Director, DMD 16. Staff-Detainee Communication A. Housing unit rounds conducted daily by security staff B. Housing unit rounds conducted daily by Deportafion Staff C. Rating AR/NA A A D Detainee requests answered within 72 hours A • D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to detainees There is a secure box available for detainees to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. Tool inventories conducted as specified B. Tools marked and readily identifiable C. • Procedures for issuance of tools to staff and detainees D. Inventory made of all tools by contractors prior to enter and exit E. There is an individual who is responsible for developing a tool control A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 365 of 740 A A A A A A A A A Corrective Action Required/comments On 5/27/2014 ICE received staff-resident requests from CEO which were designated to ICE. Multiple requests were dated from 5/23/2014, and one request was dated all of the way back to 5/19/2014. All dorm areas in the facility are scheduled to be visited by ICE Deportation Officers at least twice weekly. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc PERFORMANCE MONITORING MEASURE DWM Rating A/D/R/NA Corrective Action Required / Comments procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be F. visible on the shadow board Broken or worn out tools are surveyed and disposed of in an G. appropriate and secure manner Department heads are responsible for implementing proper tool H. control procedures as described in the standard 18. Use of Physical Force and Restraints A. Policy governing immediate/calculated use of force B. C. • D. E. F. G. All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Detainee is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints Medical staff consulted prior to deploying OC spray in calculated use H. of force situations All electronic stun devices inventoried and used by facility must be I approved by ICE National Firearms and Tactical Training Unit 19. Disciplinary System A. Rules of conduct/sanctions provided in writing B. Incident reports investigated within 24 hours C. Disciplinary panel adjudicate infractions • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 366 of 740 A A A A A A A A A A N/A N/A A A A One Use of Force incident occurred this month on 5-212014. It was video taped, documented and reviewed. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. Rating A/D/R/NA A A D. E. Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a high level of sanitation Detainees receive safety and appropriate equipment training prior to beginning work in department A minimum of two hot meals served daily F. Facility has a standard 35 day cycle menu A G. H. I J. A registered dietician conducts nutritional analysis All menu changes documented Common fare menu for authorized detainees Weekly inspections conducted and documented 21. Hunger Strikes Procedures for referring detainee to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area A A A A A. B. C. A. B. C. A. B. C. D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 367 of 740 Corrective Action Required/Comments A A A A A A A A A A A A The facility has a 42 day cycle menu. The last nutritional analysis was completed on 1/31/2014. Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating AR/NA E. All detainees receive physical examination/assessmenwithin t 14 days of arrival A F. Sick call slips available in English, Spanish and/or most prevalent second language A A. B. C. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the detainee Records are maintained of medication distribution All sharps are under strict control and accountability A sharps container is used to dispose of used sharps The medical department is maintained at a high level of sanitation 23. Personal Hygiene Clothing provided upon intake and exchanged weekly Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair D. Facility provides and replenishes personal hygiene items as needed, at no cost to detainee G H. I J. K. L. E. F. G. Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service detainee volunteers exchange garments daily 24. Suicide Prevention and Intervention A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 368 of 740 Corrective Action Required/Comments A A A A A A A A A A A A A Water temperatures of the showers were checked on 5/6, 5/18 & 5/22, and all found to be in compliance. Due Date Attachment 5.B. '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc DWM • PERFORMANCE MONITORING MEASURE The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually At Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation B. program and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch detainee D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Detainees who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of detainee D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and detainee handbook F. Facility has a system for detainees to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies A. The Field Office Director considers and approves, on a case-by-case A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 369 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A NA A Corrective Action Required / Comments Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequen D W PERFORMANCE MONITORING MEASURE M A. A. B. C. D. A. B. basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Enforcement Rating AR/NA Corrective Action Required/comments A A Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available 30. Religious Practices Detainees are allowed to engage in religious services Authorized religious items are allowed in detainee possession 31. Telephone Access A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 370 of 740 A A A A A The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment, fooseball tables, ping pang tables, Zumba classes and more. Scheduled Religious Services include: Catholic Mass 10am12pm Monday, Thursday, Friday, Saturday & Sunday. Catholic prayer time 8pm10pm everyday and Evangelical Services 2:30pm- 4:30pm and 8pm- 10pm everyday. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA A. B. Upon intake, detainees are made aware of phone policies Out of order phones reported to service provider A A C. D. E. F. G. H. I Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to detainees Special access calls are available to detainees Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and idenfified per standards Current list of Pro Bono services posted in detainee housing 33. Voluntary Work Program Facility has a voluntary work program Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for detainees Detainees are medically screened to participate A A A A A A A A. B. C. D. E. F. G. A. B. C. D. • E. Detainees receive proper training and safety equipment A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 371 of 740 Corrective Action Required/Comments ICE staff conducts weekly telephone checks. A A A A A A A A A A A D On 5/20/2014 the Compliance Officer witnessed a Resident Voluntary Worker on one of the top rungs of a 15-20 ft latter, Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCCDC Frequenc D w • F. A. B. C. D. A. B. C. D. E. A. B. C. D. and Customs Enforcement Month/Year: 04/2014 PERFORMANCE MONITORING MEASURE M U.S. Immigration Detainee housekeeping meets standards for neatness, cleanliness and sanitation 34. Detainee Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate detainees 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a detainee grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for detainees Legal materials/law library current and available for detainees Detainee access provided to include SMU Denials documented A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 372 of 740 Rating A/D/R/NA Corrective Action Required/Comments reaching with a broom to clean the ceiling of an outdoor overhanging structure. He was not wearing a safety harness and it appeared very dangerous. A A A A A A A A A A A A N/A A No grievances were submitted for the month of May 2014. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCCDC Month/Year: 04/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE E. F. G. Schedule for use implemented 10 hours weekly per detainee Access to legal material within 24 hours of written request Indigent detainees provided free stamps/envelopes for legal matters 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming detainees • Posters announcing presentation appear in common areas at least 48 B. hours prior to presentation C. Detainees in SMU receive separate presentation Facility ensures adequate presentations so all detainees wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and •A. tours in accordance with NDS 40. Staff Training IThefacility conducts appropriate orientation, initial training, and A. annual training for all staff, contractors, and volunteers B. Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance 41. Transfer of Detainees A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 373 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A N/A A A A A A A D Per the contract, the Service Provider is required to provide CPR & First Aid Training for ICE Staff. We have not had CPR or First Aid training since 6/7/2012. My CPR AD card expired on 6/7/2014. Due Date Attachment 5.B. 1., Enforcement and Removal Operations ‘"Rrt41 Compliance Monitoring Tool Facility Name: KCCDC Frequenc D w M A. B. C. D. Enforcement Month/Year: 04/2014 PERFORMANCE MONITORING MEASURE Detainee provided with detainee transfer notification form Health records/transfer summary accompany detainee Funds and personal properly accompany detainee A-File/work folder accompany detainee A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 374 of 740 S.Immigration and Customs U. Rating A/D/R/NA A A A A Corrective Action Required/Comments Due Date DANYA INTERNATIONAL Date: August 31, 2015/Resubmitted September 10, 2015 To: (b)(6),(b)(7)(C) IFRMU From (b)(6),(b)(7)(C) Danya International Re: Compliance Inspection National Family Coordinator Compliance Reviewer From August 10, 2015 to August 14, 2015,1 conducted a targeted review at the Karnes County Residential Center. The following activities were conducted. No areas of noncompliance or deficiency were identified. Standard Type of Review 1.1 Emergency Plans 1.2 Environmental Health and Safety 1.3 Transportation by Land 1.4 Housekeeping and Voluntary Work Program 2.1 Admissions and Release 2.2 Contraband 2.3 Funds and Personal Property 2.4 Key and Lock Control 2.5 Resident Census 2.6 Searches of Residents 2.7 Sexual Abuse and Assault Prevention and Intervention 2.8 Staff-Resident Communications 2.9 Tool Control 2.10 Use of Physical Control Measures and Restraints 3.1 Discipline and Behavior Management 4.1 Food Services 4.2 hunger Strikes 4.3 Medical Care 4.4 Personal Hygiene 4.5 Suicide Prevention and Intervention 4.6 Terminal Illness. Advance DireethCS and Death 5.1 Correspondence and Other Mail 5.2 Educational Policy 5.3 Escorted Trips for Non-Medical Emergencies 5.4 Marriage Requests 5.5 Recreation 5.6 Religious Practices Baseline Baseline Baseline Baseline Baseline Baseline Baseline Baseline 5.7 Telephone Access 5.8 Visitation 61. Grievance System 6.2 Law Libraries and Legal Materials 6.3 Legal Rights Group Presentations 7.1 Residential Files 7.2 News Media Interviews and Tours 73 Staff Hiring and Training 7A Transfer of Residents 7.5 Post Orders Baseline Baseline 8737 Colesville Road Silver Spring, Maryland 20910 Phone 301.561(b)(6), • Fax 301.565.3710 • www.danya.com Page 375 of 740 Overall Observations • • • • • • The staff was welcoming and professional and committed to the facility's mission of protecting women and their children. The facility was clean and well maintained. Staff communication lines were open and interdepartmental meetings were held during the inspection period. The medical department does not have an electronic filing system, but are working towards that means. There appears to be an excellent rapport between ICE and the GEO staff The class schedule mimicked that of the outside community, which should make for a better transition into their receiving communities for children upon their release. JFRMU Concerns and Recommendations Use of isolation rooms: The Facility Administrator, Rose Thompson, said the facility does not use isolation rooms. They have rooms where residents who were exposed to TB or any other possible contagious medical issue are kept separate, but the doors are never locked and the residents are allowed to go in and out of the dayroom at any time. Residents with possible TB exposure are asked to notify the medical staff before they enter the dayroom with their children so that the rooms can be sanitized once the resident vacates. The rooms are immediately sanitized after use by a resident with possible TB exposure or other contagious medical issue. There were no posters in the area stating that residents are free to go to the dayroom, but Ms. Thompson said that the residents are fully aware of this. Recommendation: Hang posters in medical rooms used for those residents exposed to TB or with other possible contagious medical issues informing residents that they are able to visit the dayroom. Lack of child centered materials in the housing units: There were no child centered decorations in the housing units. There were colorful decorations/murals in the classrooms and intake area. Recommendation: Develop plan for approval to increase presence of child/family friendly materials, such as painting suites and coordinating special arts projects for the children to provide more decorations in the housing units. Lack of cups in the recreation area: The residents are issued permanent cups during intake/orientation for their use. Instructions regarding identifying, cleaning and storing these cups was not provided during intake and instructions are not in the handbook. The Medical unit had enough paper and plastic cups for use by the residents. The recreation area did not have paper or plastic cups available. The children were refilling disposable water bottles that had their names written on them. The Gym Teacher said that they always have cups in the recreation area, but had run out that day. Recommendation: If permanent cups are distributed to each resident during intake, the process for identifying, cleaning, and storing must be documented and shared with each resident at intake. Facility should inventory cups on a weekly basis to ensure adequate supply is ordered prior to inventory depletion. Page 376 of 740 Residents are required to return to housing unit at 7:00 pm: The resident cohort that was exposed to Varicella was provided recreation at 7:00pm for one hour. Other residents are asked to return to their housing units to avoid contact. The cohort was separated from the general population and was required to remain in their housing for the entire day, limiting freedom of movement to one hour per day (7pm-8pm). The general population returned to their housing units when the cohort was using the recreation area/yard. Recommendation: Develop a plan for approval to provide the cohort freedom of movement from 8am to 8pm while maintaining the health of the rest of the residents. Concerns that the facility is not fully staffed: There were six vacant positions--four food service workers, one health care worker (LSW), and one security supervisor. Potential employees were identified and will start work upon completion of their security clearances. The security supervisor is also awaiting approval from the GEO regional authority. The facility administrator stated that existing staff covered these tasks while the position was vacant, and resident services were not impacted by these staff vacancies Recommendations All areas observed appear to be in compliance with the Family Residential Standards (FRS). However, the following recommendations were shared during the daily debriefings and are summarized below: 1.2 Environment Health and Safety Observation: After reviewing the daily inspection for the period between 7/25/15-8/9/15, it was noted that one of the main computers had a broken microphone. This was listed numerous times on the Activity Area inspection report without notation that the part was ordered. Recommendation: Once a maintenance request has been lovged, a notation listing the maintenance request number as well as the status should be notated on the daily Activity Area Inspection report to reflect that the issue was addressed. 4.3 Medical Observation: The facility is using paper files to document resident's medical information. Recommendation: IHSC COR and Field Office COR explore the implementation of all electronic health record system that will track resident medical information, calendar medical appointments, and track upcoming needs. cc: [ I (b)(6),(b)(7)(C) (b)(6 ),(b)(7)(C) LFRMU Chief U Prooram Manager Page 377 of 740 It DANYA INTERNATIONAL Date: December 9,2015 To: (b)(6),(b)(7)(C) I, National Family Coordinator .11-12MU From: (b)(6),(b)(7)(C) , Compliance Inspector Danya International, Inc. Re: Compliance Inspection of the Karnes County Residential Center From November 16, 2015 to November 19, 2015, I conducted the monthly in County Residential Center. The following activities were conducted and findings noted: 1.1 Emergency Plans 1.2 Environmental Health and Safety 1.3 Transportation by Land 1.4 Housekeeping and Voluntary Work Program 2.1 Admissions and Release 2.2 Contraband 2.3 Funds and Personal Property 2.4 Key and Lock Control 2.5 Resident Census 2.6 Searches of Residents 2.7 Sexual Abuse and Assault Prevention and Intervention 2.8 Staff-Resident Communications 2.9 Tool Control 2.10 Use of Physical Control Measures and Restraints 3.1 Discipline and Behavior Management 4.1 Food Services 4.2 Hunger Strikes 4.3 Medical Care 4.4 Personal Hygiene 4.5 Suicide Prevention and Intervention 4.6 Terminal Illness, Advance Directives and Death 5.1 Correspondence and Other Mail 5.2 Educational Policy 5.3 Escorted Trips for Non-Medical Emergencies 5.4 Marriage Requests 5.5 Recreation 5.6 Religious Practices 5.7 Telephone Access 5.8 Visitation 6.1 Grievance System 6.2 Law Libraries and Legal Materials 6.3 Legal Rights Group Presentations 7.1 Residential Files 7.2 News Media Interviews and Tours 7.3 Staff Hiring and Training 7.4 Transfer of Residents 7.5 Post Orders 8737 Colesville Road (b)(6),(b)(7 • Silver Spring, Maryland 20910 Phone 301.565 (b)( • Fax 301.565.3710 • www.danya.com Page 378 of 740 Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly, Follow tip Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly Monthly at the Karnes Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant w/ issues Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Recommendation(s) Compliant Compliant Recommendation(s) Compliant Compliant Compliance Inspection Karnes CountyResidential Center Nor. 16-19, 2015 Overall Observations • On November 19, 2015, the total Center population was 392. o Total number of school age juveniles was 126. o Total number of non-school age juveniles was 85. o Total number of families was 181. • Average daily population from October 12015 thru November 19, 2015 was 381. • Average length of stay is 6.6 days. • On December 2, 2015, the Center's expansion will be complete with the addition of two new housing units—Cypress and Willow. Cypress and Willow will provide an additional 200 beds (5 residents per suite). • As of December 2, 2015, staffing will increase to 404. • On December 14, 2015, the new recreation area adjacent to the medical unit is scheduled to open. Findings from Current Inspection 1. Areas of Noncompliance There were no areas of noncompliance identified at this time, 11. Areas of Compliance with Issues Identified 4.3 Medical Care • The health care program and the medical facilities shall be under the direction of a health services administrator (HSA) and shall be accredited and maintain compliance with the standards of the Joint Commission on the Accreditation of Health Care Organizations (.ICAH0). Finding: The medical Center is not accredited or in compliance with the standards of JCAHO as required by the FRS. Mitigation: None recommended. III. Recommendations 7.3 Staff Hiring and Training • Observation(s): The Center currently has a maximum staffing load of 194 positions. Effective December 2, 2015, the maximum staffing level will increase to 404 positions. At the time of this inspection, the Center has staffed 332 of the 404 positions. Page 2 of 4 Page 379 of 740 Compliance Inspection Karnes CountyResidential Center Nov. 16-19, 2015 • Recommendation(s): The Center should continue recruit and hire staff to ensure that the needs of the upcoming expansion are met. Status of Previously Identified Noncompliant Issues and Other Concerns I. Status of Previously Identified Noncompliant Issues or Other Concerns 5.5 Recreation • Every resident shall have daily access to indoor and/or outdoor recreation from 8:00 a.m. to dusk. Finding(s): During the inspection week of August 10, 2015, it was noted that the resident cohort exposed to Varicella was provided recreation at 7:00 p.m. for one hour. Other residents were asked to return to their housing units to avoid contact. The exposed cohort was separated from the general population and was required to remain in their housing for the entire day, limiting freedom of movement to one hour per day (7:00 p.m. — 8:00 p.m.). The general population returned to their housing units when the cohort was using the recreation area. (Observed 8/14/15) During the inspection week of September 28, 2015, residents not exposed to Varicella were still required to return to their housing unit at 7:00 p.m. The cohort exposed to Varicella was still provided recreation only between 7:00 p.m. — 8:00 p.m. There were three exposed groups still separated from the general population, which are scheduled to be moved into the general population, one-by-one, on October 10, 2015, October 11, 2015 and October 12, 2015, respectively. Given that this issue was identified in August and had, at the time of this inspection, not yet been resolved, the Center was considered noncompliant in this area. (Observed 10/01/15) At the current inspection, the Compliance Manager confirmed that all cohorts of residents exposed to Varicella were moved back into the general population. (Observed 11/19/15) Mitigation: Develop a plan for approval to provide all residents freedom of movement from 8:00 a.m. to 8:00 p.m. (Recommended 10/01115) Follow up: Resolved—The Center no longer has cohorts of residents exposed to Varicella; all exposed residents have joined the general population. The upcoming expansion will include an additional recreation area adjacent to the medical unit that can be used to keep residents separated if needed. (Observed 11/16/15) II. Status of Previously Identified Recommendations 4.3 Nledical • Observation(s): The Center is using paper Iles to document resident's medical information. (Observed 10/01/15) Page Page 380 of 740 3 of 4 Compliance Inspection Karnes CountyResidential Center Nor. 16-19, 2015 Recommendation(s): IHSC COR and Field Office COR explore the implementation of an electronic health system that will track resident medical information, calendar medical appointments, and track upcoming need. (Recommended 10/01/15) Follow up: Not Resolved—GEO does not want to deviate from their current paper medical alerts within their existing tracking system. (0b.served 11/16/15) No further action required. Other • Observation(s): There were no child-centered decorations in the housing units. There were colorful decorations/murals in the classrooms and intake area. (Observed 10/01/15) Recommendation(s): Develop plan for approval to increase presence of child/family friendly materials, such as painting suites and coordinating special arts projects for the children to provide more decorations in the housing units. (Recommended 10/01/15) Follow up: Partially Resolved—GEO is in the process of installing child friendly educational/play floor rugs within housing units. Also, the short length of stay (6.6 days) and the continuous turn over impacts residents' desires to hang up art work; however, residents are provided the opportunity. (Observed 11/16/15) • Observation(s): There are concerns that the Center is not fully staffed. There were six (6) vacant positions: four (4) food service workers, one (1) health care worker (LSW), and one (1) security supervisor. Potential employees were identified and will work upon completion of their security clearances. The security supervisor is also awaiting approval from the CEO regional authority. The Center administrator stated that existing staff covered these tasks while the position was vacant, and resident services were not impacted by these staff vacancies. (Observed 10/01/15) Recommendation(s): It is recommended that the Center address all staff vacancies by making every attempt to hire for the vacant positions. (Recommended 10/01/15) Follow up: Resolved—At the time of inspection, the six (6) vacant positions observed in October had been filled. cc: (b)(6),(b)(7)(C) 'Chief, JFRMU (b)(6),(b)(7)(C) Program Manager, Danya International, Inc. Page 4 of 4 Page 381 of 740 It DANYA INTERNATIONAL Date: October 8.2015 To: (b)(6),(b)(7)(C) 1FRMU From: (b)(6),(b)(7)(C) Compliance Reviewer Danya International, Inc. Re: Compliance Inspection of the Karnes County Residential Center National Family Coordinator From September 28, 2015 to October I, 2015, I conducted a baseline review at the Karnes County Residential Center. Based on the information gathered, the facility's compliance status with the Family Residential Standards (FRS) is as follows: 1.1 Emergency Plans 1.2 Environmental Health and Safety 1.3 Transportation by Land 1.4 Housekeeping and Voluntary Work Program 2.1 Admissions and Release 2.2 Contraband 2.3 Funds and Personal Property 2.4 Key and Lock Control 2.5 Resident Census 2.6 Searches of Residents 2.7 Sexual Abuse and Assault Prevention and Intervention 2.8 Staff-Resident Communications 2.9 Tool Control 2.10 Use of Physical Control Measures and Restraints 3.1 Discipline and Behavior Management 4.1 Food Services 4.2 Hunger Strikes 4.3 Medical Care 4.4 Personal Hygiene 4.5 Suicide Prevention and Intervention 4.6 Terminal Illness, Advance Directives and Death 5.1 Correspondence and Other Mail 5.2 Educational Policy 5.3 Escorted Trips for Non-Medical Emergencies 5.4 Marriage Requests 5.5 Recreation 5.6 Religious Practices 5.7 Telephone Access 5.8 Visitation 6.1 Grievance System 6.2 Law Libraries and Legal Materials 6.3 Legal Rights Group Presentations 7.1 Residential Files 7.2 News Media Interviews and Tours 7.3 Staff Hiring and Training 7.4 Transfer of Residents 7.5 Post Orders Baseline, 9/29/15 Baseline, 8/12/15 Baseline, 9/28/15 Baseline, 8/11/15 Baseline, 8/11/15 Baseline, 9/29/15 Baseline, 9/29/15 Baseline, 9/29/15 Baseline, 9/30/15 Baseline, 10/1/15 Baseline, 8/12/15 Baseline, 8/13/15 Baseline, 10/1/15 Not Inspected Baseline, 10/1/15 Baseline, 10/1/15 Baseline, 10/1/15 Baseline, 10/1/15 Baseline, 10/1/15 Baseline, 10/1/15 Baseline, 10/1/15 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Not hive Baseline, 8/12/15 Baseline, 10/1/15 Baseline, 10/1/15 Baseline not completed Baseline, 10/1/15 8737 Colesville Roati(b)(6),(b)(7) • Silver Spring, Maryland 20910 Phone 301.565177n Fax 301.565.3710 • www.danya.com Page 382 of 740 Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Noncompliant Compliant Not Inspected Not Inspected Baseline, 8/11/15 Compliant Not Inspected Not Inspected Not Inspected Baseline, 10/1/15 Baseline, 8/13/15 Baseline, 10/1/15 Baseline, 10/1/15 Compliant Compliant Compliant Compliant Compliance Inv on: Karnes County RC Sept. 28-Oct. 1, 2015 Overall Observations • I. There were 225 Adults, 248 minors for a total of 473 residents at the time of this inspection. Area of Noncompliance 5.5 Recreation • Every resident shall have daily access to indoor and/or outdoor recreation from 8:00 a.m. to dusk. Finding: During the inspection the week of August 10, 2015, it was noted that the resident cohort exposed to Varicella was provided recreation at 7:00 p.m. for one hour. Other residents are asked to return to their housing units to avoid contact. The cohort was separated from the general population and was required to remain in their housing for the entire day, limiting freedom of movement to one hour per day (7:00 p.m. — 8:00 p.m.). The general population returned to their housing units when the cohort was using the recreation area. During this inspection, residents are still required to return to housing unit at 7:00 p.m. The cohort exposed to Varicella is still provided recreation only between 7:00 p.m. — 8:00 p.m. There are three exposed groups still separated from the general population, which should are scheduled to be moved into the general population, one-by one, on October 10,2015, October 11.2015 and October 12, 2015. Given that this issue was identified in August and has not yet been resolved, and both adults and children are not able to have sufficient recreation time, the facility is now noncompliant in this area. Mitigation: Develop a plan for approval to provide all residents freedom of movement from 8:00 a.m. to 8:00 p.m. 11. Status of Previously Identified Recommendations 1.2 Environment Health and Safety • Observation: After reviewing the daily inspection for the period between 7/25/15-8/9/15, it was noted that one of the main computers had a broken microphone. In fact the computer's microphone was broken and a maintenance request had been completed and the microphone was on order. Recommendation: Once a maintenance request has been logged, a notation listing the maintenance request number as well as the status should be notated on the daily Activity Area Inspection report to reflect that the issue was addressed. Follow up: Resolved—Daily inspection reports listed a broken microphone. The microphone has since been fixed. Processes were revised so that once a maintenance request number is assigned and action to repair is taken, the facility staff no longer continues to notate the same issue/problem on the daily Activity Area Inspection report. Page 2 of 4 Page 383 of 740 Compliance Inv on: Karnes County RC Sept. 28-Oct. 1, 2015 413 N led ical • Observation: The facility is using paper files to document resident's medical information. Recommendation: MSC COR and Field Office COR explore the implementation of an electronic health record system that will track resident medical information, calendar medical appointments, and track upcoming needs. Follow up: Not Resolved—Medical staff continues to use a paper filing system. There is certain information that medical does have the capability of inputting into the system such as medical appointments, restrictions, medical alerts and special diets. Information that requires a doctor's signature cannot be entered. • Use of isolation rooms: The Facility Administrator (b)(b),(b)(/)(C) said the facility does not use isolation rooms. They have rooms where residents who were exposed to TB or any other possible contagious medical issue are kept separate, but the doors are never locked and the residents are allowed to go in and out of the dayroom at any time. Residents with possible TB exposure are asked to notify the medical staff before they enter the dayroom with their children so that the rooms can be sanitized once the resident vacates. The rooms are immediately sanitized after use by a resident with possible TB exposure or other contagious medical issue. There were no posters in the area stating that residents are free to go to the dayroom, but Ms. Thompson said that the residents are fully aware of this. Recommendation: Hang posters in medical rooms used for those residents exposed to TB or with other possible contagious medical issues informing residents that they are able to visit the dayroom. Posters may include messages in Spanish and English. Follow up: Resolved—Posters in Spanish were hung in rooms 542, 541, and 540 indicating that residents can go to the dayroom upon not to staff. None of these rooms are locked at any time. • Lack of child centered materials in the housing units: There were no child-centered decorations in the housing units. There were colorful decorations/murals in the classrooms and intake area. Recommendation: Develop plan for approval to increase presence of child/family friendly materials, such as painting suites and coordinating special arts projects for the children to provide more decorations in the housing units. Follow up: Not Resolved—There is a wall mounted activity board for the children, but no other child centered materials in the housing units. The residents are allowed to post their children artwork up on the walls in the housing units if they choose to. • Lack of cups in the recreation area: The residents are issued permanent cups during intake/orientation for their use. instructions regarding identifying, cleaning and storing these cups was not provided during intake and instructions are not in the handbook. The Medical unit had enough paper and plastic cups for use by the residents. The recreation area did not have paper or plastic cups available. The children were refilling disposable water bottles that had their names written on them. The Gym Teacher said that they always have cups in the recreation area, but had run out that day. Page 3 of 4 Page 384 of 740 Compliance Inv on: Karnes County RC Sept. 28-Oct. 1, 2015 Recommendation: If permanent cups are distributed to each resident during intake, the process for identifying, cleaning, and storing must be documented and shared with each resident at intake. Facility should inventory cups on a weekly basis to ensure adequate supply is ordered prior to inventory depletion. Follow up: Resolved—There is sufficient inventory of cups in the recreation area. The school's gym teacher is now responsible for ordering cups for the gymnasium. The facility installed a sanitizing station (Munchkin Sanitation System) to clean sippy cups and bottles in the Short Term Care room. Sippy cups can also be taken to the kitchen to be clean. Cleaning permanent cups is still the residents' responsibility. • Concerns that the facility is not fully staffed: There were six vacant positions--four food service workers, one health care worker (LSW), and one security supervisor. Potential employees were identified and will start work upon completion of their security clearances. The security supervisor is also awaiting approval from the GEO regional authority. The facility administrator stated that existing staff covered these tasks while the position was vacant, and resident services were not impacted by these staff vacancies. Recommendation: It is recommended that the facility address all staff vacancies by making every attempt to hire for the vacant positions. Follow up Issues Not Resolved—The facility is still not fully staffed. The status of the vacancies noted during the last inspection is below: o Four food service workers: One cook started on 8/29/15; three additional food service workers are awaiting clearance. o LSW: Awaiting clearance o Security Supervisor: Started 9/2/15 The Head Nurse, (b)(6),(b)(7) and Compliance Manager (b)(6),(b)(7)(C) confirmed that staff are covering the tasks for these vacancies as needed. cc: I Chief, .1FRMU (b)(6),(b)(7)(C) (b)(6 ),(b)(7)(C) 'Program Manager Page 4 of 4 Page 385 of 740 Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • Rating AR/NA Corrective Action Required/comments I. Emergency Plans A. B. C. D. E. F. Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available R A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. D C. Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents D. Fire prevention/control/evacuation plan A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 386 of 740 Staff is trained butmost staff is new and not fully aware of resident behavior A The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. 4/22 showed the log wasn't being signed correctly and people were adding when they should have been subtracting amounts Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE Rating A/D/R/NA E. Conduct fire/evacuation drills according to schedule/standard R F. G. Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly R A H. Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken • I J. K. A. B. C. D. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used unfil they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspecfion Transporting officers limit driving lime to 10 hours in any 15 hour period when transporting residents FER1 officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 387 of 740 R Corrective Action Required/Comments Contractor has not supplied the reports as request so this remains a risk Staff is trained but not following through with what the standards require with the current cohort Forms currently in use have numerous typing errors making comprehension of the matrial difficult/a liability A R A A A A A Beginning of the month showed numerous issues but wthe end of the month vast improvement has been shown but population is below 200 for the last week Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M E. F. G. H. A. B. C. D. E. F. G. Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within timeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system E. Residents are assigned color coded uniforms/wrist bands to reflect A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 388 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A A A A NA N/A New Resident Handbook in place and in process of translation into Spanish Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M •A. B. C. A. •B. classification level 6. Contraband Policy in place for handling contraband Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband 7. Facility Security and Control Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Rating AR/NA A A R D A C. Front entrance staff inspect ID of everyone entering/exiting A D. F. Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times R A F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 389 of 740 Corrective Action Required/comments Log books do not reflect daily or even routine inspections for contraband Plan of action was closed out and while there has been improvement many Counselors still do not properly annotate how these checks were conducted More permennant staff is now assigned to this post and are now checking IDs Random check of log books still show hugh discrempancies with what is coming and going from the facility Plan of action close out on 4/13 showed this to be an area staff still do not annotate This facility no longer has a perimeter fence and contrucfion Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M • H. Facility administrator or designee and department heads visit housing units and activity areas weekly I Comprehensive staffing analysis determines staffing needs and plans J. • Rating A/D/R/NA R D Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the K. facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its L. components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and M. interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical N. checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and 0. inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone P. surveillance, high profile residents, visiting room activities, etc R Q. R R A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 390 of 740 Current Staffing percentage for April is 83.96 and well below the 90% in the contract Missing Case workers and mental health staff Staff is not properly logging entries as seen on 4/13 A A N/A The facility does not have a fence or a perimeter alarm. A D • The facility shares intelligence informafion with ICE Corrective Action Required/Comments is on going for expansion. We no longer have an lnteligence Officer who would be assigned to gather this information. No Intel Officer for CEO but management has made strides this month to regularly infor ICE Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W M • PERFORMANCE MONITORING MEASURE 8. Funds and Personal Property A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff E. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged 9. Waiting Room in Residential Facilities A. Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placemenl in B. waiting room C. Maintain monitoring log for each resident in waiting room ! D. Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents E. held F. The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses G. are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, I diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are J. irregularly monitored every 15 minutes • • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 391 of 740 Rating AR/NA Corrective Action Required/comments of issues A A A A A A A It is done weekly at this facility A A A A A A A A A Fire evacuation plan is posted. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE Rating A/D/R/NA Corrective Action Required/Comments 10. Key and Lock Control A. Maintain inventories of all keys/locks/locking devices A B. Emergency keys are available for all areas of the facility A C. D. Chit system used to issue security equip/keys/radios A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A E. F. A R A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. At least two officers participate in count for each area Recount conducted when incorrect count is reported D A D. E. D D A. Face to photo count conducted Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator B. Housing unit officers record all resident activity in a log D C. Supervisor visits each housing area once per shift R A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 392 of 740 R 4/13 Locks were replaced on all tools in the kitchen A resident census takes place at 0730hrs, 1600hrs & 2000hrs. 4/3, 4/13, 4/24 only witnessed 1 officer conducting count on each hall 4/3, 4/13, 4/24 not all residents were verified face to photo 4/3, 4/13, 4/24 they were not all verified Every week at leat one post order was missing pages 4/13 a thorough check of log books showed major events are still not being annotated Not normally in the log book and some posts don't show it in the post order sign off sheet Due Date Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due loan emergency Anyone assigned to an armed post qualifies with the post weapons E. before assuming post duty 13 Searches of Residents A. Unit shakedowns are conducted D. B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched •D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and A. • Intervention Program B. Residents are advised of the program R Corrective Action Required/comments Most staff do not sign when only giving breaks N/A No armed posts. R Not logged in the log books 4/13 most staff still does not properly annotate this item. A random schedule has been implemented R A A A A All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • Rating AR/NA B. C. Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours D. ICE SDC visit schedules are posted in housing unit A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 393 of 740 A A A A A A Staff Resident Communication Schedule is posted in Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA A E. • Request forms are available to residents There is a secure box available for residents to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. Tool inventories conducted as specified B. Tools marked and readily identifiable C. Procedures for issuance of tools to staff and residents • D. •E. F. G. H. A. B. C. Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspecfion system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 394 of 740 Corrective Action Required/Comments Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. A A A They occur daily A A A R New policy is being followed as of 4/13 A R A A A A A 4/3, 4/13 log has been wrong or a chit has been missing Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. G. Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System A. Rules of conduct/sanctions provided in writing B. Incident reports investigated within 24 hours C. Disciplinary panel adjudicate infractions • D. E. A. Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place B. Appropriate food temperatures are maintained for both hot and cold food Rating A/D/R/NA A A A A A A A R A R R F. A A minimum of two hot meals served daily A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 395 of 740 CEO has been hesitant to enforce disciplinary measures since unrest began A Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 D. day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to E. beginning work in department C. Corrective Action Required/Comments A R Begininng of the month to now has shown improvement for consistency in logging Beginning of the month had issues but currently the kitchen is compliant No 0-1 yr old children at this time The last 2 weeks of April have shown improvement in this area Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A I J. K. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. R A A L. M. A. B. C. D. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. N. A. B. C. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 396 of 740 Corrective Action Required/Comments The facility has a 42 day cycle menu. Currently revising the menu The last 2 weeks of April have shown improvement in this area A R R A A A A A A A A Every weekend for up to a half an hour supervisors will leave the dining hall Current populafion is low and snacks have been at appropriate levels Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M F. Sick call slips available in English. Spanish and/or most prevalent second language G. H. I J. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. A sharps container is used to dispose of used sharps • L. M. N. 0. P. All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, Q. Rating A/D/R/NA A A A A A A R A A R A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 397 of 740 Corrective Action Required/Comments Families with varicella/TB have been placed into isolation rooms that do not meet minimum space requirements but the facility is under construction at this time A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. The Negative Air Pressure rooms were originally built for single occupancy. Immunizations have been offered to children and adolescents. Due Date Attachment 5.B. .(*);„ U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. • 23. Personal Hygiene Clothing provided upon intake and exchanged weekly Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear G. while uniforms. 24. Suicide Prevention and Intervention !Thefacility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 398 of 740 Rating AR/NA Corrective Action Required/comments A A A A R A A A A A A Due top low population numbers certain areas are seeing reading below 100 because of no use Voluntary workers wear Red/Pink shirt or grey sweaters and blue jeans Due Date Attachment 5.B. .(*);„ U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Residents who are chronically or terminally ill are transferred to an appropriate off-site facility The facility has written plans for addressing organ donations There is a policy addressing Do Not Resuscitate Orders The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with A. standards 28. Marriage Requests A. Marriage written requests approved by FOD 29. Recreation A. B. C. D. • A. Outdoor/indoor recreation is provided B. Access to recreation activities C. Staff conduct daily searches of recreation areas D. In unit sedentary activities are available E. Recreation areas are under continuous supervision by staff equiped A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 399 of 740 Rating AR/NA Corrective Action Required/comments A A A A A A A A A A NA A A A A A A R No posted limits to staffing Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA with radios or other communication devices, The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices A. Residents are allowed to engage in religious services B. Authorized religious items are allowed in resident possession 31. Telephone Access A. Upon intake, residents are made aware of phone policies B. Out of order phones reported to service provider C. Telephones inspected by staff D. Telephone access rules posted in each housing unit E. The number for the ICE OIG is posted in housing units F. The pro bono list is posted in housing units G. Emergency phone call messages delivered to residents H. Special access calls are available to residents I Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and identified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program F. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 400 of 740 A A A A A A A A A A A A A A A A A A A Corrective Action Required/comments ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. G. A. B. •C. D. A. B. C. Facility has a voluntary work program Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Residents receive proper training and safety equipment Resident housekeeping meets standards for neatness, cleanliness and sanitation Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 401 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A R D R Housekeeping has improved but numerous residents' rooms have been found with contraband food and room temp milks Residents are still being found unaccompanied by their mothers. 4/2,4/13,4/27 Most staff stated they had not been given a copy of the resident handbook and did not have working knowledge of its contents A R A A A Still being translated for distribution Videos are provided Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. Rating A/D/R/NA Corrective Action Required/Comments Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention E. file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be H. scheduled between 8am & 8pm. 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming residents • Posters announcing presentation appear in common areas al least 48 B. hours prior to presentation C. Residents in SMU receive separate presentafion Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours A. The facility has a procedure to address news media interview and A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 402 of 740 D Staff routinely does informal resolutions without writing it up and logging it A A N/A A A A A A A A N/A A A A A A Facility does not have an SMU. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M A. B. C. tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents Rating A/D/R/NA A A R A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided. Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. A A A. B. C. D. E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 403 of 740 Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 1:133. A A A A A 1 field trip was conducted 4/ Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 4/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available C. All children ages 0-11 remain under constant supervision of their mother. D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 404 of 740 Enforcement Rating AR/NA A A D D A A Corrective Action Required/comments No infants for the month Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. Still pending acceptance or rejection notice Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • Rating A/D/R/NA Corrective Action Required/Comments I. Emergency Plans A. B. C. D. E. F. G. A. B. C. Staff is trained but most staff is new and not fully aware how to read resident behavior Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety R A A A R A rough draft of updates was received Aug 12 System for storing/issuing/maintaining hazardous materials Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents A A 8/13 Inventories checked D. Fire prevenfion/control/evacuafion plan E. F. G. Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly A A A R A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 405 of 740 R A A Still reviewing the response to the POA, and many items are still not compliant Dates on the report do not reflect the actual dates the drills were conducted Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M H. I J. K. Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been A. repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour C. period when transporting residents b)(7 officers with valid Commercial Drivers Licenses, (CDL's) D. required in any bus transporting residents Policies and procedures are in place addressing the use of E. restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in F. accordance with the Use of Force standard ! G. Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where H. applicable. 4. Admission and Release A. ICE information is available for initial classification B. Medical screening taking place within timeframes A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 406 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A A A A A A More population this past month but staff has done well keeping up Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. G. Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system Residents are housed by age groups based upon the children E. 6. Contraband A. Policy in place for handling contraband Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A NA A A B. Contraband disposed of properly and documented R C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control Staff are required to conduct security check of assigned areas D Documentation in log books is infrequent/loose copies kept by supervisors food being taken from dining hall and no GEO staffseen stopping this activity, repeat discrepency D Midnight shift has reported that A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 407 of 740 Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA • they do NOT routinely enter the residents suite for safety or security checks B. C. D. E. • Corrective Action Required/comments All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exiting Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times A A D A F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A H. Facility administrator or designee and department heads visit housing units and activity areas weekly R I Comprehensive staffing analysis determines staffing needs and plans D J. Essential posts and positions are filled with qualified personnel D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 408 of 740 Random check of log books still show high discrepancies with what is coming and going from the facility Random check of log books on 8/15 showed this to be an area staff still do not routinely annotate This facility no longer has a perimeter fence and construction is ongoing for expansion. Still using a loose sheet as a log rather than signing a log book Current Staffing percentage for Aug is 87.43 and below the 90% in the contract mental health staff is short staffed/using 1 person in multiple positions when not allowed/not meeting minimum Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE K. L. M. • N. 0. P. Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and pracfice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc Rating A/D/R/NA D A N/A D The facility shares intelligence information with ICE 8. Funds and Personal Property A A. B. C. D. E. F. Inventory personal properly/funds is maintained Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box Staff secure every container used to store property with a tamper- A A A A A A Page 409 of 740 The facility does not have a fence or a perimeter alarm. A Q. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable staffing requirements Staff's not properly logging entries as seen on 8/15 A • • Corrective Action Required/Comments We no longer have an Inteligence Officer who would be assigned to gather this information. Administration has madea more concerted effort to inform ICE 1 letter outstanding for withheld funds and 1 for property Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Corrective Action Required/comments proof numbered strap • A. Quarterly audits of resident baggage & luggage are conducted, verified, and logged 9. Waiting Room in Residential Facilities Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement n waiting room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds (other then cribs) or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices B. Emergency keys are available for all areas of the facility A C. D. Chit system used to issue security equip./keys/radios A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily A G. A. B. C. D. E. F. G. I J. E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 410 of 740 A A A A A A A A A A A A It is done weekly at this facility Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M F. Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts Rating A/D/R/NA A A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. D. E. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator D A A A A. D 8/15 a thorough check of log books showed major events are still not being annotated POA addressed supervisor responsibility to checking every log book which means all housing is visited Most staff do not sign when only giving breaks N/A No armed posts. D Unit shakedowns are not done, only individual suites Housing unit officers record all resident activity in a log D C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents A Unit shakedowns are conducted E. A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 411 of 740 JFRMU mandate does not allow census on the midnight shift 8/13, 8/15 and 8/27 only witnessed 1 officer conducting count on each hall A B. D. Corrective Action Required/Comments Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention • The facility has a Sexual Abuse and Assault Prevention and A. Intervention Program Rating A/D/R/NA R • H B. Residents are advised of the program A A All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • A A Corrective Action Required/Comments 8/15 and 8/27 most staff still does not properly annotate this item/GEO uses loose sheets of paper as logs A random schedule has been implemented A A A A B. Housing unit rounds conducted daily by Deportation Staff C. Resident requests answered within 72 hours D. ICE SRC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 412 of 740 A A A A A They occur daily Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • H. A. B. C. D. E. • F. G. H. • A. B. C. •D. E. F. G. A. B. Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/cataloged for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 413 of 740 Enforcement Rating AR/NA A A A A A A A A A A A A A A A A A A Corrective Action Required/comments Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M C. D. E. Enforcement Rating AR/NA Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food A A A A D. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). E. Residents receive safety and appropriate equipment raining prior to beginning work in department R F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A A. B. C. • I J. K. L. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 414 of 740 Corrective Action Required/comments A A A R A A A New supervisor plan in place is ensuring quality control No 0-1 yr old children at this time Residents are not wearing safety boots/shoes as required in the kitchen The facility has a 42 day cycle menu. Unknown with 2 entrees being offered at all meals now and no menu provided to the COR Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M M. N. A. B. C. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Rating A/D/R/NA A A A A. B. C. D. Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical ! G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 415 of 740 Corrective Action Required/Comments R A A A A A A A A A Some staff do not know even after training Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating ND/RNA / Corrective Action Required/Comments A K. L. M. N. 0. P. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations. Q. A. B. C. Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair G. A R A A 23. Personal Hygiene Clothing provided upon intake and exchanged weekly D. E. F. A A Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear approved uniforms. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 416 of 740 A A A A A A A The Negative Air Pressure rooms were originally built for single occupancy. Due Date Attachment 5.B. '"RT41/4U.S.Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W M • • PERFORMANCE MONITORING MEASURE 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 417 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A NA Corrective Action Required/Comments Due Date Attachment 5.B. '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. A. A. B. C. D. E. F. A. B. A. B. C. D. E. F. G. The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 418 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A R A A A A A A A A A A No posted limits to staffing ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Due Date Attachment 5.B. .(*);„ U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M H. I Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and idenfified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate E. Residents receive proper training and safety equipment !Residenthousekeeping meets standards for neatness, cleanliness F. and sanitation G. A. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 419 of 740 Rating AR/NA A A Corrective Action Required/comments A A A A A A A A A A A D Kitchen does not enforce the safety shoe wearing has improved h but ut numerous residents' rooms chave been found with contraband m food,room temp milks C and cheese Child residents are still being found unaccompanied by their mothers. D At night and on weekends staff R R Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating AR/NA Corrective Action Required/comments are seen not enforcing rules/procedures B. C. D. A. B. C. D. E. A. B. C. D. E. F. G. H. Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for residents Legal materials/law library current and available for residents Resident access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm. 37. Legal Rights Group Presentations A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 420 of 740 A A A Videos are provided A A R R D A A N/A A A A A A Population has been low but previous month issues were not adequately resolved Staff routinely does informal resolutions without writing it up and logging it Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. A. B. C. A. A. B. C. ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 hours prior to presentation Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to attend have the opportunity 38. Detention Files Detention file created for each new arrival Detention files contain documents generated during custody Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientafion, inifial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents Rating A/D/R/NA A R N/A A A A A A A R Resident provided with resident transfer notification form A B. C. Health records/transfer summary accompany resident Funds and personal property accompany resident A A Page 421 of 740 ERO did not notify us of a presentation unfil 24hr prior Facility does not have an SMU. A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 2:133. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 8/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. A. B. A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided monthly Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available C. All children ages 0-11 remain under constant supervision of their mother. A. B. C. D. E. D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines, A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 422 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A D D A A No infants for the month Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. G. I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety Rating A/D/R/NA A A A A A A A A. System for storing/issuing/maintaining hazardous materials D B. Complete inventories of hazardous materials maintained D C. A complete list of MSDS readily accessible to staff and residents A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 423 of 740 Corrective Action Required/Comments The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. The current system is not an accurate inventory of chemicals on hand. On 8/4/2014 numerous chemicals were found unsecured in a janitorial closet in the kitchen without a proper inventory. On 8/28/2014 multiple chemicals were found unsecured in the gym area when no staff were in the area. MSDS lists are kept in the Food Service Department, Laundry Area, Programs Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE Enforcement Rating AR/NA Corrective Action Required/comments Building and the Medical Department, D. Fire prevention/control/evacuation plan A E. Conduct fire/evacuation drills according to schedule/standard A F. Staff trained to prevent contact A h blood and bodily fluids G. Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and H. disposal Safety Office (or officer) maintains files of inspection reports; I Including corrective actions taken J. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) K. are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been A. repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspection Transporting officers limit driving lime to 10 hours in any 15 hour C. period when transporting residents ISM officers with valid Commercial Drivers Licenses, (CDL's) D. required in any bus transporting residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 424 of 740 A A A A A A A A A Fire Drills are scheduled quarterly which include all areas of the building & all shifts. The generators were tested on th th th th August 5 , 12 , 19 & 26 . Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W M • F. G. H. A. B. C. D. E. F. and Customs Enforcement Month/Year: 08/2014 PERFORMANCE MONITORING MEASURE E. U.S. Immigration Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure G. Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language A. B. C. 5. Classification System All residents classified appropriately upon arrival Reassessment and reclassificafion process in place Housing assignments are based upon classification A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 425 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A D On 8/11 & 8/12 transports were completed by Trailboss without required child safety seats. A A A A A D A A A A Multiple residents complained that they had only received 1-3 sets of clothing upon admittance during the initial ramp up. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. Work assignments are based upon classification system Residents are assigned color coded uniforms/wrist bands to reflect classification level 6. Contraband •A. Policy in place for handling contraband B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A. Staff are required to conduct security check of assigned areas •B. All visitors officially recorded in a visitor log book C. Front entrance staff inspect ID of everyone entering/exifing D. Maintain a log of all incoming and departing vehicles E. Housing unit searches occur at irregular times F. Area searches documented in log book E. G. • H. I Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly Comprehensive staffing analysis determines staffing needs and plans A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 426 of 740 Enforcement Rating AR/NA NA Corrective Action Required/comments Wrist bands are no longer utilized in our facility. Residents now wear their ID as a necklace. A A A A A A A A A A N/A This facility no longer has a perimeter fence. A D Current staffing percentage for the month of August 2014 was 77.36%. This is taking into account the new staffing analysis of 189 authorized employees. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D w M PERFORMANCE MONITORING MEASURE J. K. L. M. • N. 0. • P. Q. A. B. C. D. E. F. Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and pracfice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc The facility shares intelligence informafion with ICE 8. Funds and Personal Property Inventory personal properly/funds is maintained Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperproof numbered strap A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 427 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A N/A A A A A A A A A A The facility does not have a fence or a perimeter alarm. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D PERFORMANCE MONITORING MEASURE W M • G. A. B. C. D. E. F. • G. I J. A. B. C. D. Quarterly audits of resident baggage & luggage are conducted, verified, and logged 9. Waiting Room in Residential Facilities Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement n waiting room Maintain monitoring log for each resident in wailing room Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices Emergency keys are available for all areas of the facility Chit system used to issue security equip./keys/radios Policy regarding restricted keys present and followed by staff A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 428 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A A A A Residents are no longer held in Hold Rooms, the doors no longer locked. The rooms are now called Waiting Rooms. There is a metal detector at the entrance to intake from the sally port. Fire evacuation plan is posted. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. F. Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A. Staff conduct formal census at least once per 8 hour shift/ 3x per day B. At least two officers participate in count for each area C. Recount conducted when incorrect count is reported D. Face to photo count conducted E. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility A. administrator B. Housing unit officers record all resident activity in a log C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is D. temporary, permanent, or due loan emergency Anyone assigned to an armed post qualifies with the post weapons E. before assuming post duty 13. Searches of Residents A. Unit shakedowns are conducted B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 429 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A resident census takes place at 0900hrs, 1500hrs & 2000hrs. A A A A N/A A A A A No armed posts. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequen D PERFORMANCE MONITORING MEASURE M A. The facility has a Sexual Abuse and Assault Prevention and Intervention Program A B. Residents are advised of the program A All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • Rating A/D/R/NA B. C. Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis A A A A A A A F. G. • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 430 of 740 Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. A A Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. Tool inventories conducted as specified B. Tools marked and readily identifiable Corrective Action Required/Comments A A A ICE Officers conduct daily visits to housing units. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. G. H. A. B. C. D. E. F. G. A. B. C. D. E. Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 431 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A D On 8/15/2014 the tool control area in the kitchen was observed to be missing numerous chits on items that were checked out. A A A A A A A A A A A A A A Staff representation is available Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA • Corrective Action Required/comments upon request. 20. Food Service A. B. C. Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a high level of sanitation D A A D E. The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department F A minimum of two hot meals served daily A G. Facility has a standard 35 day cycle menu A H. A registered dietician conducts nutritional analysis D D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 432 of 740 On 8/15/2014 the Dry Storage room was found propped open, the tool control room was also left open, while residents were working in the kitchen. The facility had multiple incidents reported to ICE where residents were complaining about the formula including: the amount of formula they were being issued, that the residents were unable to receive formula from the kitchen after 7pm and that the facitliy had ran out of formula. A The facility has a 42 day cycle menu. The current menu has not been signed off on by a registered dietician for the nutritional Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE Enforcement Rating AR/NA Corrective Action Required/comments analysis. I J. K. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented A A A A. B. C. D. The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A L. A. B. C. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 433 of 740 D A A A A A A A On 8/13 there were only 10 high chairs available in the facility and the current population had 14 babies, 22 one year olds and 34 two years olds. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M G. H. I J. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. A sharps container is used to dispose of used sharps L. M. All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room. The medical department is maintained al a high level of sanitation Enforcement Rating AR/NA A A A A A D A N. Female residents are provided with a female escort for medical examinations with male health care providers. A a Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 434 of 740 Corrective Action Required/comments On 8/8, 4 residents were observed in 1 medical room with 2 beds. On 8/13 multiple rooms in medical observation were observed without an adequate number of beds per family members. A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. On 8/14,2 family members were observed in a Negative Air Pressure Room, with a rollaway bed in front of the door, presenting a fire escape hazard. The rollaway bed was also blocking the front of the sink and later seen pushed in Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments front of the toilet. P. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, A A Q. Immunizations have been offered to children and adolescents. 23. Personal Hygiene A. Clothing provided upon intake and exchanged weekly B. Sheets and towels exchanged weekly A A C. Climate appropriate clothing issued and maintained in good repair D D. E. F. Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements A A A G. Food Service resident volunteers exchange garments daily and wear white uniforms. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 435 of 740 A Residents are able to get clothing washed Monday — Friday by the laundry department. Raincoats have not been issued. Cold weather attire will not be issued until October 1501 per the Service Provider. Food Service resident workers do not wear white uniforms, due to facility staff wearing white uniform shirts. The VVVP residents are given a gray Tshirt and blue jeans to wear to work. Due Date Attachment 5.B. '"RT41/4U.S.Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W M • • PERFORMANCE MONITORING MEASURE 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually At Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation B. program and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 436 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A NA Corrective Action Required/Comments Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. A. A. B. C. D. E. The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Rating A/D/R/NA Corrective Action Required/Comments A A A Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equipeed with radios or other communication devices. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 437 of 740 A A A D The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment, fooseball tables, ping pong tables, Zumba classes and more. The gym hours of operation are 0600— 2200hrs. On 8/5 the gym was found unsupervised. On 8/12 the gym was found unattended. On 8/14 the gym was found unsupervised and 3 minor children were inside. On 8/15 at 0815hrs the gym was found unstaffed. On 8/18 the gym was found locked at Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. The outdoor exercise area includes: shaded areas with sealing, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider C. D. E. F. G. Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents F. A. B. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 438 of 740 Enforcement Rating AR/NA A Corrective Action Required/comments 0846hrs. On 8/22 @ 1109hrs the gym was found locked and not available to residents. On 8/24 the gym was closed by 2000hrs. 8/28 at 0830hrs the gym was found unlocked and unsupervised, there were also chemicals found in an unsecured closet in the unlocked office in the gym. 8/29 the gym was closed by 1900hrs. On 8/31 the gym was closed by 1900hrs. This facility has a soccer field, sand volleyball court and a newly constructed playground. A A A A A A A A A ICE staff conducts weekly telephone checks. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M H. I A. B. C. D. E. Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and idenfified per standards Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program Facility has a voluntary work program Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Residents receive proper training and safety equipment F. Resident housekeeping meets standards for neatness, cleanliness and sanitation A. B. C. D. E. F. G. G. A. B. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 439 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A A A A A A A D A A On multiple occasions during the month of August children uner 10 years of age were found unaccompanied by their mothers. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. A. B. C. D. Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming residents E. L A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 440 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A D A D A A N/A A A A A A An informal grievance was received, and it was not annotated in the informal grievance log. The informal grievance log was checked and found to have no entries. There was an informal grievance investigated on 8/20/2014 that was not documented by the Service Provider. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Posters announcing presentation appear in common areas at least 48 hours prior to presentation Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with NDS 40. Staff Training The facility conducts appropriate orientafion, inifial training, and A. annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance 41. Transfer of Residents B. C. Enforcement Rating AR/NA A N/A A A A A A A A A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 441 of 740 Corrective Action Required/comments Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA B. Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. C. Educational field trips are provided. D D. Progress reports are distributed to all students on a regular and consistent schedule. 33. Child Care N/A A. A Corrective Action Required/Comments School commenced on 8/26/2014. A No Field Trips were provided for the month of August 2014. No progress reports were distributed for the month of August, as school had just began. On 8/12 Elm 118 had a resident with a 9 month old and another resident with a 2 month old; they only had one crib in their room. Also 4 more rooms were found to not have cribs in their rooms: Oak 101, 11 month old, no crib, Oak 105, playpen, but no crib, Oak 107 play pen, no crib (8 months old), Oak 109,9 month old no crib. A. B. C. All infants ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available All children ages 0-11 remain under constant supervision of their mother. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 442 of 740 D A D Multiple instances were documented throughout the month where children under 12 years of age were found Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 443 of 740 Enforcement Rating AR/NA Corrective Action Required/comments unsupervised by their parent. A A D On 8/14 the daycare had 10 children in the room with 2 recreational staff. 7 out of the 10 children were under the age of 5. Per the state of Texas Child Care Minimum Standards, a child under the age of 5 counts as two children and the ratio of staff to children is 1 to 8. Per the state requirements, there was not enough staff present in the daycare room. In addition, one recreation specialist left the room, leaving only one staff member present in the room. Due Date Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the E. year to test specific plans F. Staff work stoppage plan is available A. B. C. D. Rating AR/NA A A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. Complete inventories of hazardous materials maintained D C. A complete list of MSDS readily accessible to staff and residents A D. F. Fire prevention/control/evacuation plan Conduct fire/evacuation drills according to schedule/standard A D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 444 of 740 Corrective Action Required/comments The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. 12/20 Pine-Sol was found in the Kitchen, No Inventory or MSDS in the Kitchen for it MSDS lists are kept in the Food Service Department Laundry Area, Programs Building and the Medical Department. A fire drill was conducted on Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments October 13rh. Only 24 staff of the regularly scheduled 47 staff in the Administrative Office exited the building. •F. G. H. I J. K. A. B. C. D. E. Staff trained to prevent contact h blood and bodily fluids Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicafing safety repairs are completed immediately and vehicles are not used unfil they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspecfion Transporting officers limit driving lime to 10 hours in any 15 hour period when transporting residents (b)( officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 445 of 740 A A A A D A A A A A A Multiple suites and dayrooms have had writing on the walls by the children/multiple suites also had urine in the toilets on 12/11 Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. •G. H. A. B. C. D. E. F. G. Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system E. Residents are assigned color coded uniforms/wrist bands to reflect classification level A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 446 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A GEO is now providing cold weather clothing at intake A A A A NA A Wrist bands are no longer utilized in our facility. Residents now wear their ID as a necklace. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. A. •B. C. D. • 6. Contraband Policy in place for handling contraband Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband 7. Facility Security and Control Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exiting Maintain a log of all incoming and departing vehicles Enforcement Rating AR/NA A A D Housing unit searches occur at irregular times D F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A Page 447 of 740 12/06, 12/20, 12/25 Contraband searches did not comply with standards as most staff did not have a list of what was allowed by the facility and most did not know what was considered excessive A A A A E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/comments Most staff each day of the month were noted to miss most hourly yet irregular checks as required by law, each log entry for the night shift only held a 30min check in entry on the half hour Most log books on a per shift basis were missing this entry This facility no longer has a perimeter fence. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M H. I J. K. L. M. • N. 0. P. Q. Facility administrator or designee and department heads visit housing units and activity areas weekly Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc The facility shares intelligence information with ICE A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 448 of 740 Rating A/D/R/NA D D A Corrective Action Required/Comments Short term care, Law Library, and recreation logs do not have a log of any department head visits Current staffing percentage for the month of November 2014 was 91.13%. This is taking into account the new staffing analysis of 189 authorized employees. A A A N/A The facility does not have a fence or a perimeter alarm. A D A We no longer have an lnteligence Officer who would be assigned to gather this information. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W M • PERFORMANCE MONITORING MEASURE 8. Funds and Personal Property A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff E. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged 9. Waiting Room in Residential Facilities • A. B. C. D. E. F. G. I Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placemenl in wailing room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items! diapers and wipes. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 449 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A A A A A A A Residents are no longer held in Hold Rooms, the doors no longer locked. The rooms are now called Waiting Rooms. There is a metal detector at the entrance to intake from the sally port. Fire evacuation plan is posted. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc DWM PERFORMANCE MONITORING MEASURE Rating A/D/R/NA A. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices B. Emergency keys are available for all areas of the facility A C. D. Chit system used to issue security equip/keys/radios A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. D. E. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator Housing unit officers record all resident activity in a log Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignmenl is temporary, permanent, or due loan emergency D A A A J. E. F. A. B. C. D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 450 of 740 Corrective Action Required / Comments A A A A A A A A A resident census takes place at 0730hrs, 1600hrs & 2000hrs. All residents report to the dayrooms for count and only one GEO staff is routinely present at these counts Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents A. Unit shakedowns are conducted B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and A. Intervention Program E. Rating A/D/R/NA N/A A A • A Residents are advised of the program A A. All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit bulletin boards 16. Staff-Resident Communication Housing unit rounds conducted daily by security staff B. C. Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours C. • D. No armed posts. A A • B. Corrective Action Required/Comments D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents A A A A A A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 451 of 740 Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis Enforcement Rating AR/NA A A G. H. A. B. C. D. • •E. F. G. H. A. B. C. D. E. F. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 452 of 740 Corrective Action Required/comments A A A A A A A A A A A A A A A ICE Officers conduct daily visits to housing units. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M G. A. B. C. Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Enforcement Rating AR/NA A A A A D. Disciplinary sanctions are in accordance with standards A E. Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food A A. B. C. D. E. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 453 of 740 Corrective Action Required/Comments Corrective Sanctions for Adults is missing from the handbook, although a memorandum has been posted with the sanctions GEO is only using one Corrective Action against the residents at this time, even for residents with consecutive disciplinary infractions Staff representation is available upon request. A A D A A 12/29-30 the grills and the ovens had excessive build up of grease and no cleaning schedule is in use or posted Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA F. A minimum of two hot meals served daily A G. H. I J. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis All menu changes documented Common fare menu for authorized residents A A A A K. L. M. Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes !Procedures for referring resident to medical if verbally refused or A. observed refusing to eat beyond 72 hours B. Staff receive training in identification of hunger strike C. Process for determining reason for hunger strike 22. Medical Care A. Intake process includes medical and mental health screening B. Sick call procedures established N. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 454 of 740 A Corrective Action Required/Comments The facility has a 42 day cycle menu. The log has the exact same times listed for every inspection conducted for the month of December A D D A A A A A The Dining Hall continues to be monitored by the Chaplain and Food Service Staff. 12/11 no juices were in the refrigerators, dayroom in medical didn't have milk Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc and Customs Enforcement Month/Year: 12/2014 PERFORMANCE MONITORING MEASURE DWM U.S. Immigration Rating A/D/R/NA C. D. Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area A A E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A G H. I J. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. L. M. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation A A A A A A A N. Female residents are provided with a female escort for medical examinations with male health care providers. A 0. P. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. D A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 455 of 740 Corrective Action Required / Comments A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. The Negative Air Pressure rooms were originally built for single occupancy. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, Q. A Corrective Action Required/comments Immunizations have been offered to children and adolescents. 23. Personal Hygiene A. Clothing provided upon intake and exchanged weekly B. C. Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident D. E. F. G. Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear white uniforms. 24. Suicide Prevention and Intervention A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 456 of 740 A A A Residents are able to get clothing washed Monday — Friday by the laundry department. Now being provided at intake A D A A 12/8 and 12/16 the showers in medical were below 100 and Elm Hall had readings above 120 Food Service resident workers do not wear white uniforms, due to facility staff wearing white uniform shirts. The VWP residents are given a gray Tshirt and blue jeans to wear to work. Due Date Attachment 5.B. '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc DWM • PERFORMANCE MONITORING MEASURE The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies A. The Field Office Director considers and approves, on a case-by-case A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 457 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A NA A Corrective Action Required / Comments Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. A. B. C. D. E. F. A. B. basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Rating AR/NA Corrective Action Required/comments A A Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 458 of 740 A A A D A A A The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment, fooseball tables, ping pong tables, Zumba classes and more. On the following dates the gym was found closed (early) during posted open hours: 11/3, 11/5, 11/12,11/16 & 11/18. This facility has a soccer field, a basketball court and a newly constructed playground. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. Upon intake, residents are made aware of phone policies Out of order phones reported to service provider C. D. E. F. G. H. I Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and identified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classificafion level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate E. Residents receive proper training and safety equipment • Rating A/D/R/NA A A A A A A A A A F. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 459 of 740 ICE staff conducts weekly telephone checks. A A A A A A A A A A A A • Resident housekeeping meets standards for neatness, cleanliness and sanitation Corrective Action Required/Comments D There are drawings on the walls and doors from children. There are also large amounts of food Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M G. A. B. C. D. A. B. C. D. E. A. B. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for residents Legal materials/law library current and available for residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 460 of 740 Rating A/D/R/NA D Corrective Action Required/Comments (some spoiled) being found in the suites. In addition multiple showers were found to have mold and mildew. Residents are still being found unaccompanied by their mothers. D 12/25 and 12/26 Staff stated they had not been given a copy of the resident handbook and did not know what was considered contraband A A A A A A A A A A Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE C. D. E. F. G. H. A. B. C. D. A. B. C. A. Resident access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm, 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 hours prior to presentation Residents in SMU receive separate presentafion Facility ensures adequate presentations so all residents wanting to attend have the opportunity 38. Detention Files Detention file created for each new arrival Detention files contain documents generated during custody Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and tours in accordance with NDS 40. Staff Training A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 461 of 740 Rating A/D/R/NA Corrective Action Required/Comments N/A A A A A On the following dates the library was found closed (early) during posted open hours: 12/9,12/14, 12/15, 12/17, 12/19, 12/23,12/26. 12/30 Opened Late: 12/6, 12/14, 12/20, 12/28 D A A N/A A A A A A Our facility does not have an SMU. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M A. B. C. The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents Enforcement Rating AR/NA A A D A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. A A B. Funds and personal properly accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. C. Educational field trips are provided. D D. Progress reports are distributed to all students on a regular and consistent schedule. A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 462 of 740 Corrective Action Required/comments A We have a mental health ratio of 1:133. We have a case management ratio of 1:266. School commenced on 8/26/2014. A No Field Trips were conducted this month Report cards are distributed every 6 weeks. Progress reports are distributed every 3 weeks. The last report cards issued out were on December Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 12/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M E. A. B. C D. E. F. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available All children ages 0-11 remain under constant supervision of their mother. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 463 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A D D A A There were at least 3 documented instances of children being left unattended on 12/5, 12/6, 12/14 12/20 & 12/27. The older children are not having their Hall Passes displayed for staff to see when in the common areas. GEO staff is not enforcing this item. Due Date Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available Rating AR/NA A A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. D C. Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents D. E. Fire prevention/control/evacuation plan Conduct fire/evacuation drills according to schedule/standard A A F. Staff trained to prevent contact with blood and bodily fluids D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 464 of 740 Corrective Action Required/comments The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. On 2/1910 gallons of SANI-10 missing , dating and sizing errors in log A Trained as per their files but most don't use protective gear Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE Enforcement Rating AR/NA Corrective Action Required/comments as trained. Witnessed 2/02 A G. Emergency generators are tested bi-weekly H. Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken I J. K. 7 A. B. C. D. • E. F. G. H. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used unfil they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspecfion Transporting officers limit driving lime to 10 hours in any 15 hour period when transporting residents MI officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 465 of 740 R Forms currently in use have numerous typing errors making comprehension of the matrial difficult A D A A A A A A A A A 2/7, 2/10, 2/21 partially eaten food strewn around the compound, residents suites still have writing on walls and sticky tables and chairs Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequen D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. G. applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within timeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system E. Residents are assigned color coded uniforms/wrist bands to reflect classification level 6. Contraband A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 466 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A D 2/2 Resident handbook states that 4 copmplete sets of clothing will be handed out standard also stales 6 sets for adults and 10 for children A A A A NA Wrist bands are no longer utilized in our facility and all residents are low N/A Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. A. B. Policy in place for handling contraband Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband 7. Facility Security and Control Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Enforcement Rating AR/NA A A D D A D C. Front entrance staff inspect ID of everyone entering/exifing D. Maintain a log of all incoming and departing vehicles A • E. Housing unit searches occur at irregular times A !2/2, F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A H. Facility administrator or designee and department heads visit housing units and activity areas weekly D • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 467 of 740 Corrective Action Required/comments 2/7, 2/10, 2/21 Staff does not enforce the no food from the dining hall, residents still hoarding food in their suites 2/7, 2/10, 2/21 While staff are visable the log books are not stating security checks are being conduct at frequent yet irregular intervals, staff never seen checking suites visually Staff at central control is doing this and not the assigned front lobby/visiting officer 2/21 the log books do not annotate area searches This facility no longer has a perimeter fence and contrusfion is on going for expansion. 2/7, 2/10, 2/19 Short term care, Law Library, and recreation logs do not have a log of any department head visits, hall Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M I J. K. L. M. • N. 0. Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 468 of 740 Rating A/D/R/NA R D Corrective Action Required/Comments logs are missing department head signatures Current Staffing percentage for Feb is 86.8%.This is taking into account the new staffing analysis of 189 authorized employees. 2/21, 2/22 the gym opened late or closed early due to lack of staffing or inappropriate scheduling, 2/21, 2/22 the kitchen had 4 staff during meal service A A A N/A A The facility does not have a fence or a perimeter alarm. Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D PERFORMANCE MONITORING MEASURE W M • P. The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc Q. • The facility shares intelligence informafion with ICE S. Funds and Personal Property A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff E. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged 9. Waiting Room in Residential Facilities A. Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placemenl in B. wailing room C. Maintain monitoring log for each resident in waiting room •D. Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents E. held F. The maximum occupancy for the hold room will be posted A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 469 of 740 Rating AR/NA D D Corrective Action Required/comments We no longer have an Inteligence Officer who would be assigned to gather this information. Failed to formaly inform the COR of 3 staff being suspended for security violations/breach A A A A A A A A A A A A A Fire evacuation plan is posted. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA A. No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices B. Emergency keys are available for all areas of the facility A C. D. Chit system used to issue security equip./keys/radios A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. At least two officers participate in count for each area Recount conducted when incorrect count is reported D A G. I J. E. F. D. A A A A A A D Face to photo count conducted A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 470 of 740 Corrective Action Required/comments A resident census takes place at 0730hrs, 1600hrs & 2000hrs. 2/7, 2/10, 2/21, 2/22 All residents report to the dayrooms for count and only one GEC staff is routinely present at these counts Staff routinely do not verify the children to their IDs, Mother often report without the entire family unit Due Date Attachment 5.B. S Immigration U• • Customs „F. s and (tsPr Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M E. Each resident positively identified during count 12. Post Orders Rating AR/NA D A. Every post has a post order, current & signed by the facility administrator D B. C. Housing unit officers record all resident activity in a log Supervisor visits each housing area once per shift D A D N/A No armed posts. A B. D C. D. •A. B. C. Residents are advised of the program All staff are trained, initially and in annual refresher training, in the A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 471 of 740 2/7, 2/10, 2/21 Kitchen and Cedar Hall Post Orders missing the first 3-4 pages Most logs state "watch call complete" or the equivilant, most logs don't show any type of resident activities 2/7, 2/10, 2/19 Compound Counselor, Medical Counselor posts are missing signatures Staff sign post orders, regardless of whether the assignment s D. temporary, permanent, or due loan emergency Anyone assigned to an armed post qualifies with the post weapons E. before assuming post duty 13 Searches of Residents A. Unit shakedowns are conducted Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and Intervention Program Corrective Action Required/comments A A A A A 2/7, 2/10, 2/19 No searches are annotated in the log books Due Date . Attachment 5.B. Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequen D w M H '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations PERFORMANCE MONITORING MEASURE Rating A/D/R/NA prevention and intervention areas D. A. Sexual Assault Awareness Notice is posted on all housing unit bulletin boards 16. Staff-Resident Communication Housing unit rounds conducted daily by security staff B. Housing unit rounds conducted daily by Deportafion Staff C. Resident requests answered within 72 hours A A A A A D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis A F. G. • • Corrective Action Required/Comments H. A. B. C. D. E. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 472 of 740 Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. A A R They occur daily Only supervisors routinely report conditions A A A D A Staff only does the inventory when the contractor goes into a resident area Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE • F. G. H. A. B. C. D. E. • F. G. A. B. C. D. E. A. B. A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 473 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A A A R A A A CEO is only using one Corrective Action against the residents at this time Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA R E. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A C. D. I J. K. L. M. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 474 of 740 Corrective Action Required/comments 2/21 grill grease traps were full, night shift routinely leaves cleaning to be done by day shift for ovens on grill A A D A A The facility has a 42 day cycle menu. 2/9 chicken tenders were substituted in for the children and menu called for chicken patties, Ravioli was served rather then Spagetfi, 2/172 side dishes were mixed together, All were under the required serving sizes A D Until 2/1, 2/7, 2/8, 2/14, 2/15, 2/21/ 2/22, 2/28 kitchen staff Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA the residents, A. B. C. D. The ESA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A N. A. B. C. !Thefacility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 475 of 740 D A A A A A A A A A A A Corrective Action Required/Comments was still responsible for security in addition to cooking No FSA for most of the month of Feb, snacks are routinely out or low, some were found moldy 2/22 Due Date Attachment 5.B. .vi‘RTIf1/4 U.S. Immigration f r and • • Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating ND/RNA / A Corrective Action Required/Comments K. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an L. adequate amount of unencumbered space per requirements. M. The medical department is maintained at a high level of sanitation N. 0. P. Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, A A A R A A 0. A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. The Negative Air Pressure rooms were originally built for single occupancy. Immunizations have been offered to children and adolescents. 23. Personal Hygiene A. Clothing provided upon intake and exchanged weekly B. C. Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 476 of 740 A A A Residents are able to get clothing washed Monday — Friday by the laundry department. Now being provided at intake Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. • Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear G. white uniforms. 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 477 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A A A A Voluntary workers wear Red/Pink shirt or grey sweaters and blue jeans Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. G. • A. A. A. B. C. D. E. F. A. Legal mail opened in front of resident Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or common areas, and resident handbook Facility has a system for residents to purchase stamps SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 478 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A NA A A D A A A R A A 2/21, 2/22 Indoor recreation has been found closed and locked during open hours No posted limits to staffing ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M B. • Authorized religious items are allowed in resident possession 31. Telephone Access A. Upon intake, residents are made aware of phone policies B. Out of order phones reported to service provider C. Telephones inspected by staff D. Telephone access rules posted in each housing unit E. The number for the ICE OIG is posted in housing units F. The pro bono list is posted in housing units G. Emergency phone call messages delivered to residents H. Special access calls are available to residents I Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and identified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate E. Residents receive proper training and safety equipment Resident housekeeping meets standards for neatness, cleanliness F. and sanitation A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 479 of 740 Rating A/D/R/NA A Corrective Action Required/Comments A A A A A A A A A A A A A A A A A A A A A D There are drawings on the walls and doors from children. There Due Date Attachment 5.B. Enforcement and Removal Operations - „.F. Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Rating AR/NA D S Immigration U• • Customs and Enforcement Corrective Action Required/comments are also large amounts of food (some spoiled) being found in the suites. In addition multiple showers were found to have mold and mildew. Residents are still being found unaccompanied by their mothers. 2/7, 2/10, 2/22 Most staff stated they had not been given a copy of the resident handbook and did not know what was considered contraband A. Staff aware of handbook contents and follow procedures R Available in both English and Spanish and/or second most prevalent B. language A !Contractor stated they must get approval from JFRMU before changes could be implemented and descrepencies were found in the new handbook for Jan 2015 and still have yet to be D C. Handbook is updated as necessary corrected D. Orientation material available to illiterate residents A 35. Grievance System A. Grievance procedures in place A B. Staff awareness of procedures for emergency grievances A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 480 of 740 Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. A. B. C. D. E. F. G. H. •A. B. C. D. A. B. C. Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for residents Legal materials/law library current and available for residents Resident access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm. 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 hours prior to presentation Residents in SMU receive separate presentafion Facility ensures adequate presentations so all residents wanting to attend have the opportunity 38. Detention Files Detention file created for each new arrival Detention files contain documents generated during custody Detention files maintained in a secure area A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 481 of 740 Enforcement Rating AR/NA Corrective Action Required/comments R A D Staff routinely does informal resolutions without writing it up and logging it A A N/A A A A A A A A N/A A A A A Our facility does not have an SMU. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE A. A. B. C. 39. News Media Interviews and Tours The facility has a procedure to address news media interview and tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents Rating A/D/R/NA A A A D A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. A A B. Funds and personal properly accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. C D. Educational field trips are provided. Progress reports are distributed to all students on a regular and A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 482 of 740 Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 1:266. A A D A No Field Trips were conducted this month. 2n° month in a row Report cards and Parent Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 2/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA consistent schedule, teacher conferences were held 2/16 A. B. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available C. All children ages 0-11 remain under constant supervision of their mother. E. D. E. F. Corrective Action Required/comments All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 483 of 740 A A A D D A R Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. 2/23 staff ratio and room capacity were exceeded. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available Rating A/D/R/NA A A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. C. Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents D. Fire prevention/control/evacuation plan A E. Conduct fire/evacuation drills according to schedule/standard A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 484 of 740 Corrective Action Required/Comments R The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. 1/13 labels were missing or falling off of the Top Clean, one bottle of Spray was partially used and not annoted on the log A A fire drill was conducted facility wide with almost 100% Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE Enforcement Rating AR/NA Corrective Action Required/comments compliance from the residents F. G. H. I J. K. A. B. C. D. E. F. Staff trained to prevent contact h blood and bodily fluids Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour period when transporting residents I') officers with valid Commercial Drivers Licenses, (CDL's) MI required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 485 of 740 A A A A R 1/13, 1/27 trash is still strewn about the compound without consequence, writing on the walls and doors from children , 1/23 numerous suites required additional cleaning still at 1400 A A A A A A A Facility is not using buses at this time Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. H. A. B. C. D. E. F. G. Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within timeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system E. Residents are assigned color coded uniforms/wrist bands to reflect classification level A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 486 of 740 Enforcement Rating AR/NA A Corrective Action Required/comments A A A A A A D 1/13 Resident handbook stales that 4 copmplete sets of clothing will be handed out and most residents are not receiving all clothing at admission A A A A NA A Wrist bands are no longer utilized in our facility. Residents now wear their ID as a necklace. Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W A. B. C. A. B. • • and Customs Enforcement Month/Year: 1/2015 PERFORMANCE MONITORING MEASURE M U.S. Immigration 6. Contraband Policy in place for handling contraband Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband 7. Facility Security and Control Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Rating A/D/R/NA Corrective Action Required/Comments A A D D A 1/13, 1/27 While the facility makes random contraband inspections numerous rooms have excessive amounts of juices, milks, or fruit While staff are visable the log books are not staling security checks are being conduct at frequent yet irregular intervals Staff at central control is doing this and not the assigned front lobby/visiting officer C. Front entrance staff inspect ID of everyone entering/exifing D D. Maintain a log of all incoming and departing vehicles A A E. Housing unit searches occur at irregular times !1/13, 1/27 the log books do not F. Area searches documented in log book D annotate area searches This facility no longer has a perimeter fence and contrusfion G. Daily/Monthly fence checks completed and logged N/A is on going for expansion. Facility administrator or designee and department heads visit Short term care, Law Library, H. housing units and activity areas weekly D and recreation logs do not have A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 487 of 740 Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M I J. K. L. M. Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 488 of 740 Rating A/D/R/NA R D A A A Corrective Action Required/Comments a log of any department head visits/facility is also using a loose paper log rather than the log book and this makes it easy for back logging missing weeks, on 1/6 found that the ESA had signed her spots weeks inadvanced Current Staffing percentage for Jan is %.This is taking into account the new staffing analysis of 189 authorized employees. 1/8, 1/13, 1/17 the gym and library opened late or closed early due to lack of staffing or inappropriate scheduling, 1/10 the kitchen had 3 of the 6 workers allotted by contract Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and 0. inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone P. surveillance, high profile residents, visiting room activities, etc Q. The facility shares intelligence information with ICE S. Funds and Personal Property A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff E. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged 9. Waiting Room in Residential Facilities •N. • • Enforcement Rating AR/NA N/A A R A A A Residents are not held in waiting rooms longer than 12 hours A B. C. All residents wanded with a metal detector prior to placement n waiting room Maintain monitoring log for each resident in waiting room A A Page 489 of 740 We no longer have an Inteligence Officer who would be assigned to gather this information. A A A A A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/comments The facility does not have a fence or a perimeter alarm. Residents are no longer held in Hold Rooms, the doors no longer locked. The rooms are now called Waiting Rooms. There is a metal detector at the entrance to intake from the sally port. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M D. Rating A/D/R/NA A A. Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices B. Emergency keys are available for all areas of the facility A E. F. • G. I J. A A A A Chit system used to issue security equip./keys/radios A A A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. D. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted D A A E. F. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 490 of 740 Fire evacuation plan is posted. A A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts C. D. Corrective Action Required/Comments A A A resident census takes place at 0730hrs, 1600hrs & 2000hrs. All residents report to the dayroorns for count and only one GEO staff is routinely present at these counts Every count requires a resident Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M E. A. B. C. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator Rating A/D/R/NA A A D A A. Housing unit officers record all resident activity in a log Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignments temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents Unit shakedowns are conducted Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and Intervention Program B. Residents are advised of the program A C. All staff are trained, initially and in annual refresher training, in the prevention and intervention areas A D. E. A. B. C. D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 491 of 740 Corrective Action Required/Comments to show their ID Most logs state "watch call complete" or the equivilant, most logs don't show any type of resident activities A N/A A A A A A No armed posts. Due Date Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D w M PERFORMANCE MONITORING MEASURE D. A. Sexual Assault Awareness Notice is posted on all housing unit bulletin boards 16. Staff-Resident Communication Housing unit rounds conducted daily by security staff B. Housing unit rounds conducted daily by Deportafion Staff C. Resident requests answered within 72 hours Rating AR/NA A A A A A D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis A F. G. • H. A. B. C. D. •E. F. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspecfion system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 492 of 740 Corrective Action Required/comments A A A A A A A A A Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. H. A. B. C. D. E. F. G. A. B. C. D. E. Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Rating A/D/R/NA A A A A A A A A A A A A A A B. Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food C. Food Service department maintained at a high level of sanitation D A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 493 of 740 Corrective Action Required/Comments Handbook has been updated an now has this section GEO is only using one Corrective Action against the residents at this time A A 1/1, 1/13 the grills and the ovens had excessive build up of Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequen• c PERFORMANCE MONITORING MEASURE DWM Rating A/D/R/NA Corrective Action Required / Comments grease A E. The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A D. • I J. K. A M. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. R N. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. R L. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 494 of 740 D A A The facility has a 42 day cycle menu. 1/17 the kitchen staff attempted to use pace picante sauce and tomato soup as tomato stew and was not annotated fill ICE staff took note A Until 1/13 kitchen staff was still responsible for security in addition to cooking 1/3, 1/ 4, 1/5 rotation of milk not occurring, milk was found to pass the sell by dates, 1/17, 1/23 numerous times throughout the day dayroom Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Corrective Action Required/comments refrigerators were found to be low or out of fruit A. B. C. D. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A A. B. C. !Thefacility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability K. L. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 495 of 740 A A A A A A A A A A A A A Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M M. N. 0. P. cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, Q. Rating A/D/R/NA Corrective Action Required/Comments A A R A A A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. The Negative Air Pressure rooms were originally built for single occupancy. Immunizations have been offered to children and adolescents. 23. Personal Hygiene A. Clothing provided upon intake and exchanged weekly B. C. Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair A D. E. F. G. Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear A A A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 496 of 740 A A Residents are able to get clothing washed Monday — Friday by the laundry department. Now being provided at intake Voluntary workers wear grey Due Date Attachment 5.B. .vi‘RTIf1/4 U.S. Immigration f r and • • Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W M • • PERFORMANCE MONITORING MEASURE white uniforms, 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 497 of 740 Enforcement Rating A/D/R/NA A A A A A A A A A A A A A A NA Corrective Action Required/Comments sweaters and blue jeans Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenck D W M PERFORMANCE MONITORING MEASURE • A. A. A. B. C. D. E. F. A. B. A. 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 498 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A D A A A D A A A A Indoor recreation has been found closed and locked during open hours on numerous occasions during the month On the following dates the gym was found closed (early) during posted open hours: 1/8,1/13, 1/17 outdoor basketball court has been converted into a sealing area and outdoor ping-pong area with no shade Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M B. C. D. E. F. G. H. I Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and identified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate E. Residents receive proper training and safety equipment • F. Resident housekeeping meets standards for neatness, cleanliness and sanitation A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 499 of 740 Rating AR/NA A A A A A A A A Corrective Action Required/comments A A A A A A A A A A A A D There are drawings on the walls and doors from children. There are also large amounts of food (some spoiled) being found in the suites. In addition multiple Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. A. B. C. D. A. B. C. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Rating A/D/R/NA D Corrective Action Required/Comments showers were found to have mold and mildew. Residents are still being found unaccompanied by their mothers. R 1/1, 1/23, 1/29 Most staff stated they had not been given a copy of the resident handbook and did not know what was considered contraband A D A A A D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 500 of 740 Contractor stated they must get approval from JFRMU beforechanges could be implemented and descrepencies were found in the new handbook for Jan 2013 1/14 CEO stated they had not received any grievances but 3 were found in the ICE box and handed over Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention E. file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters H. A. B. Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm. 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 hours prior to presentation C. Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 501 of 740 Enforcement Rating AR/NA A Corrective Action Required/comments A A A N/A A A A A On the following dates the library was found closed (early) during posted open hours:1/17, Opned Late:1/10, 1/17, 1/18 R A A N/A A A A Our facility does not have an SMU. Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W M A. A. B. C. and Customs Enforcement Month/Year: 1/2015 PERFORMANCE MONITORING MEASURE C. U.S. Immigration Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and tours in accordance with NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents Rating A/D/R/NA A A A A R A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. A A B. Funds and personal properly accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. C. Educational field trips are provided. A. Page 502 of 740 We have a mental health ratio of 1:76. We have a case management ratio of 1:266. A A R A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments No Field Trips were conducted this month Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 1/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M D. E. L A. B. C. D. E. F. Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available All children ages 0-11 remain under constant supervision of their mother. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 503 of 740 Rating A/D/R/NA A Corrective Action Required/Comments Report cards are distributed every 6 weeks. Progress reports are distributed every 3 weeks. The last report cards issued out were on December 1ff. A A A R R A A There were at least 3 documented instances of children being left unattended on 1/01, 1/13, 1/14, 1/23, 1/28, 1/29 The older children are not having their Hall Passes displayed for staff to see when in the common areas. GEO staff is not enforcing this item. Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • Rating AR/NA Corrective Action Required/comments I. Emergency Plans A. B. C. D. E. F. Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available R A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety R A. System for storing/issuing/maintaining hazardous materials A B. D C. Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents D. Fire prevention/control/evacuation plan R A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 504 of 740 Staff is trained but most staff is new and not fully aware how to read resident behavior MOUs are out of date, and POAs have been requested for Emergency Plans, pending date of Aug 12 for close out 7/8 inventories checks and were missing 5gal of I-Shine, 2 15gal of Liquid Alkali, and improper labeling of inventory sheets for Pot-Pan cleaner A Plans are extremely hard to understand and read like Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M E. M F. G. H. I J. K. A. B. C. D. E. F. Enforcement Rating AR/NA Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken D A A Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations A 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour period when transporting residents Two officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 505 of 740 Corrective Action Required/comments policies, POA pending close out Aug 12 Contractor has not supplied the reports for over 4 months A A A A A A A A A Steady decline of population has helped with maintaining cleanliness Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. H. A. B. C. D. E. F. G. Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within timeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classificafion system Residents are housed by age groups based upon the children E. 6. Contraband A. Policy in place for handling contraband • B. C. Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 506 of 740 Rating A/D/R/NA A Corrective Action Required/Comments A A A A A A A A A A A NA A A R D Documentation in log books is infrequent food being taken from dining Due Date Attachment 5.B. '"RT41/4 U.S. Immigration f .0r and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments hall and no GEO staffseen stopping this activity 7. Facility Security and Control A. B. C. D. E. Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exifing Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times D A A R A F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A H. Facility administrator or designee and department heads visit housing units and activity areas weekly R I Comprehensive staffing analysis determines staffing needs and plans I • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 507 of 740 Midnight shift has reported that they do NOT routinely enter the residents' suite for safety or security checks Random check of log books still show high discrepancies with what is coming and going from the facility Random check of log books on 7/25 showed this to be an area staff still do not routinely annotate This facility no longer has a perimeter fence and construction is ongoing for expansion. Still using a loose sheet as a log rather than signing a log book Current Staffing percentage for April is and below the 90% in the contract Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE Rating A/D/R/NA Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and pracfice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc R Q. The facility shares intelligence information with ICE 8. Funds and Personal Property R A. B. C. D. E. Inventory personal property/funds is maintained Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box R A A A A J. K. L. M. • N. 0. P. R A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 508 of 740 mental health staff is short staffed Staff is not properly logging entries as seen on 7/25 A A N/A R D • • Corrective Action Required/Comments The facility does not have a fence or a perimeter alarm. Hoses were not properly logged when taken by security staff We no longer have an Inteligence Officer who would be assigned to gather this information. Administration has made improvements since May 1 letter outstanding for withheld funds Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M F. G. A. B. C. D. E. F. • G. I J. Staff secure every container used to store property with a tamperproof numbered strap Quarterly audits of resident baggage & luggage are conducted, verified, and logged 9. Waiting Room in Residential Facilities Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement in waiting room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds (other then cribs) or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Rating A/D/R/NA A A A A A A A A A A A A. Maintain inventories of all keys/locks/locking devices A B. Emergency keys are available for all areas of the facility A C. Chit system used to issue security equip/keys/radios A D. Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily A E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 509 of 740 Corrective Action Required/Comments A It is done weekly at this facility Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M F. Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts Rating A/D/R/NA Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. D. E. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator D A A A Housing unit officers record all resident activity in a log D C. R A. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents Unit shakedowns are conducted B. Random shakedowns conducted & documented E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 510 of 740 JFRMU mandate does not allow census on the midnight shift 7/13, 7/15 and 7/25 only witnessed 1 officer conducting count on each hall A B. D. Due Date A A. A. Corrective Action Required/Comments R N/A R R 7/25 a thorough check of log books showed major events are still not being annotated Not normally in the log book and some posts don't show it in the post order sign off sheet Most staff do not sign when only giving breaks (b)(7)(E) Not logged in the log books 7/12 and 7/25 most staff still does not properly annotate this [ Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. • •A. B. The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and Intervention Program • A A Corrective Action Required/Comments item/GEO uses loose sheets of paper as logs A random schedule has been implemented A A Residents are advised of the program All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • Rating A/D/R/NA B. Housing unit rounds conducted daily by Deportation Staff C. Resident requests answered within 72 hours D. ICE SRC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 511 of 740 A A A A A A A A A A They occur daily Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. G. H. A. B. C. D. E. F. G. A. B. C. D. 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/cataloged for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 512 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A D A A A A A A A A A A A A A Hose was missing from its spot on 7/8 Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food A A D. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). E. Residents receive safety and appropriate equipment training prior to beginning work in department R F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A E. A. B. C. • I J. K. L. M. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 513 of 740 Corrective Action Required/comments A A A R A A A A New supervisor plan in place is ensuring quality control No 0-1 yr old children at this time Residents are not wearing safety boots/shoes as required in the kitchen The facility has a 42 day cycle menu. Unknown with 2 entrees being offered at all meals now and no menu provided to the COR Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M N. A. B. C. The ESA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Rating A/D/R/NA A A A. B. C. D. Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A !Thefacility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability K. L. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 514 of 740 Corrective Action Required/Comments R A A A A A A A A A A A Some staff do not know even after training Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. M. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical N. examinations with male health care providers. 0. P. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations. Q. A. B. C. D. E. F. G. Enforcement Rating AR/NA Corrective Action Required/comments A A R A The Negative Air Pressure rooms were originally built for single occupancy. A 23. Personal Hygiene Clothing provided upon intake and exchanged weekly Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear approved uniforms. 24. Suicide Prevention and Intervention A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 515 of 740 A A A A R A A Took over 3min for water temp to get above 100 in medical Due Date Attachment 5.B. '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc DWM • PERFORMANCE MONITORING MEASURE The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies A. The Field Office Director considers and approves, on a case-by-case A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 516 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A NA A Corrective Action Required / Comments Due Date Attachment 5.B. Enforcement and Removal Operations - Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. A. B. C. D. E. L F. A. B. A. B. C. D. E. F. G. H. basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 517 of 740 Rating AR/NA „P. S Immigration U• • Customs and Enforcement Corrective Action Required/comments A A A A A R A A A A A A A A A A A No posted limits to staffing ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M I Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and idenfified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate • Rating A/D/R/NA A Corrective Action Required/Comments A A A A A A A A A A A G. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook D Kitchen does not enforce the safety shoe wearing Housekeeping has improved but numerous residents' rooms have been found with contraband food,room temp milks and cheese Child residents are still being found unaccompanied by their mothers. A. Staff aware of handbook contents and follow procedures D At night and on weekends staff are seen not enforcing E. Residents receive proper training and safety equipment !Residenthousekeeping meets standards for neatness, cleanliness F. and sanitation A s Acceptable D s Deficient R s At-Risk NA s Not Applicable Page 518 of 740 R R Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments rules/procedures B. C. D. A. B. C D. E. A. B. C. D. E. F. G. H. •A. Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for residents Legal materials/law library current and available for residents Resident access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm. 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 519 of 740 A A A Videos are provided A A R R D A A N/A A A A A A A Population has been low but previous month issues were not adequately resolved Staff routinely does informal resolutions without writing it up and logging it Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Posters announcing presentation appear in common areas at least 48 hours prior to presentation Residents in SMU receive separate presentafion Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and A. annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to C. be greater than 25:1. 41. Transfer of Residents B. C. Rating A/D/R/NA A N/A A A A A A A R Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. Funds and personal property accompany resident A Page 520 of 740 Facility does not have an SMU. A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 2:133. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 7/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. A. B. A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided monthly Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available C. All children ages 0-11 remain under constant supervision of their mother. A. B. C. D. E. D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines, A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 521 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A D D A A No infants for the month Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W and Customs Enforcement Month/Year: 6/2015 PERFORMANCE MONITORING MEASURE M • U.S. Immigration Rating A/D/R/NA Corrective Action Required/Comments I. Emergency Plans A. B. C. D. Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety R A A A A A C. System for storing/issuing/maintaining hazardous materials Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents D. Fire prevenfion/control/evacuafion plan A E. F. G. Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal E. F. G. A. B. H. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 522 of 740 Staff is trained butmost staff is new and not fully aware of resident behavior A A A The last table top discussion was conducted June 17 2015 A D A A R Contractor has not supplied the reports for over 3 months Staff has gone thru retraining Forms currently in use have numerous typing errors making comprehension of the matrial Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M I J. K. Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been A. repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour C., periqd when transporting residents I (b)( I officers with valid Commercial Drivers Licenses, (CDL's) D. required in any bus transporting residents Policies and procedures are in place addressing the use of E. restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in F. accordance with the Use of Force standard ' G. Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where H. applicable. 4. Admission and Release A. ICE information is available for initial classification A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 523 of 740 Rating A/D/R/NA Corrective Action Required/Comments difficult/a liability A R A A A A A A A A A A Nights and weekends the facility still has trash and half eaten food lying around Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE B. C. D. E. F. G. Medical screening taking place within fimeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language A. B. C. 5. Classification System All residents classified appropriately upon arrival Reassessment and reclassification process in place Housing assignments are based upon classification D. Work assignments are based upon classification system Residents are housed by age groups based upon the children E. Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A NA A A. 6. Contraband Policy in place for handling contraband A B. Contraband disposed of properly and documented R C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 524 of 740 D Documentation in log books is infrequent Log books do not reflect daily or even routine inspecfions for contraband/food being taken from dining hall and no GEO staffseen stopping this activity Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • A. B. C. D. E. • Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exiting Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times Rating AR/NA D A A R A F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A H. Facility administrator or designee and department heads visit housing units and activity areas weekly R I Comprehensive staffing analysis determines staffing needs and plans D • J. K. Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 525 of 740 D R Corrective Action Required/comments Midnight shift has reported that they do NOT routinely enter the residents suite for safety or security checks Random check of log books still show high discrepancies with what is coming and going from the facility Random check of log books on 6/28 showed this to be an area staff still do not annotate This facility no longer has a perimeter fence and construction is ongoing for expansion. Still using a loose sheet as a long rather than signing a log book Current Staffing percentage for April is 86.62 and below the 90% in the contract mental health staff is short staffed Staff is not properly logging entries as seen on 6/28 Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc DWM PERFORMANCE MONITORING MEASURE L. M. • N. 0. P. The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc Rating A/D/R/NA A A N/A The facility shares intelligence information with ICE 8. Funds and Personal Property A. B. C. D. E. F. Inventory personal property/funds is maintained Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperproof numbered strap G. Quarterly audits of resident baggage & luggage are conducted! verified, and logged A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 526 of 740 The facility does not have a fence or a perimeter alarm. A D • Q. Corrective Action Required / Comments R R A A A A We no longer have an Inteligence Officer who would be assigned to gather this information. Administration has made improvements since May 60 outstanding letters for resident closed accounts A A It is done weekly at this facility Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc A. B. C. D. E. F. G. I J. and Customs Enforcement Month/Year: 6/2015 PERFORMANCE MONITORING MEASURE DWM U.S. Immigration 9. Waiting Room in Residential Facilities Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placemenl in wailing room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds (other then cribs) or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items. diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Rating A/D/R/NA A A A A A A A A A A. Maintain inventories of all keys/locks/locking devices A B. Emergency keys are available for all areas of the facility A C. Chit system used to issue security equip/keys/radios A D. Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts Staff conduct formal census at least once per 8 hour shift/ 3x per day A E F. A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 527 of 740 Corrective Action Required / Comments A A A JFRMU mandate does not Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M B. C. D. E. A. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator Rating AR/NA A Housing unit officers record all resident activity in a log D C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13 Searches of Residents Unit shakedowns are conducted R Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention R E. A. B. C. D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 528 of 740 allow census on the midnight shift 6/5, 6/12, and 6/28 only witnessed 1 officer conducting count on each hall D A A A B. D. Corrective Action Required/comments 6/28 a thorough check of log books showed major events are still not being annotated Not normally in the log book and some posts don't show it in the post order sign off sheet Most staff do not sign when only giving breaks R N/A R A A J (b)(7)(E) Not logged in the log books 6/28 most staff still does not properly annotate this item. A random schedule has been implemented Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequen D The facility has a Sexual Abuse and Assault Prevention and Intervention Program A B. Residents are advised of the program A All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff B. C. • Rating A/D/R/NA A. C. • and Customs Enforcement Month/Year: 6/2015 PERFORMANCE MONITORING MEASURE M U.S. Immigration Housing unit rounds conducted daily by Deportafion Staff Resident requests answered within 72 hours D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. Tool inventories conducted as specified B. Tools marked and readily identifiable C. Procedures for issuance of tools to staff and residents • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 529 of 740 Corrective Action Required/Comments 6/28 New posters are up A A A A A A Staff Resident Communication Schedule is posted in Dayrooms and common areas. A A A A A A A They occur daily Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. G. H. A. B. •C. D. E. F. G. A. B. C. D. E. A. Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard IS. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 530 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A A A A A Corrective Action Required/Comments Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M B. C. Appropriate food temperatures are maintained for both hot and cold food Enforcement Rating AR/NA A A D. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). E. Residents receive safety and appropriate equipment raining prior to beginning work in department R F. A minimum of two hot meals served daily A G. Facility has a standard 35 day cycle menu A H. A registered dietician conducts nutritional analysis A All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. The FSA shall ensure availability of snacks, fruits, Juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes R A R •I J. K. L. M. N. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 531 of 740 Corrective Action Required/comments A New supervisor plan in place is ensuring quality control No 0-1 yr old children at this time Residents are not alaways wearing safety boots/shoes as required The facility has a 42 day cycle menu. New menu implemented mid month Unknown with 2 entrees being offered at all meals now One shift will sign for all shifts A A A New supervisor plan in place is ensuring quality control Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours F. Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. Sick call slips available in English, Spanish and/or most prevalent second language G. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required A. B. C. D. E. H. I J. Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an L. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 532 of 740 Rating A/D/R/NA Corrective Action Required/Comments A R A Some staff do not know even after training A A A A A A A R A A A A Some confusion about HIPPA law requirements for departing residents Now placed into OAK Hall rooms instead of undersized medical rooms Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M adequate amount of unencumbered space per requirements. M. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical N. examinations with male health care providers. 0. P. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations. B. C. D. E. F. G. Rating AR/NA Corrective Action Required/comments A A R A The Negative Air Pressure rooms were originally built for single occupancy. A Q. A. Enforcement 23. Personal Hygiene Clothing provided upon intake and exchanged weekly Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear approved uniforms. 24. Suicide Prevention and Intervention A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 533 of 740 A A A A D A A Medical and intake did not register above 100 during ICE spot checks Due Date Attachment 5.B. '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc DWM • PERFORMANCE MONITORING MEASURE The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies A. The Field Office Director considers and approves, on a case-by-case A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 534 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A NA A Corrective Action Required / Comments Due Date Attachment 5.B. Enforcement and Removal Operations - Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. A. B. C. D. E. L F. A. B. A. B. C. D. E. F. G. H. basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 535 of 740 Rating AR/NA „P. S Immigration U• • Customs and Enforcement Corrective Action Required/comments A A A A A R A A A A A A A A A A A No posted limits to staffing ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M I Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and idenfified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate • Rating A/D/R/NA A Corrective Action Required/Comments A A A A A A A A A A A G. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook D Kitchen does not enforce the safety shoe wearing Housekeeping has improved but numerous residents' rooms have been found with contraband food,room temp milks and cheese Residents are still being found unaccompanied by their mothers. A. Staff aware of handbook contents and follow procedures D At night and on weekends staff are seen not enforcing E. Residents receive proper training and safety equipment !Residenthousekeeping meets standards for neatness, cleanliness F. and sanitation A s Acceptable D s Deficient R s At-Risk NA s Not Applicable Page 536 of 740 R R Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments rules/procedures B. C. D. A. B. C D. E. A. B. C. D. E. F. G. H. •A. Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for residents Legal materials/law library current and available for residents Resident access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm. 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 537 of 740 A A A Videos are provided A A D R D A A N/A A A A A A A Routinely told "it's not greivable" and GEO will not utilize the log Staff routinely does informal resolutions without writing it up and logging it Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Posters announcing presentation appear in common areas at least 48 hours prior to presentation Residents in SMU receive separate presentafion Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and A. annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to C. be greater than 25:1. 41. Transfer of Residents B. C. Rating A/D/R/NA A N/A A A A A A A R Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. Funds and personal property accompany resident A Page 538 of 740 Facility does not have an SMU. A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 2:133. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 6/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. A. B. A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided monthly Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available C. All children ages 0-11 remain under constant supervision of their mother. A. B. C. D. E. D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 539 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A D D A A No infants for the month Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. Still pending acceptance or rejection notice Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D i M PERFORMANCE MONITORING MEASURE Rating A/D/R/NA Corrective Action Required/Comments I. Emergency Plans A. B. C. D. E. F. Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available R A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. R C. Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents D. E. Fire prevention/control/evacuation plan Conduct fire/evacuation drills according to schedule/standard A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 540 of 740 Staff is trained but staff shows signs of apathy and not following through on training A The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. A check of the system this month showed compliance but it has had numerous issues in the past 6 months Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M F. G. Staff trained to prevent contact h blood and bodily fluids Emergency generators are tested bi-weekly H. Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken I J. K. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicafing safety repairs are completed immediately and vehicles are not used unfil they have been A. repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspecfion Transporting officers limit driving lime to 10 hours in any 15 hour C.period when transporting residents 1(b)(7l officers with valid Commercial Drivers Licenses, (CDL's) D. required in any bus transporting residents Policies and procedures are in place addressing the use of E. restraining equipment on transportation vehicles A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 541 of 740 Enforcement Rating AR/NA R A R Corrective Action Required/comments Staff is trained but not following through with what the standards require with the current cohort Forms currently in use have numerous typing errors making comprehension of the matrial difficult A D A A A A A A 3/1, 3/6, 3/18, 3/20 partially eaten food strewn around the compound, Dayroorn Refrigerators appeared to have dirt and juices at the bottom Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M F. •G. H. A. B. C. D. E. F. G. Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system E. Residents are assigned color coded uniforms/wrist bands to reflect classification level A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 542 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A New Resident Handbook in place and further revisions are pending by JFRMU A A A A NA N/A Wrist bands are no longer utilized in our facility and all residents are low Due Date Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. A. B. • C. D. E. 6. Contraband Policy in place for handling contraband Contraband disposed of properly and documented Facility staff make a concerted effort to control contraband 7. Facility Security and Control Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exifing Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times Rating AR/NA A A R D A D R A F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 543 of 740 Corrective Action Required/comments This item has been enforced for the first half of the month however random room checks showed that not everything has been stopped A plan of action was requested and received on 3/13 for the log books due to improperly logging this requirement Staff at central control is doing this and not the assigned front lobby/visiting officer A plan of action was requested and received on 3/13 for the log books due to improperly logging this requirement This facility no longer has a perimeter fence and contrustion is on going for expansion. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M H. Facility administrator or designee and department heads visit housing units and activity areas weekly I Comprehensive staffing analysis determines staffing needs and plans J. K. L. M. • N. Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 544 of 740 Rating A/D/R/NA D D Corrective Action Required/Comments 3/1, 3/09, 3/25 Short term care, Law Library, and recreation logs do not have a log of any department head visits, hall logs are missing department head signatures Current Staffing percentage for Feb is This is taking into account the new staffing analysis of 189 authorized employees. Contractor has numerous people on suspension without properly trained people to replace them, recreational department was missing 4 of 10 for the entire month A A A N/A The facility does not have a fence or a perimeter alarm. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone P. surveillance, high profile residents, visiting room activities, etc Q. The facility shares intelligence information with ICE S. Funds and Personal Property A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff E. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged 9. Waiting Room in Residential Facilities A. Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement n B. waiting room C. Maintain monitoring log for each resident in waiting room D. Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents E. held F. The maximum occupancy for the hold room will be posted G. No bunks/cots/beds or other related make shift sleeping apparatuses 0. • • p • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 545 of 740 Rating A/D/R/NA Corrective Action Required/Comments A D D We no longer have an Inteligence Officer who would be assigned to gather this information. No Intel Officer for GEO A A A A A A A A A A A A A A Fire evacuation plan is posted. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M I J. are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Enforcement Rating AR/NA A A A. Maintain inventories of all keys/locks/locking devices A B. Emergency keys are available for all areas of the facility A Chit system used to issue security equip./keys/radios A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily A •C. D. E. A F. Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts D A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. At least two officers participate in count for each area Recount conducted when incorrect count is reported D A D. E. Face to photo count conducted Each resident positively identified during count A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 546 of 740 Corrective Action Required/comments R R 3/1, 3/9, 3/25 Kitchen items are missing required locking devices A resident census takes place at 0730hrs, 1600hrs & 2000hrs. 3/1, 3/9, 3/16, 3/25 All residents report to the dayrooms for count and only one GEC staff is routinely present at these counts Compliant this month when observed but has had issues for the last 6 months Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Corrective Action Required/comments 12. Post Orders A. Every post has a post order, current & signed by the facility administrator Housing unit officers record all resident activity in a log Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is D. temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons E. before assuming post duty 13. Searches of Residents A. Unit shakedowns are conducted B. C. B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and A. Intervention Program R D R R N/A D A A • A Residents are advised of the program All staff are trained, initially and in annual refresher training, in the A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 547 of 740 Most staff do not sign when only giving breaks (b)(7)(E) A • B. C. Kitchen and Medical have been replaced and are starting to fall apart again A plan of action was requested and received on 3/13 for the log books due to improperly logging this requirement A A A plan of action was requested and received on 3/13 for the log books due to improperly logging this requirement A random schedule has been implemented Due Date . Attachment 5.B. Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequen D w M H '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations PERFORMANCE MONITORING MEASURE Rating A/D/R/NA prevention and intervention areas D. A. Sexual Assault Awareness Notice is posted on all housing unit bulletin boards 16. Staff-Resident Communication Housing unit rounds conducted daily by security staff B. Housing unit rounds conducted daily by Deportafion Staff C. Resident requests answered within 72 hours A A A A A D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis A F. G. • • Corrective Action Required/Comments H. A. B. C. D. E. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 548 of 740 Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. A A R They occur daily Only supervisors routinely report conditions A A A D A Staff only does the inventory when the contractor goes into a resident area Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE • F. G. H. A. B. C. D. E. • F. G. A. B. C. D. E. A. B. A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 549 of 740 Rating A/D/R/NA R Corrective Action Required/Comments Chits have been missing but logs have been properly maintained A A A A A A A A A A A A R A CEO is only using one Corrective Action against the residents at this time A D Kitchen staff failed to properly log temps and then back dated Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D w and Customs Enforcement Month/Year: 3/2015 PERFORMANCE MONITORING MEASURE M C. U.S. Immigration Rating A/D/R/NA D. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). E. Residents receive safety and appropriate equipment training prior to beginning work in department D F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A I J. K. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. D A A L. M. N. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 550 of 740 R Corrective Action Required/Comments the missing log 3/13 2/21 grill grease traps were full, night shift routinely leaves cleaning to be done by day shift for ovens and grill A Are receiving training but staff is not enforcing the wearing of protective equipement The facility has a 42 day cycle menu. Met with him 3/11 3/7, 3/17 Failed to annotate substitutions A D D 3/1 to 3/18 GEO did not have a constant supervisory presence in the dining hall during meal service 3/1 to 3/18 snacks were routinely out or low Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA A. B. C. D. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A A. B. C. !Thefacility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability K. L. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 551 of 740 Corrective Action Required/comments A A A A A A A A A A A A R Families with varicella have been placed into isolation rooms that do not meet minimum space requirements Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W U.S. Immigration and Customs Enforcement Month/Year: 3/2015 PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments but the facility is under construction at this time M. N. 0. P. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, Q. A A R A A A. 23. Personal Hygiene Clothing provided upon intake and exchanged weekly B. C. Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair A D. E. F. Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements A A A G. Food Service resident volunteers exchange garments daily and wear white uniforms. 24. Suicide Prevention and Intervention A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 552 of 740 A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. The Negative Air Pressure rooms were originally built for single occupancy. Immunizations have been offered to children and adolescents. A A A Voluntary workers wear Red/Pink shirt or grey sweaters and blue jeans Due Date Attachment 5.B. '"RT41/4 U.S. Immigration fr and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc DWM • PERFORMANCE MONITORING MEASURE The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies A. The Field Office Director considers and approves, on a case-by-case A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 553 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A NA A Corrective Action Required / Comments Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W M A. B. C. D. E. L Month/Year: 3/2015 PERFORMANCE MONITORING MEASURE A. F. A. B. A. B. C. D. E. F. G. H. - basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 554 of 740 Rating AR/NA „P. S Immigration U• • Customs and Enforcement Corrective Action Required/comments A A A A A R A A A A A A A A A A A No posted limits to staffing ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W I Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and idenfified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate E. Residents receive proper training and safety equipment • !Residenthousekeeping meets standards for neatness, cleanliness F. and sanitation G. A. and Customs Enforcement Month/Year: 3/2015 PERFORMANCE MONITORING MEASURE M U.S. Immigration Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 555 of 740 Rating A/D/R/NA A Corrective Action Required/Comments A A A A A A A A A A A A D H h otusekeeping has improved bu numerous residents' rooms have been found with t contraband food and room R temp milks Residents are still being found unaccompanied by their mothers. others. R 3/1, 3/9,3/16, 3/27 Most staff stated they had not been given a copy of the resident R Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M B. Available in both English and Spanish and/or second most prevalent language Enforcement Rating AR/NA A • C. D. MI A. B. C. D. Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention E. file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be H. scheduled between Sam & 8pm. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 556 of 740 Corrective Action Required/comments handbook and did not know what was considered contraband R A New handbook approved 3/27 and needs to be translated before distribution A A R R D A A N/A A A A A A Staff routinely does informal resolutions without writing it up and logging it Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 B. hours prior to presentation C. Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientafion, inifial training, and A. annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to C. be greater than 25:1. 41. Transfer of Residents •A. • Rating A/D/R/NA A A N/A A A A A A A R Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A Page 557 of 740 Facility does not have an SMU. A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 1:133. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 3/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE C. D. A. B. C. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Enforcement Rating AR/NA A A A A R A. B. Educational field trips are provided. Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available C. All children ages 0-11 remain under constant supervision of their mother. D D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard D A R D. E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 558 of 740 Corrective Action Required/comments 1 field trip was conduct without proper planning being submitted for review A A A A Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. Contractor has submitted Due Date Attachment 5.B. 1., Enforcement and Removal Operations ‘"Rrt41 Compliance Monitoring Tool Facility Name: KCRC Frequenc D w M Enforcement Month/Year: 3/2015 PERFORMANCE MONITORING MEASURE of Texas Residential Guidelines, S.Immigration and Customs U. Rating A/D/R/NA Corrective Action Required/Comments licensing for shelter care and not residential A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 559 of 740 Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc PERFORMANCE MONITORING MEASURE D i M Rating A/D/R/NA Corrective Action Required/Comments I. Emergency Plans A. B. C. D. E. F. G. A. B. Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety R A A A A A A A A C. System for storing/issuing/maintaining hazardous materials Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents D. Fire prevention/control/evacuafion plan A E. Conduct fire/evacuation drills according to schedule/standard D F. G. Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly R A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 560 of 740 Staff is trained butmost staff is new and not fully aware of resident behavior The last table top discussion was will be conducted June 2015 A Contractor has not supplied the reports for over 2 months Staff is trained but not following through with what the standards require Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W M I J. K. A. B. C. D. E. F. ' G. H. A. and Customs Enforcement Month/Year: 5/2015 PERFORMANCE MONITORING MEASURE H. U.S. Immigration Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour period when transporting residents b)(7 officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 561 of 740 Rating A/D/R/NA R Corrective Action Required/Comments Forms currently in use have numerous typing errors making comprehension of the matrial difficult/a liability A R A A A A A A A A A A Nights and weekends the facility has trash and half eaten food lying around Due Date Attachment 5.B. .vi‘RTIf1/4 U.S. Immigration f r and • • Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE B. C. D. E. F. G. Medical screening taking place within timeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language A. B. C. 5. Classification System All residents classified appropriately upon arrival Reassessment and reclassification process in place Housing assignments are based upon classification D. Work assignments are based upon classificafion system Residents are housed by age groups based upon the children E. Enforcement Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A NA A A. 6. Contraband Policy in place for handling contraband A B. Contraband disposed of properly and documented R C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A. Staff are required to conduct security check of assigned areas A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 562 of 740 R Documentation in log books is infrequent Log books do not reflect daily or even routine inspections for contraband D Midnight shift has reported that they do NOT routinely enter the Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA • residents suite for safety or security checks B. C. D. E. • Corrective Action Required/comments All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exiting Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times A A R A F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A H. Facility administrator or designee and department heads visit housing units and activity areas weekly R I Comprehensive staffing analysis determines staffing needs and plans D • J. K. L. Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 563 of 740 D R A Random check of log books still show high discrepancies with what is coming and going from the facility Plan of action close out on 4/13 showed this to be an area staff still do not annotate This facility no longer has a perimeter fence and construction is ongoing for expansion. Still using a loose sheet as a long rather than signing a log book Current Staffing percentage for April is 85.49 and below the 90% in the contract mental health staff is short staffed Staff is not properly logging entries as seen on 5/30 Due Date Attachment 5.B. .(*);„ U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • Rating AR/NA components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and M. interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical N. checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and 0. inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone P. surveillance, high profile residents, visiting room activities, etc D Q. D A N/A A. Inventory personal property/funds is maintained B. Funds/valuables documented on receipt C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff E. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged 9. Waiting Room in Residential Facilities A. Residents are not held in waiting rooms longer than 12 hours A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 564 of 740 The facility does not have a fence or a perimeter alarm. A • The facility shares intelligence information with ICE S. Funds and Personal Property Corrective Action Required/comments R A A A A We no longer have an Inteligence Officer who would be assigned to gather this information. Facility routinely fails to inform the COR of issues 60 outstanding letters for resident closed accounts A A A It is done weekly at this facility Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc DWM PERFORMANCE MONITORING MEASURE Rating A/D/R/NA A. All residents wanded with a metal detector prior to placemen n waiting room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items! diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices B. Emergency keys are available for all areas of the facility A C. D. Chit system used to issue security equip./keys/radios A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A B. C. D. E. F. G. I J. F. F. A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 565 of 740 Corrective Action Required / Comments A A A A A A A A A A A A JFRMU mandate does not allow census on the midnight shift Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M B. C. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted E. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator A. D A D D. n Rating A/D/R/NA D Housing unit officers record all resident activity in a log D C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignmenl is temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents Unit shakedowns are conducted R Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention R E. A. B. C. D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 566 of 740 5/11, 5/14, 5/17 not all residents were verified face to photo 5/11, 5/14, 5/17 they were not all verified A B. D. Corrective Action Required/Comments 5/11, 5/14, 5/17 only witnessed 1 officer conducting count on each hall R N/A R A A 5/28 a thorough check of log books showed major events are still not being annotated Not normally in the log book and some posts don't show it in the post order sign off sheet Most staff do not sign when only giving breaks (b)(7)(E) Not logged in the log books 5/11, 5/28 most staff still does not properly annotate this item. A random schedule has been implemented Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequen D PERFORMANCE MONITORING MEASURE M A. The facility has a Sexual Abuse and Assault Prevention and Intervention Program A B. Residents are advised of the program A All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • Rating A/D/R/NA B. C. D. Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours A A A A A A ICE SDC visit schedules are posted in housing unit A E. • Request forms are available to residents There is a secure box available for residents to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. Tool inventories conducted as specified B. Tools marked and readily identifiable •C. Procedures for issuance of tools to staff and residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 567 of 740 Corrective Action Required/Comments Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. A A A A A A They occur daily Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc PERFORMANCE MONITORING MEASURE DWM D. E. F. G. H. A. B. •C. D. E. F. G. A. B. C. D. E. Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 568 of 740 Rating A/D/R/NA Corrective Action Required / Comments A A A A A A A A A A A A A A A A A 5/29 disciplinaries wee conducted according to standards Due Date Attachment 5.B. U.S. Immigration !A- and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Rating A/D/R/NA A A D E. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A I J. K. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes D A R D. L. M. N. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 569 of 740 Corrective Action Required/Comments A D Dining hall is still being over looked especially on the weekends No 0-1 yr old children at this time Residents are not wearing safety boots/shoes as required The facility has a 42 day cycle menu. Currently revising the menu 5/26 Tortillas are being substituted as bread items One shift will sign for all shifts A R A Every weekend for up to a half an hour supervisors will leave the dining hall Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA A. B. C. D. Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A G. H. I J. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. A sharps container is used to dispose of used sharps A. B. C. L. All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 570 of 740 Corrective Action Required/comments A A A A A A A A A A A A R Families with varicella/TB have been placed into isolation rooms that do not meet minimum space requirements but the facility is under construction at this time Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M M. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical N. examinations with male health care providers. 0. P. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations. B. C. D. E. F. G. • A. Corrective Action Required/Comments A R A The Negative Air Pressure rooms were originally built for single occupancy. A Q. A. Rating A/D/R/NA A 23. Personal Hygiene Clothing provided upon intake and exchanged weekly Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear white uniforms. 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator which is reviewed annually A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 571 of 740 A A A A D A A A Medical and intake did not register above 100 doing ICE spot checks Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W M • • PERFORMANCE MONITORING MEASURE Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with A. standards 28. Marriage Requests A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 572 of 740 Enforcement Rating AR/NA A A A A A A A A A A A A A NA A Corrective Action Required/comments Due Date Attachment 5.B. .vi‘RTIf1/4 S Immigration f U• • Customs .0r and Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating A/D/R/NA A. Marriage written requests approved by FOD 29. Recreation A A. B. C. D. Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available A A A A Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, F. commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices A. Residents are allowed to engage in religious services B. Authorized religious items are allowed in resident possession 31. Telephone Access A. Upon intake, residents are made aware of phone policies B. Out of order phones reported to service provider C. Telephones inspected by staff D. Telephone access rules posted in each housing unit E. The number for the ICE OIG is posted in housing units F. The pro bono list is posted in housing units G. Emergency phone call messages delivered to residents H. Special access calls are available to residents I Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 573 of 740 R A A A A A A A A A A A A A Corrective Action Required/Comments No posted limits to staffing ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc PERFORMANCE MONITORING MEASURE DWM B. C. D. E. F. G. Rating A/D/R/NA A A A A A A A. B. C. D. General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and identified per standards Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program Facility has a voluntary work program Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for residents Residents are medically screened to participate E. Residents receive proper training and safety equipment R F. Resident housekeeping meets standards for neatness, cleanliness and sanitation D • G. A. B. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 574 of 740 Corrective Action Required / Comments A A A A D D A Kitchen does not enforce the safety shoe wearing Housekeeping has improved but numerous residents' rooms have been found with contraband food,room temp milks, towels and clothing hanging from shower rods and beds. Residents are still being found unaccompanied by their mothers. At night and on weekends staff are seen not enforcing rules/procedures Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M C. D. A. B. C. D. language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention E. file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented F. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be H. scheduled between 8am & 8pm. 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming residents • Posters announcing presentation appear in common areas at least 48 B. hours prior to presentation A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 575 of 740 Rating A/D/R/NA A A Corrective Action Required/Comments Videos are provided A A D D D A A N/A A A A A A A A Routinely told "it's not greivable" and GEO will not utilize the log Staff routinely does informal resolutions without writing it up and logging it Due Date Attachment 5.B. .(*);„ U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. Residents in SMU receive separate presentafion Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and A annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to C. be greater than 25:1. 41. Transfer of Residents Rating AR/NA N/A A A A A A A R Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education A A Page 576 of 740 Facility does not have an SMU. A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/comments We have a mental health ratio of 1:76. We have a case management ratio of 2:133. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 5/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M A. B. Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided monthly Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available C. All children ages 0-11 remain under constant supervision of their mother. A. B. C. D. E. D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 577 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A D D A A No infants for the month Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. Still pending acceptance or rejection notice Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc PERFORMANCE MONITORING MEASURE D ; M Rating A/D/R/NA Corrective Action Required/Comments I. Emergency Plans A. B. C. Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary R A A D. A complete set of emergency plans is available D E. F. G. A. B. C. D. E. F. G. Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety System for storing/issuing/maintaining hazardous materials Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents Fire prevenfion/control/evacuafion plan Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 578 of 740 R A A A lot of new staff and sfill on the job training Just had an update CEO has not supplied corrected plans, this is a repeat Provided documents show a pattern for doing these exercises when no ICE staff is present to witness it Mock drill scheduled for 12/16 A D R D R A A Plans are confusing as written/Contractor was told to fix/repeat discrepency Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M H. I J. Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken K. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations A. 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review B. C. D. E. F. G. H. Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour period when transporting residents Two officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 579 of 740 Rating A/D/R/NA Corrective Action Required/Comments A R R Only provided inspection reports no mitagtion plans were provided even after being notified of issues by the CORs Cleanliness improved after construction fence was taken down A A R Personnel driving perimeter have not been/repeat item A A Facility does not have buses A A A A Post orders have been fixed Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes Inventory resident personal effects Accountability in place for admin/release Enforcement Rating AR/NA A A A A E. All visual searches documented and are not routine in procedure R F. Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language R G. 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassificafion process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system Residents are housed by age groups based upon the children E. 6. Contraband •A. Policy in place for handling contraband B. Contraband disposed of properly and documented A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 580 of 740 Corrective Action Required/comments High amount of intake/releases have made these checks difficult to complete ERO staff has been providing these items when taken at release A A A A NA A A R Documentation in log books is infrequent/loose copies kept by Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control Rating A/D/R/NA D A. B. C. D. Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exiting Maintain a log of all incoming and departing vehicles R A A A E. Housing unit searches occur at irregular times R F. Area searches documented in log book D G. N/A H. Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly I Comprehensive staffing analysis determines staffing needs and plans J. Essential posts and positions are filled with qualified personnel • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 581 of 740 R D D Corrective Action Required/Comments supervisors Food still being taken from kitchen 11/01, 11/14, and 11/20 Staff no longer "hiding" in dayrooms but not conducting rooms checks most of the shift Never once saw GEO staff enter a room all the way Random check of log books on 11/01 showed this to be an area staff still do not routinely annotate/repeat item This facility no longer has a perimeter fence and construction is ongoing for expansion. Some department heads were missing but not every week Current Staffing percentage for Sept is at 68.45%, but currently on a contract ramp up mental health and kitchen staff is short staffed/Security is using 1 person in multiple positions Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W M L. M. • N. 0. P. and Customs Enforcement Month/Year: 11/2015 PERFORMANCE MONITORING MEASURE K. U.S. Immigration Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and pracfice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc Rating A/D/R/NA D A. B. The facility shares intelligence information with ICE 8. Funds and Personal Property Inventory personal property/funds is maintained Funds/valuables documented on receipt A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 582 of 740 when not allowed/not meeting minimum staffing requirements Staff is not properly logging entries as seen on 11/01 A D N/A Fence was removed half way throught he month, still only routinely saw 1 person per hall even after the contract specified more staff The facility does not have a fence or a perimeter alarm. A D • Q. Corrective Action Required/Comments R R A We no longer have an lnteligence Officer who would be assigned to gather this information/repeat item Only respondes when prompted multiple times or a sever deficiency is found Have not received the 2 times a month report as promised back in the summer of 2015 Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • • C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff F. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged 9. Waiting Room in Residential Facilities A. Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement n B. waiting room C. Maintain monitoring log for each resident in waiting room D. Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents E. held F. The maximum occupancy for the hold room will be posted No bunks/cots/beds (other then cribs) or other related make shift G. sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, I. diapers and wipes. J. A. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 583 of 740 Rating AR/NA A A A Corrective Action Required/comments A A A A A A A A A A R A Facility has become relaxed in this standard due to high volume of intake and out process Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M B. •C. D. E. F. Rating A/D/R/NA Emergency keys are available for all areas of the facility A Chit system used to issue security equip/keys/radios A Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A A A A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. D. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted D A A E. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator D A. Housing unit officers record all resident activity in a log D C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignmenl is temporary, permanent, or due to an emergency D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 584 of 740 JFRMU mandate does not allow census on the midnight shift 11/05 only witnessed 1 officer conducting count on each hall Mothers don't bring their children at eavery count A B. D. Corrective Action Required/Comments R 11/01 a thorough check of log books showed al ot of daily events are still not being annotated Not logging it into the log book if they are present 11/01 Most staff do not sign when only giving breaks/facility Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Corrective Action Required/Comments doesn't leave a spot for breaking officers to sign No armed posts. F. Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents N/A A. Unit shakedowns are conducted D B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and A. Intervention Program R B. A • A A • A Residents are advised of the program All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • Rating A/D/R/NA B. Housing unit rounds conducted daily by Deportaffon Staff A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 585 of 740 Unit shakedowns are not done, only individual suites 11/01 most staff still does not properly annotate this item/GEO uses loose sheets of paper as logs/repeat item A random schedule has been implemented A A A A Updated schedule has been Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments posted C. D. Resident requests answered within 72 hours ICE SRC visit schedules are posted in housing unit A A E. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis A F. G. H. A. B. •C. D. •E. F. G. H. A. B. A Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control A Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspecfion system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard IS. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed D A A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 586 of 740 A Inside facility are good, outside items missing/repeat item A D A A A A 11/09 partial tools items tken from sets were not properly handled Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA C. Video tapes of incidents preserved/cataloged for 2 1/2 yrs D. Resident is seen by medical immediately after incident E. Facility subscribes to prescribed confrontation avoidance procedures F. Staff trained in use of force techniques G. Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System A. Rules of conduct/sanctions provided in writing B. Incident reports investigated within 24 hours C. Disciplinary panel adjudicate infractions D. Disciplinary sanctions are in accordance with standards E. Staff representation available 20. Food Service A. Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold B. food R C. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 D. day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to E. beginning work in department R F. A minimum of two hot meals served daily A Facility has a standard 35 day cycle menu A • •G. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 587 of 740 Corrective Action Required/Comments A A A A A A A A A A A D R Not the satellite feeding Cleanliness in the kitchen has improved, satellite feeding remains a concern Dry goods look low all month, only baby food appear to have enough for 15 days Kitchen staff making more effort to enforce safety procedures The facility has a 42 day cycle menu. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M H. I J. K. L. A registered dietician conducts nutritional analysis All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of M. the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The N. snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or ! A. observed refusing to eat beyond 72 hours B. Staff receive training in identification of hunger strike C. Process for determining reason for hunger strike 22. Medical Care A. Intake process includes medical and mental health screening B. Sick call procedures established C. Adequate medical staff available proportionate to population D. Pharmaceuticals stored in a secure area A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 588 of 740 Enforcement Rating AR/NA Corrective Action Required/Comments A D A A Unknown with 2 entrees being offered at all meals now and no menu provided to the COR/repeat item A D A A A A A A A A One is assigned but always apprears to be in the kitchen and never in the dining hall/CEO provided security staff not present during meal times/repeat item Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc PERFORMANCE MONITORING MEASURE DWM Rating A/D/R/NA E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A G H. I J. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. L. M. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. N. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. 0. P. Q. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 589 of 740 Corrective Action Required / Comments A A A A A A D Facility is relying on voluntary workers and do not hae enough to keep this area clean consistently/repeat item A R A A The Negative Air Pressure rooms were originally built for single occupancy. Due Date Attachment 5.B. .(*)., U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating AR/NA Corrective Action Required/comments and adolescents including immunizations. A. 23. Personal Hygiene Clothing provided upon intake and exchanged weekly B. Sheets and towels exchanged weekly C. Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements D. E. F. • Food Service resident volunteers exchange garments daily and wear G. approved uniforms. 24. Suicide Prevention and Intervention !Thefacility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 590 of 740 A A R Has not been consistant with the cooler weather/repeat item A A A R A A A A No set uniform for workers/wearing personal clothing and shoes/repeat item Due Date Attachment 5.B. .(*);„ U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Residents who are chronically or terminally ill are transferred to an appropriate off-site facility The facility has written plans for addressing organ donations There is a policy addressing Do Not Resuscitate Orders The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with A. standards 28. Marriage Requests A. Marriage written requests approved by FOD 29. Recreation A. B. C. D. • A. Outdoor/indoor recreation is provided B. Access to recreation activities C. Staff conduct daily searches of recreation areas D. In unit sedentary activities are available E. Recreation areas are under continuous supervision by staff equiped A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 591 of 740 Rating AR/NA Corrective Action Required/comments A A A A A A A A A A NA A A A A A A D Have found only 1 or 2 rec Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W U.S. Immigration and Customs Enforcement Month/Year: 11/2015 PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA with radios or other communication devices, F. A. B. A. B. C. D. E. F. G. H. I A. B. C. D. E. F. G. A. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and identified per standards Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program Facility has a voluntary work program A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 592 of 740 R A A A A A A A A A A A A A A A A A A A Corrective Action Required/Comments specs working for 3 areas of coverage, Construction had limited space until the middle of Nov Due Date Attachment 5.B. '"RT41/4 U.S. Immigration f' „T.. t and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequen• c PERFORMANCE MONITORING MEASURE DWM • B. C. D. Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Rating A/D/R/NA A A A E. Residents receive proper training and safety equipment R F. Resident housekeeping meets standards for neatness, cleanliness and sanitation R G. A. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook D A. B. C. Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized A A A D. Staff forward any grievances that include staff misconduct to ICE R B. C. D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 593 of 740 Corrective Action Required / Comments D A A A Enforcing safety rules more consistently but training with chemicals is still lacking Has improved but many rooms were found wih contraband food items 11/01, 11/08, and 11/20 Child residents are still being found unaccompanied by their mothers/repeat discepency At night and on weekends staff are seen not enforcing rules/procedures/repeat item Videos are provided Most staff do not refer informal grievances/repeat item Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be H. scheduled between 8am & 8pm. 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming residents • Posters announcing presentation appear in common areas al least 48 B. hours prior to presentation C. Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with FRS/NDS F. • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 594 of 740 Enforcement Rating AR/NA D Corrective Action Required/comments Staff routinely does informal resolutions without writing it up and logging it/repeat item A A N/A A A A A A A A N/A A A A A A Facility does not have an SMU. Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D w M B. and Customs Enforcement Month/Year: 11/2015 PERFORMANCE MONITORING MEASURE A. U.S. Immigration 40. Staff Training The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance Rating A/D/R/NA A A C. The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents R A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. Funds and personal properly accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided monthly Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. A A A. B. C. D E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 595 of 740 Corrective Action Required/Comments A A A A A We will have a mental health ratio of 1:104. We have a case management ratio of 1:70, once everyone is hired Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA A. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. A B. Age appropriate developmental toys are available A C. All children ages 0-11 remain under constant supervision of their mother. D D. E. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. R A F. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 596 of 740 R Corrective Action Required/comments Still no infants No long term cohorts for the month Staff routinely does not stop children who are without their mothers, everyday occurance More older children displaying passes and lanyards are being handed out to the 12 and up residents CEO constantly miss counts the ratio for the 5 and under restrictions Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available Rating A/D/R/NA A A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. Complete inventories of hazardous materials maintained A C. A complete list of MSDS readily accessible to staff and residents A D. Fire prevention/control/evacuation plan A E. Conduct fire/evacuation drills according to schedule/standard D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 597 of 740 Corrective Action Required/Comments The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. No deficiencies documented this month. MSDS lists are kept in the Food Service Department, Laundry Area, Programs Building and the Medical Department. A fire drill was conducted on October 13h. Only 24 staff of Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments the regularly scheduled 47 staff in the Administrative Office exited the building. • F. G. H. I J. K. A. B. C. Staff trained to prevent contact h blood and bodily fluids Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspection Transporting officers limit driving lime to 10 hours in any 15 hour period when transporting residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 598 of 740 A A The generators were tested on 18th & 25th, November 4th, 111h, A A D A A A A The bathroom in the Dining Hall continues to smell like urine due to residents urinating in a drain on the floor. There are multiple walls and doors that have been colored on by the resident children There also seems to be a fly problem in some of the Dayroonns and the kitchen. Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D w D. •E. F. •G. H. A. B. C. D. E. F. G. and Customs Enforcement Month/Year: 11/2014 PERFORMANCE MONITORING MEASURE M U.S. Immigration Two officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within timeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 599 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A D A GEO provided zip up fleece sweatshirts for the residents. GEO did not provide rain coats or windbreakers to the residents for inclement weather until November 23rd. On November 11th, the temperatures got down into the 30's.. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenck PERFORMANCE MONITORING MEASURE D W M A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classificafion system Residents are assigned color coded uniforms/wrist bands to reflect classification level 6. Contraband A. Policy in place for handling contraband B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A. Staff are required to conduct security check of assigned areas •B. All visitors officially recorded in a visitor log book C. Front entrance staff inspect ID of everyone entering/exiling D. Maintain a log of all incoming and departing vehicles E. Housing unit searches occur at irregular times 'F. Area searches documented in log book E. G. • H. Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 600 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A NA Wrist bands are no longer utilized in our facility. Residents now wear their ID as a necklace. A A A A A A A A A A N/A A This facility no longer has a perimeter fence. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE I J. K. L. M. • N. 0. • P. Q. A. B. Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance high profile residents visiting room activities, etc The facility shares intelligence information with ICE 8. Funds and Personal Property Inventory personal property/funds is maintained Funds/valuables documented on receipt A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 601 of 740 Rating A/D/R/NA D A Corrective Action Required/Comments Current staffing percentage for the month of November 2014 was 91.13%. This is taking into account the new staffing analysis of 189 authorized employees. A A A N/A The facility does not have a fence or a perimeter alarm. A D A A A We no longer have an lnteligence Officer who would be assigned to gather this information. Due Date Attachment 5.B. .vi‘RTIf1/4 U.S. Immigration f r and • • Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc PERFORMANCE MONITORING MEASURE DWM C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff F. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap Quarterly audits of resident baggage & luggage are conducted, G. verified, and logged • 9. Waiting Room in Residential Facilities A. • Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement n B. waiting room C. Maintain monitoring log for each resident in wailing room ! D. Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents E. held F. The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses G. are permitted inside hold rooms I J. Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 602 of 740 Enforcement Rating A/D/R/NA A A A Corrective Action Required / Comments A A A A A A Residents are no longer held in Hold Rooms, the doors no longer locked. The rooms are now called Waiting Rooms. There is a metal detector at the entrance to intake from the sally port. Fire evacuation plan is posted. A A A A A On 11/20 the kitchen bathroom was found to not have soap or toilet paper when checked around 0845hrs. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices Emergency keys are available for all areas of the facility Chit system used to issue security equip./keys/radios Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key E. accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and F. inventoried 11. Population Counts A. B. C. D. A. Staff conduct formal census at least once per 8 hour shift/ 3x per day B. At least two officers participate in count for each area C. Recount conducted when incorrect count is reported D. Face to photo count conducted E. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility A. administrator B. Housing unit officers record all resident activity in a log C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is D. temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons E. before assuming post duty 13. Searches of Residents A. Unit shakedowns are conducted A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 603 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A A resident census takes place at 0730hrs, 1600hrs & 2000hrs. A A A A N/A A (b)(7)(E) Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention • The facility has a Sexual Abuse and Assault Prevention and A. Intervention Program Rating A/D/R/NA A Corrective Action Required/Comments • H B. All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff B. C. A A Residents are advised of the program C. • A A Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours D. ICE SDC visit schedules are posted in housing unit E. F. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly A A A A A A A A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 604 of 740 Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. ICE Officers conduct daily visits to housing units. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M • H. A. B. C. D. E. • F. G. H. • A. B. C. •D. E. F. G. A. Enforcement Rating AR/NA Visiting staff observe, document and communicate current climate and conditions of confinement 17. Tool Control Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System A Rules of conduct/sanctions provided in writing A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 605 of 740 Corrective Action Required/comments A A A A A A A A A A A A A A A Corrective Sanctions for Adults is missing from the handbook, Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Corrective Action Required/comments although a memorandum has been posted with the sanctions. B. C. D. Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards A A A E. A E. Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department F. A minimum of two hot meals served daily A G. H. I J. K. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. A A A A A A. B. C. D. L. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 606 of 740 Staff representation is available upon request. A A A A A A The facility has a 42 day cycle menu. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M M. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. Enforcement Rating AR/NA D A. B. C. D. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A G. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required A N. A. B. C. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 607 of 740 D A A A A A A A Corrective Action Required/comments The Dining Hall continues to be monitored by the Chaplain and Food Service Staff. On 11/7 the medical fridge was low on supplies and contained non-edible bananas. On 11/20 the Elm Hall fridge was observed to be very dirty, and had a dead fly and half eaten apple inside. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M H. I J. Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation L. M. N. 0. P. Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, Q. Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A D A A A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. The Negative Air Pressure rooms were originally built for single occupancy. Immunizations have been offered to children and adolescents. 23. Personal Hygiene A. Clothing provided upon intake and exchanged weekly B. Sheets and towels exchanged weekly A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 608 of 740 A A Residents are able to get clothing washed Monday — Friday by the laundry department. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequen D w M PERFORMANCE MONITORING MEASURE Rating A/D/R/NA C. Climate appropriate clothing issued and maintained in good repair D D. Facility provides and replenishes personal hygiene items as needed, at no cost to resident A E. F. Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements D A G. A. B. Food Service resident volunteers exchange garments daily and wear white uniforms. 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 609 of 740 A A A Corrective Action Required/Comments Raincoats and windbreakers were not offered to the reisdents until 11/23, after the temperature had dropped into the 30's on 11/11 & 11/19. On 11/20 the bathroom in the dining hall was observed not to have soap or toilet paper. Water checks conducted on 11/4,11/12 & 11/23 were found non-compliant with temperatures recorded at 70-88 degrees. Food Service resident workers do not wear white uniforms, due to facility staff wearing white uniform shirts. The VWP residents are given a gray Tshirt and blue jeans to wear to work. Due Date Attachment 5.B. Enforcement and Removal Operations - Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W M • • PERFORMANCE MONITORING MEASURE and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or F. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with A. standards 28. Marriage Requests A. Marriage written requests approved by FOD 29. Recreation A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 610 of 740 Rating AR/NA A A A A A A A A A A A A NA A A „E S Immigration U• • Customs and Enforcement Corrective Action Required/comments Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. • • Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equiped with radios or other communicafion devices. A. B. C. D. Telephones inspected by staff Telephone access rules posted in each housing unit A. B. Rating AR/NA Corrective Action Required/comments A Outdoor/indoor recreation is provided The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider F. Enforcement A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 611 of 740 A A A D A The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment, fooseball tables, ping pong tables, Zumba classes and more. On the following dates the gym was found closed (early) during posted open hours: 11/3, 11/5, 11/12,11/16 & 11/18. This facility has a soccer field, a basketball court and a newly constructed playground. A A A A A A ICE staff conducts weekly telephone checks. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M E. F. G. H. I The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and identified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate E. Residents receive proper training and safety equipment • F. Resident housekeeping meets standards for neatness, cleanliness and sanitation A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 612 of 740 Enforcement Rating AR/NA A A A A A Corrective Action Required/comments A A A A A A A A A A A A D There are drawings on the walls and doors from children. There are also large amounts of food (some spoiled) being found in the suites. In addition multiple showers were found to have mold and mildew. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook A. Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent B. language C. Handbook is updated as necessary D. Orientation material available to illiterate residents 35. Grievance System A. Grievance procedures in place B. Staff awareness of procedures for emergency grievances C. Grievance log is utilized D. Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention E. file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters G. H. Hours of Access: Generally, law library hours of operation are to be scheduled between Sam & 8pm. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 613 of 740 Enforcement Rating AR/NA D Corrective Action Required/comments Residents are still being found unaccompanied by their mothers. A A A A A A A A A A A N/A A A A A D On the following dates the library was found closed (early) during posted open hours: 11/3, Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M •A. B. 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 hours prior to presentation C. Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with NDS 40. Staff Training !Thefacility conducts appropriate orientation, initial training, and A. annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to C. be greater than 25:1. 41. Transfer of Residents Resident provided with resident transfer notification form A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 614 of 740 Rating A/D/R/NA Corrective Action Required/Comments 11/6, 11/8, 11/15 & 11/16. A A N/A Our facility does not have an SMU. A A A A A A A D A We have a mental health ratio of 1:133. We have a case management ratio of 1:266. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA B. Health records/transfer summary accompany resident A C. D. Funds and personal properly accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. A A F A. B. C. D E. A. B. Educational field trips are provided. A Age appropriate developmental toys are available A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 615 of 740 School commenced on 8/26/2014. A D Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Corrective Action Required/Comments A On site Field Trips commenced in October 2014. Per the contract, off site monthly Field Trips are required. Report cards are distributed every 6 weeks. Progress reports are distributed every 3 weeks. The last report cards issued out were on December lst. A A A The facility ordered an addition $3,000 worth of toys for the facility this month. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 11/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA C. All children ages 0-11 remain under constant supervision of their mother. D D. E. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. D A F. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 616 of 740 D Corrective Action Required/Comments There were at least 3 documented instances of children being left unattended on 11/10, 11/11 8, 11/18. The older children are not having their Hall Passes displayed for staff to see when in the common areas. CEO staff is not enforcing this item. The Daycare was observed to have exceeded the ratio on: 11/3, 11/19 & 11/24. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments I. Emergency Plans Staff is trained but during interviews most couldn't identify emergency situations when presented A. B. C. Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary R A A D. A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety R A MOUs are up to date System for storing/issuing/maintaining hazardous materials Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents A R Missing labels and SOS sheets E. F. G. A. B. C. D. E. F. G. Fire prevention/control/evacuafion plan Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 617 of 740 D A CEO has not supplied corrected plans Has not provided requested documents R D D A A Plans are confusing as written/Contractor was told to fix/repeat discrepency Have not received logs of drills Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M H. I J. Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken K. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations A. 3. Transportation (By Land) Documentation indicafing safety repairs are completed immediately and vehicles are not used unfil they have been repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour C.period 1 when transporting residents (b)(7iofficers with valid Commercial Drivers Licenses, (CDL's) D. equired in any bus transporting residents Policies and procedures are in place addressing the use of E. restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in F. accordance with the Use of Force standard G. Vehicles have written contingency plans on board H. Vehicles are equipped with appropriate child safety seats where • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 618 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A D D He hasn't responded to requests to see records or to provide copies/repeat discrepency Residents have not been cleaning suites appropriately/not enough staff to maintain compounds A A R Personnel driving perimeter have not been A A Facility does not have buses A A R A Prerimeter did not in Oct Due Date Attachment 5.B. .(*)., U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. All visual searches documented and are not routine in procedure R F. Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language R 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassificafion process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system Residents are housed by age groups based upon the children E. 6. Contraband A. Policy in place for handling contraband B. Contraband disposed of properly and documented A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 619 of 740 Corrective Action Required/Comments A A A A E. G. • applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes Inventory resident personal effects Accountability in place for admin/release Rating AR/NA High amount of intake/releases have made these checks difficult to complete Staff have been taking cold weather clothes from residents when leaving A A A A NA A A R Documentation in log books is Due Date Attachment 5.B. .(*);„ U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. A. B. C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control Rating AR/NA D Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book Front entrance staff inspect ID of everyone entering/exifing D A A Maintain a log of all incoming and departing vehicles R E. Housing unit searches occur at irregular times R F. Area searches documented in log book D G. Daily/Monthly fence checks completed and logged N/A •D. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 620 of 740 Corrective Action Required/comments infrequent/loose copies kept by supervisors food being taken from dining hall, room checks conducted 10/28 and contraband found and no GEO staff was seen going into rooms during contracband inspecfions on 10/9 DSM reported has witnessed staff in staying in the Dayrooms during the night shift/ repeat discrepancy Log book was not annotated correctly for last week of Oct Never once saw CEO staff enter a room all the way Random check of log books on 9/28 showed this to be an area staff still do not routinely annotate This facility no longer has a perimeter fence and construction is ongoing for expansion. Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W U.S. Immigration and Customs Enforcement Month/Year: 10/2015 PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA H. Facility administrator or designee and department heads visit housing units and activity areas weekly D I Comprehensive staffing analysis determines staffing needs and plans A J. K. L. M. • N. 0. P. Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and practice to gather. analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 621 of 740 D D Corrective Action Required/Comments Last week of Oct numerous department heads missing/shift supervisors not logging into the books at all Current Staffing percentage for Sept is at 94% mental health and kitchen staff is short staffed/Security is using 1 person in multiple posifions when not allowed/not meeting minimum staffing requirements Staff is not properly logging entries as seen on 9/21 A D N/A Only one staff routinely assigned to halls and not sufficient most shifts to over see program with fencing disrupting line of sight The facility does not have a fence or a perimeter alarm. A D We no longer have an lnteligence Officer who would be assigned to gather this Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W M and Customs Enforcement Month/Year: 10/2015 PERFORMANCE MONITORING MEASURE • U.S. Immigration Rating A/D/R/NA information. surveillance, high profile residents, visiting room activities, etc Q. The facility shares intelligence information with ICE 8. Funds and Personal Property R A. B. Inventory personal property/funds is maintained Funds/valuables documented on receipt D A C. D. E. Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperproof numbered strap A A A F. G. A. B. C. D. E. Quarterly audits of resident baggage & luggage are conducted, verified, and logged 9. Waiting Room in Residential Facilities Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement in wailing room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents held A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 622 of 740 Corrective Action Required / Comments A A A A A A A Administration has been slow to respond with POAs or requested documents, 10/1, 10/26 Never received the close out of the 4 outstanding accounts for Sept as requested on 10/26 Staff reported contraband found 2 times in Oct Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M F. G. I The maximum occupancy for the hold room will be posted No bunks/cots/beds (other then cribs) or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Enforcement Rating AR/NA A A A J. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control R A. Maintain inventories of all keys/locks/locking devices A B. Emergency keys are available for all areas of the facility A C. Chit system used to issue security equip./keys/radios A D. Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A E. F. A Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. D. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted D A A Page 623 of 740 Facility has become relaxed in this standard due to high volume of intake and out process A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/comments JFRMU mandate does not allow census on the midnight shift 10/17 only witnessed 1 officer conducting count on each hall Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M E. A. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator Rating A/D/R/NA D A B. Housing unit officers record all resident activity in a log D C. Supervisor visits each housing area once per shift D D. E. Staff sign post orders, regardless of whether the assignmen s temporary, permanent, or due loan emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents A. Unit shakedowns are conducted B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and C. D. • A. Page 624 of 740 10/17 a thorough check of log books showed al ot of daily events are still not being annotated Not logging it into the log book if they are present 10/17 Most staff do not sign when only giving breaks/facility doesn't leave a spot for breaking officers to sign D N/A D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments Mothers don't bring their children at eavery count R A A A I (b)(7)(E) Unit shakedowns are not done, only individual suites 10/17 most staff still does not properly annotate this item/GEO uses loose sheets of paper as logs A random schedule has been implemented Due Date Attachment 5.B. _ci at U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating AR/NA Corrective Action Required/comments Intervention Program B. A Residents are advised of the program All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • • B. Housing unit rounds conducted daily by Deportation Staff C. Resident requests answered within 72 hours D. ICE SRC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. B. C. D. Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 625 of 740 A A A R A A A A A A D A A A They occur daily Inside facility are good, outside items missing/repeat discrepency Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D w M F. G. H. A. B. C. D. E. F. G. A. B. C. D. E. A. B. and Customs Enforcement Month/Year: 10/2015 PERFORMANCE MONITORING MEASURE E. U.S. Immigration There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/cataloged for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 626 of 740 Rating A/D/R/NA Corrective Action Required/Comments A D 10/13 items not chilled out logged as out and missing for outdoor equipment A A A A A A A A A A A A A A D Not being followed 10/17 R Not the satellite feeding Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Enforcement Rating AR/NA D A E. Residents receive safety and appropriate equipment training prior to beginning work in department D F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A I J. K. L. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of M. the residents. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 627 of 740 Corrective Action Required/comments Satellite feeding staff not using hairnets or gloves , staff not keeping floors and counters free of excessive debris D A A Residents are not wearing safety boots/shoes as required in the kitchen/ repeat discrepency The facility has a 42 day cycle menu. Unknown with 2 entrees being offered at all meals now and no menu provided to the COR A D One is assigned but always apprears to be in the kitchen and never in the dining hall/GEO provided security staff not present during meal limes Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA A. B. C. D. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A N. A. B. C. !Thefacility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability K. L. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 628 of 740 A A A A A A A A A A A A A A Corrective Action Required/comments Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W U.S. Immigration and Customs Enforcement Month/Year: 10/2015 PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. M. N. 0. P. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations. Q. D A R A The Negative Air Pressure rooms were originally built for single occupancy. A A. 23. Personal Hygiene Clothing provided upon intake and exchanged weekly B. Sheets and towels exchanged weekly C. Climate appropriate clothing issued and maintained in good repair R D. Facility provides and replenishes personal hygiene items as needed, at no cost to resident A E. F. Facility is relying on voluntary workers and do not hae enough to keep this area clean consistantly Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 629 of 740 A A D A Has not been consistant with the cooler weather Medical and intake had low readings a the 3 min mark/repeat discrepency Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Food Service resident volunteers exchange garments daily and wear approved uniforms. 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper nofifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook G. p_U • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 630 of 740 Rating A/D/R/NA R A A A A A A A A A A A A A Corrective Action Required/Comments No set uniform for workers/wearing personal clothing and shoes Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M F. G. • A. • A. A. B. C. D. Rating A/D/R/NA Facility has a system for residents to purchase stamps SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation A NA Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available A A A A Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, F. commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices A. Residents are allowed to engage in religious services B. Authorized religious items are allowed in resident possession 31. Telephone Access A. Upon intake, residents are made aware of phone policies B. Out of order phones reported to service provider C. Telephones inspected by staff D. Telephone access rules posted in each housing unit E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 631 of 740 Corrective Action Required/Comments A A D D Have found only 1 or 2 rec specs working for 3 areas of coverage, doors have been found locked during open hours Construction has severly limited this since Sept A A A A R A Only done once this month Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M E. F. G. H. I A. B. C. D. E. F. G. A. B. C. D. • The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and idenfified per standards Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program Facility has a voluntary work program Maintain a written chart with work assignments/classification level Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Enforcement Rating AR/NA A A A A A A A A A A A A A A A A E. Residents receive proper training and safety equipment D F. Resident housekeeping meets standards for neatness, cleanliness and sanitation D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 632 of 740 Corrective Action Required/comments Kitchen does not enforce the safety shoe wearing and aprons/ resident cleaners do not know proper chemical handling Cleanliness has gotten worse with residents' rooms having contraband food,room temp milks and cheese, hanging towels and clothes from beds Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. A. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Enforcement Rating AR/NA D Corrective Action Required/comments and showers areas/repeat discrepency Child residents are still being found unaccompanied by their mothers/repeat discepency D At night and on weekends staff are seen not enforcing rules/procedures/repeat discrepency A A A A. Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place B. C. Staff awareness of procedures for emergency grievances Grievance log is utilized R A D. Staff forward any grievances that include staff misconduct to ICE R B. C. D. E. A. B. Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for residents Legal materials/law library current and available for residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 633 of 740 Videos are provided A D A A Most staff ddin't know what this item was when questioned Most staff do not refer informal grievances Staff routinely does informal resolutions without writing it up and logging it Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be H. scheduled between 8am & 8pm. 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 B. hours prior to presentation C. Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and A. annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 634 of 740 Enforcement Rating AR/NA Corrective Action Required/comments N/A A A A A A A A N/A A A A A A A A Facility does not have an SMU. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents R A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided monthly Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants ages 0-1 are afforded a crib upon admission to the facility. A A C. A. B. C. D. E. A. B. C. Age appropriate developmental toys are available All children ages 0-11 remain under constant supervision of their mother. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 635 of 740 Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 2:133. A A A A A A D D No infants for the month Cohorts are only receiving coloring supplies/repeat discrepency Staff routinely does not stop children who are without their Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines, A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 636 of 740 Enforcement Rating A/D/R/NA R A A Corrective Action Required/Comments mothers, everyday occurance More older children displaying passes Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available Rating A/D/R/NA A A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. Complete inventories of hazardous materials maintained A C. A complete list of MSDS readily accessible to staff and residents A D. Fire prevention/control/evacuation plan A E. Conduct fire/evacuation drills according to schedule/standard A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 637 of 740 Corrective Action Required/Comments The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. No deficiencies documented this month. MSDS lists are kept in the Food Service Department, Laundry Area, Programs Building and the Medical Department. Fire Drills are scheduled quarterly which include all Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE Rating A/D/R/NA Corrective Action Required/Comments areas of the building & all shifts. F. Staff trained to prevent contact G. Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken H. I h blood and bodily fluids A A The generators were tested on October 7th, 14th, 21st & 28th A A On 10/5 Cedar 203 & 204 were inspected and found in a filthy condition, there was toilet paper strewn about, towels and underwear hanging from railings and a razor unattended. J. K. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used until they have been A. repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour C.: 01 when transporting residents fficers with valid Commercial Drivers Licenses, (CDL's) D. equired in any bus transporting residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 638 of 740 D A A A A A Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M E. F. G. H. A. B. C. D. E. F. Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in accordance with the Use of Force standard Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where applicable. 4. Admission and Release ICE information is available for initial classification Medical screening taking place within fimeframes Inventory resident personal effects Accountability in place for admin/release All visual searches documented and are not routine in procedure G. Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language A. B. C. 5. Classification System All residents classified appropriately upon arrival Reassessment and reclassification process in place Housing assignments are based upon classification A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 639 of 740 Rating A/D/R/NA Corrective Action Required/Comments D A A A A A A A A D A A A A GEO provided zip up fleece sweatshirts for the residents. GEO has not provided rain coats or windbreakers to the residents for inclement weather. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. Work assignments are based upon classification system Residents are assigned color coded uniforms/wrist bands to reflect classification level 6. Contraband •A. Policy in place for handling contraband B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A. Staff are required to conduct security check of assigned areas •B. All visitors officially recorded in a visitor log book C. Front entrance staff inspect ID of everyone entering/exiling D. Maintain a log of all incoming and departing vehicles E. Housing unit searches occur at irregular times F. Area searches documented in log book E. G. • H. I Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly Comprehensive staffing analysis determines staffing needs and plans A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 640 of 740 Rating A/D/R/NA NA Corrective Action Required/Comments Wrist bands are no longer utilized in our facility. Residents now wear their ID as a necklace. A A A A A A A A A A N/A This facility no longer has a perimeter fence. A D Current staffing percentage for the month of September 2014 was 88.87%. This is taking into account the new staffing analysis of 189 authorized employees. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D w M PERFORMANCE MONITORING MEASURE J. K. L. M. • N. 0. • P. Q. A. B. C. D. E. F. Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and pracfice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc The facility shares intelligence informafion with ICE 8. Funds and Personal Property Inventory personal properly/funds is maintained Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperproof numbered strap A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 641 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A N/A A A A A A A A A A The facility does not have a fence or a perimeter alarm. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D PERFORMANCE MONITORING MEASURE W M • G. A. B. C. D. E. F. • G. I J. A. B. C. D. Quarterly audits of resident baggage & luggage are conducted, verified, and logged 9. Waiting Room in Residential Facilities Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement n waiting room Maintain monitoring log for each resident in wailing room Written evacuation plan posted for each waiting room Waiting rooms contain sufficient seating for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Maintain inventories of all keys/locks/locking devices Emergency keys are available for all areas of the facility Chit system used to issue security equip./keys/radios Policy regarding restricted keys present and followed by staff A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 642 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A A A A Residents are no longer held in Hold Rooms, the doors no longer locked. The rooms are now called Waiting Rooms. There is a metal detector at the entrance to intake from the sally port. Fire evacuation plan is posted. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. F. Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A. Staff conduct formal census at least once per 8 hour shift/ 3x per day B. At least two officers participate in count for each area C. Recount conducted when incorrect count is reported D. Face to photo count conducted E. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility A. administrator B. Housing unit officers record all resident activity in a log C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is D. temporary, permanent, or due loan emergency Anyone assigned to an armed post qualifies with the post weapons E. before assuming post duty 13. Searches of Residents A. Unit shakedowns are conducted B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 643 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A resident census takes place at 0900hrs, 1600hrs & 2000hrs. A A A A A A A A A N/A A A A A I (b)(7)(E) Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequen D PERFORMANCE MONITORING MEASURE M A. The facility has a Sexual Abuse and Assault Prevention and Intervention Program A B. Residents are advised of the program A All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • Rating A/D/R/NA B. C. Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis A A A A A A A F. G. • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 644 of 740 Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. A A Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. Tool inventories conducted as specified B. Tools marked and readily identifiable Corrective Action Required/Comments A A A ICE Officers conduct daily visits to housing units. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. G. H. A. B. C. D. E. F. G. A. B. C. D. E. Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards Staff representation available A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 645 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A D On 10/21 the Maintenance Department was checked and found to have tools that were not checked out and did not have a chit in place. A A A A A A A A A A A A A A Staff representation is available Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments upon request. A. B. C. 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a high level of sanitation A A A D E. The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department F. A minimum of two hot meals served daily A G. H. I J. K. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. A A A A A D. L. M. N. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 646 of 740 On 10/23 the inventory for formula was checked and the facility did not have a 15 day supply for the amount of infants currently in the facility. A The facility has a 42 day cycle menu. A D D The Dining Hall continues to be monitored by the Chaplain and Food Service Staff. Refridgerators in the Dayrooms were found empty or mostly Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Corrective Action Required/comments empty on the following occasions: 9/6, 9/14, 9/17, 9/21, 9/22 & 9/30. In addition the logs on the refrigerators for temperature checks and restocking were not filled out daily. A. B. C. D. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A A. B. C !Thefacility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 647 of 740 A A A A A A A A A A A Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE Rating ND/RNA / Corrective Action Required/Comments A K. L. M. N. 0. P. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, Q. A A A A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. D A A Immunizations have been offered to children and adolescents. 23. Personal Hygiene A. Clothing provided upon intake and exchanged weekly B. Sheets and towels exchanged weekly C. Climate appropriate clothing issued and maintained in good repair A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 648 of 740 A A D Residents are able to get clothing washed Monday — Friday by the laundry department. Raincoats and windbreakers have not been offered to the reisdents. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear while uniforms. 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually At Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientafion B. program and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders G. • A s Acceptable D s Deficient R s At-Risk NA s Not Applicable Page 649 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A A A A A Food Service resident workers do not wear white uniforms, due to facility staff wearing white uniform shirts. The VWP residents are given a gray Tshirt and blue jeans to wear to work. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. The facility has written procedures detailing the proper nofifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies • The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with A. standards 28. Marriage Requests • A. Marriage written requests approved by FOD 29. Recreation A. B. Outdoor/indoor recreation is provided Rating A/D/R/NA Corrective Action Required/Comments A A A A A A A NA A A A A Access to recreation activities A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 650 of 740 The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment fooseball tables, ping pang tables, Zumba classes and more. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. E. F. A. B. A. B. C. D. E. F. G. H. I A. B. C. Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equipeed with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 651 of 740 Rating A/D/R/NA A A D A Corrective Action Required/Comments On the following dates the gym was found closed during posted open hours: 10/4, 10/8, 10/9, 10/11,10/14, 10/15 & 10/20. This facility has a soccer field, sand volleyball court and a newly constructed playground. A A A A A A A A A A A A A A ICE staff conducts weekly telephone checks. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. F. G. Enforcement Rating AR/NA A. B. C. D. E. Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and identified per standards Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program Facility has a voluntary work program Maintain a written chart with work assignments/classificafion level Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Residents receive proper training and safety equipment A A A A A F. Resident housekeeping meets standards for neatness, cleanliness and sanitation A G. A. B. C. D. A. B. C. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 652 of 740 Corrective Action Required/comments A A A A On 10/10 & 10/20 children were found (under the age of 7) not in the presence of their mothers. D A A A A A A A Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention E. file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm. 37. Legal Rights Group Presentations A. ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 B. hours prior to presentation C. Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody H A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 653 of 740 Rating A/D/R/NA A Corrective Action Required/Comments A A A N/A A A A A On the following dates the library was found closed during posted open hours: 10/1, 10/4, 10/5, 10/9, 10/16, 10/17, 10/18 & 10/20. D A A N/A A A A Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE C. A. A. B. C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and tours in accordance with NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents Rating A/D/R/NA A A A A D A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. A A B. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. C. Educational field trips are provided. A. A Page 654 of 740 We have a mental health ratio of 1:133. We have a case management ratio of 1:266. School commenced on 8/26/2014. A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments Field Trips commenced in October 2014. Due Date Attachment 5.B. S U.S. Immigration _CI = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 10/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. A. B. C. D. E. F. Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. Age appropriate developmental toys are available All children ages 0-11 remain under constant supervision of their mother. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 655 of 740 Rating AR/NA D Corrective Action Required/comments No progress reports were distributed for the month of October. A A A D A A A The facility ordered an addition $3.000 worth of toys for the facility this month. There were at least 3 documented instances of children being left unattended. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M A. B. C. D. E. F. G. A. B. C. D. E. F. G. H. I I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the year to test specific plans Staff work stoppage plan is available The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety System for storing/issuing/maintaining hazardous materials Complete inventories of hazardous materials maintained A complete list of MSDS readily accessible to staff and residents Fire prevention/control/evacuation plan Conduct fire/evacuation drills according to schedule/standard Staff trained to prevent contact with blood and bodily fluids Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 656 of 740 Rating A/D/R/NA Corrective Action Required/Comments R A A A R A Have only seen fire drills conducted A MOUs are up to date A A 9/9 Inventories checked A D D A A Plans are confusing as written/Contractor was told to fix Have not received logs of drills A R He hasn't responded to requests to see records or to Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W M and Customs Enforcement Month/Year: 9/2015 PERFORMANCE MONITORING MEASURE J. U.S. Immigration K. Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations A. 3. Transportation (By Land) Documentation indicating safely repairs are completed immediately and vehicles are not used until they have been repaired and inspected, is available for review B. Officers use a checklist during every vehicle inspection Transporting officers limit driving time to 10 hours in any 15 hour C.perio I ld when transporting residents b)(7) officers with valid Commercial Drivers Licenses, (CDL's) D. required in any bus transporting residents Policies and procedures are in place addressing the use of E. • restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in F. accordance with the Use of Force standard •G. Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where H. applicable. 4. Admission and Release A. ICE information is available for initial classification B. Medical screening taking place within fimeframes C. Inventory resident personal effects D. Accountability in place for admin/release E. All visual searches documented and are not routine in procedure A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 657 of 740 Rating A/D/R/NA A Corrective Action Required/Comments provide copies Overall appearance looks good A A R Personnel driving perimeter have not been A A A A A A A A A A A Facility does not have buses Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W M PERFORMANCE MONITORING MEASURE F. G. Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language A. B. C. 5. Classification System All residents classified appropriately upon arrival Reassessment and reclassification process in place Housing assignments are based upon classification D. Work assignments are based upon classification system Residents are housed by age groups based upon the children E. A. Corrective Action Required/Comments A A A A A NA A 6. Contraband Policy in place for handling contraband A B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A. B. Rating A/D/R/NA Staff are required to conduct security check of assigned areas All visitors officially recorded in a visitor log book A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 658 of 740 R D D A Documentation in log books is infrequent/loose copies kept by supervisors food being taken from dining hall and no CEO staff seen stopping this activity, repeat discrepency DSM reported has witnessed staff in staying in the Dayrooms during the night shift Due Date Attachment 5.B. ire Enforcement and Removal Operations ‘"Rrt41 Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M C. D. E. • Front entrance staff inspect ID of everyone entering/exifing Maintain a log of all incoming and departing vehicles Housing unit searches occur at irregular times Rating AR/NA D A D G. Daily/Monthly fence checks completed and logged N/A H. Facility administrator or designee and department heads visit housing units and activity areas weekly R I Comprehensive staffing analysis determines staffing needs and plans R K. L. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 659 of 740 Corrective Action Required/comments A Area searches documented in log book Essential posts and positions are filled with qualified personnel Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its U Enforcement F. J. • S • Immigration and Customs D D A Random check of log books still show high discrepancies with what is coming and going from the facility, repeat finding Random check of log books on 9/28 showed this to be an area staff still do not routinely annotate This facility no longer has a perimeter fence and construction is ongoing for expansion. Still using a loose sheet as a log rather than signing a log book Current Staffing percentage for Sept is at 90% mental health staff is short staffed/Security is using 1 person in multiple positions when not allowed/not meeting minimum staffing requirements Staff is not properly logging entries as seen on 9/21 Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • Rating A/D/R/NA components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and M. interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical N. checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and 0. inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone P. surveillance, high profile residents, visiting room activities, etc D Q. A A N/A A. B. Inventory personal properly/funds is maintained Funds/valuables documented on receipt C. Residents property searched for contraband D. Staff forward arriving residents medication to medical staff E. Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperF. proof numbered strap A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 660 of 740 The facility does not have a fence or a perimeter alarm. A • The facility shares intelligence informafion with ICE S. Funds and Personal Property Corrective Action Required/Comments R A R A A A We no longer have an Inteligence Officer who would be assigned to gather this information. Administration has made a more concerted effort to inform ICE Had to request an audit to be performed and found 4 outstanding accounts Most staff are unable to conduct a full search due to lack of female staff Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. A. B. C. D. E. F. • G. I J. Quarterly audits of resident baggage & luggage are conducted, verified, and logged 9. Waiting Room in Residential Facilities Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement in waiting room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds (other then cribs) or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control Enforcement Rating AR/NA A A A A A A A A R A. Maintain inventories of all keys/locks/locking devices A Emergency keys are available for all areas of the facility A C. Chit system used to issue security equip/keys/radios A D. Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 661 of 740 It is done weekly at this facility A B. E. Corrective Action Required/comments A Facility has become relaxed in this standard due to high volume of intake and out process Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W and Customs Enforcement Month/Year: 9/2015 PERFORMANCE MONITORING MEASURE M F. U.S. Immigration Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts Rating A/D/R/NA A A. Staff conduct formal census at least once per 8 hour shift/ 3x per day A B. C. D. At least two officers participate in count for each area Recount conducted when incorrect count is reported Face to photo count conducted D A A E. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility administrator R A. B. C. D A A. Unit shakedowns are conducted D B. Random shakedowns conducted & documented E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 662 of 740 JFRMU mandate does not allow census on the midnight shift 9/5, 9/17 and 9/18 only witnessed 1 officer conducting count on each hall Mothers don't bring their children at eavery count A Housing unit officers record all resident activity in a log Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignmenl is temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons before assuming post duty 13. Searches of Residents D. Corrective Action Required/Comments D N/A R 9/28 a thorough check of log books showed al ot of daily events are still not being annotated Most staff do not sign when only giving breaks (b)(7)(E) Unit shakedowns are not done, only individual suites 9/28 most staff still does not properly annotate this Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. • •A. B. The facility employs a schedule to insure that all areas of the facility are routinely searched Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and Intervention Program • A A Corrective Action Required/Comments item/GEO uses loose sheets of paper as logs A random schedule has been implemented A A Residents are advised of the program All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff C. • Rating A/D/R/NA B. Housing unit rounds conducted daily by Deportation Staff C. Resident requests answered within 72 hours D. ICE SRC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for F. ICE staff that is checked on a daily basis G. Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 663 of 740 A A A A A A A A A A They occur daily Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA Corrective Action Required/Comments 17. Tool Control A. B. C. D. E. F. G. H. A. B. C. D. E. F. G. A. B. C. Tool inventories conducted as specified Tools marked and readily identifiable Procedures for issuance of tools to staff and residents Inventory made of all tools by contractors prior to enter and exit There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard IS. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/cataloged for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 664 of 740 R A A A Inside facility are good, outside items missing A A A A A A A A A A A A A A 9/18, 9/20 missing log and chits for outside equipement Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D w PERFORMANCE MONITORING MEASURE M D. E. A. B. C. Disciplinary sanctions are in accordance with standards Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Rating A/D/R/NA A A A R D. Food Service department maintained at a high level of sanitation The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). E. Residents receive safety and appropriate equipment training prior to beginning work in department R F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A I. J. K. L. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or booster seats for the current population to utilize. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 665 of 740 Corrective Action Required/Comments R Not the satellite feeding Satellite feeding staff not using hairnets or gloves A R A A A Residents are not wearing safety boots/shoes as required in the kitchen The facility has a 42 day cycle menu. Unknown with 2 entrees being offered at all meals now and no menu provided to the COR Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D w M N. A. B. C. and Customs Enforcement Month/Year: 9/2015 PERFORMANCE MONITORING MEASURE M. U.S. Immigration The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or observed refusing to eat beyond 72 hours Rating A/D/R/NA R A A. B. C. D. E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 666 of 740 One is assigned but always apprears to be in the kitchen and never in the dining hall A Staff receive training in identification of hunger strike Process for determining reason for hunger strike 22. Medical Care Intake process includes medical and mental health screening Sick call procedures established Adequate medical staff available proportionate to population Pharmaceuticals stored in a secure area The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical ! G. attention is required H. Medical records are available and transferred with the resident I Records are maintained of medication distribution J. All sharps are under strict control and accountability Corrective Action Required/Comments R A A A A A A A A A Some staff do not know even after training Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating ND/RNA / Corrective Action Required/Comments A K. L. M. N. 0. P. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation Female residents are provided with a female escort for medical examinations with male health care providers. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations. Q. A A A R A The Negative Air Pressure rooms were originally built for single occupancy. A A. 23. Personal Hygiene Clothing provided upon intake and exchanged weekly B. C. Sheets and towels exchanged weekly Climate appropriate clothing issued and maintained in good repair A D. Facility provides and replenishes personal hygiene items as needed, at no cost to resident A E. F. G. Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear R A R A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 667 of 740 A A Medical and intake had low readings a the 3 min mark No set uniform for workers Due Date Attachment 5.B. .vi‘RTIf1/4 U.S. Immigration f r and • • Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W M • • PERFORMANCE MONITORING MEASURE approved uniforms. 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervention program approved and signed by the health authority and facility administrator A. which is reviewed annually Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientation program B. and annually thereafter The facility has a designated and approved isolation room for C. evaluation and treatment Staff observes and documents the status of a suicide-watch resident D. at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an A. appropriate off-site facility B. The facility has written plans for addressing organ donations C. There is a policy addressing Do Not Resuscitate Orders D. The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail A. Incoming mail screened and delivered daily B. Outgoing mail screened for contraband C. Legal mail opened in front of resident D. Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or E. common areas, and resident handbook F. Facility has a system for residents to purchase stamps G. SMU has same correspondence privileges as general population A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 668 of 740 Enforcement Rating A/D/R/NA A A A A A A A A A A A A A A NA Corrective Action Required/Comments Due Date Attachment 5.B. .vi‘RTIf1/4US Immigration fr and • • Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M • A. A. A. B. C. D. Enforcement Rating A/D/R/NA 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation A Outdoor/indoor recreation is provided Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available A A A A Recreation areas are under continuous supervision by staff equiped with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, F. commercial-grade, age-appropriate play areas and/or a soccer field. 30. Religious Practices A. Residents are allowed to engage in religious services B. Authorized religious items are allowed in resident possession 31. Telephone Access A. Upon intake, residents are made aware of phone policies B. Out of order phones reported to service provider C. Telephones inspected by staff D. Telephone access rules posted in each housing unit E. The number for the ICE OIG is posted in housing units F. The pro bono list is posted in housing units E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 669 of 740 Corrective Action Required/Comments A R R A A A A A A A A No posted limits to staffing ratios to residents and often only 1 or 2 staff members are working to watch all rec areas Construction has severly limited this in the last week of Sept Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M G. H. I Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation A. Written visitation schedule posted and accessible to the public B. General visitation log book maintained C. Visitor dress code enforced D. Visitation available 7 days a week E. Facility complies with visitation schedule F. Visitors are searched and identified per standards G. Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program A. Facility has a voluntary work program B. Maintain a written chart with work assignments/classification level C. Facility complies with work hour and pay requirements for residents D. Residents are medically screened to participate Rating A/D/R/NA A A A A A A A A A A A A A A E. Residents receive proper training and safety equipment D F. Resident housekeeping meets standards for neatness, cleanliness and sanitation D G. Residents understand and abide the facility rule that their primary responsibility is to care for their child. D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 670 of 740 Corrective Action Required/Comments Kitchen does not enforce the safety shoe wearing and aprons Cleanliness has gotten worse with residents' rooms having contraband food,room temp milks and cheese, hanging towels and clothes from beds and showers areas Child residents are still being found unaccompanied by their mothers. Due Date Attachment 5.B. .(*)., U.S. Immigration = and Customs Enforcement Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M Rating AR/NA Corrective Action Required/comments 34. Resident Handbook A. A. B. C. Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System Grievance procedures in place Staff awareness of procedures for emergency grievances Grievance log is utilized A A A D. Staff forward any grievances that include staff misconduct to ICE R B. C. D. E. A. B. C. D. E. F. G. H. Informal resolution to a resident grievance documented in detention file 36. Law Libraries and Legal Material Adequate equipment is available for residents Legal materials/law library current and available for residents Resident access provided to include SMU Denials documented Schedule for use implemented 10 hours weekly per resident Access to legal material within 24 hours of written request Indigent residents provided free stamps/envelopes for legal matters Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm, A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 671 of 740 D A A A D A A N/A A A A A A At night and on weekends staff are seen not enforcing rules/procedures Videos are provided Most staff do not refer informal grievances Staff routinely does informal resolutions without writing it up and logging it Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 B. hours prior to presentation C. Residents in SMU receive separate presentation Facility ensures adequate presentations so all residents wanting to D. attend have the opportunity 38. Detention Files A. Detention file created for each new arrival B. Detention files contain documents generated during custody C. Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and A. tours in accordance with FRS/NDS 40. Staff Training The facility conducts appropriate orientafion, inifial training, and A. annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour B. compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to C. be greater than 25:1. 41. Transfer of Residents •A. • Rating A/D/R/NA A A N/A A A A A A A R Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A Page 672 of 740 Facility does not have an SMU. A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Corrective Action Required/Comments We have a mental health ratio of 1:76. We have a case management ratio of 2:133. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 9/2015 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. Rating A/D/R/NA A A A. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Educational field trips are provided monthly Progress reports are distributed to all students on a regular and consistent schedule. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility. B. Age appropriate developmental toys are available R C. All children ages 0-11 remain under constant supervision of their mother. D A. B. C. D. E. D. E. F. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 673 of 740 Corrective Action Required/Comments A A A A A A D A A No infants for the month Cohorts are only receiving coloring supplies Staff routinely does not stop children who are without their mothers, everyday occurance The older children are not having their Hall Passes displayed for staff to see when in the common areas. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M I. Emergency Plans Staff trained, and able to identify signs of resident unrest Written plans locate emergency shut off valves and switches Evacuation routes primary and secondary A complete set of emergency plans is available Facility conducts mock emergency exercises throughout the E. year to test specific plans F. Staff work stoppage plan is available A. B. C. D. Rating A/D/R/NA A A A A A A G. The facility meets annually with local, state, & federal officials to discuss MOUs and cooperative contingency plans 2. Environmental Health and Safety A A. System for storing/issuing/maintaining hazardous materials A B. Complete inventories of hazardous materials maintained D C. D. A complete list of MSDS readily accessible to staff and residents Fire prevention/control/evacuation plan A A A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 674 of 740 Corrective Action Required/Comments The last table top discussion was conducted on 2/12/2014. A mock exercise including local law enforcement was conducted 4/10/2014. On 9/2/2014 the chemical inventory was inspected and multiple items were found to not have been logged in as used or checked out. MSDS lists are kept in the Food Service Department Laundry Area, Programs Building and the Medical Department. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE Rating A/D/R/NA E. Conduct fire/evacuation drills according to schedule/standard A F. Staff trained to prevent contact A h blood and bodily fluids Corrective Action Required/Comments Fire Drills are scheduled quarterly which include all areas of the building & all shifts. The generators were tested on , 9th, 161h, 23rd & September t G. H. I J. K. A. B. C. Emergency generators are tested bi-weekly Every employee and resident using flammable, toxic, or caustic materials receives advance training in their use, storage, and disposal Safety Office (or officer) maintains files of inspection reports; Including corrective actions taken Facility appears clean and well maintained All flammable and combustible materials (liquid and aerosol) are stored and used according to label recommendations 3. Transportation (By Land) Documentation indicating safety repairs are completed immediately and vehicles are not used unfil they have been repaired and inspected, is available for review Officers use a checklist during every vehicle inspecfion Transporting officers limit driving time to 10 hours in any 15 hour period when transporting residents A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 675 of 740 A A A D A A A A On 9/5/2014 the bathrooms utilized by the children during the school hours were observed to be extremely filthy with trash overflowing and mound os toilet paper (see picture for details). Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc PERFORMANCE MONITORING MEASURE DWM 1(15)(7)1officers with valid Commercial Drivers Licenses, (CDL's) required in any bus transporting residents Policies and procedures are in place addressing the use of E. restraining equipment on transportation vehicles Vehicles have 2 way radios, cellular telephones, equipment boxes in F. accordance with the Use of Force standard •G. Vehicles have written contingency plans on board Vehicles are equipped with appropriate child safety seats where H. applicable. 4. Admission and Release A. ICE information is available for initial classification B. Medical screening taking place within timeframes C. Inventory resident personal effects D. Accountability in place for admin/release E. All visual searches documented and are not routine in procedure D. F. G. Appropriate clothing and bedding issued Orientation material in English, Spanish or most prevalent second language 5. Classification System A. All residents classified appropriately upon arrival B. Reassessment and reclassification process in place C. Housing assignments are based upon classification D. Work assignments are based upon classification system A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 676 of 740 Rating A/D/R/NA Corrective Action Required / Comments A A A A A A A A A A A A A A A NA Cold Weather clothing will be issued on October 15h. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Residents are assigned color coded uniforms/wrist bands to reflect classification level 6. Contraband •A. Policy in place for handling contraband B. Contraband disposed of properly and documented C. Facility staff make a concerted effort to control contraband 7. Facility Security and Control A. Staff are required to conduct security check of assigned areas •B. All visitors officially recorded in a visitor log book C. Front entrance staff inspect ID of everyone entering/exiting D. Maintain a log of all incoming and departing vehicles F. Housing unit searches occur at irregular times F. Area searches documented in log book F. G. • H. I. J Daily/Monthly fence checks completed and logged Facility administrator or designee and department heads visit housing units and activity areas weekly Comprehensive staffing analysis determines staffing needs and plans Essential posts and positions are filled with qualified personnel A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 677 of 740 Rating A/D/R/NA Corrective Action Required/Comments Wrist bands are no longer utilized in our facility. Residents now wear their ID as a necklace. A A A A A A A A A A N/A This facility no longer has a perimeter fence. A D A Current staffing percentage for the month of September 2014 was 80.04%. This is taking into account the new staffing analysis of 189 authorized employees. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE F. Officers monitor all vehicular traffic entering and leaving the facility The facility has a written policy and procedures to prevent the introduction of contraband into the facility or any of its components Security officer posts located in or immediately adjacent to resident living areas to permit officers to see or hear and respond promptly to emergency situations. Personal contact and interaction between staff and residents is required and facilitated Daily procedures include: perimeter alarm system tests; physical checks of the perimeter fence; documenting the results Tools taken into the secure area of the facility are inspected and inventoried before entering and prior to departure The facility has in place a procedure and practice to gather, analyze and utilize intelligence information to include areas such as STGs, narcotics trafficking, financial info, telephone surveillance, high profile residents, visiting room activities, etc The facility shares intelligence information with ICE 8. Funds and Personal Property Inventory personal property/funds is maintained Funds/valuables documented on receipt Residents property searched for contraband Staff forward arriving residents medication to medical staff Resident funds are deposited into the cash box Staff secure every container used to store property with a tamperproof numbered strap G. Quarterly audits of resident baggage & luggage are conducted, verified, and logged K. L. M. • N. 0. • P. Q. A. B. C. D. E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 678 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A N/A A A A A A A A A A A The facility does not have a fence or a perimeter alarm. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Corrective Action Required/Comments 9. Waiting Room in Residential Facilities • A. B. C. D. E. F. G. I J. • Residents are not held in waiting rooms longer than 12 hours All residents wanded with a metal detector prior to placement in waiting room Maintain monitoring log for each resident in waiting room Written evacuation plan posted for each wailing room Waiting rooms contain sufficient sealing for the number of residents held The maximum occupancy for the hold room will be posted No bunks/cots/beds or other related make shift sleeping apparatuses are permitted inside hold rooms Residents are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. Officers closely supervise the waiting rooms. Waiting rooms are irregularly monitored every 15 minutes 10. Key and Lock Control A A A A A A A A A A. Maintain inventories of all keys/locks/locking devices A B. Emergency keys are available for all areas of the facility A C. Chit system used to issue security equip./keys/radios A D. Policy regarding restricted keys present and followed by staff Facility has a key accountability policy and procedures to ensure key accountability. The keys are physically counted daily A E. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 679 of 740 A Residents are no longer held in Hold Rooms, the doors no longer locked. The rooms are now called Waiting Rooms. There is a metal detector at the entrance to intake from the sally port. Fire evacuation plan is posted. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M F. Locks and locking devices are continually inspected, maintained, and inventoried 11. Population Counts A. Staff conduct formal census at least once per 8 hour shift/ 3x per day B. At least two officers participate in count for each area C. Recount conducted when incorrect count is reported D. Face to photo count conducted E. Each resident positively identified during count 12. Post Orders Every post has a post order, current & signed by the facility A. administrator B. Housing unit officers record all resident activity in a log C. Supervisor visits each housing area once per shift Staff sign post orders, regardless of whether the assignment is D. temporary, permanent, or due to an emergency Anyone assigned to an armed post qualifies with the post weapons E. before assuming post duty 13. Searches of Residents A. Unit shakedowns are conducted B. Random shakedowns conducted & documented The facility employs a schedule to insure that all areas of the facility C. are routinely searched D. Canines are not used for force, intimidation, or control of residents. 14. Sexual Abuse and Assault Prevention and Intervention The facility has a Sexual Abuse and Assault Prevention and A. Intervention Program • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 680 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A resident census takes place at 0900hrs, 1500hrs & 2000hrs. A A A A A A A A A N/A A A A A A I (b)(7)(E) Due Date .f ? "Tlf„T..t`'US Immigration and Customs Attachment 5.B. Enforcement and Removal Operations •• Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M B. All staff are trained, initially and in annual refresher training, in the prevention and intervention areas Sexual Assault Awareness Notice is posted on all housing unit D. bulletin boards 16. Staff-Resident Communication A. Housing unit rounds conducted daily by security staff B. C. Rating A/D/R/NA Housing unit rounds conducted daily by Deportation Staff Resident requests answered within 72 hours D. ICE SDC visit schedules are posted in housing unit E. Request forms are available to residents There is a secure box available for residents to place requests in for ICE staff that is checked on a daily basis A A A A A A A F. A Unannounced ICE staff housing unit visits occur weekly Visiting staff observe, document and communicate current climate H. and conditions of confinement 17. Tool Control A. Tool inventories conducted as specified B. Tools marked and readily identifiable C. Procedures for issuance of tools to staff and residents D. Inventory made of all tools by contractors prior to enter and exit A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 681 of 740 Staff Resident Communication Schedule is posted in Dayrooms and common areas. Request forms are available in Dayrooms and the Dining Hall. A G. • Corrective Action Required/Comments A Residents are advised of the program C. • Enforcement A A A A A ICE Officers conduct daily visits to housing units. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W M PERFORMANCE MONITORING MEASURE F. F. G. H. A. B. C. D. F. F. G. A. B. C. D. There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability A metal or plastic chit is taken in exchange for all tools issued, and when a tool is issued from a shadow board the receipt chit shall be visible on the shadow board Broken or worn out tools are surveyed and disposed of in an appropriate and secure manner Department heads are responsible for implementing proper tool control procedures as described in the standard 18. Use of Physical Force and Restraints Policy governing immediate/calculated use of force All use of force incidents documented and reviewed Video tapes of incidents preserved/catalogued for 2 1/2 yrs Resident is seen by medical immediately after incident Facility subscribes to prescribed confrontation avoidance procedures Staff trained in use of force techniques Appropriate procedures in place for using 4 and/or 5 point restraints 19. Disciplinary System Rules of conduct/sanctions provided in writing Incident reports investigated within 24 hours Disciplinary panel adjudicate infractions Disciplinary sanctions are in accordance with standards A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 682 of 740 Rating A/D/R/NA Corrective Action Required/Comments A D On 9/2 a 50 ft extension cord was found missing from the tool control area. It was not signed out or accounted for. It was later found in a closet in the Daycare room. A A A A A A A A A A A A D A Management Review Committee was conducted for resident' 00878E) Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M Enforcement Rating AR/NA Corrective Action Required/comments 072 023) on 9/11, for disorderly conduct. The resident's commissary was restricted for 3 days before they were afforded due process at a Management Review Committee (MRC). E. A. B. C. Staff representation available 20. Food Service Appropriate security measures for sharps are in place Appropriate food temperatures are maintained for both hot and cold food Food Service department maintained at a high level of sanitation A A A A D E. The facility maintains at least a 15 days supply of food items for all residents including current count of infants (this would include a 15 day supply of formula for all residents ages 0-1). Residents receive safety and appropriate equipment training prior to beginning work in department F. A minimum of two hot meals served daily A G. H. Facility has a standard 35 day cycle menu A registered dietician conducts nutritional analysis A A D. • A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 683 of 740 Staff representation is available upon request. On 9/22 the Facility Inventory was checked and found to have only 7cases of formula, which equals about 448 ounces of formula, enough for one infant for 14 days. We currently had 13 infants at the facility. A The facility has a 42 day cycle menu. Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M I J. K. All menu changes documented Common fare menu for authorized residents Weekly inspections conducted and documented The Dining Hall has an apporiate amount of high chairs and/or L. booster seats for the current population to utilize. The Facility shall assign a supervisor to be responsible for supervising the dining room and for ensuring the safety and welfare of M. the residents. The FSA shall ensure availability of snacks, fruits, juice and milk. The snack items shall be restocked at least twice daily. 21. Hunger Strikes Procedures for referring resident to medical if verbally refused or ! A observed refusing to eat beyond 72 hours B. Staff receive training in identification of hunger strike C. Process for determining reason for hunger strike 22. Medical Care A. Intake process includes medical and mental health screening B. Sick call procedures established C. Adequate medical staff available proportionate to population a Pharmaceuticals stored in a secure area N. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 684 of 740 Enforcement Rating AR/NA Corrective Action Required/Comments A A A A D D A A A A A A A On 9/29 @ 1722hrs there were no GEO staff supervising the Dining Hall. Refridgerators in the Dayrooms were found empty or mostly empty on the following occasions: 9/6, 9/14, 9/17, 9/21, 9/22 & 9/30. In addifion the logs on the refrigerators for temperature checks and restocking were not filled out daily. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc PERFORMANCE MONITORING MEASURE DWM Rating A/D/R/NA E. All residents receive physical examination/assessment within 7 days of arrival for adult women and within 24 hours for minors. A F. Sick call slips available in English, Spanish and/or most prevalent second language A G H. I J. The facility has a written plan for 24 hour emergency health care when no medical staff are on-duty or when immediate outside medical attention is required Medical records are available and transferred with the resident Records are maintained of medication distribution All sharps are under strict control and accountability K. L. M. A sharps container is used to dispose of used sharps All family units who are placed in a medical short stay room or a negative air pressure room are given the correct amount of beds or cribs to match the number of persons placed in the room, with an adequate amount of unencumbered space per requirements. The medical department is maintained at a high level of sanitation A A A A A D A N. Female residents are provided with a female escort for medical examinations with male health care providers. A 0. Medical Short Stay rooms and Negative Air Pressure rooms have an adequate amount of unencumbered space. D A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 685 of 740 Corrective Action Required / Comments On 9/2/2014 there was a family of 3 residents in medical observation in room 540, with only two beds. A female nurse accompanies Dr. Bryant during all consultations and physical exams of female residents. CEO is still placing up to 3 residents in the Negative Air Pressure (NAP) rooms which were originally meant for 1 resident. GEO has been advised that this is most likely Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M P. Female residents have access to pregnancy testing. Medical protocol is in place for the specialized treatment of children and adolescents including immunizations, Q. Enforcement Rating AR/NA Corrective Action Required/comments not adequate with the unencumbered space requirement. A A Immunizations have been offered to children and adolescents. 23. Personal Hygiene A. Clothing provided upon intake and exchanged weekly B. Sheets and towels exchanged weekly C. D. E. F. G. Climate appropriate clothing issued and maintained in good repair Facility provides and replenishes personal hygiene items as needed, at no cost to resident Showers operate between 100 degrees and 120 degrees Showers meet ADA standards and requirements Food Service resident volunteers exchange garments daily and wear white uniforms. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 686 of 740 A A D Residents are able to get clothing washed Monday — Friday by the laundry department. Raincoats have not been issued. Cold weather attire will not be issued until October 15'h per the Service Provider. A A A A Food Service resident workers do not wear white uniforms, due to facility staff wearing white uniform shirts. The VWP residents are given a gray T- Due Date Attachment 5.B. Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Frequenc D W A a a a A B. C. D. A. B. C. D. • E. F. and Customs Enforcement Month/Year: 08/2014 PERFORMANCE MONITORING MEASURE M U.S. Immigration 24. Suicide Prevention and Intervention The facility has a written suicide prevention and intervenfion program approved and signed by the health authority and facility administrator which is reviewed annually N Every new staff member receives suicide-prevention training. Suicide prevention training occurs during the employee orientafion program and annually thereafter The facility has a designated and approved isolation room for evaluafion and treatment Staff observes and documents the status of a suicide-watch resident at least once every 15 minutes 25. Terminal Illness, Advanced Directives, and Death Residents who are chronically or terminally ill are transferred to an appropriate off-site facility The facility has itten plans for addressing organ donafions There is a policy addressing Do Not Resuscitate Orders The facility has written procedures detailing the proper notifications 26. Correspondence and Other Mail Incoming mail screened and delivered daily Outgoing mail screened for contraband Legal mail opened in front of resident Incoming funds processed properly Rules for correspondence and other mail posted in housing unit or common areas, and resident handbook Facility has a system for residents to purchase stamps A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 687 of 740 Rating A/D/R/NA A A A A A A A A A A A A A A Corrective Action Required/Comments shirt and blue jeans to wear to work. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequen D W PERFORMANCE MONITORING MEASURE M G. • A. A. A. B. C. D. E. F. SMU has same correspondence privileges as general population 27. Escorted Trips for Non-Medical Emergencies The Field Office Director considers and approves, on a case-by-case basis, trips to visit an immediate family member in accordance with standards 28. Marriage Requests Marriage written requests approved by FOD 29. Recreation Outdoor/indoor recreation is provided Rating A/D/R/NA NA Corrective Action Required/Comments A A A Access to recreation activities Staff conduct daily searches of recreation areas In unit sedentary activities are available Recreation areas are under continuous supervision by staff equipeed with radios or other communication devices. The outdoor exercise area includes: shaded areas with seating, A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 688 of 740 A A A D A The residents have access to indoor & outdoor basketball courts, outdoor sand volleyball court, outdoor soccer field, indoor exercise equipment, fooseball tables, ping pong tables, Zumba classes and more. On 9/27 the gym was unlocked and unsupervised until 1400hrs. On 9/28 the gym was open from 0700hrs to 1500hrs. On On 9/29 two VWP were observed cleaning inside the gym, unsupervised. This facility has a soccer field, Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D w PERFORMANCE MONITORING MEASURE M Rating A/D/R/NA commercial-grade, age-appropriate play areas and/or a soccer field, A. B. A. B. C. D. E. F. G. H. I A. B. C. D. E. F. G. A. B. 30. Religious Practices Residents are allowed to engage in religious services Authorized religious items are allowed in resident possession 31. Telephone Access Upon intake, residents are made aware of phone policies Out of order phones reported to service provider Telephones inspected by staff Telephone access rules posted in each housing unit The number for the ICE OIG is posted in housing units The pro bono list is posted in housing units Emergency phone call messages delivered to residents Special access calls are available to residents Notification of telephone monitoring posted by unit phones 32. Visitation Written visitation schedule posted and accessible to the public General visitation log book maintained Visitor dress code enforced Visitation available 7 days a week Facility complies with visitation schedule Visitors are searched and identified per standards Current list of Pro Bono services posted in resident housing 33. Voluntary Work Program Facility has a voluntary work program Maintain a written chart with work assignments/classificafion level A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 689 of 740 Corrective Action Required/Comments sand volleyball court and a newly constructed playground. A A A A A A A A A A A A A A A A A A A A ICE staff conducts weekly telephone checks. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W M • PERFORMANCE MONITORING MEASURE Rating A/D/R/NA C. D. E. Facility complies with work hour and pay requirements for residents Residents are medically screened to participate Residents receive proper training and safety equipment A A A F. Resident housekeeping meets standards for neatness, cleanliness and sanitation A G. A. B. Residents understand and abide the facility rule that their primary responsibility is to care for their child. 34. Resident Handbook Staff aware of handbook contents and follow procedures Available in both English and Spanish and/or second most prevalent language A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 690 of 740 Corrective Action Required/Comments On 9/18 two mothers were observed handing their young infants off to other mothers in the dining hall to go and get their breakfast trays. On 9/19 a 2 year old child was found unaccompanied in elm Hall. On 9/29 a child was found unattended in Oak Hall Dayroom while the mother was outside near the playground. On 9/29, 3 unaccompanied children (2 mothers were at the hospital) were in medical SSU, and they did not have a counselor assigned to one to one observation from 04000600hrs in the morning. D A A Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M C. D. Handbook is updated as necessary Orientation material available to illiterate residents 35. Grievance System A. Grievance procedures in place B. Staff awareness of procedures for emergency grievances C. Grievance log is utilized D. Staff forward any grievances that include staff misconduct to ICE Informal resolution to a resident grievance documented in detention E. file 36. Law Libraries and Legal Material A. Adequate equipment is available for residents B. Legal materials/law library current and available for residents C. Resident access provided to include SMU D. Denials documented E. Schedule for use implemented 10 hours weekly per resident F. Access to legal material within 24 hours of written request G. Indigent residents provided free stamps/envelopes for legal matters H. •A. B. C. Hours of Access: Generally, law library hours of operation are to be scheduled between 8am & 8pm. 37. Legal Rights Group Presentations ICE/DRO approved videos played for all incoming residents Posters announcing presentation appear in common areas at least 48 hours prior to presentation Residents in SMU receive separate presentation A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 691 of 740 Enforcement Rating AR/NA Corrective Action Required/comments A A A A A A A A A N/A A A A A D A A N/A On 9/6 the Law Library was closed by 1800hrs. On 9/27 the Law Library did not open until 1000hrs. On 9/28 it was only open from 1350hrs — 1850hrs. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. A. B. C. A. A. B. C. Facility ensures adequate presentations so all residents wanting to attend have the opportunity 38. Detention Files Detention file created for each new arrival Detention files contain documents generated during custody Detention files maintained in a secure area 39. News Media Interviews and Tours The facility has a procedure to address news media interview and tours in accordance with NDS 40. Staff Training The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers Staff training is conducted according to a regular schedule with sufficient classes to maintain pre-service and in-service training hour compliance The ratio of case management staff to residents shall not be greater than 30:1. The ratio of Mental Health Clinicians to residents is not to be greater than 25:1. 41. Transfer of Residents Rating A/D/R/NA A A A A A A A D A. Resident provided with resident transfer notification form A B. Health records/transfer summary accompany resident A C. D. Funds and personal property accompany resident A-File/work folder accompany resident 32. Education Children are provided with a minimum one hour daily instruction in A A A. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 692 of 740 Corrective Action Required/Comments A We have a mental health ratio of 1:133. We have a case management ratio of 1:266. School commenced on Due Date Attachment 5.B. U.S. Immigration and Customs Enforcement and Removal Operations Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M B. science, social studies, math, language arts and physical education. Pre-Kindergarten instruction is provided to eligible four-year-old children. Enforcement Rating AR/NA 8/26/2014. A C. Educational field trips are provided. D D. Progress reports are distributed to all students on a regular and consistent schedule. D E. A. The size of the students (plus Teachers) in the classroom does not exceed the posted maximum occupancy of the room. 33. Child Care All infants' ages 0-1 are afforded a crib upon admission to the facility, A Age appropriate developmental toys are available A C. All children ages 0-11 remain under constant supervision of their mother. D Page 693 of 740 No Field Trips were provided for the month of September 2014. No progress reports were distributed for the month of September. On 9/9 room 618 was over capacity with 27 students and 2 Educational Staff. The maximum capacity for the room is 27. On 9/10, classroom 618 had 27 students present in class today; with 27 students, a Teacher and an Instructional Assistant, the room was over capacity. D B. A s Acceptable D s Deficient R s At-Risk NA s Not Applicable Corrective Action Required/Comments The facility ordered an addition $3,000 worth of toys for the facility this month. There were at least 3 documented instances of children being left unattended. Due Date Attachment 5.B. U.S. Immigration Enforcement and Removal Operations and Customs Enforcement Compliance Monitoring Tool Facility Name: KCRC Month/Year: 08/2014 Frequenc D W PERFORMANCE MONITORING MEASURE M D. E. All minor children 12 years of age and older have a Hall Pass when not under supervision by their mothers. All school aged children attend school. F. Daycare staffing ratio does not exceed that of the Minimum Standard of Texas Residential Guidelines. A = Acceptable D = Deficient R = At-Risk NA = Not Applicable Page 694 of 740 Rating A/D/R/NA Corrective Action Required/Comments A A D On 9/4 there were 27 children in the daycare with only 3 Resident Advisors. Due Date March 27, 2015 Nakamoto Group Review of South Texas Residential Facility's (STR) compliance with the National Family Residential Standard's (FRS) Life, Health & Safety (LHS) Components Overview There are a number of life, health and safety (LHS) standards and components within ICE's National Family Residential Standards that are considered critical to the safe and effective operation of an ICE Family Residential Facility. Non-compliance with an LHS standard and/or component may significantly impair the health and safety of residents and staff, diminish the basic quality of life afforded to residents; and undermine .1FRMU's mandate to implement policies designed to protect the safety and dignity of the undocumented families with children during the stay at a residential facility. Those standards include: • Emergency Plans • • Environmental Health & Safety Medical Care • Food Service • Admission and Release • Suicide Prevention and Intervention During March 22 — 25, 2015 Nakamoto subject matter experts reviewed STR s compliance with these standards, their specific findings are as follows: Emergency Plans STR is only in partial compliance with the FRS for Emergency Plans. Although the plans have been revised for Phase Two, they have not received ICE approval and have not been placed in binder as prescribed by the standard. More importantly all MOUs have not been revisited and the associated outside responders have not been shown Phase Two. Environmental Health and Safety Phase Two is not in compliance with the FRS on Environmental Health and Safety. Specifically: The fire marshal's office has not completed a final inspection and the center does not have a certificate of occupancy. The Nakamoto inspector was informed that the fire marshal will conduct a final inspection after the electrical systems are activated. There are no evacuation signs in any of the buildings. There are numerous trip hazards in the Phase Two areas still under construction. Although there are chemical storage areas, there are chemicals used by contractors in areas without an MSDS. The center does not have a fully developed cleaning plan Page 1 of 10 Page 695 of 740 for Phase Two. The medical unit is not operational and verification of separation of infectious material cannot be substantiated. Medical Care The medical building for Phase Two is not operational. While the center's medical staff has a transition plan and expects to eventually comply with the FRS, Nakamoto was unable to complete a review of this standard since there were no functional medical offices, equipment and other areas such as a pharmacy to examine. Food Service The center has a transitional plan for food service. There is a master menu that has been submitted to ICE/ERO but has not been approved. Food service plans to implement a knife control system which is not operational and cannot be reviewed. There is still some discussion on using resident workers. If the decision is to use resident workers, the center will have to document training, medical screening and appropriate safety equipment. The center does not currently have a volunteer work program with this information. Admission and Release Current admission, orientation and release policies are acceptable. The center plans to transition these to Phase Two. The admissions area is mostly complete. The center has revised the resident handbook and it is pending ICE/ERO approval. Verification will be required to determine that the new handbook is being utilized and that the ICE/ERO video is operational. Present resident clothing will be moved to the center and will have to be verified as appropriate. There is no funds drop box in the admissions area or a safe in the property room for storing valuables at this time. These will also need to be verified. Suicide Prevention and Intervention The center is in compliance with the FRS on Suicide Prevention and Intervention Policy has been developed and staff has been trained. Other Standards Specific findings and compliance ratings for other standards containing components considered crucial to the safe operation of a family residential center are listed in the following: Page 2 of 10 Page 696 of 740 Policies and Procedures Components Compliant Not Compliant Remarks 1 The facility has written policies and procedures which are inclusive of all Standards and are reviewed at least annually. Ref: Standards Not all policies and procedures have been revised and have not been reviewed by ICE/ERO. • Correspondence and Other Mail Components Compliant Identity documents (passports, birth certificates, etc.) mailed to the resident will be turned over to ICE/ERO for placement in the resident's file Ref V.3.I a Not Compliant Remarks 2 Confirmed in policy and in interviews with intake staff. Grievance Components Policies and procedures for Grievance System include: unimpeded access, emergency grievances, assurance of no retaliation for filing grievances and forwarding allegations of staff misconduct to a supervisor and JERMU. Ref p.1; V.1 Compliant Not Compliant Remarks 3. 4 Every member of the staff knows how to identify emergency grievances, including the procedures for expediting them. Ref V.4 • C Grievance policy is in place. However, there are no grievance boxes or forms in Phase Two. Will require review in Phase Two. Staff has been trained. Interview of staff found that 3 out of 3 staff were able to articulate and emergency grievance. Page 3 of 10 Page 697 of 740 Hunger Strikes Components Policy and procedure for Hunger Strikes include referrals for residents suspected of or announced to be on a hunger strike, a medical assessment, and notification to ICE/ERO. Ref: p. 2; #2 Compliant Not Compliant Remarks 5 Center has a policy and staff has been trained. The medical staff has a plan for managing hunger strikes. lir Key Control Components Policies and procedures for key and lock control include identifying highly restricted, restricted and working keys - with highly restricted keys being issued to staff assigned to such areas only. Ref Sec. D, pg 8 Compliant Not Compliant Remarks • The center has a key control policy; emergency and restrictive keys have been identified. However, there are no key boxes installed in Phase Two. The contractor has not formally passed keys to CCA, The center will need to complete a full key control system including but not limited to: inventory of keys and corresponding doors and locks, establishing a back up key system, sealing rings, assigning chits, issuing 24 hour keys, and establishing an emergency key system, including placing keys outside of the center. Will require review in Phase Two. 6 Individual gun lockers are in an area that does not allow resident or public access. Ref V.6 • 7 Emergency keys are available for every area to or from which entry or exit might be necessary in an emergency. Ref: V.i.e • I • I The center plans to place gun lockers in the sally port area and ICE/ERO office building. This has not been accomplished. Will require review in Phase Two. 8 The center does not have emergency keys for each area. Page 4 of 10 Page 698 of 740 Law Library Components A law library is provided, accessible to all residents, and is staffed with personnel to provide assistance to Non-English speaking and reading impaired residents. Ref: pill Compliant Not Compliant 9 • r Compliant Not Compliant Remarks The law library policy is in place; however the law library is not operational. The center plans to use Phase One's bulletin board in Phase Two but it cannot be moved until residents are moved to new location. Will require review in Phase Two Personal Hygiene Components 10. There is a system in place for residents to have access to and regular issuance and exchange of climate appropriate clothing, bedding, linens, towels, and personal hygiene items. Ref: V.1 0 11. The facility is equipped operable and sanitary toilets, wash basins, and private showers that are available 24 hours and may be accessed without staff assistance Ref V.5.a 0 12. Wash basin and showers have both hot (100-120 degrees Fahrenheit) and cold running water. Ref: p. 3; #5 13. Adequate and sanitary facilities are available for residents with disabilities and for washing infants and toddlers. • Remarks Policy and procedures are in place. The center provides appropriate clothing to all residents. The center will have a central storage and exchange area. There are operable toilets and wash basins in each end of the housing units. There are also showers located on each end. PA Water temperatures could not be verified. Will require review in Phase Two. The center has an accommodation plan in place. There are wash basins for infants and toddlers and for residents with disabilities. Ref V.5.d Page 5 of 10 Page 699 of 740 Components Compliant Not Compliant The center plans allows for each person to have their own bed. Infants and toddlers have appropriate cribs. 14. Each resident is provided with his or her own bed, a Ref V.7 Remarks Recreation Components 15. Policy and procedure for Recreation provides for age appropriate leisure activities including indoor and outside recreational programming. Ref: p. 2; V1 Compliant Not Compliant Remarks The center has a recreation schedule. However, this schedule should be reviewed to utilize all of the recreational opportunities at Phase Two. The present schedule posted in Phase Two could be expanded to meet all of the needs of the resident population. • Religious Practices Components 16. Residents are allowed access to personal religious property and religious services are open to all Compliant Not Compliant Remarks The center has a religious service coordinator. The personal property policy allows resident to keep personal appropriate religious property. Phase Two AL residents, Ref: p. 6; #9 has two chapels that are partially furnished. Resident and Staff Communication Components 17. Policy and procedures ensure and document that the ICE/ERO department heads conduct frequent unannounced, unscheduled visits to the facility's living and activity areas. Compliant S Not Compliant Remarks ICE/ERO plans to have staff provide frequent unannounced visits within the center. There is a schedule in the information center in Phase Two of when ICE/ERO staff will be available in the living units. Page 6 of 10 Page 700 of 740 Ref: p. 2. Ha 18. Documentation of weekly telephone tests include: random calls to preprogrammed numbers, interview of residents, and review of written resident ICE OIC verified staff has been assigned to check phones on a weekly basis. Will require review in Phase Two complaints. (Rev. 02/09) Ref: p. 4; 2 Sexual Abuse Prevention and Intervention Components 19. Policy and procedure for Sexual Abuse and Assault Prevention includes protection of a resident who alleges sexual assault, immediate protection, and referral for a medical examination and/or clinical assessment. Ref: p. 3 20. The resident orientation program and handbook include information relating to: prevention and intervention, selfprotection, reporting sexual abuse or assault to a designated staff member, and treatment and counseling. Ref: p. 4; G 21. Resident intake includes screening for sexual trauma and a history of sexually aggressive behaviors or tendencies. Ref: p. 5; H Compliant Not Compliant Remarks NE The center has a sexual abuse and assault prevention and response plan. 1r The resident handbook and orientation program includes information required. The center provides all residents with the Sex Abuse Pamphlet during orientation. Case managers meet with all residents to discuss sex abuse prevention and reporting. The Center has a sexual screening instrument to be used during the orientation process by medical staff Note: The center will need to conduct a staffing and monitoring survey prior to moving into Phase Two. This cannot be accomplished until all cameras have been installed and monitoring equipment is operational Page 7 of 10 Page 701 of 740 Staff Hiring and Training Not Compliant Components Compliant Remarks 22. Introductory training for all staff occurs prior to the employee providing direct care to families and accompanied children. Ref: p. 8; B v, The center has a training plan and all staff has been trained. 23. All personnel files include: Child Protective Service (CPS) or similar background investigations, Results of medical examinations and immunizations, Criminal and other background checks, Copies of professional licenses. Ref: p. 6; #8 v, The center policy and procedures require all of these components. 24. Life-safety subject training courses require trainees to pass written and/or practical examinations. Ref: p. 7; A r< Telephone Access Components 25. Residents are allowed access to telephones during established facility waking hours, Ref: p. 2; 44 Compliant • Not Compliant I Remarks The center has a telephone policy. Phones are available 24 hours a day. There are no phones in the medical infirmary. Will require review in Phase Two. Tool Control Components 26. Policy and procedure for Tool Control includes the storage, issuing, supervision and inventory of tools based on highly restricted, restricted and Compliant • Not Remarks Compliant The center has a tool control policy. However, the revised policy is in conflict with the FRS for Pat Searches of Residents. The center has a tool room with locked area for restricted tools. There are no tools in the area at this time. The center will have to implement a full tool control system including Page 8 of 10 Page 702 of 740 working tools, Ref: p. 2; 8 27. Acetylene and other highly flammable liquids such as gas and paint thinner only have the amount needed in one day inside the facility and are stored outside the perimeter of the facility when not in use and at the end of each work day. Ref: p. 4; E control of knifes prior to becoming operational. Will require review in Phase Two. The center has a chemical control plan that includes provision for the storage of all chemicals outside the center perimeter. However areas under construction have chemicals that are not in compliance with this component. Will require review in Phase Two. • Transportation (Land) Components Compliant Not Compliant Remarks 28. Policy and procedure for Transportation by Land includes • Providing meals during transfer • Use of Restraint including special circumstances a The center has a transportation policy. • Emergency plans Ref: p. 9; L Use of Force Components 29. Policy and procedure for Use of Force outlines immediate and calculated use of force, confrontation avoidance, authorization on appropriate force, and documentation and review procedures. Ref: V.1 Compliant • Not Remarks Compliant Policy is in place. However there is no appropriate video equipment in Phase Two. Will require review in Phase Two. Page 9 of 10 Page 703 of 740 Components Compliant Not Compliant Remarks Compliant Not Compliant Remarks 30. Use of Force policy clearly states force is not authorized for children. Ref: V.2 Visitation Components 31. Policies and procedures for visitation outlines general, legal, and religious visitation. The center has an appropriate policy. 32. Resident visitation is operational a minimum of 12 hours each day. (Rev. 02/09) REQ: JERMU 33. Private consultation rooms are available for legal representative meetings with residents. 34. Ref: p. 9; i Component: Visitation is scheduled from 8 a.m. until 8 p.m. daily. Rooms are provided. C Life Health & Safety (LHS Facility: Reviewer's Notes: Understandably the STR phase two facility is not ready to receive residents. The deficiencies noted above will have to be rectified prior to transitioning from phase one. Compliance Rating: ECompliant ENot Compliant' (b)(6),(b)(7)(C) Reviewer's Signature I Date: 3/26/2015 COMPLIANCE RATING DEFINITIONS: Compliant - Facility is operating as required and recommended for passing of LHS components with adoption of suggested recommendations, if any. Implementation of suggestions should be documented and available for review. Non Compliant - Facility fails to meet the minimal requirements for effective operation. Facility is required to submit a Quality Assurance Service Plan (QASP) within 30 days of site visit report. Revisit of facility may be warranted. Page 10 of 10 Page 704 of 740 /j,tni'cc nut Ind R. moral ()pcialuin I S. Hopicement of I lomelancl Securil) 1777 NI I flop 4 Nan \ mom() le \ a. )821' R910101t1 U.S. Immigration and Customs Enforcement July 14, 2015 MEMORANDUM FOR: (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management (b)(6),(b)(7)(C) FROM: Contracting Officer Representative Karnes C()Wily Residential Center SUBJEC71: Close Out Memorandum Ibr liCRC-15-0008 This is the formal close out memorandum for Contract Discrepanc( Report KCRC-15-0008. in reference to the facility failing to maintain a safe and secure environment by not maintaining Functional surveillance cameras. as per the contract. FRO-RISA-1 I -004 Family Residential Statement of Work. 2. a. "The plumose meads riming" i, uvfiwilittac the provishms fin- the neeessarv phiwical structures. equipment. fintililies. personnel am, .services. to provide a program me temporetry shelter care in a staff secure environment mut other related .ervices lamilv groups who CIIV Cwrrendv held in the legal custody of or c GE() was notified DR KCRC-15-0008 on Jul) IS. 2015 and the formal response was received on July. 17. 2015. due to some concerns in their reply and attachments further documentation as requested and submitted to the COR July 24.2015. 'Die documentation from GliO is not sufficiently proving that they take security and safety seriously- in regards to their cameras. The log book in Central Control ( Tere the cameras are monitored From ) does not reflect that (41j0 stallare a« are of cameras being taken off line and that others were substituted due to construction. in addition stall (lid not know ((thigh areas of the compound in i ght be considered a blind spot and N‘011iCi 110t klIOV. to dispatch supporting personnel in case of emergency. Other cameras are still displaying a degraded vie inside of the facility areas as of this memo and the last CDR response and attachments from GEO do not address this issue. The monitors referenced in the CDR are not addressed at all in the maintenance requests received. and even th011211 the cameras are no longer show ing the lines and W.I, it c blocks (as shown in the at photos) they are extremely fuzzy and the dates and times arc not readable. At this time I am recommending a one time deduction due to CEO management not addressing the concerns within the CDR mid providing a more comprehensive plan of preventative maintenance oldie cant eras. It is my concern that due to prior CDRs and Plan of Actions. that Cili( ) does not consider this area of sathty and security an area concern and does not perionn prof entathe maintenance and relies on ICE compliance staff to notify management of disrepair. or iegvioy Page 705 of 740 SUBJECT: CDR KCRC-15-0008 Page 2 Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary," A Contract Discrepancy Report that cites violations of FRS, PREA, and SOW (contract) sections that protect the community, staff contractors, volunteers, and residents from harm, permits the Contract Officer to withhold or deduct up to 15% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Page 706 of 740 ()I .‘. Heim] Muni of I lorneland Sec urils -77 [`[[i [ oop 4 I 01776771 kritomo I c \ a. 7821 7 U.S. Immigration fii and Customs 74:hai Enforcement July 20, 2015 MEMORANDUM FOR: (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management FROM: (b)(6),(b)(7)(C) Contracting Of I leer Representative Karnes Counts Residential Center SUBJECT: Close Out Memorandum Ibr KCRC-15-0009 This is the formal close out memorandum for Contract Discrepancy Report KGRC-15-0009. in reference to the facility failing to provide an adequate amount of vehicles for the daily needs of the facility, as per the contract, ERO-IGSA-I 1-004 Family Residential Statement of Work 2. a. "The purpose of thic connyct is to liwilitate the proviSiOliN fin- 111C IleCeSSUIT physical equipment. facilities, personnel mid services. to prorate U program of temporary shelter care in a sittffsecure environment and other related services to alien lantils groups who are current& held in the legal cuslock of KE - and Basic Agreement 4. B. 2. c. .Service Provider shall Jthwish sttfficient vehicles in good repair and suitable. as approved by the II 'E. iv solidi , provide the required transportation CEO was notified of CDR KCRC-15-0009 in reference to the vehicle fleet on JU1V 15.2015 and the formal response was received on July 17. 2015. and due to sonic concerns in their attachments further documentation was obtained through the no invoicing Slibmitted to the COR for the month or June 2015. When the invoiced 39Is are compared to GEO documentation it shows a total of 4 vehicles off of the facility grounds at on time. This he would not have had another vehicle to spare for an emergency run off site or to assist with perillieter duties if something developed on site. GEO also contends that it was tiling to be accommodating to the prograill by choosing to send a large group or students on a field trip. 'Eh is group only consisted of 20 students. and while there needed to be chaperons as well, a bus would have sufficed for this event. and this facility does not have one. The at current largest vehicle they have is 15 passenger van and the contractor has only 011e For a the capacity can hold up to 532 residents. At this time I am recommending a one time deduction due to GI(0 management not promptly addressing the CDR concerns and fixing or attempting to increase their fleet readiness by showing documentation of vehicle purchase requests or actual receipts of purchases for vehicles. It is my concern that, due to their response to our CDR. that CEO does not consider this area of safety and nv.ice.uov Page 707 of 740 SUBJECT: CDR KCRC-15-0007 Page 2 fleet at this facility with a security an area of concem and will only take action to increase their deduction. ry," A Contract Per ERO-1GSA-11-0004, Attachment 6.A, Performance Requirements Summa s that protect the section ct) Discrepancy Report that cites violations of FRS. PREA, and SOW (contra ct Officer to Contra the community, staff contractors, volunteers, and residents from harm, permits there is full ines determ withhold or deduct up to 15% of a monthly invoice until the Contract Officer compliance with the standard or section." Page 708 of 740 The CEO Group. loc. (b)(6),(b)(7)(C) Karnes County Residential Center 009 FM 1140 Karnes Oty 'X 78118 Contracting Officer's Representative Karnes County Residential Center 409 FM 1144 Karnes City. Texas 7811g Re: Plan of Action: Security During Construction Date: October 2.2015 Dear (b)(6),(b)(7)(C) Concern: ICE feels that the fencing gaps are too large that residents could v,alk behind it. children may crav,1 under the fences or that resident could push the fence. ICE witnessed residents tripping on the stands from the fence. Response: GEO has contacted the construction foreman and his crew lime tied the fencing pieces together to eRviate the gaps. installed construction grade orange temporary plastic safety fences to the bottom of the temporary gal\ anized fences to eliviate residents from crawling under, and the orange sandbags have been relocated to coY Cr the metal stands that hold up the galvanized fence to eliviate trip hazards. Concern: ICE feels that at times there is no direct supervision over the activities inside the compound. Staff that over see the active construction site are not wearing any form of protective equipment. ICE witnessed a unsupervised tools in a area accessible to children. ICE is un aware if the fencing construction workers have been cleared. Response: Compound staff are positioned in areas where supervision can be maintained at all times. In addition. the Ilan Resident Advisors and Entities also assist in supervision of the compound while attending to their job duties. Staff who are assigned to supervise the construction site have been issued construction grade hard hats. While conducting a follow up walk through, the tool in question was found behind the orange construction grade plastic safety fence supervised by a staff member and three construction workers. The construction crew has been advised to continue to monitor tools while in the compound. All construction workers who are assigned in the compound have been cleared by. Mr. Barcena prior to entering the facility% Sincerely, The GPI) i;risi its Inc (b)(6),(b)(7)(C) Program Director Page 709 of 740 This report provides a guideline for the center's overall status in compliance of the Immigration and Customs Enforcement Standards. Compliant The Center is in compliance with the following standards • • • • • • • • • • • • • • • • • • • • Resident Files Religious Practices- Religious Service Coordinator arrives today Emergency Plan Admission and Release Contraband Suicide Prevention Post Order Resident Census New Media Interviews and Tours Environmental Health and Safety Food Service Marriage Request Funds and Personal Property Searches of Residents I lunger Strike - Ilungcr Strike Training for staff on 6/26/2014 I louse Keeping and Voluntary Work Program Terminal Illness, Advance Directive and Death Personal Hygiene Medical Care Escorted Trips for Non Medical Emergencies Partial Compliant 90% • • • • • • • Law Library and Legal Material- Lexus/ Nexus be installed and will be operational on 6/26/2014 Key control - Compliance by July 3,2014 Telephone Access - Phone will be in the building on June 26, 2014 Visitation - Need visitation room set up. Use of Physical Control MeasuresNeed video cameras June 26, 2014 Recreation - Need age appropriate outdoor equipment by July 30, 2014 Sexual Abuse Prevention and intervention - Posters need to be installed. Page 710 of 740 • • • • Assign a SAPI coordinator 7/1/2014 Disciplinary and Behavior Management - Staff training TBD Staff Training- Staff will be trained on FRS, Suicide prevention, I1unger Strikes and Child Abuse Reporting Transportation - Post orders, emergency plans developed but not in vehicles, Water coolers order, and equipment not installed in all vehicles 7/1/2014 Tools Control - Medical Staff to develop inventory by 6/26/2014 Non Compliant • • • • • • Staff-Resident Communication - Policy in place: Forms available by 06/26/2014 Posters to be place on 6/26/2014 Scheduling to be developed by 7/1/2014 Legal Rights Group Presentation - Jennifer Fenton is coordinating this service 7/15/2014 Grievance System- No grievance boxes Policy is in place. Forms not placed in the living unit. Correspondence and Other Mail - No stamps, envelopes, stationary: No drop box. Post office box to be rented by 6/26/2014 Transfer of Residents - Policy to be Developed Educational Programs Page 711 of 740 ErUbreement and Removal Operations U.S. Department of Homeland Security 409 FM 1144 Karnes City, TX 78118 (\ ti e et C t i , DSIL U.S. Immigration and Customs Enforcement September 5th. 2014 MEMORANDUM FOR: (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management (OAQ) FROM: (b)(6),(b)(7)(C) Contracting Officer's Representative Karnes County Residential Center SUBJECT: Request for Monetary Deduction and/or Withholding for Contract Discrepancy Report KCRC-14-001 As the Contracting Officer's Representative (COR), I am respectfully requesting a monetary deduction or withholding in pay to the Service Provider of 20-30% for the Month of August 2014 due to non-deliverance of goods and services as specified in the Statement of Work and outlined in the Contract Discrepancy Report (CDR). KCRC-14-00l . Specifically, the Service Provider failed to adhere to the August Activity Schedule. When the Assistant Field Office Director (AFOD) and the COR both requested documentation regarding the actual amount of activities completed for the month of August, the requested documentation was not provided. In addition, the gymnasium was found closed before the scheduled closing time on at least 6 different days. The Service Providers response that the gymnasium operating hours have changed is incorrect. CEO has proposed a schedule change. but the schedule change has not been approved and signed off by the AFOD and .1FRMU. so it should not have been implemented without approval and notification to ICE. Additionally. throughout the month of August there were numerous other compliance issues and concerns including but not limited to: inadequate number of high chairs. inadequate number of cribs, issues with mothers receiving formula. and lack of supervision in the gymnasium and dining hall. Page 1 of 2 Page 712 of 740 There were four Plan of Actions submitted to the Service Provider in regards to these items before the CDR was issued. ICE continued to see lack of improvement primarily to the lack of staff supervision in the Dining Hall & gymnasium and formula issue, so a CDR was issued. Taking into consideration the totality of goods and services not provided for the month of August in the above annotated items, a deduction of at least 20% for the 2" half of the month of August is being requested; an approximate deduction of $198,040 is recommended. Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary "A Contract Discrepancy Report that cites violations of PBNDS and PWS Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that provide for the basic needs and personal care of detainees, permits the Contract Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary, "A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that reduce the negative effects of confinement permits the Contract Officer to withhold or deduct up to 10% of a monthly invoice until the contract Officer determines there is frill compliance with the standard or section." Page 2 of 2 Page 713 of 740 Eabreement and Removal Operations U.S. Department of Homeland Security 409 FM 1144 Karnes City, TX 78118 U.S. Immigration and Customs Enforcement September 5th. 2014 MEMORANDUM FOR- (b)(6),(b)(7)(C) Contracting Officer Office of Acquisition Management (OAQ) FROM: (b)(6),(b)(7)(C) Contracting Officer Representative Karnes County Residential Center SUBJECT: Request for Monetary Withholding for Contract Discrepancy Report KCRC-14-002 Respectfully requesting a monetary deduction or withholding from the Service Provider of 20% for the month of August 2014. On two occasions in the month of August. ICE requested video footage from incidents which happened near the soccer field. In the video footage received you cannot make out the residents identity or the actions of the residents. Per the contract. ERO-IGSA-11-0004, page 70. The Set-vice Provider shall ensure that video cameras monitor hallways, exits, and common areas. A qualified individual shall be responsible fbr monitoring this ,system inside and outside the building. Considering that the videos will be recordings of residents who may be seeking asylum or other considerations under US immigration ktw, the Service Provider is required to maintain the tapes and may not release them to anyone, unless approved by DRS. The Service Provider shall develop a plan for keeping the videos /h, the duration qt. the project period and destruction of them upon completion of the program. The Service Providers response to the Contract Discrepancy Report (CDR) was that one of the incidents happened at dusk. therefore making it more difficult to view. That statement is true. although the second incident happened at 0823hrs as specified in the CDR. In addition, a previous CDR was issued on 4/9/2013 by COR (b)(6),(b)(7)(C) that specifically identified deficiencies with the camera surveillance system (see attached CDR, response and follow up for details). Page 1 of 2 Page 714 of 740 Considering this is a repeat deficiency & CDR, the COR is requesting a 20% monetary withholding of fluids until the cameras which are in direct observation of the soccer field and right out front of the Elm Dayroom & Oak Dayroom be fixed or maintained in a status where you are able to identify actions and residents. Per ERO-IGSA-11-0004, Attachment 6.A, Performance Requirements Summary, Safety, "A Contract Discrepancy Report that cites violations of cited PBNDS and PWS (contract) sections that provide a safe work environment for staff volunteers, contractors and detainees, permits the Contracting Officer to withhold or deduct up to 20% of a monthly invoice until the Contracting Officer determines there is full compliance with the standard or section." Per ERO4GSA-11-0004, Attachment 6.A, Performance Requirements Summary, Security, "A Contract Discrepancy Report that cites violations of PBNDS and PWS (contract) sections that protect the community, staff contractors, volunteers, and detainees from harm, permits the Contract Officer to withhold or deduct up to 20% of a monthly invoice until the Contract Officer determines there is full compliance with the standard or section." Page 2 of 2 Page 715 of 740 GeO The GEO Group, Inc. September 3,2014 Department of Homeland Security Immigration and Customs Enforcement Attn.: I (b)(6),(b)(7)(C) 'Contracting Officer's Representative Kames County Residential Center Karnes City, TX 78118 Re: Dear Names County Civil Detention Center 409 FM 1144 Kames City. TX 78118 www-esooreup.com CDR Report Number: KCCDC-14-0001 Karnes County Residential Center Contract Number: EROIGSA-11-0004 AU lua1 am in receipt of the Contract Deficiency Report Number KCCDC-I 4-0001 and provide the following response and the corrective actions taken for your review and record. The activity schedule you are referencing and as discussed with yourself and Juvenile & Family Residential Management Unit, was a modified activity schedule due to the ramp up of the facility. The schedule was changed daily based on the new arrival of the residents. The facility began accepting residents on August 1, 2014. As you are aware the families had to be orientated from both ICE and GEO. It was impossible to follow the schedule exactly as written. Part of this was due to ICE needs, tours, adding Asylum, Gateways, and medical assessments. Attached is the list of programs GEO did complete, (see August Calendar of Events). The needs of the residents were met to include additional programs that were added because of various requests from ICE in changing the schedule to add the additional services such as Gateway and six (6) day a week Asylum. Facility Findings in KCCR-I4-0001 included the following and each was addressed with you and JFRMU. As we discussed on 9-2-14 in your office, we did not receive an answer back from you on our responses so it was assumed they were acceptable. In addition, GEO and ICE have weekly meetings where these items were discussed; and in those meetings it was never communicated to me that the responses were unsatisfactory and would be taken to the level of a CDR. • On 8-5-14 Tribase multi-purpose cleaner was found unsecured in the gym. There was also no rec specialist in the gym; they were all outside on the soccer field. The rec specialist was gathering children to come to the gym and play. There were no residents in the gym. This was dm, four (4) of the ramp up and the staff was trying to engage the children and mothers because as you witnessed, they were nervous about their new surroundings. Tiw Tribase is a diluted chemical, that if swallowed or sprayed. would not put a resident, either mother or child in imminent danger. However, as we discussed the Fire and Safety Officer has developed a housekeeping plan. which GEO is following. Page 716 of 740 • On 8-7-14, 8-14-14 & 8-28-14 ICE observed the Dining Hall at 0747 hours; no GEO staff was monitoring the residents. As discussed. the GEO kitchen staff was in the kitchen with a counselor at die door allowing residents in. Your concern of thc children being left unattended at the table while the mother takes her tray to the trash was discussed during orientation with the mothers. As discussed with you, the referral process was not in place because this was day 6 of the ramp up. • On 8-7-14 Residents were informing ICE Officers that their babies are not drinking the Semilac Formula. Your concern was if GEO had alternative Formula. As discussed with you. ,the resident must put in a medical request to be seen for a different form of Formula. This was also discussed in orientation with the residents. GEO would have asked that ICE infomi the residents to put in a medical request to be seen for this, but as you know ICE did not have any protocols on day 6 of ramp up, and that is why they were coming to you asking what to do. • On 8-12-14 Resident in Elm 118 stated that she is not receiving enough formula for her two month old baby. Allegation that GEO staff told her to drink the milk out of the box. As we discussed in our weekly meeting, this allegation was never sustained. The mothers know it is their responsibility to request additional fomnila through proper procedure. • On 8-12-14 residents were found to have a playpen instead of a crib. As discussed with you, CEO had ordered the additional cribs and they arrived the next day. When you and I talked in your office on 9-2-14, you expressed to me that you understood this was already handled. • On 8-13-14 there were only 10 high chairs. As discussed with you GEO had ordered the additional highchairs and they arrived the next day. When you and I talked in your office on 9-2-14 you expressed to me that you understood this was already handled. • On 8-12-14, 8-14-14, 8-18-14, 8-22-14, 8-27-14, & 8-28-14 the gym was found unstaffed, not locked, or unavailable. As discussed and based on JERMU and ICE request. the building schedule was changed to allow the residents to sleep later in the morning and prepare for school. The new building schedule reflects the gym being available for residents from 0900-2000 hours. Breakfast is from 0630 to 0830 hours. In addition, the residents have been orientated on the importance of not allowing their children to roam freely without a pass. Page 717 of 740 • • On 8-20-14 one boy broke his clavicle bone when he was allegedly "playing tag with his feet". ICE requested a copy of the video surveillance of the incident and it was never naa. The surveillance was reviewed by GEOinanagement and, as discussed with you, the time of day was dusk and the images are not clear on the video. However, as ICE has done many times in the past, you are welcome to view any video. • On 8-24-14 the Library was closed at 1500. Medical recreation was taking place during this time and there was nobody in the Library. However. supervisors have been instructed not to close the Library during posted hours of operation for any reason without getting permission from the Duty Officer. I am hopeful the information presented is sufficient to address the matters you have raised. Please contact me at any time should you require additional information. (b)(6),(b)(7)(C) Facility Administrator The GEO Group, Inc. Enclosure CC: (b)(6),(b)(7)(C) EVP, Contract Compliance VP, Central Region (b)(6),(b)(7)(C) Director, Contract Compliance, Central Region Page 718 of 740 Karnes County Residential Center Building Schedule/Horario de Edificio 0000---- Perimeter and Hall Check 0100-- Perimeter and Hall Check 0200---- Perimeter and Hall Check 0300---- Perimeter and Hall Check 0400---- Perimeter and Hall Check 0500---- Perimeter and Hall Check 0530-- Morning Announcements- Anuncios de la Mahan KCRC Staff: 1st Shift Briefing 0600-- KCRC Staff: 1st Shift on Duty Clinic Open: Diabetic Residents — Clinica Abierta: Para Los Residentes Diabeticos Open Movement Begins — Movimiento Libre Empieza Outdoor Recreation — Courtyard: - Recreacion Afuera-Patio KCRC Staff: 3rd Shift Ends Hall Check — Revision de Pasillo 0630---- Cafeteria Open: Breakfast Cafeteria — Comedor Abierto: Desayuno 0700---- Pharmacy Window Open —Ventana de Farmacia Abierta 0720---- Pharmacy Window Will Close in 10 Minutes — Ventana de la Farmacia Cerrara en diez Minutos 0730---- Pharmacy Window Closed — Ventana de la Farmacia se ha Cerrado 0750---- Cafeteria Will Be Closing in 10 Minutes — El Comedor Cerrara en Diez Minutos 0800---- Clinic: Resident Sick Call Begins — Clinica: Clinica de solicitud medica para residentes 1 08-12-14 Page 719 of 740 Empiez a Programs Building: Open — Edificio de Programa: Abierto Indoor Recreation Center: Open — Centro de RecreaciOn Bajo Techo: Abierto Law Library: Open — Biblioteca Legal: Abierta Town Hall Will be at loam in Room 622 (See Schedule for Dates) — Reunion del Ayuntamiento sera a as diez de la mafiana en cuarto 622 en (soy correct date) 0815---- School Bell Rings (Monday-Friday) — Suena la Campana de la Escuela(Lunes-Viernes) 0830---- Cafeteria Closed: Breakfast — Comedor se ha Cerrado: Desayuno Mailroom Pickup and Delivery (Monday-Friday) Town Hall Will be at 10 am in Room 622 (See Schedule for Dates) - Reunion del Ayuntamiento sera a as diez de la maliana en cuarto 622 en (say correct date) 0900-- School Begins: Grades Pre-K — 12(Monday-Friday)—Escuela Empieza (Not on Sundays) Clinic: Resident Medical Appointments Begin — Clinica Citas Medicas para Residentes Empieza Laundry Pickup — Se Lavanta Ropa Sucia Cleaning Supplies Are Passed Out Census #1 Begins- Primer Censo Empieza Town Hall Will be at loam in Room 622 (See Schedule for Dates) - Reunion del Ayuntamiento sera a las diez de la manana en cuarto 622 en (say correct date) 1000---- Commissary: Open— Comisaria: Abierta Town Hall Begins - Reuni6n del Ayuntamiento comienza ahora. (See Schedule) 1100---- School Lunch Begins (Monday-Friday): Almuerzo de Escuela Comienza 1200---- School Lunch Ends (Monday-Friday) — Almuerzo de Escuela Termina Population Lunch Begins — Almuerzo de Poblacion Comienza School Recess Begins (Monday-Friday)— recreo de la Escuela Comienza 1250--- Cafeteria Will Be Closing in 10 Minutes — El Comedor va a Cerrar en Diez Minutos 2 08-12-14 Page 720 of 740 1300---- Cafeteria Closed: Lunch — Comedor Cerrado: Almuerzo Clinic Open — Clinica: Abierta 1315---- School Recess Ends(Monday-Friday) — Recreo de la Escuela Termina 1330---- School Resumes(Monday-Friday)— Escuela Continua 1350---- Commissary Will Be Closing in 10 Minutes (SATURDAY and SUNDAY ONLY)— Co misaria se cerrara en diez minutos (SOLAMENTE SABADO y DOMINGO) 1400---- Commissary: Closed — Comisaria: Cerrada (SATURDAY and SUNDAY ONLYSOLAMENTE SABADO y DOMINGO) 1600---- School Ends(Monday-Friday)— Escuela Termina Social Time: Begins (Monday-Friday)— Hora Social Comienza Census K2 Begins — Segunda Cuenta Comienza Clinic Closed- Clinica: Cerrada 1700---- Cafeteria Open: Dinner — Comedor Abierto: Cena Clinic Open — Clinica: Abierta 1800---- Perimeter and Hall Check 1850---- Cafeteria Will Be Closing in 10 Minutes — El Comedor Cerrara en Diez Minutos 1900---- Cafeteria Closed: Dinner — Comedor Cerrado: Cena Pharmacy Window: Open — Ventana de la Farmacia: Abierta "Know Your Rights" Video will be shown on Channel 23— El video de "Conocer sus Derechos" y el video de "Orientacian" se ensenara en el Canal 23. 1920---- Pharmacy Window Will Close in 10 Minutes — Ventana de Farmacia Cerrara en diez Minutos 1930---- Pharmacy Window Closed — Ventana de la Farmacia Cerrada 1950---- Commissary Will Be Closing in 10 Minutes — Comisaria se Cerrara en Diez Minutos (Monday-Friday / Lunes-Viernes) 3 08-12-14 Page 721 of 740 2000--- Perimeter and Hall Check Program(s) Building: Closed — Edificio de Programa (s): Cerrado Law Library: Closed — Biblioteca legal: Cerrada Commissary: Closed — Comisaria: Cerrada (Monday-Friday / Lunes-Viernes) 2030---- Perimeter and Hall Check 2130---- KCRC Staff: 3rd Shift Briefing 2200---- Perimeter and Hall Check KCRC Staff: 2nd Shift Ends KCRC Staff: 3rd Shift on Duty Indoor Recreation Center: Closed — Centro de RecreaciOn bajo techo Cerrado Outdoor Recreation — Courtyard: Closed — Recreacion Afuera- Patio: Cerrado Cleaning Supplies Are Picked up 2215---- Census #3 Begins — Tercer Censo Comienza 2300---- Perimeter and Hall Check .1FRMU Approval Facility Adminis (b)(6),(b)(7)(C) Date: (b)(6),(b)(7)(C) Date: \ CI 4 08-12-14 Page 722 of 740 DANYA INTERNATIONAL tat Date: To: August 13, 2015; Revised 9/2/15 (b)(6),(b)(7)(C) National Family Coordinator IFRMU From (b)(6),(b)(7)(C) Program Manager Danya International Re: Compliance Inspection (b)(6),(b)(7)(C) From August 3,2015 to August 7,2015 South Texas Family Residential Center. The followin cti Standard 1.1 Emergency Plans 1.2 Environmental Health and Safety 1.3 Transportation by Land 1.4 Housekeeping and Voluntary Work Program 2.1 Admissions and Release 2.2 Contraband 2.3 Funds and Personal Property 2.4 Key and Lock Control 2.5 Resident Census 2.6 Searches of Residents 2.7 Sexual Abuse and Assault Prevention and Intervention 2.8 Staff-Resident Communications 2.9 Tool Control 2.10 Use of Physical Control Measures and Restraints 3.1 Discipline and Behavior Management 4.1 Food Services 4.2 Hunger Strikes 4.3 Medical Care 4.4 Personal Hygiene 4.5 Suicide Prevention and Intervention 4.6 Terminal Illness, Advance Directives and Death 5.1 Correspondence and Other Mail 5.2 Educational Policy 5.3 Escorted Trips for Non-Medical Emergencies 5.4 Marriage Requests 5.5 Recreation 5.6 Religious Practices nd I conducted a targeted review at the e conducted: Type of Review Follow up from CRCL Concern Baseline and Follow up from CRCL Concern Baseline and Follow up from CRCL Concern Evening inspection of 3 housing units Baseline Baseline and Follow up from CRCL Review Baseline and Follow up from CRCL Review 5.7 Telephone Access 5.8 Visitation 6.1 Grievance System 6.2 Law Libraries and Legal Materials 6.3 Legal Richts Group Presentations 7.1 Residential Files 7.2 News Media Interviews and Tours 7.3 Staff Hiring and Training 7.4 Transfer of Residents 7.5 Post Orders Baseline and Follow up from CRCL Review. 8737 Colesville Road (b)(6),(b)(7 Silver Spring, Maryland 20910 Phone 301.565 Fax 30 .565.3710 • www.danya.com Page 723 of 740 Overall Observations • • • • • • Commitment from staff trickles from management. Extremely impressed at the staffs professionalism and commitment to doing the right thing for the residents. There are open communication lines between departments and many collaborative meetings. Since there are lots of moving pieces (and much of it is manual) it can be hard to be sure everyone knows what they need to know all the time, but it appears to be improving. There are better ways to use technology, including the ability to scan residents rather than log by hand (school, medical) and run reports. This would help with tracking and following up on truancy in a timely manner or tracking medical appointments and follow up. Information tracking seems to one of the harder things for staff at many levels given the volume of residents and the constant movements. Staff training appears to focus more on "corrections" rather than "residential"' services—Staff were very open to the idea of JFRMU providing possible overview etc. for staff. There are some redundant or unnecessary processes that could be easily streamlined. Better direction or process could be provided when dealing with a very difficult child. Staff are hesitant to use any of the disciplinary channels available, but the child's behavior is negatively effecting other families. CRCL Dashboard Attached, please find a copy of the CRCL Dashboard items, ‘ufkul, Observations/Activities and tbv7vr Comments. Recommendations All areas observed appear to be in compliance with the Family Residential Standards (FRS). However, the following issues were observed and recommendations were shared during the daily debriefings: 2.1 Admissions and Release • Observation(s): Staff have redundant processes that require the logging of the housing unit in a green log book, but the other activities (showers, lunch, and phone calls) are logged on a log sheet. A comparison of the two processes showed that some names were omitted from the log book. In addition, the medical screening is not logged during the intake process and is logged by the medical team. Recommendation(s): Conduct immediate assessment as to whether it is possible to add the housing unit to the log sheet so that staff members do not log in two places. Staff reported during the final debrief meeting that change was made, but inspector was not able to verify before departure. Immediately assess if there a necessity to log the medical activities in in the same place as the other required activities. Follow up: Review process changes during September inspection. • Observation(s): QA manager conducts random sample of 10% of all intakes per week from different housing units. Recommendation(s): Immediately add another sampling from each intake shift to ensure that time of admission is sampled in addition to housing unit assignment. Staff reported during the final debrief meeting that change was made, but inspector was not able to verify before departure. Follow up: Review QA process and findings during September inspection and monthly going forward. • Observation(s): If a high number of residents come through intake at once, showers are not cleaned periodically between residents. Recommendation(s): Develop plan and increase cleaning of showers during high intake within 15 days of receipt of this report. Follow up: Review during September inspection. Page 2 of 4 Page 724 of 740 3.1 Discipline and Behavior • Observation(s): During the weekly mental health meeting, staff mentioned concerned about a child who is causing issues with other children. Staff questioned what disciplinary methods would be appropriate. Recommendation(s): Within 15 days of receipt of this report, implement current SOP and document any issues with implementation to JERMURCE immediately upon identification. Send any recommended modifications to SOP to JFRMU and ICE for approval. Follow up: Review during September inspection. 4.3 Medical • • Strength: Staff coordinate care with local health department upon resident's departure if needed, particularly for TB. 14-30 days of medication is provided. Observation(s): Tracking system appears to be effective, and real-time tracking of all medical appointments is easily accessible. Recommendation(s): See Tracking/Data Management 7.3 Staff Hiring and Training • Observations(s): During evening visit, identified three staff in the play room rather than at their posts. Recommendation(s): Enforce the importance of being at post or obtaining relief as needed. Ensure staff know of the repercussions and administer consistently. Expand number of random supervisory visits during all shifts to at least two times per shift. Develop and provide report monthly to ICE/JFRMU/Inspector identifying instances employees are not at required location. Follow up: Review during September inspection. 6.1 Grievance System • Observation(s): CCA has a complete and documented process for all grievances. ICE process is now being utilized. RGC board not instituted as there has never been a need for it. Recommendation(s): Add more detail regarding who, what, where, when, how when a grievance is resolved. Designate member positions to the RGC board within the next month. Follow up—Re‘iew ICE grievance process in September. Determine if CCA designated positions as required. Other Issues Identified Documentation • Observation(s): Staff have crossed out log entries or used white out to remove log entries. Recommendation(s): Within 15 days of receipt of this report, provide training to staff on documentation practices and add face page or cover sticker to remind staff on all log books. Follow up—Review during September inspection Laundry • Observation(s): Laundry room time not posted. Staff confused as to when residents can do laundry. Staff report that often the residents push the soap button many times and it jams. Staff reported during the final debrief meeting that change was made, but inspector was not able to verify before departure. Recommendation(s): Immediately post laundry room hours in all units and laundry rooms and post instructions for using the soap dispenser on all machines. Follow up—ReAiev during September inspection. Records Room • Observation(s): No logbook or entrance requirement, although it is posted on the door that only Page 3°f 4 Page 725 of 740 certain staff can access. Staff reported during the final debrief meeting that change was made, but inspector was not able to verify before departure. Recommendation(s): Immediately add logbook for visitors and modify policy to ensure entrance requirements are followed. Follow up—Review during September inspection Tracking/Data Management • Observation(s): Staff do a tremendous amount for manual logging and tracking. The coding on the resident's IDs is only scanned for the lunchtime census. Data is in different systems and not able to be integrated. Recommendation(s): Determine if the resident IDs can be used when residents go to class, medical, and other activities. This will help with tracking and identifying truancy or missed medical appointments immediately so RSs can intervene. It also registers how long a resident waits for medical services. Data would be very helpful to identify both successes and areas of improvement. Also include reporting capabilities in the assessment. Conduct an implementation feasibility assessment with possible pilot testing within 30 days of receipt of this report and submitt to ICE, JERMU and Inspector. Follow up—Re‘iew progress at September inspection. Toys • Observation(s): Very few toys were seen around the facility. There were very few in the play rooms. Staff say that they have bought a lot of toys and that the kids are hiding them. Recommendation(s): Within 15 days of receipt of this report, determine inventory required vs. inventory available of toys and recreation equipment. Ensure inventory is of large enough variety and located in multiple places so that the kids don't feel a need to hide them. Redistribute inventory nightly to medical, mental health and play rooms. Follow up—Review during September inspection. Maintenance Issues Identified—Repair required immediately • Yellow Frogs: Ripped shower mat, clogged toilet • Red Parrots: Broken window screens Lighting • Provide task lighting desk lamps for adults to use after lights out. Resources • Mental health staff go to each housing unit to conduct weekly wellness checks on all children. Allocate another golf cart for this purpose, particularly in bad weather to expedite the process.. • Provide a copy of the DMS 5 (Diagnostic Statistical Manual) for mental health staff. Other ICE Documentation Issue While conducting a routine file review, it was discovered that the wrong release form was filed in the wrong file. The file foil (b)(6),(b)(7)(C) was reviewed, and the ICE release form for (b)(6),(b)(7) was in the tile. It was confirmed that these were two different people and the correct person was released. cc: (b)(6),(b)(7)(C) Chief, JFRMU Page 4 of 4 Page 726 of 740 It DANYA INTERNATIONAL Date: October 14, 2015 To: (b)(6),(b)(7)(C) National Family Coordinator IFRMU From: (b)(6),(b)(7)(C) Program Manager (b)(6),(b)(7)(C) Danya International, Inc. Re: Compliance Inspector Compliance Inspection of the South Texas Family Residential Center From September 22, 2015 to September 25, 2015, we conducted a baseline review at the South Texas Family Residential Center. The following activities were conducted and the findings are noted below: 1.1 Emergency Plans Baseline 1.2 Environmental Health and Safety 1.3 Transportation by Land 1.4 Housekeeping and Voluntary Work Program Baseline Baseline Monthly 2.1 Admissions and Release Monthly 2.2 Contraband 2.3 Funds and Personal Property 2.4 Key and Lock Control 2.5 Resident Census 2.6 Searches of Residents 2.7 Sexual Abuse and Assault Prevention and Intervention 2.8 Staff-Resident Communications 2.9 Tool Control 2.10 Use of Physical Control Measures and Restraints 3.1 Discipline and Behavior Management 4.1 Food Services 4.2 Hunger Strikes Baseline Baseline Baseline Monthly Baseline Baseline Baseline Baseline Baseline Follow up Monthly Baseline 4.3 Medical Care Baseline 4.4 Personal Hygiene 4.5 Suicide Prevention and Intervention 4.6 Terminal Illness, Advance Directives and Death 5.1 Correspondence and Other Mail 5.2 Educational Policy 5.3 Escorted Trips for Non-Medical Emergencies 5.4 Marriage Requests 5.5 Recreation 5.6 Religious Practices 5.7 Telephone Access 5.8 Visitation 6.1 Grievance System 6.2 Law Libraries and Legal Materials 6.3 Legal Rights Group Presentations 7.1 Residential Files Baseline Baseline 8737 Colesville Road, Phone 301.565 (b)(6) • Silver Spring, Maryland 20910 Fax 301.565.3710 • www.danya.com Page 727 of 740 Noncompliant and Recommendation Provided Noncompliant Compliant Noncompliant Compliant w/ Recommendation Compliant Complaint Compliant Compliant Compliant Compliant Noncompliant Compliant Compliant Compliant Compliant Compliant Compliant w/ Recommendation Compliant Compliant Not Inspected Baseline Monthly Baseline Baseline Baseline Monthly Monthly Compliant Compliant Compliant Compliant Compliant Compliant Compliant Not Inspected Monthly Baseline Monthly Baseline Compliant Compliant Compliant Compliant Compliance Inspection: South Texas FRC Sept. 22-25, 2015 7.2 News Media Interviews and Tours 7.3 Staff Hiring and Training 7.4 Transfer of Residents 7.5 Post Orders Baseline Baseline Compliant Noncompliant Not Inspected Not Inspected Observations • There were appmximately 1,800 residents in house during this inspection. • Intake increased during the week to a daily high of 119. All logs checked showed a 6— 8 hour processing period. • The new classification process and quality assurance measurements were implemented. • Principal (b)(6) ( and Facility Administrator (b)(6) both resigned since our last inspection. • Health Authority responsibilities moved from Maxim to IHSC COR. • Medical staff began scanning resident badges upon arrival/departure and began attaching appointment times to resident identification badges this week. • Gym class began scanning student badges upon arrival/departure. • CCA staff report that there are numerous policies awaiting ICE approval. I. Areas of Noncompliance The following areas of noncompliance were identified: 1.1 E mc rgencx Plans • Each facility will have in place contingency plans to quickly and effectively respond to any emergency situations that arise and to minimize their severity. • An evacuation plan will be in place in the event of a tire or other major emergency, and the plan will he locally approved and updated at least annually. Finding: Some facility emergency plans have components that are more applicable to a correctional setting and are not appropriate for this facility. For example, there is reference to an armory; however, there is no armory onsite. There is no plan that identifies a location or process for evacuating residents in the event of an emergency. Mitigation: Review emergency plans and remove/modify components not appropriate for this setting. Expand evacuation plan to include: o MOU's with local municipalities or private businesses regarding transportation of residents; o Plan for transporting children, to include acquisition of car seats and other needed equipment; o Designated location where all residents and staff are to be transported to and from, including MOU with designated location, if needed; o Food and water supply and transportation logistics; Page 2 of 9 Page 728 of 740 Compliance Inspection: South Texas FRC Sept. 22-25, 2015 o Other items as appropriate. 1.2 Environmental Health and Safety • Pests and vermin will be controlled and eliminated. • High facility standards of cleanliness and sanitation, safe work practices, and control of hazardous substances and equipment are employed at the facility, thereby protecting residents, staff, volunteers, and contractors from injury and illness. Finding: Bees and wasps were observed in most of the outdoor areas each day. Facility installed artificial turf without a cooling system or external thermometer and residents could get burned when temperatures are over 80 degrees. The Safety Manager was not consulted prior to installation. There were many unrepaired maintenance issues observed, which included broken drawers in housing unit cabinets, broken child safety latches, trash on the ground, and signage in need of repair. Mitigation: Install mechanism for monitoring temperature and cooling turf when the temperature exceeds 80 degrees. Modify procedure to ensure that facility safety personnel are included in discussions prior to installation of new materials/equipment to identify possible hazards. Develop daily and weekly facility inspection schedule and issues to look for. Conduct regular maintenance checks of every part of the facility, schedule repairs and monitor completion. 1.4 Housekeeping and Voinntan NN ork Program Eligible adult residents will have opportunities to work and earn money while in residence, subject to the number of work opportunities available and the constraints of safety, security, and good order. Finding "'")'"))“ confirmed that there are no residents participating in the In ) and Chie Voluntary Work Program. Forty-tour were approved by ICE but have not received medical approval Mitigation: Review policy to determine what approval is needed from medical staff. Incorporate these screenings into the overall plan for triaging medical appointments and services. 2.8 Stall-Resident Communication Staff member receiving a written request shall normally respond in person or in writing as soon as possible and practicable, no longer than within 72 hours of receipt. Finding: There were seven requests (ST11.09—ST1116) from the Brown Bears that were submitted on 9/11 with a due date of 9/16. On 9/24, these requests were open. When asked, Unit Manage b 6 reported that these requests were for strollers and that more needed to be ordered. The requests were filled on 9/24. Mitigation: Monitor resident request log on a daily basis to ensure timely completion. 7.3 Staff Hiring and Training • Staff and volunteers shall adhere to their State policy prohibiting child abuse and neglect. Signed Statements of Agreement shall outline actions that constitute child abuse and neglect Page 3 of 9 Page 729 of 740 Compliance Inspection: South Texas FRC Sept. 22-25, 2015 and shall be located in personnel files. • Each new employee, contractor, and volunteer shall be provided training prior to assuming duties. Finding: Al] staff files reviewed were missing the Signed Statements of Agreement. Review of the on-the-job training records show that some were approved by the supervisor prior to completion of the last training activity. Some staff began work prior to completing all of their required training modules due to illness or other unexpected absence. Mitigation: Revise process to ensure that all supervisors are approving on-the-job training after modules are completed. Review FRS requirement for inclusion of Signed Statements of Agreement and include for all staff. Develop plan for providing training onsite for staff that miss portions of modules. Page 4 of 9 Page 730 of 740 Compliance Inspection: South Texas FRC Sept. 22-25, 2015 11. Recommendations The following recommendations are provided to improve service delivery: 1.1 Environmental Health and Salet) • Observation(s): Red boxes are used to dispose of razors. Some are marked at "biohazard" with a clear bag and some are marked "Razors Only". This could be confusing for staff when handling actual bio hazardous materials. Recommendation(s): Standardize containers used to dispose of razors and implement consistently across housing units. 2.1 Admissions and Release • Observation(s): Residents complete the intake process in 6-8 hours. Recommendation(s): Determine feasibility of reducing intake average time to less than six hours. 4.3 Medical • Observation(s): Significant overcrowding in medical unit during peak times. Staff and residents are not clear as to the purpose of the medical triage trailers. Recommendation(s): Develop and document process for use of the medical triage trailers. Ensure all staff and residents are notified. Post hours and purpose in each housing unit. Install signage on medical trailers so they are easily identified by residents. Page 5 of 9 Page 731 of 740 Compliance Inspection: South Texas FRC Sept. 22-25, 2015 111 Status of Previously Identified Recommendations The following recommendations were provided during after the previous inspection in August. The status of resolution is provided below: 2.1 \ Omissions and Release • Observation(s): Staff have redundant processes that require the logging of the housing unit in a green log book, but other activities (i.e., showers, lunch, and phone calls) are logged on a log sheet. A comparison of the two processes showed that some names were omitted from the log book. In addition, the medical screening is not logged during the intake process and is logged by the medical team. Recommendation(s): Conduct immediate assessment as to whether it is possible to add the housing unit to the log sheet so that staff members do not log in more than one place. Staff reported during the final debrief meeting that this change was made, but inspector was not able to verify before departure. Immediately assess if there is a necessity to log the medical activities in in the same place as the other required activities. Follow up: Resolved—Second log book is no longer being used. • Observation(s): QA manager conducts random sample of 10% of all intakes per week fron different housing units to review accuracy to verify correct classification of residents. Recommendation(s): Immediately add another sampling from each intake shift to ensure that time of admission is sampled in addition to housing unit assignment. Staff reported during the final debrief meeting that change was made, but inspector was not able to verify before departure. Follow up: Resolved—QA process shows full compliance with housing classification guidelines. QA process now includes sampling from shifts as well as units. • Observation(s): If a high number of residents come through intake at once, showers are not cleaned periodically between residents. Recommendation(s): Develop plan and increase cleaning of showers during high intake within 15 days of receipt of this report. Follow up: Resolved—Showers were cleaned frequently during intake. 3.1 Discipline and liehax ior • Observation(s): During the weekly mental health meeting, staff mentioned concerns about a child who is causing issues with other children. Staff questioned what disciplinary methods would be appropriate. Recommendation(s): Within 15 days of receipt of this report, implement current SOP and document any issues with implementation to JERMU/ICE immediately upon identification. Send any recommended modifications to SOP to IFRMU and ICE for approval. Follow up: Resolved—Training for case managers provided on 8/10, 8/25 and 8/26 that included review of disciplinary process. Page 6 of 9 Page 732 of 740 Compliance Inspection: South Texas FRC Sept. 22-25, 2015 4.3 Nledical • Strength: Staff coordinate care with local health department upon resident's departure if needed, particularly for TB. Fourteen to thirty days of medication is provided. • Observation(s): Tracking system appears to be effective, and real-time tracking of all medical appointments is easily accessible. Recommendation(s): Resolved—Implemented use of scanner for resident IDs. 7.3 Staff Hiring and Training • Observations(s): During evening visit, we identified three staff in the play room rather than at their posts. Recommendation(s): Enforce the importance of being at post or obtaining relief as needed. Ensure staff know the repercussions and that these are administer consistently. Expand number of random supervisory visits during all shifts to at least two times per shift. Develop and provide report monthly to ICELIFRMU/Inspector identifying instances employees are not at required location. Follow up: Not resolved—Supervisors are making sporadic checks during the midnight shift. Other shifts showed at least one and occasionally two visits during shift. 6.1 (;rieN ance System • Observation(s): CCA has a complete and documented process for all grievances. ICE processi now being utilized. RGC board not instituted as there has never been a need for it. Recommendation(s): Add more detail regarding the who, what, where, when, how in the process for when a grievance is resolved. Designate member positions to the RGC board within the next month. Follow up: Resolved—RGC board positions were identified. ICE has assigned a staff person to manage the grievance process and all grievances were documented and addressed. All CCA grievances included additional information. Documentation • Observation(s): Staff have crossed out log entries or used white out to remove log entries. Recommendation(s): Within 15 days of receipt of this report, provide training to staff on documentation practices and add face page or cover sticker to remind staff of these practices on all log books. Follow up: Resolved—We were informed that this has been covered in the training on Report Writing. Issue not observed during this inspection. Latindr) • Observation(s): Laundry room time not posted. Staff confused as to when residents can do laundry. Staff report that residents often push the soap button many times and it jams. Staff reported during the final debrief meeting that change was made, but inspector was not able to Page 7 Page 733 of 740 of 9 Compliance Inspection: South Texas FRC Sept. 22-25, 2015 verify before departure. Recommendation(s): Immediately post laundry room hours in all units and laundry rooms arid post instructions for using the soap dispenser on all machines. Follow up: Resoked—Laundry room hours and instructions for using soap dispensers were posted. Records Room • Observation(s): No logbook or entrance requirement, although it is posted on the door that only certain staff can access. Staff reported during the final debrief meeting that change was made, but inspector was not able to verify before departure. Recommendation(s): Immediately add logbook for visitors and modify policy to ensure entrance requirements are followed. Follow up: Resolved—Logbook and signage provided. raelting/Data Management • Observation(s): Staff do a tremendous amount for manual logging and tracking. The coding on the resident's IDs is only scanned for the lunchtime census. Data is in different systems and not able to be integrated. Recommendation(s): Determine if the resident IDs can be used when residents go to class, medical, and other activities. This will help with tracking and identifying truancy or missed medical appointments immediately so RSs can intervene. It also registers how long a resident waits for medical services. Data would be very helpful to identify both successes and areas of improvement. Also include reporting capabilities in the assessment. Conduct an implementation feasibility assessment with possible pilot testing within 30 days of receipt of this report and submit to ICE, JERMU and Inspector. Follow up: Partially Resolved—Scanning used for recreation and medical. S • Observation(s): Very few toys were seen around the facility. There were very few in the play rooms. Staff say that they have bought a lot of toys and that the kids are hiding them. Recommendation(s): Within 15 days of receipt of this report, determine inventory required vs. inventory available of toys and recreation equipment. Ensure inventory is of large enough variety and located in multiple places so that the kids don't feel a need to hide them. Redistribute inventory nightly to medical, mental health and play rooms. Follow up: Resolved—Toys are now in a locked cabinet in each dayroom and are collected each night for sanitation. If a resident wants a toy, they ask the resident supervisor for access. Supply in the cabinets observed was adequate. Ample quantities were available in both the medical unit and mental health unit. Page 8 of 9 Page 734 of 740 Compliance Inspection: South Texas FRC Sept. 22-25, 2015 Lighting • Observation(s): Adults do not have a light source available after lights out. Recommendation(s): Provide task lighting desk lamps for adults to use after lights out. Follow-up: Not Resolved—CCA sent proposal to ICE for approval per Resources • Observation(s): Mental health staff requested a golf cart to expedite their visits to each housing unit to conduct weekly wellness checks. Staff also requested a copy of the DMS 5 (Diagnostic Statistical Manual) for mental health staff. Recommendation(s): Allocate another golf cart for this purpose, particularly in bad weather to expedite the process. Provide a copy of the DMS-5 (Diagnostic Statistical Manual) for mental health staff. Follow Up: Not Resolved—Check at next inspection. cc: Stephen Antkowiak, Chief, IIIRMU Page 9 or 9 Page 735 of 740 The Geo Group. Inc Mail - Work Order (b)(6),(b)(7)(C) Work Order Tue, Jul 21, 2015 at 10 47 AM (b)(6),(b)(7)(C) Central Control-Camera Multiple cameras out in Central Control 8, 10, 19, 20, 29, 31, 41, 55, 56, 57, 58, 66, 71, 72, 73, 172 Multiple cameras blurry in Central Control 2, 3, 4, 5, 17, 18, 22, 23, 24, 36, 47, 54, 64, 68, 65, (b)(6),(b)(7)(C) Security Clerk The GEC Group, Inc. Karnes County Residential Center 409 FM 1144 Karnes City, TX 78118 Tel: 830 254 • Fax 30 254-2294 (b)(6),(b)(7)(C) www.geogroup.com This email and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to which they are addressed. If you are not the intended recipient or the person responsible for delivering the email to the intended recipient, be advised that you have received this email in error and that any use, dissemination, forwarding, printing or copying of this email is strictly prohibited. If you have received this email in error, please immediately notify by replying to this email. (b)(7)(E) Page 736 of 740 1/1 Work Order Work Order Created By Created 412366 Multiple Cameras Out Scheduled Start Scheduled End Date Status 07/16/2015 07/16/2015 07/22/2015 Open Reprint WO Type BRKD Breakdown Parent WO Class Priority Warranty Safety Equipment Criticality Assigned To Reported By Assigned By Multiple Equipment Campaign Campaign Event Date Started Department DEFAULT / ALL DEPARTMENTS PM Schedule Cost Code Problem Code Project Standard WO Date Completed Time Completed Equipment Equipment 200-CENTRAL CONTROL 200-Central Control Manufacturer Model Serial Number Location 200-CENTRAL CONTROL 200-Central Control Reliability Ranking Reliability Ranking Score Reliability Ranking Index 07/16/2015 08:24): Mulitple cameras out: 8, 9. 10. 14. 19, 20, 29, 30.31! 41. 55, 56, 57, 58. 66.71 72, 73. 172 Page 737 of 740 $URVIEL 3 (b)(6),(b)(7)(C) No Activity Work Order Activity Trade MAINT TECH Estimated Hours 4 GENERAL MAINTENANCE 412366 10 Activity Start Date Activity End Date People Required 07/16/2015 07/2212015 2 Booked Hours Employee/Crew Date Time On Time Off Route Route Page 738 of 740 Total Time Type of Hours Infor EAM Gee PrintWork Order Comprehensive Work Order Work Order Created By Created 381223 Multiple cameras out Scheduled Start Scheduled End Date Status KRIONOI01 06/05/2015 WO Type BRKD Breakdown Parent WO Class Priority Warranty Safety Equipment Criticality Assigned To Reported By Assigned By Multiple Equipment Campaign Campaign Event Date Started Department DEFAULT / ALL DEPARTMENTS PM Schedule Cost Code Problem Code Project Standard WO Date Completed Time Completed Equipment Equipment 200-CONTROL CENTER 200-Control Center Manufacturer Model Serial Number Location 200-CENTRAL CONTROL 200-Central Control Reliability Ranking Reliability Ranking Score Reliability Ranking Index (b)(6),(b) 106/05/2015 09:26]: Multiple cameras are out in center control. Cameras: 161 Page 739 of 740 06/05/2015 06/09/2015 Open SURVIEL 2 (b)(6),(b)(7)(C) No Infor EAM Geo Print Work Order - Comprehensive Activity Work Order Activity MAINT TECH Trade Estimated Hours 1 381223 10 Activity Start Date Activity End Date People Required GENERAL MAINTENANCE 06/05/2015 06/09/2015 2 Booked Hours Date Time On Time Off Total Time 25 if 4 - =91: Lmmimimmm a 4161. agimm(m... ar ;; Route Page 740 of 740