CORRECTIONS EXPERT'S REPORT

ON

ADELANTO CORRECTIONAL FACILITY

Prepared by:

(b)(6)

Roseville, CA
November 16, 2017

Privileged and Confidential
For Official Use Only

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ADELANTO CORRECTIONAL FACILITY
I.

SUMMARY OF REVIEW

The U.S. Department of Homeland Security (DHS), Office for Civil Rights and Civil Liberties
(CRCL), conducted a November 13-14, 2017 progress review and investigation at the Adelanto
Correctional Facility (ACF) in Adelanto, California. The prior December 9-11, 2015 onsite
investigation at this facility identified deficiencies in the areas of admission and release, special
management units, population counts, grievance system, staff misconduct, retaliation, staffdetainee communication, staffing, training, legal access, visitation, language access, health and
mental healthcare, and management team assistance. On February 2, 2016 CRCL received
notification from ICE ERO of the death of an ACF detainee alleging delayed and inadequate
medical care.1 On December 19, 2016 CRCL received an email referral from the DHS Office of
Inspector General (01G) which alleged delayed and denied access to medical care, failure to
provide medications and failure to respond to medical grievances.2 On April 19, 2017 CRCL
received a detainee complaint alleging delayed medical treatment, verbal abuse and retaliation
by medical staff.3 On May 13, 2017 CRCL received an email notification from ICE Joint
Intelligence Operations Center (AOC) Daily Detainee Assault Report of a use of force incident
report involving a detainee diagnosed with mental illness and Hepatitis C.4 On June 5, 2017
CRCL was notified by ICE of the May 30, 2017 death of a 46 year old detainee.' On June 21,
2017 CRCL received email notification from the ICE JIOC Daily Detainee Assault Report of a use
of force incident involving a detainee- correctional officer assault. On June 26, 2017 CRCL
received correspondence from The Border Rights Project on behalf of their clients alleging that
two detainees participated in a hunger strike to protest the inhumane conditions at the ACF and
in retaliation were beaten, placed in administrative segregation, denied access to medical care,
denied access to their attorney, denied grievance forms and ICE did not respond to the
detainees' requests for a credible fear interview.' Due to time limitations CRCL focused this
investigation of operations in the following areas: admission and release, special management
units, use of force, population counts, grievance system, staff misconduct, retaliation, staffdetainee communication, staffing, training, legal access, visitation, language access, health and
mental healthcare, and management team assistance. This investigation also reviewed ACF's
adherence to the 2011 Performance Based National Detention Standards (2011 PBNDS).

1 CRCL

Complaint No. 16-06-ICE-0627

2

CRCL Complaint No. 17-03-ICE-0103

3

CRCL Complaint No. 17-07-ICE-0456

4

CRCL Complaint No. 17-08-ICE-0299

5

CRCL Complaint No. 17-09-ICE-0356

6

CRCL Complaint No. 17-09-ICE-0366

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Allegations related to the deaths, medical and mental health care are addressed by the medical
and mental health experts who participated in the onsite investigations; however, I did review
medical and mental health care from a correctional perspective relative to access to care
complaints and grievances.
Through this review, I found operational deficiencies related to some of the allegations, as well
as other operational deficiencies observed during the November 13-14, 2017 onsite
investigation and document review.
This report contains recommendations to address identified deficiencies, based on correctional
experience, ICE's detention standards, and recognized correctional standards including those
published by the American Correctional Association (ACA).
II. PROFESSIONAL EXPERTISE
I am an expert corrections consultant. My educational background includes a Bachelor of
Science Degree in Organizational Behavior from the University of San Francisco and a Master's
Degree in Criminology, Law, and Society from the University of California at Irvine.
My correctional expertise results from 26 years of operating, managing, and performing direct
supervision and oversight for up to ten male and female prisons with approximately 40,000
inmates and 15,000 staff for the California Department of Corrections and Rehabilitation
(CDCR), where I served as Southern Regional Prison Administrator, Associate Director Female
Offender Programs and Services, Deputy Director of Finance, Chief of Regulation and Policy
Management, and Prison Rape Elimination Act (PREA) Executive Project Director. I was also the
Director of Rehabilitation and Activation for the Federal Medical Prison Receiver appointed by
the court in the Plata v. Schwarzenegger litigation, reporting to the Medical Receiver while also
remaining a CDCR employee. My duties for the Receiver entailed creating evidenced-based
rehabilitation program models in an integrated care environment and designing the physical
configuration of the associated program space for a medical facility being built to correct
constitutional deficiencies declared by the court. The medical facility and programs were built to
accommodate vulnerable inmates with significant medical needs and mental health issues.
I have provided expert reports and testimony for prison and jail-related litigation in the States of
Hawaii, Illinois, Massachusetts, Pennsylvania, and California, and testified in over 300 California
Senate and Assembly legislative hearings related to prison and community corrections issues.
My experience also includes teaching criminal justice-related subject matter at Stanford
University and serving as an expert panelist for criminal justice research, sentencing, gender,
transgender, correctional operations, probation, and California Public Safety Realignment issues.
I am currently the Chief of the Alameda County Probation Department which includes
responsibility for the Juvenile Justice Detention Center, and the retired Chief Adult Probation
Officer for the City and County of San Francisco. I am also a retired member of the California
Rehabilitation Oversight Board (CROB), appointed by the California State Legislature. CROB
provides oversight of the CDCR's inmate prison rehabilitation programs and reports to the
legislature. I also previously served as a Board member of the Association of Criminal Justice
Researchers.

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II.

RELEVANT STANDARDS
A.

ICE Detention Standards

ICE's 2011 PBNDS currently apply to ACF. This facility was covered by these standards during
the entire period relevant to this investigation. Consequently, I relied on the 2011 PBNDS when
looking at the specific allegations regarding conditions at the facility. Additionally, I considered
ICE Directive 11062.1: Sexual Abuse and Assault Prevention and Intervention issued May 22,
2014, which was in force and effect during this period. The PBNDS 2011 which includes section
2.11 Sexual Abuse and Assault Prevention and Intervention (SAAPI) policies was also in effect
during this period.
III.

FACILITY BACKGROUND AND POPULATION DEMOGRAPHICS

ACF is located in Adelanto, California, and is operated and managed by The GEO Group, a
private corrections company, under a dedicated Inter-Governmental Service Agreement (IGSA)
between ICE and the City of Adelanto, California, to house only ICE detainees. ACF has a rated
population count of 1940. ACF began the initial intake of detainees in August of 2011 opening
East Facility with a rated bed capacity of 650. On August 1, 2012 West Facility was opened,
adding 650 beds of housing capacity. Detainees have been housed at this facility since 2011. In
July 2015 the GEO Group added a 650-bed expansion. ACF houses male and female detainees.
The detainees are housed in a mix of dormitory and secure housing units. Housing units have
Lower and Upper tiers. Male detainees held in segregation are housed in a Special Management
Unit (SMU) at the West Facility. The SMU contains 32 cells with an upper and lower tier and has
a total capacity of 64. The administrative SMU male count at this facility was 32, and the
disciplinary SMU male count was 14 during the November 13-14, 2017 site visit. The
administrative SMU female count was three and the disciplinary SMU female count was 1 during
this population included a combination of detainees on disciplinary and administrative
segregation status.
IV.

REVIEW PURPOSE AND METHODOLOGY

The purpose of this review was to examine the specific allegations made in the complaints, as
well as to identify other areas of concern regarding the operation of the facility. As part of this
review, I examined a variety of documents; conducted a site visit of ACF on November 13-14,
2017, along with CRCL staff and experts who examined medical and mental health care; and
interviewed ICE and ACF staff and detainees. Detainee names and alien numbers and staff
names are omitted from this report, and instead listed in Appendix A.
ACF staff were helpful and cooperative during our site visit, and I appreciated their assistance. I
also appreciated the cooperation and assistance provided by ICE staff before, during, and after
our visit.
In preparation for the site visit and completion of this report, I did the following:
o

Reviewed detainee complaints

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o
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o
o

o

Reviewed .110C Daily Detainee Assault Reports
Reviewed the Border Rights Project correspondence
Reviewed the April 2016 ICE National Detainee Handbook
Reviewed relevant ICE PBNDS 2011
o Grievance System
o Detainee Handbook
o Admission and Release
o Law Libraries and Legal Material
o Recreation
o Religious Practices
o Staff-Detainee Communication
o Special Management Units
o Staff Detainee Communication
o Classification System
o Population Counts
o Disciplinary System
o Sexual Assault and Abuse Prevention and Intervention
o Facility Security and Control
Reviewed relevant ACA correctional standards

While at the ACF on November 13-14, 2017 and post visit, I did the following:
o
o
o
o
o
o
o
o
o
o
o

o
o
o
o
o
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Toured East and West Facility Housing Units
Toured the SMUs
Toured Visiting
Interviewed housing officers
Reviewed the Inter-Governmental Service Agreement between ICE and the City of
Adelanto
Reviewed institutional operational policies
Reviewed law library access at ACF
Interviewed the law librarian
Reviewed the facility schedule for the law library
Reviewed the recreation schedule for the SMUs
Interviewed custody and program personnel regarding admission and release, SMUs,
use of force, population counts, grievance system, staff misconduct, retaliation, staffdetainee communication, staffing, training, legal access, visitation, language access,
health and mental healthcare, and management team assistance.
Inspected the SMUs
Inspected telephone pro bono number postings in the SMUs
Reviewed detainee grievances logs for 1/1/2016-10/31/2017
Reviewed specific detainee grievances and responses
Interviewed Grievance Officer
Reviewed detainee disciplinary reports
Reviewed disciplinary segregation orders
Reviewed disciplinary housing logs

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o
o
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o
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Interviewed male and female detainees in East and West Facilities
Interviewed randomly selected detainees in the SMUs
Spoke with various facility staff and management during the course of the review
Met with various ICE staff during the course of the review
Reviewed detainee housing rosters
Reviewed detainee files
Reviewed the ACF supplemental detainee handbook
Reviewed Administrative Segregation and Disciplinary Segregation hearing notices,
reports, detention files, and housing logs
Reviewed detainee requests made to ICE
Reviewed the Daily Activity Schedule
Reviewed ACF policies on:
o Classification
o Detainee Programs-Recreation
o Special Management Detainees/Special Management Unit Operations
o Use of Force
o Detainee Grievance Program
o Detainee Rules and Disciplinary Procedures
o Admission and Release
o Detainee Handbook
o Staff and Detainee Communication
o Library Services
o Language Line Services
o Prevention of Sexual Assault and Abuse
o Correspondence
o Access to Telephones
o Visitation
o Training
o General Incident Reports
o Hunger Strikes

In the context of this report, a finding of "substantiated" refers to an allegation that was
investigated and determined to have occurred; a finding of "not substantiated" refers to an
allegation that was investigated and the investigation produced insufficient evidence to make a
final determination as to whether or not the event occurred; and a finding of "unfounded"
means an allegation that was investigated and determined not to have occurred. Detainee's
name and A4I's referred to in this report are listed in Appendix A.
V.

CORRECTIONS FINDINGS AND RECOMMENDATIONS
A.

Admission and Release and Language Access

The 2011 PBNDS protects the Community, detainees, staff, volunteers and contractors by
ensuring secure and orderly operations when detainees are admitted to or released from a
facility. As part of this and the previous investigation I reviewed the admission and release

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process. I interviewed staff in Receiving who are responsible for the intake screening, admission
and release of detainees. I also reviewed intake screening and classification documents in
detention files as part of my investigation. ACF continues to not conform to the Admission and
Release Detention Standard.
FINDING: ACF PRACTICE DOES NOT CONFORM TO THE PBNDS ON ADMISSION AND RELEASE
STANDARD.
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:
Recommendation
1. ACF continues to fail to meet the Admission and Release, Intake Screening Standard as
interpreters or language lines are not consistently used for LEP detainees during the
intake screening process and completion of the numerous intake forms. The facility
must correct their intake and admission process by consistently utilizing interpreters
during the intake screening and admission process and ensuring detainees are signing
documents in a language he/she understands or is provided oral assistance in order to
comply with the detention standard. (PBNDS 2011, Admission and Release)
STATUS: Not corrected-previous recommendation
B.

Special Management Units

The 2011 PBNDS protect detainees, staff, contractors, volunteers, and the community from
harm by segregating certain detainees from the general population in SMUs with an
Administrative Segregation section for detainees segregated for administrative reasons and a
disciplinary segregation section for detainees segregated for disciplinary purposes. Because of
the risks associated with the isolation of a detainee in segregation, the detention standards
mandate specific requirements for any detainee held in segregation to protect their rights.
SMUs A and B at ACF housed 46 male detainees at the time of this investigation. ACF's SMU log
identifies 15 cases with serious mental illness (SMI). The Women's SMU housed four detainees
at the time of this investigation, and the SMU log identified 3 with SMI. The total number of
detainees held in segregation at the time of this investigation was 50 detainees. The SMU
detainee's SMI diagnosis and logs are incorrect. The CRCL mental health expert identified that
26(32%) of the 50 detainees held in SMU at the time of this investigation had SMI. I additionally
found when reviewing the SMU log that the log only tracks the number of days a detainee is
held in segregation for the current stay. The longest amount of time a detainee was held in the
SMU on the November 13, 2017 log was 426 days based on detainee #4's request for protective
custody (PC). No detainee should be held in the SMU for this amount of time. Isolation alone
can create physical safety concerns and can result in mental decompensation. Thirty-six percent
(18) of the SMU population had been housed in the SMU for over thirty days. The majority of
long term stays in the SMU are based on self PC requests due to the detainee's stated safety
concerns. When I further analyzed the cases in the SMU, I found that four other detainees had
spent over three hundred days in the SMU based on multiple stays. These four detainees had
spent 370 to 904 days in the SMU. The Healthcare staff were making the required daily rounds,
but detainees were being interviewed at the cell front which prohibits an accurate assessment
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of the detainee's mental health condition. Detainees with SMI should be interviewed in a more
therapeutic manner which should include removing the detainee from the cell. One of the
rooms in the SMU should be converted into an interview room where private interviews
between mental health personnel and detainees can be effectively conducted. The mental
health expert will speak to the specific mental health cases housed in the SMU. No current
strategy exists to address the detainees held long-term in SMU. If strategies are not developed,
the mental health and other long-term detainee cases will continue to decompensate, and the
population of the SMU will continue to grow.
FINDING: ACF SMU PRACTICE DOES NOT CONFORM TO THE PBNDS ON SPECIAL
MANAGEMENT UNITS STANDARD.
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:
Recommendations
2. ERO, IHSC and ACF must audit all SMU cases to identify those detainees housed in the
SMU, partially or wholly due to mental health conditions and, develop a safe housing
alternative with more intensive mental health services including mental health groups in
a non-SMU setting for detainees with mental health conditions. (PBNDS 2011, SMU)
STATUS: Not corrected previous recommendation - Long Term segregation of housing
of detainees with serious mental health conditions should cease. A therapeutic unit
should be established to house SMI detainees, where appropriate oversight and
treatment results in those detainees eventual transition to a general population or stepdown unit.
3. The Mental Health Director and IHSC must ensure that ACF mental Health staff conduct
daily face to face rounds with all detainees in the SMU and provide appropriate mental
health assessment and treatment. (PBNDS 2011, SMU)
STATUS: Partially corrected previous recommendation - Daily rounds are being
conducted; however, one of the rooms in the SMU should be converted into an
interview room where private interviews between mental health personnel and
detainees can be effectively conducted.
4. ICE must audit all detainees held in the SMU over 30 days for protective housing reasons
and determine if transfer to another facility is more appropriate. (PBNDS 2011, SMU)
STATUS: Partially corrected previous recommendation - SMU audits are being
conducted every 30; however, 40% (20) of detainees continue to be housed over 30
days in the SMU. ICE must work with GEO to create a housing alternative for nondisciplinary placements in the SMU for over 30 days.
5. ERO must conduct an external audit of all detainees held in Administrative and
Disciplinary Segregation over 30 days to determine if transfer to another facility could
improve treatment or resolve use of the SMU for special housing. (PBNDS 2011, SMU)
STATUS: Not corrected previous recommendation
C.

Population Counts

The PBNDS 2011 requires three and encourages more custody counts of the detainee
population daily; however, the Detention Standard also requires the count system to be

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effective. The count system at ACF is not effective. There are six counts daily at the East and
West Facility. Limited improvement has been made to the count process at ACF. The 1100
count has been moved to 10:30 AM which has reduced this count's interference with feeding,
visitation, etc.; however, the PBNDS 2011 does not mandate six counts. Count can take up to 2
hours to clear. The number of counts was increased to six several years ago due to a detainee
escape and was based upon a Corrective Action Plan agreement between ICE and ACF. The six
counts at ACF creates extended delays in feeding, visiting (legal and regular), recreation, law
library, and healthcare appointments. These extended delays impact all programming. In
previous discussions with the Chief of Security, he did not have a concern with eliminating the
11:00 AM daily count which would reduce the number of counts to five; however, the 11:00 AM
count time was moved to 10:30 AM and not eliminated.
FINDING: ACF POPULATION COUNT PRACTICE DOES NOT CONFORM TO THE PBNDS ON
POPULATION COUNTS STANDARD.
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:
Recommendation
6. ERO and ACF must develop and implement an efficient population count process that
comports with the 2011 PBNDS to eliminate the problematic delays that six daily
counts cause in the delivery of meals, visitation (legal and regular), recreation, law
library access, and detainee medical appointments. (PBNDS 2011, Population Counts)
STATUS: Partially corrected previous recommendation - ACF continues to conduct six
daily population counts when the Chief of Security previously did not have a concern
with reducing the number of daily counts to five which would improve detainee access
to programs and services.
D.

Grievance System, Staff Misconduct, Retaliation,

The 2011 PBNDS protects detainees' rights and ensure they are treated fairly by providing a
procedure for them to file both informal and formal grievances and receive timely responses
relating to any aspect of his/her detention, including medical care. One important aspect of the
Grievance System Standard is detainees are protected from harassment, discipline, punishment
or retaliation for filing a complaint or grievance. Detainee #3 called the OIG hotline to make a
complaint about inadequate medical care. Included in his complaint was ACF's failure to
adequately respond to detainee #3's medical grievances. I completed a comprehensive review
of the detainee grievances for 2016 and 2017. Detainees filed 380 grievances in 2016 and 512
grievances for the period of January 2017 through October 2017. Over one-third of the
grievance complaints relate to inadequate and access to medical and mental health care issues.
This large number of healthcare related grievances is not typical in a correctional setting, and is
a key indicator that the healthcare needs of the detainee population is not being met. During
the previous investigation in 2015 the large number of medical and mental health grievances

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CRCL Complaint No. 17-03-10E-0103

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was also raised. The medical expert will provide the expert opinion on medical care and the
mental health expert will opine on the mental health care; however, grievance systems are
designed to act as am important indicator or early warning system to assist leadership of both
ICE/ACF to identify significant issues within the facility. Medical and mental-health care
concerns were also one of the major issues raised by detainees during detainee interviews that
CRCL staff and I conducted at this facility. Discourteous staff treatment and retaliation were
also raised by detainees during the detainee interviews. Detainees filed 57 staff complaint
grievances in 2016 and 37 staff complaint grievances from January through October 2017.
Alleged misconduct includes verbal disrespect and harassment of detainees by healthcare,
program, and custody staff, discrimination based on race, retaliation when detainees voice
grievances, and excessive use of force. During detainee interviews CRCL staff and I conducted,
detainees voiced numerous concerns regarding the grievance system. Detainees report having
no faith in the grievance system due to a lack of responsiveness by staff and the grievance
system being ineffective. A lack of follow through and failure to correct reported complaints
and failure to address issues of staff disrespect toward detainees are contributing factors to the
detainees' lack of faith in the grievance system. GEO does not effectively track detainee's
grievances regarding staff misconduct and does not provide ICE with a copy of each staff
complaint as mandated by the PBNDS. Critical healthcare issues are raised in the grievances and
failure to timely respond to the raised concerns can create life threatening situations for the
detainees. Additionally, once GEO and ICE are advised of medical and mental health issues and
fail to respond, the system and personnel can be at legal risk of being found to be deliberately
indifferent.
During onsite detainee interviews, the detainees reported they continue to be verbally harassed
and disrespected by ACF staff in healthcare, program, and custody, discriminated against based
on race and subjected to retaliation when they voice grievances. These reports mirror the staff
misconduct formally documented in grievances. Adult Local Detention Facility Performance
Based Standard 4-ALDF-6A-07 mandate that detainees [Inmates] are not subjected to personal
abuse or harassment.
FINDING: ACF GRIEVANCE SYSTEM FAILS TO CONFORM TO THE PBNDS. DETAINEES SUFFER
RETALIATION, VERBAL HARASSMENT AND TREATED WITH DISRESPECT BY ACF STAFF
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:
Recommendations
7. ICE/ACF Management (including the Warden), must develop a reporting system to
ensure that facility personnel effectively respond to and resolve the detainee grievance
issues assigned to them by the Grievance Coordinator. (PBNDS 2011, Grievance System)
STATUS: Not corrected previous recommendation - Responses to grievances continue to
be ineffective in addressing detainee concerns.
8. ICE/ACF Management must develop a review and trend tracking system for all
grievances reporting staff mistreatment. (PBNDS 2011, Grievance System)
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STATUS: Not corrected previous recommendation - Detainee grievances about facility
staff mistreatment are currently not submitted to ICE as mandated by PBNDS 2011. ICE
should receive a copy of all staff-related grievances upon their receipt by the GEO
Grievance Coordinator.
a. All staff grievances should be tracked by date, time, location, issue and identify of
the involved staff.
b. GEO's onsite leadership should analyze the report of grievances against staff on a
weekly basis to look for trends and detainee reports of mistreatment involving
the same staff member.
9. ACF Warden must hold facility staff accountable for substantiated abusive and
disrespectful treatment of the detainees, as determined by the Grievance Coordinator
and or other facility personnel. (PBNDS 2011, Grievance System)
STATUS: Not corrected previous recommendation
10. ACF's healthcare grievance process (medical, mental health and dental) is currently
unreliable. The ACF Medical Unit should establish a staff position that is responsible
for timely review and response to medical grievances, and ensure the appropriate
follow-up actions are taken to prevent further detainee injury or death. (PBNDS,
Grievance System) - New Recommendation
11. A separate healthcare medical grievance log should be instituted to track healthcarerelated grievance submittals and timely responses. (PBNDS, Grievance System) - New
Recommendation
12. A monthly audit should be conducted of the submitted healthcare grievances to
improve timeliness of care and ensure appropriate access to medical, mental health
and dental care. (PBNDS, Grievance System) - New Recommendation
E.

Staff-Detainee Communication, Training and Turnover

In the previous 2015 investigation ICE and ACF management cite staff communication, turnover
and medical as the three largest problems at this facility. The medical and mental health expert
will speak to the healthcare related staffing issues in this investigation. Both ICE and ACF
management previously attributed the high custody staff turnover to the pay level of the
officers. There are several other contract correctional facilities in close proximity to ACF which
previously were hiring ACF correctional officers once ACF had trained them because the other
facilities offered higher salary and benefits. ACF has increased the compensation for
correctional officers which has reduced the number of vacancies and improved retention rates.
The pay increase has stabilized the workforce.
Staffing levels at the East and West facilities was impacted by GEO eliminating over 20 officer
positions as reported during the previous 2015 investigation. The positions were eliminated
based on the reduced population levels at the facility; however, the positions that were
eliminated directly impacted the movement of the detainees to medical, feeding, visiting (legal
and regular), etc. Some of these positions have been re-instated and filled which has reduced
movement delays; however, there continues to be a lack of adequate custody positions to
provide correctional healthcare escorts to medical and mental health appointments within the
facility and to outside appointments. I have reviewed the current custody post assignment
schedule which identifies that ACF currently has 5 dedicated medical transportation officer
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positions, 7.20 medical holding cell observation officers, 1.60 medical officers, and 24 utility
officer positions. The total healthcare correctional officer staffing needs should be analyzed,
and the available positions reviewed to determine the number of custody positions needed on
each shift for each healthcare related functions and to ensure the number of correctional officer
positions needed on each shift, seven days per week are available to eliminate the custody
staffing barrier to access to care.
FINDING: ACF HAS AN INADEQUATE NUMBER OF CORRECTIONAL OFFICER HEALTHCARE
ESCORT POSITIONS WHICH CREATES A BARRIER FOR DETAINEES TO ACCESS MEDICAL AND
MENTAL HEALTH CARE
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:
Recommendation
13. ICE AND ACF leadership must develop a post-assignment schedule that creates a
staffing plan which resolves the current staffing deficiencies that are impacting
operational inefficiencies, such as excessive count times, meal delays, and limited
visitation, legal access and recreation time allotments. (PBNDS 2011, Facility Security
and Control)
STATUS: Partially corrected previous recommendation --The post assignment schedule
has been revised and additional correctional officer positions have been added
however, the correctional officer medical escort and transportation staffing should be
increased to adequately support the medical and mental health escort needs within
the facility and to outside appointments and care.
F.

Legal Access

Law Library
During the previous onsite investigation in 2015 language access was identified as a barrier to
legal access for LEP detainees. It was previously recommended that a bi-lingual librarian be
hired to support the Spanish speaking detainees. The law librarian retired which created the
opportunity for GEO to hire a bi-lingual, Spanish speaking librarian; however, GEO did not hire a
Spanish speaking librarian. This was a significant missed opportunity for GEO to provide
improved access to legal services for Spanish speaking detainees. During onsite interviews with
male detainees on November 13, 2017, detainees voiced significant complaints regarding the
lack of language assistance related to using Lexis-Nexis, obtaining legal copies and preparing
legal forms that are only available in English. Detainees reported when other detainees try to
assist them with translation the detainees are threatened with a disciplinary. The new law
librarian is not bi-lingual which also contributes to the communication difficulties with LEP
detainees.
FINDING: ACF FAILS TO PROVIDE LEGAL ACCESS TO DETAINEES IN COMPLIANCE WITH PBNDS
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:

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Recommendations
14. ACF should grant the female Law Librarian's transfer and hire a Spanish speaking
Librarian. (PBNDS 2011, Law Library and Legal Material)
STATUS: Not corrected previous recommendation -- The female law librarian retired
and created a law librarian vacancy. GEO did not hire a Spanish speaking law librarian
which continues to create legal access difficulties.
15. ACF must institute a computer training class, demonstrating use of the Lexis-Nexis
software and computers, and create a detainee worker position in each housing unit to
assist detainees with utilizing the computer system. (PBNDS 2011, Law Library and
Legal Material)
STATUS: Not corrected previous recommendation - LEP detainees continue to have
difficulties using the Lexis-Nexis computers and preparing legal related forms that are
only available in English.

G.

Limited English Proficiency-Language Access

ACF and ICE do not currently comply with providing language access to LEP detainees. Under
federal civil rights law and DHS policy, LEP detainees must be provided meaningful access to
information, programs and services within ICE detention. Title VI of the Civil Rights Act of 1964
(Title VI); Executive Order 13,166, Improving Access to Services for Persons with Limited English
Proficiency, 65 Fed. Reg. 50,121 (Aug. 11, 2000); Department of Homeland Security Language
Access Plan, February 28, 2012 mandate LEP access for individuals held in detention. This
obligation includes providing access to competent interpretation (oral) and translation (written)
services for a wide range of interactions and programs covered by the ICE standards, e.g.,
Admission and Release, Custody Classification, Sexual Abuse and Assault Prevention and
Intervention, Special Management Units, Staff-Detainee Communication; Disciplinary System;
Medical and Mental Health Care; Suicide Prevention; Detainee Handbook; Grievance Systems.
Further, not only is this a legal requirement, but a failure to provide appropriate language
services can impact the safety of detainees and staff, and undermine the facility's compliance
with detention standards and its own processes and procedures. GEO and ICE's contractual
obligations require them to provide meaningful language access for residents.
In non-medical settings, ICE and ADF staff do not routinely use language line or translate official
documents from English to Spanish for Spanish speaking detainees. LEP detainees are required
to sign documents that they do not understand which invalidates the content of the documents
and purpose of having detainees sign documents. ICE/ADF management does not believe they
can mandate staff that is Spanish speakers to use bi-lingual skills.
FINDING: ADF DOES NOT COMPLY WITH THE DHS 2012 LANGUAGE ACCESS PLAN AND DOES
NOT COMPLY WITH PBNDS LANGUAGE ACCESS FOR LIMITED ENGLISH PROFICIENT DETAINEES
STANDARDS
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:

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Previous Recommendations
16. ACF must develop a Language Line logging system and require all facility staff to record
its use; by date and A#. (DHS Access Plan 2012) (PBNDS 2011, Multiple)
STATUS: Partially corrected previous recommendation - The Language Line logs exist at
various locations within the facilities, but non-medical staff do not consistently use the
language line.
17. ICE/ADF must ensure all forms issued to detainees for informational purposes and/or
for detainee signatures must be written and/or translated in a language the detainee
comprehends. All written material provided to detainees shall generally be translated
into Spanish to comply with the Detention Standards. (DHS Language Access Plan
2012) (PBNDS, Multiple)
STATUS: Not corrected previous recommendation

H.

Detainee #1 and 2 Death Review (Names listed on Appendix A)

As Part of this investigation I was asked by CRCL to review from a correctional practice
perspective any significant factors regarding Detainee #1 and 2's8 deaths that could have
negatively impacted access to care while held at ACF. Additionally, Detainee #3 also made a
complaint via the OIG hotline9 that ACF provided inadequate medical care including failure to
provide timely or follow-up care, failure to schedule approved offsite diagnostics and other
medical related issues. My investigation identified that lack of adequate correctional staffing to
perform escorts to care internally within the facility and to conduct transports to outside care
creates a significant barrier for all detainees to access care at ACF. In my previous investigation I
identified that a significant number of correctional staff vacancies existed which negatively
impacted all operational areas within the facility. Many correctional staff vacancies have been
filled; however, there continues to be a need to increase the number of medical escorts. The
lack of adequate correctional officer medical escort positions results in delayed medical
transports to outside care and cancelled onsite medical appointments and medical clinics which
prevents timely access to medical and in some cases, can create life threatening conditions for
detainees held at this facility.
FINDING: LACK OF ADEQUATE CORRECTIONAL OFFICER MEDICAL ESCORT STAFFING CREATES
BARRIERS TO CARE AND CAN CREATE LIFE THREATENING CIRCUMSTANCES FOR DETAINEES
The PBNDS, along with additional applicable guidelines, support the following priority
recommendations:
Previous Recommendation
None. Recommendation number 13 addresses the need for GEO to conduct a staffing
analysis to determine the number of correctional medical escort officers needed to conduct

8

CRCL Complaint Nos. 16-06-ICE-0627 and 17-09-ICE-0356

9

CRCL Complaint No. 17-03-ICE-0103
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I.

medical transports to outside care and to inside medical clinics and appointments to remove
access to care barriers. No additional recommendation is needed.
Detainee #4, 5, 6 and 7- Excessive Use of Force Allegations

As Part of this investigation I was asked by CRCL to review three use of force complaints.' I
reviewed the incidents involving Detainee #4 and Detainee #5 allegations and could not
substantiate any irregularities with the use of force with these incidents based on the available
information. Videos were not available related to these two incidents. I do note that both
incidents involve detainees with mental illness. The mental health expert will identify the
consequences of not providing adequate mental health treatment for detainees. Use of force
incidents is one of the many negative consequences of not providing adequate treatment and
medications for detainees with mental illness. Providing effective mental health treatment,
medications and housing for detainees with mental illness will reduce the number of use of
force incidents at this facility.
On June 26, 2017, CRCL received correspondence from The Border Rights project on behalf of
Detainees #5 and #6 alleging both detainees were beaten, placed in segregation, denied access
to medical care, denied appropriate access to their attorney, denied grievance forms and ICE did
not respond to the detainees' requests for a credible fear interview. These actions allegedly
were taken in retaliation for these detainees participating in a hunger strike protesting their
treatment and inhumane conditions at ACF. I reviewed the incident reports and viewed the
video recording of this incident. GEO staff complied with the Use of Force Policy and PBNDS
2011 in relationship to responding to this incident. This incident involved a large number of
detainees who participated in a sit in protest locking arms and sitting at tables in the dayroom.
Custody staff provided the involved detainees with numerous opportunities to respond to
directives to return to their beds. The detainees failed to comply, and their actions began to
incite detainees in other areas of the housing unit. Custody staff gave further directives to the
involved detainees, and in order to not lose control of the unit, ultimately dispersed OC Pepper
Spray to control the situation. The use of OC Pepper spray to gain detainee compliance was
appropriate given the circumstances, and the detainee's failure to comply with multiple
directives from custody for the detainees to return to their beds. Detainees were medically
evaluated upon the conclusion of the incident. I found no evidence to support that detainees
were not provided with medical care; however, I did identify a significant issue with the
decontamination process. When exposure to OC pepper spray occurs, the appropriate method
to decontaminate effected detainees is to use cold water generally in a shower. The facility
does not have any access to cold water. The facility only provides a mix of cold and hot water
through a shower head to comply with the temperatures required for environmental health and
safety. The warm water will exacerbate the burning effect of the OC pepper spray. GEO must
obtain a cold-water source in a shower in both the East and West facilities to be used when
decontamination from an OC pepper spray incident is needed. Access to the detainees'
attorney was suspended during the initial incident and response, but was provided as soon as it
was feasible. I did not substantiate that the detainees were denied access to grievance forms.

10 CRCL Complaint Nos. 17-08-ICE-0299, 17-09-ICE-407 and 17-09-ICE-0366
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During my investigation I also reviewed ICE records in relationship to the allegation that ICE did
not respond to Detainee #5 and #6's request for a credible fear interview. There is no record of
Detainee #5 requesting a credible fear interview. Detainee #6 claimed a credible fear on May
25, 2017. On May 30, 2017 he requested a credible fear interview. On June 9, 2017 Detainee #6
received a credible fear interview. The allegation of failure to provide a credible fear interview
is not substantiated.
FINDING: ALLEGATIONS OF EXCESSIVE USE OF FORCE, FAILURE TO PROVIDE MEDICAL CARE,
FAILURE TO PROVIDE ATTORNEY ACCESS AND DENIAL OF GRIEVANCE FORMS ARE NOT
SUBSTANTIATED
Previous Recommendation
18. ACF must provide access to a cold-water shower in the East and West Facilities for use
to decontaminate detainees who have been exposed to OC Pepper Spray. (PBNDS
2011, Use of Force) - New Recommendation

VI.

SUMMARY OF OUTSTANDING PREVIOUS RECOMMENDATIONS
Below are status updates of previous ACE findings and recommendations:
1. ACE continues to fail to meet the Admission and Release, Intake Screening Standard as
interpreters or language lines are not consistently used for LEP detainees during the
intake screening process and completion of the numerous intake forms. The facility
must correct their intake and admission process by consistently utilizing interpreters
during the intake screening and admission process and ensuring detainees are signing
documents in a language he/she understands or is provided oral assistance in order to
comply with the detention standard. (PBNDS 2011, Admission and Release)
STATUS: Not corrected-previous recommendation
2. ERO, IHSC and ACE must audit all Special Management Unit (SMU) cases to identify
those detainees housed in the SMU, partially or wholly due to mental health conditions
and, develop a safe housing alternative with more intensive mental health services
including mental health groups in a non-SMU setting for detainees with mental health
conditions. (PBNDS 2011, SMU)
STATUS: Not corrected previous recommendation - Long Term segregation of housing
of detainees with serious mental health conditions should cease. A therapeutic unit
should be established to house SMI detainees, where appropriate oversight and
treatment results in those detainees' eventual transition to general population or a
step-down unit.
3. The Mental Health Director and IHSC must ensure that ACE mental Health staff conduct
daily face to face round with all detainees in the SMU and provide appropriate mental
health assessment and treatment. (PBNDS 2011, SMU)
STATUS: Partially corrected previous recommendation - Daily rounds are being
conducted; however, one of the rooms in the SMU should be converted into an

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interview room where private interviews between mental health personnel and
detainees can be effectively conducted.
4. ICE must audit all detainees held in the SMU over 30 days for protective housing reasons
and determine if transfer to another facility is more appropriate. (PBNDS 2011, SMU)
STATUS: Partially corrected previous recommendation - SMU audits are being
conducted every 30 days; however, 40% (20) of detainees continue to be housed over
30 days in the SMU. ICE must work with GEO to create a housing alternative for nondisciplinary placements in the SMU for over 30 days.
5. ERO must conduct an external audit of all detainees held in Administrative and
Disciplinary Segregation over 30 days to determine if transfer to another facility could
improve treatment or resolve use of the SMU for special housing. (PBNDS 2011, SMU)
STATUS: Not corrected previous recommendation
6. ERO and ACF must develop and implement an efficient population count process that
comports with the 2011 PBNDS to eliminate the problematic delays that six daily counts
cause in the delivery of meals, visitation (legal and regular), recreation, law library
access, and detainee medical appointments. (PBNDS 2011, Population Counts)
STATUS: Partially corrected previous recommendation - ACF continues to conduct six
daily population counts when the Chief of Security previously did not have a concern
with reducing the number of daily counts to five which would improve detainee access
to programs and services.
7. ICE/ACF Management (including the Warden), must develop a reporting system to
ensure that facility personnel effectively respond to and resolve the detainee grievance
issues assigned to them by the Grievance Coordinator. (PBNDS 2011, Grievance System)
STATUS: Not corrected previous recommendation - Responses to grievances continue
to be ineffective in addressing detainee concerns.
8. ICE/ACF Management must develop a review and trend tracking system for all
grievances reporting staff mistreatment. (PBNDS 2011, Grievance System)
STATUS: Not corrected previous recommendation - Detainee grievances about facility
staff mistreatment are currently not submitted to ICE as mandated by PBNDS 2011. ICE
should receive a copy of all staff-related grievances upon their receipt by the GEO
Grievance Coordinator.
c. All staff grievances should be tracked by date, time, location, issue and identify of
the involved staff.
d. GEO's onsite leadership should analyze the report of grievances against staff on a
weekly basis to look for trends and detainee reports of mistreatment involving
the same staff member.
9. ACF Warden must hold facility staff accountable for substantiated abusive and
disrespectful treatment of the detainees, as determined by the Grievance Coordinator
and or other facility personnel. (PBNDS 2011, Grievance System)
STATUS: Not corrected previous recommendation
10. ICE AND ACF leadership must develop a post-assignment schedule that creates a
staffing plan which resolves the current staffing deficiencies that are impacting
operational inefficiencies, such as excessive count times, meal delays, and limited
visitation, legal access and recreation time allotments. (PBNDS 2011, Facility Security
and Control)
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11.

12.

13.

14.

STATUS: Partially corrected previous recommendation - The post assignment
schedule has been revised and additional correctional officer positions have been
added however, the correctional officer medical escort and transportation staffing
should be increased to adequately support the medical and mental health escort needs
within the facility and to outside appointments and care.
ACF should grant the female Law Librarian's transfer and hire a Spanish speaking
Librarian. (PBNDS 2011, Law Library and Legal Material)
STATUS: Not corrected previous recommendation - The female law librarian retired
and created a law librarian vacancy. GEO did not hire a Spanish speaking law librarian
which continues to create legal access difficulties.
ACF must institute a computer training class, demonstrating use of the Lexis-Nexis
software and computers, and create a detainee worker position in each housing unit in
order to assist detainees with utilizing the computer system. (PBNDS 2011, Law Library
and Legal Material)
STATUS: Not corrected previous recommendation - LEP detainees continue to have
difficulties using the Lexis-Nexis computers and preparing legal related forms that are
only available in English.
ACF must develop a Language Line logging system and require all facility staff to record
its use; by date and A#. (DHS Access Plan 2012) (PBNDS 2011, Multiple)
STATUS: Partially corrected previous recommendation - The Language Line logs exist
at various locations within the facilities, but non-medical staff do not consistently use
the language line.
ICE/ADF must ensure all forms issued to detainees for informational purposes and/or
for detainee signatures must be written and/or translated in a language the detainee
comprehends. All written material provided to detainees shall generally be translated
into Spanish to comply with the Detention Standards. (DHS Language Access Plan
2012) (PBNDS, Multiple)
STATUS: Not corrected previous recommendation

New Recommendations
Below are recommendations for new deficiencies I found during the December 2017 onsite
Investigation. These recommendations are based on the 2011 PBNDS.
1. ACF's healthcare grievance process (medical, mental health and dental) is currently
unreliable. The ACF Medical Unit should establish a staff position that is responsible
for timely review and response to medical grievances, and ensure the appropriate
follow-up actions are taken to prevent further detainee injury or death. (PBNDS,
Grievance System) - New Recommendation
2. A separate healthcare medical grievance log should be instituted to track healthcarerelated grievance submittals and timely responses. (PBNDS, Grievance System) - New
Recommendation

3. A monthly audit should be conducted of the submitted healthcare grievances to
improve timeliness of care and ensure appropriate access to medical, mental health
and dental care. (PBNDS, Grievance System) - New Recommendation

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4. ACF must provide access to a cold-water shower in the East and West Facilities for use
to decontaminate detainees who have been exposed to OC Pepper Spray. (PBNDS
2011, Use of Force) - New Recommendation

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CRCL ADELANTO DETENTION FACILITY INVESTIGATION

APPENDIX A
Detainee Name and A Numbers
Detainee #1:

(b)(6)

Detainee #2:
Detainee #3:
Detainee #4:
Detainee #5:
Detainee #6:

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On-site Investigation Report -- Adelanto, December 2017
(b)(6)

December 12, 2017

Introduction
This report responds to a request by the Office for Civil Rights and Civil Liberties
(CRCL) to review and comment on the medical care provided to detainees at the
Adelanto Correctional Facility (Adelanto or ACF) by the contractor GEO, under the
authority of U.S. Immigration and Customs Enforcement (ICE). My opinions are based
on the materials provided and reviewed and an on-site investigation of the facility on
November 13th and 14th, 2017. I had previously visited the facility on December 9th-11th,
2015. My opinions are expressed to a reasonable degree of medical certainty. ICE, ICE
Health Service Corps (IHSC), Correct Care Solutions (CCS) and GEO personnel were
most pleasant and cooperative during my investigation.
Overview of Findings
Overall, the medical care at the Adelanto facility is inadequate and does not meet
the 2011 Performance Based National Detention Standards (PBNDS) standards'.
Since my last investigation, important improvements have been made. For example, the
facility now uses an electronic health record (EHR), as was recommended subsequent to
the 2015 onsite investigation. Problems previously cited with the medical management
of hunger strikes has been successfully remediated. And, the facility has now developed
a quality assurance program and is making an effort to identify and remediate problem
areas. However, major problems remain. While problems were previously and currently
identified in a number of areas, almost all of those problems continue to be linked to one
fundamental problem: incompetent clinical medical leadership; a problem cited in my
previous on-site investigation report. The consequence of incompetent medical
leadership is a medical program where care is uneven, uncoordinated, lacking in
continuity, and lacking in provision. Even with the successful deployment of an
electronic health record, medical documentation remains incomplete. Medical care
moves forward slowly and inefficiently and things fall through the cracks. There are
significant delays and denials of care for medical conditions, including serious medical
conditions.
Specific Findings

'Specific examples and citations to relevant standards will follow in the body of this
report.

1. Complaints -- The Office for Civil Rights and Civil Liberties received a high
number of complaints about medical care prior to our on-site investigation,
including six cases cited in the Retention Memo (see cases 1-6 in Appendix II) that
was sent to ICE Headquarters, and a number of complaints identified during the
on-site investigation.

Cases cited in the Retention Memo:
a. Complaint No. 16-06-ICE-0627 (Case 1 in Appendix II) involves a detainee
death. The complaint of inadequate care is substantiated. This case will be
discussed in greater detail in item 2.
b. Complaint No. 17-09-ICE-0356 (case 2) also involved a detainee death. As
that death is currently under investigation by another office in DHS, my
access to records on that case was denied. Unable to review.
c. Complaint No. 17-03-ICE-0103 (case 3) alleged inadequate care for a knee
injury. This complaint is substantiated.
d. Complaint No. 17-07-ICE-0456 (case 4) alleged inadequate care for ear pain.
This complaint is not substantiated.
e. Complaint No. 17-09-ICE-0366 (case 5) alleged inadequate medical care after
a use of force incident. This complaint is substantiated.
f. Complaint No. 17-09-ICE-0366 (case 6) alleged inadequate medical care after
a use of force incident and during a hunger strike. This complaint is partially
substantiated.

Cases identified osite in facility grievance logs (sample cases)
g. Case 7 (see Appendix II) alleged inadequate and delayed access to care for a
wrist fracture resulting in mal-union (improper healing resulting in deformity)
of a wrist fracture. This grievance matter is substantiated.
h. Case 8 alleged inadequate and delayed access to care for a complicated ankle
injury with possible joint and bone infection. This grievance matter is
substantiated.
2. Detainee Death - I have previously conducted a records review of this death and I
have reviewed the ICE Office of Detention Oversight (ODO) Detainee Death
Review (DDR). The ODO DDR found numerous inadequacies in the medical care
provided in this case. Among my findings were three inadequacies that were
likely related, in my opinion, to the fatal outcome. These include a) the failure of
the nurse to respond appropriately or evaluate the detainee when he was in acute
distress, b) multiple additional delays in getting access to needed care for the
detainee after the illness had been recognized by staff, and, c) a failure of medical
staff to manually obtain vital signs during the emergency medical evaluation.
3. Lack of Medical Leadership -- In order to be compliant with the 2011 PBNDS, a
medical program must have a leadership structure, including a Clinical Medical
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Authority (CMA, usually a physician), and a Health Services Administrator
(HSA). This "designation of authority" is critical for the organized and
appropriate provision of medical services, and the final measure of the adequacy of
the leadership is found in the care that is ultimately delivered. In my previous
report, I cited this as a problem area and reported inadequate supervision and care
as significant consequences. Although ACF made one effort by changing the
medical contractor, that new contractor left the same incompetent leadership in
place. Again, I found that poor clinical leadership has continued to result in
inadequate medical care for the ACF detainees.

4. Grievances -- Adelanto does have a grievance process and that process includes
complaints or grievances on medical care. In the previous 2015 investigation,
there were more than 200 grievances about medical care. In 2017, the number has
actually increased. Most of those complaints continue to involve delays or
denials of care. The majority of the complaints about delays or denials of care
were substantiated. In spite of both a grievance and quality assurance program,
there is no evidence that either the high number of grievances or the high number
of substantiated grievance complaints led to any effective remediation of the root
causes that lead to delayed or denied care.
5. Medical Records --Adelanto has successfully deployed an electronic health record
(EHR). This represents a significant improvement over the paper record used in
the past. However, problems relating to medical documentation persist. For
example, many documents are scanned into the medical record, often without
being reviewed and signed off by the physician (which is required) and very
frequently with no notation of the scanned documents content being reflected in
the progress notes written by the providers. This results in key medical
information being ignored and important medical consultant recommendations
being ignored and contributes to the inadequate care and delayed care observed at
the facility. Also, even though the EHR has a module for inputting an electronic
medical administration record (MAR), which ensures detainees receive their
prescribed medications or alerts the clinicians when medications are missed, the
lack of a wireless network in the facility prevents nurses from actually using this
module. As a result, paper MARs are used and then scanned later into the EHR.
This insufficient process deprives clinicians of up to date information regarding
when medications have been given, how medications have been given, and
if/when they have been refused or missed.
6. Access to Care -- My review of medical records and interviews with detainees
supported the allegations that access to medical care was slow and, in some cases,
never happened. For example, I found that treatment for fractures is not
undertaken with appropriate urgency at ACF. In a number of cases, injured
detainees with documented fractures had to wait for initial evaluation, emergency
medical consultation (if it happened at all), and definitive orthopedic care.
Providers often failed to note or act on significant findings or recommendations
made by outside medical specialists. The facility also continues to experience
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long delays for access to care for both acute and chronic medical conditions.
Discussions with the HSA identified contributing factors as inadequate provider
staffing, and inadequate custodial (security) support of the medical operation.
a. Medical Provider Staffing: The wait time to see a provider for both acute
illness/injury and chronic care needs are often excessively long, and this appears
to be due in part to the inadequate staffing of providers (both physician and nurse
practitioner). In addition to long waits for appointments to see providers, the
providers are not adequately reviewing and following up on the recommendations
made by outside medical specialist (including ER and hospital specialists) upon
the detainee/patient's return to ACF. For example, a detainee who underwent
surgery to remove her gallbladder received no post-operative visit. Another
patient who saw a urologist for an infection did not receive the antibiotics that
were recommended. Yet, another patient saw a cardiologist who made
recommended medication changes that were ignored by the ACF physician, yet
no comments or reasons were recorded in the detainee's medical record.
b. Custodial Staffing in Support of Medical Operations: A quality improvement
investigation by the medical unit identified that 60-80 clinic appointments in the
facility were cancelled due to the unavailability of a runner, and outside
appointments were often cancelled due to lack of transportation staff and/or
transport vehicles.

Summary of Key Findings
Overall, I found the medical care at this facility to be inadequate and not compliant with
the 2011 PBNDS. Key deficiencies are as follows:

1.Medical leadership and oversight DOES NOT meet the 2011 PBNDS (V. B, V. BB.
2)2
2. There is inadequate medical provider staffing (physicians and mid-levels).
Facility performance DOES NOT meet the 2011 PBNDS (II.21).
3. There is inadequate custody staffing to support the medical operation.
Facility performance DOES NOT meet the 2011 PBNDS (V.B)
4. Adelanto fails to provide timely access to care for both acute and chronic problems.
Facility performance DOES NOT meet the 2011 PBNDS. (II.!, 11.4, 11.5, 11.6,
11.7, 11.8, 11.12, II. 16, V.A.2, V.A.3, V.A.5, V.S.4).

Unless otherwise specified, all citations to 2011 PBNDS Standards are formatted to
reference subsections of the 4.3 Medical Care chapter, so, for example V. B refers to 4.3
subsection V. B.

2

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 Discussion
At the time of our on-site investigation, the medical care at Adelanto was seriously
deficient and did not meet the 2011 PBNDS. Significant deficiencies cited in a previous
CRCL investigation remained unaddressed.
I have made the following recommendations for implementation of a Corrective Action
Plan. If the facility cannot correct these deficiencies within the timeline proposed, I
would recommend that ICE pull detainees from this facility until the medical care can be
brought into alignment with the PBNDS and acceptable standards of medical care.
Initial recommendations for corrective action were provided to ICE on November 17,
2017, immediately following the on-site.

1. Medical Leadership: In 2015, CRCL clearly warned Adelanto that clinical leadership
was not competent and that negligent medical care was occurring as a result. In 2017 —
two years later — no correction was made to address this critical failure. It is more likely
than not that the failure to hire an effective, qualified clinical leader led to the inadequate
detainee medical care that contributed to medical injuries, including bone deformities and
detainee deaths, and continues to pose a risk to the safety of other detainees at ACF.
Competent, qualified and effective clinical leadership is urgently required.
New leadership cannot be recruited immediately — it will take some time to put new
leadership in place. For that reason, until competent, qualified and effective clinical
leadership can be put in place at the facility, the following measures must occur to ensure
the safety of detainees in custody at ACF:
At-risk detainees must be immediately removed from the facility (transferred to another
facility with a well-functioning medical program). Detainees at-risk include those with
chronic diseases (such as cardiac, diabetes, HIV and other chronic infectious conditions),
detainees with disabilities, anyone requiring outside medical specialist care, all detainees
over the age of 55 and anyone else deemed to be medically vulnerable due to any other
condition.
CCS, the medical contractor, in consultation with IHSC, must increase day-to-day
medical care for those detainees who remain at the facility. Attention should be focused
on the following serious areas:

2. Provider Staffing: The durrent inadequate provider staffing levels and appointment
scheduling must be corrected in order to reduce the high rate of appointment
cancellations and the chronic problem of delayed access to care. To assist with this
corrective action, providers must not be allowed to fully control and change their own
appointment schedules. Also, all detainee appointment cancellations must be monitored
1(bX6)

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 and tracked, and rescheduling the detainee for the next and first available provider must
be a priority.
The current inadequate "hand-off' procedures for those detainees returning from an
outside hospital, emergency room or medical specialty consultation must be greatly
improved. Going forward, all recommendations by outside medical consultants and
providers should be reviewed immediately by both a nurse and a provider (physician or
mid-level practitioner) upon the detainees return to the facility. All returning detainees
should be seen and examined by a facility practitioner as soon as possible within 24 hours
of return in order to review the ongoing plan of care with the detainee, supported by a full
medical note and orders being placed in the medical record as required, and prescriptions
that are immediately filled and dispensed as directed and required. If practitioners are
off-site (after hours) when the detainee is returned to the facility, the on-call provider
should be contacted, the recommendations and directions from the outside medical
provider must be relayed to the on-call provider for orders and disposition, and the
involved detainee must be the first detainee seen by the facility provider the next day. In
all cases where the ACF provider choses to deviate from the care recommended by the
outside specialist, a full and complete note must be immediately entered in the medical
record documenting the clinical rational for deviating from the recommended care.
Those providers whose medical care has been sub-standard and must be closely
monitored and supervised. Probation or temporary limitations of privileges must be
considered for those problematic providers, in order to ensure improvements.

3. Custody Staffing and Support for Medical: Custody staffing and transportation
capacity must be increased to adequately support the medical operation. No medical
appointment — either within the facility or outside (such as a consultation with an off-site
specialist) — should ever be canceled due to unavailability of medical duty officers or
"runners," or for lack of transportation vehicles (including transport by wheel chairs or
gurneys). Staffing and transportation must be increased to ensure uninterrupted access to
appropriate and needed medical care.
4. Timely Access to Care: The above issues must be addressed in order to provide
timely access to adequate medical care at ACF. During the corrective plan's deployment,
routine assessment of care in terms of timeliness and adequacy will be essential.
Sincerely,
(b)(6)

.D)(6)

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6

 Appendix I
Expert Qualifications and Methods
Expert Qualifications
1. I am a physician licensed in the state of California. I am board certified in
Internal Medicine and am a Fellow of the American College of Physicians.
2. I am a Professor of Medicine and Associate Dean of Academic Affairs at the
University of California Riverside School of Medicine.
3. I have been a physician since 1991. I have worked in the field of correctional
health care for the past 18 years. From 1997 to 2004, I was a full time
correctional physician for the Rhode Island Department of Corrections; for the
final three years I served as the State Medical Program Director for the
department where I oversaw all medical care for the State of Rhode Island prisons
and jails for both men and women, including medical, psychiatric and dental
services. From 2005 to 2011, I worked full time in the Eleanor Slater Hospital,
the state psychiatric hospital, on secured units caring for patients that included
both sentenced and forensic populations. I am a member of the American
Academy of Correctional Physicians.
4. I have written and published over twenty peer-reviewed papers in academic
journals related to prison health care and am an Associate Editor of the
International Journal of Prisoner Health Care. I currently serve as the Court
Appointed Monitor for the Consent Decree in litigation involving medical care at
Riverside County Jails. I have served as an independent expert to the Federal
Court on standards of hepatitis C management in prisons, and have served as a
plaintiff's expert in a number correctional health cases. I have consulted on
detention health issues both domestically and internationally for the Open Society
Institute and the International Committee of the Red Cross among others. I have
worked with the Institute of Medicine on several workshops related to detainee
healthcare. I co-founded and am co-director of the Center for Prisoner Health and
Human Rights at Brown University and am a Co-Investigator of the University of
California Criminal Justice and Health Consortium.
5. A more detailed listing of my experience in correctional health care, my
participation in the development of national correctional policy and standards, my
experiences as a consultant and expert witness, and a list of my publications are
included in my curriculum vitae, which is attached.
6. I am familiar with that degree of care and skill ordinarily exercised by members
of the medical and behavioral health professions involving the care and treatment
of inmates and pre-trial detainees in correctional facilities.

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 Methods of Review
In advance of the on-site investigation, I reviewed documents provided by the
Office for Civil Rights and Civil Liberties (CRCL) of the Department of
Homeland Security. During the on-site investigation, I toured the facility
including dormitories, pill lines and the medical clinic, reviewed documents and
medical records, and interviewed staff and detainees. I did focused reviews of
medical records for those detainees who had chronic medical conditions such as
asthma or high blood pressure. Clinical performance was measured by a focused
review of medical records using a standardized methodology. (The full
methodology for the review is described in the document entitled Assessment of
Quality of Medical Care in Detention Facilities, and its accompanying Reviewer
Pocket Guide.) The measures are based on nationally published accepted clinical
guidelines, or consensus guidelines where there are no published clinical
guidelines. I reviewed more than 40 individual detainee medical records
(including dental records) in total. I conducted 11 individual interviews with
detainees (seven men and four women) and I participated in a group interview
with all nine of the detainees on hunger strike. I also reviewed the care of
detainees who raised medical care issues with me or with other members of our
site review team during interviews. Where relevant to findings, reference is made
to the 2011 Performance Based National Detention Standards (PBNDS).

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 Appendix II

This section includes identifiers to protected health information. Disclosure/distribution
of this appendix should be limited accordingly.
Identity of Cases Cited in this Report
My Case No. A#
1.

Name

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16-06-ICE-0627
17-09-ICE-0356
17-03-10E-0103
17-07-ICE-0456
17-09-ICE-0366
17-09-ICE-0366

2.
3.
4.
5.
6.
7.
8.
9.

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ICE Complaint #

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 On-Site Investigation Report — Adelanto Correctional Facility, November 2017
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December 18, 2017
Introduction
This report responds to a request by the Office for Civil Rights and Civil Liberties (CRCL) to
review and comment on the mental health care provided to detainees at the Adelanto
Correctional Facility (ACF) by the contractors GEO and Correct Care Solutions (CCS) under the
authority of U.S. Immigration and Customs Enforcement (ICE). My opinions are based on the
materials provided and reviewed and an on-site investigation of the facility on November 13-14,
2017. My opinions are expressed to a reasonable degree of medical certainty. ICE, GEO and
Correct Care Solutions personnel were helpful and welcoming throughout the investigation.

Overview of Findings
Overall, the mental health care at the Adelanto facility for those with serious mental
illnesses needs significant improvement in the area of Mental Health Care and currently
does not fully meet the 2011 Performance Base National Detention Standards (PBNDS).
In December of 2015, CRCL with a team of subject matter experts, visited ACF. At that time,
the over-arching and most significant issue was the absence of appropriate medical and mental
health leadership. The same is true two years later. At Adelanto, psychiatric leadership continues
to be absent and sub-standard mental health care is occurring as a result. With the exception of
an electronic medical record (which needs significant improvements described herein), and more
out-of-cell time for detainees in administrative segregation (many of whom remain
inappropriately housed), no other major or recommended changes have been effectuated since
2015. As was true in 2015, detainees with serious mental disorders are suffering the most as they
are sometimes inappropriately diagnosed, often inappropriately housed and often inappropriately
medicated, or not medicated at all. Without psychiatric leadership to provide ongoing
supervision of cases of detainees with serious mental disorders and implement changes within
the facility to create appropriate care and housing, little has changed. There continues to be an
overall lack of knowledge of the histories of those detainees with serious mental disorders. Even
though the collection of collateral information is fundamental to the mental health treatment of
persons with serious mental disorders, there was no evidence that staff attempted to obtain
collateral historical information. Persons with serious mental disorders are still present at ACF,
and in alarming high numbers in the segregation unit, obviating the need for specific mental
health housing, which was also recommended during the 2015 onsite. Due to the lack of
diagnostic understanding and detainee history, some patients were receiving substandard and
inappropriate care. There is also poor continuity of care when detainees have to be transported
outside of the facility for acute care. On the men's side (West) of ACF, mental health evaluation
appointments continue to be hindered because the corrections officers are required to escort the
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 detainee to their clinic appointment, though in 2015 an office was recommended for the mental
health staff on the men's side, mental health staff continue to be hindered by lack of private
space in which to evaluate detainees close to their dorms. lmprovrng technology, including
installing facilityewide wireless, allowing mental health staff to use laptops connected to an
intranet, is necessary for patient safety. The clearest example of this need rs demonstrated by the
lack of an electronic medication administration record (MAR). An electronic MAR is not being
used at ACF because nurses administering medication directly to patients in their dorms are
unable to use laptops to enter the data because the facility lacks wireless. As a result, not only are
medication errors occurring, but there is a lack of medication adherence data being tracked.
These are urgent patient safety issues that the facility must address immediately. Finally. staff
report co istent confusion about the location of their patients because the electronic medical
record stem does not provide patient location and most staff do not have another reliable
manner of determining the location of their patients. This results in delayed care and is also a
patient safety issue that must be addressed immediately. Finally. with a thoughtful and qualified
leader who is involved onesite. the above recommendations, most of which were made two years
ago, could be addressed. Though a was put in place to supervise the mental health
team, much of the needed leadership and decisionrmaking Furthermore. even ifa
IS found, no mental health professional can ettectively lead if not given the ability
and authority io change fundamental aspects of how and where persons with serious mental
disorde - are pharmacologically treated and housed. Therefore, an leader must be a
with authority to make needed changes.

 

     

Specific Findings

1. Mental Health Leadership 7 Attcr our 2015 one, 6, a was put into place as
the mental health leader at ACF (Dr. -). Though he has successfully increased the
frequency with which see detainees with serious mental disorders in
segregation, he has not been given the authority or ability to fundamentally change how
detainees with serious mental disorders are housed within the facility. how histories are
taken and how collateral information is collected, how safe patient handoffs are made, or
how medication is being prescribed and how those orders are executed, operationzlized
and tracked, Though Dr._ rs working hard and at the top of his license, the critical
areas needing improvement require a leader, and a leader is
helpful for supervrsion and coordination of staff, but ultimately given the
particular inadequacies of the mental health care at ACF (many of which are medical in
nature and require a medical doctor, i.e. a to . lve). Some systems resolve
this by having a medical director and an tant clinical director (a
for example. Though there is within the corporate structure
of CCS, ACF mental health staff reported that they have little to no Contact with him.
Even the staff with whom I spoke (Dr. -) reported that lie essentially
has no clinical leader present on the ground in the facility or even any
presence over the phone or email. It is more likely than not that the failure to hire an
effective. qualified leader led to at least one dctaincc death, and continues to
pose a risk to the safety ofother detainees: Competent. qualified and et't'ective one te
mental health leadership is urgently required and the lack ofit is a violation of
the 201] 

 

 

 
 

 

 

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Inappropriate Segregation of Demineex with Serious Mental Disorders -- There
continues to be large number of detainees with serious mental disorders being housed in
Administrative Segregation, obviating Adelanto's need for a dedicated and appropriate
mental health housing unit. Additionally, detainees with serious mental disorders are
being housed in disCiplinary segregation For instance, in one case (Case 1). the detainee
remained in segregation continuously for 212 days with the reason for his placement
documented by ACF staff as "self meaning that, somehow, staff had allowed this
detainee to choose to continue his own's segregation, which it a very confusing and
inappropriate practice. Cumulativc segregation days. when multiple segregation stays
occurt were also shockingly high. In one case (Case 2). detainee had been in segregation
for a total of 904 days. Clinical staff did not consider themselves as responsible for the
segregation and/or ongoing segregation oftheir patients. For example. Dr. _stated,
"We don't segregate people, it's done by custody." There appeared to be neither authority
nor interest on the part of the clinical staff to ensure their patients were not
inappropriately segregated. In some cases, detainees reported that they wanted to be
segregated for their LGBT status (Case 4) and in at least one instance this war recorded
on a facility tracking sheet as the reason (Case 5). The physical setup in disciplinary
segregation is different and much les' safe than administrative segregation. Disciplinary
Segregation cells havedouble bunks with places for tieroft's where detainees can
successfully hang themselves. At the time detainees in
segregation had serious mental disorders (such as Schizophrenia or other primary
disorders) Staff reponed that 60% to 70% of detainees in administrative
segregation had serious mental disorders, Staff also reported that they preferred certain
detainees with serious lnental disorders to be housed in administrative segregation.
stating it is "the best option" available for some of them because ofthe absence of other
options for appropriate mental health housing; even for those who are stable. Staff also
explained that segregation i used at ACF because there is no other housing location
within the facility that allows for close observation of detainees with serious mental
disorders, which is both inhumane and in violation of ICE Directive 11065.1, Review of
the Use of Segregation for ICE Detainees (Segregation Directive) and 2011

le 'sions to Standard 2.12 "Special Management Units," which has been revised to
incorporate requirements from the Segregation Directive

 

Inadequate "Hand-offs" ofDemineex Returning from Outside Hospital: 7 Hand-offs
occur when a patient's care transitions from one provider to another. This discontinuity
creates opportunities for error when clinical information is not accurately transferred
between provider. Ineffective hand-off communication presents a critical threat to
patient safety. An estimated 80% of serious medical errors involve miscommunication
during hand-offs and transfers.' For persons requiring acute stabilization in hospital
units, communication was profoundly lacking between ACF and the outside
hospitals (API. Anaheim Global. White Memorial and Arrowhead) In fact, the staftl
interviewed stated that most frequently acute patients are taken to API. yet not
one staff ntember had ever spoken to or communicated directly With the attending
at I found no evidence that recommendations by

'Iotnt Cnnimiuinn Center for Transforming Handofl'>> communication
org/projects/detatl 

 

 

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outside hospitals were reviewed immediately upon a patient's return or that those
recommendations were considered and/or put into action at ACF. For example, an ACF
clinician receiving patients who had just been hospitalized for suicidal behavior, had no
documentation of the patient's diagnosis from the outside facility, nor were the outside
facility's medication recommendations effectuated at ACF, nor was any reasoning
recorded in the medical chart as to why those recommendations were ignored. In fact,
most often I found no references at all in the psychologist's or psychiatrist's progress
notes that their patient had even been recently hospitalized. At ACF, there is daily
documentation entitled "Hospital Admission and Follow-up" for outside facilities which
nurses do daily. This document, however, appeared to be primarily an exercise in finding
out when the detainee would return to the facility, rather than a communication tool for
care coordination. In other words, it is important to know when the detainee will return to
the facility, but it is critical to know what kind of treatment took place at the acute care
facility and what the treatment recommendations are of the acute care facility. Just
knowing when a detainee will return to ACF is not enough. ACF providers should learn
from the progress, or lack of progress of a patient and consider or enact recommendations
of hospital staff to ensure the ongoing safety and stabilization of the patient once returned
to the facility.
4. Obtaining Adequate Patient History and Collateral Information - There was zero
improvement in this area from what was found and recommended in 2015. In fact, it
appears that the 2015 mental health recommendations in this area were totally ignored. I
was unable to find a single instance of collateral information being collected for any
detainee in ACF. Furthermore, initial mental health evaluations, which are a fundamental
tool in the initiation of mental health care, continue to be poor, without mention or
documentation of any patient history from the detainee's previous facility, let alone any
collected from the detainees'previous care providers or family members. As I wrote in
my 2015 report, an essential cornerstone of psychiatric care for detainees with serious
mental disorders includes obtaining what is frequently referred to as "collateral
information."2 This term refers to a patient's historic mental health and/or medical
information, typically that the patient himself or herself would or could not provide
secondary to having a serious mental disorder and a lack of insight and/or judgment.
Obtaining collateral information is considered a standard of care in the U.S. for all mental
health professionals treating persons with serious mental disorders. Collateral information
can be obtained in the form of medical records, phone calls with former treatment
providers, or family members. Collateral information is critical to building an accurate
diagnosis and treatment plan. Similar to my observations in 2015, in 2017 when I met
with and reviewed the charts of detainees with mental disorders, I observed several cases
where diagnoses and treatment plans were inaccurate, which could have been avoided by
obtaining a collateral history. Overall, the pervasive lack of collateral information
continues to result in in persons with serious mental disorders receiving incorrect
diagnoses, suboptimal care and, inappropriate or no psychotropic (and specifically,
antipsychotic) medication.

American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults, Second Edition,
2006. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/psychevaladults.pdf

2

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 5. Inadequate Psychiatric Care (Including Problematic Patient Visits and Lack of Mental
Health Treatment with Long-Acting Injections) — ACF currently has two psychiatrists,
one which practices solely via tele-psychiatry, and the other which practices in-person at
the facility. I found that little thought (or leadership direction) was given to determining
which detainee-patients were appropriate for tele-psychiatry and which detainee-patients
required in-person care. For example, detainees in the "outpatient" areas who are more
stable and can be transported easily to clinic are those who should be receiving telepsychiatry, though at ACF, the tele-psychiatrist would "see" detainees in segregation,
which would require that detainee to be stable enough to be transported to clinic in order
to present themselves in front of the tele-psychiatry camera. One such example was a
detainee-patient in segregation with ongoing instability who at the time of our visit was
not prescribed any standing antipsychotic medication despite his decompensation and
diagnosis of schizophrenia (Case 3). While the in-person psychiatrist did see many of the
detainees in segregation, I was informed by all of the detainees who I saw in segregation
that the psychiatrist never opened their door, never went inside their cell, and/or never
pulled them out to speak with them individually, regardless of their level of stability. This
is an inappropriate standard of care for the practice of psychiatry in any setting, let alone
in a correctional setting. As I wrote in 2015, in large part due to the lack of collateral
information as described above, I observed that detainees were receiving treatment with
psychotropic medications that were often suboptimal. When treatment with psychotropic
medication is suboptimal, the detainees remained needlessly unstable, were more likely
to be housed in segregation, and were more likely in need of acute hospitalization. During
this recent onsite, I also continued to observe documentation of medication "refusals," yet
there was little evidence that psychiatric staff had worked to build rapport with detainees,
and use all the tools available to them in order to gain the detainees' medication
adherence. Though the ICE Health Service Corps National Formulary includes several
atypical and typical antipsychotic medications, these medications were often not
prescribed in appropriate or robust dosing. Furthermore, long-acting antipsychotics
(LAI's) are still not being used at Adelanto, though they are also on the formulary
(28:16.0 8.08 haloperidol decanoate and 28:16.0 8.24 fluphenazine decanoate and others
may be obtained through TAR' s), even though they represent a cornerstone of mental
health care at most correctional facilities nationally. Use of long-acting antipsychotics
increases the likelihood of detainee-patient stability, decreases safety concerns for the
detainee and staff, and lessens the need for acute care. In the case of Adelanto, their use
would decrease Adelanto's reliance on segregation housing of the seriously mentally
disordered detainee population. Training for psychiatrists in the use of decanoate
medications and training for nursing staff in administering these injections would bring
Adelanto's mental health care program into the current standard of care for treating
persons with serious mental disorders.
6. Need for an Electronic Medication Administration Record (MAR) - Currently, there is a
lack of ability to see what medications any patient is currently taking, electronically.
Though ECW (ACF's electronic medical record) has the capacity for an electronic MAR
to be used at ACF, security issues were cited as a reason not to provide wireless
throughout the facility, which prevents the nurses from documenting on laptops, in-themoment, when patients actually take their medications (which is the standard in most
correctional settings). Not only is this critical for psychiatric patients who decompensate
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 quickly when not taking their medications, but no doing so often leads to poor outcomes.
The lack of one master electronic MAR has resulted in there being three different sources
for recording current medications and current medication adherence: 1) ECW current
meds, 2) Paper MARs located in the pharmacy and 3) Clinical progress notes. I found
that these three sources often contradicted one another, which is both dangerous and can
easily lead to poor patient outcomes. Most clinical staff agreed that the paper MAR was
the best source of current information, but when clinical staff must go to great lengths
(i.e. physically visit the pharmacy to pull paper MAR' s) and spend time comparing data
to see if there are errors in medications or poor adherence, patient safety is continually at
risk. Facilities that are much larger than ACF with areas of high security, all have
wireless systems within their facilities in place. It is therefore unclear why ACF is unable
to keep up with this technological standard that other facilities maintain.
7. Need for Detainee/Patient Location Information Within the EMR - Currently, the ACF
clinical staff are unable to see where their detainee-patients are located using the ECW,
and not all clinical staff have access to GEO's location tracking system. When clinical
staff do not know where their patients are located, they sometimes will not be seen, and
they may also be mistakenly noted as being hospitalized offsite when they have actually
just returned from the hgospital to ACF, which is a vulnerable time for patients. It is also
a time when the detainee should be seen immediately and more frequently. ACF's
clinical team must know where their detainee-patients are located to ensure patient safety.
This is technically possible for GEO to connect location information to the ECW to
populate these data, but it has not been made a priority.
8. Access to Care - There are two major barriers to appropriate access to care for detainees
with serious mental disorders at ACF. One barrier is physical space. Though it was
recommended in 2015, there continues to be no physical space for clinicians to see
detainees on the men's side (West). Therefore, clinical staff must rely on officers to bring
those detainee-patients to clinic, and when there is a shortage of officers or when
mentally ill patients are reluctant to leave their housing area, patient care is greatly and
negatively affected. Again because of thelack of wireless in the facility, the clinicians are
unable to bring a laptop with them while they see patients. It is difficult to make
appropriate clinical decisions when the clinician is unable to see, in-the-moment, what
medications a patient is taking, the content of the clinician's previous notes on the
detainee-patient, or any historical information. Standards of care in most correctional
facilities involve clinicians with individual laptops moving throughout the facility,and
accessing the electronic chart via secured wireless. Yet we were informed by ACF staff
that 60 to 80 visits per week were canceled due to the lack of of transporting officer'
availability. If clinicians were allowed to access the electronic chart via laptops they carry
with them during rounds and provide informed care where their patients are located,
access to care for detainees at ACF would greatly improve.
9. Detainee Interviews - I conducted 11 individual interviews with detainees (nine men and
two women). As in 2015, the overall theme that resulted from the detainee interviews was
that adequate mental health histories were not obtained and, therefore, diagnoses were not
made or were incorrect, and psychiatric treatment plans were either lacking or incorrect.
This resulted in the detainee receiving inappropriate psychotropic medication, or no

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 medication, which caused further mental decompensation, or destabilization and, in some
cases, resulted in the need for housing in segregation.

In one exemplary case (Case 7), a detainee, despite a cumulative 259 days in segregation,
continued to have the provisional diagno of"Unspecified and was
prescribed no medication. Nowhere in his chan was there any evtdence that collateral
history was asked of him or collected from other sources, However, during my interview
with him, he immediately told me that he was classified as in the CDCR system: a
clear signal that he has a serious mental disorder requiring robust care, CDCR
refers to those detainees cla'smed as "lower to an acute onset or
significant deterioration of a serious mental disorder characterized by a definitive
impairment of reality testing and/or judgement which creates dysfunctional or disruptive
social interaction or severe impairment otacti ordaily living,M It appears that
clinical staff at ACF are not trained to ask these simple hi: orical questions that are
critical to patient care. Further. it was not possible to ascertain what type of history was
obtained on this patient, lf at all, as there was no initial mental health evaluatlon present
anywhere in hischart. Moreover, I was unable to find any recent with the st
for this detainee, though historical tacility notes demonstrated a history orhim helng
described as "acting strange in dormitory" and placement in the infimtary under
observation.

    

 

   

In another Case (Case 8), though the detainee had 87 cumulative days in segregation and
had been back and forth to API inpatient unit at an outside hospital), he was
being seen only trff-and-on by the Tele Furthermore, during his la, visit to
API, he was placed on a longeacting injection there (Haldol decanoate), yet
because of what appears to be both poor follow-up and a lack ofcontinuity ofcare, 
medication was discontinued at ACF. A 8/8/2017 note from Dr. _Shows the

'ection is ordered and to be given. but the detainee subsequently saw the Tale
and the injection was not continued and not glven. No orders for the injection
were ever carried out and there was no documentation or notes written by either
as to the reasoning behind its discontinuation, In my interview with him, it
was immediately clear that he had a serious mental disorder and needed robust
care. He also 'mmediately told me about his history at the Los Angeles Twin
Towers Correctional Facility, however nothing regarding hi history was documented in
his chart,

 

 

 

In another Case ofa male detainee who had spent 68 cumulative days in segregation
(Case 9). my examination ofhim showed acute . and thought disorganization.
He easily reported a profound mental health history to me, including multiple stays at
Patton State Hospital (in Patton. California) and Central Regional Hospital (in Butner.
North Carolina), Furthermore, he reported that he had received long-acting 
injections in the past during his treatment at these State Hospitals. Despite this history, he
was on no standing medication at ACF, and he was suffering as a result.
His tactile hallucinations led to del us that person, were touching him inappropriately,
which let! to rape allegations and investigations within the facility that were

 

 

 

Report on Department ol'Cumxttonb. California State Auditor. Bureau of State Audits:
pdt'

 

 

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its)

 

unnecessary, The paper MAR revealed that medication was prescribed as
meaning that it would only be given ifthe patient asked for it. or note, the dose of
this medication (Seroquel 400 mg) is dangerous when given all at once to a person who
does not have tolerance for this particular medication For example a person not taking
Seroquel for several clays, then quickly resuming Seroquel at a 400 mg dose would likely
experience hypotension and be at risk for falls and head injuries, This is typically a
medication which must be carefully tapered up in increments over days to safely reach a
400mg dose and giving a 400mg dose to a person all at once who has not consistently
been on this dose is totally inappropriate and dangerous as a PRN medication, This
particular detainee, like all the others that I interviewed in segregation, stated that when
he does see the the simply stands at his door
andspeaks to him through the door, and nevet' sits down with him or entem his cell for
any meaningful interaction.

In another ease ofa detainee who had been in segregation for 288 cumulative days (Case
ID), the reason cited in the facility segregation tracking sheet was again "self PC
Though this detainee was very stable upon examination, he continued to remain in
segregation because it was what the detainee himself wanted not due to a compelling
clinical reason. He was also a detainee in segregation that was being seen via Tele
Upon entering his cell, i also observed that he had a large blister pack of
ibuproten with his belonging an unusual occurrence for a detainee at this level of
observation. Typically, in segregation persons are not permitted to have anything that
they could use to harm themselves (including large amounts of pills). Those pills could
have also been shared by the detainee with peers during out-of-cell time. Allowing high
observation det' nees this amount of pills in their p0 ion i, markedly unsafe for the
detainee and his peers.

 

In another case (Case ll), an officer highlighted this particular detainee as being the most
unstable detainee segregation, reporting that he floods his cell, bangs his head, and
tells custody he is blind (ti dcluSlUn as the detainee demonstrates clear eyesight), His
documented diagnosis was schizophrenia, During my examination ofhim, he was
experien ing active auditory hallucinations. He had recently come from the inpatient
unit at yet no records were in his chart and no clinictan or
note referenced what occurred at the hospital or how it led to changes in his
care at ACF, I reviewed his electronic chart with Nurse -to make sure that. in fact,
no API records were present and, indeed, none were. In this case, the detainee did not
wish to be in segregation, and reported that his (namely auditory
hallucinations) were worsening with so much time in isolation. It is common for
such as auditory hallucinations. to get worse when persons with
schizophrenia are alone i lation tie. voices often quiet when a person is engaged with
others). The dctaincc said to me, hate to bc alone."

 

In another case (Case a female detainee in segregation for 426 cumulative days was
examined and found to be stable: not requiring segregation, clinically, for any discernible
ieason. The documented reason for her segregation on the {4 ility tracking sheet was
again, "self However, there was no documentation or clinical evidence (during my
exam with her) that this patient had a serious mental disorder or an ongoing need for
segregation.

 

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In the last case I discuss in this section, (Case 13), a detainee in segregation for149 days
with the provisional diagnosis of "Unspecified Psychosis," despite her easily providing
her history as a person with Schizophrenia, which she relayed wasdiagnosed at age 20
(the detainee is now 48 years old), continued to experience auditory hallucinations. Her
continual hallucinations were likely due to the antipsychotic medication (Geodon) that
was inappropriately prescribed by the ACF psychiatrist, who was apparently not taking
into account when the patient was provided meals and when the patient received her
medication. Geodon is absorbed effectively with the intake of food (calories).4 However,
because ACF was not coordinating the detainees meals with her medication
administration, the detainee was grossly undertreated when I saw her. According to the
medical literature, it can be estimated that she was receiving (absorbing) only 50% or less
of her Geodon dose because it was not given to the detainee with food.5
10. Complaints - The Office for Civil Rights and Civil Liberties received many medical
complaints, and fewer mental health complaints during both onsites. The mental health
deficiencies discussed previously were discovered during my routine check of detainee
records for mental health concerns, or were reported to me by other members of the
investigation team who observed detainees in the segregation unit. The two mental health
complaints discussed below were received by CRCL prior to the 2017 onsite. Both
complaints involve detainees who are psychiatrically unstable and inappropriately
segregated. Both were substantiated as discussed.
a. Complaint relates to Case 14 and involves a use of force incident involving the
detainee who is reported to have become aggressive and combative, threatening
officers and throwing tissue paper throughout his cell area. Five officers entered the
cell and, after a physical confrontation, eventually restrained the detainee who was
found to have a serious mental disorder and wasregularly housed in segregation.
Upon review of the case, the detainee was diagnosed with Schizophrenia. In the days
before this incident the detainee was described as "disheveled... Responding to
internal stimuli" and was noted as mentally decompensating. He had entered ICE
custody from the Los Angeles County Twin Towers Correctional Facility where he
was in mental health housing and receiving the antipsychotic Risperdal. During his
transition from Twin Towers to ACF, he was likely without medication for at least
one day. By the time he arrived at the at the facility,he saw a psychiatrist, and was
prescribed antipsychotic medication, three days had passed. This amount of time off
of his antipsychotic medication was likely sufficient for him to mentally
decompensate. In this case, ACF failed to provide continuity of care. Furthermore,
this detainee remained in segregation housing when we were at the facility, which
4 Reference: The effect of food on the absorption of oral ziprasidone. Psychopharmacol Bull. 2007;40(3):58-68.
"administration of ziprasidone with food is crucial to ensure optimal, reliable dose-dependent bioavailability and
thus predictable symptom control and tolerability."
5 Reference: The impact of calories and fat content of meals on oral ziprasidone absorption: a randomized, openlabel, crossover trial. J Clin Psychiatry. 2009 Jan;70(1):58-62. Epub 2008 Oct 21. "Oral ziprasidone absorption is
influenced by the presence of food, and the U.S. prescribing information instructs patients to take the medication
with food. Studies in healthy volunteers have shown that the bioavailability of ziprasidone is enhanced when it is
administered in the presence of a standard U.S. Food and Drug Administration (FDA) meal. Absorption is also
dependent on the timing of drug administration relative to food, with reduced absorption when taken 2 hours after,
rather than immediately following, food."

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 was six months after the complaint was filed with CRCL. This complaint is,
therefore, substantiated.

b. Complaint relates to Case IS and involves another use of force incident. The use of
force report 3 ites that the detainee became hostile in his cell, struck :1 Corrections
otiicer, and was eventually suhdued and placed in mechanical restraints. it was
revealed that ACF had diagnmed the detainee with and he was being
regularly housed in segregation. Upon review of his chart, 1 observed that the
detainee had, in fact, been diagnosed with Schizophrenia, and had a history oi taking
antipsyehotic medications. Two months pnor to the incident, the detainee was
documented as taking medication off-and-on. There is no evidence that
a long-acting injection was ever offered to this detainee, though he was prescribed
oral medication (perphenazine) that is available in the long-acting form. It is unclear
why he was not hospitalized just prior to thi, ncident, The incident
iiscll, unfortunately, was the extreme event that finally triggered the hospitalization. It
is documented in the chart that the motivation for the incident was delusional in
nature. Dr, -wmte, "patient is clearly unstable, not clear and his thinking and
lmpul~ive. He attacked a staff member, believing that the staff member swore at him
and spit at him (no evidence to support this), He clearly needs a higher level ofcare."
In this case. inadequate treatment was provided (Le. not attempting to
initiate a longracting injection for a detainee who poorly adherent to
his medication) and there was a delay in appropriate care provided to
this detainee (Le. the hospital transfer should have taken place before the use of force
event, when the detainee was clearly demonstrating ntental decompensation). This
complaint is substantiated.

   

   

Summary of Key Findings

Overall, 1 found the mental health care at ACF for those with serious mental illnesses inadequate
and not compliant with the 2011 Performance Base National Detention Standards 
standards.

It leadership and oversight continues to be absent at Adelanto. The lack of
leadership and oversight is it violation and DOES NOT meet the 2011 (4.3 V.

B)

2. Adelanto's electronic medical record lacks a Medication Administration Record (MAR)
and patient location information, leading to unsafe mental health care for detainees.
Mental Health record keeping at Adelanto DOES NOT meet the 2011 (4.3 II
23, 4.3 VsY.l.a)

3. Adelanto's practice of not obtaining adequate patient histories is a violation of the
and leads to inadequate and inappropriate mental health care for detainees with
all levels of mental health disorders. DOES NOT meet the 2011 P13an (4.3 V. N.3.b)

4. Adelanto continues to have inadequate and delayed access to care for persons in mental
health crisis who are in need ofacute inpatient hospitalization which DOES
NOT meet the 2011 14.3 v. NJJAD.

K51 Adelantu znt7 Protected hy Dehher-ative Pmcew Privileges Pg 10

 

5. Adelanto inappropriately houses detainees with serious mental disorders ly in
segregation, rather than housing them in an appropriate mental health housing
arrangement. Continuous and prolonged segregation housing of the mentally ill, has lead
to inadequate mental health care, and increased the likelihood of poor mental health
outcomes which DOES NOT meet the 2011 PBNDS (4.3 V. N.3.j.3) as well as ICE
Directive 11065.1, Review of the Use of Segregation for ICE Detainees (Segregation
Directive) from the PBNDS 2011 revisions to Standard 2.12 "Special Management
Units."

Discussion
Though Adelanto's mental health team appears to be working to the best of their ability within
their roles and within facility constraints, the lack of psychiatric leadership, particularly absent a
leader who has the qualifications, experience and authority to make significant changes to how
patient care is delivered, continues to result in ongoing inadequate mental health care. The most
important issue at ACF continues to be the inappropriate segregation of detainees with serious
mental disorders, obviating the need for different levels of mental health care and housing within
the facility, other than segregation. Within the last two years, the use of dormitory housing (5B)
for men has offered some degree of lower level mental health housing, though this remains
problematic as supervision is minimal, the population is mixed, and there continues to be no
opportunity for mental health evaluations in or near that housing space. Attempting to do their
best, given the situation, mental health staff have reported that they believe segregation is the
best housing option available for many of their detainee-patients; even those who are stable and
do not technically require segregation. Due to the lack of appropriate leadership, there is also an
unusual belief among the ACF mental health providers that it is somehow up to the patient to
determine their level of care. In that way, if the patient wishes to be in segregation, rather than
placing the patient in the least restrictive environment according to their clinical symptoms, the
patient be allowed to remain in restrictive housing if that is their wish. This is evidenced in the
pervasive use of "self PC" recorded as the reason, in many cases, for detainees in segregation. A
qualified psychiatric leader should audit the charts and examine all patients with mental
disorders in segregation in order to change treatment (including pharmacologic), if needed, as
well as review the appropriateness of the detainee's housing. A qualified psychiatric leader could
also work with GEO and ICE to develop a specialized mental health step-down unit, as well as
moderate observation mental health housing (or "MOH" as it is known in many facilities), which
is typically a dorm setting for persons with mental health diagnoses who are relatively stable,
who need no more than outpatient level mental health care. These levels of care are common in
correctional settings and there are many national examples that can be learned from. Finally, a
psychiatric leader would advocate for the standard of care that would include adequate use of
antipsychotic medication, including long-acting injections, safe patient handoffs to/from acute
hospitalization, taking of detainee-patient histories, collection of collateral information to inform
care, and instituting needed technological changes to ensure patient safety, such as an electronic
MAR and access to detainee-patient locations within the electronic medical record.

(b)(6)

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 Summary of Recommendations (CRCL already provided these Recommendations to ICE
and IHSC as "initial recommendations," immediately following the November 2017 onsite
investigation)
In 2015, ERO and GEO management was notified that psychiatric leadership was absent and that
sub-standard mental health care was occurring at ACF as a result. During the 2017 onsite, I
found that no corrections had been implemented to address this failure. It is likely that the failure
to hire an effective, qualified psychiatric leader contributed to at least one detainee death, and
continues to pose a risk to the safety of other detainees at ACF. Competent, qualified and
effective psychiatric leadership is urgently required. Recognizing that it will take some time to
put new leadership in place, the following measures should occur to ensure the health and safety
of detainees in ICE custody at ACF:
1. At-risk detainees should be immediately removed from the facility and transferred to
another facility with competent psychiatric leadership and a well-functioning mental
health program. That facility should be able to provide appropriate housing and treatment
for at-risk detainees with serious mental disorders. Detainees at-risk are those taking (or
refusing) antipsychotic and mood stabilizing medications, especially those detainees
currently in ACF segregation and those with recent inpatient hospital stays. DOES NOT
meet the 2011 PBNDS (4.3 V. 0.1)
2. The ACF Medical Contractor, in consultation with ICE IHSC and a skilled psychiatrist
leader, should review all cases of ACF detainees with serious mental disorders to ensure
accuracy or make appropriate changes. Attention should be focused on the following
serious areas:
a. Collateral data should be obtained for each ACF detainee with a serious mental disorder.
Moving forward, this data should be in each detainee's initial mental health evaluation
and obtained by the admitting clinician. In cases where collateral data was never
obtained, clinicians must go back and obtain it and document it in the chart. During the
investigation collateral data was absent in all cases. Typically, this data comes from the
facility where the detainee was housed prior to their transfer to ACF, or from family
members. If records cannot be obtained, ACF clinical staff should develop
communicative relationships with staff at the facilities where ACF detainees most
commonly come from and obtain this information by phone, which is permitted and
expected under HIPPA, for purposes of patient safety and coordination of care. DOES
NOT meet the 2011 PBNDS (4.3 V. 0.3.b)
b. Diagnoses and medication should be reviewed to ensure they are correct and
appropriate. Attention should be given to taking detainees off ineffective medications —
such as those only absorbed well with a meal, but are not administered at ACF meal
times, or antipsychotics prescribed as PRN's (as-needed medications) for detainees with
clear histories of taking long-acting antipsychotic injections. If patients refuse
medications or injections, the ACF mental health providers should work with them so
the detainee will accept them and document those attempts at compliance. DOES NOT
meet the 2011 PBNDS (4.3 V. 0.4)
c. There should be a housing review and assessment for each detainee with a serious
mental disorder to determine whether their housing is appropriate given the detainee's

(b)(6)

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 clinical status. Although clinical staff reported that some stabilized detainees are
segregated because they "want" to be in segregation, each detainee should be at the least
restrictive level of care, given their mental health status and progress. DOES NOT meet
the 2011 PBNDS (4.3 V. 0.5)
d. Detainees with serious mental disorders should be removed from administrative
segregation, as that environment is physically unsafe and not conducive to improving
the detainee's mental health status. DOES NOT meet the 2011 PBNDS (4.3 V. 0.5)
e. The current "hand-off' procedures for those detainees returning from an outside
hospital, emergency room or mental health specialty consultation are thoroughly
inadequate and should be greatly improved. (See recommendation 2.c under Medical
Care, for further clarity.) DOES NOT meet the 2011 PBNDS (4.3 V. 0.3.k)
f. In all cases where the ACF provider chooses to deviate from the care recommended by
an outside specialist (including a recommendation to continue a long-acting
antipsychotic injection), a full and complete note should be entered in the detainee's
medical record documenting the clinical rational for the deviation from the outside
provider's recommended care. DOES NOT meet the 2011 PBNDS (4.3 V. 0.1.b)

3. Custody staffing and transportation capacity should be increased to adequately support
the mental health operation. No clinical appointment — either within the facility or outside
— should be canceled due to officer unavailability. Staffing and transportation should be
increased to ensure uninterrupted access to appropriate medical/mental healthcare. In 2015, it
was recommended that the facility create an office on the West (men's) side for mental
health staff to be able to see male detainees without reliance on officers to escort them to
clinic, but this important recommendation was not implemented and resulted related
problems that were found during the 2017 onsite. It remains a necessary recommendation.
DOES NOT meet the 2011 PBNDS (4.3 V. 0.3).
4. ACF's medical contractor, in consultation with ICE IHSC, should immediately institute
an electronic Medication Administration Record (MAR). Currently, there is no electronic
capability allowing ACF mental health staff to see what medications any detainee-patient is
currently taking. Though the current ECW has the capacity for this, security concerns were
cited as a reason not to provide wireless throughout the facility, preventing nurses from
documenting on laptops when detainees actually take their medications (which is the
standard in most correctional settings) or refuse them. The ability to do this is critical for
psychiatric patients, who decompensate quickly when not taking their medications; often
resulting inpoor outcomes. ACF's lack of one master electronic MAR has resulted in there
being 3 different records of current medications (ECW current meds, the paper MAR and the
progress notes) which were often found to be contradictory. When clinical staff are forced to
go to great time-consuming lengths to pull up a paper MAR and compare the data for
medication errors or poor patient adherence, the detainee's safety is at risk. DOES NOT
meet the 2011 PBNDS (4.3 II 23, 4.3 V.Y.1.a)
5. ACF's medical contractor, in consultation with ICE IHSC, should immediately
populate the electronic medical record (ECW) with the detainee-patient location. When
ACF's clinical staff do not know where their detainee-patients are located, those detainees
may not be seen as needed and required. Also staff may mistakenly assume the detainee is in
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 the hospital when they, in fact, have just returned to ACF: which is a vulnerable time for
those detainees. The detainee's clinical team should know where their detainee-patient is
located. It is technically possible, and should be made a priority for GEO to connect with
ECW to populate this data, which will better ensure patient safety. DOES NOT meet the
2011 PBNDS (4.3 II 23, 4.3 V.Y.1.a)
Thank you for the opportunity to provide information and recommendations.
Sincerely,
(b)(6)

Assistant Clinical Professor
Department of Psychiatry and Biobehavioral Sciences
UCLA David Geffen School of Medicine

.D)(6)

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Appendix I
Expert Qualifications and Methods of Review
Expert Qualifications

1. I am a physician licensed in the state of California. I am board certified in general
psychiatry with a subspecialty board certification in forensic psychiatry.
2. I am an Assistant Clinical Professor of Medicine at the University of California, Los
Angeles, David Geffen School of Medicine.
3. I am the Medical Director of the Los Angeles County Office of Diversion and Reentry
for the Los Angeles County Department of Health Services. In this role I plan, develop
and implement jail diversion projects and programs designed to offer health, mental
health, and law enforcement personnel countywide a means to redirect County residents
with mental illness and/or substance use disorders away from the criminal justice systems
and into community treatment and services and establish partnerships between the Office
of Diversion and other partners within the Department of Health Services, Department of
Public Health, Department of Mental Health, the District Attorney, Public Defender,
Alternate Public Defender, the Sheriffs Department and other law enforcement agencies
throughout the County, and various community partners and providers with the goal of
implementing initiatives to increase diversion opportunities for justice-involved residents
of the County as well as develop information technology-related systems used to manage
and document diversion-related efforts and resources.
4. I am a member of the Criminal Panel for the Los Angeles Superior Court and work one
day per week at Department 95, the Los Angeles Mental Health Court, providing
competency to stand trial evaluations for the presiding judge. In my role on the criminal
panel, I enter several facilities in order to conduct evaluations, including the Los Angeles
County Jail facilities, State Hospitals and other community facilities.
5. I served as an expert over the course of approximately five years on behalf of the
plaintiffs in the Jose Antonio Franco-Gonzalez, et al. v. Eric H. Holder, Jr., Attorney
General, et al., United States District Court, Central District of California. I also serve as
a pro bono consultant for the Vera Institute of Justice on program development for
immigration court liaison services and mental competency measures/screening. I continue
to serve as an instructor to UCLA law students representing immigrants and a clinical
supervisor to UCLA and UCR residence conducting forensic evaluations for immigration
purposes.
6. I have been a physician since 2005. I've worked with persons who are underserved who
have serious mental disorders for the past 10 years. I've worked in each of the Los
Angeles County hospitals (LAC+USC Medical Center, Harbor-UCLA Medical Center
and Olive View-UCLA Medical Center) and at Twin Towers Correctional Facility
providing emergency, inpatient and outpatient care to persons with mental disorders.
7. I've published in peer-reviewed journals on the topics of persons with serious mental
disorders and the immigration detention system. I am a member of the University of
California Criminal Justice and Health Consortium, the Human Rights Committee and
(b)(6)

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Law Enforcement Liaison Committee of the American Academy of Psychiatry and the
Law.
8. A more detailed listing of my experience and publications are included in my curriculum
vitae, which is attached.
9. I am familiar with the degree of care and skill ordinarily exercised by members of the
medical and mental health professions involving the care and treatment of inmates and
pre-trial detainees in correctional facilities.

Methods of Review
In advance of the on-site investigation, I reviewed the documents provided by the Office for
Civil Rights and Civil Liberties (CRCL) of the Department of Homeland Security. During the
on-site investigation, I toured the facility including dormitories, pill lines and segregation,
reviewed documents and electronic medical records and interviewed staff and detainees. I
performed focus reviews of medical records for those detainees who had mental health
conditions, and particular those who were in segregation. I reviewed 15 individual detainee
medical charts, and conducted 11 individual interviews with detainees; I also interviewed two
staff members of the mental health treatment team.

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Appendix II
This section includes identifiers to protected health information. Disclosure/distribution of this
appendix should be limited accordingly.
Identity of Cases Cited in this Report:
My Case #
1

A#

Detainee Name

CRCL Complaint #

-(b)(6)

2
3
4
5
6
7
8
9
10
11
12
13
14
15

17-08-ICE-0299
17-094CE-0356

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Office for Civil Rights and Civil Liberties
U.S. Department of Homeland Security
Washington, DC 20528

Ce9, Homeland
Security
ND S C

April 25, 2018
MEMORANDUM TO:

Matthew Albence
Executive Associate Director
Enforcement and Removal Operation
U.S. Immigration and Customs Enforcement

FROM:

Veronica Venture
Deputy Officer
Office for Civil Rights and Civi Liberties
Dana Salvano-Dunn
Director, Complianc ranch
Office for Civil Rights and Civil Liberties

SUBJECT:

Adelanto Correctional Facility Complaint Nos. 17-03-ICE-0103,
16-06-ICE-0627, 17-07-ICE-0456, 17-08-ICE-0299, 17-09-ICE0356, 17-09-ICE-0407, 17-09-ICE- 0366, and 17-10-ICE-04011

The U.S. Department of Homeland Security's (DHS) Office for Civil Rights and Civil Liberties
(CRCL) is conducting an investigation into conditions of detention for U.S. Immigration and
Customs Enforcement (ICE) detainees at the Adelanto Correctional Facility (ACF) in Adelanto,
California. CRCL's onsite investigation, which occurred on November 13-14, 2017, was a
follow-up review to our December 2015, onsite investigation. In addition, the onsite
investigation was in response to three detainee deaths and CRCL's receipt of more recent
allegations at ACF in the following areas: medical care, mental health care, use of force, hunger
strikes, segregation, grievances, staff-detainee communication, legal access, language access,
and suicide prevention and intervention.
We greatly appreciate the cooperation and assistance provided by ICE and ACF management
and personnel before and during the onsite. As part of the review, CRCL used the same
independent subject-matter experts that we used for the 2015 onsite: a medical consultant, a
mental health consultant and a penologist. As a result of detainee and staff interviews, document
reviews, and direct onsite observations, our experts identified concerns related to medical and
mental health care, use of force, segregation and housing, grievances, staff-detainee
communication, legal access, language access, and suicide prevention and intervention. At the
1 Complaint No. 17-10-ICE-0401, alleging inadequate conditions of detention and lack of appropriate visitation, was
added to the Adelanto complaints after CRCL disseminated the Retention Memo to ICE.

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conclusion of our onsite investigation, CRCL and the subject-matter experts held an exit-briefing
where we relayed our findings to local ICE and ACF management and relevant field personnel.
During those discussions, the subject-matter experts also provided recommendations to address
many of the identified concerns.
Due to the serious nature of certain health and safety-related findings, CRCL also submitted
initial informal recommendations to ICE leadership on November 20, 2017 for immediate action.
We understand ICE has been working on addressing those matters over that last few months,
including a site visit during the week of March 12, 2018.
Enclosed with this memorandum are the reports prepared by our subject-matter experts. The
experts' priority recommendations are listed below in the body of this memorandum. CRCL
requests that ICE formally concur or non-concur with these recommendations and provide an
implementation plan for all accepted recommendations within 60 days.
Recommendations

Medical Care
CRCL's medical expert made the following priority recommendations regarding medical care at
ACF. All of these recommendations relate to the 2011 PBNDS Medical Care Standard, which
requires timely and efficient access to medical services
Medical Leadership
1 In 2015, CRCL clearly informed Adelanto that clinical leadership was not
competent and that problematic medical care was occurring as a result. In 2017 --
two years since the 2015 onsite -- the experts found no evidence that corrections
were made to address this issue. The failure to hire an effective and qualified
clinical leader contributed to the inadequate detainee medical care that resulted in
medical injuries, including bone deformities and detainee deaths, and continues to
pose a risk to the safety of other detainees at ACF. The current medical
leadership does not meet the requirements set forth in the 2011 PBNDS.
Accordingly, ACF should hire a competent, qualified, and effective onsite
clinical leader immediately. (2011 PBNDS Medical Care: 11.1 through 9, 11.12
through 16, 11.20 and 21, 11.23 and 25, 11.27, 11.29 and 30, V.A and B, V.F.1 and
3, V.G.1 through 4, V.G.6 and 7, V.G.9 through 12, V.I and J, V. L, V.Q through
S, and V.U, V.W and X, V.Y.1.b, V.Z, V.BB.2)

2. In the event that new leadership cannot be recruited immediately -- as it is likely
that it will take some time to put new leadership in place -- at-risk detainees
should immediately be removed from the facility and transferred to other
facilities with well-functioning medical programs. "At-risk" detainees include
those with chronic diseases (such as cardiac, diabetes, HIV and other chronic
infectious conditions), detainees with disabilities, anyone requiring outside
medical specialist care, all detainees over the age of 55, and anyone else deemed
to be medically vulnerable due to other conditions. (2011 PBNDS Medical Care:
11.6, V.B)

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2

Provider Staffing
The ACF medical contractor, Core Civic Solutions (CCS), in consultation with IHSC,
should increase day-to-day medical care for detainees at ACF. Attention should be
focused on the following areas of concern:
3. Current staffing levels and appointment scheduling are inadequate and lead to a
high rate of appointment cancellations and chronically delayed access to care.
The current inadequate provider staffing levels and appointment scheduling
problems should be corrected in the following ways. (PBNDS 2011 Medical
Care:
11.5 through 9, 11.21 and 22, 11.27, V.A and B, V.F.3.a, V.0 and W,
V.BB)
a. Providers should not be allowed to fully control and change their own
appointment schedules.
b. Detainee appointment cancellations at ACF should be monitored and tracked.
c. When detainee-patient cancellations are appropriate, the detainee should be
rescheduled for the first available provider.
4. Those providers whose medical care has been sub-standard should be more
closely monitored and supervised. Probation or temporary limitations of
privileges should be considered for those problematic providers, in order to ensure
improvements. (2011 PBNDS Medical Care: 11.21, V.B, V.T and U)
Detainee Returns from Offsite Care
The current inadequate "hand-off' procedures being utilized, when detainees return from
medical or mental health care at an outside hospital, emergency room or medical
specialty consultation should be improved to ensure an appropriate continuum of care.
(2011 PBNDS Medical Care: 11.1,11.7 and 8, 11.12, 11.16 and 20, V. A and B, V.F.a,
V.G.2 and 12, V.I, V.S.4 and 5, V.W) Attention should be focused in the following areas:
5. All recommendations made by outside medical/mental health consultants
and providers should be reviewed immediately by both a nurse and a
provider (physician or mid-level practitioner) upon the detainees' return to ACF.
6. All returning detainees should be seen and examined by an ACF medical or
mental health practitioner within 24 hours of return to the facility in order to
review the ongoing plan of care with the detainee. The examination should be
supported by a full medical note and placement of orders in the medical
record as required. Prescriptions should be immediately filled and dispensed.
7. If ACF practitioners are off-site (after hours) when the detainee is returned to
the facility, the on-call provider should be contacted, the recommendations
and directions from the outside medical provider should be relayed to the oncall provider for orders and disposition, and the involved detainee should be
seen by the facility provider as early as possible the next day.
8. In all cases where the ACF provider choses to deviate from the care
recommended by the outside specialist, a full and complete note should
immediately be entered in the medical record documenting the clinical rational
for deviating from the recommended care.

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Custody Staffing Support for Medical
ACF custody staffing and transportation is currently inadequate to support medical
operations and ensure uninterrupted access to appropriate and needed medical care. (2011
PBNDS Medical Care: 11.7, V.A and B, V.R and S, V.W)
9. Custody staffing and transportation capacity should be increased to
adequately support the medical operation and ensure uninterrupted access to
appropriate and needed medical care.
10. Medical appointments -- either within the facility or outside (such as a
consultation with an off-site specialist) -- should not, absent extraordinary
circumstances, be canceled due to unavailability of medical duty officers or
"runners," or for lack of transportation vehicles (including transport by wheel
chairs or gurneys).
Mental Health Care
CRCL's mental health expert made the following priority recommendations regarding medical
care at ACF. All of these recommendations relate to the 2011 PBNDS Medical Care Standard,
which requires appropriate, timely, and efficient access to mental health services.
11. Following CRCL's 2015 investigation, it was reported to ERO and GEO
management that psychiatric leadership was absent at ACF and that sub-standard
mental health care was occurring as a result. During the 2017 onsite, there was no
evidence that corrections had been implemented to address this concern. This
failure to hire an effective, qualified psychiatric leader continues to pose a risk to
the safety of other detainees at ACF. Accordingly, ACF should hire competent,
qualified and effective on-site psychiatric leadership, immediately. (2011
PBNDS Medical Care: 11.5, II. 8 and 9, 11.12, 11.14 through 16, 11.20 and 21, 11.25
and 27, 11.30; V.A.1-7, V.B, V.F.1 through 3.a, V.G.1 through 4, V.G.6, V.G.11
and 12, V.I-J.2 and 4, V.J.12 and 13, V.J.16 through 19, V.M.1 and 2, V.N.1
through 6, V.Q, V.R.1.a and f, V.R.2, V.S.4 and 5, V.U, V.W, V.X.6 through 12,
V.Y.1.b and .4.c.a), V.BB.2.e, V.DD)
12. Recognizing that it will take some time to put new leadership in place, at-risk
detainees should be removed from the facility and transferred to other
facilities with competent psychiatric leadership and a well-functioning
mental health program. Those facilities should be able to provide appropriate
housing and treatment for at-risk detainees with serious mental disorders.
Detainees at-risk are those taking (or refusing) antipsychotic and mood stabilizing
medications, especially those detainees currently in ACF segregation, and those
with recent inpatient hospital stays. (2011 PBNDS Medical Care: 11.6, V.B, V.N,
V.Q)
13.The ACF medical contractor, in consultation with ICE IHSC and a skilled
psychiatrist leader, should review all cases of ACF detainees with serious mental
disorders to ensure accuracy or make appropriate changes. Attention should be
focused on the following serious areas:

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4

a. Collateral data should be obtained for each ACF detainee with a serious
mental disorder. Moving forward, this data should be acquired and
entered in each detainee's initial mental health evaluation and reviewed
by the admitting clinician. In cases where collateral data was never obtained,
clinicians should obtain it and document it in the chart. During the
investigation, collateral data was absent in all cases reviewed. Typically, this
data comes from the facility where the detainee was housed prior to their
transfer to ACF, or from family members. If records cannot be obtained, ACF
clinical staff should develop communicative relationships with staff at the
facilities where ACF detainees most commonly come from and obtain this
information by phone, which is permitted and expected under HUTA, for
purposes of patient safety and coordination of care. (2011 PBNDS Medical
Care: 11.1 and 5, 11.15 and 23, 11.30, V.J and K, V.M and N, V.S.5, V.0 and
W, V.Y, V.BB)
b. IHSC and CCS and should review diagnoses and medication to ensure
they are correct and appropriate. Attention should be given to taking
detainees off ineffective medications -- such as those only absorbed well
with a meal, but are not administered at ACF meal times, or antipsychotics
prescribed as PRN's (as-needed medications) for detainees with clear histories
of taking long-acting antipsychotic injections. If detainee-patients refuse
medications or injections, the ACF mental health providers should work with
the detainee so the detainee will accept them, and then document those
compliance attempts. (2011 PBNDS Medical Care: In and 16, 11.20 and 27,
11.30, V.G and H, V.J.2 and 4, V.J.11 through 13, V.J. 16 and 17 narrative,
V.M, V.N.1 through 3, V.N.4 through 6, V.Q, V.R and S, V.W and Y, V.BB)
c. There should be a housing review and assessment for each detainee with
a serious mental disorder to determine whether their housing is
appropriate, given the detainee's clinical status. Although clinical staff
reported that some stabilized detainees are segregated because they have
requested to be in segregation, each detainee should be at the least restrictive
level of care when at all possible and deemed appropriate by mental health
leadership, taking into account the detainee's mental health status and
progress. (2011 PBNDS Medical Care: 11.5 and 6, 11.13, 11.27 and 30, V.F.3,
V.N, V.Q and S, V.Y, V.BB)
d. Detainees with serious mental disorders are routinely -- and inappropriately --
housed in administrative segregation at ACF. Detainees with serious mental
disorders should only be housed in administrative segregation as a last
resort, as that environment is not conducive to improving mental health
status. (2011 PBNDS Medical Care: 11.5 and 6, 11.13, 11.27 and 30, V.F.3,
V.N, V.Q and S, V.Y, V.BB; ICE Directive 11065.1, Review of the Use of
Segregation for ICE Detainees [Segregation Directive] from the PBNDS 2011
revisions to 2.12 Special Management Units)

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14. In all cases where the ACF provider chooses to deviate from the mental
health care recommended by an outside specialist (including a
recommendation to continue a long-acting antipsychotic injection), a full and
complete note should be entered in the detainee's medical record
documenting the clinical rational for the deviation from the outside provider's
recommended care. (See recommendation 8 under Medical Care for further
clarity.) (2011 PBNDS Medical Care: II.!, 11.7 and 8, 11.12, 11.16 and 20, V. A
and B, V.F.a, V.G.2 and 12, V.I, V.S.4 and 5, V.W)
15. Custody staffing and transportation capacity should be increased to
adequately support the mental health operation. No clinical mental health
appointment -- either within the facility or outside -- should be canceled due
to officer unavailability. Staffing and transportation should be increased to
ensure uninterrupted access to appropriate medical/mental healthcare. In
2015, it was recommended that the facility create an office on the West (men's)
side for mental health staff to be able to see male detainees without reliance on
officers to escort them to clinic, but this important recommendation was not
implemented and resulted in related problems that were found during the 2017
onsite. It remains a necessary recommendation. (2011 PBNDS Medical Care:
11.7, V.A and B, V.R and S, V.W)
16. ACF's medical contractor, in consultation with ICE IHSC, should
immediately institute an electronic Medication Administration Record
(MAR). Currently, there is no electronic capability allowing ACF mental health
staff to see what medications any detainee-patient is currently taking. Although
the current ECW has the capacity for this, security concerns were cited as a
reason not to provide wireless accessibility throughout the facility. This prevents
nurses from documenting on laptops when detainees take their medications or
refuse them (which is the standard process in most correctional settings). The
ability to do this is especially critical for psychiatric patients, who decompensate
quickly when not taking their prescribed medications; often resulting in poor
outcomes. ACF's lack of one master electronic MAR has resulted in there being
three different records of current medications (ECW current meds, the paper
MAR, and the progress notes) which were found to be often contradictory. When
clinical staff are forced to go to great time-consuming lengths to pull up a paper
MAR and compare the data for medication errors or poor patient adherence, the
detainee's safety is at risk. (2011 PBNDS Medical Care: 11.23 and 27, V.S,
V.Y.1.a)
17. ACF's medical contractor, in consultation with ICE IHSC, should
immediately populate the electronic medical record (ECW) with the
detainee-patients' location. When ACF's clinical staff do not know where their
detainee-patients are located, those detainees may not be seen as needed and
required. In addition, staff may mistakenly assume the detainee is in an offsite
hospital when they, in fact, have just returned to ACF, which is a vulnerable time
for those detainees. The detainee's clinical team should know where their
detainee-patient is located. It is technically possible, and should be made a
priority for GEO to connect with ECW to populate this data, which will better

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ensure patient safety. (2011 PBNDS Medical Care: 11.8 and 12, 11.20 and 23,
V.F.3.a.3 and 4, V.G.12, Y.1.a and b)
Conditions
CRCL's corrections expert made the following priority recommendations. All of these
recommendations relate to the 2011 PBNDS.
18. In 2015, CRCL recommended that ACF use interpreters and/or language lines
consistently for LEP detainees during the intake screening process and completion
of the important and required intake forms. ACF continues to fail to meet the
Admission and Release Standard. Interpreters or language lines are not being
consistently used for LEP detainees during the intake screening process and
completion of the intake forms. ACF should consistently use interpreters or
language lines for LEP detainees during the intake process. (PBNDS 2011
Admission and Release: 11.8, V.F, V.G)
19. In 2015, CRCL recommended that ACF should correct its intake and admission
process by ensuring detainees are signing documents in a language the detainee
understands, or by providing oral assistance in order to comply with the detention
standard. ACF continues to fail to meet this standard. ACF should ensure that
detainees are signing documents in a language they understand or provide
oral assistance. (PBNDS 2011 Admission and Release: 11.8, V.F, V.G)
20. In 2015 CRCL recommended that long-term segregation housing of detainees
with serious mental health conditions at ACF should cease. This was not
corrected. A therapeutic unit should be established to house Special
Management Unit (SMU) detainees, where appropriate oversight and
treatment results in those detainees' eventual transition to general
population or a step-down unit. ERO, lHSC and ACF must audit all SMU
cases to identify those detainees housed in the SMU, partially or wholly due to
mental health conditions and develop a safe housing alternative with more
intensive mental health services (including mental health group therapy) in a nonSMU setting. (PBNDS 2011 Special Management Units: 114, 11.6, 11.7)
21. In 2015, CRCL recommended that the Mental Health Director and 1HSC ensure
that ACF Mental Health staff conduct daily face-to-face rounds with all detainees
in the SMU, and provide appropriate mental health assessments and treatment.
Daily rounds are being conducted; however, one of the rooms in the SMU
should be converted into an interview room where private face-to-face
interviews between mental health personnel and detainees can be effectively
conducted. (PBNDS 2011 Special Management Units: 11.6 and 7, 11.8, V.A, V.F;
Medical Care: V.F.1, V.N)
22. In 2015, CRCL recommended that ERO should audit all detainees held in the
SMU over 30 days for protective housing reasons and determine if transfer to
another facility is more appropriate to improve treatment or resolve the
inappropriate use of the SMU for housing detainees with serious mental illnesses.
While SMU audits are being conducted every 30 days, 40% (20) of the detainees

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continue to be housed over 30 days. ERO should work with GEO to create a
housing alternative for non-disciplinary placements in the SMU for over 30
days. (PBNDS 2011 Special Management Units: 11.8 and 9, II.19,V.A, V.F)
23. In 2015, CRCL recommended that ERO and ACF develop and implement an
efficient population count process to eliminate the problematic delays that six
daily counts cause in the detainees' access to meals, medical care, visitation,
recreation, and law library. ACF continues to conduct the problematic six counts,
even though the Chief of Security was not concerned with reducing the number to
five. ICE and ACF should reduce the number of daily counts to five as a way
to improve detainee access to programs and services. (PBNDS 2011
Population Counts: V.A.!; Multiple other PBNDS 2011, including Visitation,
Recreation, Law Libraries, Food Service)
24. In 2015, CRCL recommended that ERO and ACF Management (including the
Warden) develop a reporting system to ensure that facility personnel effectively
respond to and resolve the detainee grievance issues assigned to them by the
Grievance Coordinator and then report back to the Grievance Coordinator that the
matter is resolved. This was not corrected. CRCL again recommends that ICE
and ACF should develop a reporting system to ensure that facility personnel
respond and resolve detainee grievances. (PBNDS 2011 Grievance System: 11.2
and 3, 11.6 and 8, V.A, V.B.7, V.C)
25. In 2015, CRCL recommended that ERO and ACF Management develop a
tracking system to enable review and trend analysis of all grievances involving
staff mistreatment. This was not corrected. CRCL again recommends that ICE
and ACF should develop a grievance tracking tool. (PBNDS 2011 Grievance
System: V.D and F, V.H)
26. In 2015, CRCL recommended that ICE should receive a copy of staff
mistreatment grievances upon receipt by the GEO Grievance Coordinator. This
was not corrected. CRCL again recommends that detainee grievances involving
staff misconduct should be submitted to ICE as mandated by the PBNDS.
(PBNDS 2011 Grievance System: V.F, V.G).
27. In 2015, CRCL recommended that ACF should hold facility staff accountable for
substantiated abusive and disrespectful treatment of detainees, as determined by
the Grievance Coordinator and/or other facility personnel. This was not corrected.
CRCL again recommends that ACF should hold facility staff accountable for
substantiated abusive and disrespectful treatment of detainees. (PBNDS 2011
Grievance System: V.G)
28. In 2015, CRCL recommended that ERO and ACF develop a post-assignment
schedule that creates a sufficient staffing plan that resolves the current,
problematic staffing deficiencies. The deficiencies are negatively affecting
operational needs, including excessive count times and meal delays, and
limitations in access to visitation, law library, and recreation. The post
assignment schedule has been revised and additional correctional officer positions
have been added, however this has not resolved the problem. The correctional
officer medical escort and transportation staffing should be increased to
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adequately support the medical and mental health escort needs within the
facility and to outside appointments. (PBNDS 2011 Post Orders: V; Food Service:
11.4, V.D; Visitation: 11.4 and 6, V.B and J; Recreation: 11.4, V.B; Law Library
and Legal Material: 11.2, 11.4 and 5, V.C)
29. ACF should hire staff (e.g. a Spanish-speaking law librarian) and/or develop
other mechanisms to provide language assistance to detainees who are not
proficient in English so they may utilize the Law Library. (PBNDS 2011 Law
Libraries and Legal Material: 11.8, V.I)
30. ACF should institute a computer training class demonstrating use of the
Lexis-Nexis software and computers, and create a detainee-worker position
in each housing unit to assist detainees with using the computer system.
(PBNDS 2011 Law Libraries and Legal Material: 11.8, V.I)
31. ACF should develop a Language Line logging system and require all facility
staff to record Language Line use, by date and At (DHS Language Access
Plan, 2012) (2011 PBNDS: Multiple)
32. ERO and ACF should ensure that all forms issued to detainees for
informational purposes, but especially those requiring detainee signatures,
are written and/or translated in a language the detainee comprehends, or
provide oral interpretation of these forms and document the provision. All
written material provided to detainees shall generally be translated into Spanish.
(DHS Language Access Plan, 2012) (2011 PBNDS: Multiple)
33. ACF's healthcare grievance process (medical, mental health and dental) is
currently unreliable. The ACF Medical Unit should designate a staff position
that is responsible for timely reviews and responses to the detainees' medical
grievances and ensure that timely and appropriate follow-up actions are
completed, in order to prevent further detainee injury or death. (PBNDS 2011
Grievance System: 11.2 and 3, 11.6 and 8, V.A, V.B.7, V.C)
34. A separate healthcare medical grievance log should be instituted to track
healthcare-related grievance submissions and ensure timely responses.
(PBNDS 2011 Grievance System: 11.10, V.A, V.C.2 and 4)
35. A monthly audit should be conducted of submitted healthcare grievances to
improve timeliness of care and ensure appropriate access to medical, mental
health and dental care. (PBNDS 2011 Grievance System: V.C.4)
36. ACF must provide access to a cold-water shower in the East and West wings
for decontamination of detainees who have been exposed to OC Pepper
Spray. (PBNDS 2011 Medical Care: V.F; Use of Force and Restraints: V.A.5,
V.B.6 and 11, V.B.14, V.D.2)
It is CRCL's statutory role to advise department leadership and personnel about civil rights and
civil liberties issues, ensuring respect for civil rights and civil liberties in policy decisions and
implementation of those decisions. We look forward to working with ICE to determine the best
way to resolve these complaints. You can send your response and action plan by email. If you

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have any questions, please contact Senior Policy Advisor, Moreen Murphy by telephone at l(bX6)
1(bX6)

Copies to:
Nathalie R. Asher
Acting Deputy Executive Associate Director
Enforcement and Removal Operations
U.S. Immigration and Customs Enforcement
(bX6)

Tae Johnson
Assistant Director
Custody Management
Enforcement and Removal Operations
U.S. Immigration and Customs Enforcement
(bX6)

Claire Trickler-McNulty
Acting Assistant Director
Office of Detention Policy and Planning
U.S. Immigration and Customs Enforcement
1(bX6)

Dr. Stewart D. Smith
Associate Director
ICE Health Service Corps
Enforcement and Removal Operations
U.S. Immigration and Customs Enforcement
1(bX6)

CAPT Luzviminda Peredo-Berger
Chief Medical Officer
ICE Health Service Corps
Enforcement and Removal Operations
U.S. Immigration and Customs Enforcement
1(bX6)
1(bX6)

rX6)

Enclosures

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