Of?ce of Professional Responsibility Of?ce of Detention Oversight FY 20] 7 Annual Report on Inspections October 1, 2016 September 30, 2017 US. Immigration and Customs Enforcement Table of Contents I. Introduction ........................................................................................................ 1 II. Methodology ...................................................................................................... 1 A. Site Selection ................................................................................. 2 B. Selection of Detention Standards to Review ....................................... 2 C. Priority Components ............................................................................................... 3 III. Findings from FY 2017 Inspections .............................................................. 3 A. Detainee Interviews .................................................................................. 3 B. Deficiencies by Core Standard and Subcomponent................................. 4 C. Repeat Deficiencies................................................................................... 7 D. Corrective Actions .................................................................................... 8 IV. Analysis ......................................................................................................... 9 V. Conclusion .................................................................................................. 10 Appendix A: List of FY 2017 Inspected Facilities...................................... 11 I. Introduction The Office of Detention Oversight (ODO) is a unit of the Office of Professional Responsibility (OPR), Inspections and Detention Oversight Division. As part of its oversight function, ODO conducts inspections of U.S. Immigration and Customs Enforcement (ICE) detention facilities housing detainees for periods in excess of 72 hours and having an average daily population greater than 10, to determine compliance with the ICE National Detention Standards (NDS) 2000 or the Performance-Based National Detention Standards (PBNDS) of 2008 or 2011. This annual report summarizes the results 34 inspections ODO completed in FY 2017. The report initially discusses ODO’s site selection and inspection processes, and then provides a detailed analysis of the common themes and systemic issues identified throughout year. II. Methodology ODO inspections provide ICE executive leadership and senior leaders in the Office of Enforcement and Removal Operations (ERO) with an independent assessment of the conditions of confinement at agency detention facilities. To develop a comprehensive picture of each facility, ODO completes a preliminary, pre-inspection document review and then conducts a site visit to review local records and interview key facility personnel, including the facility administrator, medical personnel, and ICE detainees. On the final day of the inspection, ODO conducts a closeout briefing with pertinent facility and local ERO personnel. Thereafter, ODO disseminates a written inspection report that documents its observations of facility operations, summarizes findings from staff and detainee interviews, and addresses concerns found during document and policy reviews. The report also credits facilities for taking corrective action to resolve any identified deficiencies during the course of the inspection. In addition to distributing the compliance report to agency leadership, ODO publishes its reports on the ICE.gov public internet site. 1 A. Site Selection ODO inspects all ICE detention facilities that have both an average daily population greater than ten and house detainees for longer than 72 hours. As a result, given the size of the agency’s detention footprint and ODO’s existing resources, ODO inspections typically occur on a threeyear inspection cycle. In FY 2017, ODO completed the second year of that rotation. ODO may nevertheless re-prioritize its scheduling dependent upon perceived risk, agency direction or national interest. B. Selection of Detention Standards to Review During the course of an inspection, ODO concentrates its review on a core set of standards (Table 1) that have particular significance to a detainee’s life, health, and safety. ODO conducts a thorough line-by-line assessment of each of those core standards. In some instances, ODO may review other standards that fall outside this core set, based on the conditions within a facility or at the request of ICE leadership. 1 For inspection reports since FY 2012 to present, see “Office of Detention Oversight – Detention Facility Compliance Inspections” at https://www.ice.gov/foia/library. 1 Table 1: CBC Core Standards for FY 2017 FY 2017 Core Standards NDS2 2008 and 20113 1. Access to Legal Material 1. Law Libraries and Legal Materials 2. Admission and Release 2. Admission and Release 3. Detainee Classi?cation System 3. Custody Classi?cation System 4. Detainee Grievance Procedures 4. Grievance System 5. Detainee Handbook 5. Detainee Handbook 6. Enviromnental Health and Safety 6. Envirormiental Health and Safety 7. Food Service 7. Food Service 8. Funds and Personal Property 8. Funds and Personal Property 9. Medical Care 9. Medical Care 10. Special Management Unit (Administrative Segregation) 10. Medical Care (Women)4 1 1. Special Management Unit (Disciplinary Segregation) 11. Special Management Units 12. Staff-Detainee Connmmication 12. Staff-Detainee 13. Signi?cant Self-harm and 13. Suicide Prevention and Intervention Suicide Prevention and Intervention 14. Telephone Access 14. Telephone Access 15. Use of Force 15. Use of Force and Restraints 16. Sexual Abuse and Assault Prevention and 16. Sexual Abuse and Assault Prevention and Intervention (with modi?cation or Intervention C. Priority Components In FY 2013, the ICE Of?ce of Detention Policy and Flaming (ODPP) designated certain sub- components of the 2008 and 2011 it considered of critical importance to facility secm?ity and/or detainee health and safety, legal rights, and quality of life while in detention as ?priority? 2 The NDS consists of 38 standards. 3 The 2008 consists of 41 standards. and the 2011 of 43 standards. 4 Because this core standard is only included in 2011. ODO assessed facility compliance with its requirements in 17.6 percent of its inspections in FY 2017. All other core standards were fully assessed at all inspected facilities. 5 ODO reviews the Sexual Abuse and Assault Prevention and Inten'ention (SAAPI) standard at all inspected facilities. For facilities with contracts or contract modi?cations in place to comply with the SAAPI 20115tandard. ODO cites ?de?ciencies? in its compliance inspection reports. where necessary. For facilities without a contract or contract modi?cation in place to comply with the SAAPI 2011 standard. ODO also reviews the facility?s program against the standard. but instead identi?es its ?ndings as ?areas of concern? in its reports. components. 6 In FY 2013, ODO then began highlighting deficiencies found within those priority components in its compliance inspection reports. Consistent with findings in the previous two fiscal years, for FY 2017, priority component deficiencies represented 21 percent of all deficiencies found for PBNDS 2008 facilities and 35 percent of all deficiencies found for PBNDS 2011 facilities. Prioritizing resolution in these areas should allow ERO to reduce the agency’s potential risk and liability and avoid potentially longlasting negative consequences for ICE detainees. III. Findings from FY 2017 Inspections A. Detainee Interviews During each inspection, ODO interviews a sampling of ICE detainees, asking them a series of questions to gauge their understanding of facility rules, their ability to access facility resources, and to assess the overall facility climate/atmosphere. In 65% of all inspections this FY, detainees raised concerns about the provision of medical care. ODO attempts to address all detainee complaints prior to conclusion of the inspection by engaging with facility staff and reviewing onsite documentation. Overall, ODO determined most medical complaints were unfounded as staff members were adequately addressing detainee care. However, on several occasions ODO has found further medical intervention was necessary and requested additional assistance accordingly. This fiscal year, ODO observed an increase in the number of older individuals in detention. ODO’s interviews of several of these individuals found they presented with urgent medical concerns with many having a previous diagnosis of a chronic condition. In at least one instance, ODO requested medical staff evaluate a 62-year old female detainee who had consistently high blood pressure readings for several weeks. ODO also found several instances of delays in scheduling off-site specialist appointments when detainee needs exceeded the capacity of the facility. In most of these cases, ODO found medical personnel failed to inform detainees that specialist appointments were scheduled and consequently, detainees mistakenly believed their medical concerns had gone unaddressed. In each of these cases and at ODO’s urging, facility personnel took the steps necessary to resolve these detainee’s concerns prior to conclusion of the inspection. Overall, in FY 2017, by its own observations and through detainee interviews, ODO identified similar concerns to those raised in FY 2016. These issues included: a perceived lack of ICE officer engagement with the detainee population, insufficient language access protocols for limited English proficient populations (including low or poor reading comprehension for second and third language speakers), and various medical care discrepancies. ODO recommends local ERO leadership provide direction to line-ERO officers regarding agency expectations of how to conduct staff-detainee communication, as well as emphasize the importance of accurately identifying each detainee’s preferred language and providing ongoing access to language services throughout the duration of a detainee’s stay. Additionally, ICE Health Services Corps personnel should ensure its compliance staff are aware of the shifting demographics of ICE’s detained population as well as make efforts to address any systemic barriers that may be hindering detainee access to specialized care. 6 ODPP identified priority components for the PBNDS 2008 and 2011. Priority components not identified for NDS. 3 B. De?ciencies by Core Standard and Subcomponent In FY 2017, ODO inspected 34 detention facilities, 21 were required to comply with the NDS, six with the 2008, and seven with the 2011. The average number of core standards reviewed per inspection, regardless of the applicable standards, was 16. Likely, in part due to the larger number of NDS facilities inspected in FY2017, the total nrunber of de?ciencies at NDS facilities (293) accormted for 60 percent of all ODO identi?ed de?ciencies. Facilities governed under 2008 accormted for 27 percent (133 in all); and facilities governed by 2011 de?ciencies (59) accounted for 12 percent of the de?ciencies ODO identi?ed. Table 2 re?ects the most common de?ciencies identi?ed at those inspected facilities governed by the NDS and provides a corresponding percentage to indicate its relative proportion of total de?ciencies. The Medical Care standard had the greatest nrunber of de?ciencies (33), followed by Environmental Health and Saftev and ooa? Service (32). Table 2A provides the NDS subcomponents identi?ed most frequently. Table 2: NDS De?ciencies by Core Standards NDS Standard (21 facilities) of grilfizileirlcies Percent Total De?ciencies Found 290 100.0 Medical Care 33 1 1.4 Food Service 32 11.0 Enviromnental Health and Safety 32 11.0 Staff Detainee Cormnunication 31 10.7 Admission and Release 30 10.3 Funds and Personal Property 19 6.6 Telephone Access 16 5.6 Special Management Units (Administrative Segregation) 14 4.8 Use of Force 13 4.5 Detainee Classi?cation System 12 4.1 Detainee Grievance Procedures 12 4.1 Special Management Units (Disciplinary Segregation) 11 3.8 Sexual Abuse and Assault Prevention and Intervention with modi?cation or PREA7 ll 3'8 Access to Legal Materials 10 3.5 Detainee Handbook 8 2.8 Suicide Prevention and Intervention 5 1.7 Searches of Detainees 1 0.3 7 In FY 2017. 10 of the 21 NDS facilities inspected were contractually obligated to comply with SAAPI 2011. Table 2A: NDS Subcomponents Cited Most Frequently8 NDS Standard Standard Subcomponent .\umber 0f Snbcomponent De?crencres Medical Care Medical Screening (New Arrivals) 12 Admission and Release Orientation 10 Staff-Detainee . . . . . Record Keepmg and File Mamtenance 8 Admission and Release New Arrivals 7 Medical Care Dental Treatment 6 Telephone Access Change Notice: April 4 6 Table 3 re?ects the most deficiencies at those inspected facilities governed by the 2008 and provides a corresponding percentage to indicate its relative proportion. With the NDS facilities, the Medical Care standard had the greatest mnnber of de?ciencies (16), followed by Sta?-Detainee Conmnmication, and Environmental Health and Safety (15). Table 3: 2008 Deficiencies by Core Standards Total De?ciencies found 133 100 Medical Care 16 12.0 Staff-Detainee Commrmication 15 11.3 Environmental Health and Safety 15 11.3 Special Management Units 14 10.5 Use of Force and Restraints 13 9.8 Telephone Access 10 7.5 Food Service 10 7.5 Law Libraries and Legal Materials 9 6.8 Classi?cation System 8 6.0 Grievance System 6 4.5 Admission and Release 6 4.5 Detainee Handbook 4 3.0 Funds and Personal Property 4 3.0 Sexual Assault and Abuse Prevention and Intervention 0 Suicide Prevention and Intervention 0 Other. Non-C ore Standards 3 2-3 8 See Appendix for a full list of de?ciencies. Table 3A: 2008 Subcomponents Cited Most Frequently9 Number of . . Subcornponent 2008 Standard Standard Subcomponent De?ciencies (Highest to Lowest) Admission and Release Orientation 4 Classi?cation System Fomrs and Time Requirements 3 Medical Screening of New Arrivals - Medical Care Medical Screening 3 Medical Care Health Appraisal 3 Telephone Access Monitoring of Detainee Telephone Calls 3 Table 4 re?ects the most common de?ciencies at those inspected facilities governed by the 2011 and provides a corresponding percentage to indicate its relative proportion, ranked by the total number of de?ciencies cited in each standard. The Grievance Svstem standard had the greatest niunber? of de?ciencies (13), followed by Sm?-Deminee Communication (5), and Funds and Personal Property (5). Table 4A provides the 2011 subcomponents identi?ed most frequently. Table 4: 2011 De?ciencies by Core Standards Total De?ciencies Found 59 100.0 Grievance System 13 22.0 Staff-Detainee Communication 5 8.5 Fluids and Personal Property 5 8.5 Environmental Health and Safety 5 8.5 Admission and Release 5 8.5 Special Management Units 4 6.8 Sexual Assault and Abuse Prevention and Intervention 4 6.8 Telephone Access 4 6.8 Medical Care 3 5.1 Custody Classi?cation System 3 5.1 Detainee Handbook 2 3.4 Food Service 2 3.4 Use of Force and Restraints 1.7 Law Libraries and Legal Materials 1 1.7 9 See Appendix for a full list of de?ciencies. 2011 Standard (7 facilities) Count Percent Medical Care WV omen) 0 0 Signi?cant Self-Harm and Suicide Prevention and Intervention 0 0 Other. Non-Core Standards 2 3.4 Table 4A: 2011 Subcomponents Cited Most Number of Subcomponent 2011 Standard Standard Subcomponent . . De?crencres Grievance System Record Keeping and File Maintenance 4 Fluids and Personal Property Inventory and Audit 3 Staff-Detainee Staff and Detainee Contact 3 Connmuncation Telephone Access Monitoring of Detainee Telephone Calls 2 Admission and Release Screening of Detainee 2 Admission and Release Orientation 2 C. Corrective Actions Initiated During Inspections When feasible, facility staff may initiate corrective actions during the course of the inspection. For example, facilities have changed housing assignments to resolve co-mingling of high and low classi?ed detainees; began conducting reassessments of detainees assigned to disciplinary and administrative segregation; revised record keeping practices to captlu?e more accurate data on grievances; revised facility handbooks to include missing information such as law library schedules; and restored detainee recreation and visitation privileges. Table 5: Corrective Actions Initiated Total Corrective Actions Initiated Admission and Release Tel hone Access Grievance tern Classi?cation tern p?i Staff-Detainee Communication Food Service Marla Units Medical Care Environmental Health and Saf Law Libraries and Material Detainee Handbook OOt?tt?ht?Nt?It?tt?ht?tt?I 10 See Appendix for a full list of de?ciencies. Suicide Prevention and Intervention Funds and Personal Property Use of Force and Restraints Sexual Abuse and Assault Prevention and Intervention oer?Ho Key and Lock Control ODO commends facilities for initiating immediate corrective action when possible which only serves to improve detainee care and overall conditions of con?nement. Table 6 illustrates the ?'equency with which facilities implement some type of corrective action over the coru'se of their inspection, broken down by the related set of detention standards. Table 6: On-Site Inspection Impact Total FY 2017 De?ciencies Found 293 133 59 Total Corrective Actions Initiated 74 20 10 Percentage of De?ciencies where Corrective Actions were Initiated 25.3 15.0 16.9 D. Repeat Deficiencies Repeat de?ciencies are those de?ciencies ODO identi?ed dining a previous compliance inspection at the facility and cited again dining a subsequent inspection.ll Dining FY 2017, ODO identi?ed 60 repeat de?ciencies (see Table 7 which represents close to a threefold increase in the incidence of repeat de?ciencies compared to the previous ?scal year (21 for FY 2016). Generally, ODO found that NDS and 2008 facilities were more likely to have a higher number of repeat de?ciencies (51 combined) than 2011 facilities (8). ODO considers the number of repeat de?ciencies when developing its annual inspection schedule. Detention Standards Compliance Unit (DSC U) within the Custody Management Division is responsible for working with the affected ?eld of?ce to implement corrective actions necessary to resolve ODO-identi?ed de?ciencies. In FY 2017, CDC and DSCU implemented closer coordination to review corrective action plans submitted by facilities. Table 7: Repeat De?ciencies by Standard Total 60 Fluids and Personal Property 9 Medical Care Admission and Release 11 A repeat de?ciency is speci?c to an ODO inspection and does not include de?ciencies identi?ed by other inspection entities. Staff-Detainee Communication 7 Detainee Grievance Procedures/System 6 Food Service 6 Detainee Classification System 4 Special Management Units 3 Environmental Health and Safety 2 Telephone Access 2 Use of Force and Restraints 2 Facility Security and Control 1 Detainee Handbook 1 Access to Legal Material/Law Libraries 1 Sexual Abuse and Assault Prevention and Intervention 1 Suicide Prevention and Intervention Medical Care (Women) 0 0 IV. Analysis On average, ODO identified 14 deficiencies during each inspection in FY 2017. Similar to ODO’s 2016 findings, issues related to Medical Care and Environmental Health and Safety represented the top number of deficiencies identified across all facility types. The frequency of deficiencies found related to Staff-Detainee Communication, Food Service, Admission and Release, and Special Management Units (SMU) was high. This year, ODO identified several instances of co-mingling differently classified detainees in housing units and other areas of the facility without adequate staff supervision/oversight, which poses a potential threat to facility security. ODO also noted a higher instance of situations in which local facility handbooks and postings were missing mandatory information, particularly in areas related to law library/legal access, grievance procedures, and communication schedules for ERO officers. While most facilities were able to document they provided the National ICE Detainee Handbook to detainees upon admission, local supplements often lacked required detail regarding local practices (as mandated by ICE standards). In addition, as indicated above in the Detainee Interview discussion, ODO found numerous instances of detainees provided handbooks in languages they could not read or understand. In each of these cases, the facilities failed to provide interpretation services to assist the detainee until ODO brought the matter to staff attention. ODO found more deficiencies in facilities operating under NDS 2000 and PBNDS 2008 than PBNDS 2011 facilities with NDS locations having 66 percent more deficiencies and PBNDS 2008 sites having 163 percent more deficiencies respectively. These findings fall in line with ODO’s analysis from previous fiscal years where a higher number of overall deficiencies occurred in NDS and PBNDS 2008 facilities. We note that in FY 2017, six of the seven PBNDS 2011 facilities ODO inspected were dedicated exclusively to ICE detainees and had permanently assigned local ERO field officer personnel on-site. Furthermore, all seven facilities had a permanently assigned Detention Service Manager (DSM). These factors likely contributed to the higher rate of compliance in meeting the more stringent requirements of PBNDS 2011. 9 While ODO found most facilities to be responsive to its concerns, ODO continued to identify a variety of themes present across all ICE-facility types. ODO specifically highlights these areas of concern for ERO’s consideration given their potential for dramatically affecting conditions of confinement and detainee care. Proactive engagement by local ERO field office leadership with facility administrators would likely help mitigate these concerns. ODO inspection reports provided to each Field Office Director present significant detail regarding each deficiency and should serve as a road map for implementing change. ERO has an opportunity to enhance its internal monitoring and oversight controls to resolve each of the themes noted in this report. Deploying training and technical assistance resources and supervisory guidance to local facility compliance teams and on-site ERO officers in the following areas may likewise result in improved outcomes and reduced liability to the agency: 1) Staff-detainee communication 2) Improving the availability of language access resources at all stages of the detention lifecycle, and 3) Targeting facility services and communication methods to the changing detainee population (increased internal apprehensions, longer detention stays, and older detainees.) V. Conclusion As FY 2018 advances, ODO will close out its final year in its current inspections rotation, which will be supplemented by additional facilities that the agency has begun using in the last year. With the implementation of the President’s executive orders on immigration, ODO may need to re-assess its current inspections model in the coming fiscal year(s), to ensure that it continues to provide an appropriate and effective oversight mechanism in response to any shifts to the agency’s detention model. Regardless, ODO will continue to collaborate with ERO to ensure all deficiencies related to the life, health, and safety of ICE detainees are prioritized and resolved expeditiously. 10 Appendix A FY 2017 ODO List of Inspected Facilities Location Inspection Dates Standards 1. Pine Prairie Correctional Center. LA November 1-3. 2016 2011 2. Clinton County Jail. NY November 15-17. 2016 NDS 2000 3. Allegany Cormty Jail. NY Nov 29-Decl. 2016 NDS 2000 4. Brooks County Detention Center. TX December 6-8. 2016 NDS 2000 5. Etowah County Detention Center. AL December 13-15. 2016 NDS 2000 6. Karnes City Correctional Center. TX January 10-12. 2017 NDS 2000 7. Nevada Southern Detention Center. NV January 24-26. 2017 2008 8. San Luis Regional Detention Center. AZ Jan 31-2 Feb 2. 2017 NDS 2000 9. Theo Lacy Facility. CA Februaiy 7-9. 2017 2008 10. ena/LaSalle Detention Facility. LA February 14-16. 2017 PNDS 2011 11. Chippewa County SSM. MI Feb 28-March 2. 2017 NDS 2000 12. Irwin Cormty Detention Center. GA March 7-9. 2017 2008 13. Yuba Cormty Jail. CA March 14-16. 2017 NDS 2000 14. Orange County Jail. NY March 21-23. 2017 NDS 2000 15. Hardin County Jail. IA March 28-30. 2017 NDS 2000 16. Hudson County Correctional Center. NJ April 3-6. 2017 2008 17. Baker Corulty Sheriffs Of?ce. FL April 10-13. 2017 NDS 2000 18. Buffalo Service Processing Center. NY April 18-20. 2017 2011 19. Eloy Federal Contract Facility. AZ April 25-27. 2017 201 1 20. Houston Contract Detention Facility. TX May 2-4. 2017 2011 21. Chase County Detention Facility. KS May 16-18. 2017 NDS 2000 22. Franklin House of Con'ections. MA May 23-25. 2017 NDS 2000 23. Caldwell County Detention Center. MO June 6-8. 2017 NDS 2000 24. Hall County Department of Corrections. NE June 13-15. 2017 NDS 2000 25. Montgomery County Jail. MO June 20-22. 2017 NDS 2000 26. Adelanto Correctional Facility. CA July 1 1-13. 2017 201 27. Strafford County Corrections. NH July 18-20. 2017 2008 28. Carver County Jail. MN July 18-20. 2017 NDS 2000 29. Dodge County Jail. WI August 1-3. 2017 NDS 2000 30. Freebom County Adult Detention Center. MN August 8-10. 2017 NDS 2000 31. York County Prison. PA August 22-24. 2017 2008 32. Stewart Detention Center. GA August 29-31. 2017 2011 33. Kenosha Cormty Detention Center. WI September 12-14. 2017 NDS 2000 34. Calhoun County Correctional Center. MI September 19-21. 2017 NDS 2000 11 12