Concerns about ICE
Detainee Treatment and
Care at Detention
Facilities

December 11, 2017
OIG-18-32

DHS OIG HIGHLIGHTS

Concerns about ICE Detainee Treatment
and Care at Detention Facilities
December 11, 2017

Why We
Did This
Inspection
In response to concerns
raised by immigrant rights
groups and complaints to
the Office of Inspector
General (OIG) Hotline about
conditions for detainees
held in U.S. Immigration
and Customs Enforcement
(ICE) custody, we conducted
unannounced inspections of
five detention facilities to
evaluate their compliance
with ICE detention
standards.

What We
Recommend
We made one
recommendation to improve
ICE’s oversight of detention
facility management and
operations.
For Further Information:

Contact our Office of Public Affairs at
(202) 254-4100, or email us at

What We Found
Our inspections of five detention facilities raised
concerns about the treatment and care of ICE
detainees at four of the facilities visited. Overall,
we identified problems that undermine the
protection of detainees’ rights, their humane
treatment, and the provision of a safe and healthy
environment. Although the climate and detention
conditions varied among the facilities and not
every problem was present at all of them, our
observations, interviews with detainees and staff,
and our review of documents revealed several
issues. Upon entering some facilities, detainees
were housed incorrectly based on their criminal
history. Further, in violation of standards, all
detainees entering one facility were strip searched.
Available language services were not always used
to facilitate communication with detainees. Some
facility staff reportedly deterred detainees from
filing grievances and did not thoroughly document
resolution of grievances. Staff did not always treat
detainees respectfully and professionally, and
some facilities may have misused segregation.
Finally, we observed potentially unsafe and
unhealthy detention conditions.

ICE Response
ICE concurred with the recommendation and has
begun corrective action to address the findings in
this report.

DHS-OIG.OfficePublicAffairs@oig.dhs.gov

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Washington, DC 20528 / www.oig.dhs.gov

%FDFNCFS




MEMORANDUM FOR:	

Thomas D. Homan
Acting Director
U.S. Immigration and Customs Enforcement

FROM: 	

John V. Kelly
Acting Inspector General

SUBJECT:	

Concerns about ICE Detainee Treatment and Care at
Detention Facilities

For your action is our final report, Concerns about ICE Detainee Treatment and
Care at Detention Facilities. We incorporated the formal comments provided by
your office.
The report contains one recommendation aimed at improving ICE’s detention
operations. Your office concurred with the recommendation. Based on
information provided in your response to the draft report, we consider
recommendation 1 open and resolved. Once your office has fully implemented
the recommendation, please submit a formal closeout letter to us within 30
days so that we may close the recommendation. The memorandum should be
accompanied by evidence of completion of agreed-upon corrective actions.
Please send your response or closure request to
OIGInspectionsFollowup@oig.dhs.gov.
Consistent with our responsibility under the Inspector General Act, we will
provide copies of our report to congressional committees with oversight and
appropriation responsibility over the Department of Homeland Security. We will
post the report on our website for public dissemination.
Please call me with any questions, or your staff may contact
Jennifer L. Costello, Assistant Inspector General for Inspections and
Evaluations, at (202) 254-4100.

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Background
U.S. Immigration and Customs Enforcement (ICE) apprehends, detains, and
removes aliens who are in the United States unlawfully. ICE Enforcement and
Removal Operations (ERO) places apprehended aliens who require custodial
supervision in detention facilities. ICE uses the following types of detention
facilities for adults:
x
x
x
x

Service processing centers – owned by ICE and operated by ICE and
contract employees; dedicated exclusively to ICE detention.
Contract detention facilities – owned and operated by private companies
under contract with ICE; dedicated exclusively to ICE detention.
Dedicated Intergovernmental Service Agreement (IGSA) facilities – state
and local facilities operating under an agreement with ICE; hold only ICE
detainees.
Non-dedicated IGSA facilities – state and local facilities operating under
an agreement with ICE; house ICE detainees in addition to other
confined populations (i.e., inmates), either together or separately.

Contracts and agreements with facilities that hold ICE detainees require
adherence to the 2000 National Detention Standards, ICE’s 2008 PerformanceBased National Detention Standards (PBNDS), or the 2011 PBNDS. One facility
we visited is operating under the 2000 National Detention Standards, one
facility operates under the 2008 PBNDS, and three operate under the 2011
PBNDS.
According to ICE, the PBNDS establish consistent conditions of confinement,
program operations, and management expectations within ICE’s detention
system. Among others, the PBNDS establish standards for environmental
health and safety, including cleanliness, sanitation, security, admission into
facilities, classification, searches of detainees, segregation (Special
Management Units), and the disciplinary system. The PBNDS also contain
standards for detainee care, including food service, medical care, and personal
hygiene; activities, including religious practices, telephone access (e.g., to
families, legal representatives, and embassies), visitation (e.g., by legal
representatives); and a grievance system. The 2008 PBNDS and 2011 PBNDS
have consistent requirements in the areas in which we identified issues.
All ICE detainees are held in civil, not criminal, custody, which is not supposed
to be punitive. ICE confines detainees administratively to process and prepare
them for deportation. Some detainees held at ICE detention facilities have been
convicted of crimes, served their prison sentence, and have been transferred to
the facility awaiting deportation by ICE or an immigration court hearing. Other
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detainees have violated immigration laws and are in detention pending
resolution of their cases. Prior to detention, ICE reviews each detainee’s
criminal record and assigns a risk level of high, medium/high, medium/low, or
low. ICE bases its risk levels on the severity of past criminal charges and
convictions.
ICE ERO has 24 Field Office Directors who are chiefly responsible for detention
facilities in their assigned geographic area. ICE ERO oversees the confinement
of detainees in nearly 250 detention facilities that it manages in conjunction
with private contractors or state or local governments, as previously noted.
ERO staff are responsible for monitoring conditions of confinement at these
facilities.
When choosing the facilities to visit, we used our professional judgement and
identified those of particular concern based on Office of Inspector General (OIG)
Hotline complaints, reports from non-governmental organizations, and open
source reporting. We made unannounced visits to six facilities: Hudson County
Jail (mixed gender), Laredo Processing Center (female-only), Otero County
Processing Center (male-only), Santa Ana City Jail (mixed gender), Stewart
Detention Center (male-only), and Theo Lacy Facility (male-only). 1 The Laredo
Processing Center, Otero County Processing Center, and Stewart Detention
Center are dedicated IGSAs; Hudson County Jail, Santa Ana City Jail, and
Theo Lacy are non-dedicated IGSA facilities.
At each facility, we examined the medical units; medical modular housing (for
detainees requiring more medical attention); kitchen, including food
preparation, food storage, and equipment cleaning areas; intake and outprocessing areas; Special Management Units (segregation); and modular
housing units, including individual cells. We also analyzed grievance
procedures and evaluated staff-detainee communication practices. We
interviewed detainees, ICE staff, and facility management staff at each facility.
We followed up on issues by reviewing files and documents.

1 On March 6, 2017, DHS OIG issued Management Alert on Issues Requiring Immediate Action
at the Theo Lacy Facility in Orange, California (OIG-17-43-MA). This report focuses on our
inspections of the other five detention facilities.
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Results of Inspection
Our inspections of five detention facilities raised concerns about the treatment
and care of ICE detainees at four facilities. Although the Laredo Processing
Center modeled quality operations, during our inspections, we identified
significant issues at the four other facilities. Overall, the problems we identified
undermine the protection of detainees’ rights, their humane treatment, and the
provision of a safe and healthy environment. Although the climate and
detention conditions varied among the facilities and not every problem was
present at all of them, our observations, interviews with detainees and staff,
and our review of documents revealed several issues. Upon entering some
facilities, detainees were housed incorrectly based on their criminal history.
Further, in violation of standards, all detainees entering one facility were strip
searched. Available language services were not always used to facilitate
communication with detainees. Some facility staff reportedly deterred detainees
from filing grievances and did not thoroughly document resolution of
grievances. Staff did not always treat detainees respectfully and professionally,
and some facilities may have misused segregation. Finally, we observed
potentially unsafe and unhealthy detention conditions.
Insufficient Protection of Detainees’ Basic Rights
Intake Issues That Could Affect Safety and Privacy
We observed some problems when detainees first arrive at facilities, which
could have repercussions for their safety throughout detention, as well as the
safety of facility staff. According to the 2011 PBNDS, upon admission (known
as intake), facility staff are supposed to expeditiously classify detainees
according to their crimes, based on “verifiable and documented information.”
Detainees’ crimes may be felonies (classified as high-risk detainees), but may
also have non-violent felony charges and convictions, which are considered low
risk. Facilities are to use these classifications to ensure that detainees are
housed with others of similar background and criminal history and that highand low-risk detainees are separated. However, because criminal background
information was not always available when the detainees arrived at the Stewart
Detention Center, facility staff there had misclassified some detainees with
high-risk criminal convictions and subsequently housed them with low-risk
detainees. Staff at Stewart admitted they assigned some detainees to housing
without having received criminal history reports.
We also received reports at the Stewart Detention Center of inadequate staffing
at intake. As a result, according to staff, they did not have enough male
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personnel to pat down detainees as required. Although staff used alternative
measures, such as a magnetometer wand, to screen incoming detainees, these
measures would not be sufficient to identify non-metallic items, drugs, or other
contraband that could pose a security risk.
In contrast, at the Santa Ana City Jail, staff confirmed detainee reports of
personnel strip searching all detainees upon admission, which they did not
document in detainee files as required. This raises two concerns. First,
according to the 2011 PBNDS, staff are not to routinely subject detainees to
strip searches unless there is “reasonable suspicion” based on “specific and
articulable facts that would lead a reasonable officer to believe that a specific
detainee is in possession of contraband.” Second, without documentation,
there is no way to ascertain whether these searches were justified or whether
they infringed on the privacy and rights of detainees.
Language Barriers Hamper Communication and Understanding
Although the PBNDS specify that language assistance be provided to detainees,
this was not always the case at the facilities we visited. The ensuing lack of
communication and understanding creates barriers between facility staff and
detainees. Consequently, this may cause confusion about facility rules and
procedures and risks turning problems that could have been resolved through
routine interaction into disciplinary issues. Ultimately, this lack of
communication and understanding impacts the overall well-being of detainees
and the security of the facility.
At some facilities, problems began at intake where facility staff failed to use
interpretation services for detainees who did not speak English. Further,
according to the PBNDS, when detainees arrive, they are supposed to receive
the ICE National Detainee Handbook and a local facility detainee handbook.
These handbooks cover essential information, such as the grievance system,
services and programs, medical care, and access to legal counsel. At three
facilities we inspected, detainees were not always given handbooks in a
language they could understand. These language barriers could prevent
detainees from fully comprehending basic facility rules and procedures. Using
interpretation services would be a relatively simple way to improve interaction
between staff and detainees and reduce misunderstandings.
At times, language barriers prevented detainees from understanding medical
staff. Although it might have cleared up confusion, staff did not always use
language translation services, which are available by phone, during medical
exams of detainees. Some medical consent forms were not always available in
Spanish, and staff did not always explain the English forms to non-English
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speaking detainees. As a result, detainees may not have been providing enough
information about their medical conditions to ensure adequate medical
treatment while in detention.
Difficulties Resolving Issues through the Grievance System and Other Channels
The PBNDS establish procedures for detainees to file formal grievances, which
are designed to protect detainees’ rights and ensure detainees are treated fairly.
However, resolution depends on facility staff properly handling and addressing
grievances without deterrents, which we identified at several facilities.
Specifically, some detainees reported that staff obstructed or delayed their
grievances or intimidated them, through fear of retaliation, into not
complaining. These deterrents may prevent detainees from filing grievances
about serious concerns that should be addressed and resolved.
We reviewed a sample of grievances that were available at the facilities we
visited. At the Stewart Detention Center, we found an inconsistent and
insufficiently documented grievance resolution process. Many serious
complaints from the sample at this facility included only cursory and
uninformative explanations of the resolution. For one particularly troubling
allegation of misconduct by facility staff, there was no clear documentation it
had been investigated, only a note that it would be investigated. We were later
able to verify that this allegation had been elevated and investigated by ICE,
but this was not explicitly documented in the facility’s grievance system.
According to the PBNDS, detainees may also seek help from ICE officials at
facilities to resolve their complaints, but some detainees we interviewed
reported that ICE personnel were not available to address their questions or
concerns because they rarely visited their housing units. Some detainees also
reported that ICE staff did not respond when contacted through written
requests.
Detainees are supposed to have access to telephones and be able to make free
calls to the Department of Homeland Security OIG. Yet, at the Otero County
Processing Center we observed non-working telephones in detainee housing
areas; at the Stewart Detention Center, when we called the OIG Hotline, we
received a message that the number was restricted.
Without an effective, compliant grievance process and access to ICE and other
channels, facilities risk escalating or ignoring problems, which may lead to a
failure to protect detainees’ rights.

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Improper Treatment of Detainees by Detention Facility Staff
We had concerns about a lack of professionalism and inappropriate treatment
of detainees by facility staff, which fostered a culture of disrespect and
disregard for detainees’ basic rights. At the Laredo Processing Center, detainees
we interviewed were generally positive about staff treating them with respect. In
contrast, detainees at the other four facilities alleged poor treatment, which
contributed to an overall negative climate.
At four facilities, detainees alleged in interviews that staff mistreated them,
citing guards yelling at detainees, as well as using disrespectful and
inappropriate language. For example, at the Santa Ana City Jail, multiple
detainees corroborated an incident in which a guard yelled at detainees for
several minutes, while threatening to lock down detainees at his discretion. We
reviewed surveillance video footage of the incident, which confirmed detainee
accounts, including a hostile and prolonged rant and threats of a lock-down.
Some detainees at the Stewart Detention Center also reported that staff
sometimes interrupted or delayed Muslim prayer times.
Potential Misuse of Segregation
Facility staff may separate detainees from the general population and place
them in either disciplinary segregation or administrative segregation for a
number of reasons, including violations of facility rules, risk of violence, or to
protect them from other detainees. Most cases we reviewed involved
administrative segregation, but some involved disciplinary segregation.
The Otero County Processing Center, Stewart Detention Center, and the Santa
Ana City Jail were violating the PBNDS in the administration, justification, and
documentation of segregation and lock-down of detainees. Staff did not always
tell detainees why they were being segregated, nor did they always
communicate detainees’ rights in writing or provide appeal forms for those put
in punitive lock-down or placed in segregation. In multiple instances, detainees
were disciplined, including being segregated or locked down in their cells,
without adequate documentation in the detainee’s file to justify the disciplinary
action. For example, one detainee reported being locked down for multiple days
for sharing coffee with another detainee. We also identified detainees who were
held in administrative segregation for extended periods of time without
documented, periodic reviews that are required to justify continued
segregation. Some detainees were locked down in their cells for violations of
minor rules without required written notification of reasons for lock-down and
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appeal options. Documentation of daily medical visits and meal records for
detainees being held in segregation was also missing or incomplete.
Some of these issues may simply be a matter of inadequate documentation, but
they could also indicate more serious problems with potential misuse of
segregation. 2
Problems with Detainee Care and Facility Conditions
Medical Care May Have Been Delayed and Was Not Properly Documented
Although the facilities provided health care services, as required by PBNDS,
some detainees at the Santa Ana City Jail and Stewart Detention Center
reported long waits for the provision of medical care, including instances of
detainees with painful conditions, such as infected teeth and a knee injury,
waiting days for medical intervention. In addition, two detainees, one at the
Hudson County Jail and another at the Santa Ana City Jail, waited several
months for eyeglasses following a vision exam that confirmed a need for them.
Finally, not all medical requests detainees claimed they submitted or the
outcomes were documented in detainee files or facility medical files.
Lack of Cleanliness and Limited Hygienic Supplies
Although the 2011 PBDNS require maintaining “high facility standards of
cleanliness and sanitation,” at Otero County Processing Center and Stewart
Detention Center we observed detainee bathrooms that were in poor condition,
including mold and peeling paint on walls, floors, and showers. At the Stewart
Detention Center, some detainee bathrooms had no hot water and some
showers lacked cold water. Also, detainees reported water leaks in some
housing areas.
Multiple detainees at the Hudson County Jail and Stewart Detention Center
also complained that some of the basic hygienic supplies, such as toilet paper,
shampoo, soap, lotion, and toothpaste, were not provided promptly or at all
when detainees ran out of them. According to one detainee, when they used up
their initial supply of certain personal care items, such as toothpaste, they
were advised to purchase more at the facility commissary, contrary to the
PBNDS, which specify that personal hygiene items should be replenished as
needed.

2 On September 29, 2017, we issued ICE Field Offices Need to Improve Compliance with
Oversight Requirements for Segregation of Detainees with Mental Health Conditions (OIG-17119).
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Potentially Unsafe Food Handling
We observed several problems with food handling and safety at four facilities,
some of which did not comply with the PBNDS for food operations and could
endanger the health of detainees. We observed spoiled, wilted, and moldy
produce and other food in kitchen refrigerators, as well as food past its
expiration date. We also found expired frozen food, including meat, and
thawing meat without labels indicating when it had begun thawing or the date
by which it must be used. Finally, at one facility, we observed food service
workers not wearing required nets to cover facial hair to ensure food safety.
Conclusion
Treatment and care of detainees at facilities can be challenging. For example,
personnel at one facility reported staffing shortages, and, according to officials,
it can be difficult for remote facilities to provide medical care to detainees.
Nevertheless, complying with the PBNDS and establishing an environment that
protects the rights, health, and safety of detainees are crucial to detention. ICE
could mitigate and resolve many of these issues through increased engagement
and interaction with the facilities and their operations.

Recommendation
We recommend that the Acting Director of U.S. Immigration and Customs
Enforcement ensure that Enforcement and Removal Operations field offices
that oversee the detention facilities covered in this report develop a process for
ICE field offices to conduct specific reviews of these areas of operations:
detainee classification, use of language services, use of segregation and
disciplinary actions, compliance with grievance procedures, and detainee care
including facility conditions. The process should include deficiency and
corrective action reporting to Enforcement and Removal Operations
headquarters to ensure deficiencies are corrected.

Management Comments and OIG Analysis
We evaluated ICE’s written comments and changed the report where we
deemed appropriate. A summary of the written response to the report
recommendation and our analysis of the response follows. Appendix B includes
ICE’s response in its entirety. In addition, we incorporated ICE’s technical
comments into the report, as appropriate.
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ICE acknowledged the importance of and challenges with detainee treatment
and care in detention facilities. ICE reported it discontinued the contract with
the Santa Ana City Jail in early 2017 and will no longer house detainees in this
facility.
ICE Response: Concur. The ICE Director and ERO field office leadership will
advise compliance personnel in the ICE facilities identified by OIG to fully
integrate special assessments of the below operational areas into their existing
auditing and compliance efforts: (1) detainee classification, (2) use of language
services, (3) use of segregation and disciplinary actions, (4) compliance with
grievance procedures, and (5) detainee care, including facility conditions.
Special emphasis in these areas will strengthen ICE's existing system of
oversight and compliance and improve overall conditions of detention.
According to ICE senior officials, ICE maintains a rigorous and multi-faceted
inspection schedule for its detention facilities, and local field management is
responsible for the areas identified in the recommendation. ICE's detention
operations are governed by national detention standards and are overseen by
field office personnel, inspections by the ICE Office of Professional
Responsibility, and other programmatic oversight and inspections by the
Detention Standards Compliance Unit, which includes the facility inspection
contract and the Detention Management Compliance Program. ICE
headquarters, particularly the Detention Management Compliance Unit, works
on a daily basis with the ERO field offices, the Office of Detention Policy and
Planning, and the DHS Office for Civil Rights and Civil Liberties to ensure that
facilities comply with ICE detention standards or take the necessary corrective
action to address problems and concerns.
OIG Analysis: ICE’s response to this recommendation addresses the intent of
the recommendation. In ICE’s corrective actions, we will look specifically at the
newly established or revised processes used to advise personnel and complete
special assessments for the operational areas outlined in the report. This
recommendation is resolved and will remain open until ICE provides evidence it
has integrated special assessments of the operational areas identified as
concerns. Once completed, ICE should provide a copy of the completed reviews
identifying the process developed to ensure deficiencies were corrected and
facilities are complying with standards.

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Appendix A
Objective, Scope, and Methodology
DHS OIG was established by the Homeland Security Act of 2002, Pub. L. No.
ï, 116 Stat. 2135, which amended the Inspector General Act of 1978.
DHS OIG initiated this inspection program in response to concerns raised by
immigrant rights groups and complaints to the DHS OIG Hotline about
conditions for aliens in U.S. Customs and Border Protection and ICE custody.
We generally limited our scope to the ICE PBNDS for health, safety, medical
care, mental health care, grievances, classification and searches, use of
segregation, use of force, language access, and staff training. We focused on
elements of the PBNDS that could be observed and evaluated without
specialized training in medical, mental health, education, or corrections. Our
visits to these six facilities were unannounced so we could observe normal
conditions and operations.
Prior to our inspections, we reviewed relevant background information,
including:
x
x
x
x
x

OIG Hotline complaints

ICE Performance-Based National Detention Standards

DHS Office for Civil Rights and Civil Liberties reports

ICE Office of Detention Oversight reports

Information from non-governmental organizations


During the inspections we:
x	 visited six facilities: Hudson County Jail, Laredo Processing Center, Otero
County Processing Center, Santa Ana City Jail, Stewart Detention Center,
and Theo Lacy Facility (previously reported);
x	 inspected areas used by detainees, including intake processing areas;
medical facilities; kitchens and dining facilities; residential areas, including
sleeping, showering, and toilet facilities; legal services areas, including law
libraries, immigration proceedings, and rights presentations; recreational
facilities; and barber shops;
x	 reviewed facilities’ compliance with key health, safety, and welfare
requirements of the PBNDS for classification and searches, segregation, use
of force and restraints, medical care, mental health care, staffing, training,
medical and nonmedical grievances, and access to translation and
interpretation;
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x	 interviewed ICE and detention facility staff members, including key ICE
operational and detention facility oversight staff, detention facility wardens
or equivalent, and detention facility medical, classification, grievance and
compliance officers;
x interviewed detainees held at the detention facilities to evaluate compliance
with PBNDS grievance procedures and grievance resolution; and
x reviewed documentary evidence, including electronic and paper medical files
and grievance logs and files.
We conducted this review under the authority of the Inspector General Act of
1978, as amended, and according to the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and
Efficiency.

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Appendix B
ICE Comments to the Draft Report

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Appendix C
Office of Inspections Major Contributors to This Report
Stephanie Christian, Acting Chief Inspector
Tatyana Martell, Lead Inspector
Jennifer Berry, Senior Inspector
Marybeth Dellibovi, Senior Inspector
Ryan Nelson, Senior Inspector
Jason Wahl, Senior Inspector
Paul Lewandowski, Inspector
Kelly Herberger, Communications and Policy Analyst
Amy Burns, Independent Referencer

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Appendix D
Report Distribution
Department of Homeland Security
Secretary
Deputy Secretary
Chief of Staff
Deputy Chiefs of Staff
General Counsel
Executive Secretary
Director, GAO/OIG Liaison Office
Assistant Secretary for Office of Policy
Assistant Secretary for Office of Public Affairs
Assistant Secretary for Office of Legislative Affairs
Office of Management and Budget
Chief, Homeland Security Branch
DHS OIG Budget Examiner
Congress
Congressional Oversight and Appropriations Committees

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