Department of Homeland Security-Condition of Confinement Worksheet, Dec. 2021

• Locations: United States of America -> Indiana • Topics: Prison Conditions

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Department of Homeland Security
Immigration and Customs Enforcement: Office of Enforcement and Removal Operations

Condition of Confinement Inspection Worksheet
(This document must be attached to each G-324A Inspection Worksheet)
This Form is to be used for Inspections of Facilities Used Over 72 Hours with 2011 SAAPI

ICE Performance-Based National Detention Standards 2008
Inspection Worksheet for Over 72 Hour Facilities with 2011 SAAPI
Inspection Team Use: (Edits Permitted, ALL FIELDS REQUIRED)

Facility Information
Facility Name: Clay County Justice Center

Facility Type: IGSA

Inspection Purpose: Follow-up

Intergovernmental Service Agreement (IGSA), ICE Service Processing Center (SPC), ICE Contract Detention Facility (CDF)

Address:
City: Brazil
County:

l
I

611 East Jackson Street

Clay

State: IN

CEO Name: Paul Harden
Inspection Information (Use following format for dates: mm/dd/yyyy)
Start Date: 12/07/2021
End Date: 12/9/2021
Lead Name: Inspector 3

Recommended Inspection Rating:

Zip: 47834

CEO Title: Sheriff

Type: Special Assessment
l Inspection
Lead Title:

Meets Standard

LCI

Review Document Issue Summary (See Document Check Section to Review/Update)

Error(s) Found:

ICE HQ USE ONLY: (DO NOT EDIT)
Form Key: 46
Notes:

Items Not Rated:

Revision Date:

10/18/2020

*Only one G324 per inspection is to be used, if you do not have the inspection form required, contact ICE HQ.
*If edits are required, to any part of this form, to conduct the inspection being performed, contact ICE HQ.

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)
G-324A PBNDS 2008 with 2011 SAAPI Detention Inspection Worksheet

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Table of Contents
INTRODUCTION TO THE G-324A OVER 72 HOUR FACILITY DETENTION INSPECTION
WORKSHEETS .......................................................................................................................................... 4
WHAT IS “PERFORMANCE-BASED”? ........................................................................................................ 4
WORKSHEET OVERVIEW .......................................................................................................................... 4
WORKSHEET COMPLETION ...................................................................................................................... 5
SECTION I: SAFETY ................................................................................................................................ 6
PART 1 – 1. EMERGENCY PLANS (KEY: A)................................................................................................... 7
PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (KEY: B) ................................................................. 11
PART 1 – 3. TRANSPORTATION (BY LAND) (KEY: C) ................................................................................. 18
SECTION II: SECURITY ....................................................................................................................... 21
PART 2 – 4. ADMISSION AND RELEASE (KEY: D)....................................................................................... 22
PART 2 – 5. CLASSIFICATION SYSTEM (KEY: E) ......................................................................................... 26
PART 2 – 6. CONTRABAND (KEY: F).......................................................................................................... 29
PART 2 – 7. FACILITY SECURITY AND CONTROL (KEY: G).......................................................................... 31
PART 2 - 8. FUNDS AND PERSONAL PROPERTY (KEY: H) .......................................................................... 35
PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (KEY: I).................................................................. 39
PART 2 – 10. KEY AND LOCK CONTROL (KEY: J)........................................................................................ 43
PART 2 – 11. POPULATION COUNTS (KEY: K) ........................................................................................... 48
PART 2 – 12. POST ORDERS (KEY: L)......................................................................................................... 50
PART 2 – 13. SEARCHES OF DETAINEES (KEY: M) ..................................................................................... 52
PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (KEY: N) ........................ 55
PART 2 – 15. SPECIAL MANAGEMENT UNITS (KEY: O) ............................................................................. 63
PART 2 – 16. STAFF-DETAINEE COMMUNICATION (KEY: P) .................................................................... 73
PART 2 – 17. TOOL CONTROL (KEY: Q)..................................................................................................... 77
PART 2 – 18. USE OF FORCE AND RESTRAINTS (KEY: R) ........................................................................... 81
SECTION III: ORDER ............................................................................................................................ 86
PART 3 – 19. DISCIPLINARY SYSTEM (KEY: S) ........................................................................................... 87
SECTION IV: CARE ............................................................................................................................... 90
PART 4 – 20. FOOD SERVICE (KEY: T) ....................................................................................................... 91
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G-324A PBNDS 2008 with 2011 SAAPI Detention Inspection Worksheet

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

PART 4 – 21. HUNGER STRIKES (KEY: U) .................................................................................................. 99
PART 4 – 22. MEDICAL CARE (KEY: V) .................................................................................................... 104
PART 4 – 23. PERSONAL HYGIENE (KEY: W) ........................................................................................... 127
PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (KEY: X) ........................................................ 130
PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (KEY: Y) .................................... 135
SECTION V: ACTIVITIES ................................................................................................................... 139
PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (KEY: Z) ................................................................ 140
PART 5 – 27. ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES (KEY: AA) ....................................... 143
PART 5 – 28. MARRIAGE REQUESTS (KEY: AB) ....................................................................................... 144
PART 5 – 29. RECREATION (KEY: AC) ..................................................................................................... 146
PART 5 – 30. RELIGIOUS PRACTICES (KEY: AD) ...................................................................................... 150
PART 5 – 31. TELEPHONE ACCESS (KEY: AE) .......................................................................................... 153
PART 5 – 32. VISITATION (KEY: AF) ........................................................................................................ 158
PART 5 – 33. VOLUNTARY WORK PROGRAM (KEY: AG)......................................................................... 161
SECTION VI: JUSTICE ........................................................................................................................ 163
PART 6 – 34. DETAINEE HANDBOOK (KEY: AH)...................................................................................... 164
PART 6 – 35. GRIEVANCE SYSTEM (KEY: AI) ........................................................................................... 169
PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (KEY: AJ) .............................................................. 172
PART 6 – 37. LEGAL RIGHTS GROUP PRESENTATIONS (KEY: AK) ........................................................... 176
SECTION VII: ADMINISTRATION & MANAGEMENT ............................................................... 178
PART 7 – 38. DETENTION FILES (KEY: AL)............................................................................................... 179
PART 7 – 39. NEWS MEDIA INTERVIEWS AND TOURS (KEY: AM) .......................................................... 181
PART 7 – 40. STAFF TRAINING (KEY: AN) ............................................................................................... 183
PART 7 - 41. TRANSFER OF DETAINEES (KEY: AO) .................................................................................. 190
DOCUMENT CHECK ........................................................................................................................... 193

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G-324A PBNDS 2008 with 2011 SAAPI Detention Inspection Worksheet

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

INTRODUCTION TO THE G-324A OVER 72 HOUR FACILITY DETENTION
INSPECTION WORKSHEETS
The Performance-Based National Detention Standards (PBNDS 2008) were designed to better
address the needs of ICE’s detainee population while maintaining a safe and secure detention
environment for staff and detainees. The revised PBNDS 2008 builds on the requirements of NDS
to more clearly delineate the results or outcomes to be accomplished by adherence to their
requirements. The PBNDS 2008 prescribe both the expected outcomes of each detention
standard and the expected practices required to achieve them. During development four new
standards were added to include standards on Searches of Detainees, Sexual Abuse and Assault
Prevention and Intervention, News Media Interviews and Tours, and Staff Training, while the two
National Detention Standards regarding Special Management Units standards were condensed
into one standard in PBNDS 2008.
WHAT IS “PERFORMANCE-BASED”?
Unlike “policy and procedures” that focus solely on what is to be done, performance-based policy
starts with a focus on the results or outcomes that the required procedures are expected to
accomplish. Each performance-based standard has been revised to produce Expected Outcomes
that are clearly stated. Each standard reflects the overall mission and purpose of the agency and
contributes to the goal that has been articulated.
Expected Practices found in the PBNDS represent what is to be done to accomplish the Expected
Outcomes that will meet the Purpose and Scope of the detention standard.
WORKSHEET OVERVIEW
Detention Inspection Worksheets are used to assess facility compliance with ICE detention
standards. This set of worksheets is derived from the policies and procedures set forth in the
PBNDS 2008. The G-324A is for use with facilities that house detainees for over 72 hours.
Various line items in the worksheets have been designated as “Priority.” Priority components
replace mandatory components in earlier PBNDS 2008 worksheets, and represent those PBNDS
requirements that ICE deems of critical importance for ensuring adequate conditions of
confinement and the safety and security of detainees and staff at all ICE authorized detention
facilities.

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G-324A PBNDS 2008 with 2011 SAAPI Detention Inspection Worksheet

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

WORKSHEET COMPLETION
Reviewers are required to complete each item within each section of the G-324A Detention
Inspection Worksheets. Worksheets are in a uniform format with three columns, with PBNDS
purpose and scope stated at the top of the worksheet. Column one contains the relevant
standard line item. Column two contains a dropdown menu for each row where a rating can be
assigned to a given line item. In addition to rating options for “Meets Standard” and “Does Not
Meet Standard,” there is an option for the review team to select “N/A.” The “N/A” rating should
be used only rarely and where applicable. In addition, the remarks section for each line item
should be filled out in as much detail as possible. If the review team fails to assign a rating to a
given line item, the default rating and thus the assigned rating on the worksheet will show as
“Not Rated.”
There is also a summary remarks and rating section at the end of each standard that must be
completed by the assigned reviewer. The remarks should be filled out with sufficient detail to
assist the Review Authority in accurately assessing overall facility compliance to the PBNDS.

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G-324A PBNDS 2008 with 2011 SAAPI Detention Inspection Worksheet

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Section I: SAFETY
Emergency Plans
Environmental Health and Safety
Transportation (By Land)

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

PART 1 – 1. EMERGENCY PLANS (Key: A)
This Detention Standard ensures a safe environment for detainees and employees by having in place contingency plans to
quickly and effectively respond to any emergency situations that arise and to minimize their severity.
Components
1.

All staff receive training in the emergency plans during
their orientation training as well as during their annual
training.

(SPCs/CDFs) Each SPC and CDF shall develop contingency
plans with local, State, and Federal law enforcement
agencies and formalize those agreements with
Memoranda of Understanding (MOUs). The facility
administrator shall review and approve contingency plans
at least annually.

Meets Standard

Training records verified staff are
trained to identify detainee
unrest to include distress and
unusual behavior.

Meets Standard

Training records confirmed
employees receive training in
emergency preparedness during
initial training and annually,
thereafter.

Meets Standard

Documentation confirmed the
facility has contingency plans for
emergency response. The
emergency plans include a locally
approved evacuation plan that is
updated annually. The plan was
approved on 05/19/2021.

PRIORITY: The facility shall have in place contingency
plans for responding to emergencies, including a locally
approved and annually updated evacuation plan.

The facility conducts emergency exercises to test specific
emergency plans to assess their effectiveness.

Remarks (1000 Char Max)

Staff are trained to identify signs of detainee unrest.

Rating

Every plan that is being developed or is final must include
a statement prohibiting unauthorized disclosure.

The facility shall establish written policy and procedures
addressing, at a minimum: chain of command, command
post/center, staff recall, staff assembly, emergency
response components, use of force, video recording,
records and logs, utility shutoff, employee conduct and
responsibility, public relations, facility security, etc.
(SPCs/CDFs) The facility shall set up a primary command
post outside the secure perimeter that is equipped as per
the Emergency Plan standard.

At least one video camera shall be maintained in the
Control Center for use in emergency situations.

Meets Standard

This IGSA facility has developed
contingency plans with local
state and federal law
enforcement. Memoranda of
Understanding Agreements
include Clay Community School
Corporation and the City of
Brazil, Indiana. The OIC reviews
and approves the contingency
plan at least annually.

Meets Standard

The Safety and Emergency
Procedures policy includes a
statement prohibiting
unauthorized use.

Meets Standard

The Safety and Emergency
Procedures policy addresses all
items listed in the standard.

Meets Standard

At this IGSA facility, the
command post is located in the
Clay County Justice Center
training room, outside the secure
perimeter.

Meets Standard

The video camera was observed
in the control center. The video

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)
camera was tested for
operability.

10. Emergency plans include emergency medical treatment
for staff and detainees during and after an incident.
Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
emergency medical treatment
for staff and detainees was not
included in the emergency plan.
Emergency plans include the
required information.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because food
service had no written plans for
providing meals to detainees and
employees during an emergency.
The food service department had
not developed plans to access
community resources.
Community resources include B
and B Foods and Save-A-Lot.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
post-emergency procedures
were not included in the
emergency plan. Emergency
plans include the required
information.

11. The FSA shall make contingency plans for providing meals
to detainees and staff during an emergency, including
access to community resources, which the FSA shall
negotiate during the planning phase.

12. The plan shall include post-emergency procedures.

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)

13. Written procedures cover:


Work/Food Strike



Fire



Environmental Hazard



Detainee Transportation System Emergency



ICE-wide Lockdown



Staff Work Stoppage



Disturbances



Escapes



Bomb Threats



Adverse Weather



Internal Searches



Facility Evacuation



Detainee Transportation System Plan



Hostages (Internal)



Civil Disturbances

Emergency Plans include each
contingency required by this
component.

Meets Standard

PART 1 – 1. EMERGENCY PLANS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.)(5000 Character Max)
Emergency Plans ensure a safe environment for detainees and employees by having in place contingency plans to quickly and
effectively respond to emergency situations and to minimize their severity. The plans are considered confidential and include
a statement prohibiting unauthorized disclosure. Officers receive training on the facility's emergency procedures.
Contingency plans include language regarding confidentiality, accountability, review, and revision. The emergency plans
address the chain of command, staff recall during emergencies, utility shutoffs, and facility security. The OIC reviews and
approves contingency plans annually. Annual review and approval of the plans are recorded on the master copy of the
Emergency Plans, even if the review resulted in no change.
Plans do not include procedures for assisting detainees with special needs during emergency or evacuation. In an emergency,
the facility ensures detainees with disabilities and detainees who are limited in their English proficiency (LEP) will be provided
with effective communication by as many means as possible.
Evaluation of this standard was based on review of the Safety and Emergency Procedures policy, Emergency Plans manual,
emergency response drills, training files and Memoranda of Agreements; interviews with Officer Bryce Barnes, Sergeants Jase
Glassburn and Albert Waters; and observation of the control center, command center, video camera operability and
perimeter security.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

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G-324A PBNDS 2008 with 2011 SAAPI Detention Inspection Worksheet

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B)
This Detention Standard protects detainees, staff, volunteers, and contractors from injury and illness by maintaining high
facility standards of cleanliness and sanitation, safe work practices, and control of hazardous substances and equipment.
Components
1.

Rating

Environmental health and safety conditions shall be
maintained at a level that meets recognized standards of
safety and hygiene, including those from the:


American Correctional Association,



Occupational Safety and Health Administration,



Environmental Protection Agency,



Food and Drug Administration,



National Fire Protection Association's Life Safety
Code, and



National Center for Disease Control and Prevention.
Does Not Meet Standard

Remarks (1000 Char Max)
During the last inspection this
component was found Does Not
Meet Standard because
Environmental health and safety
conditions were not always
maintained at a level consistent
with the recognized safety and
hygiene standards of the
organizations listed in this
component. Specifically,
sanitation levels were not
consistent in some areas.
Additionally, observation of fire
extinguishers in several areas did
not support monthly inspection,
although a master monthly
reports indicates otherwise.
During this inspection,
observation revealed sanitation
levels are not always maintained
at a level consistant with the
recognized safety and hygiene
standards of the organizations
listed in this component. This is a
repeat deficiency.

A housekeeping plan will be developed for detainee living
areas noted in the standards. The facility appears clean
and well maintained.

Does Not Meet Standard

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During the last inspection this
component was found Does Not
Meet Standard because, the
captain, who is charged with
overseeing the safety program at
this facility, stated there is no
formalized housekeeping plan.
Sanitation levels were noted as
inconsistant throughout the
facility. Specifically, shower and
bathroom areas were not clean
and free of clutter. Similarly, a
property storage area was
unkempt to include boxes
blocking electrical panels. During
this inspection, a housekeeping
plan was available for review.
Housing unit shower and
bathroom areas were observed
as not clean and well maintained.
This is a repeat deficiency.

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because staff
stated "hazardous materials are
not maintained within the secure
perimeter"; however, hazardous
materials were observed in the
facility in various quantities and
locations, which does not
support a viable chemical
control program. During this
inspection, a chemical control
program was identified. The
facility properly stores hazardous
chemicals and had accurate
inventory logs.

The facility has a system for storing, issuing, and
maintaining inventories of hazardous materials

The Maintenance Supervisor shall compile:


An up to date master index of all hazardous
substances in the facility and their locations;



A master file of MSDSs; and



A comprehensive, up-to-date list of emergency
phone numbers (fire department, poison control
center, etc.).
Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because a review
of chemical storage areas
indicated several chemicals did
not have an SDS. Additionally,
chemicals were observed
throughout the facility in other
than recognized storage areas.
Emergency numbers were
included in the SDS book;
chemical locations were not.
During this inspection, a review
of chemical storage areas
indicated all chemicals have an
SDS. Additionally, emergency
numbers and locations were
included in the SDS book.

All personnel using flammable, toxic, and/or caustic
substances follow prescribed safety procedures.

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because
interviews and personal
observations indicate there is no
training provided to staff on
chemical safety and/or use.
During this inspection, training
documentation confirmed staff
are receiving training for
prescribed safety procedures.

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

The MSDS are readily accessible to staff and detainees in
the work areas.

Hazardous materials are always issued under proper
supervision.

Rating
Meets Standard

Meets Standard

Remarks (1000 Char Max)
SDS manuels were observed in
storage and work areas.
During the last inspection this
component was found Does Not
Meet Standard because
hazardous materials were
observed in various areas other
than designated storage areas,
suggesting a lack of adherance to
issue/return procedures.
Specifically, a partial five-gallon
bucket of cautic stripper was
stored in the control room
hallway and a partial gallon of
liquid labeled as poison was
observed on top of a file cabintet
in the ICE office.
During this inspection, hazardous
materials were issued under
proper supervision.

All toxic and caustic materials stored in their original
containers in a secure area.

Excess flammables, combustibles, and toxic liquids are
disposed of properly in accordance with MSDS.

Meets Standard

Chemicals were observed in
original containers.

Meets Standard

Excess flammable, combustible,
and toxic liquids are disposed of
in accordance with the SDS.

Meets Standard

The captain is charged with
administering the safety program
and he has received hazardous
chemical training and OSHA
training as a volunteer
firefighter. He has received
additional training in his current
position.

10. The facility program will be supervised by a person who
has been trained in accordance with OSHA standards.

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because although
the captain conducted weekly
fire and safety inspections for the
facility, there were no
discrepancies noted in any of the
inspections reviewed. This
condition is not supported by
personal observations of the
facility's cleanliness and
santation, nor the reviews of
operational practices during this
inspection. During this
inspection, documentation
confirms that qualified staff
conduct weekly fire and safety
inspections for the facility.

Meets Standard

The facility conducts monthly
inspections of the facilty and
completes a report indicating the
condition of fire equipment.

Meets Standard

Inspection reports are
maintained in the captains' office
including corrective actions
taken.

Meets Standard

The facilty has an fire prevention,
control, and evacuation plan that
has been approved by the local
fire authority on 05/19/2021.

11. PRIORITY: A qualified departmental staff member shall
conduct weekly fire and safety inspections.

12. Facility maintenance (safety) staff shall conduct monthly
inspections.

13. The facility maintains files of inspection reports, including
corrective actions taken.

14. PRIORITY: The facility has an approved fire prevention,
control, and evacuation plan.

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)

Meets Standard

The fire prevention, control and
evacuation plan includes all of
the bulleted requirements except
the required exit signs and
directional arrows. A waiver,
approved by Jay M. Brooks, ICE
Deputy Assistant Director,
Detention Management Division
on 12/12/2018 regarding
evacuation diagrams in areas
where detainees could use the
for escape purposes remains in
force. A "work around" solution
was developed which required
evacuation plans to be posted
and maintained in the facility
control room and the housing
unit control rooms.

Meets Standard

A review of fire drill
documentation confirmed drills
are conducted in all areas and all
shifts and include the drawing of
emergency keys.

Meets Standard

A review of documentation
confirms Ecology Pest Control, a
licensed pest control company
performs monthly spraying at the
facility.

Meets Standard

Water is supplied by a the City of
Brazil which conducts testing of
water and waste water to ensure
compliance with applicable
standards.

Meets Standard

A review of logs indicates the
generator is tested as required
by the manufacturers
recommendations. The
McCallister Energy company
performs the maintenance on
the generator.

Meets Standard

Health care is provided by
Quality Correctional Care, and
includes a policy on needle sticks.
The handling/disposal of sharps
is outlined in training as
indicated in training curriculum.

15. The plan requires:


Monthly fire inspections.



Fire protection equipment strategically located
throughout the facility.



Public posting of emergency plan with accessible
building/room floor plans.



Exit signs and directional arrows.



An area-specific exit diagram conspicuously posted
in the diagrammed area.

16. Fire drills are conducted and documented quarterly in all
facility locations including the administrative area.

17. PRIORITY: The facility administrator shall ensure licensed
pest-control professionals perform monthly inspections
to identify and eradicate rodents, insects and vermin,
including a preventative spraying program for indigenous
insects.
18. At least annually, a state laboratory shall test samples of
drinking and wastewater to ensure compliance with
applicable Standards.

19. Emergency power generators are tested as required by
emergency plans and manufacturer’s recommendations.

20. (Medical Operations) Written procedures, to include an
exposure-control plan in the event of a needle stick,
regulate the handling and disposal of used needles and
other sharp objects.

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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Operations)

Standard

Rating
cleaning

practices



Using specified equipment; cleansers; disinfectants
and detergents.



An established schedule of cleaning and follow-up
inspections.

Meets Standard

Standard cleaning practices are
used in the medical area. The
area is cleaned daily with
chemicals supplied by security
staff.

Meets Standard

Spill kits were observed in
serveral areas of the facility and
are available as needed.

Meets Standard

Medical waste is disposed of
through a contract with
Stericycle.

Meets Standard

A review of training materials
confirms training is provided to
staff to prevent contact with
blood and other body fluids.

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because
interviews with an RN indicated
inspections were performed daily
and were documented on a
check list. However, the
documentation reflected the
office is cleaned weekly with no
mention of other areas in health
services. There are two rooms
utilized by health services and
both appeared to be in need of
routine cleaning and organizing.
During this inspection, an
inspection of the health services
area revealed adequate
sanitation levels, supported by
documentation provided by the
HSA.

Meets Standard

The captain investigates and
conducts surveys of
environmental health conditions
if required and provides required
advisory, consultive, inspections
and training as necessary.

Meets Standard

The captain reviews policy
annually, or as needed, and
recommends changes as needed.

22. (Medical Operations) Spill kits are readily available.

23. (Medical Operations) A licensed medical waste
contractor disposes of infectious/bio-hazardous waste.
24. (Medical Operations) Staff are trained to prevent contact
with blood and other body fluids and written procedures
are followed.
25. (Medical Operations) The Health Services Administrator
conducts medical-facility inspections daily.

26. A qualified staff member shall: conduct special
investigations and comprehensive surveys of
environmental health conditions, and provide advisory,
consultative, inspection, and training services regarding
environmental health conditions.
27. The assigned staff member is responsible for developing
and implementing policies, procedures, and guidelines
for the environmental health program.

Remarks (1000 Char Max)

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PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The safety program is administered by Captain Brandon Crowley, with some components assigned to other qualified staff on
a collateral basis. The captain was provided OSHA training as a former volunteer firefighter, and has completed additional
OSHA training in his current position.
Environmental health and safety conditions are not always maintained at a level consistent with the recognized safety and
hygiene standards of the organizations listed in this component. Specifically, sanitation levels were not consistent in some
areas. Toilet and shower areas in the housing units were not clean and were cluttered with various items.
A inspection of the facility confirms that fire extinguishers are checked monthly in all areas of the facility.
The overall sanitation in the detainees housing units was found to be below average. The showers and bathroom areas were
not clean.
On 12/9/2021, at 10:24 a.m., the facility performed a fire drill in the J-unit housing unit. Staff responded to the area with fire
extinguishers and other emergency equipment. Emergency keys were drawn to be utilized on a secondary exit not normally
used. The detainees were evacuated from the housing unit into the recreation area and counted.
Testing and and maintenance of the facility sprinkler system was current for 2021.
The fire prevention, control and evacuation plan includes all of the requirements except the required exit signs and
directional arrows. A waiver, approved by Jay M. Brooks, ICE Deputy Assistant Director, Detention Management Division on
12/12/2018, regarding evacuation diagrams in areas where detainees could use the for escape purposes remains in force.
The "work around" solution was to ensure that evacuation plans were posted and maintained in both the facility control
room and housing unit control rooms.
Hazardous materials were observed to be in approved containers, with SDS's and accuate inventories being reflected.
Evaluation of this standard was based on inspection of the facility; review of policies, documentation and procedures; and
interviews with detainees, Captain Brandon Crowley, Cook Tammie Fagg, Officer Bryce Barnes, Officer Kristin Bonnell and
HSA Stan Roark.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32
I Completion Date: 12/9/2021
Reviewer Signature (for printed form submission):

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PART 1 – 3. TRANSPORTATION (BY LAND) (Key: C)
This Detention Standard prevents harm to the general public, detainees, and staff by ensuring that vehicles are properly
equipped, maintained, and operated and that detainees are transported in a secure, safe and humane manner, under the
supervision of trained and experienced staff.
Standard N/A

Click the above button if all ICE Transportation is handled only by the ICE Field Office or Sub-Office in control of the detainee
case. (All Line Items and standard will be rated “N/A”)
Components

Rating

Remarks (1000 Char Max)

Meets Standard

The Security and Control policies
and Transport Post Order
address the transportation of
detainees.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
documentation was not available
to verify that annual inspections
were conducted on all vehicles in
accordance with state statutes.
During this inspection, vehicle
inspection documents were
provided.

To be assigned to a bus transporting detainees, an officer
must have successfully completed the ICE/ERO busdriver-training program or a comparable approved
training program and all local state requirements for a
Commercial Driver’s License (CDL).

Meets Standard

Documentation confirmed all bus
drivers have completed required
training and have been issued
current commercial driver's
licenses.

Supervisors maintain records for each vehicle operator.
This includes certificate of completion from bus training
program, most current physical exam used to obtain the
CDL, and a copy of the CDL.

Meets Standard

The chief deputy maintains a file
for required documents.

Maximum driving time (time on the road), for CDL
operators, is governed by USDOT.

Meets Standard

The transporting officer inspects the vehicle before the
start of each detail.

The Facility Administrator shall develop and implement
written policy, procedures and guidelines for the
transportation of detainees.
Documentation indicating annual inspection of vehicles
and annual inspection in accordance with state statutes
is available for review.

Positive identification of all detainees being transported
is confirmed.

The facility ensures that the number of detainees
transported does not exceed the vehicle manufacturer’s
occupancy level.

Meets Standard

The Use and Security of Facility
Vehicles policy requires vehicles
be inspected before each detail.
Documentation confirmed
practice.

Meets Standard

Positive identification is
confirmed with a picture of the
detainee, face sheet, I-203 form
and photo ID wristband.

Meets Standard

The administrative sergeant
ensures the number of detainees
transported does not exceed
occupancy levels. Trip sheets
confirmed practice.

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Rating

Policies and procedures are in place addressing the use of
restraining equipment on transportation vehicles.

10. Meals are provided during long distance transfers. The
meals meet the minimum dietary standards, as identified
by dieticians utilized by ICE.

Meets Standard

The Use and Security of Facility
Vehicles policy includes
language regarding use of
restraining equipment on
transportation vehicles.

Meets Standard

Documentation confirmed sack
meals meet minimum dietary
standards.Observation confirmed
a sack meal was prepared for the
detainee transport.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
procedures and schedule for
sanitizing facility vehicles were
not available. During this
inspection the documentation of
procedures and schedule were
observed. Vehicles were
observed to be clean and
sanitized.

Meets Standard

Documentation and observation
confirmed personal property of a
detainee transferring to another
facility is inventoried, inspected
and accompanies the detainee.

11. The facility administrator shall establish the procedures
and schedule for sanitizing facility vehicles.

12. Personal property of a detainee transferring to another
facility:




Is inventoried.
Is inspected.
Accompanies the detainee.

Remarks (1000 Char Max)

PART 1 – 3. TRANSPORTATION (BY LAND) – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Detainees are transported safely and humanely under the supervision of trained staff with required qualifications. Policy
requires escorting officers to properly identify the detainee they are transporting. Currently, the facility is not housing any
detainees with disabilities. The transportation supervisor is responsible for accommodating transports that include a detainee
with a disability. Sack meals are provided for transfers that occur during meal time. The facility prohibits one-on-one opposite
gender transports.
As reported by the OIC, officers are required to secure a vehicle before leaving it unattended including removing keys from
the ignition immediately upon parking the vehicle. Officers avoid parking in areas that may attract undue attention or be
vulnerable to vandalism or sabotage. Transportation officers are instructed to contact local law enforcement for advice if
they cannot locate parking with adequate security. There have been no such events during the inspection period.

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PART 1 – 3. TRANSPORTATION (BY LAND) – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Policy requires an armed officer to be posted whenever detainees enter or exit a vehicle outside a secure area. A complete
set of keys for every lock located in or on the vehicle travels with the vehicle at all times in a secure place known to every
transporting officer. An armed officer may not enter the secure area of the vehicle. If he/she must enter that area, the officer
shall first leave the weapon(s) with another officer for safekeeping.
Evaluation of this standard was based on review of the Use of Security of Facility Vehicles policy, Inmate Transports policy,
trip sheets, Transport Post Order, CDL's and training documents; observation of a transportation vehicle which was observed
to be clean; and interviews with Chief Deputy Josh Clarke, Sergeant Jase Glassburn and Captain Brandon Crowley. One
detainee was transferred during the inspection. The process was observed. Standard guidelines were observed to be
followed.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3
I Completion Date: 12/9/2021
Reviewer Signature (for printed form submission):

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Section II: SECURITY
Admission and Release
Classification System
Contraband
Facility Security and Control
Funds and Personal Property
Hold Rooms in Detention Facilities
Key and Lock Control
Population Counts
Post Orders
Searches of Detainees
Sexual Abuse and Assault Prevention and Intervention
Special Management Units
Staff-Detainee Communication
Tool Control
Use of Force and Restraints

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Rating

Remarks (1000 Char Max)

Meets Standard

Per the ICE coordinator sergeant,
written policies and procedures
address the intake and reception
of newly arrived detainees.
Detainees are provided a paper
copy of the local detainee
handbook which provides
information regarding facility
policies, rules and procedures.
Detainees are also provided the
National Detainee Handbook.
The local detainee handbook is
available on kiosks in the housing
units and on electronic tablets
provided to the detainees.
Documentation confirmed that
an orientation to the facility,
which includes a local orientation
video, is provided in the booking
area. Documentation that
detainees received the
handbooks was reviewed in
detention files.

Meets Standard

Per the ICE coordinator sergeant,
newly arriving detainees are
searched using the Tech 84 Body
Scanner. Documentation
confirmed that personal property
and valuables are searched for
contraband, inventoried,
receipted, and stored.

Meets Standard

According to the DSCO,
component requirements are
followed. A-files are maintained
in the field office.

The facility has implemented written policies and
procedures for the intake and reception of newly arrived
detainees and provided them with information about
facility policies, rules and procedures.

At intake, detainees are searched, and their personal
property and valuables checked for contraband,
inventoried, receipted, and stored.

Each detainee’s identification documents are secured in
the detainee’s A-file.

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Rating

Remarks (1000 Char Max)

Meets Standard

Per the sergeant, if medical staff
is not available, detention
officers conduct an intake
screen. They will contact the RN
either on-site or call them at
home. The RN will contact the
physician to review the screen
over the phone and get orders.
Detainees are required to
shower prior to changing into
issued color coded shirt and
pants, and a wrist band noting
their classification level. Clean
clothing, bedding, towels, linens
and gender specific items are
issued during the intake process.
Documentation of specialized
training for detention officers in
medical screening was
confirmed.

Meets Standard

Policy addresses component
requirements.

Meets Standard

Detainees are issued clothing
and bedding as appropriate for
the facility's environment and
local climate conditions, per the
sergeant.

Meets Standard

Documentation from detention
files confirmed that detainees
are identified and classified by
ICE/ERO prior to their admission.
Documentation is provided to
identify each newly arriving
detainee by ICE/ERO. Detainee Afiles are not maintained at the
facility. Non-ICE/ERO personnel
do not have access to the
detainee's A-file.

Meets Standard

A review of detention files
confirmed that a signed I-203
form with the authorizing
signature accompanies each
detainee admitted to the facility.

A medical screening will be conducted to protect the
health of the detainee and others in the facility, and the
detainee shall be given an opportunity to shower and be
issued clean clothing, bedding, towels, and personal
hygiene items.

Staff shall not routinely require a detainee to remove
clothing or require a detainee to expose private parts of
his or her body to search for contraband.
Staff shall issue those clothing and bedding items that are
appropriate for the facility environment and local
weather conditions.

Staff shall use the documentation accompanying each
new arrival for identification and classification purposes.
If the classification staff is not ICE/ERO employees
ICE/ERO shall provide the information needed for
classification. Under no circumstances may non-ICE/ERO
personnel have access to the detainees A-File.

An Order to Detain or Release the detainee (Form I-203
or I-203a), bearing the appropriate ICE/ERO Authorizing
Official signature, must accompany each newly arriving
detainee.

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Rating

Remarks (1000 Char Max)

Meets Standard

An orientation program is
delivered to all new detainees
during booking. Orientation
materials are presented by
booking officers in a manner
and/or language the detainee
can understand. Documentation
was provided, signed by the
detainee, acknowledging receipt
of the orientation.

Meets Standard

Documentation confirmed that
the National Detainee Handbook
and the local handbook are
provided to detainees. The
handbooks inform detainees of
the programs, services and
activities available. Detainees
sign a receipt for both
handbooks; these forms are filed
in the detainee's detention file.

Meets Standard

According to the DSCO,
component requirement is
followed. Documentation from
the detention files confirmed
requirement.

Meets Standard

A review of five inactive
detention files confirmed
component requirements.

Meets Standard

A review of inactive detention
files of detainees no longer at the
facility confirmed the
requirements of component.

Meets Standard

A review of detention files
confirmed component
requirements. A detention file is
maintained for each ICE detainee
and contains accurate records
pertaining to admission,
orientation, and release.

Meets Standard

According to the DSCO, all
information relative to a
detainee's release, removal or
transfer is entered into the ICE
automated recordkeeping
system (EADM) within eight
hours of the action.

PRIORITY: Facilities shall have a method to provide
ICE/ERO detainees an orientation to the facility as soon
as practicable, in a language or manner that detainees
can understand.

10. The facility shall issue to each newly admitted detainee a
copy of the ICE National Detainee Handbook and local
supplement that fully describes all policies, procedures,
and rules in effect at the facility.

11. All releases are coordinated with ICE.

12. Staff complete paperwork/forms for release as required.

13. The facility returns each detainee’s property upon
release, and each detainee receives a receipt for personal
property secured by the facility.
14. PRIORITY: The facility has a system to maintain accurate
records and documentation for admission, orientation,
and release.

15. ICE staff enter all information pertaining to release,
removal, or transfer of all detainees into the Enforce
Alien Detention Module (EADM) within 8 hours of action.

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PART 2 – 4. ADMISSION AND RELEASE (Key: D)
This Detention Standard protects the community, detainees, staff, volunteers, and contractors by ensuring secure and orderly
operations when detainees are admitted to or released from a facility.
Components
16. All orientation material shall be provided in English,
Spanish, and other language(s) as determined by the
Field Office Director.

Rating

Remarks (1000 Char Max)

Meets Standard

All orientation materials are
delivered in a manner and/or
language a detainee can
understand. English and Spanish
versions of the handbook and
orientation video were reviewed.

PART 2 – 4. ADMISSION AND RELEASE – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. Evaluation of this standard included review of policy, the local
handbook, and fifteen detention files; observation of the booking area and property rooms by the on-site inspectors; and
interviews with DSCO Tashi Tillman and ICE Coordinator Sergeant Jase Glassburn.
The community, detainees, staff, volunteers, and contractors are protected by ensuring secure and orderly operations when
detainees are admitted, transferred, and released from the facility. Communication assistance is provided to LEP detainees
when explaining admission and release policies, rules, and procedures through the use of bilingual staff, translation services,
or other means or in the form of auxiliary aids for other detainees including, but not limited to, those listed in the standard.
Training documents confirmed that staff is provided with training on the intake process. Documentation confirmed that each
detainee is provided the opportunity to place a telephone call during the admission process. An observation of the change
out room confirmed that detainees are permitted to change clothing without being visually observed by staff. An officer is
present immediately outside the change room to maintain security and be responsive when necessary.
In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and
detainees with minor disabilities. This is achieved via bilingual staff, a translation service, or other means for LEP detainees; or
in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. The
facility does not house detainees with significant physical or mental disabilities. Detainees requiring special housing
accommodations or special care due to a disability are not assigned to this facility.
During the Office of Detention Oversight (ODO) inspection on 05/13/2021, it was found that some of the Form I-203's did not
have the appropriate ICE/ERO authorizing signature. Per the ICE coordinator sergeant this has been corrected and all files
reviewed did have the signature during this review.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 5. CLASSIFICATION SYSTEM (Key: E)
This Detention Standard protects the detainees, staff, contractors, volunteers, and the community from harm, and contributes
to orderly facility operations, by requiring a formal classification process for managing and separating detainees that is based
on verifiable and documented data.
Components
1.

PRIORITY: SPC and CDF facilities use the required
Objective Classification System. IGSAs use an objective
classification system or similar system for classifying
detainees.
Staff shall use facts and other objective, credible
evidence documented in detainee’s A-file, criminal
history checks, or work-folder during the classification
process.
The classification
reclassification.

process

includes

Rating

Remarks (1000 Char Max)

Meets Standard

Detention files confirmed that
detainees are identified and
classified by ICE prior to their
admission. At this IGSA facility,
the initial classification
completed by ICE staff is used.
The ICE coordinator sergeant will
conduct a reclassification after a
detainee is in custody for ninety
days or if he/she is placed in
SMU.

Meets Standard

ICE/ERO ensures that all
detainees are classified prior to
their arrival at the facility.
ICE/ERO supervisory reviews are
in place to endorse all completed
classification scoring, as
confirmed by the RCA
documents.

Meets Standard

Only ICE/ERO staff have access to
the A-files. Intake staff review
documents provided by ICE/ERO
to identify each newly arriving
detainee. All detainees are
classified by ICE prior to
admission.

Meets Standard

At this IGSA facility, ICE detainees
are assigned color-coded
uniforms identifying them as ICE
detainees and wrist bands
reflecting their classification
level, per the ICE coordinator
sergeant.

Meets Standard

Housing assignments are based
on classification levels. Level One
and Level Three detainees are
not commingled in housing or
during recreation or feeding, per
the ICE coordinator sergeant.

Meets Standard

Detention files and objective
classification instruments
reviewed confirmed that Level
one detainees did not have a
history of assaultive or
combative behavior.

reassessment/

The facility classification system includes: Classifying
detainees upon arrival.


Separating individuals who cannot be classified upon
arrival from the general population.



The first-line supervisor or designated classification
specialist reviews every classification decision.

The intake/processing officer reviews work-folders, Afiles, etc., to identify and classify each new arrival.

In SPCs and CDFs detainees are assigned color-coded
uniforms and IDs to reflect classification levels. In IGSA’s
a similar system is utilized for each level of classification.

PRIORITY: Housing assignments are based on
classification-level. Level 1 detainees may not be
commingled with Level 3 detainees in housing, recreation
and feeding.

PRIORITY: Level 1 detainees may not have felony
convictions that included an act of physical violence, and
may not be housed with any Level 2 detainee with a
history of assaultive or combative behavior.

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Rating

Detainee work assignments are based upon classification
designations.

The classification process includes reassessment/
reclassification.
The first reassessment is to be
completed 60 days to 90 days after the initial assessment.

(SPCs/CDFs) Subsequent classification reassessments are
completed at 90 day to 120 day intervals. Special
reassessments are completed within 24 hours.

10. The facility classification system shall include procedures
for detainees to appeal their classification levels.

11. The Detainee Handbook or equivalent for IGSAs explains
the classification levels, with the conditions and
restrictions applicable to each.

Remarks (1000 Char Max)

N/A

ICE detainees do not participate
in the voluntary work program.

Meets Standard

Per the ICE coordinator sergeant,
the first reassessment is
scheduled ninety days after the
initial assessment.

Meets Standard

Subsequent reassessments occur
at ninety to 120-day intervals.
Special assessments are
completed within 24 hours.

Meets Standard

Classification appeals are
permitted. Appeal procedures
are explained in the local
handbook.

Meets Standard

The local handbook explains
classification levels including
conditions and restrictions
applicable to each.

PART 2 – 5. CLASSIFICATION SYSTEM – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard included review of policy, detention
files, classification documents, housing unit rosters, and the local handbook; interviews with ICE Coordinator Sergeant Jase
Glassburn and DSCO Tashi Tillman.
Community, staff, contractors, volunteers, and detainees are protected from harm by a documented and formal classification
process that manages and separates detainees into appropriate custody levels. Detainees are classified by ICE officers prior to
their arrival at this facility. Custody classification determinations are based on verifiable and documented data.
Medium-low custody detainees have not been convicted of assault on a correctional officer while in custody nor have a
previous institutional record suggesting a pattern of assaults while in custody. High custody, level three detainees are
considered a high-risk category and are housed in maximum security cell housing. They are always monitored and escorted
when moving outside of the housing unit. High custody detainees may be housed with medium-high custody detainees.
In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and
detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the
form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. Decisions
regarding detainees with disabilities, LEP detainee, and/or detainees included under any SAAPI/DHS PREA protection or
category will be made only after consideration of the disability, language difficulty, or SAAPI/PREA condition.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

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PART 2 – 5. CLASSIFICATION SYSTEM – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Reviewer Signature (for printed form submission):

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PART 2 – 6. CONTRABAND (Key: F)
This Detention Standard protects detainees and staff and enhances facility security and good order by identifying, detecting,
controlling, and properly disposing of contraband.
Components
1.

Rating

PRIORITY: The facility follows a written procedure for
disposition and handling contraband to include proper
destruction of contraband and return of property not
needed as evidence.

Meets Standard

According to the Control of
Contraband/Searches policy,
contraband is retained as
evidence for potential
disciplinary action or criminal
prosecution. Contraband
retained as evidence for criminal
prosecution is turned over to the
appropriate law enforcement
authority. There has been no
such contraband discovered
during the inspection period.

Meets Standard

At this IGSA facility, the OIC or
designee, consults with the oncall chaplain before confiscating
religious items.

Meets Standard

The sheriff's office has a canine
unit which is used for contraband
detection. The canine unit is not
used in the presence of ICE
detainees. The canine unit has
not been deployed during the
inspection period.

Meets Standard

Documentation confirmed
detainees are provided a
handbook during admission. The
handbook includes contraband
rules and procedures.

Contraband is retained as evidence for potential
disciplinary action or criminal prosecution.

(SPCs/CDFs) Before confiscating religious items, the
Facility Administrator or designated investigator contacts
a religious authority.

Remarks (1000 Char Max)
The Control of
Contraband/Searches policy
includes the process for
disposition and handling of
contraband to include the
destruction of contraband and
the return of property not
needed as evidence.

Facilities with canine units only use them for contraband
detection and not in the presence of ICE detainees.

Detainees receive notification of contraband rules and
procedures in the Detainee Handbook.

PART 2 – 6. CONTRABAND – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This facility is preserving, inventorying, controlling, and disposing of seized contraband according to standard guidelines and
policy.
Policy does not include contraband language regarding controlled substances not dispensed or approved by the medical
department. According to the captain, medication dispensed or approved by the medical department is considered hard
contraband if found in the possession of a detainee for whom it was not prescribed, or if not used as prescribed. Hard
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PART 2 – 6. CONTRABAND – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

contraband, which is criminal in nature, is collected, processed and disposed of by the OIC. Hard contraband that is illegal is
turned over to the sheriff's department for storage, prosecution and disposal. There has been no discovery of hard
contraband during the inspection period.
Property that is not illegal under criminal statutes, and does not pose a security threat is inventoried, receipted and either
mailed to a third party or stored with the detainee's other property. Contraband that is government property is retained as
evidence for possible disciplinary action or criminal prosecution. A copy of the property disposal record is placed in the
detainee's detention file. There has been no such discovery during the inspection period.
Evaluation of this standard was based on review of the Control of Contraband/Searches policy, detention files, activity logs
and handbook; observation of property storage room; and interviews with Sergeant Jase Glassburn and Captain Brandon
Crowley.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 7. FACILITY SECURITY AND CONTROL (Key: G)
This Detention Standard protects the community, staff, contractors, volunteers, and detainees from harm by ensuring that
facility security is maintained and that events that pose a risk of harm are prevented.
Components
1.

Rating

At least one male and one female staff are on duty where
both males and females are housed.

Comprehensive annual staffing analysis determines
staffing needs and plans and is reviewed and updated
annually.

Essential posts and positions are filled with qualified
personnel.

(SPCs/CDFs) Detainees do not have access to the Control
Center.

Facility security and safety will be monitored and
coordinated by a secure, well-equipped, and
continuously staffed control center.

Remarks (1000 Char Max)

Meets Standard

The master roster confirmed at
least one male and one female
are on duty at all times. The
facility houses males and
females.During the inspection,
no female ICE detainees were
housed.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because a
staffing analysis was not
available. A staffing analysis was
provided during this inspection.

Meets Standard

Training documentation
confirmed that essential posts
are filled with qualified
personnel.

Meets Standard

At this IGSA facility, post orders
confirmed detainees do not have
access to the control center.
Observation confirmed practice.

Meets Standard

The Correctional Officer
Assignment policy specifies "the
control center is to be
continuously staffed, secure and
well equipped". Observation
confirmed documentation.

N/A

At this IGSA facility, there are no
procedures in place requiring
component actions.

(SPCs/CDFs) The facility administrator shall establish
procedures to implement the following Control Center
requirements:
Communications center;
Maintenance of a list of the current home and cellphone
number of every officer, administrative/support services
staff, Situation Response Teams (SRTs), Hostage
Negotiation Teams (HNTs), and law enforcement
agencies.
Watch calls (officer safety checks) to the Control Center
by all staff ordinarily shall occur every half-hour between
6:00 P.M. and 6:00 A.M. Individual facility policy may
designate another post to conduct watch calls. Any
exception for staff to not make watch calls as described
requires approval of the facility administrator.

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The front-entrance officer checks the identification of
everyone entering or exiting the facility.

All visits are officially recorded in a visitor logbook or
electronically recorded.

Rating

Remarks (1000 Char Max)

Meets Standard

Documentation and observation
confirmed the front entrance
officer checks the identification
of everyone entering or exiting
the facility.

Meets Standard

Documentation and observation
confirmed all visits are officially
recorded.

Meets Standard

Documentation and observation
confirmed the facility has a
secure visitor pass system.
Visitors are required to wear a
badge indicating escort status.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
documentation was not available
to confirm that routine
procedures, emergency
situations and unusual incidents
are continually recorded in
permanent logs and/or shift
reports. During this inspection,
documentation and observation
confirmed required information
is recorded in JailTracker and/or
shift reports.

N/A

At this IGSA facility, housing unit
post orders do not follow the
event schedule format.

Meets Standard

Roving posts are located near
detainee living areas permitting
officers to see or hear and
respond promptly to emergency
situations. The control center
(tower) officer is located above
the housing unit with good line
of sight.

The facility has a secure visitor pass system.

10. Information about routine procedures, emergency
situations, and unusual incidents will be continually
recorded in permanent post logs and shift reports.

11. (SPCs/CDFs) Housing unit Post Orders in SPCs and CDFs
shall follow the event schedule format, for example,
"0515 Lights on" and shall direct the assigned officer to
maintain a unit log of pertinent information regarding
detainee activity. The shift supervisor shall visit each
housing area and initial the log on each shift.
12. Security officer posts shall be located in or immediately
adjacent to detainee living areas to permit officers to see
or hear and respond promptly to emergency situations.

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14. PRIORITY: No detainee may ever be given authority over,
or be permitted to exert control over, any other detainee.
15. The facility administrator, designated assistant facility
administrator, security supervisors, and others
designated by the facility administrator shall be required
to visit all housing units at least weekly to observe living
conditions and interact informally with detainees.
16. The facility has a comprehensive security inspection
policy.

Rating

Remarks (1000 Char Max)

Meets Standard

The Inmate Movement policy
and observation confirmed that
detainee movement from one
area to another area is controlled
by staff.

Meets Standard

The Supervision of Inmates policy
includes component language.

Meets Standard

Electronic logs verified
supervisory staff visit each
housing unit at least weekly to
observe living conditions and
interact with detainees.

Meets Standard

The Permanent Log policy
requires security inspections be
conducted on each shift.

Meets Standard

Inspection reports were
observed to be filed in the
administrative lieutenant's office.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
documentation was not available
to confirm perimeter checks.
During this inspection,
documentation and observation
confirmed perimeter checks are
conducted on each shift and
recorded electronically. The
facility does not have a fence or
an alarm system.

17. Documentation of security inspections is kept on file.

18. Daily procedures include:


Perimeter alarm system tests.



Physical checks of the perimeter fence.



Documenting the results.

PART 2 – 7. FACILITY SECURITY AND CONTROL – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Policies are in place to protect detainees, employees, and the community from harm by initiating operating procedures and
hiring a trained work force necessary to prevent events which create risk of harm and to ensure security is always
maintained.
While in the facility, employees must always have the identification card in their possession. For tracking the arrivals and
departures of contract employees, the contract employee identification card must be presented upon entering and upon
exiting the facility.
The central control center coordinates all vehicle traffic entering the sally port. Law enforcement vehicles are permitted entry
inside the sally port. No other vehicles enter the secure perimeter. No documentation was available to confirm that officers
check the inventory of tools entering and leaving the booking station (which is currently housing detainees in special
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PART 2 – 7. FACILITY SECURITY AND CONTROL – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

management status). The facility does not have a special management unit (SMU) at this time. No detainees were housed in
SMU during the inspection period.
To provide detainees with meaningful access to its programs and activities, the facility ensures that detainees with disabilities
and detainees who are limited in their English proficiency (LEP) are provided with effective communication by as many means
possible through a language line translation service.
Policy requires that unannounced security inspections are conducted by housing officers on both shifts to control the
introduction of contraband, identify and deter sexual abuse of detainees; ensure facility safety, security and good order;
prevent escapes; maintain sanitary standards; and eliminate fire and safety hazards.
Evaluation of this standard was based on review of the Control of Contraband/Searches policy, Security and Control policy,
inspection reports and training records; observation of housekeeping practices; and interviews with Sergeant Jase Glassburn
and Captain Brandon Crowley. The housing units were observed to be unclean and cluttered. Walls were observed with
graffiti; dirt and grime was observed in the dayroom areas; and bunks were observed with trash and commissary debris.
Sheets were hung in the toilet/shower area. Shower curtains were observed to be ripped and stained.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 - 8. FUNDS AND PERSONAL PROPERTY (Key: H)
This Detention Standard ensures that detainees’ personal property is safeguarded and controlled, specifically including funds,
valuables, baggage and other personnel property, and that contraband does not enter a detention facility.
Standard N/A

Click the button above (IGSA ONLY) if all ICE detainee Funds, Valuables and Property are handled only by the ICE Field
Office or Sub-Office in control of the detainee case. (All Line Items and standard will be rated “N/A”)
Components
1.

Rating

Remarks (1000 Char Max)

All detention facilities are required to have written
policies and procedures to:


Account for and safeguard detainee property from
time of admission until date of release;



Inventory and receipt detainee funds and valuables;



Inventory and receipt detainee baggage and
personal property (other than funds and valuables);

Meets Standard

Written policies address the
elements of this component.

Meets Standard

A secure storage room is
maintained for holding large
valuables. This area is only
accessible to designated
supervisors.

The detainee handbook or equivalent shall notify the
detainees of facility policies and procedures concerning
personal property.

Meets Standard

The policies and procedures
regarding personal property are
addressed in the local handbook.

At admission, staff search and inventory detainee
property only in the presence of the detainee, unless
instructed otherwise by the facility administrator.

Meets Standard

Generally, detainee's property is
searched and inventoried only in
their presence.

The facility administrator shall establish whether and,
how much cash each detainee may have in personal
possession while in detention.

Meets Standard

Detainees are not allowed to
possess cash.

Meets Standard

Identity documents are removed
from detainees by ICE prior to
intake into the facility. These
documents are maintained in the
detainees A-file. Certified copies
may be obtained by the detainee
upon request.



Inventory and audit detainee funds, valuables and
personal property;



Return funds, valuables and personal property to
detainees being transferred or release; and



Provide a way for a detainee to report missing or
damaged property.

All facilities, at a minimum shall provide:


A secured locker for holding large valuables, that can
be accessed only by designated supervisor(s); and



A baggage and property storage area that is secured
when not attended by assigned admissions
processing staff.

Identity documents, such as passports, birth certificates,
are held in each detainee's A-file but, upon request, staff
shall provide the detainee a copy of a document, certified
by an ICE/ERO official to be a true and correct copy.

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(SPCs /CDFs) Every housing area shall have lockers or
other securable space for storing detainees’ authorized
personal property. The amount of storage space shall
correspond to the number of detainees assigned to that
housing area.
Property discrepancies are immediately reported to the
Chief of Security or equivalent.

Rating

Remarks (1000 Char Max)

N/A

At this IGSA facility, detainees
are not provided a securable
locker or other form of securable
space for storing their personal
property.

Meets Standard

Property discrepancies are
immediately reported to the
captain.

Meets Standard

A review of policy and personal
observations indicated intake
and release procedures address
the elements of this component.

N/A

At this IGSA facility, an
automated, facility specific form,
is used to inventory any funds
removed from a detainee. Noncash negotiable instruments are
only excepted for deposit into
the detainees commissary fund
when they are issued from
another facility or in the form of
certified funds or money orders.

PRIORITY: Procedure ensures that:


Detainee funds and small and large valuables are
placed in a secure location;



Medical staff determine the disposition of all
medicine accompanying an arriving detainee



Detainees are able to keep a reasonable amount of
personal property in their possession, provided it
poses no threat to detainee safety or facility security;
and



Facilities return funds and valuables to detainees
being transferred or released.

10. (SPCs/CDFs) For recordkeeping and accounting purposes,
use of the G-589 Property Receipt form is mandatory to
inventory any funds removed from a detainee’s
possession, and a separate form G-589 is required for
each kind of currency and negotiable instrument.

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Rating

Remarks (1000 Char Max)

N/A

At this IGSA facility, an
automated, facility specific, form
is used to inventory any funds
removed from a detainee. Cash
and negotiable instruments are
inventoried, receipted (the
detainee is provided a copy) and
placed in a safe in the ICE office
until they can be delivered to
finance personnel for deposit.
Large valuables are maintained in
a locked cabinet in the ICE office.

11. (SPCs/CDFs) The supervisory security officer or equivalent
shall remove the contents of the drop safe during his or
her shift and initial the G-589 accountability log. The
supervisor shall:


Verify the correctness of all G-589s;



Record the amount of cash and describe each item in
the supervisors’ property log; and



Verify the proper disposition of funds and valuables
by checking the sealed envelopes in the cash box, the
property envelopes in the safe, and the safekeeping
of all large valuables in the designated secured
locked area.

12. The Facility Administrator has established quarterly
audits of baggage and non-valuable property.

Meets Standard

Monthly audits of baggage and
non-valuable property are
conducted and documented.

13. All facilities shall report and turn over to ICE/ERO all
detainee abandoned property.

Meets Standard

Abandoned or forgotten
property of detainees is turned
over to ICE personnel.

Meets Standard

Policy and procedures address
the process for reporting and
investigation incidents of
detainee property loss or
damage. Reimbursement to the
detainee for property losses
caused by the facility is
addressed in this policy. ICE is
notified by the facility of claims
of this nature.

14. PRIORITY: Facilities have and follow procedures for
reporting and investigating incidents of detainee
property loss or damage, and for reimbursing detainees
for all validated property losses caused by facility
negligence. The senior contract officer immediately
notifies the designated ICE/ERO officer of all claims and
outcomes.

PART 2 - 8. FUNDS AND PERSONAL PROPERTY – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Facility practices are sufficient to ensure detainee property is safeguarded and controlled under conditions that enhance the
security of the property. Each detainee and their property are searched for contraband. Property and valuables are
inventoried and stored in a secure area. Each detainee is treated with respect and dignity.
Detainees are permitted to keep in their possession reasonable quantities of personal property if the particular items do not
pose a threat to the security or good order of the facility. The local handbook notifies the detainees of the policies and
procedures concerning items they may retain in their possession, rules for storing or mailing unauthorized property, the
procedures for claiming property, and the procedures for filing a property claim.

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PART 2 - 8. FUNDS AND PERSONAL PROPERTY – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

A detainees' abandoned or forgotten property is forwarded to ICE for final disposition or disposed of at the direction of ICE.
Detainees may purchase store items from the commissary.
Evaluation of this standard was based on review of policy, procedures and documentation; and interviews with detainees,
Captain Brandon Crowley, Officer Bryce Barnes and Sergeant Jase Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (Key: I)
This Detention Standard ensures the safety, security, and comfort of detainees temporarily held in Hold Rooms pending further
processing. The maximum aggregate time an individual may be confined in a facility’s Hold Room is 12 hours.
Components
1.

(SPCs/CDFs) Each Hold Room shall contain sufficient
seating for the maximum room-capacity but shall contain
no moveable furniture.
(SPCs/CDFs) Each Hold Room shall be equipped with
stainless steel, combination lavatory/toilet fixtures with
modesty panels, in compliance with the Americans with
Disabilities Act of 1990.

PRIORITY: Detainees are not held in hold rooms for more
than 12 hours.

Rating

Remarks (1000 Char Max)

Meets Standard

At this IGSA facility, hold rooms
contain sufficient seating for the
maximum room capacity and
contain no moveable furniture.

N/A

At this IGSA facility, hold rooms
used to process ICE detainees are
equipped with a stainless-steel
combination lavatory/toilet.
However, hold rooms do not
have modesty panels.

Meets Standard

Logs confirmed that detainees
are not held in the hold rooms
for more than twelve hours.

Meets Standard

According to the shift supervisor,
males and females are
segregated from one another. No
detainees were observed in a
hold room during the inspection.

Meets Standard

According to the shift supervisor,
juvenile detainees are not
housed at this facility.

Meets Standard

No detainees were observed in a
hold room during the inspection.
According to the shift supervisor,
detainees who are exempt from
placement in a hold room, due to
illness, special medical, physical
or psychological needs or other
documented reasons, are placed
in a medical observation cell
under direct supervision
guidelines.

Meets Standard

No detainees were observed in a
hold room during the inspection.
According to the shift supervisor,
detainees with known or readily
apparent disabilities are placed
in a medical observation cell and
are where they are under direct
supervision.

Male and females detainees are segregated from each
other at all times.

Unaccompanied minors (under 18) and parent(s) or legal
guardians accompanied by minor children shall not be
placed in Hold Rooms, unless they have shown or
threatened violent behavior, have a history of criminal
activity, or have given staff reasonable grounds to expect
an escape attempt.
Persons exempt from placement in a Hold Room due to
obvious illness, special medical, physical and or
psychological needs, or other documented reasons shall
be seated in an appropriate area designated by the
facility administrator outside the Hold Room, or in
separate rooms, under direct supervision and control,
barring an emergency.

To the extent practicable in a hold room situation,
detainees with known or readily apparent disabilities,
including temporary disabilities, shall be housed in
manner that accommodates their mental and/or physical
condition(s) and provides for their safety, comfort and
security.

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Rating

Remarks (1000 Char Max)

Meets Standard

Detainees are provided personal
hygiene items. The hygiene items
were observed and found to
include required items.
Detainees use a fountain for
water. Detainees may purchase a
cup in commissary. There were
no admissions during the
inspection.

N/A

All hold rooms are equipped with
toilet facilities.

Meets Standard

According to the shift supervisor,
all detainees are given a pat
search for weapons and
contraband prior to being placed
in a hold room. Additionally,
detainees are observed with a
full body metal detector.

Meets Standard

According to the shift supervisor,
detainees are initially observed
by transportation officers and
then by the facility custody
officers to screen for obvious
mental or physical problems.

Meets Standard

Documentation confirmed that
booking officers maintain a log
for each detainee placed in a
hold cell. Officers use an
electronic log to document hold
room placement.

Meets Standard

According to the shift supervisor,
detainees held in a hold room for
more than six hours are provided
a meal. There were no
admissions during the inspection.
No pregnant detainees were
admitted during the inspection
period.

Meets Standard

The hold rooms were observed
to be maintained at acceptable
and comfortable levels.
Detainees are provided blankets
upon request.There were no
admissions during the inspection.

Detainees are provided with basic personal hygiene items
such as water, soap, toilet paper, cups for water,
feminine hygiene items, diapers and wipes.

If the hold room is not equipped with toilet facilities, an
officer is posted within visual or audible range to allow
detainees access to such on a regular basis.

10. All detainees are given a pat down search for weapons or
contraband before being placed in the hold room.

11. Before placing a detainee in a room, an officer shall
observe each individual to screen for obvious mental or
physical problems.

12. Each detention facility maintains a detention log for each
detainee placed in a hold cell.

13. Officers provide a meal to any detainee detained in a hold
room for more than six hours. Pregnant women have
access to snacks, milk or juice.

14. Staff shall ensure that sanitation, temperatures and
humidity in Hold Rooms are maintained at acceptable
and comfortable levels. Pregnant women and others with
evident medical needs will have temporary access to
temperature appropriate clothing and blankets.

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Rating

Remarks (1000 Char Max)

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because staff
are required to make rounds to
the hold rooms at least every
fifteen minutes. However,
documentation indicated gaps in
the fifteen-minute observation
period. During this inspection,
documentation confirmed
fifteen-minute checks were
conducted in accordance with
standard guidelines. Constant
surveillance is provided for any
detainee exhibiting signs of
hostility, depression or other
unusual behavior. Observation
confirmed that officers are
stationed so they can hear
detainees held in hold rooms.
Each hold room is equipped with
a camera allowing staff to view
activity in the room.

15. PRIORITY: Officers closely supervise hold rooms through
direct supervision, to ensure:




Continuous auditory monitoring,
Visual monitoring at irregular intervals at least every
15 minutes,
Constant surveillance of any detainee exhibiting
signs of hostility, depression, or similar behaviors.

16. The maximum occupancy for the hold room will be
posted.
17. When the last detainee has been removed, officers shall
ensure the Hold Room is thoroughly cleaned and
inspected.
18. (SPCs/CDFs) Evacuation procedures shall include posting
the evacuation map and advance designation of the
officer responsible for removing detainees from the Hold
Room(s) in case of fire and/or building evacuation.

Meets Standard

Documentation confirmed that
staff inspect the hold rooms and
have the rooms cleaned when
detainees have been removed.

N/A

This IGSA facility received a
waiver suspending the
requirement to post evacuation
procedures. Waiver was issued
08/21/2018 by Jay M. Brooks.

PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Hold rooms consist of multiple occupancy rooms equipped with metal bunks. The hold rooms are located within the secure
perimeter of the facility and possess adequate footage for the number of detainees held.
A review of randomly selected logs verified that no detainee was kept in a hold room for over twelve hours during the
inspection period. As reported by the shift supervisor detainees may be issued a mattress and a blanket, upon request, for
comfort. Detainees identified as high risk are placed on one-to-one supervision until they are seen be mental health staff.
The shift supervisor stated that whenever there is a need to enter a hold room, two officers are required to enter the room.

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PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Evaluation of this standard was based on review of the Reception and Orientation policy, Holding Room Fifteen Minute
Checks logs and detention files; interviews with Sergeant Jase Glassburn and Lieutenant Richard Eder; and observation of the
hold rooms, hygiene items and required postings. There were no admissions during the inspection.

Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 10. KEY AND LOCK CONTROL (Key: J)
This Detention Standard maintains facility safety and security by requiring that keys and locks be properly controlled and
maintained.
Components
1.

All staff shall be trained and held responsible for adhering
to proper procedures for the care and handling of keys,
including electronic key pads where they are used. Initial
training shall be accomplished before staff is issued keys,
and key control shall be among the topics covered in
subsequent annual training.

Rating

Remarks (1000 Char Max)

Meets Standard

Training records confirmed that
all staff are trained in proper
procedures for care of handling
keys. The Clay County Justice
Center Training Plan records
confirmed that new employees
completed the initial key control
training. The Law Enforcement
Training includes annual key
control training.

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because the
position of security officer had
not been established. During the
inspection, the administrative
lieutenant was assigned the key
control responsibilities. During
this inspection, a written position
description was not available.
This is a repeat deficiency.

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
recordkeeping of keys, locks and
related security equipment was
not available. During this
inspection, component
requirements were not available.
This is a repeat deficiency.

Meets Standard

The training officer trains and
directs employees on key
control, including the electronic
key pads.

Each facility administrator shall establish the position of
Security Officer, or at a minimum, assign a staff member
the collateral security officer. The Security Officer shall
have a written position description that includes duties,
responsibilities, and chain of command.

The Security Officer is responsible for all administrative
duties, including recordkeeping, concerning keys, locks,
and related security equipment.

The Security Officer shall train and direct employees in
key control, including electronic key pads where they are
used.

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PART 2 – 10. KEY AND LOCK CONTROL (Key: J)
This Detention Standard maintains facility safety and security by requiring that keys and locks be properly controlled and
maintained.
Components
5.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
documentation was not available
to include all keys, locks and
locking devices. The facility does
not have a lock shop. Security
keys are maintained in a locked
cabinet in the booking
area.During this inspection,
component requirements were
not available. This is a repeat
deficiency.

Does Not Meet Standard

The Controlled Access and Use of
Keys policy addresses
compromised keys. During the
previous inspection, this
component was rated Does Not
Meet Standard because no safe
combination integrity was
available. A safe is located in the
medical room. The staff was not
sure who had the combination to
the safe. There was no system in
place to govern the safe
combination integrity.This is a
repeat deficiency.

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
grand master-keys are
authorized in the facility.
Detainees do not have room
keys. Electronic deadlocks are
used in detainee accessible
areas. Grand-master keying is till
permitted.This is a repeat
deficiency.

The facility maintains inventories of all keys, locks and
locking devices. Lock shop inventories include a secure
master-key cabinet containing at least one pattern key.

Facility policies and procedures address the issue of
compromised keys, locks, and to ensure safe combination
integrity.

Either deadbolts or deadlocks shall be used in detaineeaccessible areas. Grand master-keying systems are not
authorized. A master-keying system may be used only in
housing units where detainees have individual room
keys.

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PART 2 – 10. KEY AND LOCK CONTROL (Key: J)
This Detention Standard maintains facility safety and security by requiring that keys and locks be properly controlled and
maintained.
Components
8.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
documentation of a preventive
maintenance program was not
available. During this inspection,
component requirement
documentation was not
available. This is a repeat
deficiency.

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
observation confirmed all key
rings were not identifiable. The
number of keys was not
identified on the ring.
Keys were easily removed on
four sets of keys. During this
inspection, documentation was
not available to identify every
key ring and every key on each
ring. This is a repeat deficiency.

Meets Standard

Emergency keys are located in
the intake unit. Emergency keys
were used during the simulation
of a fire drill.

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
Controlled Access and Use of
Keys policy includes key
accountability requirements.
However, there was no practice
or documentation to confirm
accountability. Keys were issued
and not recorded as to time, date
and employee issued the key
ring. During this inspection,
component requirement
documentation was not
available. This is a repeat
deficiency.

The Security Officer shall implement a preventive
maintenance program. The Security Officer shall maintain
all preventive maintenance records.

The Security Officer shall implement procedures for
identifying every key ring and every key on each key ring,
and for preventing keys from being removed from key
rings, once issued.

10. Emergency keys shall be on hand for every area to or
from which entry or exit might be necessary in an
emergency.
11. The facility has a written policy and implementation
procedures to ensure key accountability. Facilities shall
use standard system for the issuance and accountability
of key rings.

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PART 2 – 10. KEY AND LOCK CONTROL (Key: J)
This Detention Standard maintains facility safety and security by requiring that keys and locks be properly controlled and
maintained.
Components

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
Controlled Access and Use of
Keys policy includes restricted
key language. However, practice
was not in place to ensure
restricted key accountability.
During this inspection,
component requirements were
not available. This is a repeat
deficiency.

Does Not Meet Standard

There is no pharmacy at this
facility. The keys to the
medication cart are restricted.
During the previous inspection,
this component was rated Does
Not Meet Standard because
when observing the key issuance
procedure, it was discovered that
the nurse did not log the
pharmacy key in and out.
Practice was not in place to
ensure restricted key
accountability. During this
inspection, documentation was
not available to confirm
component requirement. This is
a repeat deficiency.

N/A

ICE officials do not have an
office. The facility does not have
a courtroom. The ICE DSCO is
issued an electronic key fob. He
has access to the administrative
areas. He keeps the key fob 24
hours a day.

Meets Standard

Weapons are stored in individual
lockers outside the secure
perimeter. Site-specific
procedures for controlling gunlocker access has been
implemented through sheriff's
office procedures.

12. The facility administrator shall establish rules and
procedures for authorizing use of restricted keys.

13. Pharmacy keys shall be strictly controlled.

14. Keys to ICE and EOIR (Executive Office for Immigration
Review) office and courtroom areas shall similarly be
restricted and controlled. If a key is authorized for
emergency withdrawal, a copy of the Restricted Key form
is to be provided to ICE.

15. Officers shall store all their weapons in individual lockers
before entering the facility. The facility administrator
shall develop and implement site-specific procedures for
controlling gun-locker access.

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PART 2 – 10. KEY AND LOCK CONTROL – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
A review of policy, procedure, logs, staff interviews and observation confirmed that keys and locks are not properly
controlled and maintained.
The shift supervisor is responsible for the issuance of all security keys located in the master control key box. According to the
Controlled Access and Use of Keys policy, the shift supervisor is responsible for the issuance of all security keys located in the
key box. Documentation was not available to confirm key accountability. Three rings were observed in service and not logged
in and/or out.
The standard required language (in the following paragraph) is not practiced, including, but not limited to:
Evacuation keys are only issued when a complete or partial evacuation of the facility is required or if it should become
necessary for assisting officers to come into the facility unaided. Operational keys are issued in the event of total or partial
power outage in the facility. No two sets of operational keys shall be in any confinement area at the same time. All security
keys issued shall be returned to master control before person possessing said key(s) leaves the facility. No security keys shall
be passed directly from person to person without first going to the supervisor to have the key reissued.
Missing, broken, and/or malfunctioning keys shall be reported immediately to the shift supervisor. All broken or
malfunctioning keys or parts thereof shall be returned to the shift supervisor who shall notify maintenance. The shift
supervisor shall conduct an immediate search and/or investigation for missing key(s). If the key(s) cannot be found the shift
supervisor shall notify the jail commander.
Evaluation of this standard was based on review of the Controlled Access and Use of Keys policy, key logs and training
records; interviews with Sergeant Jase Glassburn and Captain Brandon Crowley; and observation of the key box, key rings,
medication cart, combination safe and issuing of keys. Observation of the key box revealed that three keys were issued and
not logged. No key chit was placed on the key posts. No record of who was issued the key rings was documented. A
beginning of shift accountability was not available.
Overall Rating: Does Not Meet Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 11. POPULATION COUNTS (Key: K)
This Detention Standard protects the community from harm and enhances facility security, safety, and good order by requiring
that each facility have an ongoing, effective system of population counts and detainee accountability.
Components
1.

Rating

Staff conduct a formal count at least once each 8 hours
(no less than three counts per day). At least one of these
counts shall be a face to photo count.
Each officer shall make irregular but frequent checks to
verify the presence of all detainees in his or her charge.

The facility Control Center shall maintain a master count.

The control officer (or other designated position)
maintains an “out-count” record of all detainees
temporarily out of the facility.

An emergency count shall be conducted when there is
reason to believe a detainee is missing, or after a major
disturbance has occurred.

Remarks (1000 Char Max)

Does Not Meet Standard

Two formal counts are
conducted every 24 hours. A
third count will be added,
according to the captain.

Meets Standard

Staff are required to make
irregular checks to verify the
presence of detainees.
Observation confirmed practice.

Meets Standard

Observation confirmed that
officers in the control center
maintain the master count.

Meets Standard

The control center and booking
officers maintain the official
"out-count" record of all
detainees temporarily out of the
facility.

Meets Standard

According to Emergency Plans,
an emergency count will be
taken whenever there is reason
to believe a detainee is missing
or after a major disturbance.

PART 2 – 11. POPULATION COUNTS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The count process accounts for all detainees and includes a daily face-to-photo count. However, only two formal counts are
conducted. Other counts are informally coinducted during meal times, recreation and during shift change. The officers work
twelve hour shifts.
During observation of the afternoon count, two officers entered each housing unit and physically observed each detainee.
While conducting the count, the officer looked into showers and behind sheets on bedding to assure every detainee in the
housing unit was counted.
Detainees do not participate in the count nor the preparation of documentation of the count process. No detainee
movement is allowed during the count process without the approval of the captain or designee. The intake officer is
responsible for maintaining an out count.
Evaluation of this standard was based on review of the Inmate Counts (lockdown) policy, training records, count sheets and
JailTracker; interviews with Captain Brandon Crowley, Officer Zakry Little and Officer Noah Morris; and observation of count
procees.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 12. POST ORDERS (Key: L)
This Detention Standard protects detainees and staff and enhances facility security and good order by ensuring that each
officer assigned to a security post knows the procedures, duties, and responsibilities of that post.
Components
1.

The facility administrator shall ensure that:
 There are written Post Orders for each security post,
 Copies are available to all employees,
 Written facility policy and procedures:
o Provide official on-duty time for officers to read
the applicable Post Orders when assigned to a
post, and
o Ensure that officers read those applicable Post
Orders prior to assuming their posts.
Supervisors shall ensure that officers understand the Post
Orders, regardless of whether the assignment is
temporary, permanent, or due to an emergency.

Rating

Remarks (1000 Char Max)

Meets Standard

Post orders are available for each
security post. Staff are provided
time to read the post orders.
Staff sign a log to acknowledge
reading the post orders.
Documentation confirmed
practice.

Meets Standard

Anyone assigned to an armed post qualifies with the post
weapons before assuming post duty.
Meets Standard

Training records confirmed that
each officer assigned to an
armed post qualifies with the
post weapons before assuming
the position.

Post Orders for armed posts, and for posts that control
access to the institution perimeter, clearly state that:
Any staff member who is taken hostage is considered to
be under duress, and

Meets Standard

Any order issued by such a person, regardless of his or her
position of authority, is to be disregarded.
5.

Specific instructions for escape attempts shall be
included in the Post Orders for armed posts.

Post Orders shall be kept current at all times and formally
reviewed at least annually and updated as needed.

Meets Standard

The transportation officer post
order contains specific
instructions for officers in the
event of escape attempts.

Meets Standard

Post orders were reviewed and
found to be current and formally
reviewed. Post orders are
reviewed annually.

Post Orders and logbooks are confidential and must be
kept secure at all times and never left in an area
accessible to detainees.

Meets Standard

The facility administrator authorizes all Post Orders and
changes.

Meets Standard

The sheriff authorizes all post
orders and changes.

PART 2 – 12. POST ORDERS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The post orders include information and instructions needed to ensure that each officer assigned to a security post knows the
procedures, duties, and responsibilities of that post.
The post orders are based on policies, facility practices and specify the hours of each post. The post orders include special

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PART 2 – 12. POST ORDERS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

instructions, and general operating procedures. Officers are required to sign the applicable post order before assuming duty.
Officers are encouraged to submit a written list of suggested post order changes to the shift supervisor. The change requests
are submitted to the captain for review and to the sheriff for approval.
Evaluation of this standard was based on review of the Post Orders policy, post orders, training records and signature sheets
acknowledging receipt of the post order; observation of post orders; and interviews with Captain Brandon Crowley, Officer
Zakry Little, Officer Kristin Bonnell, Officer Taylor Bastin and Sergeant Jase Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 13. SEARCHES OF DETAINEES (Key: M)
This Detention Standard protects detainees and staff and enhances facility security and good order by detecting, controlling,
and properly disposing of contraband.
Components
1.

PRIORITY: The facility has written policy and procedures
governing searches of detainees and housing or work
areas. The policies and procedures include the
requirement that staff employ the least intrusive method
of body search practicable, based on security concerns
involved; and conduct searches without unnecessary
force and in ways that preserve the dignity of detainees.

All staff who do housing or work area searches or body
searches shall receive initial training regarding search
procedure prior to entering on duty, and annual training
in effective techniques thereafter.

The facility shall establish procedures to ensure all
housing units and work areas are searched routinely, but
irregularly.

Staff shall maintain written documentation of each
housing unit search within the individual housing unit.

Work areas shall be searched each workday by shop
supervisors, and these inspections shall be supplemented
with periodic searches by designated search teams.

Rating

Remarks (1000 Char Max)

Meets Standard

Policy addresses component
requirements. A detainee pat
search or body scan search will
be conducted unless a
determination has been made
that an unclothed or strip search
is warranted. Written policy
includes the requirement that
staff employ the least intrusive
method of body search
practicable, based on security
concerns.

Meets Standard

Per the ICE coordinator sergeant,
all new staff receive search
procedures training upon entry
on duty, as well as annual
refresher training thereafter. The
inspector examined staff search
training curriculum to confirm
rating.

Meets Standard

Review of written policy and post
orders confirmed that housing
units and work areas are to be
searched routinely but
irregularly.

Meets Standard

Housing unit searches are
documented in the housing unit
log, which was reviewed by onsite inspector.

Meets Standard

Per the ICE coordinator sergeant,
work areas are searched each
day by a supervisor and
periodically by a search team.

Meets Standard

Strip or unclothed searches are
conducted when other less
intrusive methods, such as pat
searches or scans with the Tech
84 body scanner, prove to be
ineffective. Detainees are asked
to consent to a strip search by
signing an authorization form
and the shift supervisor must
approve any such search, per the
ICE coordinator sergeant.

Strip searches are conducted only when there is
reasonable belief or suspicion that contraband may be
concealed on the person, or a good opportunity for
concealment has occurred, and when properly
authorized by a supervisor.

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Rating

PRIORITY: Strip searches are performed by an officer of
the same gender as the detainee.

Body cavity searches are conducted by designated health
personnel only when authorized by the facility
administrator (or acting administrator) on the basis of
reasonable belief or suspicion that contraband may be
concealed in or on the detainee’s person.

“Dry cells” are used for contraband detection only when
there is reasonable belief of concealment, with proper
authorization, and in accordance with required
procedures.

Remarks (1000 Char Max)

Meets Standard

Policy requires that unclothed
searches (strip searches) be
performed by an officer of the
same gender as the detainee.
There were no strip searches
during this inspection period.

Meets Standard

The inspector was informed by
staff that body cavity searches
are conducted by medical staff
only and only when authorized
by the OIC. There have been no
such searches during the
inspection period.

Meets Standard

Written policy states that the OIC
may authorize the placement of
a detainee in a dry cell under
close staff observation when
there is reasonable belief of
contraband concealment.

Meets Standard

Written policy states that if dry
cell status is ordered, a post
order will be placed by the cell to
assure instructions for observing
the detainee held in the cell.

10. The chief of security shall have post orders for closely
observing a detainee in dry cell status.

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PART 2 – 13. SEARCHES OF DETAINEES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard included review of policy, housing
unit logs, post orders, training documents, housing unit activity logs and security check documents; as well as, interview with
ICE Coordinator Sergeant Jase Glassburn.
Detainees are protected through an established search program that detects, controls, and properly disposes of contraband
discovered in searches of persons and property.
Policy and procedures are in place to enhance facility security and good order by detecting, controlling, and properly
disposing of contraband. Pat searches of detainees and non-invasive screenings with a Tech 84 body scanner are conducted
during intake processing. Pat searches are routinely conducted to control contraband. The detainees at this facility are pat
searched on a routine or random basis to control contraband without a threshold level of suspicion. The search includes a
search of the detainee's clothing and personal effects. The post orders for staff assigned to monitor detainees that are in
close observation are clear and concise. They contain all the items outlined in the standard. Detainees that are in a dry cell
status for more than seven days have the prior approval of both the OIC and medical staff.
In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and
detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the
form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. Decisions
regarding detainees with disabilities, LEP detainee, and/or detainees included under any SAAPI/DHS PREA protection or
category will be made only after consideration of the disability, language difficulty, or SAAPI/PREA condition. The facility does
not house detainees with significant physical or mental disabilities. Detainees requiring special housing accommodations or
special care due to a disability are transferred to an appropriate facility.

Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Rating

Remarks (1000 Char Max)

1. PRIORITY: Each facility has written policy and procedures
for a Sexual Abuse and Assault Prevention and
Intervention Program that includes, at a minimum:



A zero-tolerance policy for all forms of sexual abuse
or assault;



Measures taken to prevent sexual abuse or assault,
including the designation of specific staff members
responsible for staff training and detainee
education regarding issues pertaining to sexual
assault;



Procedures for immediate reporting of any
allegation of sexual abuse or assault through the
facility’s chain-of-command procedure, and to
ICE/ERO, including written documentation
requirements;



Procedures for detainees to report allegations;



Measures taken for prompt and effective
intervention to address the safety and
medical/mental health treatment needs of detainee
victims, and to preserve and collect evidence;



Procedures for referral of incidents to appropriate
investigative agencies (including law enforcement
agencies and OPR), and coordination with such
entities;



Disciplinary sanctions for staff, up to and including
termination when staff has violated agency sexual
abuse policies; and



Data collection and reporting.

The facility administrator maintains or attempts to enter
into memoranda of understanding (MOU) or other
agreements with community service providers or, if local
providers are not available, with national organizations
that provide legal advocacy and confidential emotional
support services for immigrant victims of crime.
PRIORITY: The facility administrator has designated a
Sexual Abuse and Assault Prevention and Intervention
Program Coordinator for the facility.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator,
the sexual abuse and assault
prevention and intervention
(SAAPI) program contains all of
the bulleted items listed in this
component.

Meets Standard

Per a telephone interview with
the chief of security, the facility
has an agreement with Union
Hospital located in Terre Haute,
Indiana.

Meets Standard

Per a telephone interview with
the chief of security, the facility
has a designated SAAPI program
coordinator.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that all staff received annual
training. Per a telephone
interview with the chief of
security, employees and contract
personnel receive initial training
on the facility's SAAPI program.
Annual refresher training on the
program is provided to all staff.
Volunteer visits during this
inspection period were
temporarily suspended due to
the COVID-19 pandemic. A
review of the training log verified
that annual training was
conducted for all staff on
7/6/2021 and 7/8/2021 and will
be provided annually thereafter.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator,
detainees are informed about
the SAAPI program and the zerotolerance policy during
orientation, the national
detainee handbook and the local
detainee handbook. The
orientation program and
handbooks are available in
English and Spanish.

PRIORITY: Training on the facility’s Sexual Abuse and
Assault Prevention and Intervention Program is included
in initial and annual refresher training for employees,
volunteers, and contract personnel, and address all
training topics required by the Detention Standard. The
facility maintains written documentation verifying
employee, volunteer, and contractor training.

PRIORITY: Detainees are informed about the facility’s
Sexual Abuse and Assault Prevention and Intervention
Program and zero-tolerance policy for sexual abuse and
assault through the orientation program and the
detainee handbook. Detainee notification, orientation,
and instruction must be in a language or manner that the
detainee understands.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because the
Sexual Assault Awareness Notice
was not posted on all the
housing unit bulletin boards. Per
a telephone interview with the
acting HSA and photographs
provided, the Sexual Assault
Awareness Notice, along with the
name of the program
coordinator and a local
organization that can assist
detainees, is posted on all the
housing units where ICE
detainees are housed. The
"Sexual Assault Awareness
Information" brochure is
distributed to detainees.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator,
detainees may report any
incident of sexual abuse or
assault to any staff member.

Meets Standard

Per a telephone interview with
the acting HSA and SAAPI
program coordinator, detainees
are screened by medical and
detention staff upon arrival for
potential vulnerabilities to
sexually aggressive behavior or
tendencies to act out with
sexually aggressive behavior.
Detainees likely to become
victims will be placed in the least
restrictive housing that is
available. The detainee will be
referred to mental health for
further evaluation.

6. The Sexual Assault Awareness Notice, along with the
names of the program coordinator and local
organizations that can assist detainees who have been
victims of sexual assault, is posted on all housing unit
bulletin boards.
The “Sexual Assault Awareness
Information” brochure is distributed to detainees.

Detainees are provided the option to report any incident
of sexual abuse or assault to any staff member, including
a designated staff member other than an immediate
point-of-contact line officer (e.g. the program
coordinator or a mental health specialist).

8. PRIORITY: Detainees are screened upon arrival at the
facility for potential vulnerabilities to sexually aggressive
behavior or tendencies to act out with sexually aggressive
behavior.
Detainees identified as being at risk for sexual
victimization are monitored and counseled, and placed in
the least restrictive housing that is available and
appropriate.

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A detainee who is subjected to sexual abuse or assault is
not returned to general population until proper reclassification, taking into consideration any increased
vulnerability of the detainee as a result of the sexual
abuse or assault, is completed.

10. PRIORITY: Any detainee who alleges that he/she has been
sexually assaulted is offered immediate protection from
the assailant and referred for a medical examination
and/or clinical assessment for potential negative
symptoms.

Rating

Meets Standard

Per a telephone interview with
the SAAPI program coordinator,
a detainee who is subject to
sexual abuse or assault is not
returned to general population
until proper reclassification is
completed and only after
consideration is given to any
increased vulnerability.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator
and review of policy and
procedure, any detainee who
alleges sexual assault is offered
immediate protection from the
assailant and referred for a
medical assessment for potential
negative symptoms.

Meets Standard

Per a telephone interview with
the ICE DSCO, and review of
policy and procedure, any
personnel who become aware of
an alleged assault immediately
follow the reporting
requirements outlined in
established procedure. Prompt
notification is made to ICE and to
the Brazil police department
when a detainee is alleged to be
the perpetrator and when the
perpetrator is other than a
detainee.

11. PRIORITY: Staff members who become aware of an
alleged assault immediately follow the reporting
requirements set forth in the written policies and
procedures.
When a detainee(s) is alleged to be the perpetrator, the
facility administrator ensures that the incident is
promptly referred to the appropriate law enforcement
agency having jurisdiction for investigation, and reported
to the Field Office Director.

Remarks (1000 Char Max)

When an employee, contractor, or volunteer is alleged to
be the perpetrator, the facility administrator ensures that
the incident is promptly referred to the appropriate law
enforcement agency having jurisdiction for investigation,
and reported to the Field Office Director. The local
government entity or contractor that owns or operates
the facility is also notified.

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13. Care is taken to place a victimized detainee in a
supportive environment that represents the least
restrictive housing option possible (e.g. protective
custody), but victims are not held for longer than five
days in any type of administrative segregation except in
highly unusual circumstances or at the request of the
detainee.

Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the SAAPI program coordinator
and policy, the facility uses a
coordinated, multidisciplinary
team approach to responding to
sexual abuse. Team membership
includes the SAAPI program
coordinator, medical and mental
health staff, an investigator from
the assigned investigative entity,
the ICE officer on site and other
individuals as identified by the
facility administrator.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator,
a victimized detainee is placed in
a supportive environment that
represents the least restrictive
housing option possible. Victims
are not held longer than five days
in any type of administrative
segregation except in unusual
circumstances or at the
detainee's request.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator,
a staff member suspected of
perpetrating sexual abuse or
assault is removed from all duties
requiring detainee contact
pending the outcome of an
investigation.

Meets Standard

Policy and procedure contain all
the requirements listed in this
component.

14. PRIORITY: Staff suspected of perpetrating sexual abuse or
assault are removed from all duties requiring detainee
contact pending the outcome of an investigation.

15. The facility ensures that all investigations into alleged
sexual assault are prompt, thorough, objective, fair, and
conducted by qualified investigators. Written procedures
establish the coordination and sequencing of
administrative and criminal investigations to ensure that
the latter is not compromised by the former, including
the process for conducting internal administrative
investigations only after consultation with the assigned
criminal investigative entity or after a criminal
investigation has concluded.

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PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (Key: N)
This detention standard requires that facilities that house ICE/ERO detainees act affirmatively to prevent sexual abuse and
assaults on detainees, provide prompt and effective intervention and treatment for victims of sexual abuse and assault, and
control, discipline, and prosecute the perpetrators of sexual abuse and assault.
Components
16. Information concerning the identity of a detainee victim
reporting sexual assault, and the facts of the report itself,
are limited to those who have a need-to-know in order to
make decisions concerning the detainee-victim’s welfare,
and for law enforcement/investigative purposes.
17. When possible and feasible, appropriate staff preserve
the crime scene, and safeguard information and evidence
in coordination with the referral agency and consistent
with established evidence-gathering and evidenceprocessing procedures.
18. At no cost to the detainee, the facility administrator
arranges for the victim to undergo a forensic medical
examination by external independent and qualified
health care personnel. The results of the physical
examination and all collected physical evidence are
provided to the investigative entity.

19. The program coordinator reviews the results of every
investigation of sexual abuse or assault to assess and
improve prevention and response efforts.

20. Victims are provided emergency medical and mental
health services and ongoing care as appropriate,
including testing for sexually transmitted diseases and
infections,
prophylactic
treatment,
emergency
contraception, follow-up examinations for sexually
transmitted diseases, and referrals for counseling
(including crisis intervention counseling).

Rating

Remarks (1000 Char Max)

Meets Standard

Per policy, access to information
of the identity of the victim
reporting sexual assault, and the
facts of the report, are limited to
those with a need-to-know basis.

Meets Standard

Policy and procedure require the
preservation and safeguarding of
the crime scene and evidence,
consistent with established
evidence gathering and
processing procedures.

Meets Standard

Per policy, the facility
administrator arranges for the
victim to undergo a forensic
medical examination by external
independent and qualified health
care personnel, a sexual assault
nurse examiner (SANE), at Union
Hospital, Terre Haute, at no cost
to the detainee. Results of the
examination and collected
physical evidence are provided to
the investigative entity.

Meets Standard

The SAAPI program coordinator
reviews the results of every
investigation of sexual abuse or
assault to assess and improve
prevention and response efforts.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator
and policy, all the services and
care listed in this component are
provided to the victim.

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Rating

21. All case records associated with claims of sexual abuse
are maintained in a secure location, consistent with the
confidentiality requirements of the Detention Standards
on “Medical Care” and “Detention Files.”

22. The program coordinator conducts an annual review of
aggregate data regarding sexual abuse or assault
incidents at the facility, and presents the findings to the
Field Office Director and ICE/ERO HQ for use in
determining whether changes are needed to existing
policies and practices to further the goal of eliminating
sexual abuse.

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the SAAPI program coordinator,
all case records are maintained
and secured in the program
coordinator's office consistent
with the confidentiality
requirements of the detention
standards on medical care and
detention files. There were no
reported allegations of sexual
abuse and assault during this
inspection period.

Meets Standard

Per a telephone interview with
the SAAPI program coordinator
and ICE DSCO, an annual review
of aggregate data regarding
sexual abuse or assault incidents
was conducted and provided to
ICE on 12/8/21.

STANDARD 2.11. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The facility has a comprehensive sexual abuse and assault prevention and intervention (SAAPI) program mandating zero
tolerance toward all forms of sexual abuse or assault. SAAPI policies and procedures are in place to prevent sexual assault
and abuse on detainees and to provide prompt and effective intervention and treatment for victims. Handbooks and posted
information are provided in English and Spanish.
Decisions regarding detainees with disabilities, LEP detainees, and/or detainees included under any SAAPI/DHS PREA
protection or category, will be made only after consideration of the disability, language difficulty or SAAPI/PREA condition.
Following the intake process, detainees are educated on the SAAPI program as required by the standard. Detainees are
provided instructions on how to contact DHS/OIG or ICE to report sexual abuse or assault.
All employees receive related education during orientation and annual refresher training. The SAAPI program coordinator
assists with the development of written policies, procedures, and training protocols; maintains SAAPI case records; and
serves as liaison with other agencies. The facility has a written agreement with Union Hospital, Terre Haute, for evaluation
and treatment by SAFE and SANE personnel.
Statements from detainees claiming to be victims of sexual assaults are taken seriously and professionally responded to. If
clinically indicated, prophylactic treatment and follow up examinations for sexually transmitted diseases are offered. After a
physical examination, a mental health professional evaluates the need for crisis intervention, counseling and long term follow
up as needed. During the community examination, the victim may choose to have an outside advocate present. Once the
detainee has been transferred, the facility administrator is notified. There were no SAAPI related allegations filed by ICE
detainees during this inspection period.

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STANDARD 2.11. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

The facility utilizes tele-medicine for mental health/ psychiatric encounters.
Due to the COVID - 19 pandemic, this was a hybrid inspection; an inspection of the housing units, medical unit, and the
facility overall was not conducted by this inspector.
Evaluation of the standard is based on review of policy, procedures, training documentation, photographs, detention and
health records, and training presentations; and on telephone interviews with SAAPI Program Coordinator and Chief of
Security Jase Glassburn, Acting HSA Stan Roark, RN, Mental Health Professional Keith Nelson, and ICE DSCO Tashi Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 25

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Rating

Remarks (1000 Char Max)

Meets Standard

Policies and procedures are in
place for the special
management housing unit
(SMU), including administrative
segregation and disciplinary
segregation. Policy requires that
employees document the
reasons for placement and
periodic reviews. Per the jail
commander, the use of SMU for
detainees will be moved to two
cells in the booking area. There
have been no detainees placed in
SMU during this inspection
period.

Meets Standard

The two cells that will be used in
the booking area are double
bunked and do not exceed
capacity for which they were
designed, per the jail commander
and observation of the on-site
inspector.

Meets Standard

On-site inspectors confirmed
that the SMU cells are well
ventilated, adequately lit, and
temperature controlled.

Meets Standard

The jail commander confirmed
adherence to the requirements
of this component.

Meets Standard

Per policy, detainees on SMU
status are personally observed at
least every thirty minutes on an
irregular schedule and more
often when warranted.
Documentation is maintained to
verify adherence to policy.

Written policy and procedures are in place for special
management units, including Administrative Segregation
and Disciplinary Segregation, as well as documenting the
reason(s) for placement and periodic reviews.

The number of detainees confined to each cell or room
does not exceed the capacity for which it was designed.

Cells and rooms are well ventilated, adequately lit,
appropriately heated and maintained in a sanitary
condition at all times.
Each facility shall issue guidelines concerning the
privileges detainees may have in both Administrative and
Disciplinary status.
PRIORITY: Detainees in SMUs are personally observed at
least every 30 minutes in an irregular schedule and more
often when warranted.

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Remarks (1000 Char Max)

Meets Standard

Reviewed policy notes that
detainees are placed in
protective custody status in
administrative segregation only
when there is documentation
that it is warranted and that no
reasonable alternatives are
available. Detainees are placed in
administrative segregation status
only for non-punitive reasons,
when necessary to ensure the
safety of detainees or others, the
protection of property, or the
security or good order of the
facility.

Meets Standard

A pre-hearing detention form
detailing the reason for placing a
detainee on administrative
segregation status is completed
and signed by the OIC prior to a
detainee being placed in that
status.

Meets Standard

Per policy, a copy of the order is
provided to the detainee
immediately in a language or
manner the detainee can
understand. Detainees may
appeal to the OIC.

Meets Standard

Policy addresses the
requirements listed in this
component

Meets Standard

Written procedures for placing a
detainee in disciplinary SMU
status include each of the
requirements listed in this
component. The jail commander
confirmed practice is consistent
with policy.

PRIORITY: A detainee is placed in protective custody
status in Administrative Segregation only when there is
documentation that it is warranted and that no
reasonable alternatives are available.
A detainee is placed in Administrative Segregation only
for non-punitive reasons, when necessary to ensure the
safety of detainees or others, the protection of property,
or the security or good order of the facility.

Rating

The facility administrator or designee shall complete the
Administrative Segregation Order (Form I-885 or
equivalent), detailing the reasons for placing a detainee
in Administrative Segregation, before his or her actual
placement.

A copy of the decision and justification for each review is
given to the detainee, unless, in exceptional
circumstances, this provision would jeopardize security.
The detainee is given an opportunity to appeal a review
decision to a higher authority within the facility.
A detainee will be placed in Disciplinary Segregation only
after a finding by a Disciplinary Hearing Panel that the
detainee is guilty of a prohibited act or rule violation
classified at a “Greatest,” “High,” or “High-Moderate”
level, as defined in the Detention Standard on Disciplinary
System.

10. A written order shall be completed and signed by the
chair of the IDP (or disciplinary hearing officer) before a
detainee is placed into Disciplinary Segregation. A copy
of the order shall be given to the detainee within 24
hours, unless delivery would jeopardize the safety,
security, or the orderly operation of the facility or the
safety of another detainee.

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Rating

Remarks (1000 Char Max)

11. Upon a detainee’s release from the SMU, the releasing
officer attaches the entire housing unit record to the
Administrative Segregation Order or Disciplinary
Segregation Order and forwards it to the Supervisor for
inclusion in the detainee’s detention file.

Meets Standard

The requirements of this
component are addressed in
policy.

Meets Standard

Policy address each of the
requirements noted in this
component. The frequency of
reviews is in compliance with the
requirements of the component.
All reviews are documented on a
local SMU review form. The jail
commander confirmed that
practice is consistent with policy.

Meets Standard

Per the jail commander,
permanent housing logs are
maintained for detainees on
SMU status to record the
required information upon
admission to and release from
the unit. Information recorded in
the permanent housing unit log
includes visits to the unit from
supervisory staff and other
officials. There have been no
detainees in SMU status during
this inspection period.

Meets Standard

At this IGSA facility, a separate
log is maintained to record all
persons visiting the special
management unit cells.

12. PRIORITY: There are implemented written procedures for
the regular review of all detainees in Administrative
Segregation.
A supervisor conducts a review within 72 hours of the
detainee’s placement in Administrative Segregation to
determine whether segregation is still warranted. The
review includes an interview with the detainee, and a
written record is made of the decision and the
justification.
If a detainee is segregated for the detainee's protection,
but not at the detainee's request, continued detention
requires the authorizing signature of the facility
administrator or assistant facility administrator.
When a detainee has spent seven days in Administrative
Segregation, and every week thereafter for the first 60
days and at least every 30 days thereafter, a supervisor
conducts a similar review, including an interview with the
detainee, and documents the decision and justification.
13. Permanent housing logs are maintained in SMUs to
record pertinent information on detainees upon
admission to and release from the unit, and in which
supervisory staff and other officials record their visits to
the unit.

14. (SPCs/CDFs) A separate log is maintained in the SMU that
all persons visiting the unit must sign and record:



The time and date of the visit, and
Any unusual activity or behavior of an individual
detainee, with a follow-up memorandum sent
through the facility administrator to the detainee's
file.

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Rating

Remarks (1000 Char Max)

Meets Standard

Per the jail commander, a
Special Management Housing
Unit Record is maintained on
each detainee on SMU status. All
of the information required by
this component is documented
on this record.

Meets Standard

Per policy and procedure, all
detainees placed on SMU status
must be medically evaluated and
cleared prior to being placed in
SMU status.

Meets Standard

The requirements of this
component are included in
facility policy. Policy requires that
a health care provider visits
detainees on SMU status daily
and sees every detainee.
Prescribed medication is
provided as scripted. All
detainees on SMU status have
access to regularly scheduled sick
call. Any action taken is
documented by health care staff
and the medical visit is recorded
in the SMU logbook and in the
detainee's housing record, a
form equivalent to Form I-888.

Meets Standard

Detainees in the SMU may shave
and shower daily. All other basic
services listed in this component
are received on the same basis as
general population.

15. A Special Management Housing Unit Record is
maintained on each detainee in an SMU.

16. Health care personnel are immediately informed when a
detainee is admitted to an SMU to provide assessment
and review as indicated by health care protocols.

17. PRIORITY: A health care provider visits every detainee in
an SMU at least once daily, and detainees are provided
any medications prescribed for them.
Detainees will have access to regularly scheduled sick call
regardless of housing assignment.
Any action taken is documented in a separate logbook,
and the medical visit is recorded on the detainee’s SMU
Housing Record (Form I-888).

18. Detainees in SMUs may shave and shower three times
weekly and receive other basic services (laundry, hair
care, barbering, clothing, bedding, linen) on the same
basis as the general population.

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Rating

Remarks (1000 Char Max)

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
detainees housed in
administrative segregation were
not afforded time outside their
cells over and above the required
recreation periods. During this
inspection, it was determined
that detainees in administrative
segregation are now allowed an
additional hour outside their
cells over and above the required
recreation periods. There have
been no detainees in SMU status
during this inspection period.

19. Detainees in Administrative Segregation are provided
opportunities to spend time outside their cells (over and
above the required recreation periods), for such activities
as socializing, watching TV, and playing board games and
may be assigned to work details (for example, as orderlies
in the SMU).

20. The shift supervisor sees each segregated detainee daily,
including weekends and holidays.

Meets Standard

21. The facility administrator (or designee) visits each SMU
daily.

Meets Standard

22. Detainees in SMUs are provided three nutritionally
adequate meals per day, ordinarily from the general
population menu.

23. Only for documented medical or mental health reasons
are detainees denied such items as clothing, mattress,
bedding, linens, or a pillow. If a detainee is so disturbed
that he or she is likely to destroy clothing or bedding or
create a disturbance risking harm to self or others, the
medical department is notified immediately and a
regimen of treatment and control instituted by the
medical officer.
24. Detainees in an SMU may write and receive letters the
same as the general population.

25. Detainees in an SMU ordinarily retain visiting privileges.

Meets Standard

Detainees in the SMU cells are
provided three nutritionally
adequate meals per day from the
general population menu. A
review of policy noted that
detainees will be served three
meals each day.

Meets Standard

The jail commander confirmed
the sanctions outlined in this
component have not been
imposed during this inspection
period. He stated that if the
sanctions were to be imposed, it
would be done in adherence with
the requirements of the
component.

Meets Standard

Per policy, detainees in SMU
status have the same mail
privileges as the general
population.

Meets Standard

Detainees in SMU status
ordinarily retain visiting
privileges.

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Rating

26. Adequate documentation is generated for any restricted
or disallowed general visits for a detainee in an SMU who
violated visiting rules or whose behavior indicated the
detainee would be a threat to the security or good order
of the visiting room in the past year.

Meets Standard

Policy addresses the
documentation required by this
component.

27. Under no circumstances is a detainee permitted to
participate in general visitation while in restraints.

Meets Standard

Detainees are not permitted to
visit in restraints.

Meets Standard

The jail commander confirmed
that at this IGSA facility,
detainees in protective custody
status and violent and disruptive
detainees are not permitted to
use the visitation room during
normal visiting hours, if there is
reason to believe that the
detainee may disrupt the
visitation session.

Meets Standard

Staff confirmed that at this IGSA
facility, visitation is non-contact.
Detainees who are violent and
disruptive do not receive
visitation privileges. There have
been no such restrictions during
the inspection period.

Meets Standard

During this inspection period, the
jail commander confirmed that
legal visitation has not been
denied to any ICE detainee. If this
sanction is imposed, written
justification is required.

Meets Standard

Per policy, detainees may visit
with clergy upon request. The
visits will only be denied for
security or safety concerns.
There have been no such
restrictions during the inspection
period.

Meets Standard

At this IGSA facility, the roving
officer provides the detainees in
SMU status with reading material
including religious materials.

28. (SPCs/CDFs) Detainees in protective custody and violent
and disruptive detainees are not permitted to use the
visitation room during normal visitation hours.

29. (SPCs/CDFs) Violent and disruptive detainees are limited
to non-contact visits and, in extreme cases, not permitted
to visit.

30. Ordinarily, detainees in SMUs are not denied legal
visitation.

31. Detainees in SMUs are allowed visits by members of the
clergy, upon request; unless it is determined a visit
presents a risk to safety, security, or orderly operations.

32. Detainees in SMUs have access to reading materials,
including religious materials. In SPCs and CDFs, the
Recreation Specialist offers each detainee soft-bound,
non-legal books on a rotating basis, provided no detainee
has more than two books (excluding religious material) at
any one time.

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Remarks (1000 Char Max)

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2011 SAAPI

PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O)
This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating
certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation
section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated
for disciplinary reasons.
Components
33. Detainees in SMUs have access to legal materials, in
accordance with the Detention Standard on Law Libraries
and Legal Material. Detainees are permitted to retain a
reasonable amount of personal legal material in the SMU,
provided it does not create a safety, security and/or
sanitation hazard.
Detainee requests for access to legal material in their
personal property are accommodated as soon as possible
and always within 24 hours of a detainee’s request.

Rating

Remarks (1000 Char Max)

Meets Standard

Upon request, detainees on SMU
status are escorted individually
to the law library. Detainees are
permitted to retain all personal
legal material provided it does
not create a safety, security,
and/or sanitation hazard. Per the
jail commander, a detainee's
request for access to legal
material in his or her personal
property is accommodated as
soon as possible and always
within 24 hours of the request.

Meets Standard

Per the jail commander, during
this inspection period, no
detainee was denied access to
the law library. If this sanction is
imposed, it will be in accordance
with each of the requirements
listed in this component.

34. Any denial of access to the law library is always:


Supported by compelling security concerns,



For the shortest period required for security, and



Fully documented in the SMU housing logbook.

ICE/ERO is notified every time law library access is denied.
35. Recreation for detainees in the SMU is separate from the
general population.

Meets Standard

36. The facility has policy and procedures to ensure detainees
who must be kept apart never participate in activities in
the same location at the same time.

Meets Standard

Policy addresses the items listed
in this component.

Meets Standard

Detainees in SMU status are
offered at least one hour of
recreation per day, outside their
cells and scheduled at a
reasonable time, seven days per
week. The facility does not have
outside recreation.

Meets Standard

Per policy, recreation privileges
may be denied or suspended for
safety and security concerns.
Such action requires a report to
be submitted to the jail
commander. There were no such
denials during this inspection
period.

37. Detainees in the SMU are offered at least one hour of
recreation per day, scheduled at a reasonable time, at
least five days per week. Where cover is not provided to
mitigate inclement weather, detainees are provided
weather-appropriate equipment and attire.

38. The recreation privilege is denied or suspended only if it
would unreasonably endanger safety or security.
When a detainee in an SMU is deprived of recreation (or
any usual authorized items or activity), a report of the
action is forwarded to the facility administrator.

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Rating

39. The case of a detainee denied recreation privileges is
reviewed at least once each week, as part of the reviews
required for all detainees in SMU status. The reviewer
documents whether the detainee continues to pose a
threat to self, others, or facility security and, if so, why.

Meets Standard

Per the jail commander, denials
of recreation privileges are
reviewed and documented.

Meets Standard

Per policy, the jail commander
and the health authority must
approve any denial of recreation
privileges for more than fifteen
days. The ICE/ERO is required to
be notified when a detainee is
denied recreation privileges for
more than fifteen days.

Meets Standard

Per reviewed policy, detainees in
administrative segregation status
are allowed the same telephone
access as the general population.
Detainees in disciplinary
segregation status are provided
direct free legal calls as required
by this component. Calls are only
denied for compelling
documented security concerns.

Meets Standard

After seven consecutive days in
administrative SMU status, the
detainee has the right to appeal
to the jail commander the
conclusions and
recommendations of any review
conducted.

Meets Standard

The jail commander confirmed
adherence to the requirements
of this component.

40. Denial of recreation privileges for more than 15 days
requires the concurrence of the facility administrator and
the health authority.
The facility notifies ICE/ERO when a detainee is denied
recreation privileges for more than 15 days.

41. Ordinarily, detainees in Administrative Segregation have
telephone access similar to detainees in the general
population, in a manner consistent with the special
security and safety requirements of an SMU.
Detainees in Disciplinary Segregation may be restricted
from using telephones to make general calls as part of the
disciplinary process; however, ordinarily, they are
permitted to make direct and/or free and legal calls as
described in the Detention Standard on Telephone
Access, except for compelling and documented reasons
of safety, security, and good order.
42. After seven consecutive days in Administrative
Segregation, the detainee may exercise the right to
appeal to the facility administrator the conclusions and
recommendations of any review conducted.

43. If a detainee has been in Administrative Segregation for
more than 30 days and objects to this status, the facility
administrator reviews the case to determine whether
that status should continue, taking into account the views
of the detainee. A written record is made of the decision
and the justification.
A similar review is done every 30 days thereafter.

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Remarks (1000 Char Max)

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)

Meets Standard

The jail commander confirmed
that the he would provide the
field officer director with the
information required by this
component. There have been no
such events during the
inspection period.

Meets Standard

At this IGSA facility, policy
requires that a permanent log be
maintained to record all
requirements of this component.

44. When a detainee has been held in Administrative
Segregation for more than 30 days, the facility
administrator notifies the Field Office Director.

45. A permanent log is maintained in each SMU to record all
activities concerning SMU detainees (meals served,
recreation, visitors, etc.).
In SPCs and CDFs, the SMU log records the detainee's
name, A-number, housing location, date admitted,
reasons for admission, tentative release date for
detainees in Disciplinary Segregation, the authorizing
official, and date released.

PART 2 – 15. SPECIAL MANAGEMENT UNITS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. A review of documentation; observations by on-site inspectors; and
interview with Jail Commander Brandon Crowley confirmed that the facility has designated two cells in the booking area for
special management housing. The cells provide housing for disciplinary and administrative segregation. All policies and
procedures that apply to the SMU are applicable to detainees on SMU status. During this inspection period, there were no
detainees on SMU status.
Written policy and procedure are in place to control and secure the SMU entrances, contraband, tools, and food carts.
Permanent housing logs are maintained to record specific data on detainees upon admission to and release from the unit and
for supervisory staff to record their visits to the unit.
A detainee who demonstrates good behavior during pre-disciplinary hearing detention is considered for release to the
general population while awaiting his/her disciplinary hearing. Absent compelling circumstances, such as a pending criminal
investigation, a detainee does not remain in pre-disciplinary hearing detention for a longer period of time than the maximum
term of disciplinary segregation permitted for the most serious offense charged. Seriously mentally ill detainees are given a
mental health consultation within 72 hours of placement into the SMU and are seen at least weekly by a mental health
provider for the duration of their stay in special management status.
Management, supervisory, and medical personnel visit detainees on SMU status daily. Information is communicated to a
detainee in a language or manner the detainee can understand. Written materials are generally translated into Spanish, or
when practicable, provisions for written translation are made for other significant segments of the population with limited
English proficiency. Oral interpretation or assistance is provided to any detainee who speaks another language in which
written material has not been translated or who is illiterate. Bilingual staff or the translation line is used to communicate with
non-English speaking detainees.
The Office of Detention Oversight (ODO) report on 5/13/2021 found that some of the administrative segregation files and

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PART 2 – 15. SPECIAL MANAGEMENT UNITS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

disciplinary segregation files did not contain the date or time of release on the administrative segregation orders and
disciplinary segregation order. They also found that a supervisor did not interview the detainee as part of their review.
According to the jail commander, these items have been corrected and he will be doing regular 72-hour reviews on every
detainee in SMU status.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 16. STAFF-DETAINEE COMMUNICATION (Key: P)
This Detention Standard enhances security, safety, and orderly facility operations by encouraging and requiring informal direct
and written contact among staff and detainees, as well as informal supervisory observation of living and working conditions.
It also requires the posting of Hotline informational posters from the Department of Homeland Security Office of the Inspector
General.
Components
1.

Remarks (1000 Char Max)

Meets Standard

According to the ICE coordinator
sergeant, detainees have
frequent informal access to and
interaction with facility
personnel in languages they
understand. Facility supervisors
conduct visits in detainee
housing units to monitor overall
living conditions and to listen and
respond to detainee concerns.

Meets Standard

During the last inspection, this
was rated Does Not Meet
Standard due to health concerns
of COVID-19, on-site visits from
ICE/ERO officers were
suspended. The on-site visits
began 10/07/2021. The lobby
officer documents unannounced
visits by ICE officials.
Documentation was provided
verifying the visits.

Meets Standard

This IGSA facility does not have
an on-site ICE/ERO presence. The
DSCO, however, ensures a
current weekly ICE/ERO visitation
tour/schedule is maintained and
posted in the housing units and
other common areas. Posted
schedules indicate Wednesdays
are the regular DO tour days. Per
housing unit officers and
detainees, the DO is in the
housing units at least one day
per week. Completed weekly
telephone serviceability
worksheets and facility liaison
checklists filed confirmed the
visits.

PRIORITY: ICE/ERO detainees shall have frequent
informal access to and interaction with key facility staff
members, in a language they can understand.
Facility staff shall conduct scheduled visits to address
detainees’ personal concerns and monitor living
conditions.

Rating

Each facility shall develop a method to document the
unannounced visits by ICE/ERO staff.

In SPCs, CDFs, and IGSAs with On-Site ICE/ERO Presence:
The facility administrator or Supervisory Detention and
Deportation Officer (SDDO) shall develop written
schedules of weekly visits and ensure they are posted in
detainee living and other appropriate areas. Each facility
shall have specific procedures for documenting each visit.

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Rating

Remarks (1000 Char Max)

Meets Standard

ICE/ERO detainee request forms
are available in each housing
unit, in paper and electronic
formats, along with writing
instruments for detainees to
submit written questions,
requests, grievances or concerns.
The submission of paper request
forms is accomplished through
deposit into the housing unit's
dedicated ICE mailbox. Access to
that mailbox is restricted to
ICE/ERO personnel. The
submission of electronic request
forms on the housing unit kiosk
to ICE/ERO is direct; it is
completed by pressing the send
command. Procedure requires
any paper correspondence
addressed to ICE, discovered in a
general mailbox other than an
ICE mailbox, is to be treated as
special correspondence and
immediately forwarded to
ICE/ERO. Procedure requires
assistance will be given to the
special needs of disabled,
illiterate and non-English
speaking detainees. Language
lines are available to all
personnel.

Meets Standard

This IGSA facility does not have
an on-site ICE/ERO presence.
However, detainee requests are
answered in person and in
writing within 72 hours of
receipt, according to detainee
request logbook entries.
Documentation supports
component requirements.

PRIORITY: Detainees may submit written questions,
requests, or concerns to ICE/ERO staff, using the detainee
request form, a local IGSA form, or a sheet of paper.
Each facility administrator shall:

•

Ensure that adequate supplies of detainee request
forms, envelopes, and writing implements are
available.

•

Have written procedures to promptly route and
deliver detainee requests to the appropriate ICE/ERO
officials by authorized personnel (not detainees)
without reading, altering, or delaying.

•

Ensure that the standard operating procedures
accommodate detainees with special assistance
needs based on, for example, disability, illiteracy, or
limited use of English.

•

Ensure that each facility provides a secure drop box
for ICE detainees to correspond directly with ICE
management, and that only ICE personnel have
access to the drop box.

In SPCs and CDFs and in IGSAs with ICE/ERO on-site
presence: The staff member receiving the request shall
normally respond in person or in writing as soon as
possible and practicable, but no longer than within 72
hours of receipt.

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Rating

In IGSA facilities without ICE/ERO on-site presence, each
detainee request shall be forwarded to the ICE/ERO office
of jurisdiction within two business days.

Remarks (1000 Char Max)

Meets Standard

This IGSA facility does not have
an on-site ICE/ERO presence. A
review of the request log
revealed that requests, when
received, are forwarded within
two days.

Meets Standard

During this inspection reviewed
officer's logbooks confirmed that
each of items required by this
component are recorded.

As required by the ICE/ERO Detention Standard on
Detainee Handbook, each facility’s handbook (or
supplement) shall advise detainees of the procedures to
submit written questions, requests, or concerns to
ICE/ERO staff, as well as the availability of assistance to
prepare such requests.

Meets Standard

The local handbook contains the
information addressed in this
component.

The facility administrator shall ensure that OIG Hotline
posters are posted at appropriate common areas
(recreation areas, dining areas, processing areas, etc.) to
include each housing area in SPC/CDFs.

Meets Standard

An on-site inspector confirmed
requirements of this component.

All requests to ICE/ERO staff shall be recorded in a
logbook (or electronic logbook) specifically designed for
that purpose. At a minimum, the log shall record:
•

Date of receipt;

•

Detainee’s name;

•

Detainee’s A-number;

•

Detainee’s nationality;

•

Name of the staff member who logged the request;

•

Date the request, with staff response and action, was
returned to the detainee; and

•

Any other pertinent site-specific information.

In IGSAs, the date the request was forwarded to ICE/ERO
and the date it was returned shall also be recorded.
8.

PART 2 – 16. STAFF-DETAINEE COMMUNICATION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Staff-detainee communications are conducted in accordance with the standard. ICE staff provides general information to
detainees pertaining to the immigration court process. Detainee written request can be delivered in a sealed envelope with
the name and title of the ICE official to whom it should be forwarded. Requests can also be submitted through the kiosks and
tablets in the housing units. Detainees are informed that they can obtain assistance from other detainees or facility staff in
preparing a request form. All completed detainee requests are considered confidential and are maintained in the field office.
The facility's ICE liaison officer/coordinator and the facility's telephone service provider test all detainee phones at least
weekly to verify serviceability. Staff make random calls to pre-programmed numbers for attorney and consulate services,
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PART 2 – 16. STAFF-DETAINEE COMMUNICATION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

interview a sampling of detainees regarding telephone services, and check the TTY or other reasonable accommodation
ensuring they are working and available for hearing-impaired detainees. The staff document each serviceability test and
maintains them by month for three years. OIG contact information posters are in the housing units.
The facility provides communication assistance to LEP detainees and detainees with disabilities. This includes bilingual staff,
translation services, or other auxiliary aids for detainees with disabilities, including but not limited to, those aids listed in the
Standard.
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard included interviews with DSCO Tashi
Tillman and ICE Coordinator Sergeant Jase Glassburn; review of handbooks, telephone serviceability logs, detainee request
logs, and facility liaison visit logs; and observation by on-site inspectors of required housing units’ postings.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 17. TOOL CONTROL (Key: Q)
This Detention Standard protects detainees, staff, contractors, and volunteers from harm and contributes to orderly facility
operations by maintaining control of tools, culinary utensils, and medical and dental instruments, equipment, and supplies.
Components
1.

Rating

Remarks (1000 Char Max)

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
inventory of medical equipment
was conducted and observed to
be inaccurate. Suture removal
kits most recent count was
conducted on 02/11/2021 and
reflected there were ten kits.
Inspector and staff RN count
conducted count during the
inspection period and noted
there were nine; not ten kits in
stock. The most current 23
gauge, one inch needle count
was conducted on 03/05/2020.
Count completed during this
inspection reflected that the
actual count was off by five
syringe needles. In the
maintence office, tool inventory
for the "tool bucket" was not
available. Tools are located in a
maintence office within the
secure perimeter. Culinary
equipment inventory was not
accurate. A broken tool was
observed laying in the bottom of
the tool cabinet.Two "seat belt
cutters" were observed in the
key control cabinet and were not
documented on inventory.
During this inspection, tool
counts were accurate.

PRIORITY: There is an individual who is responsible for
developing a tool control procedure and an inspection
system to insure accountability.

Meets Standard

The administrative sergeant is
assigned tool control officer
responsibilities.

PRIORITY: Each facility administrator shall develop and
implement a written tool control and storage system to
include a tool classification system, and there are policies
and procedures in place to ensure that all tools are
properly marked and readily identifiable.

Meets Standard

The Tools and Equipment and
Supplies policy includes a written
tool control and storage system.

The use of tools, keys, medical equipment and culinary
equipment is controlled.

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Rating

The facility has developed and implemented a tool
classification system.
Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because the
facility had developed a
classification system in policy.
However, the tool classification
system had not been
implemented. Policy has been
implemented.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because tool
inventories were not readily
available in the maintenance
department. The food service
inventory was incomplete.
Broken tools were not logged.
During this inspection, tool
inventories were provided.There
is no electronics shop, recreation
department, or armory.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because tool
inventories were not
conspicuously posted on the
"tool bucket" used by the
maintenance empoyees. The tool
control inventories were
provided during this inspection.

Tool inventories are required for:


Facility Maintenance Department



Medical Department



Food Service Department



Electronics Shop



Recreation Department



Armory

Tool Inventories are conspicuously posted on all tool
boards, tool boxes and tool kits.

(SPCs/CDFs) The new tools shall be issued only after the
Tool Control Officer has marked and inventoried them.
Inventories that include any portable power tools shall
provide brand name, model, size, description, and
inventory control/AMIS number.

Remarks (1000 Char Max)

N/A

The facility administrator shall schedule, and establish
procedures for, the quarterly inventorying of all tools.
Meets Standard

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At this IGSA facility, policy does
not address component
requirements.
During the previous inspection,
this component was rated Does
Not Meet Standard because
documentation was not provided
to confirm the completion of
quarterly inventorying of tools.
During this inspection,
documentation confirmed
quarterly inventorying of tools.

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

(SPCs/CDFs) Tool inventories shall be numbered and
posted conspicuously on all corresponding shadow
boards, toolboxes, and tool kits. While all posted
inventories must be accurate, only the Master Tool
Inventory Sheet in the office of the chief of security
requires the certifiers' signatures.

Rating

Remarks (1000 Char Max)

N/A

At this IGSA facility, policy does
not address component
requirements.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because The
Tools and Equipment and
Supplies policy includes
procedures governing lost tools.
However, no documentation of
implementation was provided.
During this inspection,
documentation of
implementation was provided.
There have been no lost tools
during the inspection.

N/A

At this IGSA facility, policy does
not address component
requirements.

10. The facility administrator shall develop and implement
procedures governing lost tools.

11. (SPCs/CDFs) When a restricted or non-restricted tool is
missing or lost, staff shall notify the chief of security in
writing as soon as possible.
When the tool is a restricted (Class “R”) tool, staff shall
inform the shift supervisor orally immediately upon
discovering the loss. Any detainee(s) who may have had
access to the tool shall be held at the work location
pending completion of a thorough search.
The facility administrator shall implement quarterly
evaluations of lost/missing tool files.

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Rating

Remarks (1000 Char Max)

Does Not Meet Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because The
Tools and Equipment and
Supplies policy requires that the
workers submit to an inspection
and inventory of tools.
Documentation was not available
to support practice. The
maintenance worker advised
that "he always takes the same
tool bucket into the facility."
Security officers do not inspect
the tools prior to entering the
housing unit or departing
housing unit.During this
inspection, no documentation
was available to confirm practice
required by component. This is a
repeat deficiency.

12. All visitors, including repair and maintenance workers
who are not ICE/ERO or facility employees, shall submit
to an inspection and inventory of all tools, tool boxes, and
equipment that could be used as weapons before
entering and leaving the facility. The contractor shall
maintain a copy of the tool inventory with them while
inside the facility.

PART 2-17. TOOL CONTROL – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
An inspection of relevant materials confirmed the facility is implementing procedures to ensure tools are properly accounted
for. Documentation confirmed that tool inventories are conducted daily, monthly and quarterly.
The administrative sergeant is responsible for tool control policy and practices. The tool classification system is now in place.
All new tools are labeled and inventoried before being issued. Policy requires that all visitors bringing tools into the facility
must have an accurate inventory before being granted entry and must keep the inventory with them at all times while inside
the facility. However, no documentation was available to support the practice.
According to the Tools and Equipment and Supplies policy, it is the responsibility of security staff to ensure that knives and
other kitchen implements are not concealed and taken to the housing units. At the conclusion of inmate workers shifts, they
will be searched before being returned to housing unit. The medical staff does not permit unsupervised access to
inmates/detainees. Therefore, they do not have access to medical equipment.
Evaluation of this standard was based on review of the Tools and Equipment and Supplies policy, tool logs, inventories and
tool reports; observation of posted tool inventories, etched tools for identification, tool cabinets and tool storage; and
interviews with Captain Brandon Crowley, Maintenance Supervisor Tony Bowles and Sergeant Jase Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 2 – 18. USE OF FORCE AND RESTRAINTS (Key: R)
This Detention Standard authorizes staff to use necessary physical force, after all reasonable efforts to otherwise resolve a
situation have failed, and only for protection of self, detainees, or others, for prevention of escape or serious property damage,
or to maintain the security and orderly operation of the facility.
Components
1.

Rating

Remarks (1000 Char Max)

Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
includes the component
language. There were no use-offorce incidents during the
inspection period.

Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
includes component language.

Meets Standard

Documentation confirmed
training.

Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
includes component
requirements. No pregnant
detainees have been housed
during the inspection period.

Medical personnel are consulted.

Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
includes component
requirements. No pregnant
detainees have been housed
during the inspection period.

Intermediate force weapons, when not in use, are stored
in areas where access is limited to authorized personnel
and to which detainees have no access.

Meets Standard

Intermediate force weapons are
stored in the captain's office, a
restricted access area.

Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
includes component
requirements.

PRIORITY: Staff use physical force only as a last resort
after all reasonable efforts to otherwise resolve a
situation have failed, and use only the degree of force
necessary to gain control of the situation, employing
confrontation avoidance techniques and the use-of-force
continuum.
Staff:


Does not use force as punishment.



Attempts to gain the detainee's
cooperation before resorting to force.

voluntary



Uses only as much force as necessary to control the
detainee.



Uses restraints only when other non-confrontational
means, including verbal persuasion, have failed or
are impractical.

3. PRIORITY: All officers receive training in self-defense,
confrontation avoidance techniques and the use of force
to control detainees.
Specialized training is given to officers ensuring they are
certified in all devices including chemical agents,
approved for use.
4.

PRIORITY: Staff will consult with medical staff prior to a
calculated use of force regarding the following:


Use of pepper spray/non-lethal weapons.



Pregnant detainees.



Detainees with wounds or cuts.



Detainees with special medical or mental health
needs.

Special precautions are taken when restraining pregnant
detainees.

When the detainee is in an area that is or can be isolated
(e.g., a locked cell, a range), posing no direct threat to the
detainee or others, staff must try to resolve the situation
without resorting to force.

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The facility subscribes to the prescribed confrontation
avoidance procedures.
The ranking detention official, health professionals, and
others confer before every calculated use of force.

Rating
Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
includes component
requirements.

Meets Standard

According to the Reporting Use
of Force and Weapons/Physical
Force policy , if time permits and
there is not an immediate danger
for staff security or safety, the
use-of-force team (Detention
Response Team) technique is
used.

Meets Standard

Training documents confirmed
component requirements.

Meets Standard

Policy requires that all use-offorce incidents are audiovisually
documented and reviewed by
the captain and lieutenant.
According to policy,
documentation includes the
medical examination through the
conclusion of the incident.
There were no use-of-force
incidents during this inspection
period.

Meets Standard

The video recorder was observed
in the control center, fully
powered and maintained in a
secure area.

When a detainee must be forcibly moved and/or
restrained and there is time for a calculated use of force,
staff use the use of force team technique.

10. Staff members are trained in the performance of the useof-force team technique.
11. PRIORITY: All use of force incidents are documented and
reviewed.
All use of force incidents are properly audio-visually
documented and forwarded for review. Use of Force
documentation at a minimum, shall include the medical
examination through the conclusion of the incident. All
calculated uses of force incidents must be audio-visually
recorded in its entirety from the beginning of the incident
to its conclusion.

12. Staff shall store and maintain audio-visual recording
equipment under the same conditions as “restricted”
tools.

Remarks (1000 Char Max)

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Rating

Remarks (1000 Char Max)

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
policy did not address
component requirements. This
facility utilizes the restraint chair.
During this inspection, the
Restraint Chair policy was
provided to included component
requirements.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
policy did not address the
component requirements. Policy
requires officers to contact
medical staff once the detainee
is under control. However,
documentation in the use-offorce packets did not confirm
that medical staff were
contacted after the immediate
use-of-force incidents. During
this inspection, there were no
use-of-force incidents. Therefore,
documentation is not available to
confirm practice. Policy is in
place.

Meets Standard

This facility utilizes the restraint
chair. Policy addresses
component requirements.

Meets Standard

This facility utilizes the restraint
chair. Policy addresses
component requirements.

13. Standard procedures associated with using four/five
point restraints include:


Soft (nylon/leather) restraints.



Dressing the detainee appropriately for the
temperature.



A bed, mattress, and blanket/sheet.



Checking the detainee at least every 15 minutes.



Logging each check.



Repositioning detainee often enough to prevent
soreness or stiffness.



Medical evaluation of the restrained detainee twice
per eight-hour shift.

When qualified medical staff are not immediately
available, staff position the detainee "face-up."
14. In immediate use of force situations, officers contact
medical staff once the detainee is under control.

15. The shift supervisor monitors
position/condition every two hours.

the

detainee's

He/she allows the detainee to use the restroom at these
times under safeguards.
16. All detainee checks are logged.

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Rating

Remarks (1000 Char Max)

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
documentation was not available
to confirm that use-of-force
incident reports are routinely
reviewed.There have been no
use-of-force incidents during the
inspection period. Therefore,
documentation is not available to
confirm practice. Policy is in
place.

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because, at
this IGSA facility, an incident
report is used. The form is not an
equivalent. During this
inspection, an updated
equivalent form was
provided.There were no use-offorce incidents during the
inspection period.

17. When any detainee is restrained for more than eight
hours, the facility administrator shall telephonically
notify the Assistant Field Office Director and provide
updates every eight hours until the restraints are
removed.

18. It is standard practice to review any use of force and the
non-routine application of restraints.

19. In SPCs, the use of force form is used. In other facilities
(IGSAs / CDFs) this form or its equivalent is used.

PART 2 – 18. USE OF FORCE AND RESTRAINTS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Officers receive use-of-force training during their initial training prior to assuming duty and then receive 24 hours use-offorce training during their basic training. Documentation of Taser inventory was provided. Tasers are permitted for use on
ICE detainees as a last resort. Oleoresin Capsicum/pepper spray (OC) is the only chemical agent approved for use. The canine
unit will only be deployed outside the presence of detainees. There have been no canine searches during the inspection
period. The following acts and techniques are not specifically prohibited in policy: chokeholds, carotid control holds, and
other neck restraints. Batons are not used at this facility.

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PART 2 – 18. USE OF FORCE AND RESTRAINTS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Per policy, restraints are prohibited to be used on a female detainee that is pregnant or in post-delivery recuperation unless
directed by a medical authority for purpose of their safety. Whenever restraints are used on a pregnant detainee, follow-up
of medical attention if necessary is required.
Evaluation of this standard was based on review of the Use of Force policy, Use of Restraint Chair policy, training records,
restrain inventories and Use of Restraints policy; interview with Captain Brandon Crowley; and observation of the restraint
chair and restraints.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Section III: ORDER
Disciplinary System

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PART 3 – 19. DISCIPLINARY SYSTEM (Key: S)
This Detention Standard promotes a safe and orderly living environment for detainees by expecting detainees to comply with
facility rules and regulations and imposing disciplinary sanctions to control the behavior of those who do not.
Components
1.

PRIORITY: The facility has a written disciplinary system
using progressive levels of reviews and appeals. Written
disciplinary policy and procedures shall clearly define
detainee rights and responsibilities. The policy,
procedures, and rules shall be reviewed at least annually.

Detainees will receive translation or interpretation
services throughout the investigative, disciplinary, and
appeal process, including accommodation for the hearing
impaired. The facility shall not hold a detainee
accountable for his or her conduct if a medical authority
finds him or her mentally incompetent.

PRIORITY: Time in disciplinary segregation or withholding
of privileges imposed for disciplinary violations do not
generally exceed 60 days per violation. Staff do not
impose or allow imposition of the following sanctions:
corporal punishment; deprivation of food services (to
include use of Nutraloaf or “food loaf”); deprivation of
clothing, bedding, or items of personal hygiene;
deprivation of correspondence privileges; deprivation of
legal access and legal materials; or deprivation of physical
exercise, unless such activity creates a documented
unsafe condition.
PRIORITY: The facility supplemental handbook issued to
each detainee upon admittance, shall provide notice of
the facility’s rules of conduct and prohibited acts, the
sanctions imposed for violations of the rules, the
disciplinary severity scale, the disciplinary process and
the procedure for appealing disciplinary findings.

Rating

Remarks (1000 Char Max)

Meets Standard

The written disciplinary system
includes progressive levels of
reviews, appeal procedures and
documentation procedures.
Policy clearly defines detainee
rights and responsibilities. The
policy, procedures, and rules are
reviewed annually.

Meets Standard

Per the jail commander,
translation or interpretation
services are available throughout
the investigative, disciplinary,
and appeal process including
accommodation for the hearing
impaired. If a detainee is
determined to be mentally
incompetent, they are not held
accountable for their conduct.

Meets Standard

Policy specifically addresses each
of the requirements of this
component. Time in disciplinary
segregation generally does not
exceed sixty days per violation.

Meets Standard

A review of the local handbook
confirmed it includes the
required information on the
facility's rules of conduct and the
referenced information in the
component.

Meets Standard

A review of the local handbook
confirmed it includes the
required information on the
facility's rules of conduct and the
referenced information in the
component. Copies of the rules
of conduct, rights and
disciplinary sanctions are posted
and available on the housing unit
kiosk in each dayroom.

Copies of the rules of conduct, rights, and disciplinary
sanctions shall be provided to all detainees and posted in
English, Spanish, and/or other languages spoken by
significant numbers of detainees, as follows:


Disciplinary Severity Scale



Prohibited Acts



Sanctions

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Rating

All facilities shall have graduated scales of offenses and
disciplinary consequences as provided in this section.
PRIORITY: Incident reports are investigated within 24
hours of the incident by an officer who had no
involvement in the incident. Low or moderate infractions
are adjudicated by a Unit Disciplinary Committee (UDC).
Unresolved cases and cases involving serious charges are
forwarded by the UDC to the Institution Disciplinary
Panel (IDP) for adjudication.

A staff representative is available if requested for a
detainee facing an IDP disciplinary hearing.

The facility permits hearing postponements or
continuances when conditions warrant such a
continuance. Reasons are documented.

10. Written procedures govern the handling of confidentialsource information. Procedures include criteria for
recognizing "substantial evidence."
11. All forms relevant to the incident, investigation,
committee/panel reports, etc., are completed and
distributed as required.

Remarks (1000 Char Max)

Meets Standard

The facility uses a graduated
scale of offenses and
consequences.

Meets Standard

Per policy and procedure, all
incident reports are investigated
within 24 hours of the incident
by an officer who was not
involved in the incident. Low or
moderate infractions are
adjudicated by the unit
disciplinary committee and
unresolved cases or cases
involving serious charges are
forwarded to the institution
disciplinary panel for
adjudication.

Meets Standard

Per the jail commander, a staff
representative is made available
upon request for any detainee
facing a disciplinary hearing.

Meets Standard

Per policy, hearing
postponements or continuances
are permitted when conditions
warrant; reasons must be
documented.

Meets Standard

Policy governs handling
confidential information and
provides procedures for
recognizing substantial evidence.

Meets Standard

Per policy and procedure, all
forms relevant to the incident,
investigation committee/panel
reports, etc., are completed and
distributed as required. The jail
commander confirmed that
practice is consistent with policy.

PART 3 – 19. DISCIPLINARY SYSTEM – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard was based on review of policy, the
local handbook, and reports; and staff interview with the Jail Commander Brandon Crowley. There have been no disciplinary
reports for detainees during this inspection period.
The facility uses progressive levels of appeals and reviews. Policy clearly defines detainee rights and responsibilities. The
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PART 3 – 19. DISCIPLINARY SYSTEM – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

policy indicates that detainees will not spend over thirty days in segregation for a single infraction. Upon arrival at the facility,
detainees receive a local handbook that provides notice of the rules of conduct, sanctions, disciplinary severity scale, the
disciplinary process, and the procedure to appeal the disciplinary finding. Incidents are reviewed within 24 hours and are
referred to the UDC or IDP, depending on the severity of the incident. This facility has a comprehensive disciplinary process
that affords detainees their due process rights and levels of appeals.
Detainees with LEP and disabilities are provided assistance and/or accommodations to ensure that they can meaningfully
participate in all aspects of the disciplinary process. When a detainee has a diagnosed mental illness or mental disability or
demonstrates symptoms of mental illness or mental disability, a mental health professional, preferably the treating clinician,
shall be consulted. The mental health professional will provide input as to the detainee’s competence to participate in the
disciplinary hearing, any impact the detainee’s mental illness may have had on his or her responsibility for the charged
behavior, and information about any known mitigating factors regarding the behavior. The disciplinary process is adjusted
according to the mental competence of a detainee, as diagnosed or directed by an appropriate health care professional. The
disciplinary policy guides disciplinary hearing adjustments including, but not limited to, the provision of assistance to the
detainee throughout all phases of the process; mitigation of certain behaviors; imposition of or relief from certain sanctions;
ruling a detainee incompetent due to the inability to assist in their defense or the inability to distinguish right from wrong;
and postponement of a hearing.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Section IV: CARE
Food Service
Hunger Strikes
Medical Care
Personal Hygiene
Suicide Prevention and Intervention
Terminal Illness, Advance Directives, and Death

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






Rating

Remarks (1000 Char Max)

Meets Standard

The head cook (HC) has fifteen
years of food service experience
and is ServSafe certified. She is
responsible for the components
listed.

Meets Standard

The food service knife cabinet
was secured with a handle lock
and a padlock. Knives are
secured to the workstation when
in use. Knives are used under
food service personnel
supervision.

Meets Standard

Food items which could pose a
security threat are secured in a
locked cabinet.

Meets Standard

The HC develops and reviews
detainee job descriptions
annually. ICE detainees do not
work at this facility.

Meets Standard

A review of training records of
non-ICE detainees workers
confirmed the elements of this
components are addressed
during training.

Meets Standard

Training records are maintained
for all non-ICE detainee workers.
The records were reviewed
during the inspection.

Meets Standard

Non-ICE detainee workers were
observed to be neat and clean in
appearance while at work.

PRIORITY: The food service program shall be under the
direct supervision of an experienced food service
administrator (FSA) who is responsible for:
Planning, controlling, directing, managing, and
evaluating food service;
Managing budget resources;
Establishing standards of sanitation, safety and
security;
Developing nutritionally adequate menus and
evaluating detainee acceptance of them;
Developing specifications for the procurement of
food, equipment, and supplies; and
Establishing a training program that ensures
operational efficiency and a high quality food service
program.

The knife cabinet must be equipped with an approved
locking device. Knives must be physically secured to
workstations for use outside a secure cutting room. Any
detainee using a knife outside a secure area must receive
direct staff supervision.

Special procedures govern the handling of food items
that pose a security threat.
The FSA annually reviews detainee-volunteer job
descriptions to ensure they are accurate and up-to-date.

During orientation and training session(s), the cook
supervisor or equivalent explains and demonstrates:


Safe work practices and methods.



Safety features of individual products/ pieces of
equipment.



Training covers the safe handling of hazardous
material[s] the detainee are likely to encounter in
their work.

The cook supervisor documents all training.

Detainees assigned to the food service department shall
have a neat and clean appearance.

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Detainees are served three meals every day, at least two
of which are hot meals. No more than 14 hours elapse
between the last meal served and the first meal of the
following day.

Rating

Remarks (1000 Char Max)

Meets Standard

A review of the menus confirm
that detainees are provided
three meals each day; two of
which are hot meals. The feeding
schedule reflected fewer than
fourteen hours between the
evening meal and the following
days' morning meal.

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because meals
were trayed without staff
supervision and placed in the
corridor for delivery without staff
supervision. Meals are served on
insulated trays, but not
transported in locked carts.
Trays were passed out by officers
once they were delivered to the
housing unit. During this
inspection, it was observed that
the foot carts were delivered to
the housing uits by non-ICE
detainees under constant staff
supervision. All safe food
handing procedures were
observed.

Meets Standard

Random temperatures were
taken on the food line as well as
on completed trays. All
temperatures were within
required parameters.

Meals shall always be prepared, delivered, and served
under staff supervision.

10. PRIORITY: Before and during the display, service and
transportation of food, sanitary guidelines are observed,
with hot foods maintained at a temperature of at least
140 F degrees (120 degrees in food trays) and foods that
require refrigeration maintained at 41 F degrees or
below.

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Rating

Remarks (1000 Char Max)

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because servers
utilized food grade gloves, hats,
and masks. However, no utensils
were used during the traying
process. Hamburger patties and
french fries were placed in the
tray by hand. During this
inspection, servers utilized food
grade gloves, and hair nets.
Servers were observed utilizing
utensils to plate the meal into
insulated food trays.

Meets Standard

During the last inspection this
component was found Does Not
Meet the Standard because the
thermometer used to assure
food temperatures was not
cleaned between uses. During
this inspection, a thermometer
was utilized to check food
temperatures and was properly
cleaned between uses. All other
utensils were also sanitzed as
required

13. If the facility does not have enough equipment to
maintain the minimum or maximum temperature
required for food safety, the affected items (for example,
salad bar staples such as lettuce, meat, eggs, cheese)
must be removed and discarded after two hours at room
temperature.

Meets Standard

Food is trayed and served within
required time frames. The HC
indicated food would be
disgarded after two hours at
room temperature.

14. Food shall be delivered from one place to another in
covered containers.

Meets Standard

Trays are transported to the
housing units in covered carts.

11. Servers must wear food grade plastic gloves and hair nets
whenever there is direct contact with a food or beverage.
Serving food without use of utensils is strictly prohibited.

12. Utensils shall be sanitized as often as necessary to
prevent cross-contamination and other food-handling
hazards during food preparation and service.

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Rating

Remarks (1000 Char Max)

Meets Standard

During the last inspection this
component was found Does Not
Meet the Standard because
meals were trayed without staff
supervision and placed in the
corridor for delivery without staff
supervision. Meals are served on
insulated trays, but not
transported in locked carts. Trays
were passed out by officers once
they were delivered to the
housing unit. During this
inspection, it was observed that
the food carts were delivered to
the housing units by non-ICE
detainees under constant staff
supervision. All safe food
handling procedures were
observed.

Meets Standard

A registered dietician approves
master cycle menus. The most
recent analysis was conducted
on 05/10/2021.

Meets Standard

A registered dietician approves
master cycle menus and recipes.
The most recent analysis was
conductd 05/10/2021.

Meets Standard

The HC makes menu
substitutions changes as needed
with similar items and
documents the changes.

19. Food service staff and detainee workers involved in
cooking shall ensure that potentially hazardous foods are
cooked at the required safe temperatures, as listed in the
Detention Standard on Food service.

Meets Standard

Observation confirms
temperatures are checked and
confirmed by food service staff
prior to serving.

20. Facilities are required to provide detainees requesting a
religious diet a reasonable and equitable opportunity to
observe their religious dietary practice by offering a
Common Fare Menu. Detainees whose religious beliefs
require the adherence to particular religious dietary laws
are referred to the Chaplain or FSA.

Meets Standard

The facility offers a religious diet
to detainees upon request.

15. If food carts are delivered to housing units by detainees,
they must be locked unless they are under constant
supervision of staff. All food safety procedures
(sanitation, safe-handling, storage, etc.) apply without
exception to food in transit.

16. PRIORITY: A registered dietitian shall conduct a complete
nutritional analysis that meets U.S. Recommended Daily
Allowances (RDA), at least annually, of every master-cycle
menu planned by the FSA. The dietitian must certify
menus before they are incorporated into the food service
program.
17. The FSA has established procedures to ensure that items
on the master-cycle menu are prepared and presented
according to approved recipes.
18. The FSA or designee has the authority to change menu
items if necessary, documenting each substitution, along
with its justification, with a copy to the FSA. Menu
substitutions will be in accordance with dietician
approved substitution guidelines.

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PART 4 – 20. FOOD SERVICE (Key: T)
This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a
sanitary and hygienic food service operation.
Components
21. (SPCs/CDFs) Once a religious diet has been approved, the
FSA shall issue, in duplicate, a special-diet identification
card.

Rating

Remarks (1000 Char Max)

N/A

At this IGSA facility, the HC does
not issue a duplicate special diet
identification. Special diets are
notated with the detainee's
name on a different colored tray.

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because the
facility did not have a fourteenday common fare menu.
Interviews with the HC indicated
commercial meals would be
purchased if required for
common fare. During this
inspection, documentation
confirmed a fourteen-day
common fare menu is utilized.
Hot entrees are offered at least
three times a week.

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because a
ceremonial meal schedule had
not been developed at this
facilty. During this inspection
period, a ceremonial meal was
provided to the captain.

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because the
facility did not have a common
fare menu. Interviews with the
head cook indicate commercial
meals would be purchased if
required for common fare.
During this inspection,
documentation confirms a
fourteen-day common fare menu
is utilized for prescribed religious
purposes.

Meets Standard

Medical diets are served as
prescribed by health services.

22. The common fare menu shall be based on a 14 day cycle.
The menus must be certified as exceeding minimum daily
nutritional requirements. Hot entrees shall be offered at
least three times a week.

23. The chaplain, in consultation with local religious leaders
if necessary, shall develop the ceremonial meal schedule
for the following calendar year and provide it to the
facility administrator.

24. The Common Fare Program shall accommodate
detainees abstaining from particular foods or fasting for
religious purposes at prescribed times of the year, such
as Ramadan, Passover, and Lent.

25. Detainees with certain conditions – chronic or temporary;
medical, dental, and/or psychological – shall be
prescribed special diets as appropriate.

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Rating

Remarks (1000 Char Max)

26. The sanitary standards, including proper temperature
maintenance, are required in the food service
department also apply to satellite meals, from
preparation to actual delivery.

Meets Standard

Sanitation standards, including
proper temperature
maintenance, are maintained
from preparation to serving.

27. Food for satellite meals must be prepared and held at the
proper temperatures until served. Satellite tray meals
must be delivered and served within two hours of food
being plated.

Meets Standard

Food is prepared, delivered and
served within two hours.

Meets Standard

Detainees in segregation are
served meals identical to that of
the general population.

Meets Standard

Sack meals are provided as
needed and are approved by a
dietician. The sack meals are the
same nutritional quality as other
meals prepared by food service.

Meets Standard

28. In segregation units, food rations shall not be reduced or
changed or otherwise used as a disciplinary tool.
29. Sack meals shall be provided for detainees being
transported from the facility, and detainees arriving or
departing between scheduled meal hours, and detainees
in the SMU, as provided in the standard.
Sack meals shall be of the same nutritional quality as
other meals prepared by the food service.
30. The food service staff instruct detainee volunteers on:


Personal cleanliness and hygiene;



Sanitary techniques for preparing, storing, and
serving food, and;



The sanitary operation, care, and maintenance of
equipment.

An inspection of the food service
area and a review of
documentation confirm non-ICE
detainee kitchen workers are
trained in all aspects outlined in
this component and acknowlege
this training in writing.

31. All food service personnel, including staff and detainees,
shall receive a pre-employment medical examination.
The Cook Foreman or detention staff assigned to food
service shall inspect all detainee food service workers on
a daily basis at the start of each work period. Detainees
who exhibit signs of illness, skin disease, diarrhea
(admitted or suspected), or infected cuts or boils shall be
removed from the work assignment and immediately
referred to Health Services for determination of duty
fitness.

Documentation confirmed nonICE detainees working in food
service receive a physical and TB
test prior to their work
assignment. Physical results are
maintained in health services,
while TB results are contained
within the detainee's file in food
service. Workers are inspected
upon arrival by food service staff.

Does Not Meet Standard

Documentation was not available
to confirm that food service staff
have had a pre-employment
medical examination.
32. The food service department complies with food safety
and sanitation requirements as prescribed by the
governing health inspection authority, applicable laws
and contract provisions.

Meets Standard

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The food service department
complies with food safety
standards. The Clay County
Health Department inspects the
food service operation annually.
The most recent inspection was
conducted 05/10/2021.

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

PART 4 – 20. FOOD SERVICE (Key: T)
This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a
sanitary and hygienic food service operation.
Components
33. All facilities shall meet environmental standards for
safety and sanitation.

Rating

Remarks (1000 Char Max)

Meets Standard

The facility food service
department meets
environmental standards for
safety and sanitation.

34. The FSA shall develop a schedule for the routine cleaning
of equipment consistent with the information obtained
from manufacturers or local distributors, the National
Sanitation Foundation International (NSF) standards or
equivalent standards of other agencies about the
operation, cleaning, and care of equipment.

Meets Standard

The HC has developed a cleaning
schedule for the food service
department.

35. Spray or immersion dishwashers or devices – including
automatic dispensers for detergents, wetting agents, and
liquid sanitizer – shall be maintained in good repair.
Utensils and equipment placed in the machine must be
exposed to all cycles.

Meets Standard

The facility dishwasher is in good
repair.

Meets Standard

There are separate restroom
facilities for non-ICE detainee
workers and kitchen staff. Both
of which were observed to be
properly equipped.

Meets Standard

There are no doors in food
service area where an air curtain
would be required. The facility
utilizes a licensed pest control
company to protect against
pests/vermin.

Meets Standard

Daily safety and sanitation
inspections are made and
documented by the HC. Weekly
documented inspections of the
facility are also conducted.

Meets Standard

Temperature logs were reviewed
and confirm staff check
temperatures of the dish washer,
refrigerators and freezer on each
shift daily. The HC inspects the
area daily and takes action as
required. The kitchen was
inspected by the Clay County
Health Department on
05/10/2021.

Meets Standard

A cleaning schedule for each area
of the food service area is
posted.

36. Adequate, sanitary, properly equipped, and conveniently
located toilet facilities shall be provided for all food
service staff and detainee workers.

37. The FSA is responsible for pest control in the food service
department. Air curtains or comparable devices shall be
used on outside doors where food is prepared, stored, or
served to protect against insects and other rodents.

38. The facility shall implement written procedures requiring
administrative, medical, and/or dietary personnel to
conduct the weekly inspections of all food service areas,
including dining, storage, equipment, and foodpreparation areas.
39. PRIORITY: Staff shall check refrigerator and water
temperatures daily and record the results. The FSA or
designee will verify and document requirements of food
and equipment temperatures.
The FSA or CS shall inspect food service areas at least
weekly.
An independent, external inspector shall conduct annual
inspections to ensure that the food service facilities and
equipment meet governmental health and safety codes.
40. The FSA shall develop a cleaning schedule for each food
service area and post it for easy reference.

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2011 SAAPI

Rating

41. Each FSA shall establish procedures for storing, receiving,
and inventorying food.

42. Store all products at least six inches from the floor and
sufficiently far from walls to facilitate pest-control
measures.
43. Perishables shall be stored at 35-40 F degrees to prevent
spoilage and other bacterial action, and maintain frozen
foods at or below zero degrees.
44. Inventory levels are established, monitored and
periodically adjusted to correct excesses or shortages.

Remarks (1000 Char Max)

Meets Standard

The HC has established
procedures for the storage,
receiving and inventorying of
food.

Meets Standard

An inspection of the food service
area confirm that food products
are stored appropriatly.

Meets Standard

A review documentation
confirms proper temperatures
are maintained for the storage of
cold and frozen items.

Meets Standard

Inventory levels are maintained
as required. The facility
maintains a fifteen-day supply of
food.

PART 4 – 20. FOOD SERVICE – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Food service is managed by a head cook and three part-time staff. Non-ICE detainee workers assist with food service
operations. The HC and the three part-time staff are ServSafe certified.
On 12/07/2021, the plating and delivery of the lunch meal was observed. Both staff and non-ICE detainees were observed
utilizing proper PPE. The meal was plated into insulated food trays and was delivered to the detainee housing units.
The refrigerator, freezer and dry storage areas were found to be secured during the inspection.
Food service utilizes a five-week meal cycle and menus were approved by a registered dietician.
Temperatures and logs confirm food is maintained/prepared within appropriate parameters.
An inspection of the kichen confirmed a clean and well organized area.
Several detainees indicated that they thought the food provided at the facility "is good".
Evaluation of this standard was based on an inspection of the food service department; review of policy, procedures and
documentation; interviews with detainees, HC Tammie Fagg, Captain Brandon Crowley, DSCO Tashi Tillman, and HSA Stan
Roark.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that all staff received initial and
annual training, and that medical
staff received training on
evaluation and treatment. Per a
telephone interview with the
chief of security and acting HSA,
all personnel receive pre-service
and annual training on
recognizing the signs of a hunger
strike and procedures for referral
of the hunger striker to medical
personnel for evaluation.
Training was conducted
07/06/2021-07/08/2021.
Medical personnel are kept upto-date on hunger strike
evaluation and treatment and
training will be conducted
annually.

Meets Standard

Per a telephone interview with
the acting HSA, the mental
health professional and policy
review, it was confirmed that
policy includes procedures for
identifying and referring hunger
strikers to medical personnel. A
referral to mental health is also
initiated to assess whether the
detainee's action is reasoned and
deliberate or the manifestation
of a mental illness.

Meets Standard

Per a telephone interview with
ICE DSCO, the facility
administrator and ICE/ERO are
immediately notified by the
facility via the chain of command
of a hunger strike through email.

All staff receive initial and annual training on recognizing
the signs of a hunger striker and on the procedures for
referral for medical assessment. Medical staff receive
training in hunger-strike evaluation and treatment and
remain up-to-date on these techniques.

Procedures for identifying and referring to medical staff
a detainee suspected or announced to be on a hunger
strike shall include obtaining from qualified medical
personnel an assessment of whether the detainee’s
action is reasoned and deliberate or the manifestation of
a mental illness.

PRIORITY: Facility immediately reports via the chain of
command a hunger strike to ICE/ERO.

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Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA, any detainee
declaring a hunger strike or
observed to be refusing nine
consecutive meals is referred to
medical staff for evaluation and
management. There were no
reported ICE detainee on hunger
strike during this inspection
period.

Meets Standard

Per a telephone interview with
the acting HSA, procedures on
the initial medical evaluation of a
hunger striker include all the
bulleted items listed in this
component. Weight and vital
signs are taken once every 24
hours and documented in the
medical record. Other indicated
laboratory tests are conducted as
ordered by a medical
professional. A hunger strike
monitoring form is utilized to
document all results and is
placed in the detainee's medical
record. If a hunger strike was
noted over the weekend, the
staff RN will come to the facility
to perform the required 24-hour
monitoring and documentation.

Meets Standard

Per review of policy and provided
medical records, consent for
medical treatment is obtained
during intake screening.

PRIORITY: Staff shall consider any detainee observed to
have not eaten for 72 hours to be on a hunger strike, and
shall refer him or her to the clinical medical authority for
evaluation and management.

During the initial evaluation of a detainee on a hunger
strike, medical staff shall:







Measure and record height and weight;
Measure and record vital signs;
Perform urinalysis;
Conduct psychological/psychiatric evaluation;
Examine general physical condition; and
If clinically indicated, proceed with other necessary
studies.

Medical staff record the weight and vital signs and repeat
other procedures as medically indicated of a hungerstriking detainee at least once every 24 hours.
Medical staff shall record all examination results in the
detainee's medical file.

All physical and mental examinations, treatments, and
other medical procedures require the documented
informed consent of the detainee.

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Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA and review of
provided medical records, a
refusal form is completed for any
detainee who rejects medical
evaluation or treatment. If the
detainee refuses, a notation is
made on the form and witnessed
by two detention staff. A
detainee on hunger strike is
monitored to evaluate whether
the hunger strike poses a risk to
the detainee's life and medical
personnel document repeated
treatment attempts and
counseling regarding the risk of a
hunger strike in the progress
notes.

Meets Standard

Per policy, only the clinical
medical authority in
communication with the mental
health provider may order a
detainee's release from hunger
strike treatment and would
document such an order in the
medical record. A notation in the
detention file will be made when
the detainee has ended the
hunger strike. There were no
reported hunger strikes during
this inspection period.

Meets Standard

Per a telephone interview with
the acting HSA, medical
personnel may be required to
measure and record food and
water intake and output until
ordered to discontinue by the
clinical medical authority. A
locally generated form is used to
record intake and output.

A signed Refusal of Treatment form is required of every
detainee who rejects medical evaluation or treatment. If
the detainee will not cooperate by signing, staff shall note
this on the "Refusal of Treatment" form. Any detainee
refusing medical treatment will be monitored by medical
staff to evaluate whether the hunger strike poses a risk to
the detainee’s life or permanent health.

After the hunger strike, medical staff shall provide
appropriate medical and mental health follow-up care.
Only the clinical medical authority may order a detainee's
release from hunger strike treatment and shall document
that order in the detainee’s medical record. A notation
will be made in the detention file when the detainee has
ended the hunger strike.

After consultation with the clinical medical authority, the
facility administrator may require staff to measure and
record food and water intake and output until terminated
by the clinical medical authority. An IHSC Hunger Strike
Form or equivalent must be used.

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PART 4 – 21. HUNGER STRIKES (Key: U)
This Detention Standard protects detainees’ health and well-being by monitoring, counseling and, when appropriate, treating
any detainee who is on a hunger strike.
Components
10. Unless otherwise directed by the medical authority, staff
physically deliver three meals per day to the detainee's
room, regardless of the detainee's response to a verbally
offered meal and document those meal offers.

Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA, chief of security,
and policy, staff delivers three
meals per day to the detainee's
cell regardless of the detainee's
response. Meal offers are
documented as required by the
standard.

Meets Standard

Per a telephone interview with
the acting HSA and policy, an
adequate supply of drinking
water or other beverages is
provided to the detainee.

Meets Standard

Per a telephone interview with
the chief of security and the
acting HSA, all food items not
authorized by the clinical medical
authority are removed from the
detainee's room.

Meets Standard

Per a telephone interview with
the acting HSA and ICE DSCO, a
detainee on hunger strike is
provided counseling regarding
the risks of a hunger strike and
encouraged to accept treatment
voluntarily. In the event that
involuntary treatment shall be
administered, it will be in
accordance with established
guidelines and applicable laws
and only after the clinical
medical authority determines
that the detainee's health or life
is at risk. ICE/ERO will be notified
for authorization before forced
treatment is administered. Per
the acting HSA, detainees that
need involuntary treatment will
be transferred to Union Hospital
or to another facility.

11. Provide an adequate supply of drinking water or other
beverages.

12. Remove from the detainee’s room all food items not
authorized by the clinical medical authority.

13. Before involuntary medical treatment is administered,
staff shall make reasonable efforts to educate and
encourage him or her to accept treatment voluntarily.
Involuntary medical treatment shall be administered in
accordance with established guidelines and applicable
laws and only after the clinical medical authority
determines the detainee’s life or health is at risk.

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PART 4 – 21. HUNGER STRIKES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The facility has policies and procedures addressing the identification, evaluation, and treatment of hunger-striking detainees.
Per procedure, a hunger-striking detainee is isolated in an observation cell with no personal food items or commissary. Food
and fluid intake and vital signs with weight are documented daily. Signed consent for medical treatment is obtained. Mental
health personnel will assess whether the detainee's action is reasoned and deliberate, or the result of mental illness.
If a detainee engaging in a hunger strike has been previously diagnosed with a mental health condition or is not capable of
giving informed consent due to age or illness, appropriate medical/administrative action is taken in the best interest of the
detainee. Only qualified medical staff can modify or augment standard treatment protocols. If medically necessary, detainees
are transferred to a community hospital or a detention facility appropriately equipped for treatment. Records are kept of all
interactions with the striking detainee, the provision of food, attempted and successfully administered medical treatment,
and communications between the physician, the facility administrator and ICE.
Detainees refusing to accept treatment are counseled by medical staff regarding the medical risks associated with refusal of
treatment. When clinical assessment and laboratory results indicate the detainee’s weakening condition threatens the life or
long-term health of the detainee, a physician recommends involuntary treatment. The facility administrator notifies ICE if a
detainee is refusing treatment, and the health services administrator notifies the respective FOD in writing of any proposed
plan to involuntarily feed the detainee. Any involuntary medical treatment is approved by ICE. The FOD, in consultation with
the physician, contacts the respective ICE Office of Chief Counsel and the U.S. Attorney’s Office and discusses any impending
involuntary medical treatment and makes recommendations regarding pursuing a court order. Per the acting HSA, practice in
this facility is that when involuntary treatment is indicated, the detainee will be transferred to Union Hospital or to another
facility. Medical personnel continue clinical and laboratory monitoring as necessary until the detainee’s life or health is out of
danger and continue medical and mental health follow-up as necessary.
There were no reported cases of hunger striking detainees during this inspection period.
The ODO inspection conducted May 10-13, 2021, identified that the nurse and the clinical medical authority (CMA) did not
receive annual training to recognize the signs of a hunger strike, the procedures for a referral for a medical assessment, nor
the correct procedures for managing a detainee on hunger strike; and the hunger strike policy and local operating procedure
did not include the requirement to perform a urinalysis upon the initial evaluation of a detainee on hunger strike. During this
inspection the required training was confirmed for the nurse and the CMA. The hunger strike policy was updated to include
the requirement to perform a urinalysis upon the initial evaluation of a detainee on hunger strike.
Due to the COVID -19 pandemic, this was a hybrid inspection; an inspection of the housing units, medical unit, and the facility
overall was not conducted by this inspector.
Evaluation of the standard is based on review of policy, procedures, and health records; and on telephone interviews with
Acting HSA Stan Roark, RN, Mental Health Professional Keith Nelson, Chief of Security Jase Glassburn, and DSCO Tashi
Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 25

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Rating

Remarks (1000 Char Max)

Meets Standard

Initial medical, mental health,
and dental screening are
performed by nurses and
detention officers. Primary
medical and mental health care
is provided by contractual staff
provided through a
comprehensive contractual
agreement with Quality
Correctional Care. Dental
services are provided at all times
by Urgent Dental Care, in
Indianapolis, IN. Emergency,
specialty health care and
hospitalization, as needed, would
be provided by Saint Vincent Clay
Hospital in Brazil, IN, or by Union
or Regional Hospitals, located in
Terre Haute, IN.

Meets Standard

The health services administrator
(HSA), who is a registered nurse,
is the designated administrative
health authority who has the
overall responsibility for health
care services. The designated
clinical medical authority is a
physician and has the
responsibility for making final
clinical judgment and decisions.

Every facility shall directly or contractually provide its
detainee population:


Initial medical, mental health, and dental screening,



Primary medical and dental care, Emergency care,
Specialty health care,



Timely responses, Mental health care, and



Hospitalization
community.

needed

within

the

local

A designated administrative health authority shall have
overall responsibility for health care services pursuant to
a written agreement, contract, or job description. The
administrative health authority is a physician, health
services administrator, or health agency. When the
administrative health authority is other than a physician,
final clinical judgment shall rest with the facility’s
designated clinical medical authority. In no event should
clinical decisions be made by non-clinicians.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no evidence that an
annual review of the staffing plan
was conducted and the facility
did not provide sufficient staff to
meet the requirement of the
standard. Per a telephone
interview with the acting HSA,
the staffing plan will be
reviewed annually and identifies
the positions needed to perform
the required services. The
current medical staffing plan
showed sufficient staff to
perform the required services.
Staffing consists of a CMA, a
physician, an LCSW, two RNs, a
CMA and a regional site team
leader. Quality Correctional Care
is contracted to provide nurses
fourteen hours a day, Monday
through Friday; seven hours a
day for a CMA; one visit a week
by a physician; monthly visit by
the CMA and placement on an
on-call schedule; and a bi-weekly
visit by a mental health provider,
who is on-call when not on site.

Meets Standard

The licenses and certifications of
health care personnel were
reviewed and found to be
current. Health care personnel
only perform duties that are
within the scope of their
respective practice and training
and/or pursuant to orders by
personnel authorized by law to
give such orders. All positions
have a written job description.

PRIORITY: All facilities shall provide a medical staff and
sufficient support personnel to meet these Standards. A
staffing plan, which is reviewed at least annually by the
administrative health authority, identifies the positions
needed to perform the required services.

PRIORITY: All health care staff must be verifiably licensed,
certified, credentialed, and/or registered in compliance
with applicable state and federal requirements. Health
care personnel only perform duties for which they are
credentialed by training, licensure, certification, job
descriptions, and/or written standing or direct orders by
personnel authorized by law to give such orders.

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The facility administrator, in collaboration with the
clinical medical authority and administrative health
authority, negotiates and maintains arrangements with
nearby medical facilities or health care providers to
provide required health care not available within the
facility, as well as identifying custodial officers to
transport and remain with detainees for the duration of
any off-site treatment or hospital admission.

Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA, the facility has
arrangements with Saint Vincent
and Union Hospitals, and
Hamilton Center for mental
health emergencies in order to
provide the required health care
not available within the facility.
Procedures are in place for
transport of detainees for off-site
referrals and/or treatment.

Meets Standard

Written plans address the
management of infectious and
communicable diseases. The
written plans include all of the
requirements listed in this
component.

PRIORITY: Each facility shall have written plans that
address the management of infectious and
communicable diseases, including prevention, education,
identification, surveillance, immunization (when
applicable), treatment, follow-up, isolation (when
indicated), and reporting to local, state, and federal
agencies.
Plans shall include:


Coordination with public health authorities;



Ongoing education for staff and detainees;



Control, treatment and prevention strategies;



Protection of individual confidentiality;



Media relations;



Procedures for the identification, surveillance,
immunization, follow-up and isolation of patients;



Manage infectious diseases and report them to local
and/or state health departments in accordance with
established guidelines and applicable laws; and



Management of bio-hazardous waste and
decontamination of medical and dental equipment
that complies with applicable laws and Detention
Standard on Environmental Health and Safety.

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Rating

Remarks (1000 Char Max)

Meets Standard

Review of random medical
records, intake screening forms
and telephone interview with the
acting HSA and regional manager
confirmed all detainees receive
symptomatic screening for TB
during the intake process.
Detainees arriving without recent
evidence of testing receive a TB
skin test or a chest x-ray, when
indicated. Per the regional HSA, if
this occurs on the weekend, the
staff RNs would be contacted to
arrange/provide the required
testing.

Meets Standard

Per a telephone interview with
the acting HSA, detainees with
symptoms suggestive of TB will
be placed in a negative pressure
isolation room located in the
intake area. Confirmed active TB
patients shall remain in this room
until determined by a qualified
provider to be noninfectious in
accordance with CDC guidelines.
No suspected TB cases were
reported during this inspection
period.

Meets Standard

Per a telephone interview with
the acting HSA, all confirmed and
suspected active TB cases are
reported to local and/or state
health departments and ICE
within one working day by the
designated medical personnel.
Notification is also provided for
any movement, including
hospitalization, facility transfer
or release/deportation of the
patient. This information is
provided to the IHSC Public
Health, Safety, and Preparedness
Unit. There were no confirmed/
suspected active cases during
this inspection period.

PRIORITY: All new arrivals shall receive TB screening
within 12 hours of intake and using methods in
accordance with CDC guidelines for non-minimal risk
detention facilities.

Detainees with symptoms suggestive of TB shall be
placed in a functional airborne infection isolation room
with negative pressure ventilation and promptly
evaluated for TB disease. Suspected and confirmed active
TB patients shall be placed in a functional airborne
infection isolation room with negative pressure
ventilation (on- or off-site) until determined by a qualified
provider to be noninfectious in accordance with CDC
guidelines for non-minimal risk detention facilities.

For all confirmed and suspected active tuberculosis cases,
designated medical staff shall report:





All cases to local and/or state health departments
within one working day of meeting reporting criteria
and in accordance with established guidelines and
applicable laws.
All cases to the ICE HQ Epidemiology Unit within one
working day.
Any movement of TB patients, including
hospitalizations, facility transfers, releases, or
removals/deportations to the local and/or state
health department and the ICE HQ Epidemiology
Unit.

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Rating

Meets Standard

Per a telephone interview with
the acting HSA, designated
medical personnel report to the
IHSC Public Health, Safety, and
Preparedness Unit all cases of
nationally notifiable infectious
diseases as per CDC guidelines.

Meets Standard

Per a telephone interview with
the acting HSA and review of
policy, the established plan
ensures the highest degree of
confidentiality regarding a
detainee's HIV status and
medical condition.

Meets Standard

Per a telephone interview with
the acting HSA, the need for
isolation is based on clinical
evaluation of the patient.

Meets Standard

Policy addresses blood-borne
pathogen exposure and
reporting.

Meets Standard

Per telephone interview with the
acting HSA, upon admission,
detainees are provided a copy of
the local handbook, which
includes procedures for accessing
health care services, sick call and
the medical grievance process.

Meets Standard

Per a telephone interview with
the acting HSA and photograph
provided, the medical, dental
and mental health interviews and
procedures are conducted in a
manner that provides privacy for
detainees.

Meets Standard

Per a telephone interview with
the acting HSA and photograph
provided, there is a waiting area
located in the hallway adjacent
to the examination room where
detainees are under constant
supervision by detention staff. A
toilet and drinking fountain are
accessible.

11. Facilities must develop a plan to ensure the highest
degree of confidentiality regarding HIV status and
medical condition.

12. When current symptoms are suggestive of HIV infection,
clinical evaluation shall determine the medical need for
isolation.
13. Each facility shall establish a plan to address exposure to
blood-borne pathogens, including reporting.
14. The facility shall provide each detainee, upon admittance,
a copy of the detainee handbook and local supplement,
in which procedures for access to health care services are
explained; access to health care services, sick call and a
medical grievance process shall be included in the
orientation curriculum for newly admitted detainees.
15. PRIORITY: Medical, dental, and mental health interviews,
examinations, and procedures shall be conducted in
settings that respect detainee’s privacy.

16. A holding/waiting area shall be located at the entrance to
the medical facility that is under the direct supervision of
custodial officers. A detainee toilet and drinking fountain
shall be accessible from the holding/waiting area.

Remarks (1000 Char Max)

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Rating

17. Medical records shall be kept separate from detainee
detention records and stored in a securely locked area
within the medical unit.

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA, the medical unit
utilizes paper medical records.
Records are stored in a locked
file cabinet in the nurse's office.
Access to the medical record is
limited to medical personnel
only.

N/A

Per a telephone interview with
the acting HSA, the medical unit
does not have an infirmary or
medical observation unit.

18. If there is a specific area, separate from other housing
areas, where detainees are admitted for health
observation and care under the supervision and direction
of health care personnel, the following minimum
standards shall be met:




Clearly defined scope of care services available;
Physician on call or available 24 hours per day;
Health care personnel are on duty 24 hours per day
when patients are present;
 All patients within sight or sound of a staff member;
 Housing record that is a separate and distinct section
of the complete medical record; and
 Compliance with all established guidelines and
applicable laws.
Facilities are expected to provide detainees in medical
housing access to other services such as telephone, legal
access and materials consistent with their medical
condition.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
inventories of controlled
medications, instruments,
sharps, needles and syringes
were not maintained according
to the requirements of the
standard and were unsecured.
Written pharmacy policy and
procedures address all of the
items listed in this component.
Inventories of controlled
medications, sharps,
instruments, needles and
syringes were accurate. Per the
on-site Medical SME, counts
were conducted by the out-going
and in-coming staff. Controlled
medications are stored in a
double-locked bin in a secured
medication cart. The medication
cart is kept in a secured nurse's
office when not in use. Sharps,
instruments, needles and
syringes are stored in a locked
cabinet in the nurse's office.

Meets Standard

Per a telephone interview with
the acting HSA and
documentation provided, nonprescription medications were
reviewed and approved by the
facility administrator and the
CMA on 03/13/2021. The list is
reviewed annually.

19. PRIORITY: Each facility shall have written policy and
procedures for the management of pharmaceuticals that
include procurement, inventory, prescription, dispensing,
and secure storage and disposal of all prescription and
nonprescription medicines.

20. The facility administrator and administrative health
authority shall jointly approve any non-prescription
medications that are available to detainees outside of
health services and they shall jointly review the list
annually.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation of
training received by correctional
officers conducting intake
screening. A random review of
fifteen detainee medical records
revealed that detainees received
intake screenings conducted by a
nurse or correctional officer
upon admission. The screening
included all of the bulleted items
listed in this component. A
review of the training log verified
that correction officers
completed training on intake
screening.

21. PRIORITY: Initial medical, dental, and mental health
screening shall be done within 12 hours of arrival by a
health care provider or a detention officer specially
trained to perform this function.
The screening shall inquire into the following:


Any past history of serious infectious or
communicable illness, and any treatment or
symptoms;



Current illness and health problems, including
communicable diseases;



Pain assessment;



Current and past medication;



Allergies;



Past surgical procedures;



Symptoms of active TB or previous TB treatment;



Dental problems;



Use of alcohol and other drugs;



Possibility of pregnancy;



Other health programs designated
responsible clinical medical authority;



Observation of behavior, including state of
consciousness, mental status, appearance, conduct,
tremor, sweating;



Observation and interview items related to the
detainee’s potential suicide risk and possible mental
disabilities, including mental illness;



History of suicide attempts
suicidal/homicidal ideation or intent;



Observation of body deformities and other physical
abnormalities;



Questions and an assessment regarding past or
recent sexual victimization.

the

current

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2011 SAAPI

Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that training was provided. Per a
telephone interview with the
acting HSA and training records
review, detention officers have
been trained to conduct intake
screening and on confidentiality
of patient information.

Meets Standard

Per a telephone interview with
the acting HSA, the mental
health professional and medical
records, a mental health
screening is performed during
the intake process. A referral to
mental health is initiated within
24 hours when indicated and a
mental health evaluation is
completed by a qualified mental
health professional. The mental
health professional is on-call
when not on site and is also
available through telehealth.

Meets Standard

Per policy, the initial health
screening and assessment are
documented. A random review
of detainee medical records
confirmed this procedure.

22. If screening is performed by a detention officer, the
facility shall maintain documentation of the officer’s
special training, and the officer shall have available for
reference the training syllabus, to include education on
patient confidentiality of disclosed information.

23. PRIORITY: If at any time during the screening process
there is an indication of need, or request for, mental
health services, the health authority must be notified
within 24 hours. The clinical medical authority will ensure
a full mental health evaluation if indicated.

24. All facilities shall have policies and procedures to ensure
the initial health screening and assessment is
documented.

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2011 SAAPI

Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA, detention staff,
and review of detainee health
care records, it was confirmed
detention staff completes the
initial in-processing health
screen. Upon completion, the inprocessing health screening form
is forwarded to the staff RN for
appropriate action. Within 24
hours of completion, the staff RN
on duty contacts the CMA to
review the health screening
forms and determine the priority
for treatment. This review
requires the staff RN to be
contacted on weekends when
not on duty to contact the
physician and/or the mental
health provider to review the
intake screenings and arrange for
any needed treatment and or
medications.

Meets Standard

Per a telephone interview with
the acting HSA, non-English
speaking detainees will be
provided interpretation or
translation services by utilizing
bilingual staff or through
Lionbridge translation services.
Deaf or hard of hearing
detainees will be provided
interpretation or translation
services as needed. The facility
has a TTY system.

Meets Standard

Per a telephone interview with
the acting HSA, guidelines have
been established by the CMA for
the evaluation and treatment of
newly arrived detainees who
require detoxification.

25. PRIORITY: Upon completion, the in-processing health
screening form shall be forwarded to the facility medical
staff for appropriate action. The clinical medical authority
shall be responsible for review of all health screening
forms within 24 hours or next business day to assess the
priority for treatment (for example, Urgent, Today, or
Routine).

26. PRIORITY: Non-English speaking detainees and detainees
who are deaf or hard of hearing will be provided
interpretation or translation services or other assistance
as needed for medical care activities.
Language assistance may be provided by another staff
member competent in the language or by a professional
service, such as a telephone translation service.

27. The clinical medical authority shall establish guidelines
for evaluation and treatment of new arrivals who require
detoxification.

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30. PRIORITY: The facility performs mental health intake
screening, as well as mental health evaluations based on
screening results, medical documentation, or subsequent
observations, that include prior history of mental health
treatment, medications, drug use, suicidal tendencies,
and abuse, observations of current physical and
intellectual condition, and recommendations for any
appropriate medical or custodial treatment.
Detainees are appropriately referred to a mental health
provider for diagnosis, treatment, and/or intervention,
and transferred to licensed mental health facilities where
detainee mental health needs exceed the capabilities of
the facility.

Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA and a random
medical record review, physical
assessment is conducted by the
RNs within fourteen days of the
detainee's arrival unless more
immediate attention is required
due to an acute or identifiable
chronic condition.

Meets Standard

Per a telephone interview with
the acting HSA and policy,
detainees will be provided
chaperones of the same gender
as appropriate or as requested.

Meets Standard

Per a telephone interview with
the acting HSA and medical
records, mental health screening
is conducted during the intake
screening process by medical and
detention staff. Detainees are
referred to a mental health
provider when indicated.
Transfer to a mental health
facility shall be considered if the
detainee's mental health needs
exceed the capabilities of the
facility. Documentation provided
confirmed that medical and
detention staff were trained to
perform mental health intake
screenings.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that detention officers
performing intake screening had
received training. Per a
telephone interview with the
mental health professional and
policy, any detainee referred for
mental health treatment will
receive a comprehensive
evaluation by a licensed mental
health provider as soon as
possible but not later than
fourteen days of the referral. A
treatment plan will be developed
by the provider in conjunction
with the detainee which may
consider transfer to a mental
health facility if the detainee's
mental health needs exceed the
capabilities of the medical unit. A
random review of medical
records verified this procedure. A
review of the training logs
confirmed that detention officers
received and completed their
training on mental health
screening 07/06/202107/08/2021.

Meets Standard

Per a telephone interview with
the acting HSA, the clinical
medical authority may place a
detainee at high risk for violent
behavior in isolation because of a
mental health condition. Medical
personnel conduct daily
assessments of the need for
continued isolation for the health
and safety of the detainee.

31. PRIORITY: Any detainee referred for mental health
treatment shall receive a comprehensive evaluation by a
licensed mental health provider as clinically necessary,
but no later than 14 days of the referral.
The
provider
shall
develop
an
overall
treatment/management plan that may include transfer
to a mental health facility if the detainee’s mental illness
or developmental disability needs exceed the treatment
capability of the facility.

32. The clinical medical authority may place in medical
isolation a detainee who is at high risk for violent
behavior because of a mental health condition. The
clinical medical authority must provide for reassessment
on a daily basis the need for continued medical isolation
for the health and safety of the detainee.

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Rating

33. PRIORITY: The facility shall have written procedures for
restraints for medical or mental health purposes that
specify:






The conditions under which restraints may be
applied;
The types of restraints to be used;
The proper use, application, and monitoring of
restraints;
Requirements for documentation, including efforts
to use less restrictive alternatives; and
After-incident review.

Meets Standard

Per a telephone interview with
the acting HSA, there were no
detainees placed on restraints
due to medical or mental health
purposes during this inspection
period. Policy and procedures
address all of the bulleted items
in this component.

Meets Standard

Policy for the involuntary
administration of psychotropic
medications addresses all of the
bulleted items listed in this
component. Administration
would occur only pursuant to the
specific, written and detailed
authorization of a physician. The
HSA or designee would contact
ICE prior to administration of
treatment. Per a telephone
interview with the acting HSA,
there were no detainees given
involuntary administration of
psychotropic medications during
this inspection period.

Meets Standard

Per a telephone interview with
the acting HSA, ICE detainees
who are in custody for over a
year will receive annual health
assessments to include access to
age and gender appropriate
exams. Rescreening for TB is
included in the annual
evaluations.

34. PRIORITY: Involuntary administration of psychotropic
medications to detainees shall comply with established
guidelines and applicable laws and only pursuant to the
specific, written and detailed authorization of a
physician. When psychotropic medication is involuntarily
administered, it is required that the administrative health
authority contact ERO Management, who shall contact
respective DHS/ICE Chief Counsel.
The authorizing physician shall:










Review the medical record of the detainee and
conduct a medical examination;
Specify the reasons for and duration of therapy and
whether the detainee has been asked if he or she
would consent to such medication;
Specify the medication to be administered, the
dosage, and the possible side effects of the
medication;
Document that less restrictive intervention options
have been exercised without success;
Detail how the medication is to be administered;
Monitor the detainee for adverse reactions and side
effects; and
Prepare treatment plans for less restrictive
alternatives as soon as possible.

35. A detainee that is in ICE custody for over a year shall
receive health examinations on an annual basis.
Detainees shall have access to age and gender
appropriate exams annually, including rescreening for
tuberculosis.

Remarks (1000 Char Max)

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Rating

Remarks (1000 Char Max)

Meets Standard

A random medical records
review revealed that a dental
screening exam is conducted by
the RN within fourteen days of
the detainee's arrival. Routine
dental treatment may be
provided if dental treatment is
inaccessible for prolonged
periods because of detention for
over six months.

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
medical personnel were only onsite Monday through Friday, and
as a result, could not ensure that
all sick call requests were
received and triaged within 48
hours after the detainee submits
the request. Detainees may fill
out a sick call request form, and
deposit it in the medical box
located in each housing unit or
submit a request electronically
through the tablet. Medical
personnel collect the requests
Monday through Friday, which
are triaged by medical staff
within 48 hours after the request
is received including requests on
weekends. The detainee will be
scheduled for an appointment
according to the urgency of the
medical problem. Sick call is
conducted five days a week. In
an urgent situation, the
detention officer notifies medical
staff immediately. Detainees
housed in SMU have access to
sick call by submitting a sick call
request to medical personnel
during their daily rounds twice
per day.

36. An initial dental screening exam shall be performed
within 14 days of the detainee’s arrival.




Emergency dental treatment shall be provided for
immediate relief of pain, trauma and acute oral
infection.
Routine dental treatment may be provided to
detainees in ICE custody for whom dental treatment
is inaccessible for prolonged periods because of
detention for over six (6) months.

37. PRIORITY: Each facility shall have a sick call procedure
that allows detainees the unrestricted opportunity to
freely request health care services (including mental
health and dental services) provided by a physician or
other qualified medical staff in a clinical setting.
This procedure shall include:


Clearly written policies and procedures;



Sick call process will be communicated in writing and
verbally to detainees during their orientation;



Regularly scheduled “sick call” times will be
established and communicated to detainees;



All facilities must have an established procedure in
place to ensure that all sick call requests are received
and triaged by appropriate medical personnel within
48 hours after the detainee submits the request. In
an urgent situation, the housing unit officer shall
notify medical personnel immediately.

All detainees, including those in Special Management
Units, regardless of classification, shall have access to sick
call.

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2011 SAAPI

Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA, detainees may
request medical services by
completing a sick call request
form which is available in English
and Spanish. Detainees who are
deaf or hard of hearing will be
provided interpretation or
translation services as needed.

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that annual training on CPR, AED
use, and emergency first aid was
conducted. Per a telephone
interview with the acting HSA
and the chief of security, the
facility has a written emergency
services plan for delivery of 24hour emergency health care
when medical staff is not on-site.
The physicians are placed on oncall after hours. Emergency
medical service (EMS) is
activated when indicated by
calling 911. All staff received CPR
and AED training. Annual training
in emergency first aid was also
provided. Training files were
reviewed and confirmed that
training was completed
07/06/2021-07/08/2021.
Security procedures ensure
immediate transfer for
emergency care.

Meets Standard

Per a telephone interview with
the acting HSA, an RN reviews
the sick call requests and
determines when the detainee
will be seen. Appointments are
scheduled according to the
urgency of need. Sick call
requests are filed in the medical
record.

39. PRIORITY: Each facility shall have a written emergency
services plan for the delivery of 24-hour emergency
health care.
A plan shall be prepared in consultation with the facility's
clinical medical authority or the administrative health
authority. The plan will include the following:


An on-call physician, dentist, and mental health
professional, or designee, that are available 24 hours
per day;



A list of telephone numbers for local ambulances and
hospital services available to all staff;



An automatic external defibrillator (AED) will be
maintained for use at each facility and accessible to
staff;



All detention staff shall receive cardio pulmonary
resuscitation (CPR, AED) , and emergency first aid
training annually;



Security procedures that ensure the immediate
transfer of detainees for emergency medical care.

40. Medical personnel shall review the request slips and
determine when the detainee will be seen. All facilities
shall maintain a permanent record of all sick call requests.

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PART 4 – 22. MEDICAL CARE (Key: V)
This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and
health education, so that their health care needs are met in a timely and efficient manner.
Components
41. PRIORITY: Training is provided to all detention and health
care personnel at least annually by a responsible medical
authority in cooperation with the facility administrator,
and includes:
 Responding to health-related situations within four
(4) minutes;
 Recognizing of signs of potential health emergencies
and the required responses;
 Administering first aid and cardiopulmonary
resuscitation (CPR);
 Obtaining emergency medical assistance through the
facility plan and its required procedures;
 Recognizing signs and symptoms of mental illness,
suicide risk, retardation, and chemical dependency;
 The facility’s established plan and procedures for
providing emergency medical care including, when
required, the safe and secure transfer of detainees
for appropriate hospital or other medical services,
including by ambulance when indicated.
42. The designated health authority and facility
administrator shall determine the contents, number,
location(s), use protocols, and procedures for monthly
inspections of first aid kits.

Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation of
annual training provided to all
staff. Per a telephone interview
with the acting HSA, chief of
security and review of the
training syllabus, the training
provided addresses all of the
bulleted items listed in this
component. Review of the
training logs verified that training
was conducted 07/06/202107/08/2021 and will be
conducted annually thereafter.

Meets Standard

The HSA, CMA and facility
administrator determine the
contents, number, locations, use
protocols and procedures for
monthly inspections of first aid
kits.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that detention officers received
training on distribution of
medications. Per a telephone
interview with the acting HSA
and policy, distribution of
medication is in accordance with
specific instructions and
procedures. Detention officers
received proper training in
distributing medications. An
electronic medication
administration record is utilized
to document medications given
to the detainee. A review of the
training files confirmed that
correctional officers received
training on the proper
distribution of medications from
07/06/2021-07/08/2021.
Detainees do not deliver or
administer medications to other
detainees.

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that detention officers received
training on distribution of
medications. Per a telephone
interview with the acting HSA,
correction officers received
proper training in distributing
medications. A review of the
training files confirmed that
correctional officers received
training on the proper
distribution of medications
07/06/2021-07/08/2021.

Meets Standard

Per a telephone interview with
the acting HSA, health education
and wellness information are
provided by medical personnel.

43. Distribution of medication shall be in accordance with
specific instructions and procedures established by the
administrative health authority. Written records of all
medication given to detainees shall be maintained.
Detainees may not deliver or administer medications to
other detainees.

44. If medication must be delivered at a specific time when
medical staff is not on duty, it may only be distributed by
detention officers who have received proper training by
the administrative health authority.
The facility shall maintain documentation of the training
given any officer required to distribute medication, and
the officer shall have available for reference the training
syllabus or other guide or protocol provided by the health
authority.

45. The health authority shall provide detainees health
education and wellness information.

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Rating

Meets Standard

The HSA notifies ICE/ERO of any
detainee with special needs
through email, which is
documented in the detainee's
medical record.

Meets Standard

Per a telephone interview with
the acting HSA, detainees who
require close supervision are
enrolled in a chronic care clinic
and a treatment plan conforming
to NCCHC and TJC requirements
is developed. Treatment plans
are developed in consultation
with the patient. The detainee is
evaluated by the physician, with
periodic follow up as needed.

Meets Standard

Per a telephone interview with
the acting HSA, female detainees
are given a pregnancy test during
intake screening. Detainees who
are pregnant are provided
pregnancy management,
prenatal care, addiction
management, counseling,
nutrition, and post-partum
follow-up. There were no female
detainees housed in this facility
during this inspection period.

Meets Standard

A medical records review
confirmed age and gender
appropriate examinations are
provided.

Meets Standard

Per a telephone interview with
the acting HSA, a transfer
summary form is completed for a
transferred detainee and
contains continuity of care
instructions. A seven day supply
of prescribed medication, and a
fifteen day supply in case of TB
medications, is provided for
transfer with the detainee.

48. PRIORITY: Female detainees shall have access to
pregnancy testing and pregnancy management services
that include routine prenatal care, addiction
management, comprehensive counseling and assistance,
nutrition, and postpartum follow-up.

49. Detainees shall have access to age- and genderappropriate examinations.

50. The facility administrative health authority must ensure
that a plan is developed that provides for continuity of
medical care in the event of a change in detention
placement or status.
Upon transfer to another facility or release, the medical
provider shall ensure that all relevant medical records
and at least 7 days (or, in the case of TB medications, 15
days) supply of medication shall accompany the detainee.

Remarks (1000 Char Max)

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Rating

Meets Standard

Per policy and review of a
random sample of medical
records, informed consent for
medical treatment is obtained
from a detainee during
admission. If a detainee refuses
treatment, medical personnel
will explain the risks and the
encounter is documented in the
medical record.

Meets Standard

Per a telephone interview with
the acting HSA, if a detainee
refuses a treatment that is
medically necessary, ICE/ERO will
be consulted prior to any
contemplated action involving
involuntary medical treatment.
Involuntary treatment is a
decision made only by medical
professionals under strict legal
restrictions.

Meets Standard

The facility utilizes a paper
medical record. A complete
medical record is maintained on
each detainee and kept separate
from detention records. The
records are organized and are
used by medical practitioners for
health care documentation.
Access to medical records is
limited to medical staff.

Meets Standard

Per a telephone interview with
the acting HSA and chief of
security, medical personnel and
detention staff receive training
on the Health Insurance
Portability and Accountability Act
(HIPAA). Access to health
records is limited to authorized
individuals and only when
necessary.

52. If a detainee refuses treatment and the clinical medical
authority determines that the treatment is necessary,
ICE/ERO shall be consulted in determining whether
involuntary treatment shall be pursued.
Involuntary treatment is a decision made only by medical
staff under strict legal restrictions. Prior to any
contemplated action involving involuntary medical
treatment, DHS/ICE respective Chief Counsel will be
consulted.

53. PRIORITY: The administrative health authority shall
maintain a complete health record on each detainee that
is:
 Organized uniformly in accordance with recognized
medical records standards;
 Available to all practitioners and used by them for
health care documentation;
 Properly maintained and safeguarded in a securely
locked area within the medical unit separately from
other detention records.
54. All medical providers shall protect the privacy of
detainees’ medical information in accordance with
established guidelines and applicable laws. These
protections apply, not only to records maintained on
paper, but also to electronic records where they are used.
Staff training must emphasize the need for confidentiality
and procedures must be in place to limit access to health
records to only authorized individuals and only when
necessary.

Remarks (1000 Char Max)

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56. Copies of health records shall be released by the
administrative health authority directly to a detainee or
their designee, at no cost to the detainee, upon receipt
by the administrative health authority of a written
authorization from the detainee that complies with the
Health Insurance Portability and Accountability Act
(HIPAA).

57. Detainees who indicate they wish to obtain copies of
their medical records shall be provided with the
appropriate request form. ICE/ERO, or the facility
administrator, shall provide non-English speaking
detainees and detainees who are deaf or hard of hearing
with interpretation or translation services or other
assistance as needed to make the written request and
assist in transmitting the request to the facility
administrative health authority.
58. PRIORITY: Medical staff shall notify the facility
administrator in writing, when they determine that a
detainee’s medical or psychiatric condition requires:
 Clearance by the medical staff prior to release or
transfer, or
 Medical escort during removal, deportation, or
transfer.

Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documention that
staff received training for
confidentiality of medical
information. Per a telephone
interview with the acting HSA, on
a need-to know basis, medical
personnel provide the facility
administrator and other staff
with information needed for
reasons listed in this component.

Meets Standard

Per a telephone interview with
the acting HSA, detainees
requesting a copy of their
medical records complete an
Authorization for Release of
Health Information form that
complies with HIPAA regulations.
Copies of health records are
provided at no cost.

Meets Standard

Per a telephone interview with
the acting HSA, detainees are
provided copies of their medical
records upon written request.
Translation services via a
language line will be provided as
needed in making the written
request. Detainees who are deaf
or hard of hearing will also be
provided assistance as needed.

Meets Standard

Per a telephone interview with
the acting HSA, medical
personnel notify the facility
administrator in writing when
the detainee's condition requires
clearance by medical staff prior
to release or transfer, or medical
escort during removal,
deportation or transfer.

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Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA, the medical unit
is given at least a week advance
notice prior to the release,
transfer or removal of a
detainee. An equivalent transfer
summary form is completed for
each detainee and accompanies
the detainee being transferred.
The transfer summary includes
all the bulleted items listed in
this component. The form is
placed in an envelope marked
"Confidential Medical Records".

Meets Standard

Per policy, no detainees will
participate in medical,
pharmaceutical or cosmetic
research. This does not preclude
the use of approved clinical trials
that may be warranted for a
specific treatment when
recommended and approved by
the clinical medical authority.
This would require informed
consent.

Meets Standard

Per a telephone interview with
the acting HSA, the medical unit
has a continuous quality
improvement program. A multidisciplinary committee meets
quarterly to monitor and discuss
health services outcomes.
Quarterly reports were reviewed
and these procedures were
verified.

59. PRIORITY: The administrative health authority shall be
given advance notice prior to the release, transfer, or
removal of a detainee, so that medical staff may
determine and provide for any medical needs associated
with the transfer or release.
A summary of the detainee’s medical care (transfer
summary) shall be marked “CONFIDENTIAL MEDICAL
RECORDS” and shall accompany the detainee who is
being transferred.
A transfer summary must include:






TB clearance, including PPD and Chest x-ray results,
with the test dates;
Current mental and physical health status, including
all significant health issues;
Current medications, with specific instructions for
medications that must be administered en route;
and
The name and contract information of the
transferring medical facility.

60. Detainees will not participate in medical, pharmaceutical
or cosmetic research while under the care of ICE
detention facilities. This does not preclude the use of
approved clinical trials that may be warranted for a
specific inmate’s diagnosis or treatment when
recommended and approved by the clinical medical
director. Such measures require documented informed
consent.

61. PRIORITY: The administrative health authority shall
implement a system of internal review and quality
assurance that includes data analysis, a multidisciplinary
committee with regular monitoring of health service
outcomes, and assessment of ongoing education and
training needs.

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Rating

62. The administrative health authority shall implement an
intra-organizational, external peer review program for all
independently licensed medical professionals. Reviews
are conducted at least every two years.

Meets Standard

Remarks (1000 Char Max)
This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documented
implementation of an intraorganizational, external peer
review program for
independently licensed medical
professionals. Per policy, intraorganizational clinical
performance
enhancement/external peer
review is conducted at least
every two years for all
independently licensed medical
professionals. A random review
of personnel files verified that
the last peer review was
conducted 09 /09/2021;
documentation was provided to
confirm this requirement.

PART 4 – 22. MEDICAL CARE – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Clay County Jail has policies and procedures in place addressing access to medical care. Medical, dental and mental health
care services will be provided by employees and contractors of Quality Correctional Care. Hospitalization and emergency
services are provided by Union and Saint Vincent Hospital; other services are as follows: Hamilton Center for mental health
emergencies; biohazardous waste services by Stericycle; laboratory services by LabCorp; pharmaceuticals by Diamond
Pharmacy, and x-ray services by Mobile X. The facility has one negative pressure isolation room, and no infirmary or medical
observation room. The health services unit uses a six part, paper health records system. The medical unit has one exam room,
a secured waiting or holding area, and one suicide watch/observation room which meets the requirement of the standard.
Detainees who arrive with prescribed medications or who report being on such medications are evaluated by a qualified
health care professional as soon as possible, but not later than 24 hours after arrival. When medication orders are confirmed,
provisions are made to secure medically necessary medications. Detainees are not charged for any medical services to
include pharmaceuticals dispensed by medical personnel.
Detainee treatment questions are answered by medical personnel; lab results are available to detainees post transfer or
release. The quality assurance review includes items required by the standard. Health record reviews confirmed timely access
to medical, dental and mental health screenings, TB testing and physical examinations. Decisions regarding detainees with
disabilities and/or language difficulty will be made only after consideration of the disability or language difficulty. Telephone
interview with detainees did elicit concerns with one of the detainees regarding mental health care; the acting HSA was
advised and the detainee was immediately evaluated by medical staff.
Decisions regarding detainees with disabilities, LEP detainees, and/or detainees included under any SAAPI/DHS PREA
protection or category will be made only after consideration of the disability, language difficulty or SAAPI/PREA condition.
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PART 4 – 22. MEDICAL CARE – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

There was one medical grievance filed during this inspection period.
The ODO inspection conducted May 10-13, 2021, identified that licenses for the radiology technicians were not verified,
detainee health screening forms were not reviewed by the CMA within the required time in order to assess the priority for
treatment, and training records for the nurse and security officers showed that they did not receive annual training to
respond to health-related situations within the required time. During this inspection it was confirmed that licenses for the
radiology technicians were verified, health screening forms were reviewed by the CMA timely to assess the priority for
treatment, and the nurses and security officers received training to respond to health-related situations in a timely manner.
The facility utilizes tele-medicine for mental health/psychiatric encounters.
Due to the COVID-19 pandemic, this was a hybrid inspection; an inspection of the housing units, medical unit, and the facility
overall was not conducted by this inspector.
Evaluation of the standard was based on review of policy, procedures, medical records, postings, photographs, housing unit
diagrams, handbooks, job descriptions, and training plans; and on a telephone interviews with Acting HSA Stan Roark, RN,
LCSW Keith Nelson, Chief of Security Jase Glassburn, and DSCO Tashi Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 25

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 4 – 23. PERSONAL HYGIENE (Key: W)
This Detention Standard ensures that each detainee is able to maintain acceptable personal hygiene practices through the
provision of adequate bathing facilities and the issuance and exchange of clean clothing, bedding, linens, towels, and personal
hygiene items.
Components
1.

Each detention facility shall have a written policy and
procedures for the regular issuance and exchange of
clothing, bedding, linens, towels, and personal hygiene
items.

Rating

Meets Standard

Written policy establishes
procedures for the issuance and
exchange of clothing, bedding,
linens, towels, and personal
hygiene items.

Meets Standard

Policy review and staff confirm
that detainees are able to
complete a property request
form in order to
exchange/replace any clothing
that is worn out, indelibly
stained, or bears offensive or
otherwise unauthorized
markings.

Meets Standard

During admission, detainees, at
no cost, are issued clean,
indoor/outdoor temperatureappropriate, size appropriate
presentable clothing.

Clothing that is worn out, indelibly stained, or bears
offensive or otherwise unauthorized markings should be
discarded and replaced as soon as practicable.

All new detainees shall be issued clean, indoor/outdoor
temperature-appropriate, size appropriate, presentable
clothing during in-processing at no cost to the detainee.

Each detainee assigned to a special work area shall be
clothed in accordance with the requirements of the job
and, when appropriate, provided protective clothing and
equipment.

N/A

Staff shall provide male and female detainees personal
hygiene items appropriate for their gender and shall
replenish supplies as needed. The distribution of hygiene
items shall not be used as reward or punishment.

Razors must be strictly controlled. Disposable razors will
be provided to detainees on a daily basis. Razors will be
issued and collected daily by staff.

Female detainees shall be issued and may retain feminine
hygiene items as needed.

Remarks (1000 Char Max)

Detainees are not assigned to
any work areas.

Meets Standard

Detainees are initially provided
personal hygiene items which are
replenished twice weekly. The
distribution of hygiene items is
not used as reward or
punishment. Female and male
detainees are housed at this
facility. No female detainees
were housed during the
inspection.

Meets Standard

A review of policy and
procedures for the issuance and
collection of disposable razors
confirmed this component is
being met per the standard
requirements.

Meets Standard

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Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This component was rated Does
Not Meet Standard during the
last inspection because there is
not an adequate number of
toilets in housing units C and E.
Those units have four individuals
to a cell with only one toilet. The
standard states: "All housing
units with three or more
detainees must have at least two
toilets". During this inspection, it
was found that an adequate
number of toilets are still not
available to detainees in their
housing units. Several detainees
are sleeping in bed boats in the
housing units, adding to the ratio
discrepancy. This is a repeat
deficiency.

Detainees shall be provided an adequate number of
toilets 24 hours per day that can be used without staff
assistance when detainees are confined to their cells or
sleeping areas.

An adequate number of washbasins with temperature
controlled hot and cold running water 24 hours per day.

Does Not Meet Standard

10. Operable showers that are thermostatically controlled to
temperatures between 100 and 120 degrees Fahrenheit,
to ensure safety and promote hygienic practices.

11. Detainees with disabilities shall be provided the facilities
and support needed for self-care and personal hygiene in
a reasonably private environment in which the individual
can maintain dignity.

An adequate number of
washbasins with temperature
controlled hot and cold running
water are not available 24 hours
per day, due to detainees living
in housing units on bed boats.
On 12/07/2021, a review of
temperature control logs confirm
temperatures were being
measured per the standard and
ranged between 110-120
degrees Fahrenheit.

Meets Standard

A review of housing unit water
temperature logs confirm water
temperatures between 110
degrees Fahrenheit and 120
degrees Fahrenheit.

Meets Standard

Per the ICE deportation officer
and facility staff, detainees with
disabilities would not be housed
in this facility; they would be
transferred to another detention
facility that was equipped to
meet disability requirements.

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12. PRIORITY: Detainees shall be provided with clean
clothing, linen and towels on the following basis:
 A daily change of socks and undergarments. An
additional exchange of undergarments shall be made
available to detainees if necessary for health or
sanitation reasons.
 At least twice weekly exchange of outer garments
(with a maximum of 72 hours between changes). An
additional exchange of outer garments shall be made
available to detainees if necessary for health or
sanitation reasons.
 At least weekly exchange of sheets, towels, and
pillowcases.

Remarks (1000 Char Max)

The initial issuance of clothing
items meets the bulleted items
listed in this component and
fullfills the standard
requirements.

Meets Standard

More frequent exchanges of outer garments may be
appropriate, especially in hot and humid climates.
PART 4 – 23. PERSONAL HYGIENE – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The facility maintains an excess clothing inventory of at least two hundred percent of the maximum funded detainee
capacity. Personal items of clothing are not permitted. Personal hygiene items from other sources are not permitted.
Detainees are provided with a reasonable private environment in accordance with safety and security needs. Challenged
detainees who cannot perform activities of daily living are not housed at this facility.
Each detainee is able to maintain acceptable personal hygiene practices through the provision of adequate bathing facilities
and the issuance and exchange of clean clothing, bedding, linens, towels and personal hygiene items.
There is an inadequate number of toilets in housing. Two units contain four-person cells with only one toilet, and the
standard requires two toilets. Additional detainees are also housed in these areas on bed boats.
An adequate number of washbasins with temperature controlled hot and cold running water are not available 24 hours per
day, due to detainees living in housing units on bed boats.
Evaluation of the standard was determined following review of policy and detainee handbook; inspection of the facility; and
interviews with DSCO Tashi F. Tillman, Captain Brandon Crowley and HSA Stan Roark.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Rating

Remarks (1000 Char Max)

Meets Standard

The written suicide prevention
and intervention program is
reviewed and approved by the
clinical medical authority, and
approved and signed by the HSA
and facility administrator. The
program is reviewed annually
and includes all of the bulleted
items listed in this component.

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that training was conducted. Per
a telephone interview with the
chief of security, suicide
prevention training is provided to
all employees during pre-service
and annual refresher training
sessions. Training logs were
reviewed and confirmed the
provision of this training
07/06/2021-07/08/2021.

Meets Standard

Per a telephone interview with
the acting HSA, detainees
identified as suicidal are
removed from the general
population, placed on suicide
precautions, and referred to
mental health services.

PRIORITY: The facility has a written suicide prevention
and intervention program that is reviewed and approved
by the clinical health authority, approved and signed by
the administrative health authority and Facility
Administrator and reviewed annually.
At a minimum, the Program shall include procedures to
address suicidal detainees. Key components of this
program include:



Staff training,



Identification,



Referral,



Evaluation,



Treatment,



Housing,



Monitoring,



Communication,



Intervention,



Notification and reporting,



Review, and



Debriefing.

Every new staff member receives suicide-prevention
training. Suicide-prevention training occurs during the
employee orientation and annual training.

If a detainee is identified as being suicidal, the detainee is
removed from general population, placed on suicide
precautions, and is referred immediately to qualified
medical staff.

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Rating

Remarks (1000 Char Max)

Meets Standard

This component was rated Does
Not Meet Standard during the
previous inspection because
there was no documentation
that training was conducted. Per
a telephone interview with the
chief of security, all correction
and health care employees are
trained annually on the suicide
prevention and intervention
program. A review of the
curriculum showed the program
includes all the bulleted items
listed in this component. A
review of the training log showed
that all staff received training
07/06/2021-07/08/2021.

Meets Standard

Per a telephone interview with
the licensed clinical social worker
(LCSW), detainees identified as
being at risk for suicide are
immediately referred to the
mental health provider. A
qualified health care professional
evaluates the detainee within 24
hours of the referral. A detainee
on suicide watch is evaluated on
a daily basis, with the evaluation
documented in the medical
record. Only the mental health
professional, clinical medical
authority or designee is
authorized to terminate a suicide
watch, and then only after a
suicide risk assessment is
completed.

PRIORITY: All facility staff who interact with and/or are
responsible for detainees are trained at least annually on
the facility’s Suicide Prevention and Intervention
Program, to include:


Identifying the warning signs and symptoms of
impending suicidal behavior,



Demographic, cultural, and precipitating factors of
suicidal behavior,



Responding to suicidal and depressed detainees,



Communication between correctional and health
care personnel,



Referral procedures,



Housing observation
procedures, and



Follow-up monitoring of detainees who have
attempted suicide.

and

suicide-watch

level

PRIORITY: Detainees who are identified as being “at risk”
for suicide shall immediately be referred to the mental
health provider or other appropriately trained medical
staff member for evaluation. Appropriately trained and
qualified medical staff shall evaluate the detainee within
24 hours of the referral, and re-evaluate any detainee
placed on suicide watch on a daily basis. All evaluation is
documented in the detainee’s medical record. Only the
mental health professional, clinical medical authority, or
designee may terminate a suicide watch after a current
suicide risk assessment is completed.

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Evaluation by a mental health provider of detainees who
are identified as being “at risk” for suicide will be
documented in the medical record and include:










Rating

Relevant history,
Environmental factors,
Lethality of suicide plan,
Psychological factors,
A determination of level of suicide risk,
Level of supervision needed,
Referral/transfer for inpatient care (if needed),
Instructions to medical staff for care, and
Reassessment time frames.

Detainees who are placed on suicide watch are to be reevaluated by appropriately trained and qualified medical
staff on a daily basis and this re-evaluation is documented
in the detainee’s medical record. Only the mental health
professional, clinical medical authority, or designee may
terminate a suicide watch after a current suicide risk
assessment is completed. A detainee may not be
returned to the general population until this assessment
has been completed.

Meets Standard

Per a telephone interview with
the LCSW and medical record
review, evaluation of an at-risk
detainee by a mental health
provider includes all of the
bulleted items listed in this
component. The evaluation is
documented in the medical
record.

Meets Standard

Per a telephone interview with
the acting HSA and policy,
detainees on suicide watch are
re-evaluated by a qualified
health care professional on a
daily basis. The evaluation is
documented in the detainee's
medical record. Only the mental
health professional, clinical
medical authority or designee is
authorized to terminate a suicide
watch and then only after a
suicide risk assessment is
completed.

Meets Standard

Per a telephone interview with
the chief of security, suicidal
detainees are housed in a
designated suicide watch room
that has been made as a suicideresistant as possible. Detention
personnel inspect the room
before the detainee's placement
to ensure there are no objects
that pose a threat to the
detainee's safety.

Meets Standard

Per a telephone interview with
the acting HSA, the detainee is
provided a tear- resistant gown
and blanket as determined by
the mental health professional.

PRIORITY: Suicidal detainees should be housed in a room
that has been made as suicide resistant as possible.
Security staff shall ensure that the area for suicide
observation is initially inspected so that there are no
objects that pose a threat to the detainee’s safety.

When standard-issue clothing presents a security or
medical risk, the detainee is to be provided an alternative
garment that promotes detainee and staff safety, while
preventing the humiliation and degradation of the
detainee. The clinical medical authority or designee will
determine appropriate clothing.

Remarks (1000 Char Max)

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PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X)
This Detention Standard protects detainees’ health and well-being by training staff to prevent suicide by recognize potential
signs and situations of risk and to intervene with appropriate sensitivity, supervision, referral, and treatment.
Components
10. Suicidal detainees will be monitored by assigned security
officers who maintain constant one-to-one visual
observation, 24 hours a day, until the detainee is released
from suicide watch. The assigned security officer makes a
notation every 15 minutes on the behavioral observation
checklist.

Rating

Remarks (1000 Char Max)

Meets Standard

Per policy, detainees on suicide
watch are under constant oneto-one visual observation by
detention officers in the
observation room 24 hours a
day. The officer makes a notation
every fifteen minutes on the
checklist. There were no
detainees placed on suicide
watch during this inspection
period.

Meets Standard

Per a telephone interview with
the acting HSA and detention
staff, appropriate life saving
measures are administered by
detention personnel until they
are relieved by arriving medical
personnel.

Meets Standard

Per a telephone interview with
the acting HSA and ICE DSCO, all
appropriate ICE/ERO officials and
appropriate outside authorities
are notified through the chain of
command in the event of a
suicide attempt or completed
suicide. The victim's family is
notified by ICE/ERO. Medical
personnel will complete an
incident report within 24 hours.

Meets Standard

Per a telephone interview with
the LCSW and policy, every
completed suicide and serious
suicide attempt is subject to the
mortality review process.
Debriefing must be provided to
all affected staff and detainees.

11. Following a suicide attempt, security staff shall initiate
and continue appropriate life-saving measures until
relieved by arriving medical personnel.

12. In the event of a suicide attempt or a completed suicide,
all appropriate ICE and IHSC officials shall be notified
through the chain of command. The victim’s family and
appropriate outside authorities, as appropriate, shall also
be immediately notified.
Medical staff shall complete an Incident Report Form
within 24 hours.

13. Every completed suicide and serious suicide attempt shall
be subject to a mortality review process. A critical
incident debriefing shall be provided to all affected staff
and detainees.

PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Per policy review, medical, mental health and correction staff can place a detainee on suicide watch status, but only the
mental health professional, clinical medical authority or designee can remove a detainee from watch status. When a staff
member identifies someone who is at risk of significant self-harm or suicide, the detainee is placed on constant one-to-one
observation and is immediately referred to a qualified mental health professional. Based on an evaluation, a mental health
professional develops a documented treatment plan that is placed in the medical record. The treatment plan includes
strategies and interventions to be followed by staff and the detainee if suicidal ideation reoccurs, strategies for improved
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PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

functioning, and regular follow up appointments based on level of acuity.
When medical staff determines that a detainee is at imminent risk of bodily injury, the staff may recommend hospitalization
for purposes of evaluation and treatment. A court order is sought, if necessary. After a referral for evaluation, security staff
will place the detainee in a secure environment, pending transfer.
The mental health professional will determine what clothing the suicidal detainee may wear including standard issue clothing
and tear resistant suicide smocks. Privacy accommodations are provided for showering, performing bodily functions and
changing clothing, but are implemented in a way that does not pose a safety risk for the detainee. Incidents of opposite
gender coverage during a period when the detainee is undressed would be documented. Staff of the same gender are used
for monitoring whenever possible.
Per policy, deprivations and restrictions placed on suicidal detainees are kept to a minimum. In the event of a suicide attempt
or completed suicide, all personnel who encountered the detainee before the incident will submit statements including their
knowledge of the detainee and the incident. Policy requires a critical incident debriefing for affected staff and detainees
following successful suicides.
Per telephone interview with the acting HSA and the chief of security, the suicide observation cell is located in the intake
area. Per photographs provided, a detainee is easily visible by staff posted directly at the door. There were no detainees on
suicide watch during this inspection period. No suicide attempts or completed suicides were reported during this inspection
period.
The ODO inspection conducted 05/10/2021-05/13/2021 identified that the nurse and security officers did not receive annual
training to respond to health-related situations within the required time. During this inspection the required training for the
nurse and security officers was confirmed.
The facility utilizes tele-medicine for mental health/psychiatric encounters.
Due to the COVID-19 pandemic, this was a hybrid inspection; an inspection of the housing units, medical unit, and the facility
overall was not conducted by this inspector.
Evaluation of the standard is based on review of policy, procedures, training documentation, detainee health records, and
photographs; and on telephone interviews with Acting HSA Stan Roark, RN, LCSW Keith Nelson , Chief of Security Jase
Glassburn, and ICE DSCO Tashi Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 25

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y)
This Detention Standard ensures that each facility’s continuum of health care services addresses terminal illness, fatal injury,
and advance directives and provides specific guidance in the event of a detainee’s death.
Standard N/A

Detainees, who are chronically or terminally ill, are
transferred to an appropriate off-site medical facility, if
necessary. Immediately notify the facility administrator
and/or ICE/ERO Field Office Director (FOD) of the
detainee's condition by phone or in person and
document the detainee's condition in a memorandum to
the facility administrator that briefly describes the illness
and prognosis.
The FOD or designee shall immediately notify (or make
reasonable efforts to notify) the detainee’s next-of-kin of
the medical condition and status, the detainee's location,
and the visiting hours and rules at that location, in a
language or manner which they can understand.

Remarks (1000 Char Max)

Meets Standard

Per policy, detainees who are
chronically or terminally ill are
transferred to an off-site medical
facility, if necessary. The facility
administrator and ICE/ERO are
immediately notified via email of
the detainee’s condition
describing the illness and
prognosis.

Meets Standard

Per a telephone interview with
ICE DSCO, the detainee's next-ofkin is notified of the detainee's
medical condition and status,
and the location and visiting
hours in a language which they
can understand.

Meets Standard

Per a telephone interview with
the acting HSA, the detainee will
receive assistance from the
outside hospital in completing an
Advance Directive and/or Living
Will upon request. The State of
Indiana Advance Directive form
for implementing Living Wills and
Advance Directives will be used.

Meets Standard

Per a telephone interview with
the acting HSA and policy, when
the terms of the advance
directive must be implemented,
the physician will inform the
ICE/ERO FOD or a designee and
they will notify the ICE chief
counsel.

Meets Standard

Policy and procedures
established regarding DNR orders
are in accordance with the laws
of the state.

Meets Standard

Per a telephone interview with
the acting HSA, care will continue
to be provided consistent with
the DNR order.

When the detainee is at an off-site facility, that facility is
expected to assist the detainee in completing an Advance
Directive and/or Living Will.
All facilities shall use the State Advance Directive form (in
which the facility is located) for implementing Living Wills
and Advance Directives.

Rating

When the terms of the advanced directive must be
implemented, the medical professional overseeing the
detainee’s care will contact the ICE/ERO FOD or designee
and the respective ICE Chief Counsel.

Each facility holding detainees shall establish written
policy and procedures governing DNR orders in
accordance with the laws of the state in which the facility
is located.
Health care will continue to be provided consistent with
the DNR order.

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Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
the acting HSA and policy, the
detainee’s medical file shall
include documentation validating
the DNR order.

Meets Standard

Per a telephone interview with
the acting HSA, written
procedures for notifying the
attending medical provider of
the DNR order would be
followed.

Meets Standard

Policy includes procedures
addressing organ donation by
detainees.

Meets Standard

Per a telephone interview with
ICE DSCO and policy review, it
was confirmed that written
policy and procedures are
followed for notifying ICE/ERO of
a detainee's death; ICE will notify
next of kin and consulate
officials.

Meets Standard

Per a telephone interview with
the acting HSA and ICE DSCO, the
facility has a procedure to
address the death of a detainee
while in transport.

Meets Standard

Per a telephone interview with
the acting HSA and ICE DSCO, the
body is transferred to the local
coroner in the jurisdiction where
the death occurred.

Meets Standard

Per a telephone interview with
the acting HSA and ICE DSCO, the
chaplain will notify the next-ofkin in the United States to
communicate the circumstances
surrounding the detainee's
death, upon request.

The detainee's medical file shall include documentation
validating the DNR order.

The facility shall follow written procedures for notifying
attending medical staff of the DNR order.

The facility has written procedures to address the issues
of organ donation by detainees.

10. Each facility shall have written policy and procedures that
are followed to notify ICE/ERO officials, next-of-kin, and
consulate officials of a detainee's death while in custody.

11. The facility has a policy and procedure to address the
death of a detainee while in transport.

12. The body must be transferred to the local coroner or
medical examiner in the jurisdiction where the death
occurred.

13. The Chaplain shall telephone the person named as the
next-of-kin in the United States to communicate the
circumstances surrounding the death.

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Click the above button if the facility does not accept ICE detainees who are severely or terminally ill. ALWAYS complete all
references to detainee death and related notifications. (All Line Items and standard will be rated “N/A”)
Components
14. Within seven calendar days of the date of notification (in
writing or in person), the family shall have the
opportunity to claim the remains.

15. If family members cannot be located or decline orally or
in writing to claim the remains, ICE/ERO shall notify the
consulate.

16. The facility administrator shall specify policy and
procedures regarding responsibility for proper
distribution of the death certificate.

Rating

Remarks (1000 Char Max)

Meets Standard

Per a telephone interview with
ICE DSCO, the family shall have
the opportunity to claim the
remains within seven calendar
days of the date of notification.

Meets Standard

Per a telephone interview with
ICE DSCO, if family members
cannot be located or decline
orally or in writing to claim the
remains, ICE shall notify the
consulate.

Meets Standard

Per a telephone interview with
ICE DSCO, the original death
certificate is given to the next-ofkin and a copy is placed in the Afile.

Meets Standard

Per a telephone interview with
the acting HSA and policy review,
it was confirmed that established
procedures address all of the
bulleted items in this
component.

Meets Standard

Per policy, medical staff will
arrange for the approved
autopsy to be performed by the
local coroner in accordance with
established guidelines and
appropriate laws.

17. The facility’s written procedures shall address, at a
minimum:


Contacting the local coroner or medical examiner, in
accordance with established guidelines and
applicable laws;



Scheduling the autopsy;



Identifying the person who will perform the autopsy;



Obtaining the official death certificate; and



Transporting the body to the coroner or medical
examiner’s office.

18. Medical staff shall arrange for the approved autopsy to
be performed by the local coroner or medical examiner
in accordance with established guidelines and applicable
laws.

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PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Per policy, when a detainee is hospitalized, the HSA and the IHSC field medical coordinator will follow up on a daily basis to
receive information about major developments. In conjunction with medical providers, ICE provides family members and any
others as much opportunity for visitation as possible in keeping with the safety, security and good order of the facility.
DNR policy complies with the following stipulations: A DNR order can only be written by the physician; it protects basic
patient rights and complies with state requirements; a decision to withhold resuscitative services is considered only under
specified conditions, i.e., the detainee has a terminal illness, the detainee has requested and signed the order, the decision is
consistent with sound medical practice and is not in any way associated with any measures to hasten death; the medical file
includes explicit directions regarding the DNR and forms and memoranda regarding diagnosis and prognosis, express wishes
of the detainee, immediate family's wishes, consensual decisions and recommendations of medical professionals identified
by name and title, mental competency evaluation and informed consent; and the CMA or HSA will notify the IHSC medical
director and ICE Office of Chief Counsel of the basic circumstances of any detainee with a DNR order. The facility turns over
the property of a deceased detainee to ICE within a week. ICE gives the property of the deceased to the next-of-kin within
two weeks unless it is being held as part of an investigation.
ICE may assist the family with transporting the remains to a location in the U.S. If neither family nor consulate claims the
remains, ICE schedules an indigent's burial, after contacting the Department of Veterans Affairs to determine burial benefits.
The original death certificate will be sent to the person who claims the remains and a certified copy is placed in the A-file.
The facility will provide communication assistance to LEP detainees and detainees with disabilities. While an autopy decision
is pending, no actions are taken that could affect the validity of the results. The FOD verifies an accommodates the detainee's
religious preference prior to autopsy or embalming.
There were no detainee deaths reported during this inspection period. There were no detainees requiring a DNR order,
advance directive, living will or requesting to participate in organ transplantation.
Policy and procedures govern organ donations by detainees. The organ recipient is a member of the donor's immediate
family. All costs associated with the organ donation (hospitalization, fees, etc.) are at the expense of the detainee, involving
no facility funds.
Due to the COVID-19 pandemic, this was a hybrid inspection; an inspection of the housing units, medical unit, and the facility
overall was not conducted by this inspector.
Evaluation of the standard is based on review of policy, procedures, and health records; and on telephone interviews with ICE
DSCO Tashi Tillman, and Acting HSA Stan Roark, RN.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 25

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Section V: ACTIVITIES
Correspondence and Other Mail
Escorted Trips for Non-Medical Emergencies
Marriage Requests
Recreation
Religious Practices
Telephone Access
Visitation
Voluntary Work Program

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PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (Key: Z)
This Detention Standard ensures that detainees will be able to correspond with their families, the community, legal
representatives, government offices, and consular officials consistent with the safe and orderly operation of the facility.
Components
1.

Rating

Remarks (1000 Char Max)

Meets Standard

Rules governing detainee
correspondence are provided in
the local handbook which is
available on kiosks and electronic
tablets in the housing units.

Meets Standard

The local handbook states that
ICE detainees are considered
indigent if they have less than
$15.00 in their commissary
account for thirty days. Each of
the items listed in this
component are addressed
through written policy.

Meets Standard

The rules on correspondence and
other mail are addressed in the
local handbook which is provided
on the kiosks and electronic
tablets in the housing units.

Meets Standard

Key information, to include the
local orientation video, is
provided in English and Spanish,
the languages spoken by most
detainees. The local detainee
handbook and the National
Detainee Handbook are available
in multiple languages. The
telephonic language line
translation service is used when
needed.

Meets Standard

Review of policy and the local
handbook confirmed that
incoming general
correspondence and other mail is
delivered to the detainee within
one business day of its receipt at
the facility. Outgoing
correspondence and other mail
are delivered to the U.S. postal
service within one business day
of it entering the facility mail
system. Mail is picked up
Monday through Saturday from
the housing units by security
personnel.

Each facility shall have written policy and procedures
concerning detainee correspondence and other mail.

PRIORITY: A detainee is considered "indigent" if he or she
has less than $15.00 in his or her account. Indigent
detainees will be permitted to mail a reasonable amount
of mail each week at government expense, as determined
by the Facility Administrator, including the following:


At least five pieces of special correspondence or
Legal Mail.



Three pieces of general correspondence.



Packages as deemed necessary by ICE.

The facility shall notify detainees of its rules on
correspondence and other mail through the Detainee
Handbook, or supplement, provided to each detainee
upon admittance.
The facility shall provide key information to detainees in
languages spoken by any significant portion of the
facility's detainee population.

PRIORITY: Detainee correspondence and other mail shall
be delivered to the detainee and to the postal service on
regular schedules.


Incoming correspondence shall be distributed to
detainees within 24 hours (one business day) of
receipt by the facility.



Outgoing correspondence shall be delivered to the
postal service no later than the day after it is received
by facility staff or placed by the detainee in a
designated mail depository, excluding weekends and
holidays.

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Rating

Remarks (1000 Char Max)

Meets Standard

Reviewed policy issuances
dictate procedures for inspection
for all incoming general
correspondence and other mail
for the presence of contraband.

All facilities shall implement procedures for inspecting
special correspondence and legal mail for contraband in
the presence of the detainee. Detainees shall sign a
logbook upon receipt of special correspondence and/or
legal mail to verify that the special correspondence or
legal mail was opened in their presence.

Meets Standard

Special correspondence and legal
mail are opened and inspected in
the presence of the detainee.
Detainees sign a receipt for
special correspondence and or
legal mail.

Outgoing special correspondence and legal mail shall not
be opened, inspected, or read.

Meets Standard

The mail policy addresses
component requirement.

All facilities shall implement policies and procedures
addressing acceptable and non-acceptable mail.
Meets Standard

Policy and the local handbook set
criteria for determining
acceptable and non-acceptable
mail. Written procedures
describe how this mail is
documented and processed.
Detainees are advised, in writing,
of all confiscated/returned
correspondence and other mail.

Meets Standard

Reviewed correspondence policy
address the requirements of this
component.

Meets Standard

The local handbook explains the
process by which discovered
prohibited items will be handled;
the process discribed in the
handbook is in accordance with
the requirements of this
component.

Meets Standard

Stamps may be purchased from
the commissary.

Meets Standard

Per the ICE coordinator sergeant,
writing implements, paper, and
envelopes are provided at no
cost to detainees by facility staff.

All facilities shall implement procedures for the
inspection of all incoming general correspondence and
other mail (including packages and publications) for
contraband.

10. When an officer finds an item that must be removed from
a detainee’s mail, he or she shall make a written record.
11. Prohibited items discovered in the mail shall be handled
as follows:




A receipt shall be issued to the detainee for all cash,
which shall be safeguarded and credited to the
detainee’s account in accordance with the Detention
Standard on Funds and Personal Property.
Identity documents, such as passports, birth
certificates, etc., shall be placed in the detainee's Afile. Upon request, the detainee shall be provided
with a copy of the document, certified by an ICE/ERO
officer to be a true and correct copy.

12. The facility shall provide a postage allowance at
government expense to all detainees, if the facility does
not have a system for detainees to purchase stamps.
13. The facility shall provide writing paper, envelopes, and
pencils at no cost to ICE detainees.

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Rating

Remarks (1000 Char Max)

Meets Standard

Policy notes that detainees in
special management units shall
have the same mail privileges as
those in the general population.
There were no detainees held in
special housing during the
inspection period.

14. All facilities shall have written policy and procedures
regarding mail privileges for detainees housed in a Special
Management Unit.

PART 5 – 26. CORRESPONDENCE AND OTHER MAIL – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The facility has written policy and procedures concerning detainee correspondence and other mail. The rules for
correspondence and other mail, which are provided to detainees in the handbook and are posted in the housing units,
address all information required by the standard. The quantity of correspondence a detainee may send or receive at his own
expense is not limited.
Incoming priority mail, overnight mail, certified mail and deliveries from a private package service are recorded in a logbook.
Packages and publications are subject to certain restrictions. Detainees are not permitted to send or receive packages
without the prior approval of the OIC. Detainees must pay postage for packages, unless deemed necessary by the OIC, which
includes oversized or overweight mail. Inspection of the mail is for detecting contraband and to maintain security. Incoming
general correspondence is opened, but not read, and inspected for contraband before it is delivered to the detainee.
Incoming special correspondence is opened in the presence of the detainee but not read. Outgoing general correspondence
is inspected if it is addressed to another detainee or there is reason to believe that it may present a threat to the facility or
others. Rejected mail is considered contraband and is handled in accordance with the contraband standard. Detainees may
appeal rejection of correspondence through the detainee grievance system. Upon approval of the OIC, soft contraband is
returned to the sender. The security captain ensures that the records of the discovery and disposition of contraband are
accurate and current. Correspondence to/from the news media is considered special correspondence if properly identified as
such.
In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and
detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the
form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard.
Detainees may not receive compensation or anything of value for correspondence with the media and may not act as a
reporter or publish under a byline. The facility aids any detainee without legal representation who requests certain services in
connection with a legal matter (notary public, certified mail, etc.) if the detainee has no family member, friend, or community
organization able to provide assistance. When timely communication through the mail is not possible, a reasonable amount
of communication by means of a facsimile device between the detainee and designated legal representative is permitted.
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard included review of policy and an
interview with Sergeant Jase Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 5 – 27. ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES (Key: AA)
This Detention Standard permits detainees to maintain ties with their families and the community by providing detainees
emergency staff-escorted trips into the community to visit critically ill members of the immediate family or to attend their
funerals.
Standard N/A

Click the above button if all ICE Non-Medical Emergency Escorted Trips are handled only by the ICE Field Office or Sub-Office
in control of the detainee case. (All Line Items and standard will be rated “N/A”)
Components
1.

Rating

On a case-by-case basis, and with approval of the
respective Field Office Director, the facility administrator
may allow a detainee, under ICE/ERO staff escort:


To visit a critically ill member of his or her immediate
family.



To attend an immediate-family member's funeral.

Remarks (1000 Char Max)

N/A

The facility notifies ICE of all detainee requests for nonmedical escorts. Each recommendation addresses the
individual's suitability for travel, e.g., the kind of
supervision required. The Field Office Director is the
approving official for all non-medical escorted trips.

N/A

Escorts shall ensure that detainees with physical
disabilities are provided reasonable accommodations in
accordance with security and safety concerns.

N/A

PART 5 – 27. ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
All escorted trips for non-medical emergencies are conducted by ICE officers.

Overall Rating: N/A
Reviewer Name (Printed): Inspector 3

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 5 – 28. MARRIAGE REQUESTS (Key: AB)
This Detention Standard ensures that each marriage request from an ICE/DRO detainee receives a case-by-case review and
based on internal guidelines for approval of such requests.
Components
1.

Rating

All facilities shall have in place policy and procedures to
enable eligible ICE/ERO detainees to marry.
Meets Standard

Meets Standard

Detainees may submit a request
to marry to facility personnel or
directly to ICE. Any request
submitted to the facility is
forwarded directly to ICE. The
decision to approve the request
to marry rest only with ICE.
Should ICE approve the request
to marry the detainee would be
moved to another location for
the ceremony.

Meets Standard

Per ICE personnel, each request
to marry is considered on a caseby-case basis.

Meets Standard

ICE personnel would notify a
detainee on a time and place for
the ceremony in a timely
manner.

Meets Standard

Copies of all documentation
pertaining to a marriage request
and marriage would be
maintained in the detainee's Afile and the detainee's detention
file.

A detainee, or his or her legal representative, may submit
the request for permission to marry to the facility
administrator or Field Office Director in writing.

The Field Office Director or Facility Administrator
considers detainee marriage requests on a case-by-case
basis.
The facility administrator or designated Field Office staff
shall notify the detainee in a timely manner of a time and
place for the ceremony.
Once the marriage has taken place, the facility
administrator shall forward original copies of all
documentation to the detainee’s A-file and maintain
copies in the facility’s detention File.

Remarks (1000 Char Max)
The sheriff at this facility does
not allow detainees, ICE or nonICE, to marry in this facility.
Should ICE approve a detainees'
request to marry, the detainee
would be moved to another
location for the ceremony.

PART 5 – 28. MARRIAGE REQUESTS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
A review of policy and procedures confirm that detainees are not allowed the opportunity to marry while detained in this
facility. Any request to marry is immediately forwarded to ICE for processing. Should the request be approved the detainee
will be moved to a facility where marriages can be held. This move is the responsibility of ICE. Requests are considered on a
case-by-case basis.
Detainees may seek legal assistance throughout the marriage application process. Guidelines for denying a detainee's
marriage request includes the following: the detainee is not legally eligible to be married; the detainee is not mentally
competent; the intended spouse has not affirmed, in writing, his/her intent to marry the detainee; the marriage would
present a threat to the security or orderly operation of the facility; or there are compelling government interests for denying
the request. A detainee may file an appeal to the FOD if the request is denied.

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PART 5 – 28. MARRIAGE REQUESTS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

When a request is approved, after the detainee has been moved, the following guidelines are followed: the detainee, legal
representative or other individual acting on the detainee's behalf will make all the marriage arrangements including, but not
limited to, blood tests, obtaining marriage license, and retaining an official to perform the marriage ceremony. ICE personnel
do not participate in making marriage arrangements nor serve as witnesses in the ceremony. The marriage does not interrupt
nor stay any hearing, transfer to another facility or removal from the United States. Transfers do not occur solely to prevent a
marriage. All arrangements are consistent with the security and orderly operation of the facility according to the following
stipulations: the ceremony may take place inside the facility; all expenses relating to the marriage are borne by the detainee
or person acting on the detainee's behalf; and the ceremony is private with no media publicity and only individuals essential
for the marriage ceremony attend. The ICE OIC has the right of final approval concerning the time, place and manner of all
arrangements.
There have been no marriage requests processed during the inspection period.
The evaluation of this standard was based on a review of documentation and procedures; and interviews with Captain
Brandon Crowley and Detention Standards Compliance Officer Tashi Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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The facility provides an indoor recreation program.

The facility provides an outdoor recreation program.

PRIORITY: If outdoor recreation is available at the facility,
each detainee shall have access for at least one hour
daily, at a reasonable time of day, weather permitting.
Detainees shall have access to clothing appropriate for
weather conditions. If only indoor recreation is available,
detainees shall have access for at least one hour each day
to a large recreation room with exercise equipment and
access to natural sunlight. All detainees participating in
outdoor recreation shall have access to drinking water
and toilet facilities.
If a detainee is housed for more than 45 days in a facility
that provides neither indoor nor outdoor recreation, he
or she may be eligible for a voluntary transfer to a facility
that does provide recreation.
Likewise, if a detainee is housed for more than six months
in a facility that provides only indoor recreation, he or she
may be eligible for a voluntary transfer to a facility that
also provides outdoor recreation.

PRIORITY: All facilities shall have an individual responsible
for the development and oversight of the recreation
program. In SPCs/CDFs, a recreational specialist (for
facilities with more than 350 detainees) assesses the
needs and interests of the detainees.

Rating

Remarks (1000 Char Max)

Meets Standard

An indoor recreation area,
separate from the detainee
housing units, is available for use.

Does Not Meet Standard

This component was rated as
Does Not Meet Standard during
the last inspection because
outdoor recreation is not
provided. During this inspection,
it was confirmed that outdoor
recreation is not available at this
facility. This is a repeat
deficiency.

Meets Standard

Detainees have access to a multipurpose room for recreation
purposes. This room has access
to natural light and weight
equipment fixed to the floor.
Access to drinking water and
toilet facilities is available.

Meets Standard

Detainees housed in this facility
for more than six months are
eligible for a voluntary transfer
to a facility which provides
outdoor recreation.

Meets Standard

In this IGSA facility, the captain is
responsible for ensuring
detainees have access to
recreational activities outside
their housing unit. The detainee
population is less than 350.

All facilities shall provide recreational opportunities for
detainees with disabilities.

N/A

Exercise areas shall offer a variety of equipment. Weight
training, if offered, must be limited to fixed equipment.
Free weights are prohibited.

Meets Standard

Fixed to floor weight equipment
is available in the indoor
recreation (multi-purpose) room.

Meets Standard

Detainees may walk around the
perimeter of the indoor
recreation (multi-purpose) room
for cardiovascular exercise.

Cardiovascular exercise shall be available to detainees for
whom outdoor recreation is unavailable.

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not held in this facility.

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Rating

Remarks (1000 Char Max)

PRIORITY: Dayrooms in general population housing units
shall offer board games, television, and other sedentary
activities.

Meets Standard

Dayrooms provide sedentary
recreation in the form of
television and board games.

10. Recreational activities shall be based on the facility’s size
and location. With the facility administrator’s approval,
recreational activities may include limited-contact sports,
such as soccer, basketball, volleyball, and table games,
and may extend to intramural competitions among units.
Detention personnel shall supervise dayroom activities,
distributing games and other recreation materials daily.

Meets Standard

The facility provides recreational
activities to detainees.

11. Recreation areas shall be under continuous supervision
by staff equipped with radios or other communication
devices to maintain contact with the Control Center.

Meets Standard

The indoor recreation area is
under continuous video
supervison by the control center.

Meets Standard

Detainees housed in SMU status,
either administratively or
disciplinary, are provided one
hour of out of cell recreation
each day of the week. This
opportunity is provided at a
reasonable time. The area is
climate controlled. Weather
appropriate clothing is not
required.

Meets Standard

Should a detainee be deprived of
recreation or any other
authorized item or activity, a
written report would be
forwarded to the captain and ICE
would be notified of the denial
and the reasons for the denial.
Per the lieutenant, no detainees
have been denied their
recreation opportunities.

Meets Standard

Should a detainee be deprived of
recreation, the detainee would
be provided written notification
of the denial which includes the
reason for the denial and the
conditions which must be met
before the priviledge is restored.
Per the lieutenant, no detainees
have been denied their
recreation opportunities.

12. PRIORITY: Recreation for detainees housed in the SMU
shall be separate from the general population. Detainees
in the SMU shall be offered at least one hour of recreation
per day, outside their cells and scheduled at a reasonable
time, at least five days per week. Where cover is not
provided to mitigate inclement weather, detainees shall
be provided weather-appropriate equipment and attire.

13. When a detainee in an SMU is deprived of recreation (or
any usual authorized items or activity), a written report
of the action is forwarded to the facility administrator.
Denial of recreation must be evaluated daily by a shift
supervisor.

14. When recreation privileges are suspended, the
disciplinary panel or facility administrator shall provide
the detainee written notification, the reason for the
suspension, any conditions that must be met before
restoration of privileges, and the duration of the
suspension provided the requisite conditions are met for
its restoration.

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PART 5 – 29. RECREATION (Key: AC)
This Detention Standard ensures that each detainee has access to recreational and exercise programs and activities, within the
constraints of safety, security, and good order.
Components
15. The case of a detainee denied recreation privileges shall
be reviewed at least once each week as part of the
reviews required for all detainees in SMU status.

Rating

Remarks (1000 Char Max)

Meets Standard

Should a detainee be denied
recreation, the denial would be
reviewed at least once each
week. Per the lieutenant, no
detainees have been denied their
recreation opportunities.

Meets Standard

Should a detainee be denied
recreation priviledges for more
than fifteen days, the
concurrence of the captain and
health care personnel would be
required. ICE personnel would be
consulted should this
circumstance occur. No
detainees have been denied
recreation opportunities during
the inspection period.

Meets Standard

ICE is notified when a detainee is
placed in SMU status for any
reason and would be notified
should a detianee be denied
recreation priviledges for fifteen
days or more. No detainees have
been denied recreation
opportunities.

16. Denial of recreation privileges for more than 15 days
requires the concurrence of the facility administrator and
a health care professional.

17. The facility shall notify the ICE/ERO Field Office in writing
when a detainee’s denied recreation privileges exceeds
15 days.

PART 5 - 29. RECREATION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Detainees have access to indoor recreational and exercise programs and activities within the constraints of safety and
security. Facility personnel are aware of the detainees right to request a transfer to a facility which provides outdoor
recreation after they have been in this facility for six months or more. Indoor recreation is under constant video surveillance.
The captain is responsible for ensuring programs are operated in an orderly, safe and secure manner. Detainees are not
required to forgo basic law library privileges for recreation privileges. Officers search the recreation areas before and after
each use to detect altered or damaged equipment, hidden contraband and security breaches. All recreational issued
equipment is checked for damage and general condition by officers.
COVID-19 restrictions have decreased the number of detainees that can recreate at one time. Intramural competitions and
tournaments are currently not offered.
Evaluation of this standard was based on a review of policy and documentation; observations; and an interview with
detainees, Captain Brandon Crowley and Officer Bryce Barnes.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

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PART 5 - 29. RECREATION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Reviewer Signature (for printed form submission):

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PART 5 – 30. RELIGIOUS PRACTICES (Key: AD)
This Detention Standard ensures that detainees of different religious beliefs are provided reasonable and equitable
opportunities to participate in the practices of their respective faiths, constrained only by concerns about safety, security, the
orderly operation of the facility, or extraordinary costs associated with a specific practice.
Components
1.

PRIORITY: Detainees have opportunities to engage in
practices of their religious faiths (including observance of
important holy days, observance of special diets, and use
of personal religious property) consistent with safety,
security, and the orderly operation of the facility.
Attendance at all religious activities is voluntary.

Rating

Remarks (1000 Char Max)

Meets Standard

Policy and procedures are in
place to provide detainees with
the opportunity to engage in
practices of their religious faiths,
consistent with the safety,
security, and the orderly
operation of the facility.
Religious activities are voluntary.

Meets Standard

Detainees are allowed to practice
their religious beliefs in a manner
that does not affect other
detainees not involved in the
practices. Detainees are not
required to participate in or
attend a religious activity in
order to receive a service of the
facility.

Meets Standard

The religious services schedule
addresses the limitation of
religious services provided by a
smaller number of religious
volunteers.

Meets Standard

Religious activities are managed
and coordinated by a lieutenant.
Religious programs, led by
approximately two religious
volunteers, are available to
detainees.

Meets Standard

The facility has a chaplain who
also serves as the sheriffs' office
chaplain. The chaplain provides
religious counseling upon
request of a detainee. The
chaplain has access to all areas of
the facility.

Meets Standard

Religious services are held in a
multi-purpose room.

Meets Standard

Citizen volunteers, represent the
cultural and socioeconomic parts
of the community.

Religious activities shall be open to the entire detainee
population, without discrimination based on a detainee’s
race, ethnicity, religion, national origin, gender, sexual
orientation, or disability.


The facility chaplain shall endeavor to provide
opportunities for religious practice in major
languages spoken by the residents.



Accommodations will be provided to residents who
are deaf or hard of hearing to provide them access to
the service should they wish to participate.

Facility records shall reflect the limitation or
discontinuance of a religious practice along with the
reason for such limitation or discontinuance.

PRIORITY: A facility religious services coordinator
manages and coordinates religious activities for
detainees, which are augmented and enhanced by
community clergy, contractors, volunteers, and groups
that provide individual and group assembly religious
services and counseling that the facility religious services
coordinator cannot personally deliver.
The chaplain or other religious coordinator shall have
physical access to all areas of the facility to minister to
detainees and staff.

All facilities shall designate space for religious activities.

When recruiting citizen volunteers, the chaplain and
other staff shall be cognizant of the need for
representation from all cultural and socioeconomic parts
of the community.

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Detainees who are members of faiths not represented by
clergy may conduct their own services, provided they do
not interfere with facility operations.
If requested by a detainee, the chaplain or designee shall
facilitate arrangements for pastoral visits by a
clergyperson or representative of the detainee’s faith.

10. Detainees may make a request for the introduction of a
new component to the Religious Services program
(schedule, meeting time and space, religious items and
attire) to the chaplain. The chaplain shall ask the detainee
to provide additional information to use in deciding
whether to include the practice.
11. Each facility shall have written policy and procedures to
facilitate detainee observance of important holy days,
consistent with maintaining safety, security and orderly
operations, and the chaplain shall work with detainees to
accommodate proper observances.

12. Each facility administrator shall allow detainees access to
personal religious property, as is consistent with safety,
security and orderly operation of the facility.

13. When a detainee’s religion requires special food services,
daily or during certain holy days or periods that involve
fasting, restricted diets, etc., staff shall make all
reasonable efforts to accommodate those requirements
(for example, modifying menus to exclude certain foods
or food combinations, or providing meals at unusual
hours).

Rating

Remarks (1000 Char Max)

Meets Standard

Detainees are allowed to conduct
their own services.

Meets Standard

Pastoral telephonic visits, by a
clergyperson or representative of
the detainees' faith, can be
arranged when requested by the
detainee.

Meets Standard

Detainees are encouraged to
request introduction of new
religious components not
currently offered at the facility.

Meets Standard

During the last inspection this
component was found Does Not
Meet the Standard because
Policy and procedures did not
address the observance of
important holy days. During this
inspection, a facility religious
calendar is utilized to ensure holy
days are observed.

Meets Standard

Detainees are allowed access to
personal religious property which
does not pose a threat to the
safe, secure and orderly
operation of the facility.

Meets Standard

Per the captain and a review of
policy, all reasonable efforts are
made to accommodate a
detainee's religious requirements
for special food service, fasting,
restricted diets, etc.

Meets Standard

During the last inspection this
component was found Does Not
Meet Standard because a
religious fast schedule for the
calendar year had not been
developed. During this
inspection, a religious fast
schedule for the calendar year
was available for review.

14. The chaplain shall develop the religious fast schedule for
the calendar year and provide it to the facility
administrator or designee.

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PART 5 – 30. RELIGIOUS PRACTICES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Religious services have been led by a contingent of volunteers from religious community organizations. Religious activities are
coordinated by the lieutenant. Religious activities, including participation by religious volunteers, have been reduced over the
past months due to COVID-19 restrictions.
Detainees can designate any or no religious preference during admission. With a written request to the OIC, a detainee can
request to change this designation at any time, and the change will be reviewed by the captain and effected in a timely
manner.
In the interest of maintaining the safe, secure and orderly operation of the facility and to prevent abuse or disrespect by
detainees of religious practices or observances, the lieutenant, acting as the religious services coordinator, monitors patterns
of changes in declarations of the detainee's religious preference. When the facility is determining whether to allow a
detainee to participate in specific religious activity, the lieutenant, refers to the information contained in the initial
classification and the detainee’s religious designation. Detainees showing "No Preference" can be restricted from
participating in those activities deemed appropriate for members only.
Religious diet requests are forwarded to the lieutenant or captain for review and approval. When approved, the request is
forwarded to the food service manager.
Evaluation of this standard was based upon a review of policy, procedures and documentation; and interviews with
detainees, Captain Brandon Crowley, and Sergeant Jase Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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To ensure sufficient access, each facility shall provide at
least one operable telephone for every 25 detainees.

PRIORITY: Each facility shall ensure that detainees have
access to reasonably priced telephone services. Contracts
for such services shall comply with all applicable state and
federal regulations and be based on rates and surcharges
commensurate with those charged to the general public.
Any variations shall reflect actual costs associated with
the provision of services in a detention setting.
Each facility shall maintain detainee telephones in proper
working order. Designated facility staff shall inspect the
telephones daily, promptly report out-of-order
telephones to the repair service and ensure that required
repairs are completed quickly. This information will be
logged.
Facility staff is responsible for ensuring on a daily basis
that telephone systems are operational. Any problems
identified must immediately be logged and reported to
the appropriate facility and ICE staff personnel.

Each facility shall have a written policy on the monitoring
of detainee telephone calls. If telephone calls are
monitored, the facility shall include a recorded message
on its phone system stating that all telephone calls are
subject to monitoring. At each monitored telephone,
place a notice that states that detainee calls are subject
to monitoring. A detainee’s call to a court, a legal
representative, OIG, or CRCL, or for the purposes of
obtaining legal representation, may not be electronically
monitored.

Rating

Remarks (1000 Char Max)

Meets Standard

The number of detainee
telephones provided exceeds the
number required by this
component.

Meets Standard

The facility has a contract with
Securus Technologies (Securus)
for detainee telephone services.
Securus adheres to all state and
federal regulations. Telephone
rates are reasonably priced and
comparable to the public
telephone rates.

Meets Standard

Reviewed ICE officer's telephone
serviceability logs document that
telephones are maintained in
working order, and that out of
order phones are promptly
repaired or replaced.

Meets Standard

Reviewed telephone
serviceability logs document that
telephones are routinely checked
for operability. The logs also
document that inoperable
telephones are reported to
maintainenance for repair.

Meets Standard

The telephone policy includes
component requirements. The
local handbook includes
information regarding telephone
monitoring. A notice that
telephone calls may be
monitored is posted by each
telephone and a recorded
message states that all telephone
calls are subject to monitoring.
Detainees may request an
unmonitored line for legal calls.
Special access pro bono calls via
the speed dial system are free of
charge and not recorded.

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Each facility shall provide telephone access rules in
writing to each detainee upon admission, and also shall
post these rules where detainees may easily see them in
a language they can understand. Updated telephone and
consulate lists shall be posted in the detainee housing
units. Translation and interpretation services shall be
provided as needed.
Each facility administrator shall establish and oversee
rules and procedures that provide detainees reasonable
and equitable access to telephones during established
facility “waking hours.”
Detainees are afforded a reasonable degree of privacy for
legal phone calls.

Rating

Meets Standard

The local handbook addresses
each of the items listed in this
component.

Meets Standard

Reviewed policy and the local
handbook prescribe detainee
telephone usage rules.

Meets Standard

Upon request, detainees may
make legal telephone calls from
the law library or a private office,
per the ICE coordinator sergeant.

Meets Standard

A staff member will be assigned
to assist a detainee who is having
trouble placing a confidential
call, per the ICE coordinator
sergeant.

Meets Standard

Special access speed dial
numbers affording detainees the
ability to make non-collect calls
are programmed into the
telephone system, per the ICE
coordinator sergeant.

Meets Standard

Telephone service is not limited
to collect calls. Detainees are
permitted to place calls using a
debit system. The telephone
numbers for pro bono legal
organizations, consulates, and
other free legal service providers
are posted in the housing units.
These telephone calls may be
placed at no cost to the detainee

Meets Standard

Detainees are not required to
complete a request form in order
to make a free or direct call.
Instructions on how to request
assistance in making such a call
are included in the local
handbook.

A procedure exists to assist a detainee who is having
trouble placing a confidential call.

10. The facility provides the detainees with the ability to
make non-collect (special access) calls.

11. Even if telephone service is generally limited to collect
calls, each facility shall permit detainees to make direct
or free calls to the offices and individuals listed below.
Updated lists need to be posted in the detainee housing
units.

12. If detainees are required to complete request forms to
make direct or free calls, facility staff must assist them as
needed, especially illiterate or non-English speaking
detainees.

Remarks (1000 Char Max)

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PART 5 – 31. TELEPHONE ACCESS (Key: AE)
This Detention Standard ensures that detainees may maintain ties with their families and others in the community by providing
them reasonable and equitable access to telephone services.
Components
13. PRIORITY: All detainees are able to call their consulate,
the DHS Office of the Inspector General, and any
organization on the ICE/ERO-provided list of free legal
service providers at no charge to the detainee or
receiving party. The FOD will ensure that all information
is kept current and provided to each facility. Updated
contact lists are posted in the detainee housing units.

Rating

Remarks (1000 Char Max)

Meets Standard

An on-site inspector observed
the required postings in each
housing unit. The local handbook
explains that indigent detainees
are afforded the same telephone
access as other detainees; and
that they are also assisted in
calling family or others in an
emergency at no cost to either
party.

Meets Standard

Reviewed written policy
addresses the requirements of
this component.

Meets Standard

Incoming emergency telephone
calls are routed to the shift
supervisor who takes the
necessary action to verify the
emergency and inform the
detainee, per the ICE coordinator
sergeant.

Meets Standard

Incoming emergency telephone
calls are routed to the shift
supervisor who takes the
necessary action to verify the
emergency and inform the
detainee. Detainees are
permitted to return emergency
calls as soon as reasonably
possible. Indigent detainees are
permitted to return an
emergency call free of charge

Meets Standard

Accommodations are made for
detainees who are hard of
hearing and/or have a speech
disability, per the ICE coordinator
sergeant.

Indigent detainees are afforded the same telephone
access and privileges as detainees in the general
population. The indigent detainee may also request a free
call to immediate family or others in personal or family
emergencies or for a compelling need (to be interpreted
liberally).
14. A facility may neither restrict the number of calls a
detainee places to his/her legal representatives nor limit
the duration of such calls by rule or automatic cut-off,
unless necessary for security purposes or to maintain
orderly and fair access to telephones.
15. The facility has a system for taking and delivering
emergency detainee telephone messages.

16. The facility shall take and deliver telephone messages to
detainees as promptly as possible. When facility staff
receive an emergency telephone call for a detainee, the
caller’s name and telephone number will be obtained and
given to the detainee as soon as possible. The detainee
shall be permitted to return the emergency call as soon
as reasonably possible within the constraints of security
and safety. The facility shall enable indigent detainees to
make a free return emergency call.

17. The facility shall provide a TTY device or Accessible
Telephone (telephones equipped with volume control
and telephones that are hearing-aid compatible for
detainees who are deaf or hard of hearing). Detainees
who are hard of hearing will be provided access to the
TTY on the same terms as hearing detainees.
Accommodations shall also be made for detainees with
speech disabilities.

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Rating

18. Detainees in Disciplinary Segregation may be restricted
from using telephones to make general calls as part of the
disciplinary process. Even in Disciplinary Segregation,
however, detainees shall have some access for special
purposes.

Meets Standard

Written policy addresses the
requirements noted in this
component.

19. Generally, detainees in administrative segregation should
receive the same privileges that are available to
detainees in the general population, subject to any safety
and security considerations that may exist.

Meets Standard

Per policy, detainees in
administrative segregation have
similar telephone privileges as
those in the general population.

20. Upon a detainee’s request, facility staff shall make special
arrangements to permit the detainee to speak by
telephone with an immediate family member detained in
another facility.

Meets Standard

21. LYON AGREEMENT: When a detainee requests a direct or
free Legal Call to an attorney, court, or government
agency or demonstrates a compelling need for other
direct or free calls, access is granted within 24 hours of
the request and ordinarily within 8 facility waking hours.
Further delays may be justified by extraordinary
circumstances.

Meets Standard

22. LYON AGREEMENT: The facility documents and reports
to ICE/ERO any delays in responding to requests for free
or direct Legal Calls beyond 8 facility waking hours.

Meets Standard

23. LYON AGREEMENT: Detainees are provided private
settings for Legal Calls such that calls cannot be
overheard by officers, other staff, or other detainees.

Remarks (1000 Char Max)

According to the DSCO and the
ICE coordinator sergeant, access
is granted to the detainee in
accordance with component
requirements. There have been
no such delays since the previous
inspection.

Meets Standard

If a detainee needs more privacy
than is provided in the housing
unit, the ICE coordinator
sergeant or a shift supervisor will
assist the detainee.

24. LYON AGREEMENT: The facility has a system for taking
and delivering telephone messages to detainees,
including but not limited to attorney messages, other
messages related to a detainee’s legal case, and
emergency messages, and ensures the timeliness of such
message delivery.

Meets Standard

Written policy addresses the
requirements noted in this
component.

25. LYON AGREEMENT: The facility provides translation and
interpretation services to detainees who are unable to
read written telephone access rules in the languages
provided.

Meets Standard

Written policy addresses the
requirements noted in this
component.

26. LYON AGREEMENT: Detainees in segregation or other
environments with limited physical access to telephones
have reasonable and equitable access to telephones
during waking hours (i.e., they can request telephone
calls and receive them in a timely manner).

Meets Standard

Written policy addresses the
requirements noted in this
component.

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PART 5 – 31. TELEPHONE ACCESS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard included review of policy, housing
unit logs, and handbooks; interviews with DSCO Tashi Tillman and ICE Coordinator Sergeant Jase Glassburn; and observation
by on-site inspectors of telephone banks, electronic tablets (which may be used as a telephone) and postings in housing units.
The facility permits reasonable and equitable access to telephones permitting detainees to maintain established relationships
and to conduct legal business via the telephone. Unit telephones are available to detainees during routine dayroom hours,
seven days per week. In order to place a telephone call to another country outside normal waking hours, the detainee must
submit a request to a supervisor, treatment counselor or ICE officer. Inspections of the telephone system are performed daily
by housing unit officers and weekly by ICE staff.
In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and
detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the
form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Rating

Remarks (1000 Char Max)

Meets Standard

The local detainee handbook and
postings in the housing units
address the visitation procedure,
schedule, and hours for general
visitation.

Meets Standard

All general visitation is
conducted via video.

Meets Standard

Component requirements are
addressed in policy. There have
been no such denials since the
previous inspection.

Meets Standard

Visiting rules and hours are
available by telephone and on
the facility's website. The on-site
inspector also noted that similar
information is also posted in
English and Spanish in the
visitor's waiting room.

Meets Standard

General visitation is conducted
via video. Detainees may visit
with family and friends a
minimum of thirty minutes each
The local handbook notes that
visits last a minimum of thirty
minutes.via a video telephone
connection located in their
housing unit. The video visits are
permitted 8:00 a.m. to 8:00 p.m.,
seven days a week including
holidays. There are on-site
monitors for family and friends
to visit free of charge. Video
visiting from home is permitted
for a fee.

There is a written visitation procedure, schedule, and
hours for general visitation.

Each facility administrator shall decide whether to permit
contact visits, as is appropriate for the facility’s physical
plant and detainee population.
A facility administrator may temporarily restrict visiting
when necessary to ensure the security and good order of
the facility. Each restriction or denial of visits shall be
documented in writing, including the duration of and
reasons for the restriction.
Each facility shall:


Make the schedule and procedures available to the
public, both in written form and telephonically.



Post that information in the visitor waiting area in
English, Spanish, and other major languages spoken
in the facility.

PRIORITY: General visitation is permitted during set hours
on Saturdays, Sundays, and holidays, and, to the extent
practicable, the facility accommodates the scheduling
needs of visitors for whom weekends and holidays pose
a hardship. The number of visitors a detainee receives
and the length of visits are limited only by reasonable
constraints of space, scheduling, staff availability, safety,
security, and good order. The minimum duration for a
visit is 30 minutes.

Each facility shall maintain a log of all general visitors, and
a separate log of legal visitors.

Meets Standard

If the facility establishes and maintains a dress code for
visitors, it shall be made available to the public.

Meets Standard

The facility’s visiting areas shall be appropriately
furnished and arranged, and as comfortable and pleasant
as practicable.

Meets Standard

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facility's web page.

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2011 SAAPI

The facility’s written rules shall specify time limits for
visits. The minimum time limit is 30 minutes.

Rating

Remarks (1000 Char Max)

Meets Standard

The local handbook notes that
visits last a minimum of thirty
minutes.

Meets Standard

Per policy, minors are permitted
to visit at this facility.

Meets Standard

Contact visits for social visits are
not permitted. Policy addresses
contact legal visiting conditions.

Meets Standard

According to policy, denials are
documented. There have been
no individual denials of visitation
since the previous inspection.

Meets Standard

Written policy states that baring
security concerns detainees held
in special housing units will have
similar visiting privileges.

Meets Standard

Per policy, legal visits are
permitted seven days a week,
including holidays, twelve hours
per day.

Meets Standard

The on-site inspector observed
private rooms where a detainee
may meet with their legal
representative and exchange
legal documents.

Meets Standard

Per the ICE coordinator sergeant,
legal representatives and their
assistants must clear a metal
detector and have their
belongings searched prior to
their visit.

17. The current list of pro bono legal organizations is posted
in the detainee housing areas and other appropriate
areas.

Meets Standard

The on-site inspector observed
the required postings in each
housing.

18. All requests by NGOs and other organizations to send
representatives to visit detainees must be submitted in
advance and in writing to the ICE/ERO facility
administrator or ICE/ERO Field Office supervising the
contract, state or local facility. The written request must
state the number of visitors, exact reason for the visit and
issues to be discussed.

Meets Standard

Reviewed written policy
addresses the requirements of
this component.

10. At facilities where there is no provision for visits by
minors, ICE arranges for visits by children and
stepchildren, on request, within the first 30 days.
11. Written procedures shall detail the limits and conditions
of contact visits in facilities permitting them.
12. Anytime a visit is denied, to either a general population
detainee or SMU detainee, the denial is documented.

13. While in administrative or disciplinary segregation status,
a detainee ordinarily retains visiting privileges.

14. PRIORITY: Legal visitation is available seven (7) days a
week, including holidays. Legal visitation hours provide
for a minimum of eight (8) hours per day on regular
business days, and a minimum of four (4) hours per day
on weekends and holidays.
15. Private consultation rooms are available for attorney
meetings. There is a mechanism for the detainee and
his/her representative to exchange documents.

16. Legal representatives and assistants are subject to a nonintrusive search such as a pat-down search of the person
or a search of the person’s belongings – at any time for
the purpose of ascertaining the presence of contraband.

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PART 5 – 32. VISITATION (Key: AF)
This Detention Standard ensures that detainees will be able to maintain ties through visitation with their families, the
community, legal representatives, and consular officials, within the constraints of safety, security, and good order.
Components
19. Facility visitation procedures shall cover law enforcement
officials requesting interviews with detainees. Facilities
will notify and seek approval from ICE ERO of any
proposed law enforcement officer visit with a detainee.

20. Former ICE/ERO detainees, individuals with criminal
records and individuals in deportation proceedings shall
not be automatically excluded from visiting. Individuals in
any of these categories must so notify the facility
administrator before registering for visitation privileges.

Rating

Remarks (1000 Char Max)

Meets Standard

According to the ICE coordinator
sergeant, component
requirements are followed.
There have been no such
requests since the previous
inspection.

Meets Standard

According to the ICE coordinator
sergeant, component
requirements are followed.
There have been no such
requests since the previous
inspection.

PART 5 – 32. VISITATION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The facility handles visitation in accordance with the standard. The facility maintains a general visitors log which contains the
name and alien-registration number (A-number) of the detainee visited, the visitor’s name and address, the visitor’s
immigration status, the visitor’s relationship to the detainee, the date, time in and time out. The facility has written
procedures regarding incoming property and money for detainees during visitation. Staff verifies each adult visitor's identity
before admitting him or her to the facility. Interpreters can accompany legal representatives. The facility permits messengers
who are not legal representatives or legal assistants to deliver documents to and from the facility, but not to visit detainees.
Legal representatives must present a State bar card and proper identification such as a driver’s license. A separate log is
maintained for all legal visitors, including those denied access. The logs include the reason(s) for denying access.
The facility has written procedures for legal representatives and assistants to contact ICE in advance of a visit to determine
whether an individual is detained there. The procedures also include guidelines for pre-representation meetings.
This facility has procedures in place that liberally allow the opportunity for consultation visitation for detainees subject to
expedited removal in accordance with this standard. These visits are conducted in person or by telephone similar to legal
visits. Detainees can receive visits by representatives of community service organizations, including civic, religious, cultural,
therapeutic, and other groups. All visitors are required to comply with visitation rules.
This was a hybrid inspection due to COVID-19 protocols. During the evaluation of this standard, visitation procedures in
written policy and the local handbook were reviewed; ICE Coordinator Sergeant Jase Glassburn and ICE DSCO Tillman were
interviewed.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 5 – 33. VOLUNTARY WORK PROGRAM (Key: AG)
This Detention Standard provides detainees opportunities to work and earn money while confined, subject to the number of
work opportunities available and within the constraints of safety, security, and good order. While not legally required to do
so, ICE/DRO affords working detainees basic Occupational Safety and Health Administration (OSHA) protections.
Standard N/A

Click the above button if ICE detainees are not authorized to work at the IGSA facility. (All Line Items and standard will be
rated “N/A”)
Components
1.

Rating

Detainees who are physically and mentally able to work
shall be provided the opportunity to participate in any
voluntary work program.

N/A

The detainee’s classification level shall determine the
type of work assignment for which he/she is eligible.
Level 3 detainees shall not be given work opportunities
outside their housing units/living areas.

N/A

ICE detainees may not work outside the secure perimeter
of local jails and facilities used under Intergovernmental
Service Agreements.

N/A

The facility administrator shall develop site-specific rules
for selecting work detail volunteers in a facility procedure
that will include a voluntary work program agreement.

N/A

Detainees shall not be denied voluntary work
opportunities on the basis of such factors as a detainee's
race, religion, national origin, gender, sexual orientation
or disability.

N/A

While medical or mental health restrictions may prevent
some physically or mentally challenged detainees from
working, those with less severe disabilities shall have the
opportunity to participate in the voluntary work program
in appropriate work assignments.

N/A

Detainees who participate in the volunteer work program
are required to work according to a fixed schedule.

N/A

Detainees shall receive monetary compensation for work
completed in accordance with the facility’s standard
policy.

N/A

The facility administrator shall establish procedures for
informing detainee volunteers about on-the-job
responsibilities and reporting procedures.

N/A

10. When a detainee is removed from a work detail, staff
place the written justification for the action in the
detainee’s detention file.

N/A

11. All detention facilities shall comply with all applicable
health and safety regulations and standards, to include
training.

N/A

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2011 SAAPI

Click the above button if ICE detainees are not authorized to work at the IGSA facility. (All Line Items and standard will be
rated “N/A”)
Components

Rating

12. The facility administrator shall ensure that all department
heads, in collaboration with the facility’s safety/training
officer, develop and institute appropriate training for all
detainee workers.

N/A

13. Upon a detainee’s assignment to a job or detail, the
supervisor shall provide thorough instructions regarding
safe work methods and, if relevant, hazardous materials.

N/A

14. The facility shall provide detainees with safety equipment
that meets OSHA and other standards associated with the
task performed.

N/A

15. The facility administrator shall implement procedures for
immediately and appropriately responding to on-the-job
injuries, including immediate notification of ICE/ERO.

N/A

Remarks (1000 Char Max)

PART 5 – 33. VOLUNTARY WORK PROGRAM – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Detainees do not participate in the voluntary work program.

Overall Rating: N/A
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Section VI: JUSTICE
Detainee Handbook
Grievance System
Law Libraries and Legal Material
Legal Rights Group Presentations

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PART 6 – 34. DETAINEE HANDBOOK (Key: AH)
This Detention Standard requires that, upon admission, every detainee be provided comprehensive written orientation
materials that describe such matters as the facility’s rules and sanctions, disciplinary system, mail and visiting procedures,
grievance system, services, programs, and medical care, in English, Spanish, and other languages and that detainees
acknowledge receipt of those materials.
Components
1.

PRIORITY: Upon admission to a facility, as part of the
orientation program, each detainee shall be provided a
copy of the ICE National Detainee Handbook and that
facility’s local supplement to the handbook.

The facility administrator shall ensure that the local
supplement is translated into Spanish and any other
language spoken by significant numbers of detainees in
that facility.

Staff shall require each detainee to verify, by signature,
receipt of the handbook and maintain that
acknowledgement in the detainee’s detention file.

If a detainee cannot read or does not understand the
language of the handbook, the facility administrator shall
arrange for the orientation materials to be read to the
detainee, provide the material using audio or video tapes
in a language the detainee does understand, or provide a
translator.

The facility administrator shall provide a copy of the ICE
National Detainee Handbook and the local supplement to
every staff member who has contact with detainees, and
cover its contents in initial and annual staff training.

Rating

Remarks (1000 Char Max)

Meets Standard

The ICE National Detainee
Handbook and the Clay County
Justice Center Local ICE Detainee
Handbook are issued to each
detainee upon processing into
the facility. Each detainee signs
for the receipt of both
handbooks.

Meets Standard

The local handbook is translated
into Spanish. Interpretive
assistance would be provided to
a detainee who did not
communicate in English or
Spanish. The ICE National
Detainee Handbook is available
in a variety of languages.

Meets Standard

Detainees verify, by signature,
their receipt of both handbooks.
Documentation is maintained in
each detainees detention file and
was verified during the
inspection.

Meets Standard

Facility staff are provided a copy
of the local handbook. The local
handbook is also available for
review in various locations in the
facility. Contents of the local
handbook are reviewed during
initial and annual refresher
training.

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The facility administrator shall appoint a committee to
review the local supplement annually and recommend
changes. While the handbook does not have to be
immediately revised and reprinted to incorporate every
change, the facility administrator shall establish
procedures for immediately communicating such
changes to staff and detainees.

Rating

Remarks (1000 Char Max)

Meets Standard

The local handbook is reviewed
annually. The review date on the
handbook is 01/28/2020, a
memorandum from the jail
commander indicates the local
handbook was most recently
reviewed 05/18/2021. No
revisons were made. Procedures
are in place to ensure the
immediate communication of
changes to staff and detainees.

Meets Standard

The local handbook addresses
the elements of this component.

Meets Standard

The local handbook addresses
detainees responsibilities.

Meets Standard

The local handbook addresses
the facilities classification system
and explains the classification
appeal process.

Meets Standard

The local handbook states that a
medical examination will take
place within twelve hours arrival
to the facility.

Meets Standard

The local handbook describes the
facility housing units, in-dorm
activities and the special
management unit.

Meets Standard

The local handbook addresses
the elements of this component,
including count proceedures,
meal times, special diets,
clothing exchanges, and hygiene
practices.

The detainee handbook (local supplement) address the
following issues:


Personal Items permitted to be retained by the
detainee.



Initial issue of clothes, bedding and personal hygiene
items.



How to access care.

The detainee handbook (local supplement) states in clear
language basic detainee responsibilities.

The handbook (local supplement) clearly outlines the
methods for classification of detainees, explains each
level, and explains the classification appeals process.

10. The handbook (local supplement) states when a medical
examination will be conducted.

11. The handbook (local supplement) describes the facility,
housing units, dayrooms, In-dorm activities and special
management units.
12. The handbook (local supplement) describes official count
times and count procedures, meal times, feeding
procedures, procedures for medical or religious diets,
smoking policy, clothing exchange schedules and if
authorized, clothes washing and drying procedures and
expected personal hygiene practices.

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Rating

Remarks (1000 Char Max)

Meets Standard

The process for obtaining a razor
is explained in the handbook as
well as the process for obtaining
a razor to use prior to a court
appearance.

Meets Standard

Barbering hours and hair cutting
procedures are addressed in the
handbook. Restricitions and
sanitation guidelines are also
addressed in the document.

Meets Standard

The elements of this component
are addressed in the local
handbook.

Meets Standard

Religious programming and the
process for accessing a religious
diet are addressed in the local
handbook.

Meets Standard

Commisary proceedures are
outlined in the local handbook.

Meets Standard

The local handbook informs
detainees that they will not be
allowed to participate in the
volunteer work program.

Meets Standard

The law library procedures and
schedules are addressed.
General library services are
provided through the use of a
library cart which can be
accessed during recreation
hours.

Meets Standard

The elements of this component
are addressed in the local
handbook.

Meets Standard

The local handbook addresses
the agreement that the facility
has with ICE to provide detention
space.

14. The handbook (local supplement) describes barber hours
and hair cutting restrictions.

15. The handbook (local supplement) describes; the
telephone policy, debit card procedures, direct and frees
calls; locations of telephones; policy when telephone
demand is high; and policy and procedures for emergency
phone calls.
16. The handbook (local supplement) addresses religious
programming.

17. The handbook (local supplement) states times and
procedures for commissary or vending machine usage
(where available).
18. The handbook (local supplement) describes the detainee
voluntary work program.

19. The handbook (local supplement) describes the library
location and hours of operation and law library
procedures and schedules.

20. The handbook (local supplement) describes: attorney and
regular visitation hours, policies, and procedures,
location of the list of pro bono legal organizations; group
legal rights presentations schedule and sign up
procedures.
21. The handbook (local supplement) provides local ICE
contact information.

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Rating

Remarks (1000 Char Max)

22. The handbook (local supplement) describes the facility
contraband policy.

Meets Standard

The contraband policy is
addressed in the local handbook.

23. The handbook (local supplement) describes the facility
visiting hours and schedule and visiting rules and
regulations.

Meets Standard

Visiting hours, scheduling, rules
and regulations are addressed in
the local handbook.

24. The handbook (local supplement) describes
correspondence policy and procedures.

Meets Standard

The local handbook describes the
correspondence proceedures.

Meets Standard

Disciplinary policy and
procedures to include prohibited
acts and severity scale of
sanctions are addressed in the
local handbook.

Meets Standard

An explanation of the grievance
system and the process for filing
informal and formal grievances is
addressed in the local handbook.
The appeal process is addressed
as well as the detainee's right to
file an appeal directly to ICE.

Meets Standard

The local handbook describes the
medical sick call procedures for
both general population
detainees and for those housed
in the special management unit.

Meets Standard

The local handbook describes the
facilities recreation policy.

Meets Standard

The local handbook addresses
the detainee dress code for daily
living. Detainees do not
participate in the volunteer work
program. ICE detainees are
dressed in orange and white
striped uniforms; their
classification is noted by the
color of their identification wrist
bands.

Meets Standard

Rights and responsibilities of
detainees are addressed in the
local handbook.

the

25. The handbook (local supplement) describes the detainee
disciplinary policy and procedures, including: Prohibited
acts and severity scale sanctions.


Time limits in the Disciplinary Process.



Summary of Disciplinary Process.

26. The grievance section of the handbook (local
supplement) explains all steps in the grievance process,
including informal (if used) and formal grievance
procedures.

27. The handbook (local supplement) describes the medical
sick call procedures for general population and
segregation.

28. The handbook (local supplement) describes the facility
recreation policy.
29. The handbook (local supplement) describes the detainee
dress code for daily living; and work assignments and the
meaning of color-coded uniforms.

30. The handbook (local supplement) specifies the rights and
responsibilities of all detainees.

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PART 6 - 34. DETAINEE HANDBOOK – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
The local handbook serves as an overview of and guide to the policies, procedures and rules of the facility. It is available in
English and Spanish. In addition, an orientation video is provided for review by detainees while in the holding area and
translation services are utilized to interpret the information into other foreign languages as needed.
The handbook and the ICE National Detainee Handbook inform the detainee in detail as to how to report allegations of abuse
and civil rights violations, along with violations of staff misconduct, directly to ICE headquarters or the DHS OIG. The local
handbook is free from derogatory or insensitive statements about detainee religion or culture and describes the facility's
rules, programs, procedures and requirements for detainees during their detention.
The facility provides communication assistance to detainees with disabilities and detainees who are limited in their English
proficiency (LEP). The facility provides detainees with disabilities with effective communication, which may include the
provision of auxiliary aids, such as readers, telecommunications devices for deaf persons (TTYs), and interpreters, as needed.
The facility provides detainees who are LEP with language assistance, including bilingual staff or professional interpretation
and translation services.
The evaluation of this standard was based on review of policy; a review of the local handbook; and interviews with detainees,
Officer Bryce Barnes, and Captain Brandon Crowley.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PRIORITY: Each facility shall have written policy and
procedures for a detainee grievance system that:
 Establishes a procedure for any detainee to file a
formal grievance;
 Establishes a procedure to track or log all formal
grievances;
 Establishes reasonable time limits for:
o Processing, investigating, and responding to
grievances, including medical grievances;
o Convening a grievance committee (or actions of
a single designated grievance officer) to review
formal complaints; and
o Providing written responses to detainees who
filed formal grievances, including the basis for
the decision.
 Ensures a procedure in which all medical grievances
are received by the administrative health authority
within 24 hours or the next business day;
 Establishes a special procedure for time-sensitive,
emergency grievances;
 Ensures each grievance receives supervisory review;
 Provides at least one level of appeal;
 Includes guarantees against reprisal; and
 Ensures information, advice, and directions are
provided to detainees in a language or manner they
can understand, or that interpretation/translation
services are utilized. Illiterate, disabled, or nonEnglish speaking detainees shall be provided
additional assistance, upon request.
Written procedures require that detainees are informed
about the facility’s informal and formal grievance system.

Rating

Remarks (1000 Char Max)

Policy and procedures address
the elements of this component.
Meets Standard

Detainees are able to file a
grievance electronically both on
the kiosks and tablets provided
to detainees in the housing units.

Meets Standard

Per policy, detainees are issued
the local handbook which
addresses the informal and
formal grievance system.

The grievance section of the handbook explains all steps
in the grievance process.

Meets Standard

The grievance section of the
handbook explains all the steps
in the grievance process.

Written procedures provide for the informal resolution of
oral grievances.

Meets Standard

Written proceedures provide for
the informal resolution of oral
grievances.

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Remarks (1000 Char Max)

Meets Standard

Detainees submit formal
grievances directly to the
facility's ICE coordinator/
grievance sergeant, or may file
electronically on the kiosk and
tablets in the detainee housing
units. They may obtain assistance
in the preparation of grievances
from other detainees, facility
personnel, family and/or their
attorney. Medical grievances are
forwarded directly to medical
personnel

Meets Standard

Emergency grievances are
defined and identified in policy
and described in the local
handbook

Meets Standard

Officers are trained to respond to
emergency grievances in an
expeditious manner.

Meets Standard

Detainees are provided two
levels of appeal to their
grievances and may file a
grievance directly to ICE at any
time.

Meets Standard

Separate automated grievance
logs are maintained which
contain requirements for proper
tracking. Per policy, a copy of the
completed grievance, to include
the final disposition, is placed in
the detainees detention file and
provided to the detainee.
Medical grievances are
maintained in the
detainees'medical file.

Meets Standard

Per policy, any grievance alleging
staff misconduct is forwarded to
supervisory personnel and ICE is
provided a copy of the grievance.
The grievance will be processed
through the facility's established
grievance system.

The facility administrator, or designee, shall allow a
detainee to submit a formal, written grievance to a single
designated grievance officer or the facility's grievance
committee and shall be given the opportunity to obtain
preparation assistance from another detainee or facility
staff.
Formal written grievances regarding medical care shall be
submitted directly to medical personnel designated to
receive and respond to medical grievances at the facility.

Rating

Each facility shall implement written procedures for
identifying and handling a time-sensitive emergency
grievance that involves an immediate threat to a
detainee's health, safety or welfare.
All staff will be trained to appropriately respond to
emergency grievances in an expeditious matter.
The facility’s established grievance system protocol must
provide for at least one level of appeal but may establish
more than one. In all instances detainees must receive
written decisions about their appeals within reasonable
and specified time limits.
PRIORITY: Each facility shall devise a method for
documenting detainee grievances, at a minimum, a
Detainee Grievance Log. The documentation shall include
the date of the grievance, nature of the grievance in
detail, and the date the grievance was resolved. A copy of
the grievance disposition shall be placed in the detainee’s
detention file and provided to the detainee. Medical
grievances are maintained in the detainee’s medical file.

10. PRIORITY: Staff must forward all detainee grievances
containing allegations of staff misconduct to a supervisor
or higher-level official in the chain of command. While
such grievances are to be processed through the facility’s
established grievance system, CDFs and IGSA facilities
must also forward a copy of any grievances alleging staff
misconduct to ICE/ERO.

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PART 6 – 35. GRIEVANCE SYSTEM (Key: AI)
This Detention Standard protects detainees’ rights and ensures they are treated fairly by providing a procedure by which they
may file formal grievances and receive timely responses.
Components
11. Staff shall not harass, discipline, punish, or otherwise
retaliate against a detainee who files a complaint or
grievance or who contacts the Inspector General or the
Office for Civil Rights and Civil Liberties.

Rating

Remarks (1000 Char Max)

Meets Standard

Per policy, staff are prohibited
from treating a detainee unfairly
who files a complaint or
grievance or who contacts the
Inspector General or the Office
for Civil Rights and Civil Liberties.

PART 6 – 35. GRIEVANCE SYSTEM – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Policies and procedures are in place that protect detainee rights and ensure detainees are treated fairly by providing an
avenue to file informal and/or formal grievances and to receive timely responses to those complaints. There have been no
general grievances and one medical grievance filed by detainees during the inspection period.
Written procedures are in place for handling emergency grievances and urgent access to legal counsel and the law library.
Translation and interpretation services are available as needed. Formal grievance procedures are communicated to detainees
in a language and manner they understand. All materials are translated into Spanish, or other languages if significant
segments of the detainee population have the need.
Separate automated grievance logs, one for general grievances and one for medical grievances, collect the information
required by the standard and is used to track and document grievances.
The facility provides communication assistance to detainees with disabilities and detainees who are limited in their English
proficiency (LEP). The facility can provide, if necessary, effective communication to detainees with disabilities, which may
include the provision of auxiliary aids, such as readers, telecommunications devices for deaf persons (TTYs), and interpreters
via a telephonic language line service. The facility can provide, if necessary, detainees who are LEP with language assistance,
including bilingual staff or professional interpretation and translation services.
The evaluation of this standard was based on review of the grievance policy and the grievance logs; interviews with
detainees; and interviews Captain Brandon Crowley and Stan Roark, HSA.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (Key: AJ)
This Detention Standard protects detainees’ rights by ensuring their access to courts, counsel, and legal materials.
Components
1.

Each facility shall provide a properly equipped law library
in a designated, well-lit room that is reasonably isolated
from noisy areas and large enough to provide reasonable
access to all detainees who request its use. It shall be
furnished with a sufficient number of tables and chairs to
facilitate detainees’ legal research and writing.
PRIORITY: Each detainee shall be permitted to use the law
library for a minimum of five hours per week and may not
be forced to forego his or her minimal recreation time to
use the law library, consistent with the security needs of
the institution and the detainee.
PRIORITY: The law library shall provide an adequate
number of computers with printers, access to one or
more photocopiers and sufficient writing implements,
paper, and related office supplies to enable detainees to
prepare documents for legal proceedings. Typewriters,
carbon paper, and correction tape may be substituted for
computers and printers only if approved by ICE/ERO.
Each facility administrator shall designate an employee to
inspect the equipment at least weekly and ensure it is in
good working order and to stock sufficient supplies.

Rating

Meets Standard

A computer equipped with
LexisNexis is provided in a
private room.

Meets Standard

Detainees may use the law
library computer one hour per
day, each weekday upon request.
They do not have to forgo
recreation time to use the law
library.

Meets Standard

There is a sufficient number of
computers, printers,
photocopiers, writing
implements, paper and office
supplies to enable detainees to
prepare documents for legal
proceedings. A computer
equipped with LexisNexis is
available. The jail commander is
designated to inspect the
equipment.

Meets Standard

Flash drives are available for
purchase in the commissary.
According to the ICE coordinator
sergeant, a flash drive would be
provided to an indigent detainee
for free.

Meets Standard

The LexisNexis applications on
the library's computer is
routinely updated and is current
during this inspection. The last
update was in September 2021.

Meets Standard

The jail commander is designated
responsibilities for inspecting and
maintaining the law library
computer.

Meets Standard

Detainees have access to the
LexisNexis electronic immigration
prison library which provides all
materials listed in Appendix
6.3.A. The LexisNexis law library
is available in English and
includes a Spanish tutorial.

Detainees are provided with the means to save legal work
in a private electronic format for future use.

The facility subscribes to updating services where
applicable and legal materials requiring updates are
current.

Each facility administrator shall designate a facility law
library coordinator to be responsible for updating legal
materials, inspecting them weekly, maintaining them in
good condition and replacing them promptly as needed.
PRIORITY: The law library contains all materials listed in
the “Law Libraries and Legal Materials” Standard,
Attachment A. As an alternative to obtaining and
maintaining the paper-based publications in Attachment
A, a facility may substitute the Lexis/Nexis publications on
CD ROM. Any materials listed in Attachment A which are
not loaded onto the Lexis/Nexis CD ROM must be
maintained in paper form.

Remarks (1000 Char Max)

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PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (Key: AJ)
This Detention Standard protects detainees’ rights by ensuring their access to courts, counsel, and legal materials.
Components
8.

Rating

Remarks (1000 Char Max)

The facility administrator must certify to the respective
Field Office Director – and the Field Office Director must
verify – that the facility provides detainees sufficient:


Operable computers that are capable of running the
Lexis/Nexis CEROM,



Operable printers,



Supplies for both, and



Instructions for detainees on the basic use of the
system.

Outside persons and organizations may submit published
or unpublished legal material for inclusion in a facility’s
law library. If the material is in a language other than
English, an English translation must be provided. Outside
published material is forwarded and reviewed by the ICE
prior to inclusion.

10. Detainees who require legal material not available in the
law library may make a written request to the facility law
library coordinator, who shall inform the Field Office of
the request as soon as possible.

11. The facility shall ensure that detainees can obtain
photocopies of legal material when such copies are
reasonable and necessary for a legal proceeding involving
the detainee.
12. The facility permits detainees to assist other detainees,
voluntarily and free of charge, in researching and
preparing legal documents.

13. Unrepresented illiterate or non-English speaking
detainees who wish to pursue a legal claim related to
their immigration proceedings or detention, and who
indicate difficulty with the legal materials, must be
provided with more than access to a set of Englishlanguage law books. To the extent practicable and
consistent with the good order and security of the facility,
all efforts will be made to assist disabled persons in using
the law library.

Meets Standard

The ICE coordinator stated that
requests to submit materials to
ICE detainees must be approved
by ICE/ERO. Approved materials
would, at a minimum, be
provided in English and Spanish.
There have been no such
requests since the previous
inspection.

Meets Standard

The local handbook states that
detainees may refer a request for
legal materials not available in
the law library to ICE. If
approved, the requests are
addressed in a timely manner.

Meets Standard

Detainees may obtain copies of
legal materials upon request, per
the ICE coordinator sergeant.

Meets Standard

The local handbook states that
detainees may assist one another
in researching or preparing legal
documents. It further states that
the assistance must be voluntary
and free of charge.

Meets Standard

The ICE coordinator sergeant,
other staff, or other detainees
will assist LEP or unrepresented
detainees with using the law
library.

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PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (Key: AJ)
This Detention Standard protects detainees’ rights by ensuring their access to courts, counsel, and legal materials.
Components

Rating

Remarks (1000 Char Max)

Meets Standard

The local handbook states that
detainees may keep a reasonable
amount of legal materials with
them in their housing unit or in
special housing baring security
concerns.

Meets Standard

Review of written policy found
that detainees in administrative
and disciplinary segregation are
permitted the same law library
access as those in the general
population, unless there is a
threat to safety. Written policy
also states that any denial or
restriction of detainee law library
access must be documented.

Meets Standard

Written policy states that all
restrictions or denials of
detainee law library access must
be documented. Such actions
must be justifiable; the
restriction must be for a limited
period and periodically reviewed.
Copies of the documentation
must be sent to the ICE field
office and placed in the
detainee's detention file.

17. The facility shall provide assistance to any unrepresented
detainee who requests a notary public, certified mail, or
other such services to pursue a legal matter, if the
detainee is unable do so through a family member,
friend, or community organization.

Meets Standard

Services listed in this component
are requested through the ICE
coordinator sergeant.

18. Staff shall not permit a detainee to be subjected to
reprisals, retaliation, or penalties because of a decision to
seek judicial or administrative relief or investigation of
any matter.

Meets Standard

Policy contains prohibitions for
the behaviors and actions listed
in the component.

14. The facility shall permit a detainee to retain all personal
legal material upon admittance to the general population
or Administrative Segregation or Disciplinary Segregation
units, unless this would create a safety, security, or
sanitation hazard. Stored legal materials are accessible
within 24 hours of a written request.
15. Detainees housed in Administrative Segregation and
Disciplinary Segregation units have the same law library
access as the general population, unless compelling
security concerns require limitations.

16. Denial of access to the law library must be:


Supported by compelling security concerns,



For the shortest period required for security,



Fully documented in the Special Management Unit
housing logbook, and



The reason should be documented and placed in the
detention file.

The facility shall notify the Field Office every time access
is denied and send a copy of the proper documentation.

PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Detainee's rights are protected by enabling their access to the courts, counsel and legal materials. Each detainee has the
opportunity to research his/her legal status and is provided the necessary equipment and materials to do so. Staff
accommodates detainee requests for priority access to the law library by giving preference to those facing pressing court
deadlines.
Photocopies of a detainee's casework are provided at no charge. The booking sergeant, or designee, inspects documents
offered for photocopying to ensure they are licit, but does not read the legal documents. Requests are denied only if the
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PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

document poses a security risk, threat to orderly operations, violation of any law or regulation and/or the request is clearly
abusive or excessive. Indigent detainees are provided free envelopes and stamps for domestic mail related to their legal
matters and for correspondence to a legal representative, a potential legal representative or any court. Requests to send
international mail at no cost are reviewed by ICE/ERO on a case-by-case basis.
ICE/ERO determines acceptance of outside published materials into the law library based on usefulness of the materials and
space limitations, and notifies the submitter if materials are declined. ICE/ERO answers all requests for additional legal
material promptly. Outdated legal materials are removed from the law library and damaged or stolen materials are replaced
as necessary, by the booking sergeant, or his designee.
This was a hybrid inspection due to COVID-19 protocols. Evaluation of this standard was based on interviews with ICE
Coordinator Sergeant Jase Glassburn and DSCO Tashi Tillman; observation by on-site inspectors of LexisNexis computer and
office supply inventories; and review of policy and handbook.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 6 – 37. LEGAL RIGHTS GROUP PRESENTATIONS (Key: AK)
This Detention Standard protects detainees’ rights by ensuring their access to information presented by authorized persons
and organizations for the purpose of informing them of U.S. immigration law and procedures.
Standard N/A

Click the above button if No Group Presentations were conducted within the past 12 months. (All Line Items and standard
will be rated “N/A”)
Components
1.

If upon notification by the Field Office Director that a
group presentation on legal rights has been approved,
the facility administrator shall telephone the listed
contact person to arrange a mutually acceptable date and
time for the presentation according to the standard.

Rating

N/A

PRIORITY: At least 48 hours before a scheduled
presentation, facility staff shall in each housing unit
prominently display the informational posters provided
by the presenter, and provide a sign-up sheet for
detainees who plan to attend.
The facility shall ensure that presentations are open to all
detainees, regardless of the presenter’s intended
audience, except when a particular detainee’s
attendance would pose a security risk. If a detainee in
segregation cannot attend for this reason, facility staff
shall make alternative arrangements, if the detainee or
the presenter so request.

N/A

One or more legal assistants may help with a
presentation.

N/A

The presenters ordinarily will have at least one hour for
the presentation and additional time for a question-andanswer session ICE/ERO and/or facility staff may observe
and monitor presentations, assisted by interpreters as
necessary. ICE/ERO and facility personnel will not
interrupt a presentation, except for security purposes or
if the allotted time has expired.

N/A

If approved in advance by ICE/ERO, presenters may
distribute brief written materials that inform detainees of
U.S. immigration law and procedure. The request for
approval of a presentation must list any published or
unpublished materials proposed for distribution, and the
requestor must provide a copy of any unpublished
material, with a cover page.

N/A

Following a group presentation, the facility shall permit
presenters to meet with small groups of detainees to
discuss their cases as long as meetings do not interfere
with facility security and orderly operations.

N/A

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Remarks (1000 Char Max)

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Click the above button if No Group Presentations were conducted within the past 12 months. (All Line Items and standard
will be rated “N/A”)
Components
7.

The facility may discontinue or temporarily suspend
group presentations by any or all presenters, if they:
 Pose an unreasonable security risk;
 Interfere substantially with the facility’s orderly
operation;
 Deviate materially from approved presentation
material, procedures or presenters; or if


Rating

Remarks (1000 Char Max)

N/A

The facility is operating under emergency conditions.

PRIORITY: If ICE/ERO approves an electronic presentation
submitted by qualified individuals or organizations, the
facility shall provide regularly scheduled and announced
opportunities for detainees in the general population to
view or listen to the electronic presentation(s).
Each facility shall present only ICE/ERO-approved
electronic presentations on detainee legal rights.

N/A

The facility shall maintain electronically-formatted
presentations and equipment in good condition.

N/A

PART 6 - 37. LEGAL RIGHTS GROUP PRESENTATIONS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
There have been no legal rights presentations conducted at this facility in the past twelve months.

Overall Rating: N/A
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Section VII: ADMINISTRATION & MANAGEMENT
Detention Files
News Media Interviews and Tours
Staff Training
Transfer of Detainees

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PART 7 – 38. DETENTION FILES (Key: AL)
This Detention Standard contributes to efficient and responsible facility management by maintaining for each detainee booked
into a facility for more than 24 hours a file of all significant information about that person.
Components
1.

Rating

For every new arrival whose stay will exceed 24 hours, a
designated officer shall create a detainee detention file.
The detainee detention file contains either originals or
copies of documentation and forms generated during the
admissions process.

Meets Standard

Review of detainee files
confirmed that detention files
contain documentation and
forms generated during the
admissions process.

Meets Standard

Detention files are stored in the
ICE coordinator's office which is a
secure room. Access to the office
is restricted to authorized
personnel; detainees have no
access to the office or the
detention files.

The detention files are located and maintained in a
secured area.

Each detention file remains active during the detainee’s
stay. When the detainee is released from the facility, staff
add copies of completed release documents, the original
closed-out receipts for property and valuables, the
original I-385 or equivalent and other documentation.

Remarks (1000 Char Max)
A detention file is created for
each new arrival during the
admissions process.

Per the ICE coordinator sergeant,
active files are maintained and
closed in accordance with the
requirements of this component
Meets Standard

The inspector examined detainee
files that had been marked
"closed" and found copies of the
close out documents referenced
in the component.

At a minimum, a logbook entry recording the file’s
removal from the cabinet shall include:


The detainee’s name and A-File number;



Date and time removed;



Reason for removal;



Signature of person removing the file, including title
and department;



Date and time returned; and



Signature of person returning the file.

Electronic record-keeping systems
protected from unauthorized access.

and data

Meets Standard

A log is maintained for any
detention file that is removed
from the records office. The log
includes all of the information
required by the component.

Meets Standard

The inspector was informed that
electronic files are password
protected.

are

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PART 7 – 38. DETENTION FILES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard included observation by on-site
inspectors of the detention file storage area; review of ten active detention files and five closed out detention files; and
interview with ICE Coordinator Sergeant Jase Glassburn.
A detention file is created for each newly admitted detainee during the admissions process.
Detention files are handled in accordance with the standard. The facility has procedures in place to ensure that intake officers
always have the necessary supplies, that equipment is maintained in good working order, including photocopier(s) and paper
and the equipment has the capacity to handle the volume of work generated. The officer closing the detention files makes a
notation that the file is complete and ready for archiving. The closed file is not transferred with the detainee to another
facility. Detention files are handled in accordance with the provisions of the Privacy Act and records are only released
following those guidelines.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 7 – 39. NEWS MEDIA INTERVIEWS AND TOURS (Key: AM)
This Detention Standard ensures that the public and the media are informed of events within the facility’s areas of
responsibility through interviews and tours.
Components
1.

Rating

Remarks (1000 Char Max)

Interviews by reporters, other news media
representatives, academics and parties not included in
other visitation categories in the Detention Standard on
Visitation shall be permitted access to facilities only by
special arrangement and with prior approval of the
respective ICE/ERO Field Office Director.

Meets Standard

Interviews as described in the
component require the approval
of ICE.

News media organizations shall abide by the policies and
procedures of the facility being visited or toured. Media
representatives must obtain advance permission from
the facility administrator and FOD before taking
photographs in or of any facility. The facility
administrator shall advise both media representatives
and detainees that use of any detainee's name,
identifiable photo, or recorded voice requires his or her
prior permission.

Meets Standard

Staff interviews confirmed that
the requirements of this
standard are complied with.

Media representatives shall obtain a signed release from
the detainee before photographing or recording his or
her voice. The original of the form is to be filed in the
detainee’s A-file with a copy in the facility’s Detention
File.

Meets Standard

Staff interviews confirmed that
the requirements of this
standard are complied with.

Meets Standard

Per the DSCO, ICE would
coordinate with the media
representative to obtain a signed
release from the detainee as
required by the component. The
original form would be filed in
the A-file with a copy placed in
the detention file. No ICE
detainees were interviewed since
the previous inspection.

Meets Standard

The DSCO confirmed that an ICE
public information officer would
coordinate with the Field Office
Director to ensure that press
pool protocols for
accommodating a large volume
of interview requests are
followed.

When the alien is the center of a controversy or of a
special interest or high profile case, the Field Office
Director shall consult with the Headquarters Deputy
Assistant Director, Detention Management Division,
before deciding whether to allow the interview.

A press pool may be established when the Field Office
Director and facility administrator determine that the
volume of interview requests warrants such action. The
facility administrator shall notify all media
representatives with pending or requested interviews,
tours, or visits that, effective immediately and until
further notice, all media representatives must comply
with the press pool guidelines established by the Field
Office Director.

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PART 7 - 39. NEWS MEDIA INTERVIEWS AND TOURS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
This was a hybrid inspection due to COVID-19 protocols. The evaluation of this standard included review of policy and
procedures; interviews with ICE Coordinator Sergeant Jase Glassburn and DSCO Tashi Tillman.
News media interviews and tours are handled in accordance with this standard. The facility has procedures in place that
provide a location conducive to the interviewing activity, consistent with security and good order. There are written policy
and procedures to ensure that a media request does not delay or otherwise interfere with the admission or departure of a
detainee.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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Rating

The facility conducts appropriate orientation, initial
training, and annual training for all staff, contractors, and
volunteers with appropriate assessment measures.

Remarks (1000 Char Max)
During the last inspection this
component was found Does Not
Meet the Standard because per
Indiana regulations, new
corrections officers must
complete the State of Indiana
Law Enforcement/Police
Academy - Jail School training
within their first year of
employment.

Does Not Meet Standard

During this inspection, it was
confirmed that per Indiana
regulations, new corrections
officers must complete the State
of Indiana Law
Enforcement/Police Academy Jail School training within their
first year of employment. In
addition, new Clay County jail
employees must complete a
forty hour on-the-job training
program prior to working a post
alone. A forty-hour annual
refresher training is provided and
documented to corrections
personnel. Interviews with staff
and a review of documentation
indicated volunteers and county
maintenance personnel are not
provided appropriate training.
This is a repeat deficientcy.

The amount and content of training is consistent with the
duties and function of each individual and the degree of
direct supervision that individual receives.
At least one qualified individual with specialized training
for the position coordinates and oversees the staff
development and training program. At a minimum, fulltime training personnel complete a 40-hour training-fortrainers course.

Meets Standard

Training is consistant with the
duties each individual performs
at the facility.

Meets Standard

The forty-hour jail school training
is provided by certified trainers.
The captain and lieutenant are
not full-time training personnel;
however, they provide training to
facility personnel. Each has
completed a leadership training
program.

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Training is governed and guided by a training plan that is
reviewed and approved annually by the facility
administrator.

Training shall be conducted by trainers certified in the
subject matter.

Each trainee shall be required to pass a written or
practical examination to ensure the subject matter has
been mastered.

The formal training received by each trainee shall be fully
documented in permanent training records.

Rating

Remarks (1000 Char Max)

Meets Standard

The training plan is presented as
the required topics covered in
the annual refresher plan. The
training is presented by the
captain, who serves as the facility
administrator.

Meets Standard

Training is conducted by certified
trainers.

Meets Standard

Written or practical examinations
are administered after training
sessions to ensure the subject
matter is understood.

Meets Standard

Written training records are
maintained for facility staff.

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Rating

Each new employee, contractor, and volunteer is
provided an orientation prior to assuming duties. While
tailored specifically for staff, contractors, and volunteers,
the orientation programs include, at a minimum:


ICE/ERO National Detention Standards



Working conditions



Cultural diversity for understanding staff and
detainees



Requirements of special-needs detainees



Code of ethics



Personnel policy manual



Employees' rights and responsibilities



Drug-free workplace



Health-related emergencies



Signs of suicide risk, suicide precautions, prevention,
and intervention



Hunger strikes



Use of force



Key and lock control



Overview of the criminal justice system



Tour of the facility



Facility goals and objectives



Facility organization



Staff rules and regulations



Sexual harassment/sexual misconduct awareness



Hostage situations and staff conduct if taken hostage



Program overview.

Clerical/support employees who have minimal detainee
contact receive the facility initial training and training
specific to their job duties.

Does Not Meet Standard

Remarks (1000 Char Max)

During the last inspection, this
component was found Does Not
Meet Standard because county
maintenance personnel and
volunteers are not provided
orientation training which
address at a minimum the
elements of this component.
County maintenance personnel
are not members of jail staff but
are in the facility frequently and
have interaction with detainees.
Interviews with the lieutenant
indicated religious volunteers
were not trained prior to
providing services available to
detainees and non-ICE detainees.
During this inspection, staff
interviews confirm that county
maintenance personnel and
volunteers are not provided
orientation training which
address at a minimum the
elements of this component.
Staff indicated religious
volunteers were not trained prior
to providing services available to
detainees and non-ICE detainees.
This is a repeat deficientcy.

N/A

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There are no clerical and/or
support personnel who have
minimal contact with detainees.

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)

10. Professional and support employees (including
contractors) who have regular or daily detainee contact
will receive training on the following subjects, at a
minimum:


ICE/ERO National Detention Standards update



Security procedures and regulations



Code of Ethics



Health-related emergencies



Drug-free workplace



Supervision of detainees



Signs of hunger strike



Signs of suicide risk, suicide precautions, prevention,
and intervention



Use-of-force regulations and tactics



Hostage situations and staff conduct if taken hostage



Report writing



Detainee rules and regulations



Key and lock control



Rights and responsibilities of detainees



Safety procedures



Emergency plan and procedures



Interpersonal relations



Social and cultural lifestyles of the detainee
population



Cultural diversity for understanding staff and
detainees



Communication skills



Cardiopulmonary resuscitation (CPR)/First aid



Counseling techniques



Sexual harassment
awareness

Meets Standard

and

sexual

misconduct

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There are no clerical and/or
support personnel who have
minimal contact with detainees.
Professional personnel receive
training which addresses the
elements of this component.

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
2011 SAAPI

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

During the last inspection this
component was found Does Not
Meet the Standard because
there was no documentation
provided to indicate full-time
health care personnel receive
forty hours of formal orientation
training which addresses the
elements of this component.

11. Full-time health care employees receive at least 40 hours
of formal orientation before undertaking their
assignments. In addition to the training areas above, the
health-care employee orientation program includes
instruction in the following:

















ICE/ERO National Detention Standards update
The purpose, goals, policies, and procedures for the
facility and parent agency security and contraband
regulations
Key and lock control; appropriate conduct with
detainees
Medical grievance procedures and protocols
Emergency medical procedures
Requirements of special-needs detainees
Code of ethics
Drug-free workplace
Responsibilities and rights of employees
Standard precautions
Occupational exposure
Personal protective equipment
Bio-hazardous waste disposal
Overview of the detention operations
Hostage situations and staff conduct if taken hostage

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During this inspection, there was
no documentation provided to
indicate full-time health care
personnel receive forty hours of
formal orientation training which
addresses the elements of this
component.
This is a repeat deficientcy.

Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities with
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Rating

Remarks (1000 Char Max)

Meets Standard

Documentation was provided
and reviewed which confirms the
required training has been
provided.

N/A

The facility does not have a
situation response team. Should
this type of assistance be
required patrol deputies would
be called in to assist jail
personnel.

Meets Standard

The captain and lieutenant have
received leadership training.
Documentation of the training
was reviewed during the
inspection.

12. Security personnel (including contractors) will receive
training on the following subjects, at a minimum:


ICE/ERO National Detention Standards update



Security procedures and regulations



Supervision of detainees



Searches of detainees, housing units, and work areas



Signs of suicide risk, suicide precautions, prevention,
and intervention



Indicators of hunger strike



Code of Ethics



Health-related emergencies



Drug-free workplace



Self-defense techniques



Use-of-force regulations and tactics



Hostage situations and staff conduct if taken hostage



Report writing



Detainee rules and regulations



Key and lock control



Rights and responsibilities of detainees



Safety procedures



Emergency plans and procedures



Interpersonal relations



Social/cultural lifestyles of the detainee population



Cultural diversity for detainees and staff



Communication skills



Cardiopulmonary resuscitation (CPR) and first aid



Counseling techniques



Sexual abuse and assault awareness

13. Situation Response Teams (SRTs) receive:


Specialized training
assignments.

before

undertaking

their

14. Facility management and supervisory staff receive
Management and Supervisory training.

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PART 7 – 40. STAFF TRAINING (Key: AN)
This Detention Standard ensures that staff, contractors, and volunteers are competent in their assigned duties by requiring
that they receive initial and ongoing refresher training.
Components
15. PRIORITY: Personnel authorized to use firearms receive
training that covers their use, safety, and care and
constraints on their use – before being assigned to a post
involving their possible use.

Rating

Remarks (1000 Char Max)

Meets Standard

Personnel authorized to use
firearms are provided training
which addresses the
requirements of this component.
Competency in the use of the
firearm is required annually.

Meets Standard

Only authorized and trained staff
utilize chemical agents. Those
that are authorized to use
chemical agents are provided
training which addresses the
requirements of this component.
The training includes the trainees
exposure to the chemical agent
so the trainee will have a clear
understanding of the effects of
its use. The training also includes
the decontamination of
individuals exposed to the
chemical.

All personnel authorized to use firearms demonstrate
competency in their use at least annually.
16. PRIORITY: Personnel authorized to use chemical agents
receive training in the use of chemical agents and in the
treatment of individuals exposed to a chemical agent
before being assigned to a post involving their possible
use.

PART 7 – 40. STAFF TRAINING – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Training is provided by certified trainers assigned to the Clay County Sheriff's Office.
New facility officers must complete the State of Indiana Law Enforcement/Police Academy - Jail School training within their
first year of employment. The facility has not sent new officers to the training during the inspection period.
Personnel authorized to use firearms are provided training which addresses the requirements of the standard.
Competency in the use of the firearm is required annually.
Volunteers who enter the facility are not provided an orientation training as required by the standard. Maintenance is
provided by county maintenance personnel, which are not jail personnel nor are they county personnel assigned
permanently to the jail.
Evaluation of this standard was based on review of the training plan, training policy and sign-in documents; and interviews
with Captain Brandon Crowley and Sergeant Jase Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 32

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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PART 7 - 41. TRANSFER OF DETAINEES (Key: AO)
This Detention Standard ensures that transfers of detainees from one facility to another are professionally and responsibly
managed in regard to notifications, detainee records, safety and security, and protection of detainee funds and personal
property.
Components
1.

Rating

Remarks (1000 Char Max)

Meets Standard

Policy and procedures adhere to
the requirements of this
component. Detainee transfers
are scheduled and coordinated
by ICE.

Meets Standard

ICE and facility staff informed the
inspector that I-203 forms
authorize detainee removals. The
inspector also examined I-203
forms contained in closed
detainee files.

Meets Standard

Per the ICE coordinator sergeant,
medical staff is notified of
transfers sufficiently in advance
of the transfer so that medical
staff may determine and provide
for any associated medical
needs.

Meets Standard

A medical summary is prepared
which contains the information
required by the component.

Meets Standard

Policy requires a Transfer
Summary be provided to
transportation staff before a
detainee may be transferred.

Facility policy mandates that:


Times and transfer plans are never discussed with
the detainee prior to transfer.



The detainee is not notified of the transfer until
immediately prior to departing the facility.



The detainee is not permitted to make any phone
calls or have contact with any detainee in the general
population.

A detainee may not be removed from any facility without
a Form I-203 or I-203A or equivalent authorizing the
removal of the detainee the facility.

The facility health care provider shall be notified
sufficiently in advance of the transfer that medical staff
may determine and provide for any associated medical
needs.

The sending facility's medical staff shall prepare a
Transfer Summary that must accompany the transferee.
Either the USM 553 Form or a facility-specific form may
be used, provided it shows:


TB clearance, including PPD and Chest x-ray results,
with the test dates;



Current mental and physical health status, including
all significant health issues;



Current medications, with specific instructions for
medications that must be administered en route;
and



The name and contact information
transferring medical official.

of the

Transportation staff may not transport a detainee
without the required Transfer Summary, which is
essential for detainee safety while in transit.

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Remarks (1000 Char Max)

Meets Standard

Facility staff informed the
inspector that medical personnel
will advise the facility
administrator when a detainee's
medical or psychiatric condition
requires clearance prior to
transfer or a medical escort is
required during the transfer.

Meets Standard

Reviewed policy issuances
confirmed that each element of
this component is addressed.
Interviews with staff confirmed
that the policy is also followed in
practice.

Meets Standard

Reviewed policy issuances
confirmed that each element of
this component is addressed.
Interviews with staff confirmed
that the policy is also followed in
practice.

Meets Standard

Facility staff informed the
inspector that detainees arriving
at this IGSA are provided the
opportunity to place a telephone
call within 24 hours, free of
charge.

Medical staff shall notify the facility administrator when
they determine that a detainee’s medical or psychiatric
condition requires:



Rating

Clearance by the medical staff prior to transfer, or
Medical escort during transfer.

PRIORITY: Prior to transfer, medical personnel shall
provide the transporting officers instructions and, if
applicable, medication(s) for the detainee’s care in
transit.
Detainees shall be transferred with, at a minimum, 7 days
worth of prescription medications (TB medications, a 15
days supply) to ensure continuity of care throughout the
transfer and subsequent intake process.
Medications shall be:




Placed in a property envelope with the detainee's
name and A-number on it,
Accompany the transfer, and
If unused, be turned over to an officer at the
receiving Field Office.

Before transfer, the sending facility shall return all funds
and small valuables to the detainee and close out all
forms G-589 (or local IGSA funds and valuables receipts)
in accordance with the Detention Standard on Funds and
Personal Property.
Within 24 hours of arrival at the final transfer destination
all detainees should be given the opportunity to make a
phone call. Any indigent detainee shall be permitted a
single domestic phone call at the Governments expense,
ordinarily using a PCS Emergency Card or equivalent.

PART 7 - 41. TRANSFER OF DETAINEES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max)
Transfers are approved and facilitated with consideration for the safety and security of the staff, detainees and the public.
Policy and procedures address notifications, detainee records and the protection of detainee funds and property. ICE officer
informed the inspector that indigent detainees being transferred will be authorized a single domestic phone call at the
government's expense upon arrival at their destination. Non-indigent detainees have access to make calls at their own
expense pursuant to the Detainee Telephone Access standard.

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2011 SAAPI

PART 7 - 41. TRANSFER OF DETAINEES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and
detainees with disabilities. This may be achieved via bilingual staff, translation services, or other means for LEP detainees; or
in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard.
To evaluate this standard, policy was reviewed, a detainee transfer was observed and Jail Commander Brandon Crowley and
ICE Coordinator Sergeant Glassburn were interviewed.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 11

I Completion Date: 12/9/2021

Reviewer Signature (for printed form submission):

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DOCUMENT CHECK
The document check should be run upon completion of the review form and PRIOR to submission
to DHS-ICE. This check will help ensure the form is ready for upload to DHS-ICE systems. Errors
indicate issues were found with specific data entered into the form. Items Not Rated indicate
there were line items found on the form which remain in a “Not Rated” status. This action will
also update the table of contents.
The check will take several minutes to complete, during which the screen will flash.
Review Document Issue Summary

Ratings check complete.

Check
Document:
Errors:

Error(s)
Found:

Run Check

Items Not
Rated:

No Errors Found

Items Not Rated:

All Items Rated

Run Indicator:
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