Department of Homeland Security-Conditon of Confinement Worksheet, May 2021

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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

ICE Performance-Based National Detention Standards 2008
Inspection Worksheet for Over 72 Hour Facilities
REVIEW TEAM USE: (Edits Permitted, ALL FIELDS REQUIRED)

Facility Information
Facility Name: Clay County Justice Center

Facility Type: IGSA

Review Purpose: Annual

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

Address:

City: Brazil
County:

611 East Jackson Street

1
I

Clay

State: IN

CEO Name: Paul Harden
Review Information (Use following format for dates: mm/dd/yyyy)
Start Date: 5/18/2021
End Date: 5/20/2021
Lead Name: Inspector 3

I
I

Zip: 47834

CEO Title: Sheriff

Type: Special Assessment
l ReviewLead
Title:
LCI

Review Document Issue Summary (See Document Check Section to Review/Update)
Error(s) Found:

Items Not Rated:

ICE HQ USE ONLY: (DO NOT EDIT*)
Form Name: PBNDS_2008_G324A_O72_LYON

Form Key: 27

Form Date: 5/9/2017

Form Type: PBNDS 2008

Form Review Type: Annual

Form Over/Under 72 Status: O72

*If Edits are required, contact ICE HQ for an updated form.

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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) ........................................................................ 10
PART 1 – 3. TRANSPORTATION (BY LAND) (KEY: C) ........................................................................................ 16
SECTION II: SECURITY .............................................................................................................................. 19
PART 2 – 4. ADMISSION AND RELEASE (KEY: D).............................................................................................. 20
PART 2 – 5. CLASSIFICATION SYSTEM (KEY: E) ................................................................................................ 24
PART 2 – 6. CONTRABAND (KEY: F)................................................................................................................. 27
PART 2 – 7. FACILITY SECURITY AND CONTROL (KEY: G)................................................................................. 29
PART 2 - 8. FUNDS AND PERSONAL PROPERTY (KEY: H) ................................................................................. 33
PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (KEY: I)......................................................................... 37
PART 2 – 10. KEY AND LOCK CONTROL (KEY: J) ............................................................................................... 41
PART 2 – 11. POPULATION COUNTS (KEY: K) .................................................................................................. 45
PART 2 – 12. POST ORDERS (KEY: L)................................................................................................................ 47
PART 2 – 13. SEARCHES OF DETAINEES (KEY: M) ............................................................................................ 49
PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (KEY: N) ...............................52
PART 2 – 15. SPECIAL MANAGEMENT UNITS (KEY: O) .................................................................................... 56
PART 2 – 16. STAFF-DETAINEE COMMUNICATION (KEY: P) ........................................................................... 65
PART 2 – 17. TOOL CONTROL (KEY: Q)............................................................................................................ 69
PART 2 – 18. USE OF FORCE AND RESTRAINTS (KEY: R) .................................................................................. 73
SECTION III: ORDER ................................................................................................................................... 77
PART 3 – 19. DISCIPLINARY SYSTEM (KEY: S) .................................................................................................. 78
SECTION IV: CARE ...................................................................................................................................... 81
PART 4 – 20. FOOD SERVICE (KEY: T) .............................................................................................................. 82
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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 4 – 21. HUNGER STRIKES (KEY: U) ......................................................................................................... 89
PART 4 – 22. MEDICAL CARE (KEY: V) ............................................................................................................. 94
PART 4 – 23. PERSONAL HYGIENE (KEY: W) .................................................................................................. 116
PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (KEY: X) ...............................................................120
PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (KEY: Y) ...........................................126
SECTION V: ACTIVITIES .......................................................................................................................... 131
PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (KEY: Z)........................................................................ 132
PART 5 – 27. ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES (KEY: AA) ..............................................135
PART 5 – 28. MARRIAGE REQUESTS (KEY: AB) .............................................................................................. 136
PART 5 – 29. RECREATION (KEY: AC) ............................................................................................................ 138
PART 5 – 30. RELIGIOUS PRACTICES (KEY: AD) ............................................................................................. 142
PART 5 – 31. TELEPHONE ACCESS (KEY: AE) ................................................................................................. 145
PART 5 – 32. VISITATION (KEY: AF) ............................................................................................................... 150
PART 5 – 33. VOLUNTARY WORK PROGRAM (KEY: AG) ................................................................................ 153
SECTION VI: JUSTICE ............................................................................................................................... 155
PART 6 – 34. DETAINEE HANDBOOK (KEY: AH) ............................................................................................. 156
PART 6 – 35. GRIEVANCE SYSTEM (KEY: AI) .................................................................................................. 161
PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (KEY: AJ) ..................................................................... 164
PART 6 – 37. LEGAL RIGHTS GROUP PRESENTATIONS (KEY: AK) .................................................................. 168
SECTION VII: ADMINISTRATION & MANAGEMENT ...................................................................... 170
PART 7 – 38. DETENTION FILES (KEY: AL) ...................................................................................................... 171
PART 7 – 39. NEWS MEDIA INTERVIEWS AND TOURS (KEY: AM) .................................................................173
PART 7 – 40. STAFF TRAINING (KEY: AN) ...................................................................................................... 175
PART 7 - 41. TRANSFER OF DETAINEES (KEY: AO) ......................................................................................... 181
DOCUMENT CHECK .................................................................................................................................. 184

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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.

Meets Standard

Training file documentation
confirmed that all employees
receive training in emergency
preparedness during their initial
training and annually.

Meets Standard

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

Meets Standard

Documentation of "man-down"
drills were inspected.

Meets Standard

The 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 Facility Emergency Plans
policy includes a statement
prohibiting unauthorized use.

Meets Standard

The Facility Emergency Plans
policy addresses all items listed
in the standard.

(SPCs/CDFs) The facility shall set up a primary command
post outside the secure perimeter that is equipped as per
the Emergency Plan standard.

Meets Standard

In this IGSA facility, the
command post is set up outside
the secure perimeter of the
facility in the training room at
the Clay County Justice Center.

At least one video camera shall be maintained in the

Meets Standard

The video camera was observed

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

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.

(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.

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.

Remarks (1000 Char Max)
Training records verified that
staff are trained to identify
detainee unrest to include
distress and unusual behavior.

Staff are trained to identify signs of detainee unrest.

Rating

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 1 – 1. EMERGENCY PLANS (Key: A)

Rating

in the control center. The video
camera was tested for
operability.

Control Center for use in emergency situations.

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

Remarks (1000 Char Max)

Does Not Meet Standard

Emergency medical treatment
for staff and detainees was not
included in the emergency plan.

Does Not Meet Standard

Food service has no written plans
for providing meals to detainees
and employees during an
emergency. The food service
department has not developed
plans to access community
resources.

Does Not Meet Standard

Post-emergency procedures are
not included in the emergency
plan.

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

Meets Standard

•

Facility Evacuation

•

Detainee Transportation System Plan

•

Hostages (Internal)

•

Civil Disturbances

Emergency Plans include each
contingency required by this
component.

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. All officers receive training on the facility's emergency procedures.
All contingency plans comply with detention standards for confidentiality, accountability, review, and revision. The

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

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 Facility Emergency Plans policy, Emergency Plans, emergency
response drills, training files and Memoranda of Agreements; interviews with Captain Brandon Crowley; and observation of
the control center, command center and perimeter security.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B)

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

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 an some areas.
Additionally, observation of fire
extinguishers in several areas did
not support monthly inspection,
although a master monthly
reports indicates otherwise.

Does Not Meet Standard

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 throughouut the
facility. Specifically, shower and
bathroom areas were not clean
and free of clutter. Similarly, a
property storage area was
unkempt and had boxes blocking
electrical panels.

Does Not Meet Standard

Staff state hazardous materials
are not maintained within the
secure perimiter of this facility;
however, hazardous materials
were observed in the facility in
various quantities and locations,
which does not support a viable
chemical control program.

Does Not Meet Standard

The lieutenant is charged with
oversight of the SDS program.
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.

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.

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

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.).

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B)

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

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

Hazardous materials are always issued under proper
supervision.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

Interviews and personal
observations indicate there is no
training provided to staff on
chemical safety and/or use.

Meets Standard

Does Not Meet Standard

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.

SDS were observed in storage
and work areas.
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.

Meets Standard

Chemicals were observed in
original containers.

Meets Standard

No flammable, combustible, or
toxic liquids are maintained
within the facilty.

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.

Does Not Meet Standard

Although the captain conducts
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.

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

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

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B)

Rating

Remarks (1000 Char Max)

Meets Standard

The captain conducts monthly
inspections of the facilty and
completes a report indicating
that fire extinguisher condition is
good. However, an inspection of
individual fire extinguishers tags
indicated they had only been
inspected one time in this
calendar year.

Meets Standard

Inspection reports are
maintained in the captains'
office. There were no issues
identified in any of the reports
reviewed, hence there were no
maintenance orders produced or
corrective actions taken.

Meets Standard

The facilty has an fire prevention
plan that has been approved by
the local fire authority on
05/19/2021. Documentation is
maintained in the captains'
office.

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. A drill was
simulated during the review.

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.

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.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
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.

Rating

Meets Standard

A review of invoices confirms
licensed pest control performs
monthly inspections and
remediation per the issue
identified.

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.

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.

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 the
numerous areas and avaiable as
needed.

Meets Standard

Medical waste is disposed of via
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.

21. (Medical Operations) Standard cleaning practices include:
•

Using specified equipment; cleansers; disinfectants
and detergents.

•

An established schedule of cleaning and follow-up
inspections.

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.

Remarks (1000 Char Max)

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B)

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

Interviews with an RN indicated
inspections are performed daily
and are documented on a check
list. However, the documentation
reflects 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.

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 states that he
reviews policy annually, or as
needed, and recommends
changes as needed.

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.

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 Lieutenant Neil Taylor
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. Several storage
areas and offices were cluttered and in need of basic sanitation such as sweeping and/or mopping.
Observation of fire extinguishers in several areas does not support monthly inspection although a master monthly report
indicates otherwise. Two extinguishers located in the ICE office were placed on the floor and not mounted on the wall. Some
fire exits as well as an evacuation diagrams were blocked throughout the inspection. Although the facility utilizes a red line to
enforce that nothing be within eighteen inches of the ceiling, items were observed exceding the line in two locations.
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.
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 in various areas other than designated storage areas suggesting a lack of adherance to
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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

issue/return procedures. Specifically, a partial five-gallon bucket of caustic stripper was stored in the control room hallway
and a partial gallon of fluid marked poison was observed on top of a file cabintet in the ICE office.
Interview with Stan Roark, RN, indicated inspections are performed daily in health services and are documented on a check
list. However, documentation reflects the office is cleaned weekly with no mention of other areas in health services.
Observation of the health services area suggests there is not a regularly scheduled cleaning program.
During the evaluation of this standard Captain Brandon Crowley, Lieutenant Neil Taylor and Registered Nurse Stan Roark
were interviewed; policies and logs were reviewed and the physical plant was observed.
Overall Rating: Does Not Meet Standard
Reviewer Name (Printed): Inspector 29
I Completion Date: 5/20/2021
Reviewer Signature (for printed form submission):

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

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
1.

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.

Rating
Meets Standard

Remarks (1000 Char Max)
The Inmate Transports policy
and procedures address the
transportation of detainees.

Does Not Meet Standard

Documentation was not available
to verify that annual inspections
are conducted on all vehicles in
accordance with state statutes.

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

Meets Standard

Documentation revealed that all
bus drivers have completed the
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 documents required in this
component.

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.

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.

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

Meets Standard

The Inmate Transports policy
requires that vehicles are
inspected before each detail.
Documentation confirmed
practice.

Meets Standard

Positive identification is
confirmed with a picture of the
detainee, face sheet and Form I203.

Meets Standard

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

Meets Standard

The Inmate Transports policy
includes language regarding the
use of restraining equipment on
transportation vehicles.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 1 – 3. TRANSPORTATION (BY LAND) (Key: C)

Rating

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

Meets Standard

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

Is inventoried.

•

Is inspected.

•

Accompanies the detainee.

Documentation confirmed that
sack meals provided meet the
minimum dietary standards.

Does Not Meet Standard

The procedures and schedule for
sanitizing facility vehicles is not
available. During the inspection
the procedures and schedule
were developed for sanitizing
vehicles.

Meets Standard

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

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

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. The facility does not have a handicap
accessible van to transport detainees with disabilities. The OIC would borrow a vehicle from an adjoining county if such a
need would present. Meals are provided for long-distance transfers. 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.
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 Inmate Transports policy, trip sheets, post orders, CDL's and training
documents; observation of a transportation vehicle which was observed to be unclean; and interviews with Chief Deputy Josh
Clarke, Sergeant Jace Glassburn and Captain Brandon Crowley.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3
I Completion Date: 5/20/2021

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

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

Reviewer Signature (for printed form submission):

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

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

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
1.

Rating

Remarks (1000 Char Max)

Meets Standard

The local handbook given to all
detainees at intake addresses
rules, policies, programs and
activities. New arrivals are also
shown a site specific video that
describes facility policies, rules
and procedures. The handbook
and video are available in
Spanish and English. Confirmed
via review of the local handbook
and detainee interviews.

Meets Standard

At intake detainees are pat
searched and pass through a full
body metal detector; their
personal property and valuables
are checked for contraband,
inventoried, receipted and
stored. Confirmed via detainee
interviews.

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.

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.

Meets Standard

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.

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.
Confirmed via detainee
interviews.

Meets Standard

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On site inspectors confirmed that
issued clothing and bedding are
appropriate for the facility's
environment and local climate
conditions.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 4. ADMISSION AND RELEASE (Key: D)

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.

Rating

Remarks (1000 Char Max)

Meets Standard

ICE classifies detainees prior to
transporting them to the facility.
Staff follow ICE's classification
level in assigning detainee
housing. The inspector examined
detainee classification
documents (RCA) and completed
I-203 forms in eight detainee
files. A-files are not kept at the
facility.

Meets Standard

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.
Meets Standard

A signed I-203 form
accompanies each detainee
admitted to the facility.
The inspector examined signed I 203 forms in reviewed detainee
files.
Detainees receive a local
handbook and National
Detention handbook upon
admission. Handbooks are
available in English and Spanish
and explain in detail facility rules,
regulations, expected behavior
and available program services.
In addition, an orientation video,
in both Spanish and English, is
shown during intake.
Confirmed via detainee and staff
inteviews.

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.

Meets Standard

Upon admission, detainees are
given the ICE and local
handbooks. Together, the
handbooks fully describe facility
policies, procedures, rules and
other applicable information.
Confirmed via detainee and staff
inteviews.

11. All releases are coordinated with ICE.

Meets Standard

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

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The inspector interviewed the
assistant jail administrator who
confirmed that all
paperwork/forms for release are
completed as required. Reviewed
detainee files also contained
required release forms.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 4. ADMISSION AND RELEASE (Key: D)

Rating

13. The facility returns each detainee’s property upon release,
and each detainee receives a receipt for personal property
secured by the facility.

Meets Standard

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.

Meets Standard

Remarks (1000 Char Max)

The inspector reviewed written
policy requiring that all records
and documents concerning a
detainee's admission,
orientation, and release be filed
in their detention file.

Meets Standard

16. All orientation material shall be provided in English,
Spanish, and other language(s) as determined by the Field
Office Director.
Meets Standard

Orientation materials are
provided in English and Spanish;
languages spoken by many the
detainees held at the facility.
The inspector reviewed the
Spanish version of the detainee
handbook.

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)
The facility has written policy and procedures in place related to the admissions process, which includes intake and
admissions forms and screening forms. Staff members are provided with adequate training on the admissions process. Staff
search efforts focus on commonly used hiding and smuggling places, such as pockets, waistbands, seams, collars, zipper
areas, cuffs, and shoe exteriors and interiors, including under the inner soles. Staff also inspects all open containers, and
inventories and stores factory-sealed durable goods in accordance with facility procedures. A strip search, if performed, must
take place in an area that affords privacy from other detainees and from facility staff who are not involved in the search.
Observation must be limited to members of the same sex. The strip search must be supported by reasonable suspicion and
be documented. Before strip searching, an officer makes attempts to resolve his or her suspicions through less intrusive
means, such as a thorough examination of reasonably available ICE and other law enforcement records; a pat-down search
and a detainee interview. The officers also document the results of those other, less intrusive, search methods.
The orientation procedures in this IGSA facility have been approvedby the ICE field office.
COVID-19 safety protocols have been developed and implemented for all newly admitted detainees which included, upon
entry to the intake area, detainees would be provided a mask, their body temperature would be measured and recorded, a
series of questions would be asked and recorded to determine possible exposure, and they would be placed in quarantine
status for fourteen days prior to assignment to general population. Detention officers would conduct an intake screening and,
when indicated, would contact the RN, either on-site or at home, and provide any questionable information obtained during
the intake screening. The RN would contact the physician by telephone to review the intake screening results and obtain
orders if needed.
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
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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

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.
Evaluation of the standard included review of written policy, the local handbook, and staff and detainee interviews.
The inspector interviewed Assistant Jail Administrator Neil Taylor and ICE DSCO T. Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.

Rating

PRIORITY: SPC and CDF facilities use the required Objective
Classification System. IGSAs use an objective classification
system or similar system for classifying detainees.

ICE classifies detainees prior to
the detainee's arrival at the
facility, using ICE's RCA system.
The system is an objective fact
based method of 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

Remarks (1000 Char Max)

reassessment/
Meets Standard

Classification documents are
transferred with detainees.
Detainee housing assignments
are based upon ICE's
classification.
The inspector confirmed the
rating via interviews with the ICE
and facility staff and review of
detainee classification
documents contained in detainee
files.

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 classification system requires
that all detainees be classified
upon admission prior to being
assigned to a housing unit.
Meets Standard

Unclassified detainees are
housed separately until ICE can
complete their classification.
An ICE supervisor reviews all
classification decisions.
Confirmed via staff interviews
and review of written policy.

The intake/processing officer reviews work-folders, A-files,
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.

Meets Standard

This IGSA issues orange and
white striped shirt and pants and
ID wrist bands to all detainees.
Wrist bands note the detainee's
classification level.

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

Meets Standard

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Housing assignments are based
on classification levels. Low
security level detainees are not
housed, fed or recreate with high
security level detainees.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 5. CLASSIFICATION SYSTEM (Key: E)

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.

Rating

Remarks (1000 Char Max)

Meets Standard

This IGSA's policy states that low
security detainees do not have a
felony conviction and they are
not housed with detainees who
have a history of violence.
ICE detainees do not work at this
IGSA.

Detainee work assignments are based upon classification
designations.

N/A

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

Meets Standard

(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.

Meets Standard

Detainees are reassessed at the
IGSA facility thirty days after
their arrival. Subsequent
reassessments occur at sixty-day
intervals. Special assessments
are completed within 24 hours.

Meets Standard

All detainees are given ICE and
local handbooks. The handbooks
explain 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)
Detainees are classified in accordance with the standard. The facility staff responds to a detainee request for reclassification
within 72 hours. Classification staff consider institutional disciplinary history, documented violent episodes and incidents,
medical information, and a history of victimization while in detention in determining classification. The completed
classification paperwork is filed by ICE in the A-File (right side) and a copy is given to the facility and placed in the detainee's
detention file. Detainees are offered recreational and other activities according to their classification. Detainees have an
initial assessment to include health screening within twelve hours of arrival at the facility.
Policy notes that medium custody detainees shall not have a behavior pattern or history of violent assaults whether
convicted or not. The medium 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 detainees are
considered a high-risk category and are housed in medium to maximum security housing. They are always monitored and
escorted. High custody detainees at this facility may be housed with medium custody detainees. Reclassification of a detainee
to high custody based on documented behavior including threats to the facility, other detainees or personnel will be
approved by the classification officer within 72 hours.
Reclassifications that include a reduction in custody level are referred to ICE for review and decision. All detainees placed in
disciplinary or administrative segregation for violations of facility rules are not reclassified prior to being returned to the
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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

general population.

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.
Evaluation of the standard included policy review, staff and detainee interviews, and inspection of classification documents
contained in a detainee's detention file.
The inspector interviewed Assisstant Jail Administrator Taylor and ICE DSCO Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

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.

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

In this IGSA facility, the facility
consults with the on-call 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 that
detainees receive 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.
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.

Remarks (1000 Char Max)

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

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

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

department. 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 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 such seizure of contraband.
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.
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 Captain Brandon Crowley and Lieutenant Neil
Taylor.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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.

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.

Rating

Remarks (1000 Char Max)

Meets Standard

The master roster confirmed that
at least one male and one female
is on duty at all times. The
facility houses males and
females.

Does Not Meet Standard

A staffing analysis was not
available.

Meets Standard

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

Meets Standard

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

Meets Standard

The Correctional Officer
Assignment policy specifies that
control center is to be
continuously staffed, secure and
well equipped.

N/A

In this IGSA facility, there were
no procedures in place requiring
component actions.

Meets Standard

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

(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.

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

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

PART 2 – 7. FACILITY SECURITY AND CONTROL (Key: G)

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

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Documentation and observation
confirmed that all visits are
officially recorded.

Meets Standard

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

Does Not Meet Standard

Documentation was not available
to confirm that routine
procedures, emergency
situations and unusual incidents
are continually recorded in
permanent logs and/or shift
reports.

N/A

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

Meets Standard

Posts are located near detainee
living areas to permit 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.

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

Logs verified that supervisory
staff visit the housing units 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.

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.

13. Detainee movement from one area to another area is
controlled by staff.

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.

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

PART 2 – 7. FACILITY SECURITY AND CONTROL (Key: G)

Rating

Remarks (1000 Char Max)

Meets Standard

Inspection reports are filed in the
administrative lieutenant's office.

Does Not Meet Standard

Documentation was not available
to confirm perimeter checks
were conducted.

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 OIC has established policy and procedures that require all contract employees to have
a contract employee identification card that must be presented upon entering and upon exiting the facility.
A delivery for food service was observed during the inspection. The vendor unloaded a semi-trailer directly into an indoor
sally port, which is opened by a remote control center via camera. At times during the process, both interior and exterior sally
port doors were open simultaneously as the driver unloaded the trailer with some items dropped in the kitchen and others in
the sally port. There is no perimeter fence at this facility and no security staff were present inside or outside. There does not
appear to be any search of the goods, nor security procesing of the delivery driver or vehicle. This concern is compounded by
the fact that the food service staff member receiving the order has not received any security related training.
The central control center coordinates all vehicle traffic entering the sally port. However, the rear gate entrance officer does
not check the driver's credentials, does not record vehicle information and does not ensure that all weapons are secured in a
gun locker before entering the secure perimeter. Vehicles are not searched and escorted while inside the secure perimeter.
No documentation was available to confirm that officers check the inventory of tools entering and leaving the special
management unit.
On 12/29/2020, a non-ICE detainee escaped from two officers while in custody at Union Hospital. The detainee threw an
unknown substance in one of the officer's face and fled down the hall and out of the hospital. The non-ICE detainee was
apprehended within twenty hours.
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 day and night 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,

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

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

inspection reports and training records; observation of housing unit housekeeping practices; and interviews with Captain
Brandon Crowley and Lieutenant Neil Taylor. 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.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.

Remarks (1000 Char Max)

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

Rating

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);

•

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.

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

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.

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

Meets Standard

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

Meets Standard

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.

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.

Meets Standard

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

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

PART 2 - 8. FUNDS AND PERSONAL PROPERTY (Key: H)

Rating

Remarks (1000 Char Max)

(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.

N/A

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

Property discrepancies are immediately reported to the
Chief of Security or equivalent.

Meets Standard

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.

Meets Standard

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

N/A

In 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.

N/A

In 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.

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

PART 2 - 8. FUNDS AND PERSONAL PROPERTY (Key: H)

Rating

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.

Remarks (1000 Char Max)

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)
The evaluation of this standard was based upon personal observations of the booking area, the secure property storage room
and the secure valuable storage cabinet in the ICE office. A review of policy, an examination of documents and detainee
detention files was also conducted.
The processes described above substantiated 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.
A detainees' abandoned or forgotten property is forwarded to ICE for final disposition or disposed of at the direction of ICE.
There is a commissary where detainees may purchase store items.
An Office of Detention Oversight (ODO) review conducted in November 2020, referenced several areas of concern in funds
and personal property. Specifically, that the local handbook did not address the process for a detainee to acquire copies of
identity documents, the local handbook did not address the process for storing or mailing property which is not allowed in
their personal possession, the local handbook did not address the process a detainee would use to file a claim for lost or
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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

damaged property and the local handbook did not address the process a detainee would use to withdraw funds from their
commissary account to pay for legal services. A review of the local handbook during this inspection revealed these four
concerns are now addressed. Although written policies and procedures do not address the audit of detainee detainee funds,
valuables and personal property, monthly audits of these areas are conducted and documented. In this IGSA facility, a
logbook to record funds placed into and out of the funds safe is not used; nor is an accountability logbook or a logbook to
record property placed into and taken out of the property room.
During the evaluation of this standard Captain Brandon Crowley, Lieutenant Neil Taylor and Sergeant Jase Glassburn were
interviewed.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.

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.

Rating

Remarks (1000 Char Max)

Meets Standard

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

N/A

In 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.
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 segregation cell
under direct supervision
guidelines.

Meets Standard

No detainees were observed in a
hold room during the inspection.
Detainees with known or readily
apparent disabilities are placed
in a medical segregation cell and
are where they are under direct
supervision.

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PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (Key: I)

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Detainees are provided personal
hygiene items. The hygiene items
were observed and found to
include required items. There
were no admissions during the
inspection.

N/A

All hold rooms are equipped with
toilet facilities.

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.

Meets Standard

As reported by 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

As reported by 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

The Reception and Orientation
policy includes component
requirements. Documentation
confirmed that booking officers
maintain a log for each detainee
placed in a hold cell.

Meets Standard

Detainees in a hold room for
more than six hours are provided
a meal. There were no
admissions during the inspection.

Meets Standard

The hold rooms were observed
to be maintained at acceptable
and comfortable levels.
Detainees are provided blankets
upon request.

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

PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (Key: I)

Rating

Remarks (1000 Char Max)

Meets Standard

Observation confirmed that
officers are stationed so they can
hear a detainee placed in the
hold rooms. Each hold room is
equipped with a camera allowing
staff to view activity in the room.
Staff are required to make
rounds to the hold rooms at least
every fifteen minutes.
Documentation indicated gaps in
the fifteen-minute observation
period. Constant surveillance is
provided for any detainee
exhibiting signs of hostility,
depression or other unusual
behavior. The OIC developed a
reasonable action plan which
includes a procedure to ensure
that fifteen-minute checks are
completed consistently.

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
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 has a waiver to
suspend the requirement to post
the evacuation procedures.
Waiver was issued 08/21/2018
and approved 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 are multiple occupancy rooms equipped with two metal bunks. The hold rooms are located within the secure
perimeter of the facility and possess adequate footage for the number of detainees held in a hold room.
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 are issued a mattress with sheets and a blanket. Detainees
identified as high risk are placed on one-on-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.
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 Captain Brandon Crowley, Lieutenant Neil Taylor and Officer Melissa
Hughbanks; and observation of the hold rooms, hygiene packages and required postings. There were no admissions during
the inspection.
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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

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

I Completion Date: 5/20/2021

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.

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.

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.

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 documents
confirmed that new employees
had completed the initial training
on key control. The Law
Enforcement Training Roster
confirmed that staff participated
in annual key control training.

Does Not Meet Standard

The position of security officer
had not been established.
During the inspection, the
administrative lieutenant was
assigned the key control
responsibilities. A written
position description was not
available.

Does Not Meet Standard

No documentation was available
to include recordkeeping of keys,
locks and related security
equipment.

Meets Standard

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

Does Not Meet Standard

No documentation was 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.

Does Not Meet Standard

The Controlled Access and Use of
Keys policy addresses
compromised keys. There is no
safe combination integrity. A
safe is located in the medical
room. The staff was not sure
who had the combination to the
safe.

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

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
7.

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.

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.

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

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

Grand master-keys are
authorized in the facility.
Detainees do not have room
keys. Electronic deadlocks are
used in detainee accessible
areas.

Does Not Meet Standard

No documentation of a
preventive maintenance program
is available.

Does Not Meet Standard

It was observed that not all key
rings are identifiable and provide
the number of keys on the ring.
Keys were easily removed on
four sets of keys.

Meets Standard

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

Meets Standard

Controlled Access and Use of
Keys policy includes key
accountability requirements.
However, there is not a practice
or documentation to confirm
accountability. Keys were issued
and not recorded as to time, date
and employee issed the key ring.

Does Not Meet Standard

Controlled Access and Use of
Keys policy includes restricted
key language. However, practice
is not in place to ensure
restricted key accountability.

Does Not Meet Standard

There is no pharmacy at this
facility. The keys to the
medication cart are restricted.
However, when observing the
key issuance procedure, it was
discovered that the nurse does
not log the pharmacy key in and
out. Practice is not in place to
ensure restricted key
accountability.

13. Pharmacy keys shall be strictly controlled.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
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.

Rating

Remarks (1000 Char Max)

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.

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.
Shift supervisor shall be 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.
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.
Non-security keys are maintained in a secure key box. The shift supervisor is responsible for issuing the keys. A key log is not
maintained.
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 and
issuing of keys. Observation of the key box revealed that a key was issued. No key chit was placed on the key post. No record
of who was issued the key ring was documented. Observation of medication cart key issue revealed that the nurse keeps the
pharmacy key in a safe in the medical room. There is no key log accounting for the key. The shift supervisor does not account
for the key ring.
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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

The policy requires key accountability. However, practice is not in place. A key control officer was assigned during the
inspection.

Overall Rating: Does Not Meet Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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)

Meets Standard

Three formal counts are
conducted every 24 hours. The
formal face-to-photo count is
conducted daily at 11:00 p.m.

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. As reported by the OIC and verified by
document review, this IGSA has two shifts and conducts counts no more than eight hours apart. Documentation confirmed
the count frequency, as required by the standard.
During observation of the count, two officers entered each housing unit and physically observed each detainee in the cell.
While conducting the count, the officer looked into showers and behind sheets on bedding to assure every detainee in the
cell 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 OIC or designee. The intake officer is responsible
for maintaining an out count.
Evaluation of this standard was based on a review of the Inmate Counts policy, training records, count sheets and JailTracker;
interviews with Captain Brandon Crowley, Lieutenant Neil Taylor, Officer Little and Officer Noah Minor; and observation of
count.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

Rating

Remarks (1000 Char Max)

Meets Standard

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

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)

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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 all the 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
instructions, and general operating procedures. Officers are required to sign the applicable post order before assuming duty.
All 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.
New post orders are read at the beginning of each shift by the shift supervisor. The shift supervisor then signs the post order
acknowledging having read it.
Evaluation of this standard was based on a 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.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Written policy procedures
govern searches of detainees and
all housing, work and common
areas. The reviewed policy states
that searches must be conducted
in a manner which avoids
unnecessary force,
embarrassment, or indignity to
the detainee.

Meets Standard

Staff informed the inspector that
all new staff hires 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.

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.

Meets Standard

Staff informed the inspector that
work areas are searched each
day by a supervisor and
periodically by a search team.

Meets Standard

Review of written policy
confirmed that strip searches are
conducted only when there is a
reasonable suspicion that a
detainee may be concealing
contraband. The policy further
notes that a supervisor must
authorize the search. The
inspector reviewed documents
and detainee files confirming
that the policy is routinely
followed.

Meets Standard

There were no strip searches
during the reporting period.

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.

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

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

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
8.

Rating

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.

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

Remarks (1000 Char Max)

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
cells detection is ordered a post
order will be placed by the cell to
assure instructions for observing
the detainee held in the cell.

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)
The facility handles detainee searches in accordance with the standard. There are procedures in place to conduct dormitories
and work areas searches which are primarily designed to detect contraband, prevent escapes, maintain sanitary standards,
and eliminate fire and safety hazards. The procedures also include basic correctional services during lockdowns, such as
delivery of food services, toilet access, medication delivery, and other vital services.
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.
This standard was evaluated via policy review, staff search training curriculm, and staff and detainee interviews
The inspector interviewed Assistant Jail Administrator Taylor and Sergent Glassburn.
Overall Rating: Meets Standard
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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 13. SEARCHES OF DETAINEES – Reviewer Summary
Reviewer Name (Printed): Inspector 2

(Use following format for dates: mm/dd/yyyy)

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (Key: N)

This Detention Standard requires that facilities that house ICE/DRO detainees affirmatively act 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
1.

•

Measures to prevent sexual abuse and sexual assault;

•

Policy and procedures for required chain-of-command
reporting to the highest facility official and the ICE
Field Office Director;

•

Measures for prompt and effective intervention to
address the safety and treatment needs of detainee
victims if an assault occurs; and

•

Investigation of incidents of sexual assault, and
discipline of assailants.

(SPCs/CDFs) The written policy and procedure has been
approved by the Field Office Director.

PRIORITY: All staff are trained, during orientation and in
annual refresher training, in the prevention and
intervention areas required by the Detention Standard.

Remarks (1000 Char Max)

Meets Standard

The facility has a sexual abuse
and assault prevention and
intervention (SAAPI) program
that includes, at a minimum,
each of the bulleted items in this
component.

N/A

At this IGSA facility, the written
policy and procedure has been
approved by the sheriff.

Does Not Meet Standard

This component is rated Does
Not Meet Standard because no
documentation was provided to
confirm that staff were trained,
during orientation and in annual
refresher training in the
prevention and intervention
areas required by the standard.

PRIORITY: The facility has a Sexual Abuse and Assault
Prevention and Intervention Program that includes, at a
minimum:

Rating

PRIORITY: Detainees are informed about the program in
facility orientation and the detainee handbook (or
equivalent).

Meets Standard

The Sexual Assault Awareness Notice is posted on all
housing unit bulletin boards.

Does Not Meet Standard

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Detainees are informed about
the program in the national
detainee and local handbooks
and during the intake
orientation.
This component was rated Does
Not Meet Standard because the
Sexual Assault Awareness Notice
was not posted in the housing
areas. It was posted outside of
the housing unit; however, the
PSA compliance manager contact
information was not current.
The PSA compliance manager
was informed.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (Key: N)

Rating

Remarks (1000 Char Max)

Meets Standard

At this IGSA facility, the
information brochure has been
reproduced in total in the 2016
version of the National Detainee
handbook.

Meets Standard

Per interviews with booking
personnel and the PSA
compliance manager and review
of detainee intake screenings, it
was verified detainees are
screened upon arrival for "high
risk" sexual assaultive and
victimization potential and
housed and counseled
accordingly. It was reported that
detainees who are likely to
become victims would be placed
in the least restrictive housing
that is available and appropriate.
Per the PSA compliance
manager, a detainee would
typically be housed in pod C,
which is the protective custody
unit.

Meets Standard

Per policy review, an interview
with the PSA compliance
manager, and review of a
detainee health care record, it
was verified there would be
prompt and effective
intervention. Any detainee who
alleges that he or she has been
sexually abused or assaulted,
would be immediately offered
protection from the assailant and
would be referred for a medical
examination. Policy and
procedures contain the required
process for chain-of-command
reporting.

PRIORITY: Detainees are screened upon arrival for “high
risk” sexual assaultive and sexual victimization potential
and housed and counseled accordingly.
Detainees who are likely to become victims will be placed
in the least restrictive housing that is available and
appropriate.

PRIORITY: There is prompt and effective intervention when
any detainee is sexually abused or assaulted and policy
and procedures for required chain-of-command reporting.

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

PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (Key: N)

Rating

Remarks (1000 Char Max)

Meets Standard

Per policy review, an interview
with the PSA compliance
manager, and review of a
detainee health care record, it
was confirmed, when there is an
alleged sexual assault, a
thorough investigation would be
conducted which would include
the gathering and maintaining of
evidence and referrals to the
appropriate law enforcement
agencies.

Meets Standard

Per interviews with the ICE
detention standard compliance
officer and the PSA compliance
manager and review of a
detainee health care record, ICE
is promptly notified verbally and
in writing when there is alleged
or proven sexual assault. During
the inspection period, there was
one allegation of sexual assault
and/or abuse.

Meets Standard

Victims of sexual abuse or assault
are referred to Union Hospital
located in Terre Haute, IN, for
treatment and gathering of
evidence by either SAFE or SANE
certified personnel.

Meets Standard

The PSA compliance manager is
responsible to ensure all records
associated with claims of sexual
abuse or assault are maintained,
specifically logged and tracked.
Per the PSA compliance
manager, there was one incident
during this inspection period.

Meets Standard

Tracking statistics and reports of
the one detainee incident, were
readily available for review by
the inspector.

When there is an alleged sexual assault, staff conduct a
thorough investigation, gather and maintain evidence, and
make referrals to appropriate law enforcement agencies
for possible prosecution.

10. PRIORITY: When there is an alleged or proven sexual
assault, the required notifications to ICE, facility
management, and the appropriate law enforcement
agency are promptly made.

11. Victims of sexual abuse or assault are referred to
specialized community resources for treatment and
gathering of evidence.

12. All records associated with claims of sexual abuse or
assault is maintained, and such incidents are specifically
logged and tracked by a designated staff coordinator.

13. Tracking statistics and reports are readily available for
review by the inspectors.

PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 14. 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, zero tolerance sexual abuse and assault prevention and intervention program in place.
Approved policies and procedures ensure immediate protection to victims, including prevention of retaliation, assure medical
and mental health referrals for alleged victims, specify procedures for detainees to report allegations to any staff member,
specify medical employees’ responsibility to report allegations or suspicions of sexual assault to facility staff and specify
procedures for evidence gathering and forensic medical exam protocols. Detainees are provided instructions on how to
contact DHS/OIG or ICE to confidentially report sexual abuse or assault.
Decisions regarding detainees with disabilities, LEP detainees, and/or detainees included under any SAAPI/DHS PREA
protection or category would be made only after consideration of the disability, language difficulty or SAAPI/PREA condition.
The facility is managed in such a manner as to protect detainees from sexual assault or abuse.
The OIC has designated a Prevention of Sexual Assault (PSA) compliance manager. The program manager assists with the
development of written policies and procedures and training protocols and serves as a liaison with other agencies. Employee,
contractor and volunteer training includes all the topics listed in the standard. Following the intake process, detainees are
educated on the SAAPI program and on topics as required in the standard. Statements from detainees claiming to be victims
of sexual assaults are taken seriously and professionally responded to.
Victims of sexual assault would be taken to Union Hospital where a Sexual Assault Nurse Examiner (SANE) would conduct an
examination and collect forensic evidence using an approved kit; forensic evidence is secured and the chain of custody is
maintained; testing is conducted for sexually transmitted diseases and infections and referrals for counseling are made, as
appropriate; upon request, prophylactic treatment, emergency contraception and follow-up examinations for sexually
transmitted diseases are offered; after the physical examination, a mental health professional evaluates the need for crisis
intervention, counseling and long-term follow-up. During the community forensic exam, the victim may choose to have an
outside advocate present. When the detainee has been transferred, the OIC is notified.
There was one sexual abuse and assault allegation during this inspection period and per the PSA compliance manager, as of
last week, it was still being investigated by ICE personnel. Reports related to the incident were readily available for review by
the inspector.
Evaluation of this standard was based on review of policy and procedures, visualization of detainee housing units and
postings, review of tracking logs, training curriculum/documentation, review of one detainee health care record, and staff
interviews. Interviews included, PSA Compliance Manager, Sergeant Jase Glassburn; Staff Registered Nurse (RN), Stan Roark
and ICE Deportation Officer/Detention Standards Compliance Officer, Tashi F. Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 24

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O)

Rating

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.
Meets Standard

Remarks (1000 Char Max)
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.
The inspector reviewed SMU
processing documents
confirming adherence to the
requirements of this component.

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.

Meets Standard

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

Meets Standard

Reviewed policy mandates
guidelines for the privileges
detainees may have in
administrative and disciplinary
status

Meets Standard

Per policy, detainees in the SMU
are observed every thirty
minutes at irregular intervals and
more often when warranted. A
review of the segregation log
book confirmed the practice.

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

PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O)

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 and confirmed by staff
interviews and record review,
detainees are given a copy of the
decision and justification form
for each review, unless this
provision would jeopardize
security. Detainees are informed
in writing that they have the
right to appeal the decision.

Meets Standard

Policy addresses the
requirements listed in this
component

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.

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

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
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.

Rating

Meets Standard

Remarks (1000 Char Max)
Per policy and as reported by the
lieutenant, a written order is
completed and signed by the IDP
before a detainee is placed in
disciplinary segregation status.
Copies of the order are given to
the detainee and placed in the
detention files within 24 hours,
barring safety or security
concerns.
The inspector reviewed
documents confirming
adherence to this component.

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

A review of detention files
verified that, upon a detainees
release from SMU, the housing
record is placed in the detainee's
detention file.

Meets Standard

The SMU policy includes the
requirements of the component.
A review of completed
administrative segregation
reviews confirmed the practice.

Meets Standard

A review of the administrative
segregation records verified that
records are maintained in the
SMU to record pertinent
information on a detainee's
admission to and release from
the unit.

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.

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

PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O)

Rating

Remarks (1000 Char Max)

Meets Standard

At this IGSA, separate logs are
maintained in the SMU noting
the time and circumstances of all
visits to the unit; documentation
of the visit is placed in the
detainee's file.

Meets Standard

An SMU housing record is
maintained for each detainee
held in the SMU.

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.

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.

Meets Standard

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.

Meets Standard

Per reviewed policy, a health
care provider visits each detainee
in the SMU on a daily basis.
Regular sick call is conducted;
documentation is noted in the
SMU housing record.

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.

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.
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).

Does Not Meet Standard

This component was rated Does
Not Meet Standard during the
last inspection because detainees
held in special housing are not
afforded time outside their cells
over and above the required
recreation periods.
This practice remains in policy. It
should be noted that during this
inspection there were no
detainees held in special housing.
This is a repeat deficiency.

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

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

PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O)

Rating

Remarks (1000 Char Max)

Meets Standard

Detainees in the SMU 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

Policy addresses the
requirements in this component..

Meets Standard

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

Meets Standard

Detainees in SMU ordinarily
retain visiting privileges.

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.

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.

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

Meets Standard

Staff 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.
Note: due to health safety
concerns there have been no
contact visits since April 2020.

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

PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O)

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, nonlegal books on a rotating basis, provided no detainee has
more than two books (excluding religious material) at any
one time.
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.

Rating

Remarks (1000 Char Max)

Meets Standard

Staff confirmed that at this IGSA
facility detainees who are violent
and disruptive do not receive
contact visits and, in extreme
cases, may have their visitation
privileges suspended.

Meets Standard

Per policy, detainees may visit
with clergy upon request. The
visits will only be denied for
security or safety concerns.

Meets Standard

Detainees in SMU have access to
reading materials. Policy
addresses the requirements of
this component.

Meets Standard

Policy addresses all the
requirements of this component.

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.
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.

Meets Standard

Policy addresses all the
requirements of this component.
The detention standards officer
(DSCO), reported that ICE will be
notified if a detainee is denied
access to the law library.
No detainees were denied law
library access during this
inspection period.

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

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Policy addresses the items listed
in this component.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O)

Rating

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.

Meets Standard

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.
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.

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.

Meets Standard

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.

Per policy, recreation privileges
may be denied or suspended for
safety and security concerns.
Such action requires a report to
be submitted to the OIC. There
were no such denials during this
inspection period.
Staff confirmed that any denial of
recreation privileges would be
evaluated during the seven-day
review.
No detainees were denied
recreation privileges during this
reporting period.

Meets Standard

Per policy, the OIC and the
resident health official must
approve any denial of
recreational privileges lasting
more than seven days. ICE is
notified of the denial.

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.

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.

Remarks (1000 Char Max)

Meets Standard

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

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
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.

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

Rating

Remarks (1000 Char Max)

Meets Standard

Per policy, if a detainee has been
in administrative segregation
status for more than thirty days
and objects to that status, the
OIC shall review the case to
determine whether that status
should continue. The review shall
take into account the detainee’s
views and the OIC shall
document the decision and his
justifications. A similar review
shall take place every thirty days
thereafter.

Meets Standard

The DSCO reported that ICE
receives all required
notifications. There were no
detainees on disciplinary
segregation status for more than
thirty days during this inspection
period.

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.

Meets Standard

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)
The evaluation of this standard was based on review of policy, detention files; interviews with the Assistant Jail Administrator
Taylor and DSCO Tilman; and a tour of the SMU by the on-site inspector. The facility protects detainees, staff, contractors,
volunteers, and the community from harm by segregating certain detainees from the general population in special
management housing units.
During the inspection there were no detainees in administrative segregation or disciplinary segregation status. All detainees
housed in segregated housing receive a copy of the documentation placing them in segregation status. Per staff, each prehearing detention form detailing the reasons for placing a detainee in administrative segregation is emailed to the field office
director. The SMU provides a safe housing environment for detainees who cannot live in the general population or require
segregated status for disciplinary reasons.
A detainee is not placed in involuntary segregation solely on the basis of age, gender identity, race, color, national origin, or
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PART 2 – 15. SPECIAL MANAGEMENT UNITS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

religion. Except in instances where other placements or options are not sufficient or available, detainees are not placed in
segregation based on their vulnerabilities to sexual or other types of abuse or assault.
Detainees are evaluated by a medical professional prior to placement into the SMU when feasible; or as soon as possible
when not feasible. Seriously mentally ill detainees are given a mental health consultation within 72 hours of placement into
the SMU, and are seen weekly by a mental health provider for the length of their stay in the SMU. Training in the
identification and management of mentally ill detainees such as identification of signs of mental health decomposition,
interacting with mentally ill detainees, and de-escalation techniques, is provided to the staff assigned to the SMU.
Policy and procedures are in place to control and secure access to the SMU, contraband, tools, and food carts. Administrative
segregation records are maintained and used to record specific data on detainees upon admission to and release from the
unit and for supervisors to record their visits. Detainees in disciplinary segregation will have more stringent personal property
restrictions and control than those in administrative segregation. Detainees housed in the SMU have the same law library
access as the general population.
The facility provides communication assistance to LEP detainees and detainees with disabilities. This may be achieved via
bilingual staff, translation services, TTY machine, 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 are provided translation
services or interpretation services while in the SMU to assist with their understanding of conditions of confinement as well as
their rights and responsibilities. Detainees are provided appropriate accommodations and professional assistance, such as
medical and therapeutic or mental health treatment, for special needs.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Interviews with assigned ICE and
facility staff and detainees
confirmed that detainees have
frequent informal access to and
interaction with key facility and
ICE personnel in languages they
can understand. Interviews
further confirmed that personnel
make scheduled and frequent
unannounced visits to all
detainee housing units to
monitor overall living conditions
and to listen and respond to
detainee concerns.

Does Not Meet Standard

Due to health safety concerns all
ICE staff visits have been
suspended. Facility staff
informed the inspector that prior
to the suspension all visits by
ICE/ERO personnel were
documented in the shift officers’
logbook.

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.

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.

N/A

The IGSA does not have an onsite ICE/ERO presence. The
facility's ICE liaison officer
conducts weekly on-site unit
inspections of each detainee
living quarters. The inspection is
supervised by ICE/ERO staff via a
remote telephonic connection.
with ICE staff. The on-site
inspection schedule is posted in
the housing unit.
Confirmed via review of
inspection visit documentaton
conducted by the ICE liaison
officer and supervised remotely
by ICE staff. Postings of the
scheduled visits were also
observed by the on-site SME.

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

PART 2 – 16. STAFF-DETAINEE COMMUNICATION (Key: P)

Rating

Remarks (1000 Char Max)

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.

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.

Meets Standard

Interviews with staff and review
of policy documents such as ICE
officer liaison check lists and
logs, confirmed that each
element of this component is
addressed in facility and ICE
policy and/or practice.

Meets Standard

The IGSA facility does not have
an on-site ICE/ERO presence.
Detainee requests are answered
in person and in writing within by
the facility's ICE liaison officer
working with ICE field staff within
72 hours of receipt, as confirmed
by review of request logbook
entries.

Meets Standard

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

PART 2 – 16. STAFF-DETAINEE COMMUNICATION (Key: P)

Rating

Remarks (1000 Char Max)

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

The on-site SME confirmed
compliance with 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. 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 and the facility's telephone service provider test all detainee phones at least weekly to verify
serviceability. Staff makes random calls to pre-programmed numbers for attorney and consulate services, 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

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

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

Standard.

In evaluating the standard, facility staff and detainees were interviewed; ICE officer liaison check lists and telephone
serviceability check lists were examined.
The inspector interviewed four detainees. Each of the detainees told the inspector that they felt safe and had not had any
adverse physical or verbal confrontation when interacting with facility or ICE staff. Each of the detainees interviewed voiced
complaints concerning their interaction with other non-ICE detainees; stating they were harrassed and "bullied" by the other
non-ICE detainees. All but one of the detainees stated that they did not report their situation to facility or ICE staff fearing
repriasals. One detainee stated that he did report the situation to a facility officer who spoke to the other detainees warning
them that they needed to curtail their behavior.
The inspector interviewed ICE Liaison Officer Glassburn and Officer Little.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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

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

Does Not Meet Standard

Remarks (1000 Char Max)
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 by staff RN
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. The 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 logged in
any inventory.

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

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

There is no individual responsible
for developing a tool control
procedure. During the
inspection, the captain assigned
the administrative sergeant to
the tool control officer
responsibilities.

Meets Standard

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

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

PART 2 – 17. TOOL CONTROL (Key: Q)

The facility has developed and implemented a tool
classification system.

Rating

Does Not Meet Standard

Tool inventories were not readily
available in the maintenance
department. The food service
inventory was incomplete.
Broken tools were not logged.
There is no electronics shop,
recreation department, or
armory

Does Not Meet Standard

Tool inventories were not
conspicuously posted on the
"tool bucket" used by the
maintenance empoyees.

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.

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

(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.

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

Remarks (1000 Char Max)
The facility has developed a
classification system in policy.
However, the tool classification
system has not been
implemented.

N/A

Does Not Meet Standard

In this IGSA facility, policy does
not address this component.
No documentation was provided
to confirm the completion of
quarterly inventorying of tools.

N/A

In this IGSA facility, policy does
not address this component.

Does Not Meet Standard

The Tools and Equipment and
Supplies policy includes
procedures governing lost tools.
However, no documentation of
implementation was provided.

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

PART 2 – 17. TOOL CONTROL (Key: Q)

Rating

Remarks (1000 Char Max)

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.

N/A

In this IGSA facility, policy does
not address this component.

The facility administrator shall implement quarterly
evaluations of lost/missing tool files.
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.

Does Not Meet Standard

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.

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)
A review of all relevant material confirmed that the facility has not implemented procedures to ensure that tools are
properly accounted for. Documentation confirmed that tool inventories are not conducted daily, monthly and quarterly.
During the inspection, the administrative sergeant was assigned the responsibilty for tool control. The tool classification
system is not in place. All new tools are not 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. No documentation was available to support the practice.
Practices are not in place for the following:
Policy requires that when a tool is missing or lost, staff shall notify the chief of security in writing as soon as possible. When
the tool is a restricted 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.
When a tool or equipment in the medical department is missing or lost, staff shall immediately inform the medical staff who
will immediately verbally notify the chief of security or shift supervisor and submit a written notification to the facility
administrator. The shift supervisor's office shall maintain a lost-tool file, monitor the individual reports for accuracy, ascertain
any unusual patterns or occurrences of loss in one or more shops, document search efforts, and send written notification to
the captain.
According to the Tools and Equipment and Supplies policy, it is the responsibility of security staff to ensure that knives and
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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

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. However, observation did not confirm this practice. The medical area
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 inaccurate tool inventories, tools that were not etched and tools that were not on an inventory;
and interviews with Maintenance Workers Wayne Payne and Tony Bowles, Captain Brandon Crowley and Sergeant Jase
Glassburn.
Overall Rating: Does Not Meet Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.

Remarks (1000 Char Max)

Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
includes the component
language. There were three
immediate use-of-force incidents
during the inspection period. The
use-of-force packet included one
incident report. No
documentation was included to
confirm that confrontation
avoidance techniques and useof- force continuum was
employed. During the inspection,
the captain executed a plan of
action to include remedial
training for the use-of-force
report documentation.

Meets Standard

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

Meets Standard

Training records confirmed
training.

Meets Standard

The Reporting Use of Force and
Weapons/Physical Force policy
does not include component
requirements. The captain
advised that the requirements
will be added to the policy and
practice.

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 voluntary cooperation
before resorting to force.

•

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.

Rating

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.

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PART 2 – 18. USE OF FORCE AND RESTRAINTS (Key: R)

Special precautions are taken when restraining pregnant
detainees.

Rating

Remarks (1000 Char Max)

Meets Standard

The Use of Force policy includes
component requirements.

Medical personnel are consulted.
6.

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.

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.

Meets Standard

The Use of Force policy includes
component requirements.

Meets Standard

The Use of Force policy includes
component requirements.

Meets Standard

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

Meets Standard

Training documents confirmed
component requirements.

Meets Standard

Policy requires that all use-offorce incidents are audio-visually
documented and reviewed by
the captain and lieutenant.
According to policy,
documentation includes the
medical examination through the
conclusion of the incident.
There were three immediate useof-force incidents during this
inspection period. The use-of
force-packet did not include
audio visual documentation,
medical reports or witness
statements. The captain advised
that the requirements will be
added to the policy and practice.

Meets Standard

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

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

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.

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

PART 2 – 18. USE OF FORCE AND RESTRAINTS (Key: R)

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This facility utilizes the restraint
chair. Policy does not address the
component requirements.

Does Not Meet Standard

The Use of Force policy requires
officers to contact medical staff
once the detainee is under
control. Documentation did not
confirm that medical staff were
contacted after the immediate
use-of-force incidents.

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.

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.

Does Not Meet Standard

This facility utilizes the restraint
chair. Policy does not address the
component requirement.

Does Not Meet Standard

No documentation was available
to confirm that use-of-force
incident reports are routinely
reviewed.

Does Not Meet Standard

In this IGSA facility, an incident
report is used. The form is not an
equivalent.

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

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

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)
During the inspection period, there were three immediate use-of-force incidents involving ICE detainees. Each use-of-force
"packet" included one incident report. Reports written by officers witnessing or involved in each event were not
provided/available, as required by the standard. Medical assessments for staff and/or detainees were not
provided/available. Audio visual documentation was not provided/available.
On 10/20/2020, an ICE detainee housed in the padded cell "charged out of the padded cell" during an attempt to serve his
meal. The officers gave the detainee multiple orders to comply prior to placing the detainee in the restraint chair. One
incident report was provided. No after-action report was available. No medical report was provided. No audio visual
documentation was provided.
On 11/08/2020, an ICE detainee refused escort from a holding cell to the multipurpose housing. Officers used open hand and
pressure point techniques to gain compliance. Detainee refused to comply and continued to push back to officers. The
sergeant deployed her Taser. Detainee continued to push back the officers. After the struggle, detainee was placed in the
restraint chair. One incident report was provided. No after-action report was available. No medical report was provided. No
audio visual documentation was provided.
On 03/23/2021, officers were monitoring an ICE detainee for withdraw of alcohol protocol. The intake control officer
observed sheets and blankets in the holding cell that appeared to replicate suicide materials. Officers entered the padded
cell, a struggle with the detainee began, and a Taser was deployed. One incident report was provided. No after-action report
was provided. No medical report was provided. No audio visual documentation was provided.
All staff receive use-of-force training during their initial training prior to assuming duty and then receive 24 hours use-of-force
training as part of their basic training. Documentation of Taser inventory was incomplete. Oleoresin Capsicum/pepper spray
(OC) is the only chemical agent approved for use. The following acts and techniques are not specifically prohibited:
chokeholds, carotid control holds, and other neck restraints. Batons are not used at this facility.
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, Use of Restraints
policy, use-of-force incident reports and logs; interviews with Captain Brandon Crowley and Lieutenant Neil Taylor; and
observation of the restraint chair.
Overall Rating: Does Not Meet Standard
Reviewer Name (Printed): Inspector 3

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.
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

All facilities shall have graduated scales of offenses and
disciplinary consequences as provided in this section.

Rating

Remarks (1000 Char Max)

Meets Standard

Per reviewed policy, the facility
uses progressive levels of reviews
and appeals. The policy clearly
defines detainee rights and
responsibilities. The policy,
procedures, and rules are
reviewed annually by the OIC.

Meets Standard

As reported by staff, detainees
are provided translation or
interpretation services for each
phase of the disciplinary process.
Detainees are not held
accountable for their conduct if a
medical authority finds them
mentally incompetent.

Meets Standard

Per reviewd policy, time in
disciplinary segregation, or the
withholding of privileges
imposed for disciplinary
violations, does not exceed thirty
days per violation, except under
extraordinary circumstances.
Staff does not impose or allow
the imposition of any of the
sanctions prohibited by this
standard unless the activity
creates a documented unsafe
condition.

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

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The facility uses a graduated
scale of offenses and
consequences.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 3 – 19. DISCIPLINARY SYSTEM (Key: S)

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Per reviewd policy, the facility
uses progressive levels of reviews
and appeals. The policy clearly
defines detainee rights and
responsibilities. The policy,
procedures, and rules are
reviewed annually by the OIC.

Meets Standard

Staff representatives are
available, if requested, for a
detainee to confer when facing
an IDP hearing.

Meets Standard

Per reviewed policy and as
reported by the disciplinary
sergeant, postponements are
allowed for case preparation and
health and security related
issues.

Meets Standard

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

Meets Standard

A review of records verified that
all forms relevant to the incident,
investigation, committee/panel
reports, etc. are completed and
distributed as required.

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)
The evaluation of this standard was based on review of policy, the local handbook, and reports; and staff interviews with the
Assistant Jail Administrator Taylor and Sergent Glassburn.
The facility uses progressive levels of appeals and reviews. Policy clearly defines detainee rights and responsibilities. The
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
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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

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 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

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
1.

•

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.

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 each of 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 were observed
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.

PRIORITY: The food service program shall be under the
direct supervision of an experienced food service
administrator (FSA) who is responsible for:

Rating

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.

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

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
7.

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

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

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

Meets Standard

Per the HC and a review of the
menus, three meals are provided
each day; two of which are hot
meals. The feeding schedule
reflected fewer than fourteen
hours between the evening meal
and the following days'
breakfast.

Does Not Meet Standard

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 under staff supervision
when delivered to the living
areas.

Meets Standard

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

Does Not Meet Standard

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.

Does Not Meet Standard

The thermometer used to assure
food temperatures was not
cleaned between uses.

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.

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.
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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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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
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.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

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
are passed out by officers once
they are delivered to the housing
unit.

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.

Meets Standard

A registered dietician approves
master cycle menus. The most
recent analysis was conductd
05/10/2021. The analysis was
docmented in a memorandum.

17. The FSA has established procedures to ensure that items
on the master-cycle menu are prepared and presented
according to approved recipes.

Meets Standard

Master recipes were present and
reviewed. Food is prepared per
the recipes per the HC.

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.

Meets Standard

The HC makes menu changes
with equal items and documents
these 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

Per the HC, temperatures are
checked and confirmed by food
service staff prior to serving.

Meets Standard

The HC states they have not
experienced a religious diet, but
would purchase any special
meals required.

Meets Standard

In this IGSA they do not issue a
duplicate special diet
identification. Special diets are
notated with the detainee's
name on a different colored tray.
No religious diets are currently
being served at this facility.

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.
21. (SPCs/CDFs) Once a religious diet has been approved, the
FSA shall issue, in duplicate, a special-diet identification
card.

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

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
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.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This facility does not have a
fourteen-day common fare
menu. Interviews with the HC
indicated commercial meals
would be purchased if required
for common fare.

Does Not Meet Standard

A ceremonial meal schedule has
not been developed at this
facilty.

Does Not Meet Standard

This facility does not have a
common fare menu. Interviews
with the head cook indicate
commercial meals would be
purchased if required for
common fare.

Meets Standard

Medical diets are served as
prescribed by health services.

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.
However, this facilty does utilize
"nutri-loaf" meals for disruptive
non-ICE detainees. Policy does
not allow these types of meals
for ICE detainees

Meets Standard

Sack meals are provided as
needed and are approved by a
dietician per the HC.

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.

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

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

Rating

Remarks (1000 Char Max)

Meets Standard

Personal observation indicated
non-ICE detainee kitchen
workers are trained in all aspects
outlined in this component and
acknowlege this training in
writing.

Meets Standard

Health services confirms non-ICE
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. Food
service personnel are only
required to have a TB test. A
review of documentation
indicated the three food service
staff members had current TB
test.

Meets Standard

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

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.

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.

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.

33. All facilities shall meet environmental standards for safety
and sanitation.

Meets Standard

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

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

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The HC has developed a cleaning
schedule which appears to be
very effective as evidenced by
the cleanliness of and sanitation
level of the area.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
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.

Rating

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
vendor to protect against
pest/vermin.

Meets Standard

An interview with the HC
indicated daily safety and
sanitation inspections are made
by the HC but not documented.
Personal observation of the food
service area and equipment
found them to be clean and well
organized.

Meets Standard

Temperature logs were reviewed
and confirm staff check
temperatures of the dish washer,
refrigerators and freezer, twice
daily. The HC inspects the area
daily and takes action as
required. The kitchern was
insected by the Clay County
Health Department on
05/10/2021 with no findings
noted.

Meets Standard

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

Meets Standard

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

Meets Standard

Personal observations indicated
food products were stored
appropriatly.

Meets Standard

A review of logs and
thermometers confirm proper
temperatures are maintained for
the storage of cold and frozen
items.

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.
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.

Remarks (1000 Char Max)

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

Rating

44. Inventory levels are established, monitored and
periodically adjusted to correct excesses or shortages.

Remarks (1000 Char Max)
Inventory levels are maintained
as required. The facility
maintains two weeks supply of
food on hand.

Meets Standard

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 Tammie Fagg, Head Cook, and three part time staff. Non-ICE detainee workers assists with food
service operations. The HC and the three part-time staff are ServSafe certified.
Food service operations were observed during a noon meal. During the meal non-ICE detainees were observed traying the
meal without constant supervision, and were not utilizing serving utensils. Once trayed, the meals were placed by the
workers onto open carts, and again were unsupervised. The meals were transported to the housing area where security staff
supervised the meal distribution.
The refrigerator, freezer and dry storage areas were unsecured during the observation period despite posted signs to keep
them secured when not in use.
Food service utizes a five-week meal cycle and menus were approved by a registered dietician.
Review of the tools maintained in the kitchen confirmed knives were secured by a padlock and hasp. While the cabinet frame
is metal, the actual doors to the cabinet appear to be plexiglass and could be compromised. An approximately six-inch set of
broken shears was observed stored within the cabinet and not inventoried or otherwise accounted for.
Temperatures and logs confirm food is maintained/prepared within appropriate parameters. However, the head cook used
the same thermometer to check numerous food items without appropriate sanitizing.
The kichen appeared clean and well organized. Several non-ICE detainee workers commented on the quality of meals.
A delivery for food service was observed during the inspection. The vendor unloaded a semi trailer directly into an indoor
sallyport which is opened remotely by the control center. At times during the process, both interior and exterior sallyport
doors are open simultaneously as the driver unloaded the trailer with some items dropped in the kitchen and others in the
sallyport. There is no perimeter fence at this facility and no security staff present inside or outside. There does not appear to
be a search of the goods, nor security procesing of the delivery driver or vehicle. This concern is compounded by the fact that
food service staff personnel receiving the order have not received security related training.
Evaluation of this standard was based on interviews with the Tammie Fagg, Head Cook; observation of meal traying
operations; review of temperature logs, menus, training files; observation of food service kitchen and storage areas.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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
1.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This component was rated Does
Not meet Standard because
there was no documentation
verifying that all staff received
initial and annual training on
recognizing the signs of a hunger
striker and on the procedures for
referral for medical assessment.
There was no verification that
medical staff had received
training in hunger-strike
evaluation and treatment.

Meets Standard

Review of policy and procedures
include procedures for
identifying and referring hunger
strikers to medical personnel.
Any detainee who does not eat
for 72 hours and/or refuses
beverages for twenty four hours,
would be referred to the medical
department for evaluation and
treatment. Per an interview with
a staff RN, it was confirmed a
referral to mental health would
also be initiated to assess
whether the detainee's actions
were reasoned and deliberate or
the manifestation of a mental
illness.

Meets Standard

Per interviews with medical
personnel and the designated ICE
detention standards compliance
officer, hunger strikes are
immediately reported to ICE via
the facility chain-of-command.

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

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
4.

Rating

Remarks (1000 Char Max)

Meets Standard

Per review of policy and medical
staff interviews, any detainee
observed not eating would be
referred to medical and mental
health personnel at 24-hours, 48hours and 72-hours. At 72hours, an official hunger strike
would be declared and
medical/mental health
evaluations and monitoring
would commence.

Meets Standard

Per review of policy and
procedures and an interview
with a staff RN, it was confirmed,
during the initial evaluation of a
hunger striker, medical
personnel perform all the
bulleted tasks listed in this
component and repeat other
procedures as medically
indicated, at least once every 24hours. All examination results
would be documented in the
detainee's medical file. If a
hunger strike was noted over the
weekend, the staff RN would
have to come to the facility to
perform the required 24-hour
monitoring and documentation.

Meets Standard

Per review of policy and medical
records, written informed
consent is obtained from
detainees during the intake
process. Additional procedurespecific consents are obtained as
needed.

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.
6.

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

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

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
7.

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Per review of policy and detainee
health records, a signed refusal
of treatment form is completed
any time a detainee refuses an
evaluation or treatment. Should
the detainee refuse to sign the
form, it would be noted on the
refusal of treatment form and
witnessed by two employees.
The detainee would continue to
be monitored by medical
personnel to evaluate whether
the hunger strike posed a risk to
the detainee's life or permanent
health.

Meets Standard

Per medical staff interviews and
review of policy, at the
conclusion of a hunger strike,
medical personnel would provide
appropriate medical and mental
health follow-up care. Per policy,
only the clinical
director/provider, in consultation
with the mental health
provider/psychiatrist, can order a
detainee's release from hunger
strike treatment, and that
written order would be
documented in the detainee's
medical record. A notation would
be made in the detention file
when a detainee has ended a
hunger strike. There have been
no reported hunger strikes
during this inspection period.

Meets Standard

Per review of policy and medical
staff interviews, when it is
determined that it would be
beneficial to measure and record
a detainee's food and water
intake and output an equivalent
IHSC hunger strike monitoring
form would be used to document
the information required by the
standard.

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

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 policy and procedure review,
and medical staff interviews, it
was confirmed, regardless of the
detainee's response to a verbal
offer of a meal, staff are required
to deliver three meals per day to
the detainee's cell and complete
the applicable documentaiton
per the standard requirements.

Meets Standard

Per review of facility policy and
procedures, staff members are to
provide an adequate supply of
drinking water and other
beverages to the detainee.
Beverages are provided on each
meal tray and are offered by staff
between meal deliveries.

Meets Standard

No food items are permitted in
the hunger striker's cell other
than food approved by the CMA,
who is a physician.

Meets Standard

Per an interview with medical
personnel and the ICE detention
compliance manager and review
of policy, before involuntary
medical treatment would be
administered, staff would make
reasonable efforts to educate
and encourage the detainee to
accept treatment voluntarily.
Involuntary medical treatment
would be administered in
accordance with established
guidelines and applicable laws
and only after the physician had
determined the detainee's life or
health would be at risk.
Involuntary treatment would not
be performed onsite; instead the
detainee would be transported
to either Union Hospital,
Regional hospital or to a
detention facility appropriately
equipped for such treatment.

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

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)
During initial referral, medical personnel document the reasons for placing a detainee in a single occupancy observation
room. This decision is reviewed every 72 hours. Medical personnel make the decision regarding appropriate housing
placement when food and liquid intake/output is measured.
If a detainee engaging in a hunger strike has been previously diagnosed with a mental health condition, or is incapable of
giving informed consent due to age or illness, appropriate medical/administrative action would be taken in the best interest
of the detainee.
Only qualified medical personnel modify or augment standard treatment protocols. If medically necessary, detainees are
transferred to a community hospital or a detention facility appropriately equipped for treatment. Detainees refusing to
accept treatment are counseled by medical personnel regarding the medical risks associated with refusal of treatment.
When clinical assessment and laboratory results indicate a detainee's weakening condition threatens the life or long-term
health of the detainee, a physician recommends involuntary treatment. The OIC notifies ICE if a detainee is refusing
treatment, and the staff RN notifies the IHSC managed care coordinator 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. 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.
Written policy, procedures and practice for the identification and management of hunger strikers are in place.
Since the last inspection, there have been no hunger strikes.
Evaluation of the standard was determined following a review of policy and procedures, medical treatment protocols,
training outlines and records and interviews with the medical staff RN, Stan Roark; ICE Compliance Officer, Tashi F. Tillman
and Sergeant Taylor for training documentation.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 24

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

Initial medical, mental health,
and dental screening are
performed by 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
hosptalization as needed would
be provided by either Union or
Regional hospital, located in
Terre Haute, IN.

Does Not Meet Standard

This component was rated Does
Not Meet Standard because the
administrative health authority is
not a physician, health services
administrator, or a health agency
as the standard requires. The
sheriff was designated as the
administrative health authority,
by the clinical medical authority
(CMA) in July of 2020. The CMA is
a licensed physician and per
policy, has final clinical
judgement with respect to
medical decisions. Clinical
decisions are made by qualified
clinicians.

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 as needed within the local community.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This component was rated Does
Not Meet Standard because on
the last day of the inspection,
05/20/2021, the staff RN
provided this inspector a signed
document reflecting the annual
staffing plan was reviewed by the
sheriff , who is the assigned
administrative health authority,
on 05/20/2021. Prior to this
documentation there was no
evidence of annual staffing plan
reviews being conducted by the
administrative health authority.
Medical personnel are not on
site at all times. Per review of the
stafffing plan and information
provided by medical personnel, it
was determined the facility does
not provide sufficient staff and
support personnel to meet the
requirements of the standard.

Meets Standard

Review of health care staff
licensing, certifications and
credentials found the credentials
and certifications for the certified
clinical medical assistant (CCMA)
were not available; rather she
was certified as a nurses aid and
that certification had expired as
of 12/5/2014. The staff RN was
able to verify proper current
certification and credentials
through an online source to
correct the problem during this
inspection period.

Meets Standard

Informal agreements are in place
with community hospitals and
numerous multidisciplinary
physicians to provide health care
services not available within the
facility. Detention personnel
have been identified to transport
and remain with detainees for
the duration of any off-site
treatment including
hospitalization if necessary.

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.

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.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

Established written plans address
the management of infectious
and communicable diseases. The
written plans include all of the
bulleted procedural
requirements listed in this
component. The staff RN is
responsible for reporting to
state, local and federal agencies
and to ICE. During the inspection
there were eighteen detainees in
quarantine for COVID-19. The
quarantine was scheduled to end
on 05/20/2021.

Meets Standard

Review of health records, intake
screening forms and medical
staff interviews 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 staff RNs, if this would
occur on the weekend, the staff
RNs would be contacted to
arrange/provide the required
testing.

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.

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.

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

PART 4 – 22. MEDICAL CARE (Key: V)

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 nonminimal risk detention facilities.

Rating

Meets Standard

Detainees with symptoms of
active TB infection would be
placed in one of two negative
pressure respiratory isolation
cells in the intake area. They
would remain in isolation until
proper medical
evaluation/testing could be
accomplished by a qualified
medical care provider. No
suspected TB cases were
identified duing this inspection
period.

Meets Standard

There were no
confirmed/suspected active TB
cases during this inspection
period. If an active case was
identified, per policy and
confirmed by the RN and the ICE
deportation officer/detention
standards compliance officer, the
bulleted reporting requirements
listed in this component would
be completed.

Meets Standard

Per written policy and
procedures, and interviews with
the staff RN and ICE deportation
officer/detention standards
compliance officer, all nationally
notifiable infectious diseases
would be reported to the IHSC
Public Health, Safety and
Preparedness Unit via the ICE
chain of command.

Meets Standard

The facility has a written plan to
ensure the highest degree of
confidentiality regarding HIV
status and medical condition.
The plan includes that medical
and detention staff are trained in
HIPPA which emphasizes the
need for confidentiality related
to a detainee's medical diagnosis
and/or conditions.

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.

10. PRIORITY: Designated medical staff shall report to the ICE
Epidemiology Unit all cases of nationally notifiable
infectious diseases as per the CDC guidelines, including,
but not limited to: TB, varicella (herpes zoster [shingles],
chicken pox), and recent exposures of varicella among
non-immune contacts.

Remarks (1000 Char Max)

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

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

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
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.

Rating

Meets Standard

Per policy and the staff RN,
detainees who are diagnosed
with HIV are only placed in
medical isolation based on
clinical evaluation that would
indicate a need for isolation.

Meets Standard

Per review of the current bloodborne pathogen plan, it was
confirmed that the plan met the
standard requirements, including
reporting procedures.

Meets Standard

The facility provides each
detainee a copy of the detainee
handbook and local supplement
during the intake process. The
handbook contains the
procedures to access health care
services, sick call and the medical
grievance process.

Meets Standard

Per nursing staff, it was
confirmed all medical, dental and
mental health interviews,
examinations and procedures are
conducted in settings that
respect detainee privacy.

Meets Standard

The waiting area is in the hallway
outside of the
examination/interview room. It
consists of a bench with seating
for two detainees. Detainees are
under direct supervision of a
correctional officer while in the
waiting area. Detainees have
access to a toilet and to drinking
water.

Meets Standard

Medical records are kept
separate from detainee
detention records and are stored
in a file cabinet within the
medical unit.

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.

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)

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

N/A

The medical department does
not include an infirmary, shortstay or medical observation unit.

Does Not Meet Standard

The component was rated Does
Not Meet Standard because
practice, as observed during the
inspection, was inconsistent with
policy, in that, there was no
emergency stocked medication
inventory, disposal of
medications were not being
witnessed by two persons,
narcotic controlled substances
were not being counted and
verified by two persons, sharps
inventories were not accurate,
on two different occasions during
the inspection keys to the
medication cart were found
unattended/unsecured on the
desk and counters in the medical
area, and the medication cart
and sharps storage area were not
secured when unattended by
medical personnel. Written
pharmacy policy and procedures
address the management of
pharmaceuticals and included
the requirements of the
component.

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.
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.

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

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
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.

Rating

Remarks (1000 Char Max)

Meets Standard

The administrative health
authority and clinical medical
authority have developed and
approved a list of nonprescription medications
available through commissary for
purchase by detainees. The last
review was dated 03/12/2021.

Does Not Meet Standard

This component was rated Does
Not Meet Standard because,
while the initial medical, dental
and mental health screenings
were being conducted well
within the twelve hour
requirement, there was no
documentation confirming the
detention officers performing the
intake screening had been
appropriately trained to perform
this function as required by the
standard.

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 by the 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 or
suicidal/homicidal ideation or intent;

•

Observation of body deformities and other physical
abnormalities;

•

Questions and an assessment regarding past or recent
sexual victimization.

current

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

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
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.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This component was rated Does
Not Meet Standard because
there was no documentation of
detention officer special training
to perform the intake screenings.

Meets Standard

Detention staff perform the
initial screening. If there is an
indication of need, or request for
mental health services, the CMA
would be notified within twentyfour hours and would ensure a
full mental health evaluation
would be done, by a qualified
mental health clinician if
indicated. Mental health
personnel are onsite twice
monthly and are available on call
at all times. Mental health
clinicians can interview and
evaluate detainees through
telemedicine when they are not
on-site.

Meets Standard

Policy requires the initial health
screening and assessment are
documented. A random review
of detainee medical records
confirmed this practice.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

Per an interview with the staff
RN and detention staff, and
review of detainee health care
records, it was confirmed
detention staff complete the
initial in-processing health
screen. Upon completion, the inprocessing health screening form
is forwarded to the staff RN for
appropriate action. Within 24hours 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

The facility has access to Lyon
Bridge translation services, which
provides non-english speaking
detainees telephonic translation
services. The facility has a
verified working talk to text (TTY)
machine to provide services to
detainees who are deaf and/or
hard of hearing.

Meets Standard

The clinical medical authority
(CMA) has developed and
implemented guidelines for the
evaluation and treatment of new
arrivals 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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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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
28. PRIORITY: Each facility’s health care provider shall conduct
a health appraisal including a physical examination on
each detainee within 14 days of the detainee’s arrival
unless more immediate attention is required due to an
acute or identifiable chronic condition, in accordance with
the most recent ACA Adult Local Detention Facility
standards for Health Appraisals. If there is documentation
of one within the previous 90 days, the facility health care
provider upon review may determine that a new appraisal
is not required.
29. Detainees will be provided same sex chaperones as
appropriate or as requested.

Rating

Meets Standard

Per policy and the staff RN, a
detainee receives a
comprehensive physical
examination/assessment,
conducted by an RN within
fourteen days of admission.
Review of completed physical
examinations verified practices
consistent with this component
and meets the standards and
facility policy.

Meets Standard

Policy requires provision of
chaperones of the same gender
as the detainee as appropriate or
as requested. Practice was
confirmed by the staff RN.

Does Not Meet Standard

This component is rated Does
Not Meet Standard because
there was no documentation
detention personnel have been
trained to perform an intake
medical/mental health screening.
Per medical record review and
staff interviews, it was confirmed
that detainees receive a mental
health intake screening,
conducted by detention staff, as
part of the intake health
screening process. Policy
requires referral to and follow-up
by mental health personnel
when a mental health concern is
identified. The mental health
screening includes the items
listed in this component.
Detainees are transferred to a
community hospital or a mental
health facility when care exceeds
the capability of the facility.

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.

Remarks (1000 Char Max)

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

When a detainee is referred for
mental health treatment, he/she
would receive a comprehensive
evaluation by a licensed mental
health professional within
fourteen days and a treatment
plan would be developed. If the
detainee's mental health illness
or developmental disability
needs exceed the capability of
the facility, the plan may include
transfer to a mental health
facility that can meet the
detainees needs. Review of
selected medical records
confirmed a comprehensive
mental health evaluation was
conducted within fourteen days
of the referral.

Meets Standard

Policy and medical staff
interviews confirmed, under the
authority of the CMA, any staff
member can place any detainee
who is exhibiting violent
behavior in medical isolation.
Daily reassessment by medical
personnel is required which may
include the staff RNs reporting to
the facility when they are off
duty on the weekends.

Meets Standard

Written policies and procedures
for restraints for medical or
mental health purposes included
each of the bulleted items listed
in this component.

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.

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.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

Written guidelines addressed all
of the bulleted requirements
listed in this component. Per the
staff RN, involuntary
administration of psychotropic
medications would not be
performed in the facility. If
involuntary administration of
psychotropic medications were
necessary, the detainee would be
referred to ICE and transferred to
a qualified community health
care center for observation and
treatment as needed.

Meets Standard

Per the staff RN and per written
policy, detainees in ICE custody
for over a year would receive age
and gender appropriate physical
examinations including
rescreening for tuberculosis.

Meets Standard

Review of health records
confirmed dental screening
exams are performed by the staff
RN and/or the CMA as part of the
fourteen-day comprehensive
physical assessment. If necessary
detainees are referred to an offsite dental clinic for evaluation
and treatment by a qualified
dental clinician.

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
alternatives as soon as possible.

less

restrictive

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.

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.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This component was rated Does
Not Meet Standard because
medical personnel are only on
site Monday through Friday and,
as a result, cannot ensure that all
sick call requests are received
and triaged within 48-hours after
a detainee submits a request.
Written sick call procedure
allows detainees the unrestricted
opportunity to freely request
health care, mental health and
dental services which are
provided by qualified personnel.
The procedure addresses the
bulleted points listed in this
component with the exception of
the last bulleted requirement. All
detainees, regardless of
classification, have access to sick
call. Detainees have the option
to request medical services
either electronically via the
housing unit kiosk system or by
submitting a paper request.
Paper requests are to be
collected and triaged by medical
personnel each morning,
Monday through Friday.

Meets Standard

Paper sick call requests were
printed in English and Spanish
and, per observation, were
readily available. Non-English
speaking detainees would be
provided assistance in
completing a request slip
through use of a telephone
translation service. Deaf or hard
of hearing detainees would be
provided assistance through use
of an on site TTY device.

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.

38. If the procedure uses a written request slip, they shall be
provided in English and the most common languages
spoken by the detainee population of that facility. NonEnglish speaking detainees and detainees who are deaf or
hard of hearing will be provided interpretation/translation
services as needed or other assistance as needed to
complete a request slip.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

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.

Does Not Meet Standard

This component was rated Does
Not Meet Standard because
there was no documentation
verifying that detention staff
have received annual training in
CPR, AED and emergency first
aid. All other bulleted items in
this component were met per
the standard requirments.

Meets Standard

Per the staff RN, medical staff
collect and triage sick call
requests each morning, Monday
through Friday, and determine
when the detainee should be
seen. Each sick call request is
placed in the detainees medical
file as a permanent record. The
facility does not meet the
requirements of the standard
which requires collection and
triage of requests within 48hours of submission by the
detainee, and medical personnel
are only on site Monday through
Friday.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This component was rated Does
Not Meet Standard because
there was no documentation
provided to verify that training
for detention and health care
personnel was occurring at least
annually by a responsible
medical authority in cooperation
with the facility administrator.

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
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.

aid

and

cardiopulmonary

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.

N/A

Per the staff RN, there were no
first aid kits in the facility.

Does Not Meet Standard

This component was rated Does
Not Meet Standard because, in
the absence of on site medical
personnel, detention personnel
distribute/administer
medication, and no
documentation was provided
verifying detention personnel
have been appropriately trained
to distribute/administer
medication. The facility uses an
electronic medication
administration record (E-MAR)
by Sapphire, and personnel
document each dose of
medication administered or
refused at the time of
administration. Per reviewed
policy, detainees are not
permitted to deliver or
administer medications.

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.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

This component was rated Does
Not Meet Standard because, in
the absence of on site medical
personnel, detention staff
distribute/administer
medication, and there was no
documentation verifying
detention personnel had been
appropriately trained to
distribute/administer
medication. Additionally,
detention personnel did not have
available for reference the
training syllabus or other guide
or protocol provided by the
health authority.

Meets Standard

Per the staff RN and review of
sample
informational/educational
brochures, it was determined
qualified medical staff provided
detainee health education and
wellness information as needed.

Meets Standard

Per staff interviews, it was
confirmed appropriate facility
personnel and ICE were notified
by telephone and email of any
detainee identified as having
special needs.

Meets Standard

Per the staff RN and ICE
deportation/detention standards
compliance officer, if a detainee
requires close medical
supervision, including chronic
and convalescent care, he/she
would be transferred to an
appropriate detention center
that could meet the detainee's
needs.

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.

46. The health administrative authority for each facility must
have a plan to notify ICE for any detainee with special
needs. The written notification must become part of the
detainee’s health record file.

47. PRIORITY: When a detainee requires close medical
supervision, including chronic and convalescent care, a
written treatment plan that includes access to health care
and other personnel regarding care and supervision, shall
be developed and approved by the appropriate physician,
dentist, or mental health practitioner, in consultation with
the patient, with periodic review. The written treatment
plan will conform to NCCHC and TJC requirements.

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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
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.

Rating

Remarks (1000 Char Max)

Meets Standard

Per the staff RN, female
detainees have access to each of
the services detailed in this
component. At the time of the
inspection, two female detainees
were being housed in the facility.
During the inspection period,
there were no pregnant
detainees housed in the facility.

Meets Standard

Per the staff RN and written
policy, detainees have access to
age and gender appropriate
examinations.

Meets Standard

Per review of policy, there was a
plan to ensure continuity of
medical care in the event of a
change in detention placement
or status. A transfer summary
form listing any acute or chronic
medical, dental or mental health
conditions, allergies and current
medications was completed and
provided for each detainee at the
time of removal. If indicated, at
least a seven-day supply, or in
the case of TB and HIV
medication, a thirty-day supply
of medication was provided.

Meets Standard

Per review of detainee health
care records, it was confirmed a
general informed consent to
treatment was obtained during
the intake process. Procedure
specific consent is obtained as
needed. The medical risks
associated with refusing
recommended treatment are
explained to a detainee and
thoroughly documented in the
detainee's medical file.

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.

51. PRIORITY: Documented informed consent, consistent with
standards of the jurisdiction, is obtained from a detainee
before medical treatment is administered. If a detainee
refuses consent to treatment, medical staff explain the
medical risks if treatment is declined and document their
efforts in the detainee’s medical record.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

Per medical staff interviews and
an interview with the ICE
compliance officer, ICE personnel
would be notified if a detainee
was refusing necessary
treatment or evaluation.
Included in the discussion would
be an appropriate plan of action.
Involuntary treatment, if
indicated, would meet ICE
protocols and would be
performed at an appropriate
medical facility.

Meets Standard

A complete medical record is
maintained on each detainee,
and it is kept separate from
detention records. The facility
utilizes a paper medical record to
document health care services
and information. Access to
medical records is restricted to
medical personnel and
practitioners for the provision
and documentation of health
care and mental health care
treatments and services. The
health care records are stored in
a file cabinet located in the
medical department. Copies of
health records are not placed in
detention files.

Does Not Meet Standard

This component was rated Does
Not Meet Standard because
documentation verifying staff
training in the requirements of
this component could not be
provided. Per review, policy
required all staff to be trained to
protect the privacy of a
detainee's medical information in
accordance with established
guidelines and applicable laws.

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.

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PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

The administrative health
authorty is the sheriff. The sheriff
provides designated staff
information that is necessay and
in accordance with the bulleted
items in this component.

Meets Standard

Per reviewed policy, upon receipt
of a written authorization that
complies with HIPAA from a
detainee, copies of health
records can be released by
medical personnel directly to the
detainee/designee at no cost.
The written authorization for the
release of health
records/information would be
maintained in the detainee's
medical file as a permanent
record.

Meets Standard

Per the staff RN and policy
review, it was confirmed a
detainee wishing to obtain a
copy of his/her medical record
would be provided the
appropriate request form.
Detainees are provided
assistance as needed to
complete and transmit the
written request.

Meets Standard

Per the staff RN and ICE officer,
when it has been determined
that a detainee's medical or
psychiatric condition meets the
requirements of the two bulleted
points listed in this component,
the OIC and ICE officer would be
notified in writing electronically
and transmitted through the
chain of command.

55. The administrative health authority shall provide the
facility administrator and designated staff information that
is necessary:
•

To preserve the health and safety of the detainee,
other detainees, staff, or any other person.

•

For administrative and detention decisions such as
housing, voluntary work assignments, security, and
transport.

•

For management purposes such as audits and
inspections.

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.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

Per interviews with staff RN and
ICE officer, review of written
policy and procedure, and review
of detainee health care records,
it was confirmed, generally,
twelve hours advance notice is
provided by ICE prior to the
release, transfer or removal of a
detainee. A transfer summary is
completed for each detainee
which includes each of the
bulleted items listed in this
component. Completed transfer
summaries are provided for each
detainee and packaged in an
envelope marked "confidential
medical records".

Meets Standard

With the exception of approved
clinical trials that may be
warranted for a specific
detainee's diagnosis or
treatment when recommended
and approved by the treating
physician and ICE and following
documented detainee informed
consent, detainees do not
participate in medical,
pharmaceutical or cosmetic
research.

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.

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

PART 4 – 22. MEDICAL CARE (Key: V)

Rating

Remarks (1000 Char Max)

Meets Standard

The staff RN has implemented a
system of internal review and
quality assurance, titled
Continuous Quality Improvement
(CQI), that includes data anaylsis,
a multidisciplinary committee
with regular monitoring of heath
service outcomes and
assessment of ongoing education
and training needs. The
committee meets quarterly and
written documentation of topics
discussed are maintained by the
staff RN. Quarterly
documentation was readily
available for review. The last
meeting was held 4/14/2021.

Does Not Meet Standard

This component was rated Does
Not Meet Standard because
there was no documented
implementation of an intraorganizational external peer
review program for all
independently licensed medical
professionals.

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.

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.

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)
When TB treatment is indicated, multi-drug, anti-TB therapy is administered using directly observed therapy (DOT). Active TB
disease is ruled out before treatment for latent TB infection is initiated. International referrals are coordinated with the IHSC
Public Health, Safety and Preparedness Unit and local/state health departments.
There is a written plan to address the management of hepatitis A, B and C and HIV infection. Detainees may request hepatitis
and HIV testing at any time. Medical personnel provide all detainees diagnosed with HIV/AIDS medical care consistent with
national recommendations and guidelines. Medical and pharmacy personnel ensure that all FDA medications currently
approved for the treatment of HIV/AIDS are accessible per the ICE formulary. Detainees with active tuberculosis are
evaluated for possible HIV infection. a new HIV positive diagnosis would be reported to government bodies according to state
and local laws and requirements; the HSA is responsible for ensuring that all applicable state requirements are met.
Pharmaceutical management policy includes: a formulary, obtaining non-formulary medications, prescription practices,
perpetual inventory, medication administration error reports, training and storage in a secure area (secure perimeter, limited
access, solid walls from floor to true ceiling and a solid ceiling, solid door with high security lock, secure medication storage
area).
Mental health evaluations and screenings include: reason for referral, mental health history, drug/alcohol use history, suicide
attempts, current suicidal/homicidal ideation; medications; intellectual functioning; history of abuse, pertinent physical
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PART 4 – 22. MEDICAL CARE – Reviewer Summary
condition and treatment recommendations.

(Use following format for dates: mm/dd/yyyy)

The emergency medical services plan includes provisions for expedited entrance to and exit from the facility. Non-medical
personnel contact medical personnel when questioning the need for emergency care.
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, and provisions are made to secure
medically necessary medications. Detainees are not charged for any medical services to include pharmaceuticals dispensed
by medical personnel. Separate informed consent is obtained for use of psychotropic medications.
Detainee treatment questions are answered by medical personnel. Detainees sign a refusal for treatment when appropriate.
Refusals are reviewed to determine reasons for refusal.
Detainees request an independent health examination by submitting a written request to the FOD. The cost of the exam is at
the detainee’s expense. The facility does provide for the use of mental health tele-medicine by the licensed mental health
provider.
Decisions regarding detainees with disabilities, LEP detainees, and/or detainees included under any SAAPI/DHS PREA
protection or category would be made only after consideration of the disability, language difficulty or SAAPI/PREA condition.
The facility provides timely access to medical, dental and mental health services through appropriately licensed medical
personnel for routine care and chronic and emergency conditions. Medical personnel are on site fourteen hours a day,
Monday through Friday. RNs perform the required fourteen-day physical assessments. Per review of ICE detainee medical
records available at the time of the inspection, medical intake screenings and tuberculosis screening are consistently
completed timely. The detainee medical record review indicated the fourteen-day physical examinations and assessments are
consistently completed within the required timeframe and are reviewed and signed by the physician.
Detainees requesting sick call appointments receive appropriate medical care; however, it cannot always be provided in a
timely manner related to no medical coverage on-site during the weekend. The facility has two negative pressure respiratory
isolation rooms. Written medical treatment consent is consistently obtained prior to treatment. Detainees with chronic
illnesses are medically monitored and provided appropriate medical treatment. All needed health care not available on-site is
provided through the use of community health care providers and services. ICE is notified if the medical condition of a
detainee already housed in the facility deteriorates and requires a level of medical care beyond the capabilities of the facility.
Evaluation of the standard was determined following a review of policy, medical records, training outlines and files, and
interviews with the staff RNs Stan Roark and Jackie Rominger; ICE Deportation Officer/Detention Standards Compliance
Officer, Tashi F. Tillman, and Lieutenant Taylor for training documentation.
Overall Rating: Does Not Meet Standard
Reviewer Name (Printed): Inspector 24

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

PART 4 – 23. PERSONAL HYGIENE (Key: W)

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 interview with
the sergeant in charge of
property, confirmed 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.

Remarks (1000 Char Max)

Detainees are not assigned to
any work areas.

Meets Standard

Per interview with the sergeant,
at no cost, 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
detainees are housed at this
facility; there were two present
at the time of the inspection.
Personal hygiene items issued to
male and female detainees are
consistent with the standard
requirements

Meets Standard

Inspector reviewed written logs
containing issuance and
collection of disposable razors
and confirmed this component is
being met per the standard
requirements.

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

PART 4 – 23. PERSONAL HYGIENE (Key: W)

Rating

Female detainees shall be issued and may retain feminine
hygiene items as needed.
Meets Standard

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.

There were two female
detainees housed in the facility
at the time of the inspection.
Female detainees are issued
feminine hygiene items which
they can retain as needed.
Hygiene items are replenished
twice a week.

Does Not Meet Standard

This component was rated Does
Not Meet Standard at the last
inspection due to there not being
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". This is a repeat
deficiency that was found to be
deficient a third time, during this
inspection.

Meets Standard

An adequate number of
washbasins with temperature
controlled hot and cold running
water are available 24 hours per
day. Inspector review of
temperature control logs, that
are maintained by the
maintenance department and
was able to confirm
temperatures were being
measured per the standard and
ranged between 110-120 degress
Farenheit..

Meets Standard

A review of housing unit water
temperature logs verified water
temperatures between 110
degrees Fahrenheit and 120
degrees Fahrenheit.

An adequate number of washbasins with temperature
controlled hot and cold running water 24 hours per day.

10. Operable showers that are thermostatically controlled to
temperatures between 100 and 120 degrees Fahrenheit,
to ensure safety and promote hygienic practices.

Remarks (1000 Char Max)

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

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
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.

Rating

Remarks (1000 Char Max)

Meets Standard

Per the ICE deportation officer
and detention standards
compliance manager, 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.

Meets Standard

The initial issuance of clothing
items meet the bulleted items
listed in this component and
fullfills the standard
requirements.

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.

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 units C and E. These units contain four-person cells with only one toilet,
and the standard requires two toilets. This was a repeat deficiency in the last inspection and remains a deficiency during this
inspection.
Evaluation of the standard was determined following a review of provided policy, review of detainee handbook, inspector
visit to the housing units and interviews with the ICE compliance officer, Tashi F. Tillman, and Staff RN, Stan Roark.
Overall Rating: Meets Standard
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

PART 4 – 23. PERSONAL HYGIENE – Reviewer Summary
Reviewer Name (Printed): Inspector 24

(Use following format for dates: mm/dd/yyyy)

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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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
1.

Rating

Remarks (1000 Char Max)

Meets Standard

The suicide intervention and
prevention policy is reviewed
annually, approved and signed by
the medical authority, the
administrative health authority,
the sheriff, who is also the
OIC.The program addresses each
of the bulleted items listed in this
component.

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.

Does Not Meet Standard

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.
Meets Standard

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This component is rated Does
Not Meet Standard because
there was no documetation of
staff training related to suicide
prevention and intervention.
Per medical staff interviews, it
was confirmed that a detainee
identified as being suicidal would
be placed on suicide precautions,
housed in one of four
observation cells in the booking
area or in one padded
observation room, located in the
booking area. The detainee
would immediately be referred
to mental health personnel.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X)

Rating

Remarks (1000 Char Max)

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

Does Not Meet Standard

This component is rated Does
Not Meet Standard because
there was no documetation of
annual staff training.

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.

Meets Standard

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A detainee identified as at risk
would be immediately referred
to mental health personnel for
evaluation. Per policy, the
detainee must be evaluated at
the mental health provider's next
regularly scheduled on-site visit
with the results thoroughly
documented in the detainee's
medical record. Only the
physician or mental health
professional are authorized to
release a detainee from suicide
watch and only after the
completion of a suicide risk
assessment. Currently, the
mental health professional is onsite every two weeks and is
available for calls when not onsite or by telehealth.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X)

Rating

Remarks (1000 Char Max)

Meets Standard

A detainee determined to be at
risk for suicide would be
evaluated by a medical/mental
health provider. The evaluation
would include each of the
bulleted items listed in this
component and would be
documented in the detainee's
medical record. Mental health
personnel included one part-time
licensed mental health counselor
(MHC) who is on-site every two
weeks and available on call by
telehealth when not on-site..

Meets Standard

Per medical personnel, a
detainee on suicide watch would
be evaluated by the physician
and/or the MHC when he is next
on-site with documentation in
the medical record. All other
days the MHC would contact the
facility by telephone for updates.
Per policy, nursing personnel
would evaluate a detainee daily.
Only the mental health
professional and physician have
the authority to remove a
detainee from suicide watch and
only following the completion of
a suicide risk assessment. Per
policy, a detainee cannot return
to general population until
completion of the assessment.
Review of selected medical
records documentation verified
practice.

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:
•

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.

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PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X)

Rating

Remarks (1000 Char Max)

Meets Standard

Suicidal detainees are housed in
one of five designated suicide
watch cells located in the
booking department or one of
two respiratory negative
pressure rooms. Detainees are
under camera observation, as
well as direct observation by
security personnel outside the
door for a level one suicide
watch. Per provided policy and
prior to placement, security
personnel inspect the cell for
safety concerns with the
inspection documented.

Meets Standard

Per medical personnel, a
detainee on a level one suicide
watch would be clothed in a
suicide-resistant smock and
provided a suicide-resistant
blanket and mattress. Items can
be added or taken away as
deemed appropriate by the
mental health professional or
physician.

Meets Standard

Level one suicide watch
detainees are maintained on
constant one-to-one detention
officer observation. The assigned
detention officer makes and
documents behavioral
observations at least every
fifteen minutes.

Meets Standard

Per staff interviews, it was
confirmed security staff would
initiate and continue life-saving
measures until relieved by
medical personnel. They also
have access to cut-down
equipment that can be used if a
detainee attempts suicide by
hanging.

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.

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.

11. Following a suicide attempt, security staff shall initiate and
continue appropriate life-saving measures until relieved by
arriving medical personnel.

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PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X)

Rating

Remarks (1000 Char Max)

Meets Standard

Per review of policy, a detainee
medical file, and staff interviews,
it was confirmed, that in the
event of a suicide attempt or
completed suicide, ICE and IHSC
officials would be notified. ICE
personnel would be responsible
for notifying the family and
outside authorities. Medical
personnel are required to
complete an incident report
within 24 hours.

Meets Standard

A completed suicide or serious
suicide attempt would be subject
to a mortality review. A critical
incident debriefing would be
provided to affected personnel
and detainees.

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)
There was one interupted suicide attempt during this inspection period involving a detainee who was housed in an
observation area in booking. The detainee was observed tying a noose and hanging it over a door. Officers noticed the action
and immediately entered the cell and interupted the attempt. The detainee was placed on level one suicide watch.
Detainees receive an initial mental health screening by detention staff within twelve hours of admission. Results of the
screening are documented on an approved intake screening form which includes observation and interview items related to
potential suicide risk. The intake screening becomes a permanent part of the detainee's medical record.
Detainees may be identified as being at risk for suicide at any time while in ICE custody. This identification may be through
self-referral or through daily observation and/or interaction with medical, security or ICE personnel. An at-risk detainee
referred for an evaluation would be placed in a secure environment on observation until the evaluation was completed.
Based on the evaluation, mental health personnel would develop a treatment plan which would address the environmental,
historical and psychological factors that contributed to the detainee's suicidal ideation. The plan would include strategies and
interventions to be followed by employees and the detainee if suicidal ideation reoccurred and strategies for improved
functioning and regular follow-up appointments based on level of acuity. The treatment plan would be documented in the
detainee's medical record. All detainees discharged from suicide watch are re-assessed by an appropriately trained and
qualified mental health provider or medical personnel at intervals consistent with the level of acuity. The facility uses three
levels of suicide watch status as follows: level one requires one-to-one observation with fifteen-minute documentation and
the detainee clothed in a suicide smock; level two requires staggered fifteen-minute documentation, and the detainee can be
clothed in regular facility issued clothing; and, at level three, the detainee can be in general population with 24, 48 and 72
hours follow-up with additional evaluations at two weeks and thirty days.
When medical personnel determine a detainee is at imminent risk of bodily injury or death, medical personnel would make a
recommendation to place the detainee in an observation cell designated for the purposes of evaluation and/or treatment. If
the detainee is mentally competent and refuses, ICE counsel would be consulted as to appropriate further action such as
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PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

petitioning the appropriate federal court to intervene against the detainee's refusal for purposes of his potential
hospitalization and treatment.
In the event of a suicide attempt, medical personnel arriving on the scene perform the appropriate medical evaluation and
intervention. The physician/medical director would be notified when referral to the emergency room of the local hospital was
required. In the event of a detainee death, the DHS Office of Inspector General would be notified within 48 hours, and all
personnel who came into contact with the victim prior to the incident would submit a statement including their knowledge of
the detainee and the incident. Consistent communication is maintained between medical, mental health and correctional
personnel through a variety of mechanisms including intake forms, daily briefings, shift change briefings, medical progress
notes, special needs forms, medical/psychiatric alerts and transfer summaries.
Suicide prevention policy and procedures protect the detainee's health and well-being. No training documentation was
available to confirm the requirement of staff training.
Since the last inspection, there were no serious suicide attempts or suicides.
Evaluation of this standard was determined following a review of policy, training records, and curriculum; a detainee medical
record, and interviews with Staff RNs Stan Roark and Jackie Rominger; Ice Deportation and Detention Standards Compliance
Officer Tashi F. Tillman and Lieutenant Taylor.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 24

I Completion Date: 5/20/2021

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 the staff RN and ICE officer,
the facility does not accept or
continue to house detainees who
are chronically or terminally ill.
Such detainees would be
transferred to an appropriate offsite medical facility as needed.
Administration and ICE are
notified of the detainee's status
by telephone and in writing
electronically which briefly
describes the illness and
prognosis.

Meets Standard

ICE is responsible for notifying
the detainee's next-of-kin as to
his/her medical condition,
location, visiting hours and rules.
Per ICE, the notification would be
in a language or manner which
the next-of-kin could understand.

Meets Standard

The facility uses the state of
Indiana advance directive form.
Per the RN, it is the expectation
that personnel at an off-site
medical facility would assist a
detainee in completing an
advance directive and/or living
will.

Meets Standard

When the terms of an advance
directive must be implemented,
ICE would be contacted to
coordinate and supervise the
implementation. At the time of
the inspection, no detainees had
implemented an advance
directive.

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.

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PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y)

Rating

Remarks (1000 Char Max)

Meets Standard

DNR procedures are contained in
policy and, per the staff RN, are
consistent with state laws. At the
time of the inspection, no
detainee had requested a DNR
order.

Meets Standard

Per the staff RN, If a detainee has
a DNR order, health care would
continue to be provided
consistent with with the DNR
order. The detainee would
receive all therapeutic efforts
short of resusitation.

Meets Standard

Per policy, a detainee's medical
record would include
documentation validating the
DNR order.

Meets Standard

Per policy and an interview with
staff RN, the staff RN on duty
would inform all medical and
mental health personnel verbally
and by email of a DNR order.

Meets Standard

The facility has a policy that
addresses organ donation.

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.

Meets Standard

Per policy, ICE is notified and is
responsible to notify 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.

Meets Standard

Written policy and procedure
address the death of a detainee
while in transport.

Meets Standard

Per policy and an interview with
the ICE officer, the deceased
would be transferred to the
medical examiner in the
jurisdiction where the death
occurred. This process would be
coordinated with ICE.

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.

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.

12. The body must be transferred to the local coroner or
medical examiner in the jurisdiction where the death
occurred.

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PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y)

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
13. The Chaplain shall telephone the person named as the
next-of-kin in the United States to communicate the
circumstances surrounding the death.

Rating

Meets Standard

Policy states the
chaplain/designee, in
coordination with ICE, would
contact next-of-kin living in the
United States to provide
notification of the death.

Meets Standard

Per ICE, the family would have
the opportunity to claim the
remains within seven calendar
days of the date of notification.
ICE may assist the family in
transporting the remains to a
designated location in the U.S.
ICE provides detainee property
within two weeks of the detainee
death.

Meets Standard

ICE is responsible for contacting
the consulate in the event the
family cannot be located or
declines the remains.

Meets Standard

ICE is responsible for the proper
distribution of death certificates.

Meets Standard

Written policy and procedures
address each of the bulleted
items listed in this component.

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.

Remarks (1000 Char Max)

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.

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PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y)

Rating

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.

Meets Standard

Remarks (1000 Char Max)
Interviews with staff RN and ICE
officer confirmed, in
coordination with ICE, medical
personnel would make
arrangements for an autopsy by
the medical examiner in
accordance with established
guidelines and consistent with
applicable law.

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)
When a detainee is hospitalized, the regional IHSC managed care coordinator and the HSA 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.
Advance directive guidelines include having a living will other than the generic form made available by medical personnel;
appointing another individual to make advance decisions for him/her; and having a private attorney prepare the documents
at the detainee's expense. DNR policy complies with the following stipulations: a DNR order written by a staff physician is
approved by the CMA; it protects basic patient rights and complies with state requirements; a decision to withhold
resuscitative services is considered only under specified conditions (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, the express wishes of the detainee, the immediate family's wishes, consensual decisions
and recommendations of medical professionals identified by name and title, the mental competency evaluation and informed
consent; and the clinical director or nursing personnel notify the IHSC medical director and the ICE Office of Chief Counsel of
the basic circumstances of any detainee with a DNR order.
If neither the family nor consulate claim the remains, ICE would schedule an indigent's burial after contacting the Department
of Veterans Affairs to determine burial benefits. The chaplain may advise the OIC about religious considerations in remains
disposition. ICE does not authorize cremation or donation of the remains for medical research. Written policy and procedures
on autopsies include: the ICE Office of Chief Counsel is consulted, and a written copy of the autopsy is forwarded to the ICE
Office of Chief Counsel. While an autopsy decision is pending, no actions are taken that could affect the validity of the results.
The FOD verifies and accommodates the detainee's religious preference prior to autopsy or embalming. The chaplain was not
involved in formulation of the policy and procedures.
It is established practice to notify ICE if the medical condition of a detainee already housed in the facility deteriorates and
requires a level of medical care beyond the onsite health care capabilities. The detainee would be transported to an outside
medical facility for emergency and/or impatient medical care as needed pending transfer or removal by ICE.
Since the last inspection, there have been no reported deaths, no requests submitted for DNR orders or advance directives.

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

PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

Evaluation of this standard was determined following a review of policy, and interviews with Staff RN Stan Roark and ICE
Deportation Officer and Detntion Standards Compliance Officer, Tashi F. Tillman.

Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 24

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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

PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (Key: Z)

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.

Rating
Meets Standard

Meets Standard

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.

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 satisfied through
written policy and practice.

Meets Standard

Rules for correspondence and
other mail are noted in the local
handbook which is given to each
detainee during the admissions
process.

Meets Standard

The local handbook which
provides key information to
detainees is available in Spanish
and English; languages spoken by
the majority of the detainees
held at the facility.

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.

PRIORITY: Detainee correspondence and other mail shall
be delivered to the detainee and to the postal service on
regular schedules.
•

Remarks (1000 Char Max)
Rules and regulations governing
detainee correspondence are
provided in the local handbook.

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

PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (Key: Z)

Rating

All facilities shall implement procedures for the inspection
of all incoming general correspondence and other mail
(including packages and publications) for contraband.
Meets Standard

Remarks (1000 Char Max)
Reviewed policy issuances
dictate procedures for inspection
for all incoming general
correspondence and other mail
for the presence of contraband.
Confirmed via staff and detainee
interviews.

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

Written policy and post orders
require that special
correspondence and legal mail
be opened in the detainee's
presence. The detainee signs a
logbook indicating that the mail
was opened in his presence.
Confirmed via detainee
interviews.

Outgoing special correspondence and legal mail shall not
be opened, inspected, or read.

All facilities shall implement policies and procedures
addressing acceptable and non-acceptable mail.

Meets Standard

Reviewed correspondence policy
issuances address the
requirements of this component.

10. When an officer finds an item that must be removed from
a detainee’s mail, he or she shall make a written record.

Meets Standard

Reviewed correspondence policy
issuances 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

The local handbook notes that
detainees may purchase postage.

Meets Standard

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.

Meets Standard

Staff informed the inspector that
writing paper, envelopes and
writing implements are given to
detainees free of charge.
Confirmed via detainee
interviews.

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

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
14. All facilities shall have written policy and procedures
regarding mail privileges for detainees housed in a Special
Management Unit.

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.

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 insures 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.
The evaluation of this standard included review of policy, and interviews with staff and detainees.
The inspector interviewed Assistant Jail Administrator Taylor and ICE Liaison Officer Glassburn. .
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):
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Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities

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 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.

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.

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. The sheriff does
not allow detainees in this facility
to marry. There have been no
requests to marry by ICE
detainees during this inspection
period.

Meets Standard

Per ICE personnel, each request
to marry is considered on a caseby-case basis.

Meets Standard

Per ICE personnel, should a
detainee request permission to
marry, he/she would be notified
in a timely manner of a time and
place for the ceremony.

Meets Standard

Per ICE personnel, copies of all
documentation pertaining to the
marriage request and marriage
would be maintained in the
detainees' A-file and the
detainees' 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.

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 does not allow
detainees, ICE or non-ICE, to
marry in this facility. Should ICE
approve a detainees' request to
marry, the detainee would be
moved to another location for
the ceremony. There have been
no request to marry by ICE
detainees in this inspection
period.

PART 5 – 28. MARRIAGE REQUESTS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

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

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)
There have been no requests to marry by ICE detainees in this inspection period.
A review of policy, interviews with facility personnel and an interview with the sheriff indicated 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, as determined by a qualified medical practitioner;
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.
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, reports and interviews with Clay County Sheriff
Paul Harden, Captain Brandon Crowley and Detention Standards Compliance Officer Tashi Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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
1.

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.

All facilities shall provide recreational opportunities for
detainees with disabilities.

Exercise areas shall offer a variety of equipment. Weight
training, if offered, must be limited to fixed equipment.
Free weights are prohibited.

Cardiovascular exercise shall be available to detainees for
whom outdoor recreation is unavailable.

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 in the
last inspection because outdoor
recreation is not provided.
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, the captain is
ultimately responsible for
ensuring detainees have access
to recreational activities outside
their housing unit. The detainee
population is less than 350.

N/A

Detainees with disabilities are
not held in this facility.

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.

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

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
9.

Rating

Remarks (1000 Char Max)

PRIORITY: Dayrooms in general population housing units
shall offer board games, television, and other sedentary
activities.

Meets Standard

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

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 the SMU,
either administratively or as
disciplinary sanctions, 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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Dayrooms provide sedentary
recreation in the form of
television and board games.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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. Per the captain, ICE
personnel would be consulted
should this circumstance occur.
Per the lieutenant, no detainees
have been denied their
recreation opportunities.

Meets Standard

ICE is notified when a detainee is
placed in the SMU for any reason
and would be notified should a
detianee be denied recreation
priviledges for fifteen days or
more. Per the lieutenant, no
detainees have been denied their
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, documentation, personal observations and an interview with
Lieutenant Neil Taylor.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

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

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)

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.

•

Remarks (1000 Char Max)

Meets Standard

Policy and procedures are in
place that 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.
However, due to COVID-19
restrictions, detainees are not
allowed to congregate other than
in the housing units in small
groups. Participation in all
religious activities is 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. Due to COVID-19
restrictions, detainees are
limited to meeting in smaller
groups within their housing units.

Meets Standard

Notations on the religious
services schedule addressed the
limitation of religious services
provided by religious volunteers
due to COVID-19 restrictions.

Meets Standard

Religious activities are managed
and coordinated by a lieutenant.
Prior to restrictions due to
COVID-19, five religious
programs, led by approximately
ten religious volunteers, were
available to detainees each
weekday evening.

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.
•

Rating

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.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 5 – 30. RELIGIOUS PRACTICES (Key: AD)

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.

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.

Rating

Remarks (1000 Char Max)

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

Prior to restrictions as a result of
COVID-19, religious services were
held in a multi-purpose room.

Meets Standard

Citizen volunteers, when they
were allowed into the facility,
represented the cultural and
socioeconomic parts of the
community.

Meets Standard

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.

Meets Standard

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.

Does Not Meet Standard

12. Each facility administrator shall allow detainees access to
personal religious property, as is consistent with safety,
security and orderly operation of the facility.

Meets Standard

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Pastoral telephonic visits, by a
clergyperson or representative of
the detainees' faith, can be
arranged when requested by the
detainee.

Policy and procedures do not
address the observance of
important holy days.
Detainees are allowed access to
personal religious property which
does not pose a threat to the
safe, secure and orderly
operation of the facility.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
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

Per the captain and a review of
policy, all reasonable efforts are
made to accommodate a
detainees' religious requirements
for special food service, fasting,
restricted diets, etc. There have
been no requests for a religious
diet made by a detainee in this
inspection period.

14. The chaplain shall develop the religious fast schedule for
the calendar year and provide it to the facility
administrator or designee.
Does Not Meet Standard

A religious fast schedule for the
calendar year has not been
developed, hence not provided
to the captain or designee. The
captain indicated they had not
had any detainees observing
Ramadan, of which the
observance period recently
ended.

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)
Under normal circumstances, religious programming has been offered multiple times each week. The services have been led
by a contingent of volunteers from five different religious community organizations. Religious activities were coordinated by
the lieutenant prior to COVID-19 restrictions. Religious activities, including participation by religious volunteers, have been
curtailed 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 lieutenant or 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 interviews with Lieutenant Neil Taylor, Captain Brandon Crowley and Sergeant
Jase Glassburn; and a review of policy.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
1.

Rating

Remarks (1000 Char Max)

Meets Standard

Interviews with staff confirmed
that each housing unit has a ratio
of telephones to detainees
better than that required by this
component. The rating was also
confirmed via detainee
interviews.

Meets Standard

The inspector was informed that
the facility has a contract with a
nationally recogonized telephone
service provider who 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.

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.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
5.

Rating

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.
Meets Standard

Remarks (1000 Char Max)
The local handbook addresses
telephone monitoring. The
inspector confirmed that each
housing unit telephone has a
placard mounted on the
telephone casing stating
telephone calls are subject to
monitoring and a similar
announcement is made through
the receiver prior to each call
connection.
The handbook notes that
special/legal telephone calls to a
court, a legal representative,
OIG, CRCL or for the purpose of
obtaining legal representation
are not monitored.
The on-site SME was able to
reach the OIG Hot Line using the
direct dial number programmed
in a housing unit telephone. .

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.

Meets Standard

The local handbook addresses
each of the items listed in this
component.

Each facility administrator shall establish and oversee rules
and procedures that provide detainees reasonable and
equitable access to telephones during established facility
“waking hours.”

Meets Standard

Reviewed policy and the local
handbook prescribe detainee
telephone usage rules

Detainees are afforded a reasonable degree of privacy for
legal phone calls.

Meets Standard

A procedure exists to assist a detainee who is having
trouble placing a confidential call.

Meets Standard

ICE liaison staff informed the
inspector that they routinely
allow detainees use of private
land line telephones to make a
confidential call.
Confirmed via detainee
interviews.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

Rating

Remarks (1000 Char Max)

Meets Standard

The inspector confirmed that
special access speed dial
numbers affording detainees the
ability to make non-collect calls
are programmed into the
telephone system.

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.

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.

Meets Standard

This IGSA does not require
detainees to complete request
forms 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.
The on-site SME observed the
required postings in each
housing unit.

Meets Standard

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.

Meets Standard

15. The facility has a system for taking and delivering
emergency detainee telephone messages.

Meets Standard

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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.

Reviewed written policy
addresses the requirements of
this component.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
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.

Rating

Remarks (1000 Char Max)

Meets Standard

Reviewed ICE officer request logs
document that detainee
telephone messages are
delivered to detainees in a timely
manner.
Detainee interviews confirmed
that detainees are allowed to
make a free return emergency
call.

Meets Standard

The local handbook address each
of the items required by this
component.

Meets Standard

Written policy address 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

Accommodations shall also be made for detainees with
speech disabilities.
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.

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.

Meets Standard

The ICE liaison officer routinely
allows detainees use of their
office land line telephones to
make a confidential call.
Confirmed via detainee
interviews.

The ICE liaison officer routinely
allows detainees the use of a
private telephone to make a
confidential call.
Confirmed via detainee
interviews.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

Rating

Remarks (1000 Char Max)

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 address 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 address 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 address the
requirements noted in this
component.

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)
Telephone access is handled in accordance with the standard. ICE/ERO staff test phones for detainees at least weekly to
verify serviceability. They also make random calls to pre-programmed numbers for attorney and consulate services; interview
a sampling of detainees regarding telephone services, and review written detainee complaints regarding telephones.
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.
Evaluation of this standard included reviewing policy, procedures, and the local handbook; on site examiniation of
information posters in detainee housing units; and interviewing staff and detainees.
The inspector interviewed ICE Liaison Officer Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
1.

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.

Rating

Remarks (1000 Char Max)

Meets Standard

The local detainee handbook lists
visitation hours, schedules and
procedures.

Meets Standard

Due to health safety concerns all
general visitation is conducted
via video.
Written policy addresses the
requirements of this component.

Meets Standard

Visiting rules and hours are
available by telephone and on
the facility's website. The
inspector also noted that similar
information is also posted in
English and Spanish in the
visitor's waiting room.

Meets Standard

Due to health safety concerns all
general visitation is conducted
via video. Detainees may visit
with family and friends a
minimum of thirty minutes each
week via a video telephone
connection located in their
housing unit. The video visits are
permitted during waking hours 8:00 a.m. - 8:00 p.m. - seven days
a week including holidays.

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

The facility’s written rules shall specify time limits for
visits. The minimum time limit is 30 minutes.

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.

Due to health safety concerns all
general visitation is conducted
via video.

The dress code is noted in the
facility's web page.

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.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 5 – 32. VISITATION (Key: AF)

Rating

Remarks (1000 Char Max)

11. Written procedures shall detail the limits and conditions of
contact visits in facilities permitting them.

Meets Standard

Written policy addresses the
requirement of this component.

12. Anytime a visit is denied, to either a general population
detainee or SMU detainee, the denial is documented.

Meets Standard

Per policy all visitation denials
must be documented.

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 SME observed
private rooms where a detainee
may meet with their legal
representative and exchange
legal documents.

Meets Standard

Staff informed the inspector that
legal representatives and their
assistants must clear a metal
detector and have their
belongings searched prior to
their visit.

Meets Standard

The on-site SME inspector found
the required postings in each
housing.

Meets Standard

Reviewed written policy
addresses the requirements of
this component.

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.

Meets Standard

Staff informed the inspector that
interviews of detainees by law
enforcement officials must be
approved by ICE prior to the visit.

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.

Meets Standard

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.

17. The current list of pro bono legal organizations is posted in
the detainee housing areas and other appropriate areas.
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.

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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.
Due to health safety concerns as of April 2020 all general visitation is conducted via video. Detainees may visit with family
and friends a minimum of thirty minutes each week via a video telephone connection available in their housing unit. The
video visits are permitted during waking hours - 8:00 a.m. - 8:00 p.m. - seven days a week including holidays. Detainee visits
with their legal representatives remain as noted above.
The facility has established procedures governing whether and, if so, under what circumstances animals may accompany
human visitors onto or into facility property.
During the evaluation of this standard, visitation procedures in written policy and the local handbook were reviewed, and
employees and detainees were interviewed
The inspector interviewed Assistant Jail Administrator Taylor and ICE DSCO Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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

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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Remarks (1000 Char Max)

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 5 – 33. VOLUNTARY WORK PROGRAM (Key: AG)

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 work at this facility.

Overall Rating: N/A
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

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 as well as the Clay
County Justice Center Local ICE
Detainee Handbook (local
handbook) is 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

Jail personnel are provided a
personal 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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PART 6 – 34. DETAINEE HANDBOOK (Key: AH)

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

Per the jail commander, 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.

The local handbook addresses
this component.

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.

Meets Standard

The handbook (local supplement) clearly outlines the
methods for classification of detainees, explains each
level, and explains the classification appeals process.

Meets Standard

10. The handbook (local supplement) states when a medical
examination will be conducted.

Meets Standard

11. The handbook (local supplement) describes the facility,
housing units, dayrooms, In-dorm activities and special
management units.

Meets Standard

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.

Meets Standard

The local handbook addresses
the elements of this component.

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.

13. The handbook (local supplement) describes times and
procedures for obtaining disposable razors and explains
that detainees attending court will be afforded the
opportunity to shave first.

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PART 6 – 34. DETAINEE HANDBOOK (Key: AH)

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.

Rating

Remarks (1000 Char Max)

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

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.

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.

Meets Standard

The elements of this component
are addressed in the local
handbook.

21. The handbook (local supplement) provides local ICE
contact information.

Meets Standard

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

19. The handbook (local supplement) describes the library
location and hours of operation and law library procedures
and schedules.

the

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PART 6 – 34. DETAINEE HANDBOOK (Key: AH)

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Disciplinary policy and
procedures to include prohibited
acts and severity scale of
sanctions are addressed in the
local handbook.

Meets Standard

An in-depth explanation of the
grievance system and the
process for filing informal and
formal grievances is addressed.
The appleal process is addressed
as well as the detainees' right to
file an appeal directly to ICE.

27. The handbook (local supplement) describes the medical
sick call procedures for general population and
segregation.

Meets Standard

28. The handbook (local supplement) describes the facility
recreation policy.

Meets Standard

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.

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 all
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.

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.

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

PART 6 - 34. DETAINEE HANDBOOK – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

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 upon a review of policy, a review of the local handbook and an interview with
Captain Brandon Crowley and Lieutenant Neil Taylor.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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
1.

Rating

Remarks (1000 Char Max)

Meets Standard

Policy and procedures address
the elements of this component.

Meets Standard

Per policy, detainees are issued
the local handbook which
addresses the informal and
formal grievance system.

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;

Convening a grievance committee (or actions of a
single designated grievance officer) to review
formal complaints; and

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 non-English
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.

The grievance section of the handbook explains all steps in
the grievance process.

Meets Standard

Written procedures provide for the informal resolution of
oral grievances.

Meets Standard

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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
5.

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Detainees submit formal
grievances directly to the
facility's ICE coordinator/
grievance sergeant. 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. Per the grievance sergeant,
written responses are provided
to detainee grievances within
reasonable and specified time
frames. There have been no
general grievances filed by
detainees in this inspection
period. There have been two
medical grievances filed by
detainees in this inspection
period.

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.

Formal written grievances regarding medical care shall be
submitted directly to medical personnel designated to
receive and respond to medical grievances at the facility.
6.

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.

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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
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.
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, 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.

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 two medical grievances filed by detainees in this 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 a review of the grievance policy and the grievance logs, interviews with
detainees and interviews with Captain Brandon Crowley, Lieutenant Neil Tayor and Registered Nurse Stan Roark.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

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.

Rating

Remarks (1000 Char Max)

Meets Standard

The inspector examined
photographs of the law library
and noted that the library is: in a
private room; well equipped;
reasonably isolated from other
areas of the facility. The library
also has a sufficient number of
work stations with an adequate
number of chairs, and table
space affording detainees with a
suitable environment to conduct
their legal research.

Meets Standard

The inspector confirmed that:
detainees may use the law library
one hour each day Monday
through Friday: and they do not
have to forego recreation time to
use the library. Rating based on
review of the local handbook and
detainee interviews.

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.

Meets Standard

Detainees are provided with the means to save legal work
in a private electronic format for future use.

Meets Standard

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.

The law library has two computer
work stations; each computer is
defaulted to a printer. The
facility's library has sufficient
office supplies to help detainees
prepare documents for legal
proceedings.
Staff is responsible for inspecting
the library's equipment and
supplies.

Meets Standard

The LexisNexis applications on
the library's computes is
routinely updated and is current
during this inspection.

Meets Standard

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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
7.

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.

Rating

Remarks (1000 Char Max)

Meets Standard

The inspector confirmed that
LexisNexis software is installed
on each of the library computers
and contains the materials
required by this component. The
assigned ICE DSCO informed the
inspector that any additional law
materials asked for may be
obtained by a detainee making a
request to facility or ICE staff.

Meets Standard

ICE's on site assigned staff
verified that the required
certifications and field office
validation are in place.

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.

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

The handbook states that staff
will assist detainees in
photocopying legal materials
necessary for their legal
proceedings.

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.

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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

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 English-language 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

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.

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

Staff informed the inspector that
the referenced requests are
referred to ICE.

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

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)

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

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)
Law library and legal materials are handled in accordance with the standard. The facility has procedures in place that
effectively prevent detainees from damaging, destroying or removing equipment, materials or supplies from the law library.
Staff accommodates detainee requests for additional law library time to the extent that is consistent with the orderly and
secure operation of the facility. Special priority access to the library is given to requests from a detainee who is facing a court
deadline. The facility provides indigent detainees with free envelopes and stamps for mail related to a legal matter, including
correspondence to a legal representative, a potential legal representative or any court. Requests to send international mail
are honored as is reasonable. The detainee handbook outlines the rules and procedures governing access to legal materials
and the procedures are also posted in the law library along with a list of the law library's holdings.
In order to enhance the provision of access to legal materials 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.
ICE officers routinely provide updated LexisNexis software for installation on the library's computers. The last update was
installed January, 2021.
Evaluation of the standard included review of policy, and; interviews with detainees, ICE and facility staff members.
The inspector interviewed Assistant Jail Administrator Taylor and DSCO Tillman.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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

Remarks (1000 Char Max)

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

PART 6 – 37. LEGAL RIGHTS GROUP PRESENTATIONS (Key: AK)

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.

Rating

Remarks (1000 Char Max)

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

•

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).

N/A

Each facility shall present only ICE/ERO-approved
electronic presentations on detainee legal rights.
9.

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.
The inspector interviewed Assistant Jail Administrator Taylor.
Overall Rating: N/A
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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.

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)

Meets Standard

Interviews with facility staff
confirmed that detention files
are created for every new
admission during intake.

Meets Standard

Review of detainee files (eight)
confirmed that detention files
contain documentation and
forms generated during the
admissions process.

Meets Standard

The inspector examined
photographs of the lockable
cabinets located in a secure area
of the facility where detainee
files are located.
Staff informed the inspector that
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.

Meets Standard

Electronic record-keeping systems and data are protected
from unauthorized access.

Meets Standard

The inspector was informed that
all facility "e" files are password
protected.

PART 7 – 38. DETENTION FILES – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

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

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)
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.
Evaluation of the standard included review of policy, examination of ten active detainee files and one archived filed, and staff
interviews.
The inspector interviewed Assistant Jail Administrator Taylor and Sargent Glassburn.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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 with ICE and facility
staff confirmed that requests to
interview a detainee are referred
to ICE for approval.

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

The assigned ICE staff confirmed
that the Field Office is consulted
regarding any issues concerning
the case of a high-profile
detainee.

Meets Standard

ICE personnel 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 were
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.

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)
There are written policy and procedures in place that ensure that a media request does not delay or otherwise interfere with
the admission in-processing or departure of a detainee.
The privacy of detainees and staff, including the right of a detainee not be photographed or recorded, is protected. Media
representatives, media visitors, tours, personal interviews, press pools and visits by NGOs are all coordinated and approved
by ICE officials. Access is not denied based on the political or editorial viewpoint of the requestor. Prior to the tour, the OIC or
designee explains the terms and guidelines of the tour to the visitors.
During the evaluation of this standard, policy and procedures were reviewed, ICE staff were interviewed and documents
referencing a recent media tour of the facility were reviewed.
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PART 7 - 39. NEWS MEDIA INTERVIEWS AND TOURS – Reviewer Summary
(Use following format for dates: mm/dd/yyyy)

The inspector interviewed Assistant Jail Administrator Taylor and ICE DSCO Tillman.

Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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

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
1.

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.

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

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. This training is
provided at county jails around
the state, including this facility
on occasion. In addition, new
Clay County jail employees must
complete a forty hour on-the-job
training program prior to
working a post alone. A fortyhour annual refresher training is
provided and documented to
corrections personnel. Interviews
with the lieutenant and a review
of documentation indicated
volunteers and county
maintenance personnel are not
provided appropriate training.

The facility conducts appropriate orientation, initial
training, and annual training for all staff, contractors, and
volunteers with appropriate assessment measures.

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.

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.

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

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Written or practical examinations
are administered after training
sessions to ensure the subject
matter is understood.

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
7.

The formal training received by each trainee shall be fully
documented in permanent training records.

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.

Rating

Remarks (1000 Char Max)

Meets Standard

Does Not Meet Standard

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.
Although volunteers are not
currently allowed in the facility
due to COVID-19 restrictions,
policy does not address the
required training they must
receive.

N/A

There are no clerical and/or
support personnel who have
minimal contact with detainees.

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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

Rating

Remarks (1000 Char Max)

Meets Standard

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.

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 and sexual misconduct awareness

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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

Rating

Remarks (1000 Char Max)

Does Not Meet Standard

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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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

Rating

Remarks (1000 Char Max)

Meets Standard

During the previous inspection,
this component was rated Does
Not Meet Standard because
there was insufficient
documentation that security staff
were consistently receiving
training in each of the subjects
listed in this component. Training
provided to officers is in
compliance with Indiana state
law and covers the required
topics of this component.
Documentation was not available
to indicate security personnel
receive the minimum training
required in the component.
During this inspection,
documentation was provided
and reviewed which indicated
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

Not all jail personnel are
authorized to use 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)
Evaluation of this standard was based on review of the training plan, training policy, sign-in documents and interviews with
the captain and lieutenant. There is no certified trainer assigned to the facility. Training is provided by certified trainers
assigned to the Clay County Sheriff's Office. As noted above volunteers, when allowed into 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. These maintenance personnel do willingly
adhere to safety and security protocols of the jail.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 29

I Completion Date: 5/20/2021

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

The inspector was informed by
ICE staff that: transfer
notifications are processed by
the local ICE field officer; and
detainee transfer plans are not
discussed prior to a detainee's
transfer so the detainee would
not be able to call or tell another
detainee in the general
population about the pending
transfer.

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.

Meets Standard

ICE and facility staff informed the
inspector that I-203 forms
authorize detainee removals
The inspector also examined I203 forms contained in closed
detainee files.
The inspector was informed that
health care providers are given
notice of upcoming detainee
transfers.
The medical SME confirmed
adherence to the requirements
of this component.

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 of the transferring
medical official.

Transportation staff may not transport a detainee without
the required Transfer Summary, which is essential for
detainee safety while in transit.

Meets Standard

Interviews with ICE staff
confirmed that the facility is in
compliance with each of the
requirements of this component.

Meets Standard

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

PART 7 - 41. TRANSFER OF DETAINEES (Key: AO)

Rating

Medical staff shall notify the facility administrator when
they determine that a detainee’s medical or psychiatric
condition requires:
•

Clearance by the medical staff prior to transfer, or

•

Medical escort during transfer.

Meets Standard

Remarks (1000 Char Max)
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.
The medical SME confirmed
adherence to the requirements
of this component.

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.

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

Interviews with ICE staff
confirmed that the facility is in
compliance with the
requirements of this component.

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.

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 officers
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.

Page 182 of 184
FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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 and Assistant Jail Administrator Taylor and Sergeant Glassburn were
interviewed.
Overall Rating: Meets Standard
Reviewer Name (Printed): Inspector 2

I Completion Date: 5/20/2021

Reviewer Signature (for printed form submission):

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27

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

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
Check Document:
Errors:

Run Check

Ratings check complete.
Error(s)
Found:

Items Not
Rated:

No Errors Found

Items Not Rated:

All Items Rated

Run Indicator:

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G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27