U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
Miami Field Office
Baker County Detention Center
Macclenny, Florida

August 6 – 8, 2013

COMPLIANCE INSPECTION
BAKER COUNTY DETENTION CENTER
MIAMI FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................2
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................9
Detainee Relations ...............................................................................................................9
ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ..........................................................................................10
Detention Files ...................................................................................................................11
Environmental Health and Safety ......................................................................................13
Medical Care ......................................................................................................................15
Special Management Unit - Administrative Segregation ..................................................18
Special Management Unit - Disciplinary Segregation.......................................................20
Staff-Detainee Communication .........................................................................................21

INSPECTION PROCESS
The U.S. Immigration and Customs Enforcement (ICE), Office of Professional
Responsibility (OPR), Office of Detention Oversight (ODO) conducts broad-based compliance
inspections to determine a detention facility’s overall compliance with the applicable ICE
National Detention Standards (NDS) or Performance-Based National Detention
Standards (PBNDS), and ICE policies. ODO bases its compliance inspections around specific
detention standards, also referred to as core standards, which directly affect detainee health,
safety, and well-being. Inspections may also be based on allegations or issues of high priority or
interest to ICE executive management.
Prior to an inspection, ODO reviews information from various sources, including but not limited
to, the Joint Intake Center (JIC), Enforcement and Removal Operations (ERO), detention facility
management, and other program offices within the U.S. Department of Homeland
Security (DHS). Immediately following an inspection, ODO hosts a closeout briefing at which
all identified deficiencies are discussed in person with both facility and ERO field office
management. Within days, ODO provides ERO a preliminary findings report, and later, a final
report, to assist in developing corrective actions to resolve identified deficiencies.

REPORT ORGANIZATION
ODO’s compliance inspection reports provide executive ICE and ERO leadership with an
independent assessment of the overall state of ICE detention facilities. They assist leadership in
ensuring and enhancing the safety, health, and well-being of detainees and allow ICE to make
decisions on the most appropriate actions for individual detention facilities nationwide.
ODO defines a deficiency as a violation of written policy that can be specifically linked to ICE
detention standards, ICE policies, or operational procedures. Deficiencies in this report are
highlighted in bold and coded using unique identifiers. Recommendations for corrective actions
are made where appropriate. The report also highlights ICE’s priority components, when
applicable. Priority components have been identified for the 2008 and 2011 PBNDS; priority
components have not yet been identified for the NDS. Priority components, which replace the
system of mandatory components, are designed to better reflect detention standards that ICE
considers of critical importance. These components have been selected from across a range of
detention standards based on their importance to factors such as health and safety, facility
security, detainee rights, and quality of life in detention. Deficient priority components will be
footnoted, when applicable. Comments and questions regarding this report should be forwarded
to the Deputy Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

(b)(6), (b)(7)c

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August 2013
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Detention and Deportation Officer
Management Program Analyst
Contract Inspector
Contract Inspector
Contract Inspector

1

ODO, Headquarters
ODO, Headquarters
Creative Corrections
Creative Corrections
Creative Corrections

Baker County Detention Center
ERO Miami

EXECUTIVE SUMMARY
ODO conducted a Compliance Inspection (CI) of the Baker County Detention Center (BCDC) in
MacClenny, Florida, from August 6 to 8, 2013. BCDC, which opened in September 2009, is
owned by Baker County Correctional Development Corporation and operated by the Baker
County Sheriff’s Office. ERO began housing detainees at BCDC in 2009, under an
intergovernmental service agreement with Baker County. The facility recognizes three security
classification levels (Level I - low, Level II - medium-low and medium-high, and Level III high), and houses both male and female
Capacity and Population Statistics
Quantity
detainees for periods in excess of
Total Bed Capacity
508
72 hours. The CI evaluated BCDC’s
Detainee Bed Capacity
250
compliance with the 2000 NDS, and the
Average Daily Population
228
Sexual Assault and Abuse Prevention
Average Length of Stay (Days)
36
and Intervention (SAAPI) 2011 PBNDS
Male Population Count (as of August 6, 2013)
171
because it also applies at BCDC.
Female Population Count (as of August 6, 2013)

12

The Jacksonville Sub-Office, under the
direction of the ERO Field Office Director (FOD) in Miami, Florida (ERO Miami), is
responsible for ensuring facility compliance with ICE policies and the ICE NDS. An Assistant
Field Office Director and a Supervisory Detention and Deportation Officer oversee NDS
compliance and staff-detainee communication. There is no Detention Service Manager assigned
to BCDC.
The Director of Corrections is the highest-ranking official at BCDC, and is responsible for
oversight of daily operations.
staff members were supporting BCDC management
(b)(7)e
at the time of the inspection. Trinity Food Services provides food service and Armor
Correctional Health Care provides medical care. BCDC holds no accreditations.
In November 2010, ODO conducted an inspection of BCDC under the 2000 NDS. Among the
21 standards reviewed, 12 were in full compliance. ODO cited 23 deficiencies in nine standards.
During this CI, ODO reviewed 18 standards and found BCDC compliant with 12. ODO found
six deficiencies, one each in the following six NDS: Detention Files, Environmental Health and
Safety, Medical Care, Special Management Unit - Administrative Segregation, Special
Management Unit - Disciplinary Segregation, and Staff-Detainee Communication. Priority
components have not yet been identified for the NDS, and ODO found no deficient priority
components in the 2011 SAAPI PBNDS; therefore, no priority components were found deficient
during this review.
This report details all deficiencies and refers to the specific, relevant sections of the NDS. ERO
will be provided a copy of this report to assist in developing corrective actions to resolve all
identified deficiencies. These deficiencies were discussed with BCDC and ICE personnel during
the inspection, and at a closeout briefing conducted on August 8, 2013.
During the admission process, detainees undergo screening interviews, complete questionnaires,
and receive facility-issued personal hygiene items, clothing, towels, and bedding. Detailed
medical, dental, mental health and sexual abuse history screenings are performed at the intake
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area. English and Spanish versions of the BCDC facility handbook and the ICE National
Detainee Handbook are provided to all newly arriving detainees. ODO reviewed 12 detention
files and verified detainees received and signed for a copy of the handbook upon admission.
Orientation is provided through a video available in both English and Spanish. Detainee
property is inventoried, logged, and documented on a personal property form, and stored in a
secure area. Pat-down searches are conducted on all detainees, and strip searches are not
conducted without reasonable suspicion of contraband possession. ODO reviewed 30 detention
files and found all included required documentation. At release, detainees sign a receipt for
valuables and personal property, and surrender facility-issued clothing and bedding.
BCDC uses wristband identification tags and colored uniforms to distinguish between detainees
in different classification levels. BCDC classifies detainees as low, medium-low, medium-high,
or high level based on information provided by ERO. (b)(7)e officers in booking perform initial
classification, and reviews/overrides are performed by a supervisor as needed. Detainees are
placed in housing units with detainees having comparable criminal records and disciplinary
histories.
Detainees are provided with information on informal, formal, and emergency grievance
procedures through the detainee handbook. ODO interviewed detainees and confirmed they
were knowledgeable of grievance procedures. A captain is designated as the grievance
coordinator for BCDC. A review of the grievance log found there were 38 grievances filed in
the past year: 12 grievances regarding a variety of food service and diet-related issues; five
pertaining to medical services; and five related to time allowed in the law library. The remaining
16 grievances were filed for a variety of other issues relating to facility operations. Review of
the grievance log and 15 randomly-selected grievances confirmed the investigations were
thorough and complete, and detainees received a reply in a timely manner.
The facility handbook describes rules and regulations, as well as the services and programs
available to detainees. The BCDC handbook was last updated on March 12, 2013. ODO
reviewed 30 detention files to determine if copies of the handbooks were issued to each newly
arrived detainee. Both the ICE National Detainee Handbook and the facility handbook are
available in English and Spanish. ODO confirmed both handbooks are issued to detainees in
their respective languages. The facility staff informed ODO that translations are provided
through interpretive services for detainees who are unable to communicate in English or Spanish.
ODO observed BCDC staff members creating detention files for each detainee as part of the
admissions process. The files are activated on the Smart Cop computer system through
assignment of a booking number. Detention files are maintained in a secure area at the facility.
A log tracks the removal of detention files from the cabinet, which includes the detainee’s name,
the signature of the person removing the file, and the signature of the person returning the file.
However, the logbook did not include the A-File number, the date and time removed, the reason
for removal, the title and department of the person removing the file, or the date and time
returned.
ODO reviewed the Disciplinary Policy standard at BCDC to determine if sanctions imposed on
detainees who violate facility rules are appropriate and if the discipline process includes
progressive levels of reviews, appeals, procedures, and documentation, in accordance with the
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ICE NDS. ODO interviewed staff and reviewed facility policies and disciplinary reports. No
disciplinary hearings involving a detainee were scheduled during the inspection. Disciplinary
reports are investigated by a supervisor, and all evidence and documentation is reviewed by the
Unit Disciplinary Committee or Institutional Disciplinary Panel, consistent with the standard.
Interpretation services are available to detainees throughout the disciplinary process. The
detainee handbook contains the required notice of rights and information regarding prohibited
acts and disciplinary procedures.
From July 1, 2012 until the time of the CI, a total of 96 disciplinary hearings were held.
Documentation reflects guilty findings were rendered in 66 cases; the remaining 30 resulted in
dismissal. ODO reviewed 21 randomly selected disciplinary reports, and found the requirements
of the standard and facility policy were met.
ODO reviewed the Environmental Health and Safety standard at BCDC to determine if the
facility maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances, in accordance with the ICE NDS. ODO found the facility
maintained high levels of sanitation at the time of the inspection. Hazardous materials are stored
outside the secure perimeter of BCDC. Review of reports confirmed the facility’s water supply
is tested and certified, and the emergency generator is tested and maintained as required by the
standard.
ODO’s review confirmed the facility’s fire plan meets the standard. Documentation shows fire
drills are conducted monthly, and include the drawing and testing of emergency keys. ODO
observed exit diagrams, in English and Spanish, throughout the facility. BCDC was inspected by
the state fire marshal in February 2013, with no cited violations.
Hair care is provided in the multi-purpose rooms of the male and female housing units. ODO
observed some equipment and supplies required by the standard were unavailable, including
covered metal waste containers, haircloths, and laundered towels. This is a repeat finding from
past inspections conducted by ERO and ODO.
Trinity Services Group manages food service operations. Food service staffing consists of a
food service manager an (b)(7)e ood production supervisors. (b)(7)e county inmates worked in
the kitchen at the time of the inspection; no ICE detainees work in food service. Review of
documentation confirmed employees and inmate workers received a medical clearance. ODO
observed inmate workers being inspected by staff for signs of illness or personal hygiene
concerns prior to their shift.
The facility has a satellite feeding operation. Meal items are placed in insulated trays, loaded
onto carts, and delivered to the housing unit by a correctional deputy. Each detainee is
checked-off on a meal roster to document special diets and to confirm all detainees are fed.
ODO verified all menus were certified by a registered dietitian, and religious and medically
prescribed meals were provided and properly documented. During the inspection, 27 detainees
were on medical diets and 19 required religious diets.
ODO reviewed the local hunger strike policy, and medical staff confirmed the facility has
comprehensive local policies exceeding NDS requirements. Healthcare staff provides
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counseling on potential health consequences of a hunger strike. ODO was informed there have
been five documented hunger strikes since the 2010 ODO inspection. The medical record
review confirmed hunger strike management was consistent with local policy and NDS.
BCDC has two dedicated law libraries containing two computer terminals with the most-recent
version of Lexis-Nexis. Law library hours are posted in the libraries and in each detainee
housing unit. The facility handbook provides guidance on use of the law library, hours, and
procedures for requesting additional time. Detainees in special housing units are provided an
opportunity to use the law libraries based on a flexible schedule, with similar time allowances as
the general population.
Medical services at BCDC are provided by Armor Correctional Health Services, Inc. There are
two examination/treatment rooms offering sufficient privacy, and containing emergency
equipment, a patient restroom and shower, and offices for the Health Services Administrator,
administrative assistant, and medical providers. The medical area also includes a nurses’ station,
behind which the secure pharmacy and medical records room are located. In addition, there are
four medical observation rooms, two of which provide negative pressure air flow for tuberculosis
isolation, and a waiting area.
The medical record review confirmed all detainees were screened for symptoms of tuberculosis
upon admission and received a Purified Protein Derivative skin test or a chest X-ray, with one
exception. A detainee admitted on June 19, 2013, required a chest X-ray due to a past positive
skin test; however, documentation reflected the X-ray was not performed until June 28, 2013.
The X-ray was negative for the presence of tuberculosis.
ODO cites as a best practice BCDC’s commitment to an effective continuous-quality medical
care improvement program. Documentation reflects the program actively monitors performance
of the usual aspects of care and sets performance improvement targets. Semi-annual patient
satisfaction surveys are included as part of the program.
BCDC has comprehensive written policies providing for the prevention, reporting, and
investigation of sexual assaults. ODO evaluated BCDC’s sexual abuse and assault program
policies and procedures against the Sexual Abuse and Assault Prevention and
Intervention (SAAPI) standard from the 2011 PBNDS. BCDC signed a contract modification
with ICE on October 31, 2012, agreeing to comply with the 2011 SAAPI standard. According to
the Office of Acquisitions, the effective date of the modification was January 29, 2013, for all
written policies and procedures.
The administrative sergeant is designated as the Prison Rape Elimination Act (PREA)/SAAPI
coordinator. ODO interviewed the sergeant and found him fully knowledgeable of PREA and
the SAAPI standard, as well as his duties as the program coordinator. ODO recommended to the
program coordinator that all requirements related to SAAPI be incorporated into one policy to
support easy accessibility and provide a single source for information and procedures. The
facility has a sexual assault response team, which includes medical, mental health, security, and
investigative staff. Team members work collaboratively, and a partnership is in place with the
Women’s Center of Jacksonville’s Rape Recovery Team. A review of(b)(7)eandomly selected
detention officer training files confirmed completion of the training program upon hire and
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annually. Staff interviews supported they are knowledgeable with respect to the SAAPI program
and understand their responsibilities.
There have been two reported incidents of potential sexual assaults involving ICE detainees
since the last ODO inspection. The first incident occurred on April 13, 2011, when a detainee
reported he “did not feel right” and thought his roommate did something sexual to him during his
sleep. The detainee was examined by medical staff at the local hospital and was referred to the
local rape crisis center. There was no evidence of sexual assault. The case was investigated by
law enforcement and subsequently closed. The second allegation occurred on February 4, 2013,
and involved a detention officer allegedly having a sexual encounter with a United States
Marshals Service inmate. The Supervisory Immigration Enforcement Agent and SAAPI
coordinator informed ODO they opened a case because they were unsure at the time if there were
additional victims, including ICE detainees. It was determined no ICE detainees were assaulted
by the officer. The case is currently with state authorities and is pending prosecution. Both
cases were reported to ERO, and ERO reported the cases to the ICE/OPR JIC.
ODO reviewed the Special Management Unit (SMU)–Administrative Segregation and SMU–
Disciplinary Segregation standards at BCDC to determine if the facility has procedures in place
to temporarily segregate detainees for administrative and disciplinary reasons, in accordance
with the ICE NDS. Three male detainees were assigned to administrative segregation and two
male detainees to disciplinary segregation during the inspection. ODO reviewed documentation
and verified the detainees received copies of the segregation orders. Review of segregation
records confirmed medical staff made rounds daily, and detainees had access to recreation,
telephones, visitation privileges, and the law library, as well as correspondence privileges, as
required by the standard.
There are four cells in the booking area designated for both administrative and disciplinary
segregation, with separation by cell assignment. ODO observed each cell is equipped with a
toilet, sink, and portable “Stack-a-Bunk” beds, which are not secured to the floor or the wall in
accordance with the standard.
ODO reviewed the Staff-Detainee Communication standard by interviewing ICE personnel and
detainees, and reviewing ERO logbooks and the Facility Liaison Visit Checklists. (b)(7)e
Deportation Officers are permanently assigned to the facility to monitor NDS issues. The field
office has a local policy requiring staff to document when they conduct visits. BCDC provides
ERO staff with an office on-site to accommodate staff-detainee communication.
Immigration Enforcement Agents visit the housing units daily to address detainee requests and
concerns. According to the posted schedules observed in the housing units, Deportation Officers
visit on Thursdays to perform case management duties. The Supervisory Detention and
Deportation Officer visits the living and activity areas weekly and monthly. All visits are
recorded in logbooks located at the front entrance of the facility and in each housing unit. ODO
found the logbooks consistent with the frequency of visits reported by ERO. Visits are also
documented on a Facility Liaison Visit Checklist, maintained at the ERO Jacksonville
Sub-Office. ODO visited three housing units and the SMU, and confirmed each had a logbook
to document ICE visits.

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Detainees have the opportunity to submit written questions, requests, or concerns to ERO
personnel and facility staff via a request form, printed in English and Spanish. If the detainee
wishes to direct his or her request to ICE, a locked box is available in each housing unit. BCDC
staff does not have access to the locked box. ICE staff retrieves the requests daily and responds
to the requests as soon as possible, within 72 hours of receiving the request. Similarly, facility
staff informed ODO they also address detainee requests immediately, log the information, and
send a copy of the request to ICE. ODO reviewed 300 requests submitted by detainees between
May 6, 2013, and August 6, 2013, to determine if the requests were addressed within 72 hours.
The majority of requests reviewed related to the status of immigration proceedings. ODO found
the requests are logged electronically and responses were provided within 72 hours. BCDC’s log
contained the date the detainee request was received, the detainee’s name, the detainee’s
A-number, the officer logging the request; the date of staff response, and the date the request is
returned to the detainee. However, detainee nationality was not tracked.
All staff members receive initial and ongoing suicide prevention training, which includes the
identification of suicide risk factors, recognizing the signs of suicidal thinking and behavior,
referral procedures, suicide prevention techniques, and responding to an in-progress suicide
attempt. BCDC uses a curriculum developed by the Armor Director of Mental Health Services,
which is presented by the licensed mental health counselor. Review o
andomly selected
detention staff training files confirmed staff completed initial and ongoing suicide prevention
training.
ODO verified detainees are screened for suicide risk during the intake process. The medical
record review found two of 25 detainees identified through the screening process or thereafter as
being at- risk for suicide. Review of the medical records found both were placed in a suicide
watch cell and immediately referred to mental health staff.
There were no detainees on suicide watch at the time of the inspection. ODO was informed there
have been six suicide attempts and 24 documented suicide watches at BCDC since the
2010 ODO inspection. ODO reviewed six of the most recent cases. The medical record review
confirmed practice was consistent with the local policy and NDS.
Detainees on suicide watch are housed in one of two designated cells. ODO observed control
center staff monitoring detainees through closed circuit surveillance cameras. The practice of
continuous observation through cameras was confirmed in interviews of administrative and
detention staff. ODO found documentation of 15-minute checks in all six suicide watch records
reviewed. In addition to observation by detention staff, ODO notes and cites as a best practice,
direct observation every 15 minutes by nursing staff, documented on a log included in the
medical record.
ODO verified there is one telephone for every 16 detainees, exceeding the NDS requirement.
ODO observed detainees using the telephones in each housing unit, and detainee interviews
verified accessibility of the telephones. Notifications that telephone calls are subject to
monitoring are posted on each telephone, and access rules for use of telephones were observed at
telephone locations. ICE detainees may request to make unmonitored calls to other numbers by
submitting a request to the Immigration Enforcement Agent. If approved, either the Immigration
Enforcement Agent or the ICE case worker will allow the detainee to place the call from the ICE
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office. Serviceability checks verified all telephones in the detainee housing areas were in good
working order. Review of telephone serviceability worksheets confirmed weekly completion by
the Immigration Enforcement Agent as required.
BCDC has a comprehensive use of force policy addressing all requirements of the NDS.
Confrontation avoidance is emphasized in policy as well as in training, and was evident in video
recordings of use of force incidents reviewed by ODO. ODO reviewed training files of
(b)(7)erandomly selected staff, and confirmed completion of pre-service and annual training in the
use of force. The facility does not use any electro-muscular disruption devices. The Special
Response Team is comprised of(b)(7)eofficers who received specialized training. In the event an
immediate use of force incident is captured by a security camera, the video is reviewed and
included with written documentation on the incident.
There have been six use of force incidents at the facility since July 2012, all of which involved
use of immediate force. ODO found no deficiencies in the use of force NDS at BCDC.

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the Director of Corrections and the Supervisory Detention and Deportation
Officer regarding ERO and BCDC’s working relationship. The BCDC Director of Corrections
stated the working relationship between ERO and BCDC staff is “better than excellent.” The
Director of Corrections stated ERO supervisors and officers visit detainees in the housing units
on a regular basis, and is satisfied with the immediate responses received from ERO. The
Supervisory Detention and Deportation Officer echoed these sentiments. The Supervisory
Detention and Deportation Officer did not express to ODO any needs or concerns about
performing the agency’s missions.

DETAINEE RELATIONS
ODO randomly selected and interviewed 20 detainees (15 males and five females) regarding
quality of life issues at BCDC. All interviews with ODO were voluntary and conducted in a
group setting. None of the detainees interviewed had ever filed a grievance at BCDC. Further,
none reported having ever witnessed or experienced any mistreatment, discrimination, or abuse
(physical, verbal, or sexual) while at BCDC.
Detainees provided positive feedback with regards to the following at BCDC:
 Frequency of visits by ERO staff,
 Issuance and replenishment of personal hygiene items,
 Access to indoor recreation,
 Access to the law library several times each week,
 Receipt of detainee handbooks, and
 Access to grievance forms.
Detainees expressed concerns about the following at BCDC:
 Lack of communication with Deportation Officers (i.e., immigration case status),
 Small food portions,
 High costs associated with telephone calls,
 Treatment (alleged being “treated like criminals”),
 Delays in the provision of dental care, and
 Mold in showers stalls in B-4.
ODO researched the issues raised by these detainees and found no deficiencies related to the
associated standards. ODO found no deficiencies in both the Staff-Detainee Communication and
Food Service standards. ODO brought telephone call rates to the attention of facility leadership
and the Director of Corrections stated he had no control over rates. None of the detainees
interviewed reported having filed any grievances regarding their treatment at BCDC. ODO
reviewed the medical records of those detainees who complained about dental care and found
they were receiving adequate and timely treatment in accordance with the Medical Care
standard. Finally, ODO did not find mold in the showers as alleged by the detainees in B-4.
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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 NDS and found BCDC fully compliant with the following
12 standards:
1. Access to Legal Material
2. Detainee Classification System
3. Detainee Grievance Procedures
4. Detainee Handbook
5. Disciplinary Policy
6. Food Service
7. Hunger Strikes
8. Sexual Abuse and Assault Prevention and Intervention (2011 PBNDS)
9. Suicide Prevention and Intervention
10. Telephone Access
11. Terminal Illness, Advance Directives, and Death
12. Use of Force
As the standards above were compliant at the time of the review, a synopsis for these standards
was not prepared for this report.
ODO found deficiencies in the following six areas:
1. Detention Files
2. Environmental Health and Safety
3. Medical Care
4. Special Management Unit–Administrative Segregation
5. Special Management Unit–Disciplinary Segregation
6. Staff-Detainee Communication
Findings for these standards are presented in the remainder of this report.

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DETENTION FILES (DF)
ODO reviewed the Detention Files standard at BCDC to determine if files are created containing
all significant information on detainees housed at the facility for over 24 hours, in accordance
with the ICE NDS. ODO toured the admissions and release area, and property room; reviewed
detention files, logbooks, policies, and procedures; and interviewed staff.
ODO observed BCDC staff members creating detention files for each detainee as part of the
admissions process. The files are activated on the Smart Cop computer system through
assignment of a booking number. BCDC staff also confirmed file activation with a notation on
the inside cover of each detention file.
ODO reviewed training folders of(b)(7)e BCDC officers and confirmed they received training on
the classification of detainees. Staff members were also trained in creating, managing, and
archiving detention files. Correctional officers informed ODO they received in-service training
and additional Phase-1 Classification training in June 2012.
ODO’s review of detention files and interviews with intake processing staff confirmed initial
classification and primary assessment forms are completed within 12 hours. Secondary
assessments are completed 30 days after the date of the primary assessment. Re-classification is
performed upon release from disciplinary segregation. ERO has not implemented the four-level
Risk Classification Assessment system at BCDC, to incorporate classification of detainees based
on PREA and other special vulnerable population needs.
ODO reviewed 15 active and 15 archived detention files, and found required documents are
maintained and include booking cards, detainee photographs, personal property inventory sheets,
housing identification cards, classification worksheets, property receipts (Form G-589), and
acknowledgement forms documenting receipt of the detainee handbook and facility orientation.
All of the 15 archived detention files reviewed contained notations as to when each file was
completed and ready for archiving. Additionally, BCDC complied with NDS requirements for
the sharing of documents in detention files, allowing the documents to be forwarded from the
detention files to a requesting facility or to a detainee’s legal representative.
Detention files are maintained in a secure area at the facility. A log documents information
pertaining to the removal of detention files from the cabinets, including the detainee’s name, the
signature of the person removing the file, and the signature of the person returning the file.
However, the logbook did not include the A-File number, the date and time removed, the reason
for removal, the title and department of the person removing the file, or the date and time
returned (Deficiency DF-1 (III)(F)(2)). During the CI, ODO addressed with facility staff the
NDS requirement for recording file removal details to enable the facility to locate detention files
and to comply with privacy provisions.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DF-1
In accordance with the ICE NDS, Detention Files, section (III)(F)(2), the FOD must ensure, “At
a minimum, a logbook entry recording the file’s removal from the cabinet will include:
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a.
b.
c.
d.
e.
f.

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.”

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at BCDC to determine if the
facility maintains a high standard of cleanliness and sanitation, safe work practices, and control
of hazardous materials and substances, in accordance with the ICE NDS. ODO toured the
facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous
chemical management, and other relevant documentation.
A tour of the facility showed sanitation was maintained at a very high level. Hazardous
materials are stored outside the secure perimeter of BCDC. Observation confirmed a system is
in place for storing, issuing, and maintaining inventories of all hazardous materials used at
BCDC. Material Safety Data Sheets and a master index of chemicals were available and
complete, and documentation was current. Review of reports confirmed the facility’s water
supply is tested and certified, and the emergency generator is tested and maintained as required
by the standard. Pest control invoices reflect monthly and as-needed eradication services are
provided.
ODO’s review confirmed the facility’s fire plan meets the standard. Documentation shows fire
drills are conducted monthly, and include drawing and testing of emergency keys. ODO
observed exit diagrams in English and Spanish were present throughout the facility. BCDC was
inspected by the state fire marshal in February 2013, with no cited violations.
Hair care is provided in the multi-purpose rooms of the male and female housing units.
Barbering equipment, including spray sanitizer for the clippers, is issued by the pod officer and
returned after use. Other equipment and supplies required by the standard, including covered
metal waste containers, haircloths, and laundered towels, were unavailable
(Deficiency EH&S-1 (III)(P)(1)(2)). This is a repeat finding from past inspections conducted
by ERO and ODO.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1)(2), the
FOD will ensure that “Sanitation of barber operations is of the utmost concern because of the
possible transfer of diseases through direct contact or by towels, combs and clippers. Towels
must not be reused after use on one person. Instruments such as combs and clippers will not be
used successively on detainees without proper cleaning and disinfecting. The following
standards will be adhered to:
1. The operation will be located in a separate room not used for any other purpose. The floor
will be smooth, nonabsorbent and easily cleaned. Walls and ceiling will be in good repair
and painted a light color. Artificial lighting of at least 50-foot candles will be provided.
Mechanical ventilation of 5 air changes per hour will be provided if there are no operable
windows to provide fresh air. At least one lavatory will be provided. Both hot and cold
water will be available, and the hot water will be capable of maintaining a constant flow of
water between 105 degrees and 120 degrees.

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2. Each barbershop will be provided with all equipment and facilities necessary for maintaining
sanitary procedures of hair care. Each shop will be provided with appropriate cabinets,
covered metal containers for waste, disinfectants, dispensable headrest covers, laundered
towels and haircloths.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at BCDC to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE NDS. ODO toured the clinic, reviewed policies and procedures, verified medical staff
credentials, observed a physical examination, and interviewed the Health Services Administrator
and the Supervisory Detention and Deportation Officer. ODO examined 25 medical records of
detainees falling into the following categories: chronic care, female detainees, detainee
complaints (addressed in another section of this report), hunger strike, suicide watch, and healthy
detainees. All records were spot-checked for sick call-timeliness and reviewed for transfer
documentation.
Medical services at BCDC are provided by Armor Correctional Health Services, Inc. The
facility currently holds no accreditations. The clinic is open 24 hours a day, seven days a week,
and is administered by the Health Services Administrator, who is a registered nurse. Clinical
oversight is provided by the corporate regional medical director, who is on-site once a month and
available for consultation for complex chronic care issues as needed. Full-time provider
coverage is provided on-site by an advanced registered nurse practitioner. Mental health services
are provided by a psychiatrist on-site four hours a week, and (b)(7)efull-time licensed mental health
counselor. The nurse practitioner, psychiatrist, and mental health counselor are also available
on-call. A local dentist provides dental services on a referral basis. These positions are
augmented by a director of nursing; (b)(7)e full-time and (b)(7)e as-needed, registered nurses; (b)(7)e
full-time and (b)(7)e as-needed, licensed practical nurses; (b)(7)eadministrative assistant; and (b)(7)e
medical records clerk. All permanent and as-needed staff members are employed by Armor.
ODO verified the staffing plan is reviewed annually, and there were no vacancies at the time of
the review. All professional licenses were present and the primary source was verified for
authentication purposes. ODO finds staffing sufficient to provide basic medical services to
detainees housed at BCDC.
In the event a detainee requires medical services beyond the scope of care available at BCDC,
transfer is available to the Krome Service Processing Center, the Ed Frasier Hospital, or the
Shands Hospital at the University of Florida in Jacksonville. Off-site mental health services are
available at Meridian Behavioral Health in Jacksonville or at the Northeast Florida State
Hospital. Ambulance services are provided by the emergency response ambulance based in
Macclenny, approximately one mile away.
The clinic is small but adequate and well-equipped. There are two examination/treatment rooms
offering sufficient privacy and containing emergency equipment, a patient restroom and shower,
and offices for the Health Services Administrator, administrative assistant and medical providers.
The clinic also includes a nurses’ station, behind which the secure pharmacy and medical records
room are located. In addition, there are four medical observation rooms, two of which provide
negative pressure air flow for tuberculosis isolation, and a waiting area. A detention officer is
always present for custody supervision when detainees are in the clinic. When necessary, the
DHS Language Line telephone interpretation service is used when conducting medical
encounters with detainees with limited English language proficiency, as directly observed by
ODO. BCDC does not charge detainees co-pays or other fees for healthcare services.

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Nursing staff conduct intake screenings in a private examination room within 12 hours of
admission. The medical record reviews found all detainees requiring immediate attention for
medical issues or for medications were referred to the provider for follow-up. Essential
medications were ordered and given as required. The intake screening forms were reviewed by
the nurse practitioner to assess priority for treatment in the 25 medical records reviewed by
ODO. All females are tested for pregnancy.
Health appraisals, which include a hands-on physical examination, are conducted by registered
nurses. ODO’s medical record review found 22 physical examinations were conducted and
signed by the physician between five and 12 days following the detainees’ arrival. However,
ODO found three cases where detainees refused the physical examinations. ODO confirmed
refusal forms describing potential consequences were signed by the detainee; however, the
reason for their refusal was not documented on the form or in the progress notes, and physical
examinations were not offered again at a later date. During the review, the Health Services
Administrator rescheduled physical examinations for two of the three detainees; the third had
been transferred. The Health Services Administrator performed one of the examinations during
the review, observed by ODO. Upon discussion of the issue with the Health Services
Administrator, she stated she previously identified a pattern of refusals in 2010, and from
January to June 2011, and completed a Quality Assurance Process Study to examine the issue.
Of all patients refusing physical examinations during the period (ICE detainees, United States
Marshals Service detainees, and county inmates), 95 percent were ICE detainees. During
interviews, some detainees voiced frustration at having to have another examination upon
transfer, even if within 90 days; others stated they were not sick and did not believe they needed
a physical examination. Analysis determined there was a lack of education on the importance of
baseline physical examinations and of the consequences from foregoing them. ODO
recommends improving patient education to minimize refusals, and when detainees do refuse,
ensuring follow-up attempts are made and documented.
The medical record review confirmed all detainees were screened for symptoms of tuberculosis
upon admission, and received a Purified Protein Derivative skin test or a chest X-ray, with one
exception. A detainee admitted on June 19, 2013, required a chest X-ray due to a past positive
skin test; however, documentation reflected the X-ray was not performed until June 28, 2013
(Deficiency MC-1 (III)(D)). The X-ray was negative for the presence of tuberculosis.
Detainees request healthcare services by submitting written request forms directly to nursing
staff, which are available in English, Spanish, and Creole. The forms are printed in duplicates,
allowing issuance of a copy to the detainee, with the original being maintained in the medical
record. ODO observed these forms in the housing units, and are available from nursing staff on
medication rounds twice a day, seven days a week. Face-to-face triage in the housing unit is
conducted by a registered nurse when necessary; otherwise, the medical record review found
triage is conducted the next day. Sick call is conducted on a daily basis in the clinic following
Armor nursing protocols. ODO confirmed medical requests were addressed and completed in a
timely manner as appropriate to the nature of the complaint. Detainees housed in segregation
obtain sick call request forms from the unit officer or nursing staff, and hand them directly to
nurses during daily wellness checks.

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The medical record review confirmed detainees with chronic medical conditions are monitored
and receive appropriate care consistent with provider orders. ODO observed one particularly
noteworthy case where a diabetic detainee was identified as intrinsically unstable (“brittle”). In
an attempt to more closely monitor the detainee’s blood sugar as related to his diet, medical staff
had him report to the clinic at meal times to eat his meals there.
ODO cites as a best practice BCDC’s commitment to an effective, continuous quality
improvement program. Documentation reflects the program actively monitors performance of
the usual aspects of care and sets performance improvement targets. Semi-annual patient
satisfaction surveys are included as part of the program.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure, “All new
arrivals shall receive initial medical and mental health screening immediately upon their arrival
by a health care provider or an officer trained to perform this function. All new arrivals shall
receive TB screening by PPD (mantoux method) or chest x-ray. The PPD shall be the primary
screening method unless this diagnostic test is contraindicated; then a chest x-ray is obtained.

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SPECIAL MANAGEMENT UNIT (SMU)‒ADMINISTRATIVE
SEGREGATION
ODO reviewed the Special Management Unit‒Administrative Segregation standard at BCDC to
determine if the facility has procedures in place to temporarily segregate detainees for
administrative reasons, in accordance with the ICE NDS. ODO toured the segregation areas,
reviewed policies, and interviewed staff and detainees.
A review of facility procedures and discussions with supervisory staff confirmed administrative
segregation at BCDC is a non-punitive form of separation from the general population when the
presence of the detainee poses a threat to self, other detainees, staff, property, or the security and
orderly operation of the facility. BCDC’s SMU for male detainees consists of
16 double-occupancy cells in dorm B7. The SMU is used for both administrative and
disciplinary segregation, with separation afforded by cell assignment. The unit was well lit, in
good sanitary condition, adequately ventilated, and temperature-controlled. Each cell has two
beds affixed to the wall, a sink and toilet combination, and a shower. There is a recreation area
adjacent to the unit where detainees in segregation receive recreation privileges consistent with
the general population. A system of non-contact video visitation is provided for detainees in the
SMU, as well as the general population. Telephones are present in the SMU, and use of the law
library in the unit next door is permitted upon request. ODO verified detainees in segregation
receive the same meals as detainees in general population.
There are four cells in the booking area designated for use as the SMU for female detainees. The
cells are used for both administrative and disciplinary purposes, with separation by cell
assignment. ODO observed each cell is equipped with a toilet, sink, and portable “Stack-aBunk” beds, which are not secured to the floor or the wall (Deficiency SMU AS-1 (III)(D)(2)).
(Because the same cells are used for disciplinary segregation, this deficiency is also cited in
SMU-Disciplinary Segregation.) The one female detainee in segregation during the review had
flipped the bed upside down and placed her mattress in it. The SMU routinely houses potentially
disruptive detainees who pose a threat to themselves or others. Securing beds to the walls or
floor ensures the beds cannot be used as a weapon or barricade. The captain corrected the
deficiency during the inspection by designating for segregation other cells that have bunks
affixed to the wall. The detainee in segregation was moved to one of the newly designated cells.
There is a shower in the area, and recreation, visitation, the law library, and telephones are
available for use in the female general population housing unit when other detainees are secured
in their cells.
There were three male detainees assigned to administrative segregation during the inspection.
One detainee was in protective custody at his own request; one detainee was pending review as a
possible escape-risk, pending receipt of further information from another facility; and one
detainee was assigned for observation by medical staff. The detainee in protective custody had
been in the SMU for three weeks, and the detainee pending determination of possible escape-risk
had been segregated for two weeks. Medical staff released the third detainee after one day. The
female detainee had been in administrative segregation for protective custody at her own request
since May 21, 2013. ODO reviewed documentation and verified the detainees received copies of
the segregation orders, required reviews were conducted, and the FOD was notified when
required. Segregation records confirmed medical staff made rounds daily, and detainees had
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access to recreation, telephones, visitation, and the law library, as well as correspondence
privileges, as required by the standard.
Starting in April 2013, detainees assigned to segregation have been tracked using a running log.
Review of the log found that, in addition to the four detainees on administrative segregation
during the inspection, 36 detainees had been assigned to administrative segregation since the log
was implemented. ODO reviewed documentation for five of the 36 detainees and confirmed
compliance with the NDS. Only one detainee was in the SMU in excess of 30 days. He had
requested protective custody and remained in that status until he was transferred to another
facility after approximately three months. ODO confirmed reviews were conducted in
accordance with the NDS, and ICE was notified.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU AS-1
In accordance with the ICE NDS, Special Management Unit-Administrative Segregation,
section (III)(D)(2), the FOD must ensure “The quarters used for segregation shall be well
ventilated, adequately lit, appropriately heated and maintained in a sanitary condition at all times.
All cells must be equipped with beds. The beds shall be securely fastened to the cell floor or
wall.”

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SPECIAL MANAGEMENT UNIT (SMU)–DISCIPLINARY
SEGREGATION
ODO reviewed the Special Management Unit-Disciplinary Segregation standard at BCDC to
determine if the facility has procedures in place to temporarily segregate detainees for
disciplinary reasons, in accordance with the ICE NDS. ODO toured the segregation areas,
reviewed policies, and interviewed staff and detainees. BCDC’s SMU for male detainees
consists of 16 double-occupancy cells in dorm B7. The SMU is used for both administrative and
disciplinary segregation, with separation afforded by cell assignment. The unit was well lit, in
good sanitary condition, adequately ventilated, and temperature-controlled. Each cell has two
beds affixed to the wall, a sink and toilet combination, and a shower. There is a recreation area
adjacent to the unit where detainees in segregation receive recreation privileges consistent with
the general population. A system of non-contact video visitation is provided for detainees in the
general population, as well as for detainees in the SMU. Telephones are present in the SMU, and
use of the law library in the unit next door is permitted upon request. ODO verified detainees in
segregation receive the same meals as detainees in general population.
There are four cells in the booking area designated for use as the SMU for female detainees. The
cells are used for both administrative and disciplinary purposes, with separation by cell
assignment. ODO observed each cell is equipped with a toilet, sink, and portable “Stack-aBunk” beds, which are not secured to the floor or the wall (Deficiency SMU DS-1 (III)(D)(6)).
(Because the same cells are used for administrative segregation, the same deficiency is cited in
SMU-Administrative Segregation.) The SMU houses potentially disruptive detainees who pose
a threat to themselves or others. Securing beds to the walls or floor ensures the beds cannot be
used as a weapon or barricade. The captain corrected the deficiency during the inspection by
designating other cells for segregation that have bunks affixed to the wall. There is a shower in
the area, and recreation, visitation, law library and telephones are available for use in the general
population housing unit when other detainees are secured in their cells.
There were no females and two male detainees in disciplinary segregation during the inspection.
One detainee was serving ten days of disciplinary segregation for disrespect to an official, and
the other was serving 30 days in disciplinary segregation for possession of a weapon. ODO
reviewed documentation and verified the detainees received copies of the disciplinary
segregation orders. Review of segregation records confirmed medical staff made rounds daily,
and detainees had access to recreation, telephones, visitation, and the law library, as well as
correspondence privileges, as required by the standard. Starting in April 2013, detainees
assigned to segregation have been tracked using a running log.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU DS-1
In accordance with the ICE NDS, Special Management Unit–Disciplinary Segregation,
section (III)(D)(6), the FOD must ensure “The quarters used for segregation shall be well
ventilated, adequately lit, appropriately heated and maintained in a sanitary condition at all times.
All cells must be equipped with beds. The beds shall be securely fastened to the cell floor or
wall.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at BCDC to determine if procedures
are in place to allow formal and informal contact between detainees and key ICE and facility
personnel; and if ICE detainees are able to submit written requests to ICE personnel and receive
timely responses, in accordance with the ICE NDS. ODO interviewed staff and detainees, and
reviewed ERO logbooks and the Facility Liaison Visit Checklists.
The ERO Jacksonville Sub-Office has oversight responsibilities at BCDC, and has devised
policies and procedures for staff-detainee communication. ODO reviewed a sign-in log and
interviewed BCDC staff to confirm regular unannounced visits are conducted and documented.
ODO’s review of the logbook in the housing units and the SMU confirmed ERO management
staff visits are documented.
Based on the interviews with detainees and BCDC staff, ODO verified Deportation Officers and
Immigration Enforcement Agents conducted regular scheduled visits to interact with detainees.
The Immigration Enforcement Agents visit the housing units daily to address detainee requests
and concerns. (b)(7)e Deportation Officers visit every Thursday to perform case management
duties. ODO found the logbook consistent with the frequency of visits reported by ERO. Visits
are also documented on Facility Liaison Visit Checklists and maintained at the ERO Jacksonville
Sub-Office as required by the Model Protocol, in accordance with the DRO Headquarters’
Change Notice, National Detention Standards, and Model Protocol, dated June 15, 2007.
Detainees are able to submit written questions, requests, or concerns to ERO personnel and
facility staff. Request forms are available in English and Spanish in each housing unit. Each
housing unit is equipped with a drop box for written requests submitted directly to ICE. ICE
staff retrieves the requests daily and provides responses to detainees within 72 hours of receiving
the requests. BCDC staff informed ODO that detainees’ requests are addressed immediately
upon receipt, logged, and a copy of the completed request is given to ERO staff. ODO reviewed
300 detainee requests from May 6, 2013 through August 6, 2013. The requests are electronically
logged and responded to within 72 hours. The majority of the requests included inquiries
regarding the status of immigration proceedings, and a small number concerned miscellaneous,
facility-related matters. ODO observed the requests log and found it contained the date of
receipt, the detainee’s name, the detainee’s A- number, the name of the officer logging the
request, the date of the request, and the staff response or action. However, the column for the
detainee’s nationality was left blank (Deficiency SDC-1 (III)(B)(2)(d)).
According to the NDS, the completed requests are required to be filed in each detainee’s
detention file and maintained for at least three years. ODO reviewed 30 detention files of
detainees who have filed a request, and verified the completed requests were included.
The detainee handbook includes information on how to submit written questions, requests, or
concerns to ICE and facility staff. The DHS Office of Inspector General Hotline posters are
displayed in the housing units and in both libraries.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2)(d), the
FOD must ensure “All requests shall be recorded in a logbook specifically designed for that
purpose. The log, at a minimum, shall contain: (d. Nationality).”

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