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
New Orleans Field Office
LaSalle Detention Facility
Jena, Louisiana

March 19 – 21, 2013

COMPLIANCE INSPECTION
LASALLE DETENTION FACILITY
NEW ORLEANS FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................7
Inspection Team Members ...................................................................................................7
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................8
Detainee Relations ...............................................................................................................8
ICE PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................9
Grievance System ..............................................................................................................10
Medical Care ......................................................................................................................12
Suicide Prevention and Intervention ..................................................................................16

This report details all identified deficiencies and refers to the relevant sections of the PBNDS.
ERO will be provided a copy of this report to assist in developing corrective actions to resolve
the deficiencies. These deficiencies were discussed with LDF personnel on-site during the
inspection and with ERO and LDF management during a closeout briefing conducted on
March 21, 2013.
Overall, ODO found LDF to be orderly and well managed. ODO observed a high level of
sanitation throughout the facility. ODO attributes the low number of deficiencies observed
during this inspection to the consistent monitoring of detention conditions at LDF by ICE
personnel and facility staff. LDF management has designated a compliance officer to oversee
internal compliance with the PBNDS. An on-site Detention Service Manager conducts weekly
inspections and annual reviews of the facility. The LDF compliance officer and ICE staff meet
monthly to address detainee needs and PBNDS compliance issues.
Procedures are in place to protect the health, safety, security, and welfare of detainees during the
admission and release process. ODO reviewed 30 detention files, interviewed facility staff and
detainees, and observed the admission and release process. Detainees are classified and
medically screened upon admission to the facility, and classifications are reassessed at
appropriate intervals. Detainees are provided with appropriate clothing, adequate hygiene
supplies, the ICE National Detainee Handbook, and the facility handbook. Both handbooks are
available in English and Spanish. Facility management provides a video orientation to all
detainees. Property and funds are properly inventoried and securely stored at admission.
LDF has a comprehensive policy addressing the classification of detainees. Detainees are
classified by ICE prior to admission to LDF, and LDF adheres to the classification level assigned
by ICE. A review of 25 detention files and 15 alien files confirmed the presence of
documentation verifying proper assignment of classification levels. A review of the facility
grievance log and interviews with classification staff confirmed that no grievances or appeals
have been filed regarding detainee classification levels. ODO verified reclassification hearings
are conducted in compliance with facility policy and the PBNDS.
The facility handbook addresses all requirements of the PBNDS. Copies of the facility
handbook and the ICE National Detainee Handbook, in Spanish and English, are readily
available in the admissions area at LDF. ODO reviewed 25 detention files and confirmed each
file contained a signed intake property form acknowledging receipt of both handbooks. ODO
observed the intake processing of 39 detainees and witnessed the issuance of detainee
handbooks. The most recent update of the facility handbook occurred on September 30, 2012.
The disciplinary policy at LDF addresses all requirements of the PBNDS. The policy contains
graduated severity scales of prohibited acts and disciplinary sanctions, and encourages informal
resolutions for minor infractions. Prohibited acts and sanctions, the disciplinary process,
detainee rights, and appeal procedures are also addressed in the facility handbook. ODO
confirmed there were 122 detainee disciplinary hearings during the 12 months preceding this CI.
ODO randomly selected and reviewed 21 disciplinary reports and verified they were completed
in accordance with facility policy and the PBNDS. There were no disciplinary hearings
conducted during this CI.

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ODO verified all hazardous materials and substances are stored in locked cabinets accessible
only by staff. Chemical control is well managed by LDF. An annual fire inspection was
completed, and the Fire Safety Evacuation plan was reviewed and approved by the Louisiana
State Fire Marshal on December 18, 2012. All buildings within the LDF complex are in
compliance with applicable fire codes. Evacuation plans, in English and Spanish, are
prominently posted throughout the facility. The master index of hazardous substances and
Material Safety Data Sheets are appropriately maintained. Drinking water at LDF is tested
quarterly. The emergency power generators are tested each week for one hour, which exceeds
the PBNDS requirement for bi-weekly testing. ODO confirmed all medical sharps and syringes
are properly inventoried and documented during each shift by the incoming and the outgoing
nurse.
The food service operation is managed by LDF employees. Staff includes a Food Service
Supervisor, a production manager, an administrative support staff person, and(b)(7)ecook
specialists. There are 20 detainees assigned to work in food service. ODO verified all staff and
detainees receive pre-employment medical clearances. All areas of the food service operation
are clean and organized. Inspection of the tool room confirmed utensils and tools are properly
secured and accounted for. Food preparation equipment is clean and properly installed. ODO
confirmed the master cycle menu is reviewed annually by the Food Service Supervisor, and
certified by a registered dietician based on a complete nutritional analysis. The master menu is a
42-day cycle that includes three hot meals per day. Religious diets are approved by the
Chaplain, and medical diets are provided when ordered by the medical unit. ODO confirmed the
registered dietician also approves all religious and medical diet menus.
ODO observed all meals are delivered to housing units in closed containers under escort by LDF
staff. Detainees receiving special diet trays sign an acknowledgement to confirm receipt of the
appropriate meal. ODO interviewed detainees in the housing units and received positive
comments regarding the menu.
LDF funds and personal property policy and procedures provide for the accounting, inventory,
and safeguarding of detainee property from the time of admission until the time of release. The
property storage area is located next to the admission and release area behind locked doors
accessible only by LDF supervisory staff. Funds and valuables are properly inventoried and
logged by LDF supervisory staff, and held in a safe located in the office of the shift supervisor.
All property storage areas are monitored 24 hours a day by control room staff via closed circuit
cameras. Abandoned property belonging to detainees is forwarded to ICE for disposition in
accordance with the PBNDS. All detainee property bags are clearly tagged with the name and
the facility identification number of each detainee. The property storage area is clean and well
organized.
Detainees have the opportunity to file informal, formal, and emergency grievances, and detainees
can appeal grievance decisions. Grievance forms, in English and Spanish, are available in each
detainee housing unit. The LDF grievance system policy is comprehensive and addresses all
requirements of the PBNDS. Interviews confirmed detainees are aware of their right to
communicate directly with ICE if they are dissatisfied with a grievance decision or the response
to an appeal. The facility handbook contains information regarding the grievance process.

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accommodate high-volume processing demands. A review of 25 records found five initial health
screenings were not completed within 12 hours of admission. Of those five, four were
completed within 24 hours of admission, and one was completed three days after admission.
A chest x-ray is administered in the LDF digital x-ray room to identify tuberculosis prior to
completion of intake processing. Initial assessments include screening for intoxication and
substance withdrawal, suicide risk factors, acute medical and dental problems, communicable
diseases, and follow-up care needs. ODO confirmed medical, dental, and mental health referrals
are promptly and appropriately submitted. Detainees are verbally oriented to the sick call
process and are provided patient education pamphlets, printed in English and Spanish, addressing
prevention of infectious diseases and access to healthcare. Medical personnel use Interpretalk to
communicate with detainees who speak a language other than English or Spanish. There is an
ample number of LDF medical staff fluent in Spanish.
Sick call occurs three times daily in the general population housing units. ODO confirmed nonmedical personnel are not involved in the collection of medical information. On weekdays,
triage is conducted the same day the complaint is received. On weekends and holidays, only
urgent complaints are evaluated the same day, while all others are scheduled for the next
weekday.
ODO confirmed there were no detainee deaths, suicides, or suicide attempts during the
12 months preceding this CI.
The LDF Classification Administrator is the designated Sexual Abuse and Assault Prevention
and Intervention (SAAPI) Coordinator. ODO confirmed there have been three incidents of
sexual abuse since March 2012, which were all investigated by the Jena Police Department.
ODO reviewed the three investigative files. Two cases involving female detainees who were
allegedly touching and kissing were unsubstantiated. Both of these incidents were reported to
the Joint Intake Center, and Significant Incident Reports were generated documenting the
incidents. The third incident, which was witnessed by facility staff, involved an allegation
involving mutual kissing between two female detainees. The allegation was sustained, and both
detainees were disciplined for engaging in a sexual act. This incident was not reported to the
Joint Intake Center, and a Significant Incident Report was not generated. On April 29, 2013,
ODO consulted with ERO as to why the incident was not reported to the Joint Intake Center.
ERO New Orleans advised, due to there not being an aggressor or a victim, and pursuant to
guidance received from ERO Headquarters Field Operations, the incident did not warrant the
reports being generated. The PBNDS also does not require a report to be generated if there is no
perpetrator. The incident was documented by the facility and referred to the Jena Police
Department. The Jena Police Department further advised there was no criminal act. Medical
examinations by facility healthcare staff were completed in all three cases. The SAAPI
Coordinator tracked the investigations and ensured ERO received proper notification.
LDF policy and procedure regarding segregation addresses all requirements of the PBNDS. At
the time of the inspection, a detainee was serving 30 days in disciplinary segregation. The
detainee was placed in disciplinary segregation for the following infractions: conduct that
disrupts or interferes with the security and orderly operation of the facility; insolence towards a
staff member; and possessing unauthorized clothing. ODO confirmed the sanction was imposed
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via an appropriate disciplinary process, and the segregation order was issued by the Disciplinary
Hearing Committee in accordance with the PBNDS. There were five detainees (three male; two
female) on administrative segregation, three of whom were assigned to this status for protective
custody reasons. The fourth detainee was identified by ICE as a high profile case presenting a
potential security risk if housed in general population. The fifth was assigned to administrative
segregation for continually disruptive behavior in general population and repeated disciplinary
incidents. ODO verified each detainee in administrative segregation received an administrative
segregation order, and all required status reviews were conducted. The special management unit
log entries confirmed visits by facility staff, medical personnel, and ICE officers. Meals,
recreation, telephone access, showers, and visitation privileges are provided in accordance with
facility policy and the PBNDS.
The LDF staff-detainee communication policies allow detainees to have informal and
unrestricted access and interaction with ERO and facility staff. ERO visitation schedules are
conspicuously posted in all detainee housing units. The ICE AFOD regularly meets with LDF
management and visits the housing units multiple times each month to observe conditions of
confinement. ODO reviewed the Facility Liaison Visit Checklists generated from
December 2012 to February 2013, and confirmed ERO officers consistently conduct multiple
weekly scheduled and unscheduled visits to address detainee concerns and monitor conditions of
confinement. Detainees are permitted to submit formal written questions, concerns, or requests
to ERO and facility staff via a request form, printed in English and Spanish, available in each
housing unit. ODO reviewed 300 randomly-selected requests submitted by detainees between
September 1, 2012, and February 28, 2013. ODO verified each request was documented and
recorded in an electronic request log, and a response was provided within 72 hours. The
majority of requests were inquiries regarding the status of immigration proceedings. There were
a small number of requests concerning matters such as replenishment of hygiene supplies,
requests for additional law library time, and miscellaneous facility-related matters.
The inspection confirmed the suicide watch cells, which are connected to the medical clinic, are
clean and absent of items that could aid a suicide attempt. The LDF training plan addresses
suicide risk identification, management of suicide gestures and attempts, and procedures for
mental health referrals. Examination of b)(7)etraining records for custody staff found suicide
prevention and intervention information is provided during staff orientation and annual refresher
training. ODO reviewed the medical file of a detainee previously placed on suicide watch and
confirmed the suicide watch was terminated by an NP who lacked the authority to do so. LDF
policy clearly states only the Clinical Director or a mental health professional is authorized to
terminate a suicide watch and return a detainee to general population.
LDF has a comprehensive written policy governing the use of force addressing all requirements
of the PBNDS. The facility has (b)(7)emember Correctional Emergency Response Team. Afteraction review teams are comprised of the ICE Chief Immigration Enforcement Agent, the LDF
Warden, the LDF Deputy Warden, the LDF Chief of Security, and the HSA. There have been
14 use of force incidents at LDF since March 2012 (eight immediate; six calculated). ODO
reviewed documentation and verified the detainees involved in each incident were immediately
examined by medical staff, and an after-action review was conducted post-incident in all
14 cases.

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INSPECTION PROCESS
ODO inspections evaluate the welfare, safety, and living conditions of detainees. ODO primarily
focuses on areas of noncompliance with the ICE National Detention Standards or the ICE
PBNDS, as applicable. The PBNDS apply to LDF. In addition, ODO may focus its inspection
based on detention management information provided by ERO Headquarters and ERO field
offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at LDF to determine compliance with current policies
and detention standards. Prior to the inspection, ODO collected and analyzed relevant
allegations and detainee information from multiple ICE databases, including the Joint Integrity
Case Management System, the ENFORCE Alien Booking Module, and the ENFORCE Alien
Removal Module. ODO also gathered facility facts and inspection-related information from
ERO Headquarters staff to prepare for the site visit at LDF.

REPORT ORGANIZATION
This report documents inspection results, serves as an official record, and is intended to provide
ICE and detention facility management with a comprehensive evaluation of compliance with
policies and detention standards. It summarizes those PBNDS that ODO found deficient in at
least one aspect of the standard. ODO reports convey information to best enable prompt
corrective actions and to assist in the on-going process of incorporating best practices in
nationwide detention facility operations.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
PBNDS, ICE policy, or operational procedure. When possible, the report includes contextual
and quantitative information relevant to the cited standard. Deficiencies are highlighted in bold
throughout the report and are encoded sequentially according to a detention standard designator.
Comments and questions regarding the report findings should be forwarded to the Deputy
Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

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

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Special Agent (Team Leader)
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector
Contract Inspector

ODO, Houston
ODO, Houston
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the LDF Warden, the LDF Deputy Warden, the AFOD, and the SDDO. The
LDF Warden and the LDF Deputy Warden stated the working relationship between ERO and
LDF staff is excellent, and morale among LDF employees is high. The LDF Warden and the
LDF Deputy Warden stated ERO supervisors and officers visit detainees in the housing units on
a regular basis.
The AFOD and SDDO stated the working relationship between ICE and LDF staff is excellent;
however, morale among ERO personnel is currently low, because the extended leave of (b)(7)e
ERO officers has overburdened remaining staff.

DETAINEE RELATIONS
ODO interviewed 45 randomly-selected detainees (35 males; ten females) to assess detention
conditions at LDF. All detainees stated they received hygiene supplies at admission, and the
hygiene items are replenished at no cost. There were no complaints regarding food service or
medical care. All detainees stated they had access to recreation, religious services, telephones,
visitation privileges, and the law library.
Eight of 45 detainees stated they did not receive the ICE National Detainee Handbook or a
facility handbook. ODO reviewed the detention files of the eight detainees and verified each
signed an acknowledgement form confirming receipt of both detainee handbooks.
Nine detainees stated they could not identify a Deportation Officer, but all stated they knew how
to contact a Deportation Officer, if necessary. Names and telephone numbers of ICE staff are
posted throughout the housing units. A majority of detainees stated they frequently observe
ERO officers visiting the housing units each week to communicate with detainees.
One detainee expressed concern over the monitoring of his cholesterol levels by medical staff.
The detainee stated he had been seen by medical staff on a regular basis, and his most recent
appointment was two days prior to the interview. ODO confirmed with medical personnel that
proper monitoring and treatment is being provided.

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ICE PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 PBNDS and found LDF fully compliant with the following
13 standards:
Admission and Release
Classification System
Detainee Handbook
Disciplinary System
Environmental Health and Safety
Food Service
Funds and Personal Property
Law Libraries and Legal Material
Sexual Abuse and Assault Prevention and Intervention
Special Management Units
Staff-Detainee Communication
Telephone Access
Use of Force and Restraints
As these standards were compliant at the time of the inspection, a synopsis for these standards
was not prepared for this report.
ODO found deficiencies in the following three standards:
Grievance System
Medical Care
Suicide Prevention and Intervention
The findings for each of these standards are presented in the remainder of this report.

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at LDF to determine if a process to submit formal
or emergency grievances exists, and responses are provided in a timely manner, without fear of
reprisal. In addition, the review was conducted to determine if detainees have an opportunity to
appeal responses, and if accurate records are maintained, in accordance with the ICE PBNDS.
ODO interviewed staff and detainees, and reviewed LDF policies, the grievance log, and
detainee files.
Detainees have the opportunity to file informal, formal, and emergency grievances, and appeal
grievance decisions. Grievance forms, printed in English and Spanish, are available in each
detainee housing unit. The LDF grievance system policy is comprehensive and addresses all
requirements of the standard. The detainee handbook advises detainees of the grievance process.
Detainees stated they are aware of their right to communicate directly with ICE if they are
dissatisfied with a grievance decision, or to appeal a grievance response from an LDF official.
The facility maintains a grievance log to document and track formal and informal grievances
submitted by ICE detainees. A review of the grievance log found detainees submitted 91 formal
grievances from September 2012 to March 2013. There were four grievances related to the
disciplinary process, six grievances related to legal issues, six grievances related to property,
eight grievances related to facility operations, 11 grievances related to conditions of
confinement, 17 grievances related to food service, 17 grievances related to problems with staff,
and 22 grievances related to medical care. A review of all medical grievances and a random
sample of 15 grievances in other categories identified no trends or patterns, and all grievances
were processed as required by the PBNDS, with one exception. One of the 17 grievances
regarding staff involved alleged officer misconduct. On January 3, 2013, a detainee alleged a
staff member harassed him with repeated searches without cause. During an interview with
ODO, the LDF Grievance Officer stated grievances alleging staff misconduct are not
immediately forwarded to ERO (Deficiency GS-1). In these cases, LDF management conducts
an investigation to determine whether ICE notification is warranted. Failure to immediately
forward grievances that allege staff misconduct prevents ICE management from proactively
engaging facility management to resolve the issues.
The grievance log documented 95 grievances were informally resolved from September 2012 to
March 2013. LDF policy allows a detainee who is not satisfied with an informal resolution to
appeal the decision to the Detainee Grievance Committee within five days. The Detainee
Grievance Committee consists of the LDF Deputy Warden, who serves as the chairperson of the
committee,(b)(7)e GEO employee, and (b)(7)eICE officer. LDF policy also allows detainees to
bypass the informal grievance process and file a formal grievance at any point in the process.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE PBNDS, Grievance System, section (V)(G), the FOD must ensure
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

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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/DRO.
All ICE/DRO staff are reminded of the requirement of Administrative Manual 5.5.201,
Reporting and Resolving Allegations of Employee Misconduct. All ICE employees are
responsible for immediately reporting either orally or in writing any allegation of misconduct to
their supervisor or a higher-level ICE official in their chain of command or directly to the ICE
Office of Professional Responsibility or the DHS Inspector General. This reporting requirement
applies without exception to all detainee allegations of officer misconduct, whether formally or
informally submitted.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at LDF to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE PBNDS. ODO toured all areas where medical services are provided, reviewed policies
and procedures, and examined 25 detainee medical files, including the records of females and
chronic care patients. ODO interviewed the HSA, the staff physician, the pharmacist, the
Infection Control Coordinator, the training manager, nurses, mental health professionals, and
administrative support staff.
The LDF medical clinic is operated by IHSC. IHSC staff at LDF is supplemented with
personnel from the USPHS, and contractors from STG International. The LDF clinic consists of
four examination rooms, an urgent care room, a dental suite with one chair, a pharmacy, a
laboratory, a digital x-ray room, a medical records office, and multiple administrative offices. A
six-cell medical short stay unit attached to the clinic is used for isolation, quarantine, and suicide
watch. Two of the short stay unit cells have an anteroom with a window to allow observation of
detainees with infectious conditions. A nursing office and a security station within the clinic
afford sight and sound supervision. All cells have negative pressure capability, are clean, and
contain no items to facilitate a suicide attempt. The waiting area for detainees is adequately
accommodating, and includes both a restroom and a water fountain. There is an additional
examination room in each of the housing units where a nurse conducts assessment and triage
each workday. Space and medical equipment are sufficient for the provision of healthcare
services. All areas were secured throughout the inspection.
The Acting CMA is a regional IHSC physician who provides off-site support. STG International
provides a full-time contract physician, who is on-call 24 hours a day and available at the facility
Monday through Friday, a psychiatrist, a social worker, a psychologist, a pharmacist,(b)(7)e
pharmacy technicians (b)(7)e administrative support staff,(b)(7)e NPs(b)(7)eLPNs, and(b)(7)eRNs. There
are(b)(7)enurses and a dentist, who are all clinical USPHS officers. One of the USPHS nurses
serves as the Infectious Disease Coordinator and the Assistant HSA, and another nurse serves as
the Performance Improvement Coordinator. On-call services are provided via an NP rotation.
Training files and credential files for all medical staff are complete, and licenses are primary
source verified. The staffing plan, which is reviewed annually, shows vacancies for a Clinical
Director, a full-time RN, and a part-time LPN. ODO confirmed STG International is actively
recruiting to fill these positions; however, the HSA stated active physician recruiting by STG
International has been unsuccessful to date.
The medical clinic provides 24-hour nursing coverage and processes a high volume of detainee
arrivals at various hours throughout the week. The HSA stated it is common for LDF to receive
in excess of 100 detainee arrivals at a time, which makes adherence to assessment deadlines
challenging. Based on interviews and observations, ODO determined the on-site Clinical
Director position should be filled to ease the workload of the staff physician and to allow closer
clinical supervision.
ODO found the infection control program at LDF to be efficient and resourceful. The Infectious
Disease Coordinator demonstrated a solid knowledge base regarding tuberculosis, HIV, hepatitis,
influenza, and varicella. The written infection control plan addresses all subject matter required
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by the PBNDS, and clinical practice guidelines are readily available to reference strategies for
the treatment of infectious diseases commonly found in a correctional environment. Logs and
reports confirmed routine reporting of infectious disease cases to both the State Health
Department and IHSC. LDF also participates in TB Net, which is a reporting program that
supports continuity of care and medication treatment for deported detainees. ODO observed
sharps disposal boxes mounted in every area where hypodermic needles are used, and the
biohazard closet was clean, organized, and compliant with Occupational Safety and Health
Administration standards. The clinic uses contractor Stericycle for disposal of bio-hazardous
medical waste.
LDF has a full-service pharmacy managed by a contract pharmacist who is currently awaiting
commission into the USPHS. ODO confirmed written policies, formularies, inventories, and
National Pharmacy and Therapeutics Committee meeting minutes are complete. The pharmacist
stated he does not attend departmental meetings. ODO recommends attendance by the
pharmacist at quarterly and governing body meetings, so error trends, procedure updates, and
corrective plans required for compliance with policies and regulations can be successfully
communicated. Training logs confirmed nurses receive the appropriate training for
administering medication. The pharmacy is secured with a high security lock and controlled
access.
The initial health screening of detainees is completed and electronically documented by nurses in
the intake processing area. Two sick call rooms in adjacent housing units are also available to
accommodate high-volume processing demands. A review of 25 records found five initial health
screenings were not completed within 12 hours of admission (Deficiency MC-1). Of those five,
four were completed within 24 hours of admission, and one was completed three days after
admission. ODO noted the CMA or alternate designated clinical authority failed to sign initial
screening forms within 24 hours or on the next business day in order to prioritize the level of
care needed. IHSC Operations Memorandum, effective May 10, 2011, authorized an RN, NP, or
physician to review the IHSC 795A, Intake Screening Form, and instructed the CMA at each
facility to designate, in writing, categories of personnel authorized to conduct these reviews. In
response, the Acting Clinical Director at LDF issued a memorandum, effective May 20, 2011,
which stated, “The charge nurse or designee(s) will review all intake screening forms within
24 hours, or the next business day, of completing the intake screening process. Midlevel
providers may assist and perform this review during periods of large influxes provided essential
provider level workload is complete.” The HSA stated a charge nurse has not been identified
among the RNs on staff, and an alternate has not been designated in writing to assume
responsibility for the review of intake screening forms (Deficiency MC-2).
A chest x-ray is administered in the LDF digital x-ray room to identify tuberculosis prior to
completion of intake processing. Initial assessments include screening for intoxication and
substance withdrawal, suicide risk factors, acute medical and dental problems, communicable
diseases, and follow-up care needs. ODO confirmed medical, dental, and mental health referrals
are promptly and appropriately submitted. Detainees are verbally oriented to the sick call
process and are provided patient education pamphlets, printed in English and Spanish, addressing
prevention of infectious diseases and access to healthcare. Medical personnel use Interpretalk to
communicate with detainees who speak a language other than English or Spanish. There is an
ample number of LDF medical staff fluent in Spanish.
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At the time of intake, detainees are assigned a category of either healthy or unhealthy for the
scheduling of 14-day health appraisals and a physical examination (PE). An NP performs a PE
for detainees in the unhealthy category; a PE for a healthy detainee is performed by an RN
trained by the physician to perform this function. Documentation of training is present in the file
of each RN. ODO verified a PE, with a dental examination, occurred within the mandatory
14-day time frame in each of the 25 records examined by ODO. However, one physical
examination performed by an RN was not reviewed and signed by the physician. In addition to
this case, which was identified during the medical record review, review of the electronic
medical record queue found eight additional files containing documentation of a PE overdue for
review by the physician (Deficiency MC-2).
The mental health department consists of a full-time psychiatrist, a full-time psychologist, and a
full-time social worker. Each of these professionals reported five to six referrals or follow-up
visits per day. Through interviews with mental health staff, ODO determined an effective
working relationship with the medical department exists. There is an efficient referral process,
with prompt completion of mental health assessments. A review of nine medical files of
detainees in the mental health clinic confirmed appropriate assessment and follow-up care.
Sick call occurs three times daily in the general population housing units. ODO confirmed nonmedical personnel are not involved in the collection of medical information. On weekdays,
triage is conducted the same day the complaint is received. On weekends and holidays, only
urgent complaints are evaluated the same day, while all others are scheduled for the next
weekday. Physician-approved nursing protocols for non-emergent healthcare needs allow
administration of over-the-counter medications by an RN or an LPN. Instructions and patient
information are consistently noted during chart reviews. Referrals to a diagnosing and
prescribing practitioner are made when medical issues are beyond the knowledge or scope of
practice of the triage nurse. Sick call occurs in the special management units a minimum of once
daily, and triage is conducted in the same manner provided to the general population. ODO
verified logs recording requests, triage, and sick call are maintained in the clinic.
ODO confirmed the written local emergency plan is complete, calling for the provision of
24-hour coverage, posting of emergency contacts, and maintaining availability of two automated
external defibrillators. Two emergency go-bags, located in the urgent care room, are inventoried
and sealed. Medical staff receives training in the use of emergency equipment at orientation and
annually. Emergency transport is provided by LaSalle Parish Ambulance. A review of training
records for all medical staff and(b)(7)ecustody staff confirmed all received orientation and annual
training in first-aid, cardiopulmonary resuscitation (CPR), use of an automated external
defibrillator, and suicide precaution and intervention. Copies of CPR cards were present in all
files reviewed.
Twenty of the 25 records reviewed were for detainees receiving treatment from the chronic care
clinic. All chronic care files contained treatment plans with appropriate diagnostic testing and
follow-up. Referrals for specialty services are sent to the LaSalle General Hospital, which is
approximately 50 miles from LDF. Medical and psychiatric alerts are noted in the medical files
of chronic care patients to alert ICE staff to special needs prior to transfer. Medical files for
transferring detainees are placed in sealed envelopes marked “Medical Confidential,” and display
the name and A-number of each detainee.
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The 25 records reviewed contained consent forms for the use of specific medications in the three
cases where psychotropic drugs were required. ODO notes the side effects of the prescribed
medications were not included on the forms. ODO recommends detainees sign an additional
form describing the potential side effects of each prescribed psychotropic medication.
According to the HSA, quarterly administrative meetings are not held due to scheduling
difficulties (Deficiency MC-3). The failure to hold these meetings hinders formal
communication among clinical staff related to identification of problems, data analysis, and
corrective planning.
LDF implemented an electronic medical record system in April 2011. ODO identified one
printed physical assessment that did not include the name or A-number of the detainee on the
final five pages of the document. The HSA stated he would contact the company to assess the
problem. ODO recommends inclusion of appropriate identifying information on every page of
printed medical records.
ODO confirmed there were no detainee deaths, suicides, or suicide attempts during the
12 months preceding this CI.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE PBNDS, Medical Care, section (V)(I)(1), the FOD must ensure
initial medical, dental, and mental health screening shall be done within 12 hours of arrival by a
health care provider or detention officer specially trained to perform this function.
DEFICIENCY MC-2
In accordance with the ICE PBNDS, Medical Care, section (V)(J), the FOD must ensure the
clinical medical authority shall be responsible for review of all health appraisals to assess the
priority for treatment.
DEFICIENCY MC-3
In accordance with the ICE PBNDS, Medical Care, section (V)(X)(1), the FOD must ensure the
administrative health authority shall convene a meeting at least quarterly and include other
facility and medical staff as appropriate. The meeting agenda shall include, at a minimum:
 An account of the effectiveness of the facility health care program;
 Discussions of health environment factors that may need improvement;
 Review and discussion of communicable disease and infectious control activities;
 Changes affected since the previous meetings; and
 Recommended corrective actions, as necessary.
Minutes of each meeting shall be recorded and kept on file.

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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at LDF to determine if the
health and well-being of detainees are protected by training staff in effective methods of suicide
prevention, in accordance with the ICE PBNDS. ODO reviewed facility policies and procedures,
intake screening documentation, teaching plans, and training records. ODO also interviewed the
HSA and the LDF training manager.
Inspection confirmed the suicide watch cells, which are connected to the medical clinic, are clean
and contain no items to facilitate a suicide attempt. The LDF training plan addresses suicide risk
identification, management of suicide gestures and attempts, and procedures for mental health
referrals. Examination of(b)(7)etraining records for custody staff confirmed suicide prevention and
intervention information is provided to LDF staff at orientation and during annual refresher
training. The LDF training manager instructs this class.
There were no suicides or suicide attempts during the 12 months preceding this CI. Medical files
for two detainees placed on suicide watch confirmed the detainees were referred for mental
health services and placed on continuous observation following verbal threats of suicide. In one
of the two cases, the psychiatrist terminated the suicide watch following an evaluation. In the
second case, the suicide watch was inappropriately terminated by an NP who lacked the
authority to do so (Deficiency SP&I-1). LDF policy authorizes only the Clinical Director or a
mental health professional to terminate a suicide watch and return a detainee to the general
population. The HSA stated the previous policy violation was acknowledged and appropriate
action was taken by LDF management with respect to the staff member.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with the ICE PBNDS, Suicide Precaution and Intervention, section (V)(D), the
FOD must ensure 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.

Office of Detention Oversight
March 2013
OPR 201304463

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LaSalle Detention Facility
ERO New Orleans