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 York Field Office
Monmouth County Correctional Institution
Freehold, New Jersey

April 24-26, 2012

FOR INTERNAL USE ONLY.
This document may contain sensitive commercial, financial, law
enforcement, management, and employee information. It has been written for the express use of the
Department of Homeland Security to identify and correct management and operational deficiencies. In
reference to ICE Policy 17006.1, issued 09/22/05; any disclosure, dissemination, or reproduction of this
document, or any segments thereof, is prohibited without the approval of the Assistant Director, Office of
Professional Responsibility.

COMPLIANCE INSPECTION
MONMOUTH COUNTY CORRECTIONAL INSTITUTION
NEW YORK FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ....................................................................................................... 1
INSPECTION PROCESS
Report Organization ........................................................................................................ 5
Inspection Team Members ............................................................................................... 5

OPERATIONAL ENVIRONMENT
Internal Relations ............................................................................................................ 6
Detainee Relations ........................................................................................................... 6

ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ........................................................................................ 7
Detainee Classification System ........................................................................................ 8
Detainee Grievance Procedures ....................................................................................... 9
Detainee Transfer .......................................................................................................... 10
Environmental Health and Safety................................................................................... 11
Funds and Personal Property .......................................................................................... 13
Staff-Detainee Communication ...................................................................................... 15
Telephone Access .......................................................................................................... 17

EXECUTIVE SUMMARY
The Office ofProfessional Responsibility (OPR), Office ofDetention Oversight (ODO)
conducted a Compliance Inspection (CI) of the Monmouth County Correctional Institution
(MCCI) in Freehold, New Jersey, from April 24-26, 2012. MCCI, which opened in I969, is
owned by Monmouth County and operated by the Monmouth County Sheriff. U.S. Immigration
and Customs Enforcement (ICE), Office ofEnforcement and Removal Operations (ERO), began
housing detainees at MCCI on December I, 2000, under an Intergovernmental Service
Agreement (IGSA) between ICE and Monmouth County. Male and female detainees of security
classification levels II and III (Level I- lowest threat; Level II- medium threat; Level IIIhighest threat) are detained at the facility for periods in excess of72 hours. MCCI has a total
capacity of I ,362, with 334 beds dedicated to ICE detainees. At the time ofthe inspection,
MCCI housed 249 detainees (2I2 male; 37 female). The average daily detainee population is
291. The average length of stay for detainees is approximately 74 days. Food service is
provided under contract by Gourmet Dining. Medical care is provided under contract by Correct
Care Solutions (CCS). The facility holds accreditations from the American Corrections
Association (ACA), and the National Commission on Correctional Health Care (NCCHC).
The ICE, ERO, Field Office Director, New York, New York (FOD/New York), is responsible
for ensuring facility compliance with ICE policies and the National Detention Standards (NDS).
ICE has(b)(7)eImmigration Enforcement Agent (lEA) onsite who is permanently assigned to
MCCI. An Assistant Field Office Director (AFOD) physically located at the FOD/New York
Office has oversight responsibility at MCCI. An ICE Detention Service Manager (DSM), also
based at the FOD/New York Office, conducts oversight visits one week per month. The DSM
was not at the facility at the time of inspection.
The Monmouth County Sheriff is the highest ranking official at MCCI and is responsible for
oversight of daily operations. In addition to the Sheriff, supervisory staff at MCCI includes a
Warden, a Deputy Warden, (b)(7)eCaptains(b)(7)eLieutenants, and(b)(7)eSergeants. The total number
of non-ICE staff, including supervisory personnel, is(b)(7)e Supervisory medical staff consists of
a full time Health Services Administrator (HSA), a Director ofNursing, and a physician who
serves as the Medical Director. Clinic staff is comprised of(b)(7)ephysicians who provide medical
coverage during weekends and holidays, (b)(7)epart-time advanced nurse practitioners who are
onsite a combined total of 40 hours per week, and(b)(7)epart-time dentist who is onsite twice
weekly for an average of24 hours per week. Nursing staff consists of (b)(7)e full-time Registered
Nurses (RN) and(b)(7)efull-time Licensed Practical Nurses (LPN). Full-time nursing staff is
(b)(7)e
complemented by(b)(7)eRNs and
LPNs who work on a part-time basis. There is a full-time PhD
psychologist who serves as the Mental Health Coordinator, a psychologist who provides
coverage in the absence of the Mental Health Coordinator, a part-time psychiatrist who is onsite
six to eight hours per week,(b)(7)eLicensed Certified Social Workers, and(b)(7)epsychiatric RNs.
ODO verified all medical staff had current licenses and CPR certifications.
In August 2008, ODO's predecessor, the Detention Facilities Inspection Group (DFIG),
conducted a Focus Review at MCCI of I2 NDS. Of the standards reviewed, five were in full
compliance. The remaining seven standards accounted for 30 confirmed deficiencies. There
was no follow-up inspection subsequent to the August 2008 Focus Review.
In February 20I2, ERO Detention Standards Compliance Unit contractor, Nakamoto Group, Inc.,
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conducted an annual review of the ICE NDS at MCCI. The facility received an overall rating of
"Acceptable" and was found to be in compliance with all 35 standards reviewed.
During this CI, ODO reviewed I6 NDS. Nine standards were determined to be fully compliant;
13 deficiencies were identified in the following seven standards: Detainee Classification System
(I grievance), Detainee Grievance Procedures (2), Detainee Transfer (I), Environmental Health
and Safety (3), Funds and Personal Property (2), Staff-Detainee Communication (3), and
Telephone Access (I).
This report details all deficiencies and refers to the specific, relevant sections ofthe NDS. ERO
will be provided a copy ofthis report to assist in developing corrective actions to resolve the I3
identified deficiencies. These deficiencies were discussed with MCCI personnel onsite during
the inspection as well as during the closeout briefing conducted on April26, 20I2.
Overall, ODO found MCCI to be well-managed and in compliance with the standards inspected.
A majority of identified deficiencies were administrative in nature and involved errors or
omissions involving documentation such as the placement of security classification paperwork
and detainee request paperwork in detention files. Several deficiencies involved omissions of
required content in the local detainee handbook. All detainees are subject to a strip search upon
completion of a contact visit, because contact visits allow some degree of physical touching.
This policy is documented within the local detainee handbook. If detainees do not wish to be
searched in this manner, they may opt out of contact visitation. No deficiencies or areas of
concern were noted during the review of the Special Management Unit NDS or the Use of Force
NDS.
MCCI has a designated law library with nine computers for detainee use. In addition to the law
library, there are I3 computers located in housing units that are available to ICE detainees. All
computers are equipped with Westlaw, an online-legal research service, and Lexis-Nexis. The
law library also contains hard copies of legal materials for detainee use. MCCI law library
personnel are knowledgeable regarding the requirements ofthe NDS. The library is accessible to
detainees I2 hours per day. Additional time in the library is available upon request.
Detainees have the opportunity to file grievances and appeal grievance decisions. A designated
Lieutenant serves as the Grievance Coordinator. MCCI does not have a procedure in place for
identifying and handling emergency grievances. Emergency grievance procedures provide staff
with clear instructions on how to handle issues requiring urgent attention. A review of 40
detainee grievances filed during the five months preceding the CI confirmed that all had been
adjudicated according to policy. Review of grievance responses verify all were appropriate and
provided the detainee with adequate information regarding the outcome ofthe grievance. ODO
verified that responses to grievances filed by detainees were provided within seven days of the
initial inquiry, which complies with the NDS.
ODO confirmed that all detainees receive a handbook at admission. Detainee handbooks are
available in English and Spanish. Detainees confirm receipt of the handbook by signing a
facility acknowledgement form that is placed in each detention file.
A review ofthe Food Service NDS at MCCI confirmed that detainees are provided with a
nutritious and balanced diet in a sanitary manner. Food service staff consists of an Operations
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Director, an Assistant Operations Director, and(b)(7)eInmate Training Instructors. The Operations
Director and the Assistant Operations Director have received ServSafe certification, which is a
food safety training and certificate program administered by the National Restaurant Association.
Staff is supported by a work crew ofMonmouth County inmates. ICE detainees do not work in
the food service area. Inmates assigned to food service receive the required medical clearance
and training prior to performing duties in food service. ODO verified religious and medically
prescribed meals are provided and properly documented. ODO confirmed a registered dietitian
from the Gourmet Dining corporate office in Madison, New Jersey, reviews and certifies all
menus.
ODO found Medical Care at MCCI to be well-managed. The MCCI health services policy and
the facility handbook state that copays are charged for medical treatment and services. Though
the policy specifically exempts ICE detainees from copay requirements, this exemption is not
stated in the handbook. ODO recommends revision ofthis section ofthe handbook, so detainees
are not potentially deterred from seeking necessary medical services.
The medical unit has 24-hour nursing coverage, seven days a week, and staffing is adequate.
ODO verified all medical personnel have current licenses and cardiopulmonary resuscitation
(CPR) certifications. ODO reviewed the training records of(b)(7)ecorrectional officers (CO) and
found that all had documentation of current CPR and first aid certifications. CPR is a mandatory
topic at initial and annual refresher training sessions. There is a Memo ofUnderstanding (MOU)
with Cherry Hill Women's Center to provide Obstetric and Gynecological services for female
detainees as necessary.
Medical intake is conducted by the nursing staff within five hours of arrival. Every detainee is
screened for signs and symptoms of active tuberculosis (TB), and a protein derivative test (PPD)
is administered. Detainees with a positive PPD history are scheduled for chest x-rays within
three days of arrival, and those with positive symptoms are immediately placed in a negative
pressure room for evaluation and treatment for TB as needed. A significant number ofMCCI
staff is Spanish-speaking and performs Spanish interpretation as needed. A telephone translation
service is available to assist communication with detainees who speak languages other than
Spanish.
ODO found no documentation of preventative maintenance inspections having been performed
on medical equipment. The HSA stated that no preventative maintenance has occurred. ODO
recommends that a preventative maintenance schedule be established and strictly followed. The
HSA stated that a preventative maintenance contract will be secured as soon as possible.
ICE staff conducts scheduled visits to the housing units weekly. (b)(7)e EA is assigned to MCCI on
a full-time basis. Supervisory Detention and Deportation Officers (SDDO) make unscheduled
visits to the facility on a monthly basis. The Field Office Director (FOD), Deputy Field Office
Director (DFOD), and AFOD also conduct unscheduled and unannounced visits. The AFOD
visits the facility on a monthly basis, while the FOD and DFOD make periodic unannounced
visits throughout the year. Detainees have the opportunity to submit requests to MCCI personnel
and ICE staff. Requests from detainees are processed by the lEA assigned to the facility, and are
documented in a log book that notes the date a request is received, and the date each detainee is
provided a response. ODO confirmed that detainee requests are addressed within 72 hours as
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required by the NDS.
During this CI, ODO found no deficiencies under the Use of Force NDS; however, ODO notes
that MCCI policy regarding this standard does not assert that calculated rather than immediate
use of force is feasible in most cases, that special precautions are to be taken when restraining
pregnant detainees, or that staff will wear protective gear when restraining detainees with open
cuts or wounds. By definition, an immediate use of force situation is created when detainee
behavior constitutes a serious and immediate threat to the detainee, staff, other detainees,
property, or the security and orderly operation of the facility. It may be necessary for staff to
respond to these situations without a supervisor's direction or presence. A calculated use of force
occurs when there is no immediate threat to the detainee or others, and time is available for
officers to formulate strategy and assess the possibility of resolution in the least confrontational
manner possible. To achieve compliance with the NDS, ODO recommends revision ofMCCI
written policy.
Detainees have access to daily recreation, can send and receive mail, may receive visitors, and
are given the opportunity to attend religious services.

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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 NDS or the ICE Performance Based National
Detention Standards (PBNDS), as applicable. The NDS apply to MCCI. In addition, ODO may
focus its inspection based on detention management information provided by ERO Headquarters
(HQ) and ERO field offices, and on issues of high priority or interest to ICE executive
management.
ODO reviewed the processes employed at MCCI 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 (JICMS), the ENFORCE Alien Booking Module (EABM), and the
ENFORCE Alien Removal Module (EARM). ODO also gathered facility facts and inspectionrelated information from ERO HQ staff to prepare for the site visit at MCCI.

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 NDS that ODO found deficient in at least
one aspect ofthe standard. ODO reports convey information to best enable prompt corrective
actions and to assist in the ongoing process of incorporating best practices in nationwide
detention facility operations.
OPR classifies program issues into one of two categories: deficiencies and areas of concern.
Specific deficiencies and areas of concern are identified in bold with sequential numbers in this
report. OPR defines a deficiency as a violation of written policy that can be specifically linked
to the NDS, ICE policy, or operational procedure. OPR defines an area of concern as something
that may lead to or risk a violation ofthe NDS, 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
Detention and Deportation Officer
Contract Inspector
Contract Inspector
Contract Inspector

5

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

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the MCCI Warden, Deputy Warden, and the Acting ERO AFOD responsible
for oversight ofthe facility. During the interviews, all personnel stated that the working
relationship between ERO and MCCI is good and morale is high. The Warden and Deputy
Warden stated that staffing levels at MCCI are sufficient to meet mission requirements.
The AFOD stated that additional staff and vehicles would be desirable. There are currently two
lEA vacancies within the field office.

DETAINEE RELATIONS
ODO randomly selected and interviewed 23 detainees (I 9 male; 4 female) to assess the overall
living and detention conditions at MCCI. Three detainees complained about response times to
medical requests and overall medical care. ODO reviewed these complaints and found that
medical care concerns had been addressed appropriately. Three detainees, one male and two
females, stated they had been strip searched. ODO verified that these searches were properly
documented and were performed in compliance with the NDS. ODO confirmed the searches
were conducted in response to contraband in the housing units, and MCCI staff found contraband
on one ofthe female detainees interviewed by ODO.
All detainees are subject to a strip search upon completion of participation in contact visitation.
These are visits where some degree ofphysical touching is permitted. This policy is documented
within the facility handbook. If detainees do not wish to be searched in this manner, they may
opt for a non-contact visit.
Eight detainees stated the quality of the food service could be improved. ODO confrrmed a
registered dietitian from the Gourmet Dining corporate office in Madison, New Jersey, reviews
and certifies all menus. All detainees stated they have access to recreation, can send and receive
mail, may receive visitors, and are given the opportunity to attend religious services.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 NDS and found MCCI fully compliant with the following nine
standards:
Access to Legal Material
Admission and Release
Detainee Handbook
Food Service
Medical Care
Suicide Prevention and Intervention
Special Management Unit (Administrative Segregation)
Special Management Unit (Disciplinary Segregation)
Use ofForce
As these standards were compliant at the time of the review, a synopsis for these areas was not
prepared for this report.
ODO found deficiencies in the following seven standards:
Detainee Classification System
Detainee Grievance Procedures
Detainee Transfers
Environmental Health and Safety
Funds and Personal Property
Staff-Detainee Communication
Telephone Access
Findings for these standards are presented in the remainder of this report.

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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System NDS at MCCI to determine ifthere is a
requirement for a formal classification process for managing and separating detainees based on
verifiable and documented data. ODO reviewed the detainee handbook, detention files, and
interviewed ICE and facility staff.
MCCI staff is trained onsite to identify ICE classification objectives and procedures in order to
appropriately classify detainees. Only detainees with criminal convictions are housed at MCCI.
ERO personnel at the Varick Street Service Processing Center in New York, NY, perform the
initial classification of detainees. The classification assessment paperwork and the Form I -203
(Order to Detain/Release Alien) accompany detainees to MCCI. ICE conducts the classification
process prior to a detainee's admission to MCCI. MCCI staff reviews and abides by the
classification determination made by ICE. Detainees classified at Levels II and III are housed in
the same housing units, which have been designated specifically for ICE detainees.
Reassessments are conducted after the first 30 days of detention or whenever it is necessary to
re-determine the assigned classification level. In what ODO considers a best practice, MCCI
utilizes a computer based automated system that issues alerts when it is time to perform
classification reassessments, which includes a system override that is available if detainees
require reclassification prior to an alert being issued. ODO confirmed that detainees can appeal
their security classification.
MCCI maintains separate files for classification documentation; however, classification
documentation is not maintained in detainee detention files. This was confirmed during a review
of detention files (Deficiency DCS-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE NDS, Detainee Classification System, section (III) (B), the FOD
must ensure the officer will place all original paperwork relating to the detainee's assessment and
classification in his/her A-file (right side), with a copy placed in the detention file.

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedure NDS at MCCI to determine if a process to
submit formal or emergency grievances exists, and responses are provided in a timely manner,
without fear ofreprisal. In addition, the review was conducted to determine if detainees have an
opportunity to appeal responses, and if accurate records are maintained. ODO observed housing
units, interviewed ICE and facility staff, and ICE detainees, and reviewed policies and
procedures, the detainee handbook, and grievance logs.

000 verified that MCCI has policies and procedures for detainees to file both formal and
informal grievances. There is a grievance committee, and detainees may appeal the decisions of
the committee. Grievance forms are readily available in all detainee housing units.
A Lieutenant serves as the Grievance Coordinator. ODO reviewed 40 grievances filed between
January 10, 2012, and April 23, 2012. Eight grievances pertained to medical care, eight were
related to mail service, and four pertained to food service. The remaining grievances reviewed
related to various detainee concerns ranging from broken recreational equipment to complaints
about the room temperature of housing units. The response time for the grievances reviewed
ranged from the same day the grievance was filed, to seven days from the date of filing. There
were no appeals or outstanding grievances pending at the time of the review.
ODO confirmed that the facility did not have a procedure for identifying and handling an
emergency grievance (Deficiency DGP-1). Emergency grievance procedures provide staffwith
clear instructions on how to handle issues requiring urgent attention. The detainee handbook did
not include any mention that assistance is available to detainees who wish to file a grievance is
available at MCCI (Deficiency DGP-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD
must ensure that each facility shall implement procedures for identifying and handling an
emergency grievance. An emergency grievance involves an immediate threat to a detainee's
safety or welfare. Once the receiving staff member approached by a detainee determines that
he/she is in fact raising an issue requiring urgent attention, emergency grievance procedures will
apply.
DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(2), the FOD
must ensure the facility shall provide each detainee, upon admittance, a copy of the detainee
handbook or equivalent. The grievance section of the detainee handbook will provide notice of
the following: The procedures for filing a grievance and appeal, including the availability of
assistance in preparing a grievance.

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DETAINEE TRANSFER (DT)
ODO reviewed the Detainee Transfer NDS at MCCI to determine iftransfers of detainees from
one facility to another are responsibly managed in regard to notification, detention records,
safety and security, and protection of detainee funds and property. ODO reviewed policies and
procedures, detention files, and interviewed ICE personnel and facility staff.
ERO management stated the majority of detainee transfers occur within the FOD/New York area
of responsibility (AOR) and serve operational purposes. ERO management stated they are aware
ofiCE policy 11022.1; issued January 4, 2012, which is applicable to transfers outside ofthe
field office. ODO verified the medical transfer summary sheets (USM 553) are completed
properly and accompany detainees during transfer. ICE staff is responsible for initiating,
processing, and notifying all attorneys of record when a transfer occurs.
ODO interviewed ICE and facility staff about the transfer notification procedure to determine
whether appropriate notification is provided to detainees based on prevailing security concerns.
ICE staff stated detainees are notified oftransfers based on existing security concerns. ICE staff
stated that copies of transfer notification sheets are not placed in the detainee detention files
(Deficiency DT-1). ·

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DT-1
In accordance with the ICE NDS, Detainee Transfer, section (III)(A)(3), the FOD must ensure at
the time ofthe transfer, ICE will provide the detainee, in writing, with the name, address and
telephone number ofthe facility he/she is being transferred to. The attached Detainee Transfer
Notification Sheet shall be used for this purpose. The detainee will also be instructed that it is
his/her responsibility to notify family members. A copy of the transfer notification sheet will be
placed in the detainee's detention file.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety NDS at MCCI to determine if the facility
maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances. ODO toured the facility, interviewed staff, and reviewed
policies and procedures, documentation of inspections, hazardous chemical management and
inventories, and fire drills.
ODO verified MCCI maintains four sets ofthe master Material Safety Data Sheets (MSDS)
index in the Facility Affairs Supervisor's Office, Central Control, Health Services, and the
Maintenance Department. MSDS binders with location-specific materials were found
throughout the facility. ODO inspection confirmed that chemicals and combustible materials are
stored and issued as required by the NDS. The Monmouth County Fire Marshal reviewed and
approved the Emergency Evacuation Plan for the facility, and ODO reviewed documentation
verifying that the Fire Marshall had completed a quarterly fire inspection on March 25, 2012.
The facility is equipped with smoke detectors, sprinklers, standpipe hoses, and fire extinguishers.
ODO verified these systems are inspected and tested by a local contractor on an annual basis.
Facility sanitation is maintained at an acceptable level.
Monthly fire drills cover certain areas ofthe facility, with all areas covered once per quarter.
Fire drills are not conducted in each department every month. Review of fire drill reports
confirmed that emergency keys are not drawn during each drill (Deficiency EH&S-1). Facility
management demonstrated use of emergency keys during the inspection and stated that the
policy will be revised to require that emergency keys be drawn and tested during each fire drill.
Verifying the operability of emergency keys assures expeditious egress in the event of an
emergency that necessitates an evacuation.
Review of test reports for the emergency generator found the facility conducts tests on a monthly
basis rather than every two weeks as required by the NDS (Deficiency EH&S-2). Frequent
testing of the emergency generator ensures the system is operational and ready for use in
emergency situations. MCCI management stated the emergency generator was recently installed
and quarterly testing is conducted under warranty. Facility management plans to contract with a
local generator-service company to perform required quarterly testing following the warranty
period.
MCCI does not have a separate room designated for barber operations. Instead, detainee barbers
cut hair in the dayroom area of the housing pod. Hot and cold water is available in the dayroom;
however, covered metal containers for waste, dispensable headrest covers, laundered towels and
haircloths are not provided (Deficiency EH&S-3). Sanitation regulations were conspicuously
posted.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4), the FOD
must ensure monthly fire drills will be conducted and documented separately in each department.
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a. Fire drills in housing units, medical clinics, and other areas occupied or staffed during
non-working hours will be timed so that employees on each shift participate in an annual
drill.
b. Detainees will be evacuated during fire drills, except in areas where security would be
jeopardized or in medical areas where patient health could be jeopardized or, in
individual cases when evacuation of patients is logistically not feasible. Staff- simulated
drills will take place instead in the areas where detainees are not evacuated.
c. Emergency-key drills will be included in each fire drill, and timed. Emergency keys
will be drawn and used by the appropriate staff to unlock one set of emergency exit doors
not in daily use. NFP A recommends a limit of four and one-half minutes for drawing
keys and unlocking emergency doors.

DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (111)(0), the FOD
must ensure power generators will be tested at least every two weeks. Other emergency
equipment and systems will undergo quarterly testing, with follow-up repairs or replacement as
necessary.
The biweekly test ofthe emergency electrical generator will last one hour. During that time, the
oil, water, hoses and belts will be inspected for mechanical readiness to perform in an emergency
situation. The emergency generator will also receive quarterly testing and servicing from an
external generator-service company. Among other things, the technicians will check starting
battery voltage, generator voltage and amperage output.

DEFICIENCY EH&S-3
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(l )(2), the
FOD must ensure sanitation ofbarber operations is ofthe utmost concern because ofthe 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.
2. Each barbershop will be provided with all equipment and facilities necessary for
maintaining sanitary procedures ofhair 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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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property NDS at MCCI to determine if controls are in
place to inventory, issue receipts for, maintain, and safeguard detainees' personal property.
ODO interviewed staff, reviewed policies and procedures, and observed the processing of
detainees.
MCCI has written policies and procedures that provide for the control and safeguarding of
detainee funds and personal property. ODO observed the processing of detainees into and out of
the facility. Property was properly logged and inventoried during the initial intake process and
documented on a property form. ODO observed the property room was clean and wellorganized. Valuables were placed in clear, plastic, zippered property bags secured with
numbered, plastic security locks, and placed in a secure safety deposit box.
Detainees do not keep money in their possession. Money is placed in sealed envelopes and
deposited into a drop safe located in the detainee admission area. ODO verified receipts are
completed and provided to detainees. Envelopes containing money are removed by a member of
the accounting staff; the Intake Supervisor serves as a witness. This occurs on the next work
day, and all funds are deposited in the commissary accounts ofthe detainees.
Interviews with staff, a review of available documentation, and direct observation ofthe intake
area found there is no written procedure for the inventory and audit of detainee funds, valuables
and personal property (Deficiency F&PP-1). MCCI staff stated they conduct quarterly reviews
of property; however, those reviews are not documented or governed by written procedures to
support accuracy and consistency. Comprehensive, regular audits assure detainee funds and
valuables are accounted for, and discrepancies are identified and investigated.
The detainee handbook does not provide information on facility policies and procedures
concerning personal property (Deficiency F &PP-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must
ensure each facility shall have a written procedure for inventory and audit of detainee funds,
valuables, and personal property.
DEFICIENCY F&PP-2
In accordance with the ICE NDS, Funds and Personal Property, section (III)(J), the FOD must
ensure the detainee handbook or equivalent shall notify the detainees of facility policies and
procedures concerning personal property, including:
1. Which items they may retain in their possession;
2. That, upon request, they will be provided an INS-certified copy of any identity document
(passport, birth certificate, etc.) placed in their A-Files;
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3. The rules for storing or mailing property not allowed in their possession;
4. The procedure for claiming property upon release, transfer, or removal;
5. The procedures for filing a claim for lost or damaged property.

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STAFF-DETAINEE COMMUNICATION (SDC)
000 reviewed the Staff-Detainee Communication NOS at MCCI to determine if procedures are
in place to allow formal and informal contact between detainees and key ICE and facility staff,
and ifiCE detainees are able to submit written requests to ICE staff and receive responses in a
timely manner. ODO reviewed logbooks, the detainee handbook, and interviewed ICE and
MCCI staff and detainees.
An lEA is assigned to MCCI on a full-time basis to monitor detention conditions and address
inquiries and requests from detainees. ODO interviewed the AFOD who has oversight
responsibilities at MCCI to determine whether designated agency heads conduct regular
unannounced visits to living areas within the facility. The AFOD stated that unannounced visits
are conducted at MCCI, and the FOD, DFOD, and AFOD have conducted visits to the facility
and detainees' living areas at least once each month. 000 verified these visits through a review
of a visitation logbook maintained at the entrance to the facility.
ICE visitation schedules are posted in each housing area. An interview of eight detainees verified
that six out ofthe eight (75%) had met their DO, and all eight detainees were aware ofthe
procedures for contacting a DO.
Detainee request forms are available in the housing units. Interviews ofiCE staff and a review
oflogbooks confrrmed responses to detainee requests are provided within 72 hours, in
accordance with the NOS. No procedures exist to ensure detainees can obtain assistance in
preparing detainee request forms (Deficiency SDC-1).
ODO reviewed written requests from detainees to staff, the model protocol for ERO Facility
Liaison Visit Checklist, and weekly telephone serviceability worksheet logbooks. The ERO
Facility Liaison Visit Checklist and weekly telephone serviceability worksheets are current and
complete. 000 verified that completed detainee request forms are not maintained in detention
files (Deficiency SDC-2). ODO also confirmed that there is no information in the MCCI
detainee handbook regarding procedures for detainees to obtain assistance in preparing request
forms (Deficiency SDC-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE National Detention Standard, Staff-Detainee Communication, section
(III)(B), the FOD must ensure a detainee may obtain assistance from another detainee, housing
officer, or other facility staff in preparing a request form. The OIC shall ensure that the standard
operating procedures cover detainees with special requirements, including those who are
disabled, illiterate, or know little or no English. Each facility will accommodate the special
assistance needs of such detainees in making a request.

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DEFICIENCY SDC-2
In accordance with the ICE National Detention Standard, Staff-Detainee Communication, section
(III)(B)(2), the FOD must ensure all completed detainee requests will be filed in the detainee's
detention file and will remain in the detainee's detention file for at least three years.
DEFICIENCY SDC-3
In accordance with the ICE National Detention Standard, Staff-Detainee Communication, section
(III)(B)(3), the FOD must ensure the facility shall provide each detainee, upon admittance, a
copy of the detainee handbook or equivalent. The handbook shall state that the detainee has the
opportunity to submit written questions, requests, or concerns to ICE staff and the procedures for
doing so, including the availability of assistance in preparing the request.

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at MCCI to determine if detainees are provided
with reasonable and equitable access to telephones during established facility waking hours. To
ensure sufficient access, the facility shall provide at least one telephone for detainee use for
every 25 detainees held in accordance with the ICE NDS. ODO reviewed local policies and
procedures and the detainee handbook, interviewed staff, inspected the areas where telephones
are located, and tested the functionality of several randomly-selected telephones.
An adequate number of operational telephones are present in the housing units. A sticker is
placed at the top of each phone notifying detainees that calls are subject to monitoring. When
detainees need to speak to an attorney, designated phones are brought to an isolated area outside
ofthe housing units to ensure privacy.
ODO verified that detainees in the Special Management Unit (SMU) are allowed telephone
privileges similar to detainees in general population; however, if a detainee in the SMU is denied
access to a telephone, there is no log to document the reason for the restriction as required by the
NDS (Deficiency TA-l).

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY TA-l
In accordance with the ICE NDS, Telephone Access, section (III)(G), the FOD must ensure staff
shall permit detainees in the Special Management Unit for disciplinary reasons to make direct
and/or free calls as described above, except under compelling security conditions. These
conditions shall be documented.
Staff shall permit detainees in the Special Management Unit for other than disciplinary reasons
(e.g., protective custody, suicide risk) to have telephone access similar to detainees'[sic] in the
general population, but in a manner consistent with the special security and safety requirements
of detainees in these units.

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