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
ERO Detroit Field Office
Morrow County Correctional Facility
Mount Gilead, Ohio

March 24–26, 2015

COMPLIANCE INSPECTION
MORROW COUNTY CORRECTIONAL FACILITY
ERO DETROIT FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................7
ICE 2000 NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................8
Access to Legal Material .....................................................................................................9
Admission and Release ......................................................................................................11
Detainee Classification System..........................................................................................13
Detainee Grievance Procedures .........................................................................................14
Detainee Handbook ............................................................................................................16
Environmental Health and Safety ......................................................................................17
Food Service ......................................................................................................................19
Funds and Personal Property .............................................................................................21
Medical Care ......................................................................................................................23
Special Management Unit – Administrative ......................................................................25
Special Management Unit – Disciplinary ..........................................................................28
Staff-Detainee Communication .........................................................................................30
Suicide Prevention and Intervention……………………………………………………..32
Telephone Access ..............................................................................................................33
Use of Force .......................................................................................................................36

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 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 replaced 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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Inspections & Compliance Specialist (Team Lead) ODO
Inspections & Compliance Specialist
ODO
Inspections & Compliance Specialist
ODO
Contractor
Creative Corrections
Contractor
Creative Corrections
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(b)(6), (b)(7)c

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Contractor
Contractor

Creative Corrections
Creative Corrections

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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Morrow County Correctional Facility (MCCF) in
Mount Gilead, Ohio, from March 24 to 26, 2015. MCCF, which opened in 1996, is owned by
Morrow County and operated by the Morrow County Sheriff’s Office. ERO began housing
detainees at MCCF in October 2009 under an Intergovernmental Service Agreement. Male and
Female detainees of security classification levels I through III are detained at the facility for
periods in excess of 72 hours. The inspection evaluated MCCF’s compliance with the 2000
NDS.
Capacity and Population Statistics
Quantity
Total Bed Capacity

90

The ERO Field Office Director in
ICE Detainee Bed Capacity
64
Average Daily Population
78
Detroit, Michigan, is responsible for
Average
ICE
Detainee
Population
32
ensuring facility compliance with the
Average
Length
of
Stay
(Days)
14
2000 NDS and ICE policies. An
Male Detainee Population (as of 03/24/2015)
24
Assistant Field Office Director
(AFOD) is responsible for the
Female Detainee Population (as of 03/24/2015)
1
facility. ERO staff members are not
located on-site. A Detention Service Manager is not assigned to MCCF. MCCF has not signed a
contract modification to comply with the 2011 Sexual Abuse and Assault Prevention and
Intervention (SAAPI) standard.
A Captain is responsible for oversight of daily facility operations and is supported by(b)(7)e
personnel. Morrow County Sheriff’s Office provides food services and contracting company
Premier Health Care Services, Incorporated of Dayton, Ohio provides medical services. The
facility holds no accreditations.
This inspection represents ODO’s first visit to MCCF. During this inspection ODO reviewed 15
NDS. ODO found a total of 55 deficiencies in all 15 standards reviewed as follows: Access to
Legal Materials (5 deficiencies), Admission and Release (2), Detainee Classification System (2),
Detainee Grievance Procedures (5), Detainee Handbook (3), Environmental Health and Safety
(4), Food Service (5), Funds and Personal Property (4), Medical Care (1), Special Management
Unit – Administrative Segregation (3), Special Management Unit – Disciplinary Segregation (3),
Staff-Detainee Communication (4), Suicide Prevention and Intervention (1), Telephone Access
(9), and Use of Force (4). ODO identified three opportunities where the facility initiated
corrective actions during the inspection.1
This report details all deficiencies and refers to the specific, relevant sections of the 2000 NDS.
ERO will be provided a copy of this report to assist in developing corrective actions to resolve
all identified deficiencies. ODO discussed preliminary findings with MCCF and ERO
management during the inspection and at a closeout briefing conducted on March 26, 2015.
MCCF has written policies and procedures addressing admission and release procedures for
detainees being transferred from ERO offices. The facility has a policy that prohibits strip
searches of detainees. Arriving detainees are pat-searched, fingerprints and photographs are
1

Corrective actions initiated by the facility are annotated as “C.”

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taken, property and any monies are inventoried, and clothing and hygiene supplies are issued.
MCCF does not have a video orientation to the facility, or a formal orientation of any type.
Detainees are not provided a facility handbook or the ICE National Detainee handbook upon
admission to the facility. Instead, detainees are asked if they would like a copy of the facility’s
inmate handbook. Copies of the ICE National Detainee Handbook are available in the housing
units.
Booking officers inventory detainees’ personal property upon arrival. All property is stored in a
secure, well-ventilated storage room in a secured locker labeled with the detainee’s name and Anumber. Access to the property storage room is restricted to booking officers, and in their
absence, the shift supervisor. The facility does not have a written policy or procedure for
property reported missing or damaged and does not obtain a forwarding address from detainees
for use in the event personal property is lost or abandoned.
Detainees are classified during the booking process by correctional staff. ODO reviewed 25
detainee detention files and found no classification forms were filed. There was no record of
detainees being reclassified at 60 and 90 day intervals since arriving. The facility handbook did
not have any information explaining classification levels or the appeal process.
The facility employs a system called TurnKey© Kiosk. The system is used for detainees to file
grievances and other requests. The system allows detainees to file grievances with an emergency
option available. The grievances are received by the shift supervisor and resolved at the lowest
level possible. When oral grievances are resolved, the results are not documented or placed in
the detainee’s detention file. The facility does not have a grievance committee. The response to
the grievance is returned via the kiosk system. Detainees are able to review the response by
logging into the system. A copy of the grievance is not filed in the detainee’s detention file.
The facility has a designated law library containing the furnishings and supplies required by the
standard. There were no weekly inspections conducted, legal material was not updated and
detainees were not provided notice of the hours of operation.
Overall, the sanitation at the facility was acceptable. Issues were identified in hazardous
substance tracking and storage, laundry, and fire safety inspections. Facility exit diagrams are in
English only and do not indicate the locations of emergency equipment.
The facility has written procedures for weekly inspections of the food service areas. The
facility’s food service staff members are not trained in custody issues.
Healthcare services are provided by a registered nurse who serves as the Health Service
Administrator (HSA), and a physician who serves as the clinical director. The HSA is a Morrow
County employee; the physician is contracted through Premier Health Care Services. The HSA
is on-site eight hours per day five days a week and on-call 24 hours a day, seven days a week.
The physician provides on-site services a minimum of once every two weeks for as many hours
as needed, and on-call services 24 hours a day, seven days a week. Mental health care is
provided by Central Ohio Mental Health, to include the services of a psychiatrist and mental
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health therapists/counselors. The mental health staff provides on-site services on an as needed
basis. Dental services are provided off-site at Comfort Dental located in Marion, Ohio.
The clinic consists of one main room with adjacent toilet facilities and a storage closet. The
room has an examination table, desk area, locking cabinet for medical records, and a secure cart
for medications, needles and syringes. There is a secure waiting area adjacent to the clinic which
is supervised by correctional staff. Adequate privacy for patient encounters is afforded within
the clinic. The facility does not have a negative pressure room for housing detainees with
symptoms suggestive of tuberculosis. The policy mandates detainees requiring respiratory
isolation are transferred to the local hospital under appropriate precautions and notification of
ICE. Additional healthcare and emergency services are provided by the Morrow County
Hospital in Mount Gilead and/or Ohio State University Medical Center in Columbus.
ODO reviewed the suicide prevention and intervention standard and found the facility designates
two rooms for suicide watch in the booking area. Use of the rooms for this purpose was
approved by the clinical director, the mental health services provider, and correctional staff.
However, the rooms contain a toilet privacy wall which obstructs full vision into the rooms.
ODO’s review of documentation found a detainee was removed from suicide watch without a
risk assessment.
The special management units are Pod A and Pod B. Each pod is a two level, six cell unit used
for both administrative and disciplinary segregation with separation afforded by both cell and
level assignment. There were no detainees on disciplinary or administrative segregation at the
time of the inspection. The SMUs are well ventilated, adequately lit, appropriately heated, and
maintained in a sanitary condition. Permanent logs are not maintained in the SMU and status
reviews of detainees in SMU greater than 30 days are not conducted.
ICE staff conducts weekly scheduled and unscheduled visits. The days and times for scheduled
visits are posted in housing units, along with notices highlighting the Department of Homeland
Security, Office of Inspector General hotline. Detainees can submit written ICE request forms to
facility staff or ICE officials via the Turn Key Kiosk, located in each housing unit. The facility
has not established standard operating procedures covering detainees with limited language
proficiency or special needs requiring assistance submitting request forms to ICE. Detainee
requests are properly addressed and responded to in a timely manner by ERO. Copies of
completed detainee request forms are not filed and maintained in the detainee’s detention file.
The facility was not contractually required to comply with the 2011 Sexual Abuse and Assault
Prevention and Intervention (SAAPI) standard at the time of the inspection; however, efforts to
comply with the standard are noted. The facility established comprehensive zero-tolerance
written policy and procedures addressing the Prison Rape Elimination Act (PREA). The facility
has a counselor in charge of the PREA program who comes to the facility weekly.
A posting of the facility’s zero tolerance for sexual abuse and assault and reporting procedures
are posted in the housing units and booking areas. Detainees receive a PREA risk screening
during admission to identify a prior history of sexual abuse, or those that may be susceptible to
abuse.
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ERO staff members inspect phones regularly and report inoperable telephones. ODO verified
serviceability checks by reviewing weekly serviceability worksheets. An operational check of
the telephones in each of the two housing units was conducted and the phones were found to be
in good working order. The listings for pro bono services, DHS Office of Inspector General,
consulates, and embassies, and telephone operating instructions were available near the
telephones in each housing unit. Detainees are only allowed to use the phones for ten minutes,
rather than the required 20 minutes, and all calls are electronically monitored, including legal
phone calls.
Staff members are not trained in calculated use-of-force team techniques. Protective gear was
not available for use during a reported incident. No handheld cameras are available to record use
of force incidents and there is no documentation of medical evaluation following use-of-force
incidents. After action reviews are not conducted by either the facility or ICE.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO attempted to interview 25 detainees, but only six detainees volunteered to participate in the
process. Interview participation is voluntary and none of the detainees made allegations of
mistreatment, abuse, or discrimination. The majority of detainees reported being satisfied with
facility services, with the exception of the detention areas referenced below:
Access to Legal Materials: One detainee alleged they did not know the law library hours, how to
access it, or what the library included. Another detainee stated they would use the law library,
but the computer and printer were usually not working. The facility handbook does not have
information explaining how to access the law library. There was no designated staff member
assigned to the law library to ensure the equipment is working properly. ODO discussed these
detainee allegations with the AFOD for the facility.
Food Service: Two detainees complained about cold food, small portions, and no fresh fruit.
ODO reviewed the Food Service standard and observed the lunchtime meal on March 25, 2015.
The noon meal was observed and ODO found food was served at the appropriate temperature
and in the correct portions.
Medical Care: Two detainees alleged it took several days to receive a response to a medical
request. ODO reviewed the medical files of the two detainees and found responses were
provided to the detainees for their medical requests in appropriate timeframes.

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 15 NDS and found 55 deficiencies in the following 15 standards:
1. Access to Legal Materials
2. Admission and Release
3. Detainee Classification System
4. Detainee Grievance Procedures
5. Detainee Handbook
6. Environmental Health and Safety
7. Food Service
8. Funds and Personal Property
9. Medical Care
10. Special Management Unit – Administrative Segregation
11. Special Management Unit – Disciplinary Segregation
12. Staff-Detainee Communication
13. Suicide Prevention and Intervention
14. Telephone Access
15. Use of Force
Findings for these standards are presented in the remainder of this report.

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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at MCCF to determine if detainees have
access to a law library, legal materials, and supplies and equipment to facilitate the preparation
of legal documents, in accordance with the ICE 2000 NDS. ODO toured the law library,
interviewed staff, and reviewed the detainee handbook.
The law library is located in a designated room near the control room. The law library is well-lit,
contains sufficient furnishings, and is equipped with a desktop computer and monitor. Detainees
have access to paper, writing utensils, an onsite notary, and envelopes and stamps. Legal
documents can be printed and copies are made with the assistance of a staff member. MCCF
staff advised they do not currently have a designated employee to perform weekly inspections of
the law library as required by the NDS (Deficiency ALM-1). ODO verified the computer
contained a current version of LexisNexis.
Detainees can access the law library by making a verbal request to MCCF staff. Access is
granted daily during the waking hours, which are 7:00 a.m. to 10:30 p.m. Although MCCF staff
advised detainees are permitted access throughout the week during waking hours, the facility
does not have a documented schedule in place that is provided to the detainees (Deficiency
ALM-2).
Facility staff informed ODO that detainees in SMU for disciplinary issues are not afforded the
opportunity to access the law library (Deficiency ALM-3). However, ODO was informed
illiterate and limited English proficient detainees are provided assistance with their legal
paperwork, as needed. Detainees with appropriate language, reading, and writing abilities are
also allowed to provide assistance. The staff provides indigent detainees with free envelopes,
stamps, notary services, and certified mail for legal matters.
The facility handbook does not inform detainees the law library is available for use or how to
request access (Deficiency ALM-4). The facility does not inform detainees of the procedure for
requesting additional time, the procedure for requesting legal reference materials not maintained
in the law library, or the procedure for notifying a designated employee that library material is
missing or damaged. The policies and procedures are not posted in the law library (Deficiency
ALM-5).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE 2000 NDS, Access to Legal Material, section (III)(B), the FOD must
ensure, “The facility shall designate an employee with responsibility to inspect the equipment at
least weekly and ensure that it is in good working order, and to stock sufficient supplies.”
DEFICIENCY ALM-2
In accordance with the ICE 2000 NDS, Access to Legal Material, section (III)(G), the FOD must
ensure, “The facility shall devise a flexible schedule to permit all detainees, regardless of
housing or classification, to use the law library on a regular basis.”
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DEFICIENCY ALM-3
In accordance with the ICE 2000 NDS, Access to Legal Material, section (III)(M), the FOD must
ensure, “Detainees housed in Administrative Segregation or Disciplinary Segregation units shall
have the same law library access as the general population, unless compelling security concerns
require limitations.”
DEFICIENCY ALM-4
In accordance with the ICE 2000 NDS, Access to Legal Material, section (III)(Q), the FOD must
ensure, “The detainee handbook or equivalent, shall provide detainees with the rules and
procedures governing access to legal materials, including the following information:
1.
2.
3.
4.

that a law library is available for detainee use;
the scheduled hours of access to the law library;
the procedure for requesting access to the law library;
the procedure for requesting additional time in the law library (beyond the 5 hours per
week minimum);
5. the procedure for requesting legal reference materials not maintained in the law library;
and
6. the procedure for notifying a designated employee that library material is missing or
damaged.”
DEFICIENCY ALM-5
In accordance with the ICE 2000 NDS, Access to Legal Material, section (III)(Q), the FOD must
ensure, “These policies and procedures shall also be posted in the law library along with a list of
the law library’s holdings.”

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ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at MCCF to determine if procedures are in
place to protect the health, safety, security and welfare of each person during the admission and
release process, in accordance with the ICE NDS. ODO reviewed policies, procedures and the
detainee handbook, inspected detention files, interviewed MCCF and ERO staff, toured the
intake and property area, and observed the release process.
The facility has written policies and procedures addressing admission and release procedures.
Detainees are transferred from the ERO office in Columbus, Ohio. MCCF policy prohibits strip
searches of detainees. Arriving detainees are pat searched, fingerprints and photographs are
taken, property and any monies are inventoried, and clothing and hygiene supplies are issued.
Detainees were not given receipts for their property and funds.1
MCCF applies the classification determined by ERO, as documented on Form I-216, Record of
Persons and Property Transferred. Medical intake screening is conducted by officers trained to
conduct the intake medical screening. The completed intake screening form and medications
transferred with the detainees are forwarded to healthcare staff
The intake forms are scanned into an electronic record keeping system. Hard-copy files are
created and filed by the detainee’s bed number. ODO’s review of 25 detainee files found the
files only contained a photograph of the detainee and Form I-203, Order to Detain or Release
Alien. Scanned copies of other intake documentation were found in the electronic record.
The facility does not have a video orientation to the facility or a formal orientation for detainees
(Deficiency AR-1). Detainees are not provided with the facility handbook or the ICE National
Detainee Handbook upon admission to the facility (Deficiency AR-2). Instead, detainees are
asked if they would like a copy of the facility handbook, and copies of the ICE National Detainee
Handbook are available in the housing units.
ODO observed out-processing for six detainees during the inspection. Required documentation
was completed, personal property was returned, commissary accounts were closed and funds
were reimbursed to the detainees in cash. The detainees received receipts acknowledging funds
and property were returned.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
In accordance with the ICE NDS, Admission and Release, section (III)(J), the FOD must ensure,
“All facilities shall have a medium to provide INS detainees an orientation to the facility. In
IGSAs the INS office of jurisdiction shall approve all orientation procedures.”

1

A deficiency was sited under the Funds and Personal Property Standard.

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DEFICIENCY AR-2
In accordance with the ICE NDS, Admission and Release, section (III)(K), the FOD must ensure,
“Upon admission every detainee will receive a detainee handbook. It will fully describe all
policies, procedures, and rules in effect at the facility, in accordance with the “Detainee
Handbook” standard.”

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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System standard at MCCF to determine if there is a
formal classification process for managing and separating detainees based on verifiable and
documented data, in accordance with the ICE NDS. ODO toured the facility and classification
area, interviewed staff, reviewed detainee files and classification living unit rosters, and observed
the classification process.
ODO interviewed the booking officer regarding the classification process. The booking officer
stated all detainees are classified during booking. Facility staff reviews ERO provided forms,
Form I-203, “Order to Detain or Release Alien,” and Form I-216, “Record of Persons and
Property Transferred,” and any other background information ERO may provide to determine the
detainee’s classification level. The facility staff member that oversees classification stated they
contact ERO if additional information is needed. All of the detainees were classified as “Low”
during this inspection.
ODO reviewed 25 detention files and found no classification forms in the files (Deficiency DCS1).
The facility handbook did not provide detainees with an explanation of classification levels or
how to appeal their classification (Deficiency DCS-2).

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.”
DEFICIENCY DCS-2
In accordance with the ICE NDS, Detainee Classification System section (III)(I), the FOD must
ensure “The detainee handbook’s section on classification will include the following:
1. An explanation of the classification levels, with the conditions and restrictions
applicable to each.”
2. The procedures by which a detainee may appeal his/her classification.”

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedure standard at MCCF 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 2000 NDS.
ODO reviewed detention files, logbooks, policies, and the facility handbook, and interviewed
staff. When oral grievances are resolved, the results are not documented or placed in the
detainee’s detention file (Deficiency DGP-1). The facility does not have a grievance committee
to review formal complaints (Deficiency DGP-2).
MCCF incorporates the use of a system called a Turn Key Kiosk. The system is used for
detainees to file grievances and other requests. The system allows detainees to file grievances
with an emergency option available. The grievances are received by the shift supervisor and
resolved on the lowest level possible. The response to the grievance is returned via the system.
Detainees are able to review the response by logging in to the system. A copy of the grievance
does not remain in the detainee’s detention file for at least three years (Deficiency DGP-3). The
facility will forward any grievances alleging staff misconduct to ERO. The facility has
established an appeals process for formal grievances, which is processed through the Turn Key
Kiosk.
The facility does not provide each detainee, upon admittance, a copy of the facility handbook or
equivalent (Deficiency DGP-4). The grievance section of the facility handbook does not provide
the necessary elements outlined in the standard, including: the difference in procedures between
formal and informal grievances; the availability of assistance in preparing a grievance; the
procedures for resolving a grievance or appeal; and the policy prohibiting staff from retaliating
against a detainee; or the opportunity to file a complaint about officer misconduct directly with
the Department of Homeland Security, Office of the Inspector General (Deficiency DGP-5).
The facility maintains a grievance log to document and track grievances filed by detainees.
ODO reviewed eight grievances. None of the grievances involved staff misconduct. The
grievances were related to issues with property, commissary, food service and the use of nail
clippers. Staff responded to all grievances either in writing or via the Turn Key Kiosk.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(1), the FOD
must ensure, “If an oral grievance is resolved to the detainee’s satisfaction at any level of review,
the staff member need not provide the detainee written confirmation of the outcome, however the
staff member will document the results for the record and place his/her report in the detainee’s
detention file.”

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DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(2), the FOD
must ensure “The OIC must allow the detainee to submit a formal, written grievance to the
facility’s grievance committee.”
DEFICIENCY DGP-3
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must
ensure, “A copy of the grievance will remain in the detainee’s detention file for at least three
years.”
DEFICIENCY DGP-4
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G), the FOD
must ensure, “The facility shall provide each detainee, upon admittance, a copy of the detainee
handbook or equivalent.”
DEFICIENCY DGP-5
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G), the FOD
must ensure, “The grievance section of the detainee handbook will provide notice of the
following:
1. The opportunity to file a grievance, both informal and formal.
2. The procedures for filing a grievance and appeal, including the availability of assistance
in preparing a grievance.
3. The procedures for resolving a grievance or appeal, including the right to have the
grievance referred to higher levels if the detainee is not satisfied that the grievance has
been adequately resolved. The level above the CDF-OIC is the INS-OIC.
4. The procedures for contacting the INS to appeal the decision of the OIC of a CDF or an
IGSA facility.
5. The policy prohibiting staff from harassing, disciplining, punishing or otherwise
retaliating against any detainee for filing a grievance.
6. The opportunity to file a complaint about officer misconduct directly with the Justice
Department by calling 1-800-869-4499 or by writing to:
Department of Justice
P.O. Box 27606
Washington, DC 20038-7606”

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DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at MCCF to determine if the facility provides
each detainee with a handbook, written in English and any other languages spoken by a
significant number of detainees housed at the facility, describing the facility’s rules and
sanctions, disciplinary system, mail and visiting procedures, grievance system, services,
programs, and medical care, in accordance with the ICE 2000 NDS. ODO reviewed the facility
handbook, staff training records, detention files, and interviewed staff and detainees.
The facility booking officer stated the facility handbook is offered to new detainees during intake
if they want a copy. The facility staff stated that a digital version of the facility handbook is
available on the facility kiosk for the detainees to review. However, when ODO used the kiosk
with the assistance of facility staff, no facility handbooks were accessible.
ODO found no documentation that facility staff received a copy of the facility handbook and
were trained on the contents of the facility handbook (Deficiency DH-1).
During an interview with staff, ODO was informed there are no procedures in place for
immediately communicating handbook revisions to facility staff and detainees (Deficiency DH2) and there is no appointed committee to conduct annual reviews of the facility handbook
(Deficiency DH-3). The last revision of the facility handbook was published in 2011.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE 2000 NDS, Detainee Handbook, Section (III)(G), the FOD must
ensure, “The OIC will provide a copy of the handbook to every staff member who has contact
with detainees. These staff members will also receive training focused on its contents.”
DEFICIENCY DH-2
In accordance with the ICE 2000 NDS, Detainee Handbook, Section (III)(H), “The handbook
will not be immediately reprinted to incorporate every revision. The OIC will instead establish
procedures for immediately communicating such revisions to staff and detainees: posting copies
of the changes on bulletin boards in housing units and other prominent areas; informing new
arrivals during orientation process; distributing a memorandum to staff, and so forth.”
DEFICIENCY DH-3
In accordance with the ICE 2000 NDS, Detainee Handbook, Section (III)(I), “An appointed
committee will conduct annual reviews of the handbook, after the annual reviews and revisions
by facility department heads and the OIC.”

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at MCCF 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 toured the facility,
interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical
management, and fire drills.
The sanitation of the facility was acceptable; however, ODO found significant soap scum build
up in the housing unit restrooms.
The facility does not maintain a master index of hazardous substances used within the facility, to
include locations, emergency contact numbers, and documentation of semi-annual review
(Deficiency EH&S-1). Binders with Material Safety Data Sheets (MSDS) were found in
locations where hazardous chemicals were used. Inventories were checked and confirmed
accurate. The door to the laundry area was not secured (Deficiency EH&S-2).
MCCF has a designated fire and safety officer. ODO’s review of documentation confirmed
weekly fire and safety inspections were conducted, and monthly inspections were conducted by
maintenance personnel with reports forwarded to the jail administrator.
ODO confirmed monthly fire drills include drawing and testing of emergency keys are
conducted; however, emergency key drills were not timed (Deficiency EH&S-3). The exit
diagrams posted throughout the facility are eight-by-ten inch photo copies which are too small to
be legible. The diagrams are in English only and do not indicate the locations of emergency
equipment (Deficiency EH&S-4).
Documentation of generator testing, pest control, and water certification were present and in
compliance with the standard. Inspection of the medical department found sharps were properly
inventoried and accounted for. Disposal of bio-hazardous waste is handled under contract with a
private contractor.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with ICE NDS, Environmental Health and Safety, section (III)(C), the FOD must
ensure, “The Maintenance Supervisor or designate will compile a master index of all hazardous
substances in the facility, including locations, along with a master file of MSDSs. He/she will
maintain this information in the safety office (or equivalent), with a copy to the local fire
department. Documentation of the semi-annual reviews will be maintained in the MSDS master
file.
The master index will also include a comprehensive, up-to-date list of emergency phone numbers
(fire department, poison control center, etc.).”

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DEFICIENCY EH&S-2
In accordance with ICE NDS, Environmental Health and Safety, section (III)(G)(1), the FOD
must ensure, “All toxic and caustic materials must be stored in secure areas, in their original
containers, with the manufacturer’s label intact on each container.”
EFICIENCY EH&S-3
In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the FOD
must ensure, “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. NFPA recommends a limit of four and one-half minutes for drawing keys and
unlocking emergency doors.”
DEFICIENCY EH&S-4
In accordance with ICE NDS, Environmental Health and Safety, section (III)(L)(5), the FOD
must ensure, “In addition to a general area diagram, the following information must be provided
on existing signs:
a. English and Spanish instructions;
c. Emergency equipment locations.”

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at MCCF to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO
interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed
policy and relevant documentation.
The food service operation at MCCF is managed by contractor Aramark Correctional Service.
Staffing consists of the food service supervisor and (b)(7)ekitchen foremen, supported by (b)(7)e
county inmate worker. Documentation was available certifying all food service staff and the
inmate worker received medical screening and clearance prior to working in the kitchen. In
interviews with Aramark staff and jail personnel, it was determined the food service staff are not
trained in custody issues such as contraband detection and key control (Deficiency FS-1). ODO
confirmed staff received Serv-Safe certification and were provided with the ICE NDS. Food
service personnel were observed wearing clean uniforms, hats, gloves, and beard guards for
facial hair.
The facility has a five-week general cycle menu certified by a registered dietitian based on a
complete nutritional analysis. Procedures meeting the requirements of the standard are in place
for religious, common fare and medical diets. There were no detainees on common fare diets
and three were receiving medical diets at the time of the inspection. ODO observed the
preparation and serving of breakfast, lunch and dinner meals and noted food temperatures
routinely being tested by staff. Using a digital food thermometer, ODO confirmed food
temperatures met NDS requirements upon preparation and service. ODO sampled the meal and
found the items good tasting, of good quality and served in ample portions.
Meals are served to the general population in a dining room and detainees in the SMU are served
meals on thermal trays. ODO noted the trays had an extreme buildup of hard water deposits.
The facility has a sanitation program, which includes clean-as-you-go procedures posted
throughout the kitchen area. ODO observed the procedures were not followed during meal
preparation, and the overall sanitation of the area was poor. Food spills were noted on the floor,
and grease and dirt were observed on walls and ceilings (Deficiency FS-2). Sticky areas were
found on refrigerator doors, and stainless steel tables had water marks (Deficiency FS-3). Trash
containers did not have lids (Deficiency FS-4). While the facility has written procedures for
weekly inspections of the food service areas, there was no documentation to support these
procedures were implemented and followed (Deficiency FS-5). Sanitation improved during the
course of the inspection.
Documentation of monthly treatments by Absolute Pest was produced. No knives are used in the
food service operation. ODO confirmed tools and utensils were properly controlled. Hazardous
chemicals were properly controlled, stored and inventoried.
Freezer and coolers were found in good sanitary condition, and temperatures recorded on logs
met requirements. The dry storage room was organized and clean and mandated clearances were
met. Procedures are in place for rotating stock.
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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE NDS, Food Service, section (III)(B)(1), the FOD must ensure, “The
facility training officer will devise and provide appropriate training to all food service personnel
in detainee custodial issues. Among other things, this training will cover INS’s detention
standards.”
DEFICIENCY FS-2
In accordance with ICE NDS, Food Service, section (III)(H)(5)(c), The FOD must ensure, “All
facilities shall meet the following environmental standards: Routinely cleaned walls, floors, and
ceilings in all areas.”
DEFICIENCY FS-3
In accordance with ICE NDS, Food Service, section (III)(H)(5)(h), The FOD must ensure, “All
facilities shall meet the following environmental standards: To prevent cross-contamination,
kitchenware and food-contact surfaces should be washed, rinsed, and sanitized after each use and
after any interruption of operations during which contamination could occur.”
DEFICIENCY FS-4
In accordance with ICE NDS, Food Service, section (III)(H)(5)(j), The FOD must ensure, “All
facilities shall meet the following environmental standards: Garbage and other trash shall be
collected and removed as often as possible. The garbage/refuse containers shall have sufficient
capacity for the volume, and shall be kept covered cleaned frequently, and insect- and rodent
proof. The facility shall comply with all applicable regulations (local, state, and federal) on
refuse-handling and disposal.”
DEFICENCY FS-5
In accordance with ICE NDS, Food Service, section (III)(H)(13)(a), the FOD must ensure, “The
facility shall implement written procedures for the administrative, medical, and/or dietary
personnel conducting the weekly inspections of all food service areas, including dining, storage,
equipment, and food-preparation areas.”

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at MCCF to determine if controls are
in place to inventory, receipt, store, and safeguard detainees’ personal property, in accordance
with the ICE NDS. ODO reviewed policies, interviewed staff, inspected property storage areas,
and reviewed detainee files.
Booking officers inventory personal property upon arrival. All detainee property is stored in a
secure, well-ventilated storage room in a secured locker tagged with the detainee’s name and Anumber. Access to the property storage room is restricted to booking officers and in their
absence, the shift supervisor. Detainees do not sign and receive a copy of the property inventory
(Deficiency F&PP-1).
The facility utilizes the electronic TurnKey© system for depositing and accounting of detainee
funds. When a detainee arrives with U.S. currency, the intake officer counts the money in the
detainee’s presence. The officer inserts the money into the Turnkey system which counts it and
provides a printed receipt for the detainee and establishes a commissary account. Access to the
cash deposited in the Turn Key system is restricted to the accounts receivables clerk, who
empties the drop box once a week, verifies the monies and deposits them in the facility trust
fund. Documentation reflects funds are audited once a month by the office administrator and
yearly by the Morrow County auditor’s office. Foreign currency is inventoried and placed in a
sealed envelope, then secured in the detainee’s property bag. Detainees do not sign and receive
receipts for foreign funds.
The facility handbook delineates what property a detainee can and cannot have in their
possession, how property is stored, and whom to contact in the event of lost or damaged
property. It does not explain how to obtain any personal identification documentation they may
need, such as passport, or birth certificate (Deficiency F&PP-2).
Booking officers do not obtain a forwarding address from detainees for use in the event personal
property is lost or abandoned (Deficiency F&PP-3). In addition, the facility does not have a
written policy or procedure for property reported missing or damaged (Deficiency F&PP-4).
ODO found no documented cases of lost, damaged, or abandoned property at the facility.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with ICE NDS, Funds and Personal Property, section (III)(D), the FOD must
ensure, “Each facility shall have a written standard procedure for inventory and receipt of
detainee funds and valuables.”
DEFICIENCY F&PP-2
In accordance with ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must
ensure, “The detainee handbook or equivalent shall notify the detainees of facility policies and
procedures concerning personal property, including: That, upon request, they will be provided an

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INS-certified copy of any identity document (passport, birth certificate, etc.) placed in their Afiles;”
DEFICIENCY F&PP-3
In accordance with ICE NDS, Funds and Personal Property, section (III)(C), the FOD must
ensure, “Standard operating procedure will include obtaining a forwarding address from every
detainee who has personal property that could be lost or forgotten in the facility after the
detainee’s release, transfer, or removal.”
DEFICIENCY F&PP-4
In accordance with ICE NDS, Funds and Personal Property, section (III)(H), the FOD will
ensure, “Each facility shall have a written policy and procedures for detainee property reported
missing or damaged.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at MCCF to determine if detainees have access to
healthcare and emergency services to meet their health needs in a timely manner, in accordance
with the ICE NDS. ODO toured the facility and the health services unit, reviewed medical
policies and procedures, and examined 25 detainee medical records. In addition, ODO reviewed
the credentials of all healthcare staff and interviewed the HSA, captain and correctional staff.
The facility holds no national accreditations. Healthcare services are provided by a registered
nurse, who is a Morrow County employee, who serves as the HSA, and a physician, who is
employed by Premier Health Care Services, Incorporated, who serves as the clinical director.
The HSA is on-site eight hours per day five days a week and on call 24 hours a day, seven days a
week. The physician provides on-site services a minimum of once every two weeks for as many
hours as needed, and provides on-call services twenty-four hours per day, seven days per week.
ODO was informed the physician comes to the facility the day health appraisals are performed to
assure their immediate review.
Mental health care is provided by Central Ohio Mental Health, to include the services of a
psychiatrist and mental health therapists/counselors. At the time of the inspection, the mental
health staff were providing on- site services when called; however, a contract for 40 hours per
week of on-site coverage was being finalized. Dental services are provided off-site at Comfort
Dental located in Marion, Ohio. ODO verified the credentials and licensure of the HSA and
physician were current and primary source verified.
The clinic consists of one main room with adjacent toilet facilities and a storage closet. The
room has an examination table, desk area, locking cabinet for medical records, and a secure cart
for medications, needles and syringes. There is a secure waiting area adjacent to the clinic which
is supervised by correctional staff. Adequate privacy for patient encounters is afforded within
the clinic. The facility does not have a negative pressure room for housing detainees with
symptoms suggestive of tuberculosis (TB). MCCF’s policy mandates detainees requiring
respiratory isolation are transferred to the local hospital under appropriate precautions and
notification of ICE. Additional healthcare and emergency services not available at the facility
are provided by the Morrow County Hospital in Mount Gilead and the Ohio State University
Medical Center in Columbus.
Medical and mental health intake screening is performed by correctional officers upon detainee
arrival. Training in performing intake screening is provided upon hire and annually by the HSA.
Certification of training completion was documented in the training files of (b)(7)eandomly
selected officers. Detainees are tested for TB by way of purified protein derivative skin test or
chest x-ray, completed by a contract mobile x-ray service. ODO’s review of 25 medical records
confirmed intake screening forms were reviewed by the HSA, and all documented completion of
TB testing. Signed consent for treatment statements were present.
The initial health appraisal is conducted by the HSA and includes a hands-on physical
examination and dental screening. Training and certification of the HSA by the clinical director
in performing physical examinations and dental screenings was documented. All 25 medical
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records documented review of the health appraisals by the clinical director and completion
within 14 days of admission.
The facility has a telephonic language interpretation service for language assistance when
needed. ODO was informed the HSA and clinical director speak Spanish. Detainees request
health care by way of an electronic kiosk system programmed in English and Spanish, or by
submitting written requests to the HSA. A review of 30 sick call requests found all were triaged
upon receipt and the detainees were seen for sick call in one to three days. The HSA conducts
sick call using protocols approved by the clinical director.
Pharmacy services are provided through a contractual agreement with Diamond Pharmacy,
which fills patient-specific prescriptions using the blister-pack system. Rite Aid Pharmacy of
Mount Gilead provides emergency pharmaceuticals. Medications are distributed by trained
officers and documented on distribution forms. The forms are reviewed by the HSA, who
transcribes the information onto medication administration records. ODO reviewed 20
completed distribution forms and the corresponding medication administration records. All were
complete with no discrepancies noted.
ODO’s medical record review included four detainees with hypertension. All four detainees
were on medications and their blood pressure was monitored per the clinical director’s orders.
Per the clinical director’s orders, elevated blood pressure readings were to be referred to him for
further evaluation. Documentation reflected one of the four detainee’s blood pressure was
elevated for 30 consecutive days with no evidence of referral to the clinical director (Deficiency
MC-1). ODO brought this finding to the HSA’s attention, where the detainee was subsequently
brought to the clinic for evaluation. Upon determining his blood pressure remained elevated, the
HSA contacted the clinical director. New medication orders were received and the detainee was
scheduled for a follow up appointment with the clinical director during the course of the
inspection.
First aid kits are located between the two housing units and in central control and booking.
There is one automated external defibrillator (AED) located in central control. ODO confirmed
the first aid kits are routinely inventoried and the operability of the AED is checked. A review of
training records for the medical staff and ten randomly selected officers confirmed current
training in first aid, cardiopulmonary resuscitation (CPR) and AED. In addition, the officers’
records documented training in recognition of medical and mental health emergencies, referral
procedures, infections and communicable diseases, hunger strikes, and recognition of acute
manifestation of certain chronic illnesses (seizures, intoxication and withdrawal, drug toxicity
and adverse reaction to medication) and suicide prevention and intervention.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY MC&I-1
In accordance with the ICE NDS, Medical Care, section (III)(A), the FOD must ensure, “Every
facility will provide its detainee population with initial medical screening, cost-effective primary
medical care and emergency care.”

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SPECIAL MANAGEMENT UNIT (SMU)
ADMINISTRATIVE SEGREGATION
ODO reviewed the Special Management Unit - Administrative Segregation standard at MCCF 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 SMU, reviewed
policies, interviewed staff, and inspected detainee files for required documentation.
Pod A and Pod B are used for detainees requiring separation from the general population. Pod A
houses males and Pod B houses females. Each pod is a two level, six cell unit used for both
administrative and disciplinary segregation with separation afforded by both cell and level
assignment. Two cells are single occupancy and the other four cells are double occupancy.
The SMUs have a dayroom with a shower, telephones, reading materials, a television, and a
kiosk for ordering commissary and filing requests for services and grievances. The cells are
equipped with a toilet, sink, desk, and beds affixed to the wall. An intercom is available in each
cell for communication directly to the control center. ODO’s inspection found the SMUs well
ventilated, adequately lit, appropriately heated, and maintained in a sanitary condition.
Detainees are monitored by an officer assigned to central control, which is an enclosed work
station elevated above the housing units. Observation by the control officer is both direct and by
way of video surveillance cameras; also, an officer makes rounds within the units every hour.
In addition to use for detainees assigned to segregation status, cells in Pods A and B are used as
“step down” housing for detainees determined to require closer control and monitoring than
provided in the general population dormitory, including detainees removed from administrative
segregation status. The restrictions and living conditions closely parallel those applied to
detainees assigned to administrative segregation. No detainees were assigned to "step down"
status during the inspection; however, ODO notes that should this occur in the future, the
detainees would be subject to a higher level of restriction on movement and privileges than
detainees in the general population, without application of the requirements of the SMU
standard.
Detainees in the SMU are confined to their cells for two full days a week and are allowed out
only if they receive a visit (Deficiency SMU AS-1). The remaining five days detainees have one
hour out-of-cell time per day, during which they may shower, watch television, use the telephone
or submit requests via the kiosk system. According to policy and staff, detainees are provided
with access to the law library, visitation and religious services upon request.
There were no detainees housed in the SMU at the time of the inspection. According to
documentation and staff report, four detainees were placed on administrative segregation status
in the year preceding the inspection. ODO confirmed written orders approved by a supervisor
were completed; however, there was no documentation indicating copies of the orders were
provided to the detainees (Deficiency SMU AS-2).

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In the first case, the detainee was assigned to administrative segregation on April 22, 2014 for
threatening another inmate. Despite the recorded basis for the assignment, there is no
documentation the disciplinary process was initiated. Administrative segregation was
discontinued the same day, although the detainee remained in Pod A on the step-down status
previously discussed in this report.
In the second case, a detainee was assigned to administrative segregation on May 21, 2014 after
punching another detainee in the nose. Administrative segregation was discontinued two days
later and the detainee was moved to step-down status in Pod A. He received 30 days disciplinary
segregation on May 25, 2014.
On August 16, 2014 the third detainee was placed in administrative segregation after it was
reported he was engaging in inappropriate sexual conduct in general population., There was no
documentation in the detention file indicating the disciplinary process was initiated, and whether
a sexual assault or abuse investigation was conducted. The detainee was removed from
administrative segregation status the day after assignment and moved to step-down status in Pod
A. Documentation reflects he was removed via ICE air on August 19, 2014.
In the fourth case, a detainee was assigned to administrative segregation on February 3, 2015
pending a disciplinary hearing for refusing to move to another housing unit and threatening staff.
He was transferred to another facility on February 10, 2015.
ODO was unable to confirm the four detainees received privileges and services required by the
NDS because MCCF does not maintain a permanent log (Deficiency SMU AS-3). Staff reported
they make required entries on the facility’s Special Management Unit Housing Record form;
however, the forms were not retained. Corrective action was initiated during the inspection by
reissuance of the form and instructing staff to scan the forms into detainee files (C-1).
Facility policy does not require that a status review take place until a detainee has been in
administrative segregation for 30 days. A detainee on administrative segregation for 72 hours
did not receive a status review. The NDS requires a status review within 72 hours after
placement, and every seven days for the first month.
Staff stated anytime a detainee is placed in administrative segregation, the ERO Supervisory
Immigration Enforcement Agent (SIEA) is notified. The SIEA was interviewed and confirmed
he was notified of the four placements in the past year and that he received written reports.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU AS-1
In accordance with the ICE NDS, Special Management Unit - Administrative Segregation,
section (III)(D)(1), the FOD must ensure, “Detainees in administrative segregation shall receive
the same general privileges as detainees in the general population, consistent with available
resources and security considerations.”

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DEFICIENCY SMU AS-2
In accordance with the ICE NDS, Special Management Unit - Administrative Segregation,
section (III)(B), the FOD must ensure, “A written order shall be completed and approved by a
supervisory officer before a detainee is placed in administrative segregation, except when
exigent circumstances make this impracticable. In such cases, an order shall be prepared as soon
as possible. A copy of the order shall be given to the detainee within 24 hours, unless delivery
would jeopardize the safety, security, or orderly operation of the facility.”
DEFICIENCY SMU AS-3
In accordance with the ICE NDS, Special Management Unit - Administrative Segregation,
section (III)(E), the FOD must ensure, “A permanent log will be maintained in the SMU. The
log will record all activities concerning the SMU detainees, e.g., meals served, recreation,
visitors, etc.”

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SPECIAL MANAGEMENT UNIT (SMU)
DISCIPLINARY SEGREGATION
ODO reviewed the Special Management Unit - Disciplinary Segregation standard at MCCF 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 SMU, reviewed policies,
and interviewed staff.
Pod A is MCCF’s SMU for male detainees and Pod B is the SMU for female detainees. Each
pod is a two level, six cell unit used for both administrative and disciplinary segregation with
separation afforded by both cell assignment and level. Two cells are single occupancy and the
other four cells are double occupancy.
The SMUs have a dayroom with a shower, telephones, reading materials, a television and a kiosk
for ordering commissary and filing requests for services and grievances. The cells are equipped
with a toilet, sink, desk, and beds affixed to the wall. An intercom is available in each cell for
communication directly to the control center. ODO’s inspection found the SMUs well
ventilated, adequately lit, appropriately heated, and maintained in a sanitary condition.
Detainees are monitored by an officer assigned to central control, which is an enclosed work
station elevated above the housing units. Observation by the control officer is direct and by way
of video surveillance cameras; also, an officer makes rounds within the units every hour.
Detainees on disciplinary segregation are confined to their cells two days a week. Five days per
week, they are allowed one hour out-of-cell time.
There were no detainees on disciplinary segregation at the time of the inspection. A review of
documentation found there were three detainees sanctioned with disciplinary segregation in the
year preceding the inspection. In one case, the detainee was sanctioned with 30 days for
assaulting another detainee. The detainees in the other two cases were sanctioned with 15 days
disciplinary segregation, one for stealing a soda from a facility refrigerator; the other for stealing
a cell phone from a property bag while in the booking area.
During a review of disciplinary sanction reports, ODO noted only the finding and sanctions were
recorded on the hearing records, no basis for the finding was documented as required by facility
policy. In addition, ODO noted sanctions included loss of a mattress and blanket (Deficiency
SMU DS-1). During the inspection, corrective action was initiated by revision of the facility
policy (C-2).
ODO was unable to confirm the three detainees sanctioned with disciplinary segregation
received privileges and services required by the NDS because the facility does not maintain a
permanent log (Deficiency SMU AS-2). Staff reported they make required documentation on
the facility’s Special Management Unit Housing Record form; however, the forms were not
retained. Corrective action was initiated during the inspection by reissuance of the form and
instructing staff to scan the form into the detainee’s file (C-3).

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Per staff interviews, detainees in disciplinary segregation are not provided with access to the law
library (Deficiency SMU DS-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU DS-1
In accordance with the ICE NDS, Special Management Unit - Disciplinary Segregation, section
(III)(D)(9), the FOD must ensure, “A detainee may be deprived of clothing, mattress, blanket,
pillow, etc., for medical or psychiatric reasons only, as determined by the medical officer.”
DEFICIENCY SMU DS-2
In accordance with the ICE NDS, Special Management Unit - Disciplinary Segregation, section
(III)(E)(1), the FOD must ensure, “A permanent log will be maintained in the SMU.”
DEFICIENCY SMU DS-3
In accordance with the ICE NDS, Special Management Unit - Disciplinary Segregation, section
(III)(D)(15)(e), the FOD must ensure, “Access to legal and non-legal reading material shall be as
follows: When developing the schedule for law library-access, the OIC will set aside blocks of
time for the detainees in disciplinary segregation. These detainees will be afforded legal access
comparable to, but not the same as, that of the general population. Security constraints may
impose limits on law-library access.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at MCCF to determine if procedures
are in place to allow formal and informal contact between detainees and key ICE and facility
staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses
in a timely manner, in accordance with the ICE 2000 NDS.
ICE staff conducts weekly scheduled and unscheduled visits at MCCF. The days and times for
scheduled visits are posted in housing units, along with notices highlighting the Department of
Homeland Security, Office of Inspector General hotline. During visits ICE officials check on the
overall condition of the facility and responds to detainee requests. Visits are documented in the
ERO’s logbook. ODO reviewed Facility Liaison Checklists and telephone serviceability
worksheets to verify weekly checks are completed and that records are maintained. Also a
review of the logbooks was conducted and found that detainee requests are responded to within
72 hours.
Detainees can submit written ICE request forms to facility staff or ICE officials on a Turn Key
Kiosk, located in each housing unit. ICE officials maintain a log to document detainee requests.
The electronic log captures the date of receipt; the detainee’s name and nationality; A-number;
name of the staff member who logged the request; the date the request was returned to the
detainee; other pertinent information; and the date the request was forwarded to ICE. However,
detainees cannot send sealed requests to ERO without the facility reading, altering, or delaying
the request (Deficiency SDC-1).
The facility does not have written procedures specifying how detainees can route requests to ICE
officials or established standard operating procedures covering detainees with special
requirements that may need assistance from another detainee, housing unit officer, or other
facility staff member in preparing a request form (Deficiency SDC-2).
Detainee requests are properly addressed and responded to in a timely manner by ERO, but ODO
found that copies of completed request forms are not filed and maintained in the detainee’s
detention file (Deficiency SDC-3).
The facility handbook does not include instruction for detainees that need assistance in preparing
an ICE request (Deficiency SDC-4).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must
ensure, “The detainee request form shall be delivered to ICE staff by authorized personnel (not
detainees) without reading, altering, or delay. The detainee may, if he or she chooses, seal the
request in an envelope and clearly mark the envelope with the name, title or office the request is
to be forwarded to.”

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DEFICIENCY SDC-2
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must
ensure, “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.”
DEFICIENCY SDC-3
In accordance with the ICE NDS, 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-4
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3),the FOD
must ensure, “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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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at MCCF 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 NDS. ODO reviewed the policy and suicide prevention
training lesson plan, inspected medical and detention staff training records, and interviewed the
Health Service Administrator, captain and staff.
In the facility booking area there are two rooms designated for use for a suicide watch. Use of
the rooms for this purpose was approved by the clinical director, the mental health services
provider, and correctional staff. Inspection of the rooms found they have a half-wall near the
toilet for privacy purposes. The wall obstructs full vision into the room, allowing a detainee to
potentially attempt suicide out of the officer’s view. The facility issues suicide resistant gear
including mattress, blanket and gown to prevent this from occurring; however, there is no
assurance a detainee on suicide watch may not be passed contraband that could facilitate a
suicide attempt.
The HSA informed ODO that in the year preceding the inspection, two detainees were placed on
suicide watch, including one placed on the status following a suicide attempt. The detainee who
attempted suicide had been scheduled for deportation and was found in his housing unit with a
sheet around his neck stating he was going to kill himself. A review of documentation supported
placement on suicide watch and monitoring in accordance with the standard. ODO found the
detainee was removed from suicide watch without a suicide risk assessment or the authorization
of the Clinical Director. In one case, the detainee was released from suicide watch by a mental
health professional.
A review of the medical record for the detainee that attempted suicide included a transfer
summary documenting the HSA cleared him for removal, effectively discontinuing the suicide
watch. On this form, the HSA did not make note of the detainee’s suicide attempt or placement
on suicide watch status. Absent this information on the transfer summary, it is unknown whether
the transporting officers were aware the detainee may be at risk for suicide (Deficiency SP&I-1).
ODO’s review of MCCF’s suicide prevention and intervention training plan confirmed all
required elements are covered. The training records of medical staff and(b)(7)e andomly selected
officers documented completion of initial and annual training.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(B), the FOD
must ensure, “Upon change of custody, the staff with custody will inform the staff assuming
custody about indications of suicide risk.”

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at MCCF to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and
others in the community, in accordance with the ICE NDS. ODO interviewed facility staff and
detainees; reviewed policy, procedures, and the facility handbook; and conducted functionality
tests on the telephones located in detainee housing units.
Detainees have reasonable and equitable access to telephones. The facility does not provide
telephone access rules in writing to each detainee upon admittance (Deficiency TA-1). The
telephone availability ratio for each housing pod is approximately three detainees per telephone.
Telephones are turned on each day at approximately 7:00 a.m. and turned off at lockdown each
evening at 10:30 p.m. If time limits are necessary time limits of ten minutes are imposed
(Deficiency TA-2). A TTY device is located near the control room. The facility moves the TTY
phone to a private room for detainee use.
SECURUS is the telephone service provider. Pre-paid calling cards may be purchased through
the Turn Key Kiosk for $11.00 a card. The detainees are issued a user name and password to use
the credits on the card. If making a collect call or paying with a pre-paid calling card, local calls
are $0.20 per minute and long distance calls are $0.36 per minute. Local and long distance calls
incur a $2.75 surcharge. International calls are $0.89 per minute with a $3.95 surcharge. The
phone systems do not permit detainees to make calls to immediate family members detained in
other facilities (Deficiency TA-3). The facility does not grant requests for inter-facility family
calls to discuss legal matters (Deficiency TA-4).
ERO staff members inspect phones regularly and report out-of-order telephones for repair. ODO
verified serviceability checks by reviewing weekly serviceability worksheets. ODO conducted
operational checks of telephones in each of the two housing units and found them to be in good
working order. The listings for pro bono services, DHS Office of Inspector General, consulates,
and embassies, and telephone operating instructions were available near the telephones in each
housing unit.
The phone system is setup to electronically monitor all detainee telephone calls to include legal
telephone calls (Deficiency TA-5). The facility does not have a written policy on the monitoring
of detainee telephone calls (Deficiency TA-6). Notification that calls are subject to monitoring
are posted on each telephone, but is not included in the facility handbook (Deficiency TA-7).
Telephones are available in the intake area for detainees to make private and unmonitored legal
calls. The procedure for obtaining an unmonitored call is not posted at each monitored telephone
or included in the facility handbook (Deficiency TA-8). Detainees are provided with the option
of using a private room for legal calls, but the availability of this option is not provided in the
facility handbook. Detainee calls to a court, a legal representative, or for the purposes of
obtaining legal representation are monitored by the facility (Deficiency TA-9).

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the 2000 NDS, Telephone Access, section (III)(B), the FOD must ensure,
“As described in the “General Provisions” standard, the facility shall provide telephone access
rules in writing to each detainee upon admittance, and also shall post these rules where detainees
may easily see them.”
DEFICIENCY TA-2
In accordance with the 2000 NDS, Telephone Access, section (III)(F), the FOD must ensure,
“The facility shall not restrict the number of calls a detainee places to his/her legal
representatives, nor limit the duration of such calls by rule or automatic cut-off, unless necessary
for security purposes or to maintain orderly and fair access to telephones. If time limits are
necessary for such calls, they shall be no shorter than 20 minutes, and the detainee shall be
allowed to continue the call if desired, at the first available opportunity.”
DEFICIENCY TA-3
In accordance with the 2000 NDS, Telephone Access, section (III)(H), the FOD must ensure,
“Upon a detainee’s request, the facility shall make special arrangements permitting the detainee
to speak by telephone with an immediate family member detained in another facility.”
DEFICIENCY TA-4
In accordance with the 2000 NDS, Telephone Access, section (III)(H), the FOD must ensure,
“The facility shall liberally grant requests for inter-facility family calls to discuss legal matters.”
DEFICIENCY TA-5
In accordance with the 2000 NDS, Telephone Access, section (III)(J), the FOD must ensure,
“Facility staff shall not electronically monitor detainee telephone calls on their legal matters,
absent a court order.”
DEFICIENCY TA-6
In accordance with the 2000 NDS, Telephone Access, section (III)(K), the FOD must ensure,
“The facility shall have a written policy on the monitoring of detainee telephone calls.”
DEFICIENCY TA-7
In accordance with the 2000 NDS, Telephone Access, section (III)(K), the FOD must ensure, “If
telephone calls are monitored, the facility shall notify detainees in the detainee handbook or
equivalent provided upon admission.”
DEFICIENCY TA-8
In accordance with the 2000 NDS, Telephone Access, section (III)(K)(2), the FOD must ensure,
“It shall also place a notice at each monitored telephone stating: the procedure for obtaining an
unmonitored call to a court, legal representative, or for the purposes of obtaining legal
representation.”

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DEFICIENCY TA-9
In accordance with the 2000 NDS, Telephone Access, section (III)(K), the FOD must ensure, “A
detainee’s call to a court, a legal representative, or for the purposes of obtaining legal
representation will not be aurally monitored absent a court order.”

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USE OF FORCE (UOF)
ODO reviewed the Use of Force standard at MCCF to determine if necessary use of force is
utilized only after all reasonable efforts have been exhausted to gain control of a subject, while
protecting and ensuring the safety of detainees, staff and others, preventing serious property
damage, and ensuring the security and orderly operation of the facility, in accordance with the
ICE NDS. ODO toured the facility, interviewed the use-of-force instructor, examined use-offorce incident files, and reviewed the facility policy and training records.
The use-of-force policy addresses requirements in the NDS, including confrontation avoidance
and using force only as a last resort. Staff is not trained in the technique and necessary
protective gear is not available (Deficiency UOF-1). Staff stated they may call for a special
operations response team from facilities within the state of Ohio correctional system; however,
the nearest facility is approximately 17 miles away and no mutual aid agreements were on file.
The facility does not have a handheld video camera to record calculated use-of-force incidents
(Deficiency UOF-2). There are security cameras positioned throughout the facility; however,
the cameras are not a substitute for a handheld camera due to the limited range and the fact there
is no audio. In addition, the video from security cameras is retained only when criminal charges
are filed; otherwise, there is no video record of use-of-force incidents.
Detention officers attend a 142 hour corrections academy and upon completion, are certified by
the state of Ohio. Included in the academy training are modules on communication techniques,
cultural diversity and dealing with the mentally ill, as well as self-defense and the application of
restraints. All staff must attend refresher training in defensive tactics annually. Once assigned,
officers may elect to carry oleoresin capsicum (OC) spray in a canister on their duty belt. To do
so, they must be initially certified and recertified every year. The training records of the (b)(7)e
staff that carry OC spray were reviewed and documentation of current certification was present.
The OC spray instructor was interviewed and produced the curriculum used for this training. In
the year preceding the inspection, there were no incidents involving the use of OC spray on a
detainee. No other intermediate weapons such as batons or tasers are used.
There were three use-of-force incidents in the year preceding the inspection. Each involved use
of immediate force and review of documentation confirmed none called for application of
calculated use of force techniques.
In the first case, a detainee pushed past an officer to exit a booking cell. Staff used verbal
commands and pressure point controls to gain control of the detainee and return him to his cell.
In the second case, a detainee attempted suicide by hanging and was placed in a restraint chair
after evaluation by medical staff. Documentation reflects he was checked every ten minutes, and
his blood pressure and heart rate were checked hourly. The detainee was placed on suicide
watch thereafter.

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The third case involved a detainee who refused to move to another housing unit when ordered
and threatened staff. The detainee was directed to the wall, handcuffed and escorted to a cell in
the booking area.
The files of the three incidents contained detailed incident reports from all staff involved. The
facility policy requires examination by medical personnel as soon as possible after a use-of-force
incident, but there was no documentation of medical evaluation following two of the three useof-force incidents (Deficiency UOF-3).
Facility policy requires use-of-force incidents be investigated and evaluated by a supervisor
within 24 hours. Although facility staff stated supervisors regularly review each incident, there
was no documentation of after -action reviews to assess the reasonableness of actions taken in
two of the three use-of-force incident files (Deficiency UOF-4).
Any use-of-force incident involving a detainee is reported by telephone to the SIEA. The SIEA
was interviewed and confirmed he is notified by telephone when force is used on a detainee and
receives the written reports when available. No grievances were filed in the year preceding the
inspection regarding the use of force.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF-1
In accordance with the ICE NDS, Use of Force, section (III)(A)(4), the FOD must ensure,
“When a detainee must be forcibly moved and/or restrained during a calculated use of force, the
use-of-force team technique shall apply.”
DEFICIENCY UOF-2
In accordance with the ICE NDS, Use of Force, section (III)(J)(3), the FOD must ensure, “Staff
shall immediately obtain and record with a video camera any use-of force incident, unless such a
delay in bringing the situation under control would constitute a serious hazard to the detainee,
staff, or others, or would result in a major disturbance or serious property damage.”
DEFICIENCY UOF-3
In accordance with the ICE NDS, Use of Force, section (III)(G)(2), the FOD must ensure, “After
any use of force or forcible application of restraints, medical personnel shall examine the
detainee, immediately treating any injuries. The medical services provided shall be
documented.”
DEFICIENCY UOF-4
In accordance with the ICE NDS, Use of Force, section (III)(K), the FOD must ensure, “Written
procedures shall govern the use-of-force incident review, whether calculated or immediate, and
the application of restraints. The review is to assess the reasonableness of the actions taken
(force proportional to the detainee's actions), etc. IGSA will pattern their incident review process
after INS. INS shall review and approve all After Action Review procedures.”

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