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
Boston Field Office
Plymouth County Correctional Facility
Plymouth, Massachusetts

November 27 – 29, 2012

COMPLIANCE INSPECTION
PLYMOUTH COUNTY CORRECTIONAL FACILITY
BOSTON FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................6
Inspection Team Members ...................................................................................................6
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................7
Detainee Relations ...............................................................................................................7
ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................8
Access to Legal Material .....................................................................................................9
Environmental Health and Safety ......................................................................................11
Medical Care ......................................................................................................................13
Recreation .........................................................................................................................16
Terminal Illness, Advanced Directives and Death ............................................................17

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the Plymouth County Correctional Facility (PCCF)
in Plymouth, Massachusetts, from November 27 to 29, 2012. The facility opened in May, 1994,
and began housing inmates from the State of Massachusetts, the County of Plymouth, and the
U.S. Marshals Service (USMS). In June 1998, U.S. Immigration and Customs
Enforcement (ICE) began housing ICE detainees at PCCF. The 1,800-bed, 364,995 square foot
facility is owned by the Commonwealth of Massachusetts, and operated by the Plymouth County
Sheriff’s Department. Of the 1,800 beds, 430 are designated for ICE male detainees. There are
no female detainees held at the facility.
The ICE Office of Enforcement and Removal Operations (ERO) houses detainees at PCCF under
an intergovernmental service agreement. PCCF houses male ICE detainees using four
classification levels, Level 1 (low, non-violent), Level 2L (medium low, no history of violence,
assault, or combativeness), Level 2H (medium-high, documented histories of violence, assault,
or combativeness), and Level 3 (high, violent history) for over 72 hours. The average daily
detainee population is 302, and the average length of stay for detainees is 48 days. At the time of
this CI, the facility housed 300 male ICE detainees 62 Level 1, 37 Level 2L, 42 Level 2H, and
159 Level 3. The facility is accredited by the American Correctional Association through 2014.
The ERO Field Office Director, Boston, Massachusetts (ERO Boston) is responsible for ensuring
facility compliance with ICE policies and the ICE National Detention Standards (NDS). There
are (b)(7)eERO officers stationed at the facility: an Immigration Enforcement Agent (IEA) serving
as the jail liaison, and a Supervisory Detention and Deportation Officer (SDDO) from ERO
Boston. Both officers are responsible for oversight of all ICE detention matters at PCCF. There
is a Detention Services Manager assigned to monitor facility compliance with the NDS at PCCF.
The facility Superintendent is the highest ranking official at the facility, and is responsible for
oversight of daily operations. In addition to the Superintendent, there are(b)(7)esecurity staff
members consisting of a Deputy Superintendent, Assistant Deputy Superintendents, shift
commanders, captains, lieutenants, sergeants, and correctional officers. There are (b)(7)esupport
staff members at PCCF consisting of program directors and educational supervisors, case
managers, facilities management, and clerical staff.
The last ODO Quality Assurance Review was conducted in September 2009, during which 42
deficiencies were identified. An ODO Follow-up Inspection was conducted in September 2010
to determine the corrective actions taken for the deficiencies identified in the Quality Assurance
Review Report. During the Follow-up Inspection, ODO staff found four (10 percent) repeated
deficiencies. ODO and ERO staff found corrective actions were taken on all deficiencies
revisited in the following standards: Access to Legal Material, Admission and Release,
Correspondence and Other Mail, Detention Files, Detainee Handbook, Food Service, Funds and
Personal Property, Hold Rooms in Detention Facilities, Key and Lock Control, Medical Care,
Special Management Unit, Suicide Prevention and Intervention, Tool Control, and Visitation.
Deficiencies revisited in the following standards were not corrected and were found by ODO,
along with ERO management at PCCF, to be noncompliant with the ICE NDS: Environmental
Health and Safety, Post Orders, Staff Detainee Communication, and Use of Force.
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In June 2012, ERO Detention Standards Compliance Unit contractor, The Nakamoto Group,
Inc., conducted an annual review of the NDS at PCCF. The facility received an overall rating of
“Acceptable,” and was found compliant with all 38 standards reviewed.
During this CI, ODO reviewed 21 NDS. Sixteen standards were determined to be fully
compliant. Eight deficiencies were identified in the following five standards: Access to Legal
Material (2 deficiencies), Environmental Health and Safety (2), Medical Care (2), Recreation (1),
Terminal Illness, Advanced Directives, and Death (1). One deficiency in Environmental Health
and Safety regarding the lack of a dedicated barbershop is a repeat deficiency from the
September 2009 Quality Assurance Review.
Overall, ODO found PCCF well-managed and in compliance with most of the standards
inspected. ODO observed sanitation at the facility to be at a high level. Many of the deficiencies
identified were minor with minimal impact to life-safety issues and the overall operational
readiness of the facility.
This report details all deficiencies and refers to the specific, relevant sections of the NDS. ERO
will be provided a copy of this report to assist in developing corrective actions to resolve the
eight identified deficiencies. These deficiencies were discussed with PCCF personnel on-site
during the inspection and during the closeout briefing conducted on November 29, 2012.
The grievance system at PCCF provides for both formal and informal grievances. PCCF staff
encourages detainees to resolve their grievances at the lowest level possible. At the time of the
CI, there were no unresolved grievances. The PCCF detainee grievance policy corresponds with
the language in the NDS and the grievance system allows for detainees to appeal decisions.
Appeals are reviewed by a grievance committee and the committee provides detainees with a
written decision within five days of receiving the appeal. The grievance coordinator overseas the
appeals process to ensure adherence to policy. ODO reviewed all 22 of the grievances filed
between August 2012 and November 2012. Nine of the grievances involved medical care, eight
related to clothing replacement, four concerned food service, and one related to telephone access.
All grievances reviewed were responded to within five days of being filed. A review of the
grievance log confirmed grievances are logged with all pertinent information including the
nature of the grievance and the date of resolution. Original copies of all grievances are
maintained for three years in a master grievance file, located in a file cabinet in the PCCF
booking area. The grievance coordinator maintains a handwritten grievance log to document and
track grievances filed by detainees. ODO confirmed there were no grievances related to officer
misconduct. Detainees interviewed stated they believe the grievance system is fair and functions
as described in the detainee handbook.
Facility staff informed ODO the facility has a program driven by the Prison Rape Elimination
Act to provide for analysis of the incidence and effects of prison rape, and to provide
information, resources, recommendations and funding to protect individuals from prison rape.
PCCF has a local policy, entitled Sexual Misconduct with Inmates. Information concerning the
policy is provided in the detainee handbook and included in the orientation video shown to
detainees upon initial entry into the facility. The information is available in both English and
Spanish in the handbook. All detainees sign an acknowledgement form indicating they are
aware of and received the information concerning sexual misconduct with inmates. The signed
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acknowledgement forms are kept in each detainee’s detention file. During the past 12 months,
there were no reported incidents of sexual misconduct at PCCF. Employees are responsible for
their conduct and ensuring their behavior conforms to the Sexual Misconduct policy. Each
employee, supervisor, and manager is required to fully cooperate in any investigation regarding
an allegation of sexual misconduct or abuse of inmates or detainees. All employees who have
witnessed prohibited conduct are required to report the conduct immediately, and a written report
detailing the incident must be also filed as soon as possible.
ICE personnel make scheduled and unscheduled weekly visits to the PCCF detainee housing
units to monitor living conditions and address detainee concerns. One IEA serves as the ICE
liaison to PCCF, and is on-site at the facility approximately three times per week. The IEA visits
each housing unit and conducts staff-detainee communication with the approximately
300 detainees during those three days. The IEA’s visitation schedule is posted in each housing
unit and his visits are documented by the facility. During an interview, the IEA stated his
workload is extremely heavy and he would not be able to handle any more than 300 detainees,
and he would likely be able to give the detainees more individualized attention if he had fewer to
attend to. Additionally, an SDDO conducts unscheduled visits to the facility and each housing
unit at least one day each week.
During the past 12 months, there was one calculated and three immediate use of force incidents
involving ICE detainees. Review of documentation in all four cases confirmed full compliance
with the standard and facility policy, including medical examinations of the detainees involved,
notifications to ICE, and after action reviews. PCCF’s Use of Force After-Action Review Report
summarizes actions taken during the incident, and identifies any areas of non-compliance with
policy or the standard, if applicable. Standing members of the After-Action Review Committee
are the Tactical Response Team (TRT) commander, shift commander, medical director, and
assistant facility superintendent.
At the time of the inspection there was one ICE detainee housed in disciplinary segregation
status. Review of documentation found the detainee was sanctioned with segregation for a
period of 13 days through the facility’s disciplinary process. Inspection of daily activity sheets
confirmed the detainee received privileges and services as required by the standard and facility
policy, including outdoor recreation. The unit logbook documented rounds by medical and
supervisory staff. There were three ICE detainees in administrative segregation during the
review. Review of documentation confirmed segregation orders were issued in all three cases.
In two cases, the detainees were assigned to administrative segregation pending disciplinary
hearings, and in the third case, the detainee was in protective custody. ODO confirmed status
reviews were conducted as required by the standard, and justification for continuation on
administrative segregation was documented. Inspection of daily activity sheets confirmed the
detainees received privileges and services as required by the standard and facility policy,
including recreation five times per week, and legal and social visitation. The unit logbook
documented daily rounds by medical, ICE and supervisory staff. ODO observed the Special
Management Units to be well-lit, temperature-appropriate, and clean.
The facility’s food service operation is managed by contractor Trinity Services Group. Staffing
consists of the food service administrator, assistant food service administrator, and a cook
foreman, supported by a crew of inmate workers. No ICE detainees work in food service. ODO
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update the list of stock medications. ODO supports this action, and recommends the facility use
the local pharmacy it has identified as its secondary supplier for medications not on the stock list.
There have been no detainee deaths at PCCF. ODO verified detainees are screened for suicide
risk during the intake process. Detainees on suicide watch are housed in one of five cells located
in the booking area, one of which is padded. Inspection confirmed the cells are suicideresistant, and free from any protrusions or objects that could assist in a suicide attempt. There
have been no suicides at PCCF. In the past year there have been 39 suicide watches and one
suicide attempt. Based on interviews with mental health staff, ODO determined placement on
watch results from pro-active and cautionary determination by mental health staff that a detainee
may be at risk for suicide. Review of three suicide watch records, including the detainee who
attempted suicide, confirmed practice is consistent with policy and in accordance with the NDS.
Review of facility policies confirmed they address terminal illness, advance directives, and Do
Not Resuscitate orders in compliance with the NDS. ODO notes the policy on detainee death
does not state the FBI and ICE Health Service Corps (IHSC) have the authority to order
autopsies.

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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, as applicable. The NDS apply to PCCF. In addition, ODO may focus its
inspection based on detention management information provided by ERO Headquarters and
ERO field offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at PCCF to determine compliance with current policies
and detention standards. Prior to the inspection, ODO collected and analyzed relevant
allegations and detainee information from multiple ICE databases, including the Joint Integrity
Case Management System, the ENFORCE Alien Booking Module, and the ENFORCE Alien
Removal Module. ODO also gathered facility facts and inspection-related information from
ERO Headquarters staff to prepare for the site visit at PCCF.

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 of the standard. ODO reports convey information to best enable prompt corrective
actions and to assist in the on-going process of incorporating best practices in nationwide
detention facility operations.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
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

Management & Program Analyst (Team Leader)
Special Agent
Management & Program Analyst
Contract Inspector
Contract Inspector
Contract Inspector

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

Plymouth County Correctional Facility
ERO Boston

OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the PCCF Superintendent, the administrative lieutenant, an ERO Deputy Field
Office Director, Assistant Field Office Director, an SDDO, and an IEA. During the interviews,
all personnel from PCCF and ERO stated the working relationship between PCCF and ERO
personnel is good, and morale among PCCF and ERO staff is high. The assistant deputy
superintendent stated he has consistently observed the IEA visiting the housing units each day,
and communicating with ICE detainees to address their issues and concerns.
The SDDO and the Deportation Officer both stated ERO is adequately staffed to manage and
handle the current detainee population at PCCF. ERO management staff stated whenever the
ICE detainee population gets above 300, an additional IEA is sent to PCCF to assist in the
management of detainees. The assistant deputy superintendent stated there are currently
(b)(7)e vacancies in the security area, and(b)(7)e in support.
correctional officer candidates
(b)(7)e
were in training in the Plymouth County Training Academy during the time of the review.

DETAINEE RELATIONS
ODO randomly interviewed four Level 1 detainees, four Level 2L detainees, four Level 2H
detainees, and six Level 3 detainees at PCCF, for a total of 18 detainee interviews. The periods
of detention for these 18 detainees ranged from four days to four months. There were no
detainee complaints regarding medical care, recreation, access to telephones, religious services,
grievances, or visitation. All detainees confirmed they were provided a full supply of personal
hygiene items upon admission to the facility, and they have all maintained a full supply of these
items for the duration of their stay. Sixteen detainees stated they received an ICE National
Detainee and a local handbook, and two detainees stated they did not receive the ICE National
Detainee Handbook. ODO reviewed the detention file of the two detainees and verified they
signed the intake form acknowledging receipt of the ICE handbook.
The detainees knew the name of their Deportation Officers, but had never met them. The
detainees had contact numbers, but stated that whenever they would call, no one answered the
telephone. All detainees stated an IEA visits the units on a daily basis to discuss issues and
concerns. All stated they were satisfied with the quality of the food and the food service. ODO
verified that a registered dietician certifies the caloric and nutritional content of all meals. Food
portions met all dietary and nutritional requirements.
All detainees stated they were routinely strip searched by facility personnel each time they
returned from contact visits. ODO confirmed PCCF officials were conducting documented strip
searches of detainees in accordance with facility policy by reviewing the record of search
documentation maintained in the detention file. PCCF management stated they are aware of the
requirements under the Change Notice, which requires that each strip search, and the reasonable
suspicion justifying each strip search, be documented.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 21 NDS and found PCCF fully compliant with the following
16 standards:
Admission and Release
Detainee Grievance Procedures
Detainee Handbook1
Disciplinary Policy
Food Services
Funds and Personal Property
Hold Rooms in Detention Facilities
Hunger Strikes
Religious Practices
Special Management Unit – Administrative Segregation
Special Management Unit – Disciplinary Segregation
Staff-Detainee Communication
Suicide Prevention and Intervention
Telephone Access
Use of Force
Visitation
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 five standards:
Access to Legal Material
Environmental Health and Safety
Medical Care
Recreation
Terminal Illness, Advanced Directives, and Death
Findings for each of these standards are presented in the remainder of this report.

1

Deficiencies relating to omissions from the detainee handbook are noted under the relevant NDS that requires the
information. See Access to Legal Material (Deficiency ALM-1 and ALM-2).
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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at PCCF to determine if detainees have
access to a law library, legal materials, courts, counsel, and document copying equipment to
facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO
interviewed detainees and staff, reviewed policies and the facility’s local detainee handbook,
reviewed law library usage logs, and toured the areas used as law libraries.
PCCF provides a designated room within each housing unit for use as a law library. These
rooms have sufficient space to facilitate detainees’ legal research and writing, and are large
enough to provide reasonable access to all detainees who request to use the law library. Each
law library provides one operating computer, which contains updated Lexis-Nexis CD-ROM
legal materials. These materials are updated quarterly, with the most recent update occurring on
October 12, 2012. PCCF inspects the computers in each law library at least weekly to ensure
they are in good working order. PCCF allows detainees to have access to the law libraries at
least five hours per week as required by the NDS. All required law library supplies, including
paper and writing implements, are available to detainees upon request. Additionally, printing
and photocopies of legal documents are provided to detainees upon request by an on-site attorney
or paralegal. Finally, detainees may request legal materials not contained in the Lexis-Nexis or
BICE databases. These materials are provided by the attorney or paralegal at the facility.
The facility’s local detainee handbook does not notify detainees of the scheduled hours of access
to the law library, the procedure for requesting additional time in the law library, 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
(Deficiency ALM-1). Having these procedures listed in the detainee handbook facilitates and
promotes efficient use of the law library and its resources.
The facility provides detainees a copy of the Political Asylum/Immigration Representation
Project’s Self-Help Manual for Immigration Detainees upon request. This manual identifies the
submitter and preparer of the material, and contains the date of preparation as required by the
NDS, but it does not clearly state that ICE did not prepare and is not responsible for the contents
of the material (Deficiency ALM-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1, DEFICIENCY ALM-2
In accordance with the ICE NDS, Access to Legal Material, section (III)(Q)(2-6), 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:
2. the scheduled hours of access to the law library;
3. the procedure for requesting access to the law library;
4. 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

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6. the procedure for notifying a designated employee that library material is missing or
damaged.
These policies and procedure shall also be posted in the law library along with a list of the law
library’s holdings.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at PCCF 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; reviewed policies; and examined documentation of inspections, hazardous
chemical management, generator testing, and fire drills.
ODO’s inspection confirmed all chemicals, flammables, and combustible materials are stored
and issued as required by the standard and local policy. Hazardous substances are strictly
controlled, and monthly fire drills are conducted for each shift. Staff were interviewed and
found to be knowledgeable concerning maintaining running inventories of stored chemicals and
flammable materials. The master index of hazardous substances and MSDS were up-to-date;
however, there was no documentation of semi-annual reviews (Deficiency EH&S-1). Facility
staff stated the index and MSDS are updated when a product is added or discontinued; however,
scheduled reviews of the full contents are not conducted. Semi-annual review assures the index
and MSDS are accurate and complete.
ODO found the overall sanitation level of the facility was good. Staff conducts weekly firesafety and sanitation inspections of the entire facility; daily sanitation inspections of the medical
department are completed every day by medical personnel. The facility’s fire prevention,
control, and evacuation plan, dated December 12, 2011, was reviewed and approved by the
Plymouth Fire Department. Review of documentation confirmed PCCF maintenance staff test
the facility’s two emergency electrical power generators bi-weekly for a period of one hour.
Preventive maintenance and servicing of the generators is performed by Milton Power Systems
Division, Milford, Massachusetts. ODO confirmed pest control services are provided, and the
water supply is tested in compliance with the standard.
PCCF does not have a dedicated barbershop with access to a lavatory with hot and cold running
water (Deficiency EH&S-2). This deficiency was cited during the September 2009 Quality
Assurance Review, and the ERO 2011 and 2012 annual inspections. Barbering is conducted in a
designated common area in the housing units. Hair care sanitation regulations are posted in the
area, and Barbicide disinfectant is available to sanitize hair care equipment. ODO was informed
the facility does not plan to create a dedicated barbering area due to costs associated with
plumbing.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD
must ensure the Maintenance Supervisor or designee 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.

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

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at PCCF to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE NDS. ODO toured the clinic, reviewed policies and procedures, reviewed medical staff
licenses, and interviewed health care and administrative staff. ODO examined 30 medical
records of detainees falling into the following categories: chronic care, listed on the sick call log
for November 21, 2012, complaints (summarized in another section of this report), hunger strike,
suicide watch, and random healthy. All records were spot-checked for sick call timeliness, and
reviewed for transfer documentation.
Healthcare is provided by employees of the Plymouth County Sheriff’s Office and under contract
with CPS. The clinic is open 24 hours a day, seven days a week. It is administered by the HSA,
who is a registered nurse and new in the position. ODO finds staffing adequate to provide basic
medical services for detainees. All professional licenses were present; however, (b)(7)e of(b)(7)
provider licenses had not been primary-source verified with the issuing state boards for
authentication purposes (Deficiency MC-1). The HSA completed primary-source verification of
these licenses during the inspection.
Jordan Hospital is used for emergency services and a higher level of medical care than can be
provided at the facility. Specialty cases are referred to Boston Medical Hospital. Detainees who
require inpatient mental health treatment are sent to Shattuck Hospital in Boston, Massachusetts.
The clinic contains two examination/treatment rooms, three medical observation cells including
two with negative air-flow for tuberculosis isolation, an X-ray room, a dental suite, a medical
records room, a secure medication room, a nurses’ station, a shower room, a mental health office,
(b)(7)e
a break room, a staff restroom, the HSA’s office, and the Assistant HSA’s office.
ODO found the clinic to be
(b)(7)e
adequately sized and equipped.
Nursing staff conduct routine intake screenings in which chronic care, mental health, and
medication needs are identified. While reviewing medical records, ODO found three cases
where medication needs identified at intake were not addressed in a timely manner
(Deficiency MC-2). In one case, nurses contacted the physician and received medication orders
for a diabetic detainee admitted on a Thursday evening. The orders were for a sliding scale
dosage of insulin to be determined based on the detainee’s current blood sugar readings;
however, the medical record documented the first blood sugar reading was not taken and the
detainee did not receive insulin until the following morning. In the other two cases, nurses
determined the detainees were on medication for hypertension, and promptly pursued and
received physician orders for medication Lisinopril. One of the detainees, admitted on a
Thursday evening, did not receive the medication until Saturday. There is no documentation the
second detainee, also admitted on a Thursday, ever received Lisinopril. Five days later the
detainee’s physical examination was conducted, and the order was changed to an alternative
hypertension medication. He received that medication the next day. During interview, the HSA
stated Lisinopril is not currently on the list of stock medications determined by their
pharmaceutical supplier, State Office of Pharmacy Services (SOPS). She stated SOPS will
supply as stock only the top 25 medications used in the facility. Since the HSA has only been in
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her position for one week, she did not know when the list of stock medications was last
reviewed. During the inspection, the HSA scheduled a meeting with the SOPS clinical
pharmacist to review and update the list of stock medications. ODO supports this action, and
recommends the facility use the local pharmacy it has identified as its secondary supplier for
medications not on the stock list.
Tuberculosis screening is accomplished by administration of a purified protein derivative (PPD)
skin test on admission. The medical record review determined compliance with this requirement
in all 30 medical records reviewed; however, ODO notes the follow-up chest X-ray for one
positive PPD was performed one day later than the maximum 72-hours recommended by the
Centers for Disease Control. The HSA stated she will review the contract with the X-ray
company, and assure it provides as-needed services in addition to the usual two days per week
schedule. Physical examinations are completed by a provider between one and 14 days after
arrival. Full compliance with the physical examination requirements of the standard was
supported by the medical record review in all 30 cases.
Detainees access health care services by completing a sick call request available in English,
Spanish, and Portuguese. Observation confirmed forms are available in each housing unit and
deposited directly into a locked box mounted on the wall. Nursing staff retrieve and triage the
requests for clinical priority on a daily basis. Detainees housed in segregation use the same
procedure, and are also seen face-to-face during daily nursing rounds. Nursing staff conduct sick
call seven days a week using physician-approved protocols. Examination rooms in the housing
unit are used for sick call and provide for privacy. ODO verified follow-up appointments and
referrals were completed as required. PCCF does not charge detainees co-pays.
ODO recognizes as a best practice PCCF’s “Chronic Disease Treatment Planning” form. The
form is formatted to support comprehensive treatment planning and monitoring of the particular
chronic condition, and is designed to address such strategies as diet, exercise, medication, labtesting, and short and long term goals. The form is included in the medical record of detainees
with chronic conditions.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(C), the FOD must ensure the health
care staff will have a valid professional licensure and or certification. The USPHS,
Division of Immigration Health Services, will be consulted to determine the appropriate
credentials requirements for health care providers.
In accordance with IHS Policy 4.3.1.1, each licensed independent practitioner portfolio must
contain, at a minimum, written evidence the professional licensure or certification (all current,
past, active, and inactive) have been verified at the primary source.
DEFICIENCY MC-2
In accordance with the ICE NDS, Medical Care, section (III)(I), the FOD must ensure
distribution of medication will be according to the specific instructions and procedures

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established by the health care provider. Officers will keep written records of all medication
given to detainees.

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RECREATION (R)
ODO reviewed the Recreation standard at the PCCF to determine if detainees are provided
access to recreational programs and activities within the constraints of a safe and secure
environment, in accordance with the ICE NDS. ODO interviewed detainees and staff, toured the
indoor and outdoor recreation areas, and reviewed recreation logs.
PCCF employs a full-time recreation specialist who is responsible for the development and
oversight of the recreation program at the facility. Detainees may watch television in housing
unit dayrooms, but do not have access to board games or other sedentary activities
(Deficiency R-1). The recreation specialist indicated that PCCF management recently decided
to eliminate all board games from the facility, and card games and dominoes were on order to
replace them.
Weather-permitting, detainees in each housing unit also have access to a fenced-in outdoor
recreation area, which adjoins the housing unit. Access to the area is permitted without
restriction whenever detainees are in the housing unit dayrooms. Additionally, twice per week,
detainees are permitted to use an indoor gymnasium for one hour at a time. The gymnasium
contains basketball and soccer equipment, as well as medicine balls and jump ropes. Detainees
are permitted to participate in supervised limited-contact games of soccer and basketball inside
the gymnasium. The schedule for gymnasium use is posted in each housing unit.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY R-1
In accordance with the ICE NDS, Recreation, section (III)(G)(3), the FOD must ensure
dayrooms in general-population housing units will offer board games, television, and other
sedentary activities.

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TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (TIADD)
ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not
Resuscitate orders and organ donations, at PCCF to determine if the facility’s policies and
practices are in accordance with the ICE NDS. ODO interviewed medical staff, and reviewed
policies and procedures.
There have been no detainee deaths at PCCF. Review of facility policies confirmed they address
terminal illness, advance directives, and Do Not Resuscitate orders in compliance with the NDS.
ODO notes the policy on detainee deaths does not state the FBI and ICE Health Service Corps
have the authority to order autopsies (Deficiency TIADD-1). ODO recommends policy revision
to support compliance with the standard.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TIADD-1
In accordance with the ICE NDS, Terminal Illness, Advanced Directives, and Death,
section (III)(J), the FOD must ensure, with the Chaplain's assistance, the OIC shall develop and
implement written procedures for making autopsy arrangements, including: contacting the local
coroner; scheduling the autopsy; identifying the person who will perform the autopsy; obtaining
the official death certificate, and transporting the body to the coroner’s office.
The FBI, local coroner, or the USPHS may order an autopsy and related scientific or medical
tests to be performed in cases involving homicide, suicide, fatal illness or accident, or
unexplained death.
DIHS may order an autopsy or post-mortem operation for other cases, with the written consent of
a person authorized under State law to give such consent (e.g., the coroner, next-of-kin, or, to
authorize a tissue transfer, the deceased him/herself.

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