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
Saint Clair County Jail
Port Huron, MI

November 4–6, 2014

COMPLIANCE INSPECTION
SAINT CLAIR COUNTY JAIL
DETROIT FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................2
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................8
ICE 2008 PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................9
Admission and Release ......................................................................................................10
Detainee Handbook ............................................................................................................11
Disciplinary System ...........................................................................................................12
Food Service ......................................................................................................................14
Funds and Personal Property .............................................................................................16
Grievance System ..............................................................................................................17
Law Libraries and Legal Material......................................................................................19
Medical Care ......................................................................................................................21
Sexual Abuse and Assault Prevention and Intervention ....................................................29
Staff-Detainee Communication .........................................................................................31
Suicide Prevention and Intervention ..................................................................................32
Special Management Units ................................................................................................33

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

Inspections & Compliance Specialist (Team Lead)
Inspections & Compliance Specialist
Contractor
Contractor
Contractor
Contractor

Office of Detention Oversight
November 2014
OPR 201406911

1

ODO
ODO
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections
Saint Clair County Jail
ERO Detroit

EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Saint Clair County Jail (SCCJ) in Port Huron,
Michigan from November 4 to 6, 2014. SCCJ, which opened in 2005, is owned by Saint Clair
County and operated by the Saint Clair County Sheriff’s Office. ERO began housing detainees
at SCCJ in 2007 under an Intergovernmental Service Agreement. Male and female detainees of
security classification levels I through VIII are detained at the facility for periods in excess of 72
hours. The inspection evaluated
SSCJ’s compliance with the 2008
Capacity and Population Statistics
Quantity
PBNDS.
The ERO Field Office
Director (FOD), in Port Huron,
Michigan, is responsible for ensuring
facility compliance with the 2008
PBNDS and ICE policies. One ICE
employee is located at SCCJ. There
is no ERO Detention Service
Manager (DSM) assigned to SCCJ.

Total Bed Capacity

491

ICE Detainee Bed Capacity

100

Average Daily Population

469

Average ICE Detainee Population

54

Average Length of Stay (Days)

30

Male Detainee Population (as of 11/4/14)

64

Female Detainee Population (as of 11/4/14)

3

A Sheriff is responsible for oversight of daily facility operations and is supported by (b)(7)e
personnel. Aramark provides food services and Mercy Hospital provides medical services. The
facility holds no accreditations.
This inspection represented ODO’s first visit to SCCJ. During this inspection ODO reviewed 15
PBNDS and found SCCJ compliant with three standards. ODO found a total of 31 deficiencies,
15 of which relate to priority components, 1 in the remaining 12 standards: Admission and
Release (1 deficiency), Detainee Handbook (1), Disciplinary System (3), Food Service (1),
Funds and Personal Property (1), Grievances System (3), Law Libraries and Legal Material (2),
Medical Care (11), Sexual Abuse and Assault Prevention and Intervention (2), Staff-Detainee
Communication (2), Suicide Prevention and Intervention (1), and Special Management Units (3).
ODO made one recommendation regarding facility training. 2
This report details all deficiencies and refers to the specific, relevant sections of the 2008
PBNDS. 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 SCCJ and ERO
management during the inspection and at a closeout briefing conducted on November 6, 2014.
The admission process for detainees entering SCCJ consists of screening interviews; completing
questionnaires; and issuing detainees personal hygiene items, clothing, towels, and bedding.
Detailed medical, dental, mental health and sexual abuse history screenings are performed at the
intake area. English and Spanish versions of the SCCJ facility handbook and the ICE National
Detainee Handbook are provided to all newly arriving detainees. Facility policy states strip1

Deficient priority components were found in the following seven standards: Disciplinary System (1), Grievance
System (1), Law Libraries and Legal Material (1), Medical Care (8), Sexual Abuse and Assault Prevention and
Intervention (2), Staff-Detainee Communication (1) and Suicide Prevention and Intervention (1).
2
Recommendations are annotated in this report as “R.”

Office of Detention Oversight
November 2014
OPR 201406911

2

Saint Clair County Jail
ERO Detroit

searches will be conducted only if there is reasonable suspicion that a detainee is concealing
contraband. However, ODO observed a new detainee being strip searched without reasonable
suspicion, and the search was not documented. An SCCJ lieutenant stated strip searches do not
occur without reasonable suspicion, but officers interviewed by ODO reported strip searches are
conducted on a routine basis.
SCCJ uses the North Pointe/Compas Classification system and JICS software for managing and
separating detainees based on verifiable and documented data. This system assigns detainees to
one of eight classification levels with level one being the highest threat level. SCCJ has a
comprehensive policy addressing classification of detainees. Detainees are classified upon
admission and prior to assignment to a housing unit. Detainees may request a review of their
classification level within ten days of primary classification or reclassification. A review of 20
detention files confirmed all necessary documentation supporting proper assignment of
classification levels was present. A review of the facility grievance log and interviews with
classification staff found there have been no appeals or grievances regarding classification
matters.
SCCJ’s disciplinary system is fully addressed in facility policy and includes progressive levels of
review and appeal procedures. The written hearing records included only notation of the
sanctions imposed. Documentation reflects the detainees were provided with written notification
of the findings and sanctions; however, they were not provided with the reason for the findings.
This represents a deficient priority component. ODO reviewed ten randomly selected detainee
files and found a disciplinary action which had been dismissed was still in the detainee’s file.
The facility initiated corrective action during the course of the inspection. A review of SCCJ
policy and staff interviews confirmed detainees in disciplinary segregation are only allowed to
have a mattress between the hours of 9:00 p.m. and 6:00 a.m. Every day at 6:00 a.m., mattresses
are confiscated by staff and stored until 9:00 p.m. This represents a deficient priority component.
During the course of the inspection, the facility initiated corrective action through issuance of a
memorandum ordering that this practice be discontinued.
SCCJ has written policies and procedures which provide for the control and safeguarding of
detainees’ funds and personal property. Detainees are issued the SCCJ handbook and the ICE
National Detainee Handbook during the intake process. The facility handbook does not provide
information on the policies and procedures for obtaining certified copies of identity documents
and procedures for the medical grievance process. Also there was no procedure for requesting
interpretive services for essential communication.
SCCJ has a mobile law library, consisting of two rolling carts, each equipped with a computer
and keyboard. The same law library privileges are afforded to detainees in special management
units; however, the facility does not inspect the equipment weekly. This represents a deficient
priority component. Also the facility handbook does not contain information notifying detainees
of the procedure for requesting legal reference materials or the procedure for notifying a
designated employee that library material is missing or damaged.
ODO confirmed detainees have reasonable and equitable access to telephones at SCCJ. There
are two phones in each of the 22-bed housing units, two phones in each of the 20-bed housing
units, and two phones in the 16-bed special management unit. The intake area has eight phones
Office of Detention Oversight
November 2014
OPR 201406911

3

Saint Clair County Jail
ERO Detroit

for use by detainees during the admissions process. Telephone access rules are also described in
the facility handbook, and were posted in English and Spanish at each telephone location.
During initial processing, detainees are given their own copy of the speed dial listing for the
Department of Homeland Security Office of Inspector General and various consulates and
embassies, along with pro-bono legal services. ODO conducted a serviceability check of all
phones in detainee housing areas and intake, and confirmed all were in good working order. A
review of telephone serviceability worksheets for the past year confirmed ICE staff conducted
weekly inspections. SCCJ staff also conducts weekly serviceability checks of all telephones.
A review of the facility’s policy and procedures found detainees are able to file formal
grievances, including medical and emergency grievances; and receive written responses,
including the basis for the decision, in a timely manner. The facility handbook does not provide
detainees notice of: how complaints and grievances should be handled orally and informally by
staff in their daily interaction with detainees; that the detainee always has the right to file a
formal grievance and pursue the formal process; the right to file a grievance both informally and
formally; the process for filing emergency grievances; and the procedures for contacting ICE to
appeal a decision of the facility. The facility initiated corrective action by updating the
handbook to include this information.
While SCCJ routinely resolves detainee grievances orally and informally at the lowest level
possible, the results are not documented in the detainee’s detention file or in a log. Facility staff
stated that while copies of grievance dispositions are provided to detainees, copies are not placed
in detention files. This represents a deficient priority component.
Food service at SCCJ is provided by the contractor, Aramark Correctional Services. Staff
includes a food service director and (b)(7)e food service supervisors, supported by a crew of (b)(7)e
county inmate workers. ODO checked the sack meals provided to detainees being transported.
The meal included two non-pork meat sandwiches and a fruit item. The meal did not include a
dessert item or extra item such as packaged fresh vegetables or a packaged snack food.
ERO staff makes scheduled and unscheduled visits on a regular basis. Detainees can request an
envelope and submit ICE request forms to SCCJ staff members, but there is no secure drop box
for detainees to correspond directly with ICE management. This represents a deficient priority
component. The facility initiated corrective action during the course of the inspection. ODO
confirmed the log contained the date of receipt; detainee’s name, A-number, the date the request
was returned to the detainee; and other pertinent information. However, the log did not contain a
box area on the log form for the nationality and the name of the staff member who logged the
request. Prior to completion of the inspection, the facility initiated corrective action.
Medical care has been provided under contract with St. Joseph Mercy Port Huron Hospital
(SJMPHH) since December 2013. A registered nurse (RN), who holds the title of nurse
coordinator, is responsible for administrative oversight of clinic operations. Nursing coverage is
provided 24 hours a day, seven days a week. Mental health services are provided under a
separate contract with the Saint Clair County Community Mental Health Authority. A mental
health nurse practitioner, mental health social worker, and a counselor provide a combined total
of 40 hours on site per week. Dental services are provided at Dental Clinic of Port Huron.

Office of Detention Oversight
November 2014
OPR 201406911

4

Saint Clair County Jail
ERO Detroit

Emergency medical services are provided by Tri-Hospital ambulance service, with a response
time of about ten minutes.
A review of training logs and(b)(7)erandomly selected training files confirmed officers received
training during their initial orientation; however, the training syllabus was not available for
ODO’s review, nor was it available for officers’ reference as required by the standard. SCCJ
does not include all health-related inquiries required by the standard; specifically, observation of
detainee behaviors, identification of high risk behaviors for HIV infection and other blood-borne
pathogens, past medications, past surgical procedures, homicidal tendencies, and past suicide
attempts. It was also found in five cases that sections of the form were not completed. This
represents a deficient priority component. The facility initiated corrective action during the
course of the inspection. ODO’s review also found the medical director did not co-sign any of
the intake screenings, nor did any other medical professional. This represents a deficient priority
component. A review of SCCJ’s infection control plan found it did not address all components
mandated by the standard; specifically, it did not address ICE notification procedures, protection
of confidentiality, media relations, and management of biohazard waste. This represents a
deficient priority component.
The physical examinations were all performed within 14 days of the detainees’ arrival and the
physician co-signed the examinations conducted by the RN. However, the medical director did
not record the date of his review; therefore, it could not be verified the process was completed
within 14 days. This represents a deficient priority component. The mental health social worker
reported assessments are completed within three days for routine referrals, and within 24 hours
for urgent and emergent cases. Review of the medical records of two detainees receiving mental
health treatment confirmed adherence to these timeframes. ODO noted the absence of
comprehensive mental health assessments and treatment plans in the records. This represents a
deficient priority component.
All medications arrive in unit dose packaging, which are inventoried and placed in locked
medication carts. ODO’s review of the facility’s pharmacy plan found it did not address all
components required by PBNDS, including prescription practices, procurement, and inventory
and disposal of all prescription and non-prescription pharmaceuticals. This represents a deficient
priority component. The facility initiated corrective action during the course of the inspection.
ODO found no evidence health education and wellness education materials are issued to
detainees. This determination was based on review of orientation materials, tour of the housing
units, the intake area and medical clinic, and inspection of medical files. The nurse coordinator
stated she plans to obtain free pamphlets from various on-line sources.
The medical record review found signed consent for treatment forms were not included in any of
the 30 medical records reviewed. The record review also found two detainees receiving
psychotropic medication had not signed consent specific to the medications given. This
represents a deficient priority component. As a corrective action, the facility added blanket
consent statements to the intake screening form.
Documentation was produced reflecting meetings involving the nurse coordinator, SJMPHH vice
president of operations/chief nursing officer, the medical director, a mental health professional,
Office of Detention Oversight
November 2014
OPR 201406911

5

Saint Clair County Jail
ERO Detroit

and jail administrators are held on a monthly basis. However, there was no documentation of
meetings for one quarter of 2014, May 29, 2014 to September 25, 2014. While the minutes
reflected the meetings included discussion of problem resolution, a formal quality assurance
program has not been established to identify standard discrepancies, establish corrective action,
and monitor program improvements as required in the standard. This represents a deficient
priority component.
SCCJ has a 16 bed Special Management Unit (SMU). There is a separate shower area located
off the dayroom and an adjacent outdoor recreation area. Inspection found the unit was well
ventilated, adequately lit, appropriately heated, and maintained in a sanitary condition. At the
time of the inspection, two detainees were serving disciplinary segregation sanctions in the
SMU. While touring the unit, ODO observed the detainees did not have mattresses in their cells.
A review of SCCJ’s policy found it states detainees in disciplinary segregation are allowed to
have a mattress only between the hours of 9:00 pm and 6:00 am. The facility handbook states
that following completion of a sanction for minor, major, or serious rule violations, the housing
sergeant will determine whether the detainee’s behavior has improved sufficiently to be returned
to less restrictive housing. Because the sanction is complete when the review is conducted, this
language implies the sergeant has the authority to lengthen the sanction imposed through the
disciplinary process. Prior to the completion of the inspection, the facility removed the passage
from the handbook. Status reviews were conducted as required; however, in eight of nine cases,
the date and time of release and the authorizing staff member were not documented.
There were no detainees on suicide watch at the time of the inspection. A review of (b)(7)e
randomly selected officers’ training records found documentation of training in suicide
prevention and intervention upon hire; however, the officers did not receive annual training. The
most recent refresher training was provided in February 2013. This represents a deficient
priority component.
The facility and ERO have not received any reports of sexual abuse or assault within the 12
months preceding the inspection. A sergeant is the designated PREA Coordinator of the facility,
and another sergeant is the PREA Compliance Manager. ODO reviewed staff training materials
and found training did not include: recognition of situations where sexual abuse or assault may
occur; recognition of the physical, behavioral, and emotional signs of sexual abuse or assault and
ways to prevent such occurrences; or prevention, recognition, and appropriate response to
allegations or suspicions of sexual assault involving detainees with mental or physical
disabilities. This represents a deficient priority component.
The facility screens detainees during intake for possible victimization and predatory factors.
ODO reviewed the facility handbook and orientation and found it does not include prevention
and intervention strategies or information about self-protection and indicators of sexual abuse.
This represents a deficient priority component.
The SCCJ policy on use of force states only the minimum amount of force necessary to
overcome the resistance offered will be used. The policy also requires use of verbal deescalation skills and other methods first, and use of physical force only as a last resort.

Office of Detention Oversight
November 2014
OPR 201406911

6

Saint Clair County Jail
ERO Detroit

SCCJ authorizes use of tasers and oleoresin capsicum (OC) spray by supervisors within the
facility, and by officers while on transportation duty. ODO’s review of training records for (b)(7)e
randomly selected officers confirmed current training in tasers and OC, as well as completion of
initial and annual use of force training. Tasers are stored in a locked cabinet in the supervisor’s
office and review of the sign out log confirmed issuance is documented.

Office of Detention Oversight
November 2014
OPR 201406911

7

Saint Clair County Jail
ERO Detroit

OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 25 randomly-selected detainees (22 males and three females); ranging from
three days to approximately one year at the facility, to assess the conditions of confinement at
SCCJ. Two detainees were interviewed using interpreters via the language line.
Interview participation was voluntary and none of the detainees reported having witnessed or
experienced any mistreatment, discrimination, or abuse (physical, verbal or sexual) while at
SCCJ. All detainees observed seeing ICE staff in the housing units at least twice a week. They
also confirmed receiving the ICE National Detainee Handbook and the SCCJ facility handbook.
All had access to recreation, religious services and the law library. The majority of detainees
reported being satisfied with facility services, with the exception of a few complaints about
medical/dental and food service.
Medical Care: A few detainees had complaints regarding dental care. Those three detainees
expressing inadequate care for dental problems were referred to the medical care consultant who
followed up with the facility, and all were seen promptly pursuant to their sick call slips. Motrin
was ordered for all three, and one was also placed on an antibiotic. SCCJ currently has a
partnership with the Dental Clinic of Port Huron to treat the detainees, if needed.
Food Service: One of the detainees on a religious diet complained about receiving the same
kosher meal every day, without any change in food. ODO looked into the issue and found that
the facility has six different kosher meals available and the meals are rotated daily.

Office of Detention Oversight
November 2014
OPR 201406911

8

Saint Clair County Jail
ERO Detroit

ICE 2008 PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 15 PBNDS and found SCCJ fully compliant with the following
three standards:
1. Classification System
2. Telephone Access
3. Use of Force and Restraints
As the standards above were compliant at the time of the inspection, a synopsis for these
standards is not included in this report.
ODO found 31 deficiencies in the following 12 standards.
1. Admission and Release
2. Detainee Handbook
3. Disciplinary System
4. Food Service
5. Funds and Personal Property
6. Grievance System
7. Law Libraries and Legal Material
8. Medical Care
9. Sexual Abuse and Assault Prevention and Intervention
10. Staff-Detainee Communication
11. Suicide Prevention and Intervention
12. Special Management Units- Administrative and Disciplinary
Findings for these standards are presented in the remainder of this report.

Office of Detention Oversight
November 2014
OPR 201406911

9

Saint Clair County Jail
ERO Detroit

ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at SCCJ 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 2008 PBNDS. ODO reviewed policies, procedures
and detention files, observed the admission process, and interviewed staff and detainees.
ODO’s review of policy and observation of the intake process confirmed it includes
identification of detainees, medical assessment, classification, inventory of funds and property,
and issuance of personal hygiene items and clothing. Inspection of 20 detainee files confirmed
the presence of required forms and information, including orders to detain and signed
acknowledgements of receipt for the ICE National Detainee Handbook and facility handbook.
Facility policy states strip searches will be conducted only if there is reasonable suspicion that a
detainee is concealing contraband. However, ODO observed a new detainee was strip-searched
without reasonable suspicion, and the search was not documented (Deficiency AR-1). Though
the lieutenant stated strip searches do not occur without reasonable suspicion, officers
interviewed by ODO reported strip searches are conducted on a routine basis.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
In accordance with the ICE 2008 PBNDS, Admission and Release, section (V)(B)(4)(a), the
FOD must ensure, “Staff shall not routinely require a detainee to remove clothing or require a
detainee to expose private parts of his or her body to search for contraband. A strip search must
take place in an area that affords privacy from other detainees and from facility staff who are not
involved in the search. Observation must be limited to members of the same sex. The
articulable facts supporting the conclusion that reasonable suspicion exists should be
documented.”

Office of Detention Oversight
November 2014
OPR 201406911

10

Saint Clair County Jail
ERO Detroit

DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at SCCJ 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 2008 PBNDS. ODO reviewed the SCCJ
handbook, and interviewed staff and detainees.
Detainees are issued the SCCJ handbook and the ICE National Detainee Handbook during the
intake process; both in English or Spanish, or any other languages as determined by the FOD.
ODO’s review of 15 randomly selected detention files confirmed that all 15 received a facility
and ICE National Detainee Handbook.
ODO reviewed the facility handbook for all of the required components. The handbook listed
the procedures of the detainee grievance system but was lacking the procedures for the medical
grievance process. Also there was no procedure for requesting interpretive services for essential
communication (Deficiency DH-1). The facility prints new handbooks and distributes them to
detainees when there are significant changes to rules or procedures. All other updates are passed
orally or through a posted memo in the housing units.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE 2008 PBNDS, Detainee Handbook section (V)(2), the FOD must
ensure, “While all applicable topics form the ICE National Detainee Handbook must be
addressed, it is particularly important that each local supplement notify each detainee of:
•
•

The detainee Grievance System, including medical grievances.
Procedures for requesting interpretive services for essential communication.”

Office of Detention Oversight
November 2014
OPR 201406911

11

Saint Clair County Jail
ERO Detroit

DISCIPLINARY SYSTEM (DS)
ODO reviewed the Disciplinary System standard at SCCJ to determine if sanctions imposed on
detainees who violate facility rules are appropriate, and if the discipline process includes due
process requirements, in accordance with the ICE 2008 PBNDS. ODO interviewed detainees
and staff, reviewed the disciplinary policy and detainee handbook, and examined disciplinary
files.
SCCJ’s disciplinary system is fully addressed in facility policy and includes progressive levels of
review and appeal procedures. Prohibited acts are classified as infractions, minor, serious, and
major. Detainees are informed of facility rules and regulations, the disciplinary process and
sanctions, and appeal procedures by way of the facility handbook. Detainee rights in the
disciplinary process are also addressed in the handbook.
ODO reviewed documentation of all five incidents which resulted in disciplinary segregation
sanctions in the six months preceding the inspection. In two cases, the disciplinary hearing
committee did not create a written record which included documentation confirming the
detainees were advised of their rights, the evidence considered, or explanation of the reason for
the committee’s decisions. The written hearing records included only notation of the sanctions
imposed. Documentation reflects the detainees were provided with written notification of the
findings and sanctions; however, they were not provided with the reason for the findings
(Deficiency DS-1). This practice also violates SCCJ policy requiring a record of disciplinary
hearings which include the decision, disposition and reason for the action. Prior to completion of
the inspection, corrective action was initiated by issuance of a memorandum reminding staff who
serve on the disciplinary hearing committee of documentation requirements.
During a review of ten randomly selected detainee files, a disciplinary action which resulted in
dismissal was found (Deficiency DS-2). The detainee had been charged with assault, but was
determined to have acted in self-defense at his hearing. Retention of dismissed disciplinary
incidents in detainee files also violates SCCJ policy. The facility initiated corrective action prior
to completion of the inspection through the issuance of a memorandum reminding staff to
destroy incident reports resulting in not guilty findings.
On a tour of the special management unit, it was observed detainees serving disciplinary
sanctions were not allowed to keep their mattress while confined to their cell. A review of SCCJ
policy and staff interviews confirmed detainees in disciplinary segregation are allowed to have a
mattress between the hours of 9:00 p.m. and 6:00 a.m. At 6:00 a.m. every day, mattresses are
confiscated by staff and stored until 9:00 p.m. (Deficiency DS-3). 3 The removal of the
mattresses occurred as a matter of routine and without any evidence the mattress was being
misused in any way. Following discussion with supervisory staff, corrective action was initiated
by issuance of a memorandum ordering that this practice be discontinued.

3

Priority component.

Office of Detention Oversight
November 2014
OPR 201406911

12

Saint Clair County Jail
ERO Detroit

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DS-1
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(H)(5)(7), the FOD
must ensure, “The Institution Disciplinary Panel shall:
5. Prepare a written record of any hearing. This record must show that the detainee was
advised of his or her rights. It must also document the evidence considered by the Panel
and subsequent findings and the decision and sanctions imposed, along with a brief
explanation.
7. Serve the detainee with written notification of the decision, which must contain the
reason for the decision.”
DEFICIENCY DS-2
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(K)(3), the FOD
must ensure, “The disciplinary report and accompanying documents are not placed in the file of a
detainee who is found not guilty. The facility, however, may retain the material in its own files
for Institution statistical or historical purposes.”
DEFICIENCY DS-3
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(A)(4), the FOD must
ensure, “Staff may not impose or allow imposition of the following sanctions: corporal
punishment; deprivation of food services to include use of Nutraloaf or “food loaf’; deprivation
of clothing, bedding or items of personal hygiene; deprivation of correspondence privileges;
deprivation of legal access and legal materials; or deprivation of physical exercise unless such
activity creates a documented unsafe condition.”

Office of Detention Oversight
November 2014
OPR 201406911

13

Saint Clair County Jail
ERO Detroit

FOOD SERVICE (FS)
ODO reviewed the Food Service standard at SCCJ to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE 2008 PBNDS.
ODO interviewed staff, inspected storage areas, observed meal preparation and service, and
reviewed policy and relevant documentation.
Food service at SCCJ is provided by the contractor, Aramark Correctional Services. Staff
includes a food service director and (b)(7)e food service supervisors, supported by a crew of (b)(7)e
county inmate workers. No ICE detainees are assigned to work in food service. Documentation
of medical clearances for staff and the work crew was produced. ODO’s inspection confirmed
workers are visually checked prior to each shift for signs of health and hygiene concerns. All
kitchen workers were observed wearing clean uniforms, hairnets, beard guards for facial hair,
and gloves.
A review of documentation confirmed the facility’s 2,800 calorie per day menu was certified by
a registered dietitian based on a complete nutritional analysis. Religious and medical diets were
provided in accordance with standard. At the time of the inspection, one detainee was receiving
a medically ordered diet and eight detainees were on approved religious diets.
SCCJ has a satellite feeding operation. ODO observed preparation of one meal and accompanied
food carts to the housing areas. Staff used digital food thermometers to test temperatures as
items were prepared and placed on trays. Trays were placed on food carts which were moved to
the units by an inmate worker under supervision of a correctional officer. Detainees showed
their identification wristbands to the housing unit officer, who checked their names on the roster
prior to issuing the trays. This procedure supports accountability for special diets and allows
identification of detainees who do not accept a tray. ODO sampled the meal and confirmed all
items were on the menu were of satisfactory taste.
ODO also checked the sack meals provided to detainees being transported. The meal included
two non-pork meat sandwiches and a fruit item. The meals did not include a dessert item or
extra item such as packaged fresh vegetables or a packaged snack food (Deficiency FS-1). ODO
was informed corrective action would be taken by including an extra item going forward. ODO
found an additional item was included in sack meals upon follow-up during the inspection.
Sanitation in the kitchen was maintained at a superior level. Documentation was produced
reflecting food service supervisors conduct daily inspections, and the food service manager
conducts a comprehensive monthly inspection. Pursuant to Michigan state law, county jail
kitchens are inspected every two years. The last inspection was on January 29, 2013, and an
independent food safety service conducts an annual inspection under contract with Aramark
Correctional Services. No knives are used in the kitchen, and ODO verified other utensils were
properly controlled. Food storage areas, including the coolers, freezer, and dry food storage
area, were clean and well organized. All food items in the cooler and freezer were properly
covered, labeled and dated. Containers, bags, and boxed items in the dry storage area were all
dated to ensure stock rotation and proper clearance from walls and the ceiling was observed.

Office of Detention Oversight
November 2014
OPR 201406911

14

Saint Clair County Jail
ERO Detroit

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE 2008 PBNDS, Food Service, section (V)(I)(6)(c), the FOD must ensure,
“Each sack shall contain at least two sandwiches per meal, of which at least one will be meat
(non-pork). Commercial bread or rolls may be preferable because they include preservatives.
To ensure freshness, fresh, facility-made bread may be used only if made on the day of lunch
preparation. Sandwiches should be individually wrapped or bagged in a secure fashion, to
prevent the food from deteriorating. Meats, cheeses, etc., should be freshly sliced the day of
sandwich preparation. Leftover cooked meats shall not be used after 24 hours.
In addition, each sack shall include: One ration of a dessert item, like cookies, doughnuts, and
fruit bars. Such extras as properly packaged fresh vegetables, e.g., celery sticks, carrot sticks,
and commercially packaged “snack foods,” e.g. peanut butter crackers, cheese crackers,
individual bags of potato chips. These items enhance the overall acceptance of the lunches.”

Office of Detention Oversight
November 2014
OPR 201406911

15

Saint Clair County Jail
ERO Detroit

FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at SCCJ to determine if controls are in
place to inventory, receipt, and store and safeguard detainees’ personal property, in accordance
with the ICE 2008 PBNDS. ODO interviewed staff, reviewed policies and procedures, inspected
the storage area and observed the processing of detainees.
SCCJ has written policies and procedures which provide for the control and safeguarding of
detainees’ funds and personal property. ODO observed the property of arriving detainees was
properly searched, inventoried and logged in the facility’s computer system, and stored in a
secured property room. Receipts were issued and copies were placed in the property bag.
Inspection of the property room found it neat and well-organized.
Detainees are not authorized to keep money in their possession. Money is placed in a sealed
envelope and deposited in a drop safe located in the processing area. All envelopes are removed
by a staff member of the facility’s finance department the next work day and deposited in a
commissary account. Upon release or transfer from SCCJ, detainees receive a check for
remaining funds and sign a Release of Funds form verifying all funds were accounted for.
ODO’s review of 20 detention files confirmed required receipts were present.
The facility handbook addresses the requirements of the standard with one exception. It does not
include notice that, upon request, a detainee may be provided an ICE-certified copy of any
identity document placed in the A-File (Deficiency F&PP-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE 2008 PBNDS, Funds and Personal Property, section (V)(C), the FOD
must ensure, “The detainee handbook or equivalent shall notify the detainees of the facility
policies and procedures concerning personal property, including:
•

That upon request, they shall be provided a ICE/ERO-certified copy of any identity
document (passport, birth certificate, etc.) placed in their A-files.”

Office of Detention Oversight
November 2014
OPR 201406911

16

Saint Clair County Jail
ERO Detroit

GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at SCCJ 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 2008 PBNDS.
A review of the facility’s policy and procedures found detainees are able to file formal
grievances, including medical and emergency grievances, and receive written responses,
including the basis for the decision, in a timely manner. Staff and detainees mutually resolve
most complaints and grievances orally and informally in their daily interaction. The facility
handbook does not provide detainees notice of: the expectation that, to the greatest extent
possible, complaints and grievances should be handled orally and informally by staff, but that the
detainee always has the right to file a formal grievance and pursue the formal process; the right
to file a grievance both informally and formally; the process for filing emergency grievances; or
the procedures for contacting ICE to appeal a decision of the facility (Deficiency GS-1). The
facility initiated corrective action during the course of this inspection by updating the handbook
to include this information.
While SCCJ routinely resolves detainee grievances orally and informally at the lowest level
possible, the results are not documented for record in the detainee’s detention file or in a log
(Deficiency GS-2). If unable to informally resolve a complaint, or if the detainee wishes to
forgo this step and proceed directly to a written grievance, the detainee must submit a written
request to receive a grievance form. The housing sergeant will log and route or respond to the
grievance. Detainees may appeal any grievance to the jail lieutenant. If the detainee is not
satisfied with the lieutenant’s decision, the detainee may appeal to ICE.
ODO’s review of the grievance log confirmed it was current and included the grievance number,
nature of the grievance, and the date it was both received and resolved. The grievance log for the
previous 12 months contained no grievances filed by detainees. Facility staff stated that while
copies of grievance dispositions are provided to detainees, copies are not placed in detention files
(Deficiency GS-3). 4

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE 2008 PBNDS, Grievance System, section (V)(B), the FOD must
ensure, “The facility shall provide each detainee, upon admittance, a copy of the Detainee
Handbook/local supplement, in which the grievance section provides notice of:
•

4

The expectation that, to the greatest extent possible, complaints and grievances should be
handled orally and informally by staff in their daily interaction with detainees.
Nevertheless, the detainee always has the right to file a formal grievance and pursue the
formal grievance process.

Priority component.

Office of Detention Oversight
November 2014
OPR 201406911

17

Saint Clair County Jail
ERO Detroit

•
•
•

The right to file a grievance, including medical grievances, both informal and formal.
The process for filing emergency grievances.
The procedures for contacting ICE/ERO to appeal a decision in a CDF or IGSA facility.

DEFICIENCY GS-2
In accordance with the ICE 2008 PBNDS, Grievance System, section (V)(C)(1), the FOD must
ensure, “If an oral grievance is resolved, the employee need not provide the detainee written
confirmation of the outcome but shall document the result for the record in the detainee’s
Detention File and in any logs or data systems the facility has established to track such actions.”
DEFICIENCY GS-3
In accordance with the ICE 2008 PBNDS, Grievance System, section (V)(E), the FOD must
ensure, “A copy of the grievance disposition shall be placed in the detainee’s detention file and
provided to the detainee.”

Office of Detention Oversight
November 2014
OPR 201406911

18

Saint Clair County Jail
ERO Detroit

LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)
ODO reviewed the Law Library and Legal Material standard at SCCJ to determine if detainees
have access to a law library, legal materials, courts, counsel and supplies to facilitate the
preparation of legal documents, in accordance with the ICE 2008 PBNDS. ODO observed the
law libraries, interviewed staff and detainees and reviewed policies as well as the facility
handbook.
SCCJ has a mobile law library, consisting of two rolling carts each equipped with a computer
and keyboard. One serves as the general law library, and the second computer is designated as
the ICE law library, although detainees may request and use either. Detainees request use of the
law library by submitting the designated form to the housing unit deputy. The library is
available on a first come, first served basis. Time will be limited to one hour per day, but if no
other requests are pending, additional time will be permitted during normal free time hours.
Once requested and available, the mobile carts are moved into the classroom of the housing unit
where the detainee may access it with reasonable privacy, quiet, and good lighting. The same
law library privileges are afforded to detainees in special management units.
The facility does not inspect the equipment weekly (Deficiency LL&LM-1). 5 Detainees may
save legal work with a USB thumb drive, which is available for purchase in the commissary, or
provided to indigent detainees at no charge.
ODO verified the computer contained a current version of LexisNexis. SCCJ provides four
laptops with word-processing software. Printing and photocopying of legal documents are
performed upon request. Detainees may access the onsite notary free of charge by submitting a
written request. All indigent detainees are provided free envelopes and stamps for legal mail,
writing paper and pencils.
The SCCJ facility handbook does not contain information notifying detainees of 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 LL&LM-2). These policies and procedures were not posted in the law library, but
the facility initiated corrective action on site during this inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY LL&LM-1
In accordance with the ICE 2008 PBNDS, Law Libraries and Legal Material, section (V)(D), the
FOD must ensure, “Each facility administrator shall designate an employee to inspect the
equipment at lease weekly and ensure it is in good working order and to stock sufficient
supplies.”

5

Priority component.

Office of Detention Oversight
November 2014
OPR 201406911

19

Saint Clair County Jail
ERO Detroit

DEFICIENCY LL&LM-2
In accordance with the ICE 2008 PBNDS, Law Libraries and Legal Material, section (V)(O), the
FOD must ensure, “The Detainee Handbook or supplement shall provide detainees with the rules
and procedures governing access to legal materials, including the following information:
5. The procedure for requesting legal reference materials not maintained in the law library.
6. The procedure for notifying a designated employee that library material is missing or
damaged.
These policies and procedures shall also be posted in the law library along with a list of the law
library’s holdings.”

Office of Detention Oversight
November 2014
OPR 201406911

20

Saint Clair County Jail
ERO Detroit

MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at SCCJ to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE 2008 PBNDS. ODO toured the clinic area, reviewed policies and procedures,
interviewed healthcare staff and administrators, and examined the medical files of 30 detainees,
14 of whom had chronic medical conditions.
SCCJ has no accreditations. Since December 2013, medical care has been provided under
contract with St. Joseph Mercy Port Huron Hospital (SJMPHH). A registered nurse (RN), who
holds the title of nurse coordinator, is responsible for administrative oversight of clinic
operations. Nursing coverage is provided 24 hours a day, seven days a week. The RN is on site
Monday through Friday from 8:00 a.m. to 4:30 p.m. and on call during non-business hours. On
occasions she is unavailable, on-call coverage is provided by the SJMPHH vice president of
operations and chief nursing officer, who oversees the contract and supervises the RN. Other
nursing staff includes (b)(7)elicensed practical nurses (LPN) that are responsible for medication
administration, assisting with sick call clinic, and performing clerical duties as needed. The
clinical medical authority is the medical director, a doctor of osteopathy who also serves as the
emergency room director at SJMPHH. The medical director and (b)(7)ephysician assistant are
present at the facility a minimum of two hours per week each, on different days. In addition, the
medical director provides rotational on-call services with
SJMPHH physicians.
(b)(7)e
ODO verified all licenses were current and primary source verified. Based on the population
size, the staffing complement was found to be adequate.
Mental health services are provided under separate contract with Saint Clair County Community
Mental Health Authority. A mental health nurse practitioner, mental health social worker, and a
counselor provide a combined total of 40 hours on site per week. Dental services are provided at
Dental Clinic of Port Huron. Emergency medical services are provided by Tri-Hospital
ambulance service, with a response time of about ten minutes. Training records of all medical
personnel and(b)(7)erandomly selected detention officers documented current certification in
cardiopulmonary resuscitation, first aid, and emergency medical response. ODO observed there
were two automated external defibrillators and two first aid kits, one each in the control room
and visiting area, and an emergency go-bag with breakaway lock and inventory located in the
examination room. A list of telephone numbers for emergency contacts was posted in the clinic
area.
SCCJ’s medical clinic is compact, consisting of a single, private examination room, a separate
room which serves as a two-person nursing station, secure medication room, medical records
office with secure storage, and employee break room. A small waiting area is located at the
clinic’s entrance, with seating for two or three detainees and a connecting restroom with drinking
water accessibility. A small desk in the waiting area allows close observation by the officer
when detainees are present. During the course of the inspection, ODO did not observe more than
one detainee in the clinic at a time. Detention officers are responsible for conducting medical
and mental health intake screening upon detainee arrival. A review of training logs and (b)(7)e
randomly selected training files confirmed officers received training during their initial
orientation; however, the training syllabus was not available for ODO’s review, nor was it
available for officers’ reference as required by the standard (Deficiency MC-1). It is further
Office of Detention Oversight
November 2014
OPR 201406911

21

Saint Clair County Jail
ERO Detroit

noted ODO was informed security personnel provided the training. A review of 30 detainee
medical files confirmed detainees were screened within 12 hours of arrival, though the screening
form used at SCCJ does not include all health-related inquiries required by the standard;
specifically, observation of detainee behaviors, identification of high risk behaviors for HIV
infection and other blood-borne pathogens, past medications, past surgical procedures, homicidal
tendencies, and past suicide attempts. ODO further noted that in five cases, sections of the form
were not completed (Deficiency MC-2). 6 Information on medication needs was missing in two
records, history of alcohol/drug use was missing in two additional records, and housing
disposition based on medical findings was not recorded in one record. Additionally, two of the
screening forms did not include the signature of the screening officer. Corrective action was
initiated by the facility during the course of the inspection by revision of the screening form to
include missing elements, and issuance of a written directive to booking officers regarding its
thorough completion. Though a positive step, ODO recommends that officers be re-trained by
medical personnel, using a curriculum approved by the medical director made available for
officers’ reference at all times (R-1). ODO’s review also found the medical director did not
review or co-sign any of the intake screenings (Deficiency MC-3), nor did any other medical
professional.
The primary method of tuberculosis (TB) screening is purified protein derivative (PPD) skin
testing. Chest x-rays for past or present positive PPD tests are provided by a mobile service,
Visiting Physician Associates. Documentation of testing within 12 hours of detainee arrival was
present in all 30 records reviewed. SCCJ does not have a room equipped with negative airflow
for respiratory isolation. According to the nurse coordinator, a detainee with suspected TB
would be transferred to SJMPHH. A review of SCCJ’s infection control plan found it did not
address all components mandated by the standard; specifically, it did not address ICE
notification procedures, protection of confidentiality, media relations, and management of
biohazard waste (Deficiency MC-4). 7 There were no cases of infectious illness where the
requirements for ICE notification and media relations applied, and SCCJ follows proper patient
confidentiality and biohazard waste management protocols. The facility initiated corrective
action during the inspection.
ODO’s medical record review found the RN conducted physical examinations that included
dental screenings in 28 of 30 cases, and the medical director completed the remaining two
because the detainees had chronic conditions. The physical examinations were all performed
within 14 days of the detainees’ arrival and the physician co-signed the examinations conducted
by the RN. However, the medical director did not record the date of his review; therefore, it
could not be verified the process was completed within 14 days (Deficiency MC-5). 8 During the
course of this inspection, the facility revised the form to include a section to document the cosignature date. Training in completing physical examinations and dental screenings was
documented in the RN’s training file.
ODO found no detainees who were held at SCCJ for a year or more, requiring annual health
examinations or tuberculosis screening. The records of 14 detainees with chronic medical
6

Priority component.
Priority component.
8
Priority component.
7

Office of Detention Oversight
November 2014
OPR 201406911

22

Saint Clair County Jail
ERO Detroit

conditions documented routine monitoring in accordance with individual treatment plans
developed by the provider. ODO confirmed the three female detainees held at the time of the
inspection were tested for pregnancy with negative results. According to policy and the nurse
coordinator, obstetric and gynecological care is provided at SJMPHH.
Sick call requests printed in English and Spanish are available from housing unit officers.
According to the nurse coordinator, LPNs gather requests directly from detainees while
conducting medication rounds in general population and special management units. The requests
are immediately triaged and recorded in the sick call log. For requests not requiring evaluation
by a provider, physician-approved nursing protocols are followed. Physician and physician
assistant sick call clinics are conducted on Tuesdays and Fridays. ODO confirmed timely triage
and follow up for all ten sick call requests reviewed. The detainee handbook states healthcare
services may be accessed by way of sick call request forms; however, it does not address how to
obtain the forms or state they should be handed directly to medical personnel. Inclusion of this
information is recommended.
Use of the Certified Languages International telephonic interpretation service during medical
encounters was observed, and documentation of use of the service was documented in detainees’
medical records. Instructions on use of the language service were posted.
As noted previously, mental health services are provided under contract with Saint Clair County
Community Mental Health Authority (CMA). According to the mental health social worker, the
CMA staff is responsible for completing evaluations of detainees referred to them and for
providing follow up services. The mental health social worker reported assessments are
completed within three days for routine referrals, and within 24 hours for urgent and emergent
cases. Review of the medical records of two detainees receiving mental health treatment
confirmed adherence to these timeframes. ODO noted the absence of comprehensive mental
health assessments and treatment plans in the records (Deficiency MC-6). 9 The mental health
social worker stated it is CMA’s position that the Health Insurance Portability Accountability
Act law does not permit providing this documentation for inclusion in the SCCJ medical record.
ODO’s review of the most recent monthly meeting minutes found this has been identified as a
problem and the medical director and CMA mental health nurse practitioner are attempting to
resolve.
The medication room within the clinic is securely controlled, with access limited to the nurses.
Advanced Care Pharmacy in Port Huron accepts SCCJ’s prescriptions, and if faxed prior to 3:00
pm, will deliver the same day. All medications arrive in unit dose packaging, which are
inventoried and placed in locked medication carts. ODO’s review of the facility’s pharmacy
plan found it did not address all components required by the PBNDS, including prescription
practices, procurement, and inventory and disposal of all prescription and non-prescription
pharmaceuticals (Deficiency MC-7). 10 The facility initiated corrective action during the
inspection by revising the pharmacy plan. Medications are distributed by nursing staff.

9

Priority component.
Priority component.

10

Office of Detention Oversight
November 2014
OPR 201406911

23

Saint Clair County Jail
ERO Detroit

ODO found no evidence health education and wellness education materials are issued to
detainees (Deficiency MC-8). This determination was based on review of orientation materials,
tour of housing units, the intake area and medical clinic, and inspection of medical files. The
nurse coordinator stated she plans to obtain free pamphlets from various on-line sources.
The medical record review found signed consent for treatment forms were not included in any of
the 30 medical records reviewed. The nurse coordinator informed ODO SCCJ has not instituted
informed consent procedures. As a corrective action, blanket consent statements were added to
the intake screening form prior to the inspection closeout. The record review also found two
detainees receiving psychotropic medication had not signed consent forms specific to the
medications given (Deficiency MC-9). 11 According to the mental health social worker, consent
forms for psychotropic medication were on file at the CMA clinic, but copies were not forwarded
for inclusion in the SCCJ medical record.
Documentation was produced reflecting meetings involving the nurse coordinator, SJMPHH vice
president of operations/chief nursing officer, the medical director, a mental health professional,
and jail administrators are held on a monthly basis. However, there was no documentation of
meetings for one quarter of 2014, and May 29, 2014 to September 25, 2014
(Deficiency MC-10). While the minutes reflected the meetings included discussion of problem
resolution, a formal quality assurance program has not been established to identify standard
discrepancies, establish corrective action, and monitor program improvements
(Deficiency MC-11). 12 The SJMPHH vice president of operations/chief nursing officer
completed a single audit on August 14, 2014, which assessed compliance with timeliness of
intake screening and physical assessments, sick call, physician clinics, infection control
interventions, and safety standards. All were found to be in full compliance for the time period
of December 17, 2013 to June 30, 2014.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(I)(1), the FOD must ensure, “If
screening is performed by a detention officer, the facility shall maintain documentation of the
officer’s special training, and the officer shall have available for reference the training syllabus,
to include education on patient confidentiality of disclosed information.”
DEFICIENCY MC-2
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(I)(1), the FOD must ensure,
“The medical screening shall inquire into the following:
•
•
•
•
11
12

Any past history of serious infectious or communicable illness, and any treatment or
symptoms; current illness and health problems, including communicable diseases;
Pain assessment;
Current and past medication;
Allergies;

Priority component.
Priority component.

Office of Detention Oversight
November 2014
OPR 201406911

24

Saint Clair County Jail
ERO Detroit

•
•
•
•
•
•
•
•
•

Past surgical procedures;
Symptoms of active TB or previous TB treatment;
Dental problems;
Use of alcohol and other drugs;
Possibility of pregnancy;
Other health programs designated by the responsible clinical medical authority;
Observation of behavior, including state of consciousness, mental status, appearance,
conduct, tremor, sweating;
History of suicide attempts or current suicidal/homicidal ideation or intent; observation of
body deformities and other physical abnormalities;
Questions and an assessment regarding past or recent sexual victimization.”

DEFICIENCY MC-3
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(I)(1), the FOD must ensure,
“The clinical medical authority shall be responsible for review of all health screening forms
within 24 hours or next business day to assess the priority for treatment (example, Urgent,
Today, or Routine).”
DEFICIENCY MC-4
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(C), the FOD must ensure,
“Each facility shall have written plans that address the management of infectious and
communicable diseases, including prevention, education, identification, surveillance,
immunization (when applicable), treatment, follow-up, isolation (when indicated), and reporting
to local, state, and federal agencies.
Plans shall include:
•
•
•
•
•
•
•
•

Coordination with public health authorities;
Ongoing education for staff and detainees;
Control, treatment and prevention strategies;
Protection of individual confidentiality;
Media relations;
Procedures for the identification, surveillance, immunization, follow-up and isolation of
patients;
Manage infectious diseases and report them to the local and/or state health departments in
accordance with established guidelines and applicable laws; and,
Management of bio hazardous waste and decontamination of medical and dental
equipment that complies with applicable laws and Detention Standard on Environmental
Health and Safety.”

DEFICIENCY MC-5
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(J), the FOD must ensure,
“Each facility’s health care provider shall conduct a health appraisal including a physical
examination on each detainee within 14 days of the detainee’s arrival unless more
immediate attention is required due to an acute or identifiable chronic condition, in accordance
with the most recent ACA Adult Local Detention Facility standards for Health Appraisals. If
Office of Detention Oversight
November 2014
OPR 201406911

25

Saint Clair County Jail
ERO Detroit

there is documentation of one within the previous 90 days, the facility health care provider upon
review may determine that a new appraisal is not required.”
DEFICIENCY MC-6
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(K)(4), the FOD must ensure,
“Any detainee referred for mental health treatment shall receive a comprehensive evaluation by a
licensed mental health provider as clinically necessary, but no later than 14 days of the referral.
The provider shall develop an overall treatment/management plan that may include transfer to a
mental health facility if the detainee’s mental illness or developmental disability needs exceed
the treatment capability of the facility.”
DEFICIENCY MC-7
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(F), the FOD must ensure,
“Each facility shall have written policy and procedures for the management of pharmaceuticals
that include:
•
•
•
•
•
•
•
•
•
•
•
•

A formulary of all prescription and non-prescription medicines stocked or routinely
procured from outside sources;
A method for promptly approving and obtaining medicines not on the formulary;
Prescription practices, including requirements that medications are prescribed only when
clinically indicated, and that prescriptions are reviewed before being renewed;
Procurement, receipt, distribution, storage, dispensing, administration and disposal of
medication;
Secure storage and disposal and perpetual inventory of all controlled substances (DEA
Schedule II-V), syringes and needles;
Medicine administration error reports shall be kept for all administration errors;
All staff responsible for administering or having access to pharmaceuticals will be trained
on medication management before beginning duty;
All pharmaceuticals shall be stored in a secure area;
Administration and management in accordance with state and federal law;
Supervision by properly licensed personnel;
Administration of medications by properly trained personnel under the supervision of the
health services administrator, or equivalent;
Accountability for administering or distributing medications in a timely manner and
according to licensed provider orders.

DEFICIENCY MC-8
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(Q), the FOD must ensure, “The
health authority shall provide detainees health education and wellness information on such topics
as dangers of self-medication, personal hygiene and dental care, prevention of communicable
diseases, smoking cessation, self-care for chronic conditions, and the benefits of physical
fitness.”
DEFICIENCY MC-9
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(T), the FOD must ensure,

Office of Detention Oversight
November 2014
OPR 201406911

26

Saint Clair County Jail
ERO Detroit

•
•

“Upon admission at the facility, documented informed consent will be obtained for the
provision of health care services.”
“For any additional procedure, a separate documented informed consent will be
obtained.”

DEFICIENCY MC-10
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(X)(1), the FOD must ensure,
“The administrative health authority shall convene a meeting at least quarterly and include other
facility and medical staff as appropriate. The meeting agenda shall include, at a minimum:
•
•
•
•
•

An account of the effectiveness of the facility health care program;
Discussions of health environment factors that may need improvement;
Review and discussion of communicable disease and infectious control activities;
Changes effected since the previous meetings; and
Recommended corrective actions, as necessary.

Minutes of each meeting shall be recorded and kept on file.
DEFICIENCY MC-11
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(X)(2), the FOD must ensure,
“The administrative health authority shall implement a system of internal reviews and quality
assurance. Elements of the system shall include:
•
•
•
•
•

Participating in a multidisciplinary quality improvement committee.
Collecting, trending, and analysis of data along with planning interventions,
reassessments.
Evaluating defined data.
Analyze the need for ongoing education and training.
On-site monitoring of health service outcomes on a regular basis.”

Office of Detention Oversight
November 2014
OPR 201406911

27

Saint Clair County Jail
ERO Detroit

SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION
(SAAPI)
ODO reviewed the Sexual Abuse and Assault Prevention and Intervention standard at the SCCJ
to determine if facilities act to prevent sexual abuse and assaults on detainees, provide prompt
and effective intervention and treatment for victims of sexual abuse and assault, and control,
discipline, and prosecute the perpetrators, in accordance with the ICE 2008 PBNDS.
A sergeant is the designated PREA Coordinator of the facility, and another sergeant is the PREA
Compliance Manager. ODO reviewed written policy and procedures and found them in
compliance with the standard. ODO also reviewed staff training materials and found training did
not include: recognition of situations where sexual abuse or assault may occur; recognition of the
physical, behavioral, and emotional signs of sexual abuse or assault and ways to prevent such
occurrences; and prevention, recognition, and appropriate response to allegations or suspicions
of sexual assault involving detainees with mental or physical disabilities
(Deficiency SAAPI-1). 13
The facility screens detainees during intake for possible victimization and predatory factors.
ODO observed the sexual assault poster hung in all housing units, as well as the SCCJ PREA
zero tolerance posters. ODO reviewed the facility handbook and orientation and found it does
not include prevention and intervention strategies or information about self-protection and
indicators of sexual abuse (Deficiency SAAPI-2). 14
The facility and ERO have not received any reports of sexual abuse or assault within the
previous 12 months. This was verified through the Joint Intake Case Management System.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SAAPI-1
In accordance with the ICE 2008 PBNDS, Sexual Abuse and Assault Prevention and
Intervention, section (V)(F), the FOD must ensure, Training on the facility’s Sexual Abuse and
Assault Prevention and Intervention program shall be included in training for employees,
volunteers, and contract personnel and shall also be included in annual refresher training
thereafter.
Training shall include:
•
•
•

13
14

Recognition of situations where sexual abuse or assault may occur;
Recognition of the physical, behavioral, and emotional signs of sexual abuse or assault
and ways to prevent such occurrences;
Prevention, recognition, and appropriate response to allegations or suspicions of sexual
assault involving detainees with mental or physical disabilities”

Priority component.
Priority component.

Office of Detention Oversight
November 2014
OPR 201406911

28

Saint Clair County Jail
ERO Detroit

DEFICIENCY SAAPI-2
In accordance with the ICE 2008 PBNDS, Sexual Abuse and Assault Prevention and
Intervention, section (V)(G), the FOD must ensure, “The facility administrator shall ensure that
the orientation program required by the Detention Standard on Admission and Release, and the
detainee handbook required by the Detention Standard on Detainee Handbook, notify and inform
detainees about the facility’s Sexual Abuse and Assault Prevention and Intervention Program and
that they include (at a minimum):
•
•

Prevention and intervention;
Self-protection”

Office of Detention Oversight
November 2014
OPR 201406911

29

Saint Clair County Jail
ERO Detroit

STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at SCCJ 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 2008 PBNDS. ODO reviewed policies,
procedures, request forms, and logs; and interviewed detainees and staff.
ODO found ERO staff makes scheduled and unscheduled visits on a regular basis. During these
visits, ERO staff provides detainees with general information concerning the removal process;
and responds to detainee questions, requests, and concerns. Visits are documented by ERO on
the ICE facility liaison visit checklist and maintained in the office of the on-site Immigration and
Enforcement Agent (IEA).
Detainees can submit ICE request forms and submit them to SCCJ staff members. Detainees can
request an envelope to place a request, but there is no secure drop box for detainees to
correspond directly with ICE management (Deficiency SDC-1). 15 The facility initiated
corrective action during the inspection by installing a secure drop box for the detainees to use.
ODO confirmed the log contained the date of receipt; detainee’s name, A-number, the date the
request was returned to the detainee; and other pertinent information. However, the log did not
contain a box area on the log form for the nationality and the name of the staff member who
logged the request (Deficiency SDC-2). The facility initiated corrective action during the
inspection by adding the correct boxes on the log form.
SCCJ’s handbook advises detainees of the procedures to submit written questions, requests or
concerns to ERO. ODO verified SCCJ and ERO staff tests all telephones for detainee use
weekly. ODO also verified ERO staff documents and completes serviceability tests on a form,
and completes the facility liaison visit checklist on a weekly basis. The DHS Office of Inspector
General Hotline posters were observed in every housing unit and in appropriate common areas.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE 2008 PBNDS, Staff-Detainee Communication, section (V)(B), the
FOD must ensure, “The facility shall provide a secure drop box for ICE detainees to correspond
directly with ICE management. Only ICE personnel shall have access to the drop box.”
DEFICIENCY SDC-2
In accordance with the ICE 2008 PBNDS, Staff-Detainee Communication, section (V)(B)(2), the
FOD must ensure, “All request shall be recorded in a logbook (or electronic logbook)
specifically designed for that purpose. At a minimum, the log shall record:
•
•

15

Detainee’s nationality
Name of the staff member who logged the request

Priority component.

Office of Detention Oversight
November 2014
OPR 201406911

30

Saint Clair County Jail
ERO Detroit

SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at SCCJ 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 2008 PBNDS. ODO interviewed staff and reviewed the
facility’s policies and procedures, intake screening documentation, and training records.
SCCJ’s policy addresses all elements required by the PBNDS. There were no detainees on
suicide watch at the time of the inspection. According to the nurse administrator, the facility
does not maintain a listing of detainees placed on suicide watch review; therefore, ODO was
unable to review any medical records to confirm compliance with the standard. ODO was
informed detainees placed on suicide watch are assigned to a cell immediately adjacent to the
officers’ station in the special management unit. Inspection found cells suicide resistant and
devoid of items which could facilitate a suicide attempt. The mental health social worker stated
detainees on suicide watch are evaluated daily and may be removed from the status only
following suicide risk assessment.
A review of(b)(7)erandomly selected officers’ training records found documentation of training in
suicide prevention and intervention upon hire; however, the officers did not receive annual
training. The most recent refresher training was provided in February 2013
(Deficiency SP&I- 1). 16 The mental health social worker reported she has provided training to
jail staff on specific mental illnesses, but has not presented suicide prevention and intervention
training on an annual basis. According to SCCJ’s training manager, training is planned for
December 2014, though no evidence of formal scheduling was produced. The vice president of
operations responsible for oversight of the health services contract informed ODO she will work
with the facility to establish an annual training program.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(A), the FOD must ensure, “The
facility staff who interact with and/or are responsible for detainees shall be trained during
orientation and at least annually, on:
•
•
•
•
•
•
•
•

16

recognizing verbal and behavioral cues that indicate potential suicide,
demographic, cultural, and precipitating factors of suicidal behavior,
responding to suicidal and depressed detainees,
effective communication between correctional and health care personnel,
necessary referral procedures,
constant observation and suicide-watch procedures,
follow-up monitoring of detainees who have already attempted suicide, and
reporting and written documentation procedures.”

Priority component.

Office of Detention Oversight
November 2014
OPR 201406911

31

Saint Clair County Jail
ERO Detroit

SPECIAL MANAGEMENT UNITS (SMU)
ODO reviewed the Special Management Unit standard at SCCJ to determine if the facility has
procedures in place to temporarily segregate detainees for disciplinary and administrative
reasons, in accordance with the ICE 2008 PBNDS. ODO toured the SMU, reviewed facility
policies and SMU logs, inspected detainee files, and interviewed staff and detainees.
SCCJ has a 16 bed SMU. There is a separate shower area located off the dayroom and an
adjacent outdoor recreation area. Inspection found the unit was well ventilated, adequately lit,
appropriately heated, and maintained in a sanitary condition. Furniture and fixtures within the
cells were appropriate.
Medical staff makes rounds in the SMU seven times daily. Officers are required to make rounds
at least twice per hour at random intervals. To electronically record rounds, officers swipe their
identification cards on card readers positioned at each end of the range of cells. Supervisors are
required to visit the SMU daily. ODO reviewed the electronic record of rounds for a 24 hour
period during the inspection and confirmed rounds were conducted at irregular 30 minute
intervals by officers, and supervisory staff made a daily round each shift. An electronic record of
meal service, medication delivery and medical visits, recreation, and other privileges and
services is also maintained. ODO’s review found entries reflected compliance with the standard.
At the time of the inspection, two detainees were serving disciplinary segregation sanctions in
the SMU. While touring the unit, ODO observed the detainees did not have mattresses in their
cells. A review of SCCJ’s policy found it states detainees in disciplinary segregation are allowed
to have a mattress only between the hours of 9:00 pm and 6:00 am (Deficiency SMU-1).
Following discussion with supervisory staff, corrective action was initiated during the course of
this inspection by issuance of a memorandum discontinuing this practice.
The detainee handbook states that following completion of a sanction for a minor, major, or
serious rule violation, the housing sergeant will determine whether the detainee’s behavior for
determination of whether it has improved sufficiently to be returned to less restrictive housing.
Because the sanction is complete when the review is conducted, this language implies the
sergeant has the authority to lengthen the sanction imposed through the disciplinary process
(Deficiency SMU-2). Prior to completion of the inspection, corrective action was taken by
removing the passage from the handbook.
During the inspection, one detainee was assigned to administrative segregation status by order of
medical staff pending further evaluation. An administrative segregation order was issued
documenting the reason. ODO was unable to determine the number of detainees assigned to
administrative segregation in the year preceding the inspection because SCCJ’s log of SMU
placements does not differentiate detainees from inmates. Random review of the log did,
however, identify nine detainees previously assigned to administrative segregation. Of the nine
cases, two were placed in administrative segregation pending evaluation by mental health staff,
five were segregated due to disruptive and assaultive behavior, one requested protective custody
for reasons which were not documented, and one was on hunger strike monitoring. In each case,
a written order was completed, the reason for the placement was sufficiently detailed, the
placement was approved by a supervisor, and the detainee was provided with a copy of the order.
Office of Detention Oversight
November 2014
OPR 201406911

32

Saint Clair County Jail
ERO Detroit

Three of the nine detainees were released from segregation within three days and the remaining
six detainees were released nine to 20 days following placement in the SMU. Status reviews
were conducted as required; however, in eight of nine cases, the date and time of release and the
authorizing staff member were not documented (Deficiency SMU-3). To correct this deficiency
going forward, SCCJ modified its form to include a section to record this information.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU-1
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(B)(11)(b), the
FOD must ensure, “A detainee may be denied such items as clothing, mattress, bedding, linens,
or pillow for medical or mental health reasons if his or her possession of such items raises concerns
for detainee safety and/or facility security.”
DEFICIENCY SMU-2
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(D)(3)(b), the
FOD must ensure, “A security supervisor may shorten, but not extend, the original sanction for a
detainee.”
DEFICIENCY SMU-3
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(C)(2)(g), the
FOD must ensure, “When a detainee is released from the SMU, the releasing officer shall
indicate date and time of release on the Administrative Segregation Order. The completed order
is then forwarded to the chief of security for inclusion into the detainee’s detention file.”

Office of Detention Oversight
November 2014
OPR 201406911

33

Saint Clair County Jail
ERO Detroit