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ICE Detention Standards Compliance Audit - South Texas Detention Complex, Pearsall, TX, ICE, 2015

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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 San Antonio Field Office
South Texas Detention Complex
Pearsall, Texas

April 21–23, 2015

COMPLIANCE INSPECTION
SOUTH TEXAS DETENTION COMPLEX
ERO SAN ANTONIO FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................8
ICE 2011 PERFORMANCE BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................9
Environmental Health and Safety ......................................................................................10

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

Office of Detention Oversight
April 2015
OPR 201504628

Inspections & Compliance Specialist (Team Lead) ODO
Inspections & Compliance Specialist
ODO
Inspections & Compliance Specialist
ODO
ODO
Management & Program Analyst
Contractor
Creative Corrections
1

South Texas Detention Complex
ERO San Antonio

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

Office of Detention Oversight
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Contractor
Contractor
Contractor

Creative Corrections
Creative Corrections
Creative Corrections

2

South Texas Detention Complex
ERO San Antonio

EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the South Texas Detention Complex (STDC) in
Pearsall, Texas, from April 21 to 23, 2015. STDC, which opened in 2005, is owned and
operated by the GEO Group (GEO). ERO began housing detainees at STDC in 2005 under a
Contract Detention Facility Agreement. Male detainees of security classification levels I through
III are detained at the facility for periods in excess of 72 hours. The inspection evaluated
STDC’s compliance with the 2011
Capacity and Population Statistics
Quantity
PBNDS.
Total Bed Capacity
1904
ICE Detainee Bed Capacity

1904

Average Daily Population
1588
The ERO Field Office Director
Average ICE Detainee Population
1588
(FOD) in San Antonio, Texas, is
Average
Length
of
Stay
(Days)
43
responsible for ensuring facility
Male Detainee Population (as of 04/21/2015)
1494
compliance with the 2011 PBNDS
and ICE policies. An ERO Assistant
Female Detainee Population
N/A
Field Office Director (AFOD) and (b)(7)e
ERO staff members are located onsite. A Detention Service Manager is assigned to STDC.

A Warden is responsible for oversight of daily facility operations and is supported by (b)(7)e
personnel. The GEO Group provides food services and the ICE Health Service Corps (IHSC)
provides medical services. The facility holds both an American Correctional Association (ACA)
and a National Commission on Correctional Health Care (NCCHC) accreditations.
In February 2012, ODO conducted an inspection of the STDC under the 2008 PBNDS. During
the inspection ODO reviewed 15 PBNDS; 14 standards were found to be fully compliant. One
standard, Funds and Personal Property, had deficiencies.
During this inspection ODO reviewed fifteen 2011 PBNDS and found STDC compliant with 14
standards. ODO found a total of one deficiency (not relating to priority components) in the
Environmental Health and Safety standard. The facility initiated corrective action during the
inspection. 1 ODO cited one best practice in the Sexual Abuse Assault Prevention and
Intervention (SAAPI) standard. 2
This report details all deficiencies and refers to the specific, relevant sections of the 2011
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 STDC and ERO
management during the inspection and at a closeout briefing conducted on April 23, 2015.
Detainees assigned by ERO to STDC are brought into the main booking area where the detainees
are pat-searched and inspected with a handheld metal detector. Per facility policy, a strip search
is conducted only when there is a reasonable suspicion of a detainee bringing contraband into the
facility.

1
2

Corrective actions initiated by the facility are annotated as “C.”
Best practices are annotated in this report as “BP.”

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Initial medical intake screening is completed by IHSC nursing staff within 12 hours of a
detainee’s arrival. The detainee also signs a general consent for treatment statement during
medical screening.
Photo identification cards are issued to each detainee. A second photo identification card is
forwarded to the detainee’s assigned housing unit to be used when conducting periodic face to
face counts.
A classification officer meets with a detainee during intake processing and uses the ICE Custody
Classification Worksheet to determine the classification level. STDC classifies detainees as low,
medium–low, medium, medium-high, and high custody. As a means of custody level
identification, detainees are issued color coded uniforms and wrist bands. The initial
classification decision is reviewed by the intake supervisor prior to the detainee leaving the
intake area. ODO’s review of 45 detention files of detainees of all classification levels
confirmed classification documentation and supervisory approval was present. STDC
classification policy requires that detainees have a classification review every 60 to 90 days.
The ICE National Detainee Handbook and facility detainee handbook are issued to detainees
during the intake process. Detainees sign an acknowledgement form for both handbooks and a
copy of the acknowledgement is placed in each detainee’s detention file. The STDC detainee
handbooks are available in both English and Spanish. The facility has a committee that conducts
an annual review of the handbook. The last revision of the STDC detainee handbook was
conducted in March 2015.
STDC has written policies and procedures that provide for the control and safeguarding of
detainee funds and personal property. ODO observed the processing of detainees into and out of
the facility. Property was properly logged and inventoried during the initial intake process and
documented on a property form. ODO observed the property room was clean and wellorganized. Valuables were placed in clear, plastic, zippered property bags secured with
numbered, plastic security locks, and placed in a secure safety deposit box.
Grievance forms are available in the housing units and detainees may obtain assistance from
another detainee or facility staff in preparing a grievance. STDC provides detainees with
envelopes in which to seal grievances, identifying them as sensitive or medically sensitive.
STDC maintains a grievance log to document and track grievances filed by detainees. Detainees
can appeal any grievance decision to the grievance committee. If a detainee is not satisfied with
the grievance committee’s decision it may be further appealed to the facility administrator or
ICE.
The facility has a designated room used as the law library. That room is monitored by a
correctional officer to ensure detainees do not damage legal materials or equipment. The law
library can accommodate nine detainees per session. There are nine computers, one printer,
desks and chairs in this area. A mobile computer cart with a computer is available for detainees
housed in the special management unit. The computers are equipped with the latest version of
the LexisNexis software.

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STDC’s safety manager conducts and documents weekly fire and safety inspections of the entire
facility. Monthly inspections are conducted jointly by the safety manager, maintenance
personnel, and medical staff, with reports forwarded to the warden. In addition, quarterly
inspections of the facility are conducted and documented by administrative staff. The exit
diagrams posted in the living units provide the required information in English and Spanish,
emergency equipment locations, and areas of safe refuge. An area of safe refuge is not
designated on the exit diagrams in the medical housing unit, food service or administrative areas
All staff and detainees involved in food service were observed practicing proper food handling
procedures during food production and tray preparation. Detainees wore proper hair and beard
restraints, gloves, boots and white uniforms. The overall sanitation of the kitchen and storage
areas during the inspection was exceptional. ODO observed safety and sanitation procedures for
cleaning and sanitizing food service equipment were in place and followed. Cleaning agents
were being properly used and all hazardous chemicals were properly controlled, stored and
inventoried. Storage areas were clean and organized. Procedures are in place for rotating food
stocks.
The health services department is staffed 24 hours a day, seven days a week by the ICE Health
Services Corp (IHSC) and contractor, InGenesis Medical Staffing. The approved staffing plan
authorizes(b)(7)epositions, to include a Health Services Administrator (HSA), assistant HSA,
clinical director, staff physician,(b)(7)emidlevel providers,(b)(7)eregistered nurses (RN), and(b)(7)e
licensed vocational nurses (LVN). Mental health staff consists of a psychiatrist and (b)(7)e icensed
clinical social workers (LCSW), and dental services are provided by (b)(7)edentists and (b)(7)edental
assistants. In addition, there is a pharmacist, (b)(7)epharmacy technicians, (b)(7)emedical record
technicians and an administrative assistant. Because the clinical director position has been
vacant since 2013, the IHSC Western Regional Clinical Director stationed in San Diego,
California, serves as STDC’s designated clinical medical authority. ODO was informed he has
access to all detainee medical records by way of the electronic medical record system, and
conducts record reviews on a daily basis. The staff physician position was also vacant at the
time of the inspection, as were (b)(7)e RN, (b)(7)emidlevel provider, and (b)(7)eLVN positions. ODO’s
review of credential and competency files of all licensed medical personnel found them well
organized and current, and credentials were primary source verified.
The facility clinic has four examination rooms, an urgent care/treatment room, a one-chair dental
operatory, nurses’ station, pharmacy, laboratory, digital x-ray room, large conference room,
medical records office, and two mental health interview rooms. Two holding areas located side
by side at the clinic entrance, each accommodating seven detainees, are used for patient waiting
rooms. The detainees are supervised by correctional staff. Each detainee holding area has a
toilet and accessible drinking water. Sanitation in the clinic is maintained at a very high level.
The facility also has a 20 bed medical housing unit staffed by RNs and LVNs 24 hours a day,
seven days a week. This unit has four rooms equipped with negative pressure for respiratory
isolation. In addition, there are rooms in the facility’s intake area and adjacent to the special
management unit for screening and sick call. All areas used for patient encounters provide
adequate privacy.

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The facility also screens detainees during the admissions process for possible victimization and
predatory factors related to the prevention of sexual abuse and assault. The facility classification
officers provide a briefing during detainee orientation stating the facility’s zero tolerance policy
and how to report allegations of sexual abuse, assault or fear of abuse or assault. The briefing is
provided in both English and Spanish. ODO observed the ICE SAAPI posters hung in all
housing units and other areas where detainees are present.
In addition to the information on the ICE SAAPI posters, a detainee can dial “9” from any
detainee phone in any area of the facility and an e-mail message will be sent to senior staff
notifying them a detainee has either a fear of sexual abuse or assault or has been the victim of
sexual abuse or assault. The detainee enters his unique Personal Identification Number (PIN)
into the phone and dials the number “9”. The phone system then generates an e-mail that is sent
to senior facility staff. The senior staff members coordinate an immediate response to remove
the detainee to safety. The e-mail sent by the dial “9” phone systems identifies the specific
detainee and the specific phone from which the call was made. ODO identified the dial “9”
system and associated immediate response from facility staff as a best practice (BP-1).
ICE staff conducts weekly scheduled and unscheduled visits at STDC. The dates and times for
scheduled visits are posted in each housing unit. During visits, ICE officials check the overall
condition of the facility and respond to detainee requests. Visits are documented in the facility’s
electronic logbook. ODO reviewed Facility Liaison Checklists and telephone serviceability
worksheets to verify weekly checks were completed and that records are maintained.
Detainees can submit written requests to ICE staff by filling out an ICE Detainee Request Form
and placing the request in a secure lock box mounted on the wall of the housing unit. ICE staff
collects the detainee request forms daily.
The facility special management unit (SMU) has two tiers, each with 18 single occupancy cells
and a secured shower. Separation of detainees on administrative segregation and disciplinary
segregation is afforded by cell assignments. ODO found the cells freshly painted, appropriately
heated, adequately ventilated, well lit, and very clean. All were equipped with appropriate
furniture and fixtures, with an intercom to communicate with control room staff. The SMU has a
dayroom with a television mounted on the wall, and a metal stool for sitting and viewing.
Officers electronically record detainee cell checks every ten minutes by pressing a wall mounted
sensor with a wand carried by the officer. In addition, officers are required to document checks
every 15 minutes by making a hand-recorded entry in the “Detainee Segregation Log Book”
positioned at the door of each cell.
Detainees placed on suicide observation are housed in two designated rooms in the medical
housing unit or in cell H9 in the intake area. Cell H9 is padded, and used only when a detainee’s
behavior is self-destructive. The observation rooms and cell H9 have been approved by mental
health, medical and correctional staff. All observation rooms are free of objects or structural
elements that could facilitate a suicide attempt. Suicide-resistant smocks, blankets and
mattresses are issued to detainees on suicide watch. When a suicide watch is initiated, a
correctional officer is positioned outside the cell door for constant observation of the detainee on
suicide watch.
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Detainees have reasonable and equitable access to telephones at STDC. The facility provides
telephone access rules in writing to each detainee upon admittance. The telephone availability
ratio for each housing pod is approximately 10 detainees per telephone. Telephones are turned
on each day at approximately 6:30 a.m. and turned off at lockdown each evening at 10:30 p.m.
STDC has a text telephone (TTY) phone located in the control room. The facility transfers the
TTY phone to a private room for detainee use. Detainees that need to use the TTY phone are
provided the same access to the TTY phone as other detainees are provided access to the regular
telephones.
STDC has a comprehensive use of force policy addressing all procedural requirements of the
2011 PBNDS, including confrontation avoidance and using force only as a last resort. Per the
facility policy, any calculated use of force must be authorized by the Warden or his designee.
STDC officers complete 120 hours of initial training and 40 hours of annual in-service training
in the use of force.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 25 detainees. Interview participation was voluntary and none of the detainees
made allegations of mistreatment, abuse, or discrimination. The majority of detainees reported
being satisfied with facility services with the exception of the complaints below:
Law Libraries and Legal Materials: One detainee stated that he had requested use of the law
library the previous week, but had not been allowed to use the law library. ODO checked with
the officer responsible for the law library and the detainee was scheduled for the next available
time the law library was available.
Food Service: Four detainees complained the food was not good and they received small
portions. ODO observed the lunch meal on April 22, 2015, and found the food was served in
appropriate amounts in accordance with the facility menu.
Staff-Detainee Communication: Nine detainees were not sure who their deportation officer was
or when ICE visits the housing pods. ODO reviewed staff detainee communications at the
facility and found no deficiencies with either the policy or process. The names of the deportation
officers and the days the officers visit the housing pods are clearly posted in each housing pod
and stated in the facility handbook.
Hygiene Items: Ten detainees complained that the facility was issuing used razor blades for
shaving. ODO inspected the razor being issued to the detainees and found that the facility does
not issue used razors to detainees. New razors are issued to detainees and after use they are
picked up and placed in a medical sharps container for disposal.

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ICE 2011 PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 15 PBNDS and found STDC fully compliant with the following 14
standards:
1. Admission and Release
2. Custody Classification System
3. Detainee Handbook
4. Funds and Personal Property
5. Food Service
6. Grievance Procedures
7. Law Libraries and Legal Materials
8. Medical Care
9. Sexual Abuse and Assault Prevention & Intervention
10. Significant Self-Harm and Suicide Prevention and Intervention
11. Special Management Units
12. Staff-Detainee Communication
13. Telephone Access
14. 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 one deficiency in the following standard:
1. Environmental Health and Safety
Findings for the standard are presented in the remainder of this report.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at STDC 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 ICE 2011 PBNDS. ODO toured the
facility, interviewed staff, and reviewed procedures and documentation of inspections, hazardous
chemical management, and fire drill documentation.
ODO observed sanitation throughout the facility was maintained at a high level. The food
service department was particularly well maintained, with superior levels of sanitation.
ODO’s inspection found inventories of hazardous substances were complete and current. A
master index of all hazardous substances in the facility, including locations and emergency
numbers, was available in the safety manager’s office and the storage unit located outside of the
secure perimeter. Documentation reviewed by ODO reflects the index is reviewed annually by
the safety manager and a copy is provided to the local fire department. ODO confirmed binders
with Material Safety Data Sheets were present at each location where chemicals are stored and
used. Staff completes annual training in fire emergencies and the use and control of hazardous
substances and chemicals.
STDC’s safety manager conducts and documents weekly fire and safety inspections of the entire
facility. Monthly inspections are conducted jointly by the safety manager, maintenance
personnel, and medical staff, with reports forwarded to the warden. In addition, quarterly
inspections of the facility are conducted and documented by administrative staff.
ODO confirmed quarterly fire drills which include drawing and testing emergency keys are
conducted in all facility locations, including administrative areas. The exit diagrams posted in
living units provide the required information in English and Spanish, emergency equipment
locations, and areas of safe refuge. The exit diagrams in the medical housing unit, food service
and administrative areas did not designate an area of safe refuge (Deficiency EH&S-1). This
deficiency was corrected during the inspection (C-1).
Documentation of generator testing, pest control, and water certification were present and
compliance with the standard was confirmed. Inspection of the medical department found sharps
were properly inventoried and accounted for. Disposal of bio-hazardous waste is handled under
contract with a private contractor.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with 2011 PBNDS, Environmental Health and Safety, section (V)(C)(5), the FOD
must ensure, “In addition to a general area diagram, the following information must be provided
on existing signs:
a. Instructions in English, Spanish and the next most prevalent language at the
facility;
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b. ‘You are here’ markers on exit maps: and
c. Emergency equipment locations.
‘Areas of Safe Refuge’ shall be identified and explained on diagrams. Diagram
posting shall be in accordance with applicable fire safety regulations of the
jurisdiction.”

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