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ICE Detention Standards Compliance Audit - Tulsa County Jail, Tulsa, OK, ICE, 2012

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U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Management Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
Dallas Field Office
Tulsa County Jail
Tulsa, Oklahoma

September 11 - 13, 2012

COMPLIANCE INSPECTION
TULSA COUNTY JAIL
DALLAS FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...............................................................................................1
INSPECTION PROCESS
Report Organization .................................................................................................6
Inspection Team Members .......................................................................................6
OPERATIONAL ENVIRONMENT
Internal Relations .....................................................................................................7
Detainee Relations ...................................................................................................7
ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ................................................................................8
Access to Legal Material .........................................................................................9
Admission and Release ..........................................................................................11
Detainee Classification System..............................................................................13
Detainee Grievance Procedures .............................................................................14
Environmental Health and Safety ..........................................................................16
Food Service ..........................................................................................................18
Funds and Personal Property .................................................................................19
Medical Care ..........................................................................................................20
Telephone Access ..................................................................................................22
Use of Force ...........................................................................................................24

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the Tulsa County Jail (TCJ) in Tulsa, Oklahoma,
from September 11 to 13, 2012. TCJ, which opened in August 1999, is owned by the Tulsa
Criminal Justice Authority and operated by the Tulsa County Sheriff’s Office. U.S. Immigration
and Customs Enforcement (ICE), Office of Enforcement and Removal Operations (ERO) began
housing detainees at TCJ in January 2008 under an intergovernmental service agreement (IGSA)
between ICE and the Tulsa County Sheriff’s Office. Male and female detainees of all security
classification levels (Level I – lowest threat, Level II – medium threat, Level III – highest threat)
are detained at the facility for periods in excess of 72 hours. TCJ has a total capacity of
1,714 beds, and can accommodate a maximum of 190 ICE detainees. At the time of the CI, TCJ
housed 156 ICE detainees (154 males, 2 females). The average daily detainee population is 167.
The average length of stay for an ICE detainee is 27 days. Aramark provides food service under
contract. Correctional Healthcare Companies provides medical care under contract. TCJ holds
accreditation from the American Corrections Association and the National Commission on
Correctional Health Care.
The ICE ERO Field Office Director in Dallas, Texas (ERO Dallas) is responsible for ensuring
facility compliance with ICE policies and the ICE National Detention Standards (NDS). An
Assistant Field Office Director stationed at the ERO office in Oklahoma City, Oklahoma
(ERO Oklahoma City) has oversight responsibility for TCJ. ICE staff permanently assigned to
TCJ is comprised of(b)(7)eSupervisory Detention and Deportation Officer,(b)(7)e Deportation
Officers, and (b)(7)eImmigration Enforcement Agent. There is no Detention Service Manager
assigned to TCJ.
The Sheriff is the highest-ranking official at TCJ, followed by the Undersheriff. The TCJ Jail
Administrator is responsible for oversight of daily facility operations. Supervisory staff at TCJ is
comprised of(b)(7)emajor (b)(7)e captains(b)(7)esergeants, and (b)(7)e corporals. TCJ non-supervisory
staff consists of (b)(7)edetention officers,(b)(7)etransportation officers, and jail administrative staff.
In July 2010, ODO conducted a Quality Assurance Review at TCJ. Of the 29 NDS reviewed,
four were in full compliance. ODO cited 35 deficiencies in 25 of the 29 standards reviewed.
In May 2012, ERO Detention Standards Compliance Unit contractor, the Nakamoto Group, Inc.,
conducted an annual review of the ICE NDS at TCJ. The facility received an overall rating of
“Acceptable,” and was found compliant with all 36 standards reviewed.
During this CI, ODO reviewed 16 NDS. Six standards were determined to be fully compliant,
while 19 deficiencies were identified in the following ten standards: Access to Legal
Material (3 deficiencies), Admission and Release (3), Detainee Classification System (1),
Detainee Grievance Procedures (3), Environmental Health and Safety (2), Food Service (1),
Funds and personal Property (1), Medical Care (1), Telephone Access (3), and Use of Force (1).
Four of these were repeat deficiencies from the 2010 ODO Quality Assurance Review, one each
in Detainee Grievance Procedures, Environmental Health and Safety, Funds and Personal
Property, and Telephone Access.

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This report details all deficiencies and refers to the specific, relevant sections of the NDS. ERO
will be provided a copy of this report to assist in developing corrective actions to resolve the
19 deficiencies. These deficiencies were discussed with TCJ management and ICE personnel
during the inspection, as well as during the closeout briefing conducted on September 13, 2012.
The majority of the deficiencies had minimal effects on detainee life-safety and the overall
operational readiness of the facility.
ODO found the overall sanitation level of the facility acceptable, other than two showers in
housing unit F-18 and one shower in F-19 with broken tiles, mildew, and a build-up of soap
scum. The facility safety officer was present during the inspection, and placed a work order to
have the showers cleaned and repaired. Repairs were not completed prior to the conclusion of
the CI.
TCJ uses an electronic kiosk system which is located in each detainee housing area. Detainees
use the system’s English and Spanish options to request medical care, place commissary orders,
file grievances, and make requests. ODO recognizes the use of the electronic kiosk system as a
best practice, as it allows efficient and timely processing of these requests.
TCJ has a dedicated law library equipped with four computers, loaded with the most recent
version of Lexis/Nexis software, and sufficient chairs and tables for detainee use. The library
staff ensures that, upon request, detainees can access copying services, paper, and writing
implements for a fee of $.10 per item. Fees are deducted from individual commissary accounts
prior to providing the requested supplies. Detainees without funds on account are considered
indigent and are provided the requested supplies free of charge. These materials should be
provided free of charge to all detainees. TCJ does not have written policies describing the
procedures to assist illiterate and non-English speaking detainees. ODO noted TCJ does not post
the law library schedule in detainee housing areas.
During the admissions process, detainees undergo a medical screening, attend a facility
orientation, and receive the TCJ facility handbook and the ICE National Detainee Handbook.
Both handbooks are available in English and Spanish. ODO verified ICE provides the
information and forms needed for the classification process, and detainees are classified by TCJ
staff upon arrival. Assigned classification levels are not reviewed by a supervisor for accuracy
and completeness. ODO also observed ICE detainees are issued photo identification cards that
do not identify or distinguish detainee classification levels. ODO advised facility staff that
detainee classifications should be readily identifiable on-sight via color-coded detainee uniforms
or wristbands that cannot be easily removed.
When detainees are released or transferred out of the facility, TCJ staff does not fingerprint
detainees. TCJ staff stated they do not fingerprint detainees upon release, because this occurs
during the admission process. During the release process, ODO observed TCJ staff identify ICE
detainees only by name, date of birth, and mother’s name, rather than by fingerprints.
TCJ has a grievance system that allows detainees to file emergency grievances, as well as formal
and informal grievances, and to appeal grievance decisions. Responses to informal, verbal
grievances are not documented and recorded in individual detention files. ODO verified formal
grievances were responded to within five days of the grievance being filed. A review of the TCJ
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grievance log verified formal or written grievances are logged with all pertinent information,
including the nature of the grievance and the date of resolution. Log numbers are assigned in
chronological order for each grievance; however, review of 20 detention files confirmed copies
of the grievance forms are not maintained in individual detention files.
The TCJ facility handbook provides procedures for filing informal, formal, and emergency
grievances, but the handbook does not provide instructions regarding how detainees can contact
ICE to appeal a grievance decision made by the TCJ Jail Administrator, or file a complaint about
officer misconduct directly with the Department of Homeland Security, Office of Inspector
General (OIG). However, informational posters are conspicuously posted in all detainee housing
units to advise detainees of the process for reporting misconduct allegations to the OIG.
ODO verified Material Safety Data Sheets and a master index of hazardous substances are
available and complete. Reports for water quality and pest control services are available and
current. Exit diagrams are posted throughout the facility. The diagrams are printed in English
and Spanish, and show the locations of emergency equipment. Inventories of hazardous
substances are accurate. Monthly fire drills are conducted in each area of the facility.
Aramark provides food service under contract, and is supported by a crew of ICE detainee and
inmate workers. ODO verified all food service personnel receive medical clearances. ODO
observed the staff was actively involved in the preparation and service of meals to ensure all
food items were correctly prepared, served at the appropriate temperatures, and properly
presented. ODO verified religious and medically prescribed meals are provided, with proper
documentation on file. The kitchen is well equipped, food items are properly stored, and a high
level of sanitation is maintained throughout the food service area. Inspection of the food carts
used to deliver trays found they had hasps (fasteners), but did not have locks to prevent
tampering or transference of contraband.
TCJ has written policies and procedures to provide for the control and safeguarding of the funds
and personal property of detainees. Property is inventoried and logged during the intake process,
and documented on a personal property form. This process was verified by inspecting five
property forms attached to detainee property bags. Inspection confirmed detainee valuables are
kept in plastic zippered property bags, sealed with numbered zip ties. ODO observed the
property room was well-organized, clean, and secure.
Health services are provided 24 hours a day, seven days a week. The medical clinic is of
adequate size and sufficiently equipped to serve the detainee population. Administrative
oversight of the clinic is provided by the Health Services Administrator, and a full-time
physician is the clinical medical authority. Additional full-time staff positions include a
psychiatrist, an advanced practice registered nurse practitioner, a director of nursing, (b)(7)e
licensed professional mental health counselors, (b)(7)e registered nurses,(b)(7)elicensed practical
nurses, and (b)(7)ecertified medication aides. At the time of the review, there were vacancies for
(b)(7)e mental health counselor, (b)(7)elicensed practical nurse, and (b)(7)eadvanced practice registered
nurse practitioner. Part-time staff includes(b)(7)edentist,(b)(7)edental assistant,(b)(7)e registered
nurses, (b)(7)e licensed practical nurses, (b)(7)e certified medication aides, and (b)(7)e
obstetrics/gynecology physician. The medical staff is supported by (b)(7)e clerical staff. All

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professional licenses were present and primary source verified. ODO determined staffing was
adequate to meet the health needs of detainees at TCJ.
Review of(b)(7)ecustody staff training records found all hold current certification in
cardiopulmonary resuscitation (CPR) and first aid. Review of training records for all medical
staff found no record of CPR and first aid for the part-time physician. The physician was on
extended leave, and the Correctional Healthcare Companies was unsuccessful in contacting her
to verify current certification.
Nursing staff complete medical and mental health screening of detainees at intake. Screening
includes testing for tuberculosis by way of tuberculin skin test. Consent for treatment is obtained
during the intake process. A physical examination is completed by a designated registered nurse.
ODO verified the registered nurse is trained, and a physician reviews and countersigns each
physical examination. The medical record review confirmed a physical examination is
completed within six days on average, well within the 14 days required by the standard. In
addition, the record review confirmed each physical examination is hands-on and countersigned
by the physician.
Detainees enter sick call requests via the electronic kiosk system in the housing units. TCJ staff
stated sick call forms are available in hard copy format if the kiosk system malfunctions. The
forms are deposited in a locked box and retrieved by medical staff twice daily. Nursing staff
triage sick call requests upon receipt, and conduct daily sick call in a designated private room in
each housing unit, or in the clinic.
ODO verified scheduled and unscheduled visits are conducted weekly by ICE management and
staff. Detainees can submit written questions, requests, or concerns to TCJ and ICE staff by
completing a request form via the kiosk system or by completing a hard copy detainee request
form. The requests are collected by facility staff, and timely routed to ICE. Requests are filed in
individual detention files, and responded to within 72 hours. ICE also maintains an electronic
request log for documenting and tracking detainee requests submitted to ICE.
ODO observed a total of 180 telephones throughout the facility, including eight telephones in
each housing unit designated for detainee use. Detainees confined to the special management
unit also have access to telephones. ODO interviewed facility staff and ICE personnel, and
learned the facility recently upgraded their telephone system with voice recognition technology.
The system is set up to recognize and identify a detainee, and enable the detainee to make a
telephone call from any telephone within the facility; however, the telephones in the detainee
housing units were not working properly due to distortion issues with the voice recognition
function. The telephone contractor responsible for the telephone system was working on the
system during the CI.
There has never been a detainee death at TCJ. From January 2012 through September 2012,
there had been four detainee suicide watches and one detainee suicide attempt. Records prior to
2012 were not available for review. The medical record of the detainee who attempted suicide
confirmed mental health treatment and suicide watch management were consistent with the NDS
and TCJ policy.

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ODO reviewed the TCJ Sexual Abuse and Assault Prevention and Intervention policy.
Information concerning sexual abuse and assault prevention and intervention is posted in English
and Spanish in all housing units and other locations throughout the facility. TCJ has
implemented total adherence to its policy, and the Tulsa County Sheriff’s Office has a zero
tolerance policy regarding inmate rape and sex-related offenses and attempts. TCJ staff advised
ODO that there have been no allegations of detainee sexual abuse or assault.
No ICE detainees have been placed in disciplinary segregation during the 12 months preceding
the CI. The special management unit consists of three single-cell units, one with 12 beds, the
second with 14 beds, and the third with 22 beds. Each of the three units has its own dayroom
and shower area. An outdoor recreation area is adjacent to the units. Review of TCJ policy
confirmed disciplinary segregation is imposed as a sanction through the disciplinary process.
The policy adequately addresses conditions of confinement and privileges required by the NDS.
TCJ staff receives annual training in use of force. This includes confrontation avoidance and the
use of force team technique. Since September 2011, there has been only one use of force
incident involving an ICE detainee. Review of documentation by ODO verified it was an
immediate use of force incident involving a detainee who resisted being placed in restraints.
Reports reflected the force used was minimal and appropriate. There were no injuries, and the
detainee was examined by medical staff immediately following the incident. ERO Dallas was
notified; however, TCJ management did not conduct an after-action review for 29 days following
the incident, rather than within the required two working days of the detainee’s release from
restraints.

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INSPECTION PROCESS
ODO inspections evaluate the welfare, safety, and living conditions of detainees. ODO primarily
focuses on areas of noncompliance with the ICE NDS or the ICE Performance Based National
Detention Standards, as applicable. The NDS apply to TCJ. In addition, ODO may focus its
inspection based on detention management information provided by ERO Headquarters (HQ)
and ERO field offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at TCJ to determine compliance with current policies
and detention standards. Prior to the inspection, ODO collected and analyzed relevant
allegations and detainee information from multiple ICE databases, including the Joint Integrity
Case Management System, the ENFORCE Alien Booking Module, and the ENFORCE Alien
Removal Module. ODO also gathered facility facts and inspection-related information from
ERO HQ staff to prepare for the site visit at TCJ.

REPORT ORGANIZATION
This report documents inspection results, serves as an official record, and is intended to provide
ICE and detention facility management with a comprehensive evaluation of compliance with
policies and detention standards. It summarizes those NDS that ODO found deficient in at least
one aspect of the standard. ODO reports convey information to best enable prompt corrective
actions and to assist in the on-going process of incorporating best practices in nationwide
detention facility operations.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
NDS, ICE policy, or operational procedure. When possible, the report includes contextual and
quantitative information relevant to the cited standard. Deficiencies are highlighted in bold
throughout the report and are encoded sequentially according to a detention standard designator.
Comments and questions regarding the report findings should be forwarded to the Deputy
Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

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

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Special Agent (Team Leader)
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

6

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

Tulsa County Jail
ERO Dallas

OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the TCJ Jail Administrator and the ERO Assistant Field Office Director. Both
reported the working relationship between TCJ and ICE personnel is excellent, morale is high,
and the working conditions are adequate to accomplish all required duties. The TCJ Jail
Administrator stated she observes ICE staff visiting detainees in the housing units multiple times
per week, communicating with detainees, and addressing detainee issues and concerns.
TCJ staff stated they do not receive any formal training regarding the ICE NDS.

DETAINEE RELATIONS
ODO interviewed 19 randomly-selected ICE detainees (17 male, 2 female) to assess the overall
living and detention conditions at TCJ. Detainees did not express any complaints or concerns
regarding the detainee handbook, recreation, food service, religious services, visitation, or the
law library.
All detainees stated they did not know who their Deportation Officer was, but stated ICE
personnel visit the housing units daily to speak with any detainees who have questions about
their immigration cases. ODO did not observe Deportation Officer visitation schedules posted in
the housing units.
All detainees complained the facility’s telephones were not working properly. Facility staff
stated the telephone system was experiencing problems. The TCJ telephone contractor was
troubleshooting the issues during the CI, but the situation was not resolved prior to completion of
the inspection.
Two detainees complained about not receiving timely medical care. ODO reviewed these
complaints and determined both detainees received adequate and timely treatment.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 NDS and found TCJ fully compliant with the following
six standards:
Detainee Handbook1
Disciplinary Policy
Special Management Unit (Administrative Segregation)
Special Management Unit (Disciplinary Segregation)
Staff-Detainee Communication
Suicide Prevention and Intervention
As these six standards were compliant at the time of the review, a synopsis for these standards
was not prepared for this report.
ODO found deficiencies in the following ten standards:
Access to Legal Material
Admission and Release
Detainee Classification System
Detainee Grievance Procedures
Environmental Health and Safety
Food Service
Funds and Personal Property
Medical Care
Telephone Access
Use of Force
Findings for each of these standards are presented in the remainder of this report.

1

The detainee handbook met all the requirements in the Detainee Handbook NDS. Other, separate NDS also
require certain information be in the handbook. The TCJ handbook was missing certain information specified in
other NDS; these omissions are reported as Deficiency ALM-1, Deficiency DGP-3, and Deficiency F&PP-1 under
the relevant NDS.
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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at TCJ to determine if detainees have
access to a law library, legal materials, courts, counsel, and document copying equipment to
facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed
policies, procedures, and the detainee handbook, inspected the law library, and interviewed staff
and detainees.
TCJ has a dedicated law library equipped with four computers, loaded with the most recent
version of Lexis/Nexis software, and sufficient chairs and tables for detainee use. The library
staff ensures that, upon request, detainees have access to copying services, paper, and writing
implements for a fee of $.10 per item. This fee is taken out of the detainee’s account prior to
providing the requested supplies. Detainees without funds on account are considered indigent,
and are provided the requested supplies free of charge. The facility should provide these
materials free of charge to all detainees (Deficiency ALM-1). TCJ does not have a written
policy describing procedures to assist illiterate and non-English speaking detainees
(Deficiency ALM-2).
The TCJ facility handbook does not inform detainees of the procedure for requesting legal
reference materials not maintained in the library. The TCJ facility handbook also does not
contain a description of the procedure for notifying a designated employee that library material is
missing or damaged. ODO observed TCJ management did not post law library schedules in the
ICE detainee housing units (Deficiency ALM-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must
ensure the law library shall provide an adequate number of typewriters and/or computers, writing
implements, paper, and office supplies to enable detainees to prepare documents for legal
proceedings.
The facility shall designate an employee with responsibility to inspect the equipment at least
weekly and ensure that it is in good working order, and to stock sufficient supplies.
Equipment and office supplies shall generally include:
1. Typewriters with replacement typewriter ribbon and correction tape. Computers may also be
provided for detainee use.
2. Carbon paper (unless a copier is available)
3. Writing implements
4. Writing tablets
5. Non-toxic liquid paper
DEFICIENCY ALM-2
In accordance with the ICE NDS, Access to Legal Material, section (III)(L), the FOD must
ensure unrepresented illiterate or non-English speaking detainees who wish to pursue a legal

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claim related to their immigration proceedings or detention and indicate difficulty with the legal
materials must be provided with more than access to a set of English-language law books.
Facilities shall establish procedures to meet this obligation, such as:
1. helping the detainee obtain assistance in using the law library and drafting legal documents
from detainees with appropriate language and reading-writing abilities; and
2. assisting in contacting pro bono legal-assistance organizations from the INS-provided list.
If such methods prove unsuccessful in providing a particular non-English-speaking or illiterate
detainee with sufficient assistance, the facility shall contact the INS to determine appropriate
further action.
DEFICIENCY ALM-3
In accordance with the ICE NDS, Access to Legal Material, section (III)(Q)(2)(5)(6), the FOD
must ensure the detainee handbook or equivalent, shall provide detainees with the rules and
procedures governing access to legal materials, including the following information:
2. the scheduled hours of access to the law library;
5. the procedure for requesting legal reference materials not maintained in the law library; and
6. the procedure for notifying a designated employee that library material is missing or
damaged.
These policies and procedures shall also be posted in the law library along with a list of the law
library’s holdings.

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ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at TCJ to determine if procedures are in
place to protect the health, safety, security, and welfare of each person during the admission and
release process, in accordance with the ICE NDS. ODO reviewed policies, procedures, and
detention files; observed the admission process; and interviewed staff and detainees.
During intake processing, ODO noted detainees undergo medical screenings, answer questions,
complete questionnaires and forms, attend facility site orientation, and receive a TCJ facility
handbook and the ICE National Detainee Handbook. Both handbooks are available in English
and Spanish. Detainees are provided with appropriate clothing and hygiene supplies at no cost.
ODO verified ICE detainees are issued identification cards, but the identification cards do not
identify or distinguish the classification level of detainees. ODO advised facility staff that
detainee classifications should be readily identifiable on sight via color-coded detainee uniforms
or wristbands that cannot be easily removed (Deficiency AR-1). Inmates and detainees are
classified in the same manner and neither population receives distinctive uniforms or wristbands.
TCJ management stated they do not distinguish between ICE detainees and inmates in their
facility for the protection of the detainees, because detainees may be treated differently by local
inmates if they are easily identifiable.
TCJ personnel do not complete a missing property form when a newly-admitted detainee claims
property has been lost or left behind at a previous facility (Deficiency AR-2). TCJ directs
detainees who claim missing or lost property to contact ICE via telephone.
When detainees are released or transferred out of the facility, TCJ staff does not fingerprint
detainees (Deficiency AR-3). TCJ staff stated they do not fingerprint detainees upon release,
because this occurs during the admission process. During the release process, ODO observed
TCJ staff identify ICE detainees only by name, date of birth, and mother’s name, rather than by
fingerprints.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
In accordance with the ICE NDS, Admission and Release, section (III)(C), the FOD must ensure
the classification process determines the appropriate level of custody for each detainee. Once
this is established, staff can issue the detainee clothing/wristband in the appropriate color for
his/her classification level.
DEFICIENCY AR-2
In accordance with the ICE NDS, Admission and Release, section (III)(I), the FOD must ensure
the officer shall complete a Form I-387, “Report of Detainee’s Missing Property” when any
newly arrived detainee claims his/her property has been lost or left behind. IGSA facilities shall
forward the completed I-387s to INS.

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DEFICIENCY AR-3
In accordance with the ICE NDS, Admission and Release, section (III)(J), the FOD must ensure
staff must complete certain procedures before any detainee’s release, removal, or transfer from
the facility. Necessary steps include completing and processing forms, closing files,
fingerprinting; returning personal property; and reclaiming facility-issued clothing, bedding, etc.
INS will approved [sic] the IGSA release procedures.
Note: The Admission and Release NDS has two “J” sections. This citation refers to the second
“J,” titled Releases.

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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System standard at TCJ to determine if there is a
formal classification process for managing and separating detainees based on verifiable and
documented data, in accordance with the ICE NDS. ODO toured the booking area and
classification department, interviewed staff, and reviewed classification documentation and local
policy.
Newly-arrived ICE detainees are classified by TCJ booking staff. ODO verified ICE provides
the information and forms necessary for the classification process. TCJ booking staff originates
two files: one is maintained in booking and contains all forms provided by ICE; the second is
maintained in the classification department and contains all classification documents. Inspection
of 12 detainee classification files found none contained documentation of review by a supervisor
(Deficiency DCS-1). Supervisory review assures classification levels are appropriately and
objectively assigned.
Review of the facility’s policy and detainee handbook confirmed required information and
procedures are addressed. ODO verified detainees are assigned to housing units based on their
classification level and in accordance with the NDS. Procedures are in place to reclassify
detainees, if necessary.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE NDS, Detainee Classification System, section (III)(C), the FOD must
ensure, in all detention facilities, a supervisor will review the intake/processing officer’s
classification files for accuracy and completeness. Among other things, the reviewing officer
shall ensure that each detainee has been assigned to the appropriate housing unit.
In addition, the reviewing officer will recommend changes in classification due to:
1. incidents while in custody;
2. a classification appeal by a detainee or recognized representative (see below); or
3. specific, articulable facts that surface after the detainee's in-processing.

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedures standard at TCJ 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 NDS. ODO interviewed staff and detainees, reviewed policies and procures and reviewed
grievances, grievance responses, and the grievance log.
TCJ has a grievance system allowing detainees to file emergency grievances, as well as formal
and informal grievances, and to appeal grievance decisions. Informal grievances are lodged and
responded to verbally. Interviews with facility staff determined informal grievance responses are
not documented and recorded in individual detention files (Deficiency DGP-1).
If the grievance is not resolved at the informal level, or if the detainee decides to skip the
informal process, the detainee may proceed with submitting a formal grievance in writing. A
grievance committee reviews the initial findings within five working days of the formal
grievance and provides a written response to the detainee stating the decision and the reason for
the decision. If a detainee agrees with the proposed resolution, the grievance form is signed and
a copy is placed in the grievance logbook. If the detainee is not satisfied with the decision, an
appeal can be filed with the TCJ Jail Administrator. The TCJ Jail Administrator reviews the
appeal, and the detainee receives a written decision within five days.
Grievance forms are available upon request from TCJ housing unit staff. In addition, detainees
are able to complete a grievance via the TCJ electronic kiosk system. ODO reviewed
20 grievances filed between January 2012 and September 2012. All grievances reviewed were
responded to within five days of filing. A review of the grievance log demonstrated that
grievances are logged with all pertinent information, including the nature of the grievance and
the date of resolution. Log numbers are assigned in chronological order for each grievance.
However, copies of the grievances were not placed in individual detention files
(Deficiency DGP-2). This is a repeat deficiency from the July 2010 ODO inspection.
The TCJ facility handbook provides procedures for filing informal, formal, and emergency
grievances, but the handbook does not provide instructions regarding how detainees can contact
ICE to appeal a grievance decision made by the TCJ Jail Administrator, or file a complaint about
officer misconduct directly with the Department of Homeland Security, Office of Inspector
General (OIG) (Deficiency DGP-3). Informational posters are conspicuously posted in all
detainee housing units to advise detainees of the process for reporting misconduct allegations to
the OIG. ODO recommends TCJ revise the handbook to include grievance and appeal
procedures applicable to ICE detainees, and the procedures for contacting the OIG to report
misconduct allegations.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(1), the FOD
must ensure the detainee is free to bypass or terminate the informal grievance process, and
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proceed directly to the formal grievance stage. If an oral grievance is resolved to the detainee’s
satisfaction at any level of review, the staff member need not provide the detainee written
confirmation of the outcome, however the staff member will document the results for the record
and place his/her report in the detainee’s detention file.
DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must
ensure a copy of the grievance will remain in the detainee’s detention file for at least three years.
The facility will maintain that record for a minimum of three years and subsequently, until the
detainees leaves INS custody.
DEFICIENCY DGP-3
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(4)(6), the
FOD must ensure the facility shall provide each detainee, upon admittance, a copy of the
detainee handbook or equivalent. The grievance section of the detainee handbook will provide
notice of the following [among others]:
4. The procedures for contacting the INS to appeal the decision of the OIC of a CDF or an
IGSA facility.
6. The opportunity to file a complaint about officer misconduct directly with the Justice
Department.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at TCJ 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 NDS. ODO toured the facility,
interviewed staff, and reviewed procedures and documentation of inspections, hazardous
chemical management, and fire drills.
ODO verified Material Safety Data Sheets and a master index of hazardous substances are
available and complete. Inventories of hazardous substances are accurate. Reports for water
quality and pest control services are available and current. Exit diagrams are posted throughout
the facility. The diagrams are printed in English and Spanish, and show the locations of
emergency equipment.
ODO found the overall sanitation of the facility was acceptable. However, during inspection of
housing units and shower areas, ODO noted two showers in housing unit F-18 and one shower in
F-19 had broken tiles, mildew, and a build-up of soap scum. The TCJ safety officer was present
during the inspection, and placed a work order to have the showers cleaned and repaired.
Repairs were not completed prior to conclusion of the CI.
Monthly fire drills are conducted in each area of the facility. Fire drill reports document the
location, participants, and time each drill was announced and completed. Emergency keys are
not drawn and tested during fire drills (Deficiency EH&S-1). Drawing and testing emergency
keys supports staff familiarity with the keys, locks, and exit routes, and assures expeditious
egress in the event of an emergency.
The facility does not have a dedicated barbering area. Barber operations are conducted in
housing unit multi-purpose rooms, which are also used for passing out meal trays, interviews,
educational activities, and group meetings. The rooms have hot and cold running water, and
barbering supplies are made available, but sanitation regulations are not posted
(Deficiency EH&S-2). This is a repeat deficiency from the 2010 ODO inspection and the
2012 ERO inspection. TCJ management stated barbering is conducted in the multi-purpose
rooms to limit the movement of detainees throughout the facility.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the
FOD must ensure emergency key drills will be included in each fire drill, and timed. Emergency
keys will be drawn and used by the appropriate staff to unlock one set of emergency exit doors
not in daily use. NFPA recommends a limit of four and one-half minutes for drawing keys and
unlocking emergency doors.
DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1)(4), the
FOD must ensure sanitation of barber operations is of the utmost concern because of the possible
transfer of diseases through direct contact or by towels, combs and clippers. Towels must not be
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reused after use on one person. Instruments such as combs and clippers will not be used
successively on detainees without proper cleaning and disinfecting. The following standards will
be adhered to:
1. The operation will be located in a separate room not used for any other purpose. The floor
will be smooth, nonabsorbent and easily cleaned. Walls and ceiling will be in good repair
and painted a light color. Artificial lighting of at least 50-foot candles will be provided.
Mechanical ventilation of 5 air changes per hour will be provided if there are no operable
windows to provide fresh air. At least one lavatory will be provided. Both hot and cold
water will be available, and the hot water will be capable of maintaining a constant flow of
water between 105 degrees and 120 degrees.
4. Each barbershop will have detailed hair care sanitation regulations posted in a conspicuous
location for the use of all hair care personnel and detainees.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at TCJ to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO
reviewed policies and documentation, interviewed staff, inspected food storage and preparation
areas, and observed meal preparation and service.
Food service is operated by contractor Aramark and supported by a crew of ICE detainee and
inmate workers. ODO verified all food service personnel receive medical clearances. The staff
ensures food items are correctly prepared, served at the appropriate temperature, and are properly
presented. ODO verified religious and medically prescribed meals are provided, with proper
documentation on file. A nutritional analysis of the master cycle menu and determination of
adequacy were conducted by a registered dietician on April 13, 2012. Documentation of pest
control services, and water and equipment temperature checks verified compliance with the
standard. The kitchen is well equipped, food items are properly stored, and sanitation is at a high
level throughout the food service area.
TCJ has a satellite system of meal service involving preparation of meals in the kitchen and
delivery to housing units on trays. Inspection of the food carts used to deliver trays found they
had hasps (fasteners), but did not have locks (Deficiency FS-1). Locks on food carts prevent
food tampering and transference of contraband.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE NDS, Food Service, section (III)(C)(2)(g), the FOD must ensure, if
the facility does not have enough equipment to maintain the minimum or maximum temperature
required for food safety, the affected items (e.g., salad bar staples such as lettuce, meat, eggs,
cheese) must be removed and discarded after two hours at room temperature.
Food will be delivered from one place to another in covered containers. These may be individual
containers, such as pots with lids, or larger conveyances that can move objects in bulk, such as
enclosed, satellite-feeding carts. Food carts must have locking devices.
All food safety provisions (sanitation, safe-handling, storage, etc.) apply without exception to
food in transit.

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at the TCJ to determine if controls are
in place to inventory, issue receipts for, maintain, and safeguard detainees’ personal property, in
accordance with the ICE NDS. ODO interviewed staff, reviewed policies and procedures, and
inspected the property room.
TCJ has written policies and procedures which provide for the control and safeguarding of
detainees’ funds and personal property. Because no detainees were received or transferred from
the facility during the review, ODO did not observe intake or release processing. Property is
inventoried and logged during the intake process and documented on a personal property form.
This process was verified by inspecting five property forms attached to detainees’ property bags.
Clothing is placed in hanging clothing bags on a rotating conveyor system in the secure property
room. The property room was well-organized and clean. Valuables were placed in plastic
zippered property bags secured with numbered zip ties. The bags were stored in a secure area.
Inspection of the valuables bags for five detainees confirmed they were secure and in their
assigned location.
Detainees do not keep money in their possession. Monies are placed in sealed envelopes and
deposited in a drop-safe located in the detainee admission area. The envelopes are removed by a
member of the accounting staff in the presence of the Intake Supervisor, and the funds are
deposited into the detainees’ commissary accounts the following business day.
The TCJ handbook does not state that, upon request, all detainees will be provided an
ICE-certified copy of any identity document, such as a passport or birth certificate, placed in
their respective A-files (Deficiency F&PP-1). This is a repeat deficiency from the July 2010
ODO inspection

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must
ensure the detainee handbook or equivalent notifies the detainees of facility policies and
procedures concerning personal property, including upon request, detainees will be provided an
ICE-certified copy of any identity document (passport, birth certificate, etc.) placed in their A
files.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at TCJ to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE NDS. ODO toured the medical clinic, reviewed policies and procedures, examined
25 medical records, verified medical staff credentials, and interviewed the Health Services
Administrator, the director of nursing, the psychiatrist, and staff.
TCJ is accredited by the American Correctional Association and the National Commission on
Correctional Health Care. The clinic is operated by contractor Correctional Healthcare
Companies. Health services are provided 24 hours a day, seven days a week. Administrative
oversight of the clinic is provided by the Health Services Administrator. A full-time physician is
the clinical medical authority. Additional full-time staff positions include a psychiatrist, an
advanced practice registered nurse practitioner, a director of nursing,(b)(7)elicensed professional
mental health counselors, (b)(7)e registered nurses(b)(7)eicensed practical nurses, and (b)(7)ecertified
medication aides. At the time of the review,(b)(7)emental health counselor,(b)(7)elicensed practical
nurse, and(b)(7)eadvanced practice registered nurse practitioner positions were vacant. Part-time
staff includes (b)(7)edentist,(b)(7)edental assistant,(b)(7)e registered nurses, (b)(7)e licensed practical
nurses, (b)(7)e certified medication aides, and(b)(7)eobstetrics/gynecology physician. The medical
staff is supported by (b)(7)e clerical staff. All professional licenses are present and primary source
verified. ODO determined staffing is adequate to meet detainee health needs.
Review of(b)(7)ecustody staff training records found all hold current certification in
cardiopulmonary resuscitation (CPR) and first aid. Review of training records for all medical
staff found no record of CPR and first aid certifications for the part-time physician
(Deficiency MC-1). The physician was on extended leave and Correctional Healthcare
Companies could not verify current certification.
The medical clinic is sufficiently equipped to serve the detainee population. There are two exam
rooms, a secure pharmacy, a radiology room, and a large nursing station. TCJ implemented an
electronic medical records system in March 2011, and has scanned many earlier records into the
system. There are 28 rooms available for patient care, including ten which have negative air
pressure for tuberculosis isolation, and four designated for suicide watch.
Medical and mental health screening is completed by nursing staff at intake. Screening includes
testing for tuberculosis by way of tuberculin skin test. Consent for treatment is obtained during
the intake process. ODO verified documentation of screening, tuberculosis testing, and consent
for treatment was present in all 25 medical records reviewed.
A physical examination is completed for each detainee by a designated registered nurse. ODO
verified the registered nurse is trained, and a physician reviews and countersigns each physical
examination. The medical record review confirmed a physical examination is completed within
six days on average, well within the 14 days required by the standard. In addition, the record
review confirmed all physical examinations were hands-on and counter-signed by the physician.
Detainees enter sick call requests into the kiosk system available in each of the housing units,
which has a Spanish language option. During interviews, officers informed ODO that sick call
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forms are available if the computer system malfunctions. The forms are deposited in a locked
box and retrieved by medical staff twice daily. Nursing staff triage sick call requests upon
receipt, and conduct daily sick call in a designated private room in each housing unit, or in the
clinic. Detainees are not charged a fee for healthcare services.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure
detention staff will be trained to respond to health-related emergencies within a 4-minute
response time. This training will be provided by a responsible medical authority in cooperation
with the OIC and will include the following [among others]:
2. The administration of first aid and cardiopulmonary resuscitation (CPR).

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at TCJ to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and
others in the community, in accordance with the ICE NDS. ODO toured the facility, interviewed
ERO and facility staff, as well as ICE detainees, and reviewed telephone serviceability records
maintained by ERO.
ODO observed a total of 180 telephones throughout the facility, including eight telephones in
each housing unit designated for detainee use. Detainees confined to the special management
unit also have access to telephones. TCJ management stated emergency personal calls are
allowed for detainees, and incoming messages are taken and provided to detainees. ICE staff
provides telephone access in a private office for detainees to contact family members for
emergencies, as well as for calls related to legal matters. All detainees interviewed stated they
were provided ample access to telephones; however, detainees stated the telephones were not
working properly.
ODO interviewed facility staff and ICE personnel, and learned the facility recently upgraded
their telephone system with voice recognition technology. Detainees record a voice message to
the system, and the system is supposed to recognize and identify a detainee, and enable the
detainee to make a telephone call from any telephone within the facility. However, the
telephones in the detainee housing units were not working properly, due to a voice recognition
distortion issue (Deficiency TA-1). Detainees complained during interviews of having difficulty
making telephone calls. ODO learned, due to the sensitive recording requirements to operate the
telephones, Spanish-speaking detainees were having problems understanding the instructions in
English. The telephone contractor responsible for the telephone system was troubleshooting the
issue during the CI; however, repairs were not completed prior to the conclusion of the
inspection.
The detainee handbook provides the rules for telephone usage; however, a written copy of the
telephone rules was not posted in general areas of the housing units where detainees could easily
see them (Deficiency TA-2). This is a repeat deficiency from the July 2010 ODO inspection.
ODO also observed there were no notices posted on the telephones in the detainee housing areas
indicating all telephone calls are subject to monitoring, or the procedures for obtaining an
unmonitored call to a court, legal representative, or for obtaining legal presentation
(Deficiency TA-3). These issues were not resolved prior to the conclusion of the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE NDS, Telephone Access, section (III)(D), the FOD must ensure the
facility shall maintain detainee telephones in proper working order. Appropriate facility staff
shall inspect the telephones regularly, promptly report out-of-order telephones to the repair
service, and ensure that required repairs are completed quickly.

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DEFICIENCY TA-2
In accordance with the ICE NDS, Telephone Access, section (III)(B), the FOD must ensure, as
described in the “General Provisions” standard, the facility shall provide telephone access rules
in writing to each detainee upon admittance, and also shall post these rules where detainees may
easily see them.
DEFICIENCY TA-3
In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure the
facility shall have a written policy on the monitoring of detainee telephone calls. If telephone
calls are monitored, the facility shall notify detainees in the detainee handbook or equivalent
provided upon admission. It shall also place a notice at each monitored telephone stating:
1. that detainee calls are subject to monitoring; and
2. the procedure for obtaining an unmonitored call to a court, legal representative, or for the
purposes of obtaining legal representation.
A detainee’s call to a court, a legal representative, or for the purposes of obtaining legal
representation will not be aurally monitored absent a court order. The OIC retains the discretion
to have other calls monitored for security purposes.

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USE OF FORCE (UOF)
ODO reviewed the Use of Force standard at TCJ to determine if necessary use of force and the
use of restraints is employed only after all reasonable efforts have been exhausted to gain control
of a subject, while protecting and ensuring the safety of detainees, staff, and others; preventing
serious property damage; and ensuring the security and orderly operation of the facility, in
accordance with the ICE NDS. ODO toured the facility, inspected equipment, and reviewed
local policies, training records, and use of force documentation.
TCJ has a comprehensive written policy governing the use of force. Staff receives annual
training on the subject, including confrontation avoidance and use of force team technique.
Review of(b)(7)etraining files confirmed completion of training requirements. A handheld video
camera is available for use in calculated use of force situations.
ODO was informed, since September 2011, there has been only one use of force incident
involving an ICE detainee. Review of documentation found it was an immediate force incident
involving a detainee who resisted being placed in restraints. Reports reflected the force used was
minimal and appropriate. There were no injuries, and the detainee was examined by medical
staff immediately following the incident. ERO Dallas was notified; however, the facility did not
conduct an after-action review for 29 days following the incident, rather than within the required
two working days of the detainee’s release from restraints (Deficiency UOF-1). Prompt
completion of after-action reviews assures any necessary follow-up or investigation may be
quickly initiated and appropriate action taken.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY UOF-1
In accordance with the ICE NDS, Use of Force, section (III)(K), the FOD must ensure written
procedures shall govern the use-of-force incident review, whether calculated or immediate, and
the application of restraints. The review is to assess the reasonableness of the actions taken
(force proportional to the detainee's actions), etc. IGSA will pattern their incident review process
after INS. INS shall review and approve all After Action Review procedures.
Report Completion
The After Action Review Team shall complete and submit its After-Action Review Report to the
OIC within two working days of the detainee’s release from restraints. The OIC shall review
and sign the report, acknowledging its finding that the use of force was appropriate/
inappropriate.

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