American Correctional Association

Accreditation
Report

Commission on Accreditation for Corrections
U.S. Immigration and Customs Enforcement
Eloy Detention Center
Eloy, Arizona

The mission of the Commission on Accreditation for Corrections is to
upgrade and improve practices and conditions in adult and juvenile
correctional facilities and programs through an accreditation process
which is founded on a commitment to accountability, professionalism
and respect for basic human rights and which recognizes sound and
effective correctional practices, while striving towards excellence in the
field of corrections.

American Correctional Association
206 NORTH WASHINGTON STREET ALEXANDRIA VA 22314
703.224.0000 FAX 703.224.0079

www.aca.org

August 21, 2009
U.S. Immigration and Customs Enforcement
Eloy Detention Center
Eloy, Arizona

Congratulations!
It is a pleasure to officially inform you that the Eloy Detention Center was accredited by
the Commission on Accreditation for Corrections at the American Correctional Association 2009
Congress of Correction on August 10, 2009 in Nashville, Tennessee.
Your accreditation represents the satisfactory completion of a rigorous self-evaluation,
followed by an outside review by a team of independent auditors.
Every profession strives to provide a high quality of service to society. To know that
you, your staff, and other officials are complying with the requirements of the accreditation
process is indeed a statement of a high level of commitment to the staff and persons under your
care.
On behalf of the Commission on Accreditation for Corrections, thank you for your
commitment to the corrections profession.
Sincerely,

Lannette Linthicum
Lannette Linthicum, Chairperson
Commission on Accreditation for Corrections

American Correctional Association
206 NORTH WASHINGTON STREET ALEXANDRIA VA 22314
703.224.0000 FAX 703.224.0079

www.aca.org

For Immediate Release

Eloy Detention Center
Awarded National Accreditation
Lannette Linthicum, Chairperson of the Commission on Accreditation for Corrections (CAC),
recently announced the accreditation of the Eloy Detention Center, U.S. Immigration and
Customs Enforcement. The award was presented in conjunction with the American Correctional
Association Congress of Correction Conference in Nashville, Tennessee on August 10, 2009.
In presenting the award, Lannette Linthicum, Chairperson of the CAC, and Harold Clarke,
President of the American Correctional Association (ACA), complimented the facility on their
professional level of operation and their success in completing the accreditation process. The
agency is one of over 1,500 correctional organizations currently involved in accreditation across
the nation.
The accreditation program is a professional peer review process based on national standards that
have evolved since the founding of the Association in 1870. The standards were developed by
national leaders from the field of corrections, law, architecture, health care, and other groups
who are interested in sound correctional management.
ACA standards address services, programs, and operations essential to effective correctional
management. Through accreditation, an agency is able to maintain a balance between protecting
the public and providing an environment that safeguards the life, health, and safety of staff and
offenders. Standards set by ACA reflect practical up-to-date policies and procedures and
function as a management tool for agencies and facilities throughout the world.
The three-year accreditation award granted to the Eloy Detention Center does not signal the end
of their involvement in the accreditation process. During the award period, staff will work to
improve any deficiencies identified during the audit and maintain continuous compliance with
the standards.

American Correctional Association
206 NORTH WASHINGTON STREET ALEXANDRIA VA 22314
703.224.0000 FAX 703.224.0079

www.aca.org

FOUNDED 1870

EXECUTIVE COMMITTEE
Harold W. Clark, MA
President
Patricia L. Caruso, MI
Vice President
Daron Hall, TN
President-Elect
Christopher B. Epps, MS
Treasurer
Gary D. Maynard, MD
Immediate Past President
Ana T. Aguirre, TX
Board of Governors
Representative
Mark H. Saunders, OH
Board of Governors
Representative
James A. Gondles, Jr., CAE
Executive Director

Congratulations on your accreditation award! You are now a member of the
elite in achieving correctional excellence. The certificate you have received is
but a small symbol of the enormous dedication and commitment demonstrated
by each and every member of your staff to the accreditation process, and I urge
you to display it prominently as a continual reminder of the level of
professionalism achieved. This is just the beginning of your journey, however,
for the true test of excellence is the test of time. It is critical that your operation
be able to sustain this achievement over time and be constant through both
prosperity and adversity.
The logo of the Commission on Accreditation for Corrections depicts a sextant.
Those who chose this symbol did so because “the sextant is an instrument used
by a navigator to pinpoint the location of his ship in relation to the established
points of reference in the universe, with the purpose of charting his future
course.” This is the exact purpose of accreditation; objectively reviewing an
agency or facility and giving it a goal for which to strive, a destination to reach.
Accreditation is the sextant for our profession; let it be your guide as well.
Thank you for your commitment to the American Correctional Association and
the standards and accreditation process.

Mark A. Flowers, Director
Standards and Accreditation
American Correctional Association

Overview of the American Correctional Association
The American Correctional Association is the oldest and most prestigious correctional
membership organization in the United States. Founded in 1870, ACA currently represents more
than 20,000 correctional practitioners in the United States and Canada. Members include all
levels of staff from a wide variety of correctional disciplines and programs, as well as
professionals in allied fields and representatives from the general public. In addition, the
Association represents the interests of 74 affiliated organizations whose goals, while similar to
those of ACA, focus on specialized fields and concerns within the realm of corrections.
At its first organizational meeting held in Cincinnati, Ohio, in 1870, the Association elected
then-Ohio governor and future U.S. President, Rutherford B. Hayes, as its first president. The
Declaration of Principles developed at that first meeting became the guidelines for correctional
goals in both the United States and Europe.
Since that time, ACA has continued to take a leadership role in corrections and work toward a
unified voice in correctional policy. In recent years, one of the Association=s major goals has
been the development of national correctional policies and resolutions of significant issues in
corrections. These policies are considered for ratification at the Association=s two annual
conferences and ratified policies are then disseminated to the field and other interested groups.
ACA has also had a major role in designing and implementing professional standards for
correctional practices, as well as methods for measuring compliance with those standards.
The Association conducts research and evaluation activities, provides training and technical
assistance, and carries out the regular responsibilities of any professional membership
organization, including a full publications program. The Association=s two annual conferences,
held in varying cities across the nation, attract more than 5,000 delegates and participants each
year from the 50 states, U.S. territories, and several foreign countries.
Membership in ACA is open to any individual, agency, or organization interested in the
improvement of corrections and the purposes and objectives of the Association. Members
include the majority of state, local, provincial, and territorial correctional agencies, individual
correctional institutions and local jails, pretrial programs and agencies, schools of criminal
justice in colleges and universities, libraries, and various probation, parole, and correctional
agencies. Most of ACA=s members are employed at the federal, state, and local levels. Members
also include more than 200 volunteers affiliated with these agencies as administrators or as
members of advisory boards and committees.

Organizational Purposes of the American Correctional Association
Among the most significant purposes of the Association as outlined in its Constitution, are:
To promote the coordination of correctional organizations, agencies, programs, and
services to reduce fragmentation and duplication of effort and increase the efficiency of
correctional services on a national basis.
To develop and maintain liaisons and a close working relationship in America with
national, regional, state, and local associations and agencies in the correctional,
criminal justice, civic, and related fields for mutual assistance and the interchange of
ideas and information, and to extend and strengthen cooperative working relationships
with similar associations and agencies on the international level.
To develop and promote effective standards for the care, custody, training, and treatment
of offenders in all age groups and all areas of the correctional field: detention facilities
and services, institutions and other facilities for juvenile and adult offenders, probation,
parole, community residential centers, and other community-based programs and
services.
To conduct studies, surveys, and program evaluations in the correctional field, and
provide technical assistance to correctional organizations, departments, institutions, and
services.
To publish and distribute journals and other professional materials dealing with all types
of correctional activities.
To promote the professional development of correctional staff at all levels.
In carrying out these purposes, ACA sponsors programs for policy analysis, demonstration, and
research. ACA also provides testimony, consultation, publications, conferences, workshops, and
other activities designed to stimulate constructive action regarding correctional issues.
Standards and Accreditation
Perhaps ACA=s greatest influence has been the development of national standards and the
accreditation process. ACA standards address services, programs, and operations essential to
effective correctional management. Through accreditation, an agency is able to maintain a balance
between protecting the public and providing an environment that safeguards the life, health, and
safety of staff and offenders. Standards set by ACA reflect practical up-to-date policies and
procedures and function as a management tool for over 1,500 correctional agencies in the United
States.

Organizational Structure of the American Correctional Association
Executive Committee
The Executive Committee is composed of the elected officers of the Association - president, vice
president, treasurer, two Board of Governors= members, the immediate past president, the president-elect,
and the ACA executive director. The Executive Committee meets at least quarterly and exercises most of
the powers of the Board of Governors during the intervals between meetings of the board.
Board of Governors
ACA=s bylaws vest control of the Association with an 18-member elected Board of Governors composed
of the officers of the Association and five at-large members. To ensure the interdisciplinary nature of the
Association, board members must represent the following areas:
At-Large Citizen (not employed in corrections)
Correctional Administration (Adult)
Correctional Administration (Juvenile)
Institutions (Adult)
Institutions (Juvenile)
Probation (Adult)
Probation (Juvenile)
Parole or Post-Release Supervision (Adult)
Community Programs (Adult)

Community Programs (Juvenile)
Aftercare or Post-Release
(Juvenile)
Detention (Adult)
Detention (Juvenile)
At-Large (Ethnic Minority) (3)
Education
Member At-Large

Supervision

Delegate Assembly
The Delegate Assembly is composed of delegates from the professional affiliates, geographical chapters,
membership at-large, Board of Governors, past presidents of ACA, and representatives of each military
service. The Delegate Assembly can establish policy, define Association positions on broad social and
professional issues, and determine major programs and legislative priorities. They meet at least twice
annually, at the Winter Conference and Congress of Correction.
Committees
The majority of the Association=s activities take place through committees. Each committee chair reports
to the Association=s Board of Governors at least twice a year. In this way, the Association collectively
benefits from the involvement and contribution of the hundreds of individuals who function on the
various committees. Ad-hoc committees are appointed by the president of the Association.
The current committees and councils are:
Committee on Affirmative Action
Committee on Constitution and Bylaws
Committee on International Relations
Committee on Congress Program Planning

Committee on Legal Issues
Committee on Correctional Awards
Committee on Membership
Committee on Military Affairs

Council of Professional Affiliates
Council of Dual-Membership Chapters and
State and Geographical Affiliates
Nominating Committee
Council on Professional Education
Credentials Committee
Research Council

Eligibility Committee
Resolutions & Policy Development Comm
Committee on Ethics
Standards Committee
Legislative Affairs Committee

Affiliates and Chapters
Affiliates and state chapters are major features of the Association=s structure. They represent
professional, regional, and state groups across the United States and Canada. Affiliates and chapters
contribute to the professional development of all members by providing consultation in their respective
areas of interest and by participating in seminars and workshops at ACA=s annual conferences.
The following affiliates and chapters are currently associated with ACA:
Alabama Council on Crime and Delinquency
Alston Wilkes Society
American Assn for Correctional Psychology
American Correctional Chaplains Association
American
Correctional
Food
Service
Association
American Correctional Health Services Assn
American Institute of Architects
American Jail Association
American Probation and Parole Association
Arizona Probation, Parole, and Corrs Assn
Association for Corrl Research and Info Mgmt
Assn of Paroling Authorities, International
Assn of State Correctional Administrators
Assn of Women Executives in Corrections
International Assn of Correctional Officers
Iowa Corrections Association
Juvenile Justice Trainers Association
Kansas Correctional Association
Kentucky Council on Crime and Delinquency
Louisiana Correctional Association
Maryland Criminal Justice Association
Michigan Corrections Association
Middle Atlantic States Correctional Association
Minnesota Corrections Association
Missouri Corrections Association
National Association of Adult and Juvenile State
Corrections Mental Health Directors
National Assn of Blacks in Criminal Justice
National Association of Juvenile Corrl Agencies

Association on Programs for Female Offenders
Central States Correctional Association
Colorado Correctional Association
Connecticut Criminal Justice Association
Correctional Association of Massachusetts
Correctional Accreditation Managers Assn
Correctional Education Association
Correctional Industries Association
Family and Corrections Network
Florida Council on Crime and Delinquency
Illinois Correctional Association
Indiana Correctional Association
International Assn of Corrl Training Personnel
International Community Corrections Assn
National Association of Probation Executives
National Coalition for Mental and Substance
Abuse Health Care in the Justice System
National Correctional Recreation Association
National Council on Crime and Delinquency
National Juvenile Detention Association
Nebraska Correctional Association
Nevada Correctional Association
New Jersey Chapter Association
New Mexico Correctional Association
New York Corrections and Youth Svcs Assn
North American Association of Wardens &
Superintendents
North Carolina Correctional Association
Ohio Correctional and Court Svcs Association

Oregon Criminal Justice Association
Parole and Probation Compact Administrators
Association
Pennsylvania Assn of Probation, Parole, and
Corrections
Prison Fellowship
South Carolina Correctional Association
Southern States Correctional Association
Tennessee Corrections Association

Texas Corrections Association
The Salvation Army
Utah Correctional Association
Virginia Correctional Association
Volunteers of America
Washington Correctional Association
Western Correctional Association
Wisconsin Correctional Association

Major Activities of the American Correctional Association
Legislation
The American Correctional Association is involved with all major issues affecting corrections today.
Members and ACA staff maintain close working relationships with committees of the U.S.
Congress and all federal agencies and groups whose decisions affect correctional policy. Expert
testimony on a wide range of correctional issues is prepared for congressional committee and
subcommittee hearings, and recommendations are provided to federal administrative agencies.
To ensure that the concerns and issues of the corrections profession are represented in proposed
legislation and public policy, ACA=s legislative liaison is addressing legislative and government
concerns that will impact the corrections profession. ACA has established partnerships between
chapters and affiliates and other national policy making organizations to present a strong collective
voice for correctional reform throughout the world.
Professional Development
The purpose of the Association=s Professional Development Department is to plan, promote, and
coordinate professional development through training seminars, workshops, and published materials
including curriculums, resource guides, and monographs.
ACA=s training plan calls for a variety of professional development activities. Nationally advertised
workshops cover topics such as training for trainers, management training, community-based
employment programs, and stress management. On-site workshops for state and local departments
of corrections are offered in curriculum development, supervision, communications, and reportwriting skills.
The Training for Correctional Staff Trainers workshops further the skills of correctional
professionals qualified to initiate and deliver training. These workshops also enable agencies to
comply with national standards for accreditation and ensure that training is job-related and
professionally developed and presented.
The department also offers correspondence courses to further professional development. More than
6,000 correctional personnel have completed or are in the process of completing ACA=s selfinstruction training program for correctional officers. This program, developed under the auspices
of the National Institute of Corrections, provides 40 hours of basic training in accordance with ACA
standards. A score of at least 80 percent on the comprehensive examination must be attained to
achieve certification.
The Association has similar courses available for correctional supervisors, juvenile caseworkers, and
food service employees. Additional courses which cover report writing skills, correctional
management skills, legal issues for probation and parole officers, and legal issues for correctional
officers are also available.

Publications
As one of the leading publishers of practical correctional publications, ACA produces books, videos,
and lesson plans. Among the wide ranging subjects available are management, community, security,
counseling, law, history, and health. These excellent resources for career advancement appeal to
practitioners and scholars alike. Directories for every major sector of corrections are also published
by ACA.
The following is just a few of the many publications that ACA offers:
Corrections Today is the major corrections magazine in the United States. Published seven
times a year, it focuses on the interests of the professional correctional employee and
administrator. Articles include reports of original research, experiences from the field,
discussion of public policy, and the perspectives of prominent practitioners and
academicians.
On the Line is published five times a year and contains national and local news of interest to
the criminal justice professional.
Corrections Compendium Newsletter publishes cutting-edge information about the
corrections environment. Survey information is compiled from 52 U.S. and 14 Canadian
correctional systems.
The Juvenile and Adult Directory has been published since 1939. A revised edition of the
directory is released each January. This publication is the only up-to-date, comprehensive
directory of all U.S. and Canadian juvenile and adult correctional departments, institutions,
agencies, and paroling authorities.
The National Jail and Adult Detention Directory was first published in 1978. It is a source
of information concerning jails. The directory, published every two years, attempts to list all
jails in the United States that house offenders or detainees for more than 48 hours.
The Probation and Parole Directory, updated every two years, provides over 500 pages of
information regarding federal, state, and county adult and juvenile probation, parole and
aftercare systems in the United States. It includes statistics on caseloads, expenditures, and
personnel.
The State of Corrections, formerly The Proceedings, includes the events of both the
Congress of Correction and the Winter Conference. Published since 1870, it includes
selected speeches and panel presentations concerning the latest thoughts and practices in the
criminal justice field.
Correctional standards are the most significant improvement in correctional programming.
As the basis for accreditation, they give administrators a nationally recognized system for
upgrading and improving their correctional services. The Association currently publishes
over 20 manuals for every correctional discipline.

To aid in the development of policy with relation to accreditation, Guidelines for the
Development of Policies and Procedures are available for adult correctional institutions,
adult parole authorities/adult probation and parole field services, adult local detention
facilities, adult community residential services, juvenile detention facilities, and juvenile
training schools.
Conventions
ACA hosts two national conventions each year that attract more than 5,000 professionals from all
aspects of corrections; the Winter Conference held in January, and the Congress of Correction, held
in August. These events include a variety of workshops, exhibits, and seminars devoted to
addressing topics specific to the corrections profession.
Contracts and Grants
The American Correctional Association has a history of successful grant and contract management
and administration. ACA has completed contracts and grants of more than $30 million. These
diverse initiatives, which are funded through federal and private sources, add to the technical
expertise and knowledge of the organization as well as to the total field of corrections.
Standards and Accreditation
Perhaps ACA=s greatest influence has been the development of national standards and the
accreditation process. ACA standards address services, programs, and operations essential to
effective correctional management. Through accreditation, an agency is able to maintain a balance
between protecting the public and providing an environment that safeguards the life, health, and
safety of staff and offenders. Standards set by ACA reflect practical up-to-date policies and
procedures and function as a management tool for over 1,200 correctional agencies in the United
States.

Overview of the Commission on Accreditation for Corrections
The Commission on Accreditation for Corrections (CAC) is a private, nonprofit organization
established in 1974 with the dual purpose of developing comprehensive, national standards for
corrections and implementing a voluntary program of accreditation to measure compliance with
those standards.
The Commission was originally developed as part of the American Correctional Association. In
1979, by joint agreement, the Commission separated from the Association in order to independently
administer the accreditation program. Between 1978 and 1986, the organizations shared the
responsibility for developing and approving standards and electing members of the Commission. On
November 7, 1986, the Commission on Accreditation for Corrections officially realigned itself with
the American Correctional Association.
The Commission is composed of a board which meets at least twice each year. The responsibility of
rendering accreditation decisions rests solely with the Commission. The members of the
Commission represent the full range of adult and juvenile corrections and the criminal justice
system. They represent the following categories:
National Association of Juvenile Correctional Agencies (1 representative)
Council of Juvenile Correctional Administrators (1 representative)
Association of State Correctional Administrators (2 representatives)
National Sheriff=s Association (2 representatives)
American Jail Association (1 representative)
North American Association of Wardens and Superintendents (1 representative)
International Community Corrections Association (1 representative)
American Probation and Parole Association (1 representative)
Association of Paroling Authorities International (1 representative)
National Juvenile Detention Association (1 representative)
American Bar Association (1 representative)
American Institute of Architects (1 representative)
National Association of Counties (1 representative)
Correctional Health (Physician) (1 representative)
Juvenile Probation/Aftercare (1 representative)
Adult Probation/Parole (1 representative)
At-Large (17 representatives)
Citizen At-Large (Not in Corrections) (1 representative)
Association staff
Accreditation activities are supported by the staff of the American Correctional Association,
Standards and Accreditation Department, under the leadership of the director of the department.
Standards and Accreditation Department staff are responsible for the daily operation of the
accreditation program. Agencies in the process have contact primarily with the accreditation
specialist responsible for their state or agency.

Auditors
Over 600 corrections professionals in the United States have been selected, trained, and employed
on a contract basis by the Association. These individuals perform the field work for the Association
which includes providing assistance to agencies working toward accreditation, conducting on-site
audits of agencies to assess compliance with standards and confirming that requirements are met,
and monitoring to ensure maintenance of the conditions required for accreditation. Teams of
auditors, referred to as visiting committees or audit teams, are formed to conduct standards
compliance audits of agencies seeking accreditation and reaccreditation.
Auditors are recruited nationally through announcements in prominent criminal justice publications
and at major correctional meetings. Affirmative action and equal employment opportunity
requirements and guidelines are followed in the recruitment of auditors. All auditors employed by
the Association have a minimum of three years of responsible management experience, have
received a recommendation from an agency administrator, and have demonstrated knowledge in the
substantive area(s) in which they are employed to assist the Association. In addition, all auditors
must successfully complete the Association=s auditor training and be members of the ACA in good
standing.
Standards Development
Development of the ACA standards began in 1974 with an extensive program of drafting, field
testing, revising, and approving standards for application to all areas of corrections. Since then,
approximately 1,500 correctional facilities and programs have adopted the standards for
implementation through accreditation, and many others have applied the standards informally
themselves.
In the development of standards, the goal was to prescribe the best possible practices that could be
achieved in the United States today, while being both realistic and practical. Steps were taken to
ensure that the standards would be representative of past standards development efforts, reflect the
best judgment of corrections professionals regarding good corrections practice, recognize current
case law, and be clear, relevant, and comprehensive. The standards development and approval
process has involved participation by a wide range of concerned individuals and organizations.
Twenty-two manuals of standards are now used in the accreditation process:
Standards for the Administration of Correctional Agencies
Standards for Adult Parole Authorities
Standard for Adult Probation and Parole Field Services
Standard for Adult Correctional Institutions
Standards for Adult Local Detention Facilities
Standards for Small Jail Facilities
Standards for Electronic Monitoring Programs
Standards for Adult Community Residential Services
Standards for Adult Correctional Boot Camps
Standards for Correctional Industries
Standards for Correctional Training Academies

Standards for Juvenile Community Residential Facilities
Standards for Juvenile Correctional Facilities
Standards for Juvenile Probation and Aftercare Services
Standards for Juvenile Detention Facilities
Standards for Juvenile Day Treatment Programs
Standards for Juvenile Correctional Boot Camps
Standards for Therapeutic Communities
Standards for Small Juvenile Detention Facilities
Standards for Performance-Based Health Care in Adult Correctional Institutions
Certification Standards for Food Service Programs
Standard for Adult Correctional Institutions (in Spanish)
The standards establish clear goals and objectives critical to the provision of constitutional and
humane correctional programs and services. The standards include the requirement for practices to
promote sound administration and fiscal controls, an adequate physical plant, adherence to legal
criteria and provision of basic services. Basic services called for by the standards include the
establishment of a functional physical plant, training of staff, adoption of sanitation and safety
minimums, and provision of a safe and secure living environment. In offering specific guidelines for
facility and program operations, the manuals of standards address due process and discipline,
including access to the courts, mail and visitation, searches, and conditions of confinement of special
management offenders.
The standards are systematically revised to keep pace with the evolution of correctional practices
and case law, after careful examination of experiences, and after applying them over a period of time
and circumstances. The ACA Standards Committee, which includes membership from the
Commission on Accreditation for Corrections, is responsible for standards development and
revision.
The ACA publishes biannual supplements to the standards with updated information and clarifications
until new editions of standards manuals are published. Each supplement addresses standards
interpretations, deletions, revisions, and additions for all manuals of standards issued by the Standards
and Accreditation Department.
Suggestions and proposals for revisions to the standards from the field and interested others are
encouraged. The Standards and Accreditation Department has developed a standards proposal form
specifically for this purpose. The standards proposal form can be obtained from the Standards
Supplement, the ACA website, or Standards and Accreditation Department staff (Appendix A). Proposals
should be submitted via the ACA website.

Accreditation Process Descriptions
For over 120 years, the American Correctional Association has been the only national body involved in
the development of standards for the correctional field. ACA standards are supported by ACA's
Standards and Accreditation Department and the Commission on Accreditation for Corrections, which is
the evaluating and certifying body for accreditation. The department is responsible for the administration
of accreditation and ongoing development of correctional standards.
The accreditation process is a voluntary program for all types of correctional agencies. For these
agencies, accreditation offers the opportunity to evaluate their operations against national standards, to
remedy deficiencies, and to upgrade the quality of programs and services. The recognized benefits of
such a process include: improved management; a defense against lawsuits through documentation;
demonstration of a "good faith" effort to improve conditions of confinement; increased accountability
and enhanced public credibility for administrative and line staff; a safer and more humane environment
for personnel and offenders; and the establishment of measurable criteria for upgrading programs,
staffing, and physical plant on a continuous basis.
A major component of the accreditation process is the standards compliance audit conducted by a visiting
committee. The purpose of the audit is to measure operations against the standards, based on
documentation provided by the agency.
The Visiting Committee Report
The results of the standards compliance audit are contained in the visiting committee report, a document
prepared by the visiting committee chairperson. The report is distributed to the agency administrator and
members of the visiting committee. This report is also submitted to the Commission on Accreditation for
Corrections for consideration at the accreditation hearing.
The following information is usually contained in the visiting committee report:
Agency and Audit Narrative
The agency narrative includes a description of program services, a description of physical plant,
number of offenders served on the days of the audit, a summary significant incidents and consent
decrees, class action lawsuits and/or judgments against the agency/facility, if applicable.
The audit narrative, prepared by the visiting committee chairperson, describes audit activities
and findings. The narrative examines issues or concerns that may affect the quality of life
and services in an agency or facility. Quality of life issues include areas such as staff
training, adequacy of medical service, sanitation, use of segregation and detention, reported
and/or documented incidences of violence and crowding in institutions, offender activity
levels, programming and provision of basic services. The audit narrative also contains
comments as a result of staff and offender interviews, and a detailed explanation of all
noncompliant and not applicable standards.

Agency Response
The agency has four options for standards found in noncompliance: a plan of action, an
appeal, a waiver request, or a discretionary compliance request.
A plan of action is a detailed statement of tasks to be performed in order to achieve
compliance with a standard found in noncompliance at the time of the audit. The plan
of action designates staff responsibilities and timetables for completion.
An appeal is the agency's attempt to change the visiting committee's decision on a
standard. The result of a successful appeal is a change in the status of the standard
and a recalculation of the compliance tally.
A waiver may be requested when noncompliance with a standard does not adversely
affect the life, health, or safety of staff and offenders and when quality of life
conditions compensate for the lack of implementation of a plan of action. The
granting of a waiver by the Commission waives the requirement for submitting a
plan of action; however, it does not change the noncompliant finding.
A discretionary compliance request is when there are circumstances in which
agencies choose not to comply with a particular standard for a variety of reasons.
These reasons include:
P
P
P
P
P

An unwillingness to request funds from a parent agency or funding source
A preference to satisfy the standard/expected practice’s intent in an
alternative fashion
An objection from a parent agency, higher level government official, or
funding source to the nature of the standard/expected practice
A clear policy in place at a higher level that is contrary to the requirements of
the standard/expected practice
An existing provision in a collective bargaining agreement that makes
compliance impossible (without bargaining with the employees’ union to
effect such a change).

Auditor=s Response
This section contains the visiting committee's final reply to all responses received from the
agency and includes comments regarding the acceptability of plans of action, appeals, and
waivers.

Accreditation Hearings
The Commission on Accreditation for Corrections is solely responsible for rendering accreditation
decisions and considers an agency=s application at its next regular meeting following completion of
the visiting committee report. The Commission is divided into panels that are empowered to reach
and render accreditation decisions. These panels hear the individual application for accreditation
and include a quorum of at least three Commissioners which includes the panel hearing chairperson.
Agencies are notified in writing of the date, time, and location of the hearings by Standards and
Accreditation Department staff.
The panel hearing is the last step in the process. With the panel chairperson presiding, panel
members discuss issues and raise questions relative to all aspects of agency operations and
participation in the process. The information presented during the hearing and in the visiting
committee report is considered by the panel members in rendering accreditation decisions.
The agency is invited to have a representative at the hearing and, in most cases, one or more
individuals attend. When special conditions warrant, the visiting committee chairperson or a
member of the visiting committee also may be asked to attend the hearings. When this occurs, the
auditor provides information to help clarify controversial issues and responds to questions and
concerns posed by panel members.
Attendance by any other parties (i.e. media representatives, public officials, or personnel from
agencies other than the applicant) occurs only with the permission of the applicant agency. In these
cases, the applicant agency representatives and panel members discuss procedures to be followed
before commencement of the hearing.
Conduct of Hearings
The panel schedule provides ample time for review of each individual agency pursuing
accreditation. Hearings are conducted by the panel chairperson in accordance with established
procedures. Panel proceedings require that a formal vote be taken on all final actions, i.e., agency
appeals, waiver requests, and the final accreditation decision of the Commission. All panel
proceedings are tape-recorded to assist in preparing minutes of the hearings. Panel activities
generally occur as follows:
P
P
P
P
P
P

applicant agency representatives are requested by Standards and Accreditation
Department staff to be on-call to allow for scheduling flexibility
a designated waiting area is usually provided for this purpose
when the panel is ready to review the agency, the Standards and Accreditation
Department staff representative notifies agency representative(s)
the hearing opens with an introduction by the panel chairperson
the agency representative is asked to give a brief description of the program
if a visiting committee member is present at the hearing, the panel chairperson may
request that the auditor present an account of the visit, focusing on matters
particularly pertinent to the decision or specific panel actions. In some cases,
however, the panel may wish to call on the visiting committee member only to

P

P

request additional information at different points during the hearing
the panel chairperson leads a standard by standard review of non-compliance issues.
The agency representative presents information relative to their requests for waivers,
plans of action, appeals, and discretionary compliance requests. The agency may
also present additional materials, including photographs or documentation, for
review by the panel.
following the agency presentation, the chairperson has the option of calling the panel
into executive session to consider the information provided, determine findings, and
make an accreditation decision. Whether or not panel deliberations occur in the
presence of agency personnel or in executive session varies from panel to panel,
considering the preference of panel members and the sensitivity of issues to be
discussed regarding the application.

In final deliberations, the Commission panel:
P
P
P

ensures compliance with all mandatory standards and at least 90 percent of all other
standards
responds with a formal vote to all appeals submitted by the applicant agency
responds with a formal vote to all requests for waivers, discretionary compliance,
and plans of action submitted by the applicant agency

At this time, the panel also:
P

assures that an acceptable plan of action will be submitted for every non-compliant
standard, including those standards for which appeals of non-compliance and waiver
requests have been denied by the panel. In judging the acceptability of plans of
action, the panel ensures that all of the information requested on the form is
provided. Furthermore, the feasibility of plans to achieve compliance is considered,
including specific tasks, time frames, and resource availability (staff and funding) for
implementing proposed remedies.

P

addresses to its satisfaction any concerns it has with visiting committee comments
about the quality of life in the facility or program, patterns of non-compliance, or any
other conditions reviewed by the panel relating to the life, health, and safety of
residents and staff

For each application, a roll call vote to award accreditation, extend an agency in Candidate or
Correspondent Status, or deny accreditation is conducted. The options for final action available to
the panel are outlined in the next chapter.
If the panel has deliberated in executive session, agency representatives are invited back into the
meeting and informed of the panel=s final decision and actions or recommendations on all other
issues raised by the applicant. If accreditation has not been granted, the chairperson discusses with
agency personnel specific reasons for the decision and the conditions of extension in Candidate or
Correspondent Status and procedures for appeal.

Accreditation Decisions
The decisions available to the Commission panel relating to the accreditation of an agency are:
P

Three-year accreditation award based on sufficient compliance with standards,
acceptance of adequate plans of action for all non-compliant standards and
satisfaction of any other life, health, and safety conditions established by the panel.
The balance of the contract must be paid in full in order to receive a certificate of
accreditation.

P

Extension of the applicant agency in Candidate Status (initial accreditation only) for
reasons of insufficient standards compliance, inadequate plans of action, or failure to
meet other requirements as determined by the panel. The Commission may stipulate
additional requirements for accreditation if, in its opinion, conditions exist in the
facility or program that adversely affect the life, health, or safety of the offenders or
staff. Extension of an applicant in Candidate Status is for a period of time specified
by the panel and for identified deficiencies if in the panel's judgment, the agency is
actively pursuing compliance.

P

Probationary Status is determined when the panel specifies that compliance levels
are marginal, there is a significant decrease in compliance from the previous audit (in
the case of reaccreditation), or there are quality of life issues that would indicate
continued monitoring. While an award of accreditation is granted, a monitoring visit
must be completed and the report presented at the next meeting of the Commission.
The cost for a monitoring visit is borne by the agency at a rate of cost plus 25%. The
agency does not have to appear before the Commission for the review of the
monitoring visit report. If they choose to do so, all related travel expenses are borne
by the agency. Specific expectations for removal from probation are outlined.

P

Denial of accreditation removes the agency from Accredited Status (in the case of
reaccreditation) and withdraws the agency from the accreditation program. Situations
such as insufficient standards compliance, inadequate plans of action, failure to meet
other requirements as determined by the panel or quality of life issues may lead to
the denial of accreditation. If an agency is denied accreditation, it is withdrawn from
the process and is not eligible to re-apply (as an applicant) for accreditation status for
a minimum of six months from the date of that panel hearing. The Commission will
explain the process for appeal.

The agency receives written notification of all decisions relative to accreditation after the hearing.
Appeal Process
The accreditation process includes an appeal procedure to ensure the equity, fairness, and reliability
of its decisions, particularly those that constitute either denial or withdrawal of Accredited Status.
Therefore, an agency may submit an appeal of any denial or withdrawal of accreditation.

The basis for reconsideration is based on grounds that the decision(s) were:
P
P
P
P

arbitrary, capricious, or otherwise in substantial disregard of the criteria and/or
procedures promulgated by the Commission
based on incorrect facts or an incorrect interpretation of facts
unsupported by substantial evidence
based on information that is no longer accurate

The reasonableness of the standards, criteria, and/or procedures for the process may not serve as the
basis for reconsideration. The procedures for reconsideration are as follows:
P

The agency submits a written request for reconsideration to the Director of Standards
within 30 days of the adverse decision stating the basis for the request.

P

The Executive Committee of the Commission, composed of the officers of the
Commission, reviews the request and decides whether or not the agency=s request
presents sufficient evidence to warrant a reconsideration hearing before the
Commission. The agency is notified in writing of the Executive Committee=s
decision.

P

If the decision is made to conduct a hearing, the hearing is scheduled for the next full
Commission meeting and the agency is notified of the date.

P

The agency, at its option and expense, has the right of representation, including
counsel.

P

Following the hearing held before the Commission, the decision, reflecting a
majority opinion, is made known to the agency immediately.

P

Pending completion of the reconsideration process, the agency maintains its prior
status. Until a final decision has been reached, all public statements concerning the
agency=s accredited status are withheld.

P

Following completion of the reconsideration process, any change in the status of an
agency is reflected in the next regularly published list of accredited agencies.

Accredited Status
The accreditation period is three years, during which time the agency must maintain the level of
standards compliance achieved during the audit and work towards compliance of those standards
found in non-compliance. Regular contact with Standards and Accreditation Department staff
should also be maintained.
Annual Report
During the three year accreditation period, the agency submits an annual report to the Standards and
Accreditation Department. This statement is due on the anniversary of the accreditation (panel
hearing) date and contains the following information:
Current standards compliance levels - This includes any changes in standards compliance since
accreditation, listing on a standard-by-standard basis any standard with which the agency has fallen
out of compliance or achieved compliance.
Update of plans of action - A progress report is included with respect to plans of action submitted to
the hearing panel, indicating completion of plans resulting in compliance with standards and revised
plans reflecting the need for additional time, funds, and/or resources to achieve compliance.
Significant Events - A report is made of events and occurrences at the agency during the preceding
year that impact on standards compliance, agency operation, or the quality of services provided by
the agency. This might include:
P
P
P
P
P
P
P

a change in the agency administration and/or major staffing changes
mission change or program revisions
changes in the offender population, including number of offenders or general
offender profile
physical plant renovations, additions, or closings
any major disturbances, such as extended periods of lock-down, employee work
stoppages, etc
any significant incident to include allegations of physical/sexual abuse
a death from other than natural causes

Standards and Accreditation Department staff review the annual report received from the agency and
respond to clarify issues or request additional information if necessary.
In addition to submission of the annual report, the agency is responsible for notifying Standards and
Accreditation Department staff of any major incident, event, or circumstance that might affect
standards compliance. This notice must be provided to the Standards and Accreditation Department
immediately following the event. For example, an agency must notify the Standards and
Accreditation Department if it is the subject of a court order, has a major disturbance, escape,
physical/sexual abuse (to include allegations), employee work stoppage, death from unnatural
causes, or experiences a major fire or other disaster. It is the responsibility of the accredited agency
to inform Standards and Accreditation Department staff or provide them with copies of news

articles, special reports, or results of investigations that address conditions that affect standards
compliance.
Finally, the Standards and Accreditation Department may request that the agency respond to public
criticism, notoriety, or patterns of complaint about agency activity that suggests failure to maintain
standards compliance. The Standards and Accreditation Department may conduct an on-site
monitoring visit to the agency to verify continued compliance.
Monitoring Visits
Monitoring visits to agencies in Accredited Status are conducted by an ACA auditor(s) in order to
assess continuing compliance with the standards. A monitoring visit may be conducted at any time
during the accreditation period, with advance notice to the agency. The determination of need for a
monitoring visit is based on:
P
P
P

compliance levels, findings, and recommendations by the Commission on
Accreditation for Corrections during the hearing
incidents or events reported by the agency in its annual report
problems indicated by adverse media reports or correspondence received by
Standards and Accreditation Department staff, disturbances at the agency, or special
investigations

The length of the visit varies depending on the number of standards or special issues that must be
addressed during the visit. The visits are conducted similar to standards compliance audits, but on a
reduced scale. Monitoring visits are charged to the agency at a rate of cost plus twenty-five percent.
Activities, as a general rule, involve a review of all mandatory standards, all standards found in noncompliance at the time of accreditation, and any other concerns identified by the Commission. The
visit also involves a tour of the agency and interviews with staff and offenders to ensure
maintenance of the requirements of accreditation. It concludes with an exit interview during which
the auditor informs the agency staff of the findings of the visit.
Following the visit, the auditor prepares a monitoring visit report that addresses findings of the visit.
The report includes a list of standards reviewed, explanation of non-compliance findings, results of
the tour and interviews with agency staff and offenders, and discussion of any issues believed to be
relevant to the agency=s accreditation. The report, as with others prepared by auditors, is reviewed
and sent to the agency by Standards and Accreditation Department staff.
When a monitoring visit to the agency reveals deficiencies in maintaining compliance levels that
existed at the time of accreditation, or less than 100 percent compliance with mandatory standards,
the agency prepares a response providing explanation of the problems indicated in the report. When
the agency has failed to maintain compliance with all mandatory standards, the monitoring visit
report and the agency response are submitted to the Commission on Accreditation for Corrections
for review during a regular hearing. Agency representatives are advised of the date, time, and
location of the review, and are invited to attend. At the discretion of the Commission, the agency
may be placed in probationary status and a revisit conducted to determine if deficiencies have been

corrected.
Revocation of Accreditation
If the Commission panel believes that an agency=s failure to maintain continuous compliance with
certain standards is detrimental to life, health, and safety of residents and staff, the Commission may
place an agency on probation. Probationary Status lasts for a specific period of time designated by
the Commission to allow for correction of deficiencies. At the end of the probationary status,
another monitoring visit will be conducted to ensure that the deficiencies have been corrected. The
cost of this visit is borne by the agency. Following the visit, a report is prepared for review by the
Commission at its next regularly scheduled meeting. The Commission again reviews the program
and considers removing the probationary status or revoking accreditation. When the agency corrects
the deficiencies within the probationary status period and the corrections have been verified and
accepted, the agency resumes its status as an accredited agency. An agency that does not
satisfactorily correct the deficiencies may be withdrawn from accreditation.
Another condition that may result in a rehearing and consideration of revocation is following a
significant event in an agency (i.e. major disturbance, death from other than natural causes or allegations
of physical/sexual abuse of offenders). Failure to notify the Standards and Accreditation Department in a
timely manner may result in suspension of the agency’s accreditation. Once ACA is notified of the major
event, the Director of Standards and Accreditation may consult with the Executive Committee of the
Commission, who may request a monitoring visit. If a visit is warranted, ACA will notify the agency and
a date will be established with the concurrence of the facility. The monitoring visit will take place within
14 days of this notification. The monitoring visit report will be sent to the Director of Standards within 7
days of the monitoring visit and then forwarded to the Executive Committee of the Commission.
Following review of the report, a determination will be made by the Executive Committee as to whether
revocation of accreditation is warranted. Prior to any rehearing, agency representatives will be notified,
so that any issues may be addressed and responded to in writing.
Accreditation is revoked for the following reasons:
P
P
P
P
P
P

failure on the part of the agency to adhere to the provisions on the contract
failure on the part of the agency to maintain continuous compliance with the standards at
levels sufficient for accreditation
intentional misrepresentation of facts, lack of good faith, or lack of deliberate speed or a
concerted effort to progress in the accreditation process, including the implementation of
plans of action
failure to notify ACA of significant incidents in the annual report to the Commission
adverse conditions of confinement that affect the life health, and/or safety of staff and
offenders
failure to comply with the conditions of probation or suspension

Standards and Accreditation Department staff notify the agency in writing of the specific reasons
identified by the Commission for the revocation hearing. Agencies may appeal the decision of the
Executive Committee to the full board of the Commission on Accreditation for Corrections. Appeals
must be submitted within 30 days. The agency may apply to re-enter the process 180 days after the

revocation of accreditation.
Expiration of Accredited Status
Accreditation is granted for a three year period. Unless the agency has applied for reaccreditation and
completed activities in the process required for reaccreditation, the Commission withdraws the agency
from Accredited Status after this three year period.
For agencies in Accredited Status that are seeking subsequent accreditation, administrative extensions of
Accredited Status may be granted under certain conditions. For example, relocation of the facility, staff
turnover, and major renovations often warrant an extension. In these cases, a written request to the
Director of Standards and Accreditation is required, outlining the reasons for extending the accreditation
period. Agencies that fail to successfully complete an audit within the three year period, or do not
receive an extension prior to their expiration date, are withdrawn from Accredited Status.

Visiting Committee Report and Hearing Minutes

CONFIDENTIALITY
The American Correctional Association and the Commission on Accreditation for Corrections do not disclose to external parties specific information
contained in this Accreditation Report or information discussed in the Accreditation Hearing. The Association encourages all participating agencies to
provide information to the media about their accreditation activities, including disclosure of the Self-Evaluation and Accreditation Report.

COMMISSION ON ACCREDITATION FOR CORRECTIONS
PANEL ACTION REPORT
The Gaylord Opryland
Nashville, Tennessee
August 9, 2009

United States Immigration and Customs Enforcement
Eloy Detention Center
Eloy, Arizona

Agency Representatives:

b6, b7c
Captain
Commander
Administrator

b6

Compliance Manager
Health Services

Panel Members:
b6

Staff:

b6

Panel Action
No action was required by the panel.
Accreditation Panel Decision
Moved :
Seconded:

Commissioner
Commissioner

Three-Year Accreditation:

Yes

No

Accreditation Vote

Yes

No

Robert Kennedy, Chair
Edwin Buss
Justin Jones
Albert Murray

9
9
9
9

Prepared by

b6

b6

Standards and Accreditation Specialist

Final Tally
Mandatory
Non-Mandatory

Prepared by

100%
100%

b6

Standards and Accreditation Specialist

COMMISSION ON ACCREDITATION FOR CORRECTIONS
STANDARDS COMPLIANCE INITIAL AUDIT
Division of Immigration Health Services
Eloy Detention Center
Eloy, Arizona
March 30 - April 1, 2009

VISITING COMMITTEE MEMBERS
RN, Chairperson
Correctional Consultant
2942 Neidhart Road
Marion, Ohio 43302
(740) 389- b6
b6

b6

b6

MBA, MPH, CPM, CCHP-A
Health Services Consultant
2008 Doomar Drive
Tallahassee, Florida 32308
(850) 570- b6
b6

A.

Introduction
The initial audit of the U.S. Public Health Service’s Medical Unit at the Eloy Detention
Facility, Eloy, Arizona was conducted on March 30 to April 1, 2009, by the following
b6
b6
team:
, R.N., Chairperson and
, Member.

B.

Facility Demographics
Rated Capacity: 1,596
Actual Population: 1503
Average Daily Population for the last 12 months: 1500
Average Length of Stay: 64.78 Days
Security/Custody Level: Medium
Age Range of Detainees: 18-73
Gender : Male & Female
Full-Time Medical Staff: 51

C.

Facility Description
The 1,596-bed facility holds federal detainees for Immigration and Customs Enforcement
(ICE). The facility is located on the outskirts of Eloy, Pinal County, Arizona and is 61
miles from Phoenix Airport.
The formal address is:
ELOY DETENTION CENTER
1705 EAST HANNA Rd.
Eloy, AZ 85231
The male and female detainees are housed in six housing units. The facility consists of
17 support buildings. Eloy Detention Center, which opened in May, 1994, was the
Federal Bureau of Prison’s first contract for a secure facility with a private company.
The 392,000-square foot facility contains state-of-the-art safety and security equipment,
including electronic controls and closed-circuit television cameras. The institution also
has four courtrooms for deportation hearings.
The United States Public Health Services (USPHS) assumed medical services on
February 1, 2007.

D.

Pre-Audit Meeting
The Visiting Committee team met on March 29, 2009 at the Holiday Inn in Eloy,
Arizona, to discuss the information provided by the Association staff and the officials
from the Eloy Detention Center

2

The chairperson divided the Stand-Alone Health Care for Jails (HC), 1st Edition, 2008
Supplement standards as follows:
Standards #1-HC-1A-011 to 1-HC-3A-10:
Standards #1-HC-3A-11 to 1-HC-7C-03:
E.

b6
b6

, Chairperson
, Member

The Audit Process
1.

Transportation
The team was escorted daily to the facility by Captain Ron Dickey of the
Corrections Corporation of America staff.

2.

Entrance Interview
The audit team proceeded to the Administrative Board Room with Warden
b6, b7c
b6, b7c
and Assistant Warden
.
Also present were:

b6

Warden
Assistant Warden
Chief of Security
Chief of Unit Management
Assist. Chief of Security
Human Resources Manager
ICE-SDDO
ICE-AOIC
ICE-AFOD
Quality Assurance Manager
Unit Manager
Recreation Manager
Unit Manager
Investigator
Food Service Manager
Maintenance Supervisor
Unit Manager
Unit Manager
Training Manager
Security Threat Group Coordinator
Unit Manager
Classification Coordinator
Case Manager
Personnel Assistant II
Shift Supervisor
Health Services Administrator

3

b6, b7c

b6

Physician Assistant/Compliance
RN/HSA
Shift Supervisor
Admin. Clerk, Human Resources
Unit Manager
Clinical Director
Human Resourced Generalist

The Visiting Committee expressed the appreciation of the Association for the
opportunity to be involved with Eloy Detention Facility in the accreditation
process.
It was explained that the goal of the visiting team was to be as helpful and nonintrusive as possible during the conduct of the audit. The chairperson emphasized
the goals of accreditation toward the efficiency and effectiveness of correctional
systems throughout the United States. The audit schedule was also discussed at
this time.
3.

Facility Tour
The team toured the entire facility from 8030 to 1215.
The following persons either accompanied the team on the tour and/or responded
to the team's questions concerning facility operations:
8:30

Training Classroom

8:35

Security Briefing Room, Ice Hallway, North Visitation, Correctional
Officer b6,b7c

8:40

Ice Administration

8:43

Armory Office, Senior Correctional Officer
b6,b7c
Officer

8:50

Court Hallway, Correctional Officer

9:00

Fox Housing Unit, Unit Manager
Fox 300 Pod, Correctional Officer

b6,b7c

b6,b7c

b6,b7c

, Correctional Officer

b6,b7c

b6,b7c

9:10

Fox 200 Pod, Correctional Officer

9:25

Fox Outbuilding, Safety Manager

9:27

Echo Housing Unit, Unit Manager b6,b7c , Counselor
b6,b7c
(ICE Compliance Team), Correctional Officer

4

, Correctional

b6,b7c

b6,b7c

b6,b7c
b6,b7c

9:30

Echo 500 Pod, Correctional Officer

9:33

Echo 100 Pod, Senior Correctional Officer
b6,b7c
Officer,
, Correctional Officer

9:45

b6,b7c

, Correctional

b6,b7c
b6,b7c

North Special Housing Unit, Correctional Officer b6,b7c , Correctional
b6,b7c
Officer
North Special Housing Unit: Medical Observation
Correctional Officer b6,b7c
Correctional Officer b6,b7c , Correctional
b6,b7c
b6,b7c
Office,
, Delta Housing Unit, Unit Manager
b6,b7c
Counselor

10:18 Receiving And Discharge, Senior Correctional Officer b6,b7c , Senior
b6,b7c
b6,b7c
Correctional Officer
, Senior Correctional Officer
Correctional Officer b6,b7c
10:35 Kitchen/Dining, Food Service Manager
b6,b7c
Canteen Employees b6,b7c ,

b6,b7c
b6,b7c

, Correctional Officer
, b6,b7c , b6,b7c

11:00 Maintenance, Maintenance Supervisor Mccrea, Administrative Clerk
b6,b7c

11:15 Tool Room (Inside Maintenance), Tool Room Correctional Officer
b6,b7c

11:23 Charlie Housing Unit, Unit Manager
11:35 Bravo Housing Unit, Unit Manager
Bravo 500 Pod, Correctional Officer

b6,b7c

, Counselor

b6,b7c

b6,b7c

Correctional Officer

b6,b7c

11:40 South Special Housing, Security Threat Group Coordinator
b6,b7c
Senior Correctional Officer
Correctional Officer
b6,b7c
Correctional Officer
11:45 Alpha Housing Unit, Unit Manager
200 Pod, Case Manager b6,b7c
11:55 Commissary,
12:00 Mailroom -

b6,b7c

b6,b7c

,

,

b6,b7c

, Counselor

b6,b7c

b6,b7c

12:07 Property - Correctional Officer

b6,b7c

12:15 Medical - Dentist b6,b7c , Correctional Officer
Armory - Armorer Senior Correctional Officer
b6,b7c
North Library - Library Aide -

5

b6,b7c

b6,b7c
b6,b7c

b6,b7c

b6,b7c

,

b6,b7c

, Alpha

4.

South Chapel - Chaplain b6,b7c , Administrative Clerk
Conditions of Confinement/Quality of Life

b6,b7c

During the tour, the medical team evaluated the conditions of confinement at the
facility with respect to overall medical concerns and services.
The following medical narrative description of the relevant services and
functional areas summarizes the findings regarding the quality of life.
Medical, Dental, and Mental Health
Initial observation of the waiting room found a clean appearing space with an
acceptable seating area with water and a clean rest room provided.
The Medical Department consists of five clinic provider rooms, two satellite
examination rooms, two triage rooms, one intake office, and one dental suite with
two chairs.
The Auditors found all of the necessary supplies safely secured. The emergency
bag contained all of the proper supplies, including medications such as
Nitroglycerin, Aspirin, Epinephrine, and Glucagon. Everything was found in
readiness for an emergency event. No outdated medications or supplies were
identified. The AED was tested and found operative. Eloy is rich in AEDs
having one in the Medical Area and 11 others distributed throughout the facility.
It should be noted that the emergency area is not over equipped.
All emergencies and referrals are sent to Casa Grande Hospital Emergency Room
Maricopa Medical Center (MMC) in Phoenix.
EDF does not have an infirmary.
EDF does have one Negative Pressure cell which presently is not operational. A
requested work order was reviewed. Repair parts are on order. The Negative
Pressure cell does have bathing facilities, Hot/Cold water and is Handicap
accessible.
There are five suicide observation rooms; five in the North Special Housing Unit
and one in the female housing.
The Medication Room is adequately secure with controlled substances under
double lock. The Medical auditor conducted a sample count of controlled
substances which was correct as was a similar sharps and syringe count.
Emergency drugs are also kept in the Medication Room as well as in the
Emergency bag as noted above. Needed mediations are obtained from McKesson
and/or Diamond Pharmacy Services. In the event of emergencies, stat
medications are obtained from Walgreen’s Pharmacy in Casa Grande, Arizona.

6

Pharmacy inspections were conducted by Detention Facility Inspection Group on
February 10-12, 2009 and Creative Corrections Inspection Committee on
February 17-19, 2009
Medications are dispensed at pill call windows strategically placed for both the
North and South sides of the facility. Examples of medications dispensed by pill
call are controlled medications, antibiotics, and psychotropic. Keep on Person,
self administered, medications such as Anti-hypertensive, antibiotics, and nonnarcotic analgesics are permitted. Over the Counter medications such as Aspirin,
Tylenol, Ibuprofen, and vitamins are available for purchase in the commissary.
Non-compliant patients not receiving life threatening medications are counseled
after missing three consecutive doses. Psychotropic medications commonly
prescribed at EDF are Seroquel, Risperidone, Haldol, Prolixin, Abilify,
Thorazine, and Trilafon. Approximately 150 psychotropics are administered
daily.
A sampling of the Medication Administrative Records was reviewed and found to
be without error.
Supplies for Universal Precautions were adequately available and well stocked.
Supplies are obtained from Seneca Medical Supply. No problems were noted.
Biohazardous waste is disposed in dedicated receptacles. After collection from
the various rooms, the waste is removed by SteryCycle, Inc.
MSDS sheets are available in several locations throughout EDF and readily
available in binders in the Medical area. A cursory review of the collection was
found correct and appropriate.
A correctional officer provides security whenever detainees are in the Medical
area.
Detainees have direct access to the medical department through the utilization of a
sick call system, by doctor’s appointment, by scheduled appointment and through
the declaration of a medical emergency.
Requests for sick call are initiated from the general population via a health
services request which is deposited in a designated box located near Food Service.
The requests are then triaged by a registered nurse who arranges for the patient to
be seen at Nurse’s sick call in his/her housing area. The average time from initial
request to being seen by medical personnel is less than 24 hours. This is
documented in a log which was reviewed and found appropriate.
With respect to Segregation, detainees are seen daily by a member of the medical
team and stops are made at each cell. This visit is documented in a “door card” as
well as at individual segregation log and in clinic Segregation log. Segregation

7

rounds are conducted on daily basis at or around 0830.
Detainee complaints are handled at the time of encounter. Staff secure a verbal
response from each inmate assigned to those areas as to whether or not they need
to be seen by a medical professional.
General sick call hours are held from 0800 – 1700 Daily; Monday – Friday. On
weekends urgent sick call requests are evaluated by an on-duty RN.
The EDF Medical is staffed as follows:
Three Physicians
Three PAs
RNs 15 FT, Four PT
LPNS Eight FT, Four PT
Clerical Five FT, Two PT
One AA
Two Pharmacists
Two Pharmacy techs
One radiology tech
Two nurse assistant,
Three Medical Assistants
The physician’s services are provided by the USPHS with supplemental services
supplied by contracted local providers. In addition, specialty consults are also
provided by contracted providers.
The Medical Records area was found to be well secured and quite spacious.
Confidentiality of records is maintained per policy. EDF does not utilize a
computerized Medical Record System. A check of several files indicates good
organization and maintenance.
b6
Communicable Diseases/Infection Control Coordinator is Lt.
RN. Lt.
b6
received Special In-service on epidemiology from USPHS HQ in
Washington, D.C. This training was primarily on TB. The ICC is also aware of
current Pandemic flu training being offered to USPHS personnel. As ICC he
checks PPDs, Flu and Hepatitis B injections. TB tests are offered annually to
detainees and staff.

PPDs are not offered to detainees due to the shortness of their incarceration.
Instead, all detainees are diagnostically X-rayed. Staff, on the other hand, is
offered PPDs.
When a detainee is diagnosed with any communicable disease, he/she is placed in
medical isolation if necessary, given education, and medicated. All cases of
communicable disease are reported to the Arizona Department of Health Services

8

as well as to the Division of Immigration Health Services HQ.
There have not been any major outbreaks of MRSA in individuals with common
loci.
Cardiopulmonary resuscitation is renewed annually. Spot checks confirmed
b6
b6
b6
annual certifications for
, RN;
, DDS;
b6
b6
, RN; and
, CDR
The reception process for new arrivals was reviewed. Medical, Dental, and
Mental Health orientation to health care is conducted immediately upon or soon
after the detainee’s arrival. Orientation information is disseminated to the
detainees in their native language verbally and in writing. For other languages,
the institution has means of utilizing translators from Translation Service.
Uniquely, a pamphlet is provided in Mandarin Chinese.
The Visiting Committee observed medical and psychological staff conducting
admission assessments on newly admitted detainees. It was observed that
medical, dental or psychological problems were noted and the detainee referred to
the proper discipline for immediate follow-up. This process was observed during
the arrival of 33 detainees. All procedures were done professionally and in
accordance with Division Immigration Health Services (DIHS) procedures for
arrival of new detainees. This procedure meets ACA Standards.
The Dental Department is well equipped with two dental stations with the ability
to take digital dental X-rays in one of the stations. The dental area was extremely
clean and well-maintained. Dental services are provided 40 hours per week.
Staffing includes a dental assistant, dental hygienist, and a full-time dentist. Wait
time from receipt of request until seen is one-two days. Wait time between
appointments depends on treatment requited.
Cleanings are offered after being in custody one year. Urgent cases, extractions,
temporary fillings, denture repair, temp crowns, periodontal cleanings, and root
canals are offered.
Outside consultations sent to Maricopa Medical Center or to Casa Grande
Regional Medical Center. As in Medical, universal precautions are observed and
all supplies are available.
An inventory of the tools, sharps, and chemicals is in place and all inventories are
conducted as required by policy and ACA standards. The inventory records were
examined and found to be accurate. The inventory was conducted with detainees
requiring dental services on weekends or holidays are examined by the on duty
medical staff and, if needed, referred to the dentist. The dentist is available after
hours for phone consultation with the medical staff. In case of an emergency, the
detainee is sent to a local emergency room. Process for dental emergencies is on
a same day basis by dentist or by provider if the dentist is not on site.

9

Hygiene instructions are given routinely upon intake, at physical examinations,
and at dental appointments. Toothbrushes and toothpaste is issued by CCA.
Floss will be available in commissary.
Daily digital Radiology services are provided at EDF, thus no developing is
performed on site and no need for chemical inventory. The types of X-rays
performed are limbs, chest, and general diagnostic work. X-ray interpretation is
performed by University of Maryland Radiologists. The X-ray report is received
by the facility within 4 hours. Emergencies are sent to Casa Grande Regional or
MMC.
EDF does not have a phlebotomist. Laboratory services provided at the
institution are phlebotomy, sputum collections, fingersticks, hemoglobin, and
stool for occult blood. Specimens are sent to LabCorp, Inc or the Arizona State
Laboratory. Results are typically received within 24 hours depending upon
specimen type or study required.
For specialties such as Nephrology, Urology, etc. detainees are sent to free world
specialist as arranged by the USPHS. Wait time from request to being seen is five
to 60 days depending on specialty. There are no on-site specialty services at EDF.
The Mental Health Department consists of one Psychiatrist and two Licensed
Social Workers. The Department provides crisis intervention and individual
counseling, and dual diagnosis with Substance Abuse cases. Individual Treatment
Plans are maintained. Detainees have access to Mental Health Services through
sick call or provider referral. Generally, referred detainees are seen within 24-48
hours. In Segregation, daily rounds are conducted for referrals and/or diagnosed
Mental Health patients.
Emergency Mental Health problems are seen
immediately when mental health is on site or within 24 hours otherwise.
The process for a detainee who says he/she is suicidal or states he/she will harm
him/herself is that an assessment is completed and placed on one on one constant
observation rooms with protocols in place for restrictions. A standardized form is
used for communication with security staff. Suicidal detainees are housed,
treated, and placed under constant watch provided by CCA Security. They are in
a vacant North SHU Suicide cell and issued a non-tear shroud. The patient may
be permitted reading material, is fed only finger food, and housed for an
indeterminate time. He/she will not be transferred to a hospital except for medical
reasons.
Mental Health Training is provided to health care staff on mental health
assessments.
Psychotropics are prescribed as noted above. A medicated detainee is evaluated
by the psychiatrist approximately every two to six weeks.

10

Mental health rounds are conducted by mental health team daily in Segregation
for mental health patients, detainees on observation and monthly for others.
Restraints can be but have not yet been authorized by a UPHS physician. There is
an existing restraint policy. There is no charged co-pay for any USPHS
treatment.
Institutional drills are conducted twice a year and documented with a written
critique.
Informal medical grievances are addressed by and answered first by either the
Health Care Administrator or Clinical Director who must respond within three
business days. There were only 25 reported grievances related to health care
services during the past twelve months, out of which only one was found in favor
of the detainee.
With regard to therapeutic diets, there seems to be differing understandings by the
departments involved. Special diets such as ADA, low sodium, etc. are ordered
by the medical unit when so indicated. According to the Medical Department, 71
detainees are receiving prescribed therapeutic diets. However, when interviewed
during the institutional tour Food Service listed 287 “special diets”. It was
subsequently learned that Food Service lists “special diets” to include both
religious and therapeutic diets. It did not appear to the Visiting Committee that
there was any tracking of therapeutic diets. Further investigation into this matter
included observation as to how therapeutic diets were tracked.
For all detainees, meals were tracked by a scanning of ID cards electronically.
The Committee was advised that when a detainee on therapeutic diet would have
his/her ID scanned, a notification would appear on the screen. The detainee
would then be furnished his/her “special diet” card which was handed through the
kitchen window, and a special tray was then given to the detainee. Observation of
this procedure determined the following:
• no notification of special diet appeared on the computer screen
• the issuing of a medical diet was dependent upon the “honesty” of the
detainee producing the diet card
• there did not appear to be any tracking as to how many therapeutic diets
were issued.
Supposedly, non-compliant detainees were reported to Medical who then would
counsel and educate the detainee. It was learned that non-compliant patients were
only occasionally reported to Medical.
It was apparent to the visiting committee that Therapeutic Diet compliance is in
question. It is recommended that a conference be held with USPHS, Food
Service, and CCA administration to investigate this issue and formulate a
combined plan of action as to how Therapeutic Diet compliance can be improved.

11

It is further suggested that this plan of action be presented to the Hearing Panel.
The Quality Assurance team is multidisciplinary including the following: Clinical
Director, Program Manager, RNs, Pharmacists, Infection Control Nurse, Health
Services Administrator, Radiology, and Safety and Sanitation. The committee
meets quarterly. The minutes are reviewed by each member of the committee.
Although there are quarterly goals in the current studies, there are no yearly goals.
This is understandable in that the Performance Improvement Committee was only
recently organized. It is recommended by the Visiting Committee that the
performance improvement team (QA) meet before the end of the fiscal year,
October 1, 2009 to October 30, 2010 and convert current quarterly studies into
annual measurable goals. It is requested that the annual goals be presented to the
Hearing Panel also.
It was also emphasized to EDF Medical that their inter-disciplinary committee
should include representation from EDF Security, Food Service and/or
Administration.
F.

Examination of Records
Following the facility tour, the team proceeded to the Medical Department to review the
accreditation files and evaluate compliance levels of the policies and procedures.
Accreditation files were well-documented, easy to use, and well-organized. Since this is
an initial accreditation, the Medical Department has no notices of non-compliance with
local, state, or federal laws or regulations.
1.

Litigation
The Medical Department had no consent decrees, class action lawsuits or adverse
judgments.

2.

Significant Incidents/Outcome Measures
The Outcome Measures Worksheet was reviewed and found to be within
appropriate ranges for this facility. During the period of the report, the facility
had 1,500 average daily population and 10,464 annual admissions. The
Worksheet shows 2 suicide attempts with no suicides. There were only 25
reported grievances related to health care services during the past 12 months, out
of which only 1 was found in favor of the detainee. A review of Significant
Incidents and Outcome Measures found little of note other than 2 deaths of
natural causes. (Coronary Vasculatis & Cerebral Vascular Accident)

3.

Departmental Visits
Team members remained in the Medical department daily and were consistently
reviewing conditions relating to departmental policy and operations:

12

4.

Shifts – The visiting committee observed Medical Operations in the morning,
afternoon and evening/night.
a.

Day Shift – 0600 to 1400
The team was present at the facility during the day shift from 0530 to 1800
and we were able to observe clinical operations, including pill call during
these hours. The committee was able to meet and converse with LCDR b6
b6
b6
b6
b6
LCDR
, CDR
,
, LPN, LT
,
b6
b6
b6
, MD.

b.

Evening Shift – 1400 to 2000
The team was present at the facility during the evening shift from 1400 to
b6
1800 and met primarily with the Mental Health staff
,
b6
LSW, LT
, and Dr. b6 .

c.

Night Shift – 2000 to 0600
The team was present at the facility during the night shift from 0530 to
b6
b6
0600. During this time nurses
, LPN and
, LPN, A
lengthy conversation was held between the team and the night nurses. It
was particularly noted by the team with regard to the important function
served by this staff. Furthermore, the team was present during shift
change and report.
Since this was an initial audit, there were no previously Non-compliant
Standards or Plans of Action

G.

Interviews
During the course of the audit, team members met with both staff and offenders to verify
observations and/or to clarify questions concerning facility operations.
1.

Offender Interviews
18 male detainees in the Echo Housing Area and 17 female detainees in the Delta
Housing area were interviewed. Since both units had segregation units several
detainees in each were interviewed. Overall, in both Housing Units the detainees
responded that they were satisfied with receiving health services, food, personal
safety, and communication with health and correctional staff.
During these interviews, the female sick call process was observed in the Delta
unit, where health services also had a mini-clinic which reduces the need for
movement of female detainees to health care services.
Detainees were treated fairly and had access to staff regarding their concerns.

13

2.

Staff Interviews
The following Medical Department staff was formally interviewed during the
course of the audit:
(1200-0700 AM Shift)
(Sick Call Delta Unit)

b6
b6
b6

(Sick Call Delta Unit)
(0400 - 1200 Shift)

b6
b6

Dentist

b6
b6

CAPT
LT
LCDR
CDR
LCDR

b6
b6
b6
b6
b6

, LPN

b6

LT

b6

, LPN
, LPN

b6
b6

LT

b6
b6
b6

LT
Dr.

(Dental Assistant)
HAS

, MD
, LSW
b6

b6

All staff members were very professional, knowledgeable, cooperative, and
dedicated to the mission of providing health services. Several USPHS Staff had
been assigned at this facility for many years and there was a general satisfaction
with this Medical Department. There was a spirit of cooperation and teamwork
within the Health Unit and also with the assigned CCA Correctional Staff and
those at the various housing units.
H.

Exit Discussion
The exit interview was held at 11:00 a.m. in the Conference Room with Warden
b6, b7c
and 35 staff in attendance.
Also in attendance was

b6

b6, b7c

, Managing Director CCA

b6
Chair
, in concert with Admin/Security Chair
procedures that would follow the audit.

b6

, explained the

The team discussed the compliance levels of the mandatory and non-mandatory standards
and reviewed the individual findings with the group.

14

The chairpersons expressed appreciation for the cooperation of everyone concerned and
congratulated the facility team for the progress made and encouraged them to continue to
strive toward even further professionalism within the correctional field.

15

COMMISSION ON ACCREDITATION FOR CORRECTIONS
AND THE
AMERICAN CORRECTIONAL ASSOCIATION

COMPLIANCE TALLY

Manual Type
Supplement
Facility/Program
Audit Dates
Auditor(s)

Health Care for Jails, 1st Edition
2008 Standards Supplement
Detention Health Services
Eloy Detention Center, Eloy, Arizona
March 30-April 1, 2009
b6
R.N., Chairperson
b6
, Member

MANDATORY

NON-MANDATORY

Number of Standards in Manual

43

85

Number Not Applicable

0

8

Number Applicable

43

77

Number Non-Compliance

0

0

Number in Compliance

43

77

Percentage (%) of Compliance

100%

100%

!

Number of Standards minus Number of Not Applicable equals Number Applicable

!

Number Applicable minus Number Non-Compliance equals Number Compliance

!

Number Compliance divided by Number Applicable equals Percentage of Compliance

16

COMMISSION ON ACCREDITATION FOR CORRECTIONS
Division of Immigration Health Services
Eloy Detention Center
Eloy, Arizona
March 30 - April 1, 2009
Visiting Committee Findings
Mandatory Standards
Not Applicable

Standard # 1-HC-1A-02
WHEN MEDICAL CO-PAYMENT FEES ARE IMPOSED, THE PROGRAM
ENSURES THAT, AT A MINIMUM, THE FOLLOWING ARE OBSERVED:
ƒ
ƒ

ALL OFFENDERS ARE ADVISED, IN WRITING, AT THE TIME OF
ADMISSION TO THE FACILITY OF THE GUIDELINES OF THE COPAYMENT PROGRAM
NEEDED OFFENDER HEALTHCARE IS NOT DENIED DUE TO LACK OF
AVAILABLE FUNDS
CO-PAYMENT FEES SHALL BE WAIVED WHEN APPOINTMENTS OR
SERVICES, INCLUDING FOLLOW UP APPOINTMENTS, ARE INITIATED
BY MEDICAL STAFF.

FINDINGS:
Detainees are not charged co-pay for Medical Services.
Standard # 1-HC-1A-21
ALL IN-TRANSIT OFFENDERS RECEIVE A HEALTH SCREENING BY HEALTHTRAINED OR QUALIFIED HEALTH CARE PERSONNEL ON ENTRY INTO THE
AGENCY SYSTEM. FINDINGS ARE RECORDED ON A SCREENING FORM THAT
WILL ACCOMPANY THE OFFENDER TO ALL SUBSEQUENT FACILITIES
UNTIL THE OFFENDER REACHES HIS OR HER FINAL DESTINATION.
HEALTH SCREENS WILL BE REVIEWED AT EACH FACILITY BY HEALTHTRAINED OR QUALIFIED HEALTH CARE PERSONNEL. PROCEDURES WILL
BE IN PLACE FOR CONTINUITY OF CARE.

17

FINDINGS:
Facility does not receive in-transit detainees.
Standard # 1-HC-1A-34
OFFENDERS HAVE ACCESS TO A CHEMICAL DEPENDENCY TREATMENT
PROGRAM. WHEN A CHEMICAL DEPENDENCY PROGRAM EXISTS, THE
CLINICAL MANAGEMENT OF CHEMICALLY DEPENDENT OFFENDERS
INCLUDES AT A MINIMUM THE FOLLOWING:
$
A STANDARDIZED DIAGNOSTIC NEEDS ASSESSMENT ADMINISTERED
TO DETERMINE THE EXTENT OF USE, ABUSE, DEPENDENCY, AND/OR
CO-DEPENDENCY;
$
A MEDICAL EXAMINATION TO DETERMINE MEDICAL NEEDS AND/OR
OBSERVATION REQUIREMENTS;
$
AN INDIVIDUALIZED TREATMENT PLAN DEVELOPED AND
IMPLEMENTED BY A MULTI DISCIPLINARY TEAM;
$
PRE-RELEASE RELAPSE-PREVENTION EDUCATION INCLUDING RISK
MANAGEMENT; AND
$
THE OFFENDER SHALL BE INVOLVED IN AFTERCARE DISCHARGE
PLANS.
FINDINGS:
Facility does not have a chemical dependency treatment program.
Standard # 1-HC-2A-04
WHEN INSTITUTIONS DO NOT HAVE QUALIFIED HEALTH CARE STAFF,
HEALTH TRAINED PERSONNEL COORDINATE THE HEALTH DELIVERY
SERVICES IN THE INSTITUTION UNDER THE JOINT SUPERVISION OF THE
RESPONSIBLE HEALTH AUTHORITY AND WARDEN OR SUPERINTENDENT.
FINDINGS:
Facility has full qualified HC providers and staff.
Standard # 1-HC-3A-10-1
IF TELE-HEALTH IS USED FOR PATIENT ENCOUNTERS, THE PLAN INCLUDES
POLICIES FOR:
ƒ
ƒ
ƒ
ƒ

PATIENT CONSENT
CONFIDENTIALITY/PROTECTED HEALTH INFORMATION
DOCUMENTATION
INTEGRATION OF THE REPORT OF THE CONSULTATION INTO THE

18

PRIMARY HEALTH CARE RECORD
FINDINGS:
Facility does not have tele-health.
Standard # 1-HC-5A-06
OFFENDERS HAVE ACCESS TO OPERABLE WASHBASINS WITH HOT AND
COLD RUNNING WATER IN THE MEDICAL HOUSING UNIT / INFIRMARY
AREA AT A MINIMUM RATIO OF ONE BASIN FOR EVERY 12 OCCUPANTS,
UNLESS STATE OR LOCAL BUILDING / HEALTH CODES SPECIFY A
DIFFERENT RATIO.
FINDINGS:
EDC does not have an infirmary or a medical housing unit.
Standard # 1-HC-5A-09
THERE ARE SUFFICIENT BATHING FACILITIES IN THE MEDICAL HOUSING
UNIT / INFIRMARY AREA TO ALLOW OFFENDERS HOUSED THERE TO
BATHE DAILY.
FINDINGS:
EDC does not have an infirmary or a medical housing unit.
Standard # 1-HC-5A-10
OFFENDERS HAVE ACCESS TO TOILETS AND HAND-WASHING FACILITIES
24 HOURS PER DAY AND ARE ABLE TO USE TOILET FACILITIES WITHOUT
STAFF ASSISTANCE WHEN THEY ARE CONFINED IN THE MEDICAL
HOUSING UNIT OR IN THE INFIRMARY AREA. TOILETS ARE PROVIDED AT A
MINIMUM RATIO OF ONE FOR EVERY 12 OFFENDERS IN MALE FACILITIES
AND ONE FOR EVERY 8 OFFENDERS IN FEMALE FACILITIES. URINALS MAY
BE SUBSTITUTED FOR UP TO ONE-HALF OF THE TOILETS IN MALE
FACILITIES. ALL HOUSING UNITS WITH THREE OR MORE OFFENDERS
HAVE A MINIMUM OF TWO TOILETS. THESE RATIOS APPLY UNLESS STATE
OR LOCAL BUILDING/HEALTH CODES SPECIFY A DIFFERENT RATIO.
FINDINGS:
There is no medical housing unit or infirmary at this facility.

19

Significant Incident Summary
This summary is required to be provided to the chair of your audit team upon their arrival. The information contained on this form will also be summarized in the
narrative portion of the visiting committee report and will be incorporated into the final report. It should contain data for the last 12 months; indicate those months
in the boxes provided. Please type the data. If you have questions on how to complete the form, please contact your regional manager.
Facility: Eloy Detention Facility (Division of Immigration Health Services)

Year: May 2008 – February 2009
Months

Incidents
Assault:
Offenders/
Offenders*

Indicate types (sexual**,
physical, etc.)
# With Weapon
# Without Weapon

Assault:
Offender/
Staff

Indicate types (sexual**,
physical, etc.)
# With Weapon
# Without Weapon

Number of Forced
Moves Used***

(Cell extraction or other
forced relocation of
offenders)

Disturbances****
Number of Times
Chemical Agents Used
Number of Times Special
Reaction Team Used
Four/Five Point
Restraints

Number
Indicate type (chair, bed,
board, etc.)

Offender Medical Referrals
as a Result of Injuries
Sustained

#’s should reflect
incidents on this form,
not rec or other source

Escapes

# Attempted
# Actual

Substantiated
Grievances
(resolved in favor of
offender)

Reason (medical, food,
religious, etc.)

Deaths

Reason (violent, illness,
suicide, natural)

Number

Number

05/08

06/08

07/08

08/08

09/08

10/08

11/08

12/08

01/09

02/09

Phys.

Phys.

Phys.

Phys.

Phys.

Phys.

Sexual

Phys.

Phys.

Phys.

Phys.
0

0

0

0

1

0

0

0

0

0

0

3

3

2

2

3

3

2

1

2

Sexual

Phys.

Phys.

Phys.

Phys.

Phys.

Phys.

Phys.

Phys.

Phys.

0

0

0

0

0

2

0

1

0

0

2

1

0

3

3

4

2

6

1

4

1

2

3

2

8

3

3

5

2

1

0

0

0

0

0

0

0

1

0

0

0

0

0

0

1

0

0

2

0

0

0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

0

1

0

1

0

1

1

0

1

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Staff

N//A

N/A

N/A

N/A

N/A

N/A

Staff

N/A

Staff

Phys.

(1/1)

Other
0

0

0

0

0

2

0

5

9

0

N/A

N/A

Natural

N/A

N/A

Natural

N/A

N/A

N/A

N/A

0

0

1

0

0

1

0

0

0

0

*Any physical contact that involves two or more offenders
**Oral, anal or vaginal copulation involving at least two parties
***Routine transportation of offenders is not considered Aforced@
****Any incident that involves four or more offenders. Includes gang fights, organized multiple hunger strikes,
work stoppages, hostage situations, major fires, or other large scale incidents

20

Name of Facility: Eloy Detention Center (Division of Immigration Health Services)
Number of Months Data Collected

Date: 03/28/09
12

Health Care Outcome Measure Worksheet

Appendix A

Health Care Outcomes
Standard
1A

Outcome
Measure
(1)
divided by
(2)
divided by
(3)

divided by

(4)
divided by
(5)
divided by
(6)
divided by
(7)

divided by
(8)

divided by
(9)
divided by
(10)

Numerator/Denominator
Number of offenders diagnosed with a MRSA infection within the
past twelve (12) months
The average daily population
Number of offenders diagnosed with active tuberculosis in the past
twelve (12) months
Average daily population.
Number of offenders who are new converters on a TB test that
indicates newly acquired TB infection in the past twelve (12)
months
Number of offenders administered tests for TB infection in the past
twelve (12) months as part of periodic or clinically-based testing,
but not intake screening.
Number of offenders who completed treatment for latent
tuberculosis infection in the past twelve (12) months
Number of offenders treated for latent tuberculosis infection in the
past twelve (12) months.
Number of offenders diagnosed with Hepatitis C viral infection at a
given point in time
Total offender population at that time.
Number of offenders diagnosed with HIV infection at a given point
in time
Total offender population at that time.
Number of offenders with HIV infection who are being treated with
highly active antiretroviral treatment (HAART) at a given point in
time
Total number of offenders diagnosed with HIV infection at that
time.
Number of selected offenders with HIV infection at a given point in
time who have been on antiretroviral therapy for at least six
months with a viral load of less than 50 cps/ml
Total number of treated offenders with HIV infection that were
reviewed.
Number of offenders diagnosed with an Axis I disorder (excluding
sole diagnosis of substance abuse) at a given point in time
Total offender population at that time.
Number of offender admissions to off-site hospitals in the past
twelve (12) months

21

Value

Calculated
O.M.

11
1500

0.0073

2
1500
0

0.0013

0

0

7
21

0.33

2
150

0.006

9
1500
8

0.006

9

0.88

1

8

0.125

90
1500
45

0.06

divided by
(11)

Average daily population.
Number of offenders transported off-site for treatment of
emergency health conditions in the past twelve (12) months

1500
204

0.03

divided by
(12)

Average daily population in the past twelve (12) months.
Number of offender specialty consults completed during the past
twelve (12) months
Number of specialty consults (on-site or off-site) ordered by
primary health care practitioners in the past twelve (12) months.
Number of selected hypertensive offenders at a given point in time
with a B/P reading > 140 mmHg/ >90 mm Hg
Total number of offenders with hypertension who were reviewed.

1500
1394

0.136

1780

0.78

(14)

Number of selected diabetic offenders at a given point in time who
are under treatment for at least six months with a hemoglobin A1C
level measuring greater than 9 percent

32

divided by
(15)

Total number of diabetic offenders who were reviewed.
The number of completed dental treatment plans within the past
twelve (12) months
the average daily population during the reporting period.
Number of health care staff with lapsed licensure or certification
during a twelve (12) month period
Number of licensed or certified staff during a twelve (12) month
period.
Number of new health care staff during a twelve (12) month period
that completed orientation training prior to undertaking their job
Number of new health care staff during the twelve (12) month
period.
Number of occupational exposures to blood or other potentially
infectious materials in the past twelve (12) months
Number of employees.
Number of direct care staff (employees and contractors) with a
conversion of a TB test that indicates newly acquired TB infection
in the past twelve (12) months

165
19

0.19

1500
0

0.012

51

0

divided by
(13)
divided by

2A

divided by
(1)
divided by
(2)
divided by
(3)
divided by
(4)

divided by

3A

(1)
divided by
(2)
divided by
(3)

divided by

Number of direct care staff tested for TB infection in the past
twelve (12) months during periodic or clinically indicated
evaluations.
Number of offender grievances related to health care services
found in favor of the offender in the past twelve (12) months
Number of evaluated offender grievances related to health care
services in the past twelve (12) months.
Number of offender grievances related to safety or sanitation
sustained during a twelve (12) month period
Number of evaluated offender grievances related to safety or
sanitation during a twelve (12) month period.
Number of adjudicated offender lawsuits related to the delivery of
health care found in favor of the offender in the past twelve (12)
months
Number of offender adjudicated lawsuits related to healthcare
delivery in the past twelve (12) months

22

10
63

0.16

22
22

1

2
59
1

0.033
1

47

0.02

1
25

0.04

0
0

0

0

0

0

4A

(1)
divided by
(2)
(3)
divided by
(4)
divided by
(5)
divided by
(6)

Number of problems identified by quality assurance program that
were corrected during a twelve (12) month period
Number of problems identified by quality assurance program
during a twelve (12) month period.
Number of high-risk events or adverse outcomes identified by the
quality assurance program during a twelve (12) month period.
Number of offender suicide attempts in the past twelve (12)
months
Average daily population
Number of offender suicides in the past twelve (12) months
Average daily population
Number of unexpected natural deaths in the past twelve (12)
months
Total number of deaths in the same reporting period.
Number of serious medication errors in the past twelve (12)
months

23

4
4

1

1
2
1500
0
1500
2

0.0013

2
23

1

0