Department of Homeland Security-Conditon of Confinement Worksheet, May 2021
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Department of Homeland Security Immigration and Customs Enforcement: Office of Enforcement and Removal Operations Condition of Confinement Inspection Worksheet (This document must be attached to each G-324A Inspection Worksheet) This Form is to be used for Inspections of Facilities Used Over 72 Hours ICE Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities REVIEW TEAM USE: (Edits Permitted, ALL FIELDS REQUIRED) Facility Information Facility Name: Clay County Justice Center I Facility Type: IGSA Review Purpose: Annual Intergovernmental Service Agreement (IGSA), ICE Service Processing Center (SPC), ICE Contract Detention Facility (CDF) Address: City: Brazil County: 611 East Jackson Street 1 I I Clay State: IN CEO Name: Paul Harden Review Information (Use following format for dates: mm/dd/yyyy) Start Date: 5/18/2021 End Date: 5/20/2021 Lead Name: Inspector 3 l I I Zip: 47834 CEO Title: Sheriff Type: Special Assessment l ReviewLead Title: LCI I Review Document Issue Summary (See Document Check Section to Review/Update) Error(s) Found: Items Not Rated: 0 0 ICE HQ USE ONLY: (DO NOT EDIT*) Form Name: PBNDS_2008_G324A_O72_LYON Form Key: 27 Form Date: 5/9/2017 Form Type: PBNDS 2008 Form Review Type: Annual Form Over/Under 72 Status: O72 *If Edits are required, contact ICE HQ for an updated form. FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Table of Contents INTRODUCTION TO THE G-324A OVER 72 HOUR FACILITY DETENTION INSPECTION WORKSHEETS .................................................................................................................................................4 WHAT IS “PERFORMANCE-BASED”?................................................................................................................4 WORKSHEET OVERVIEW .................................................................................................................................4 WORKSHEET COMPLETION .............................................................................................................................5 SECTION I: SAFETY .......................................................................................................................................6 PART 1 – 1. EMERGENCY PLANS (KEY: A) ..........................................................................................................7 PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (KEY: B) ........................................................................ 10 PART 1 – 3. TRANSPORTATION (BY LAND) (KEY: C) ........................................................................................ 16 SECTION II: SECURITY .............................................................................................................................. 19 PART 2 – 4. ADMISSION AND RELEASE (KEY: D).............................................................................................. 20 PART 2 – 5. CLASSIFICATION SYSTEM (KEY: E) ................................................................................................ 24 PART 2 – 6. CONTRABAND (KEY: F)................................................................................................................. 27 PART 2 – 7. FACILITY SECURITY AND CONTROL (KEY: G)................................................................................. 29 PART 2 - 8. FUNDS AND PERSONAL PROPERTY (KEY: H) ................................................................................. 33 PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (KEY: I)......................................................................... 37 PART 2 – 10. KEY AND LOCK CONTROL (KEY: J) ............................................................................................... 41 PART 2 – 11. POPULATION COUNTS (KEY: K) .................................................................................................. 45 PART 2 – 12. POST ORDERS (KEY: L)................................................................................................................ 47 PART 2 – 13. SEARCHES OF DETAINEES (KEY: M) ............................................................................................ 49 PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (KEY: N) ...............................52 PART 2 – 15. SPECIAL MANAGEMENT UNITS (KEY: O) .................................................................................... 56 PART 2 – 16. STAFF-DETAINEE COMMUNICATION (KEY: P) ........................................................................... 65 PART 2 – 17. TOOL CONTROL (KEY: Q)............................................................................................................ 69 PART 2 – 18. USE OF FORCE AND RESTRAINTS (KEY: R) .................................................................................. 73 SECTION III: ORDER ................................................................................................................................... 77 PART 3 – 19. DISCIPLINARY SYSTEM (KEY: S) .................................................................................................. 78 SECTION IV: CARE ...................................................................................................................................... 81 PART 4 – 20. FOOD SERVICE (KEY: T) .............................................................................................................. 82 Page 2 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 21. HUNGER STRIKES (KEY: U) ......................................................................................................... 89 PART 4 – 22. MEDICAL CARE (KEY: V) ............................................................................................................. 94 PART 4 – 23. PERSONAL HYGIENE (KEY: W) .................................................................................................. 116 PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (KEY: X) ...............................................................120 PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (KEY: Y) ...........................................126 SECTION V: ACTIVITIES .......................................................................................................................... 131 PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (KEY: Z)........................................................................ 132 PART 5 – 27. ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES (KEY: AA) ..............................................135 PART 5 – 28. MARRIAGE REQUESTS (KEY: AB) .............................................................................................. 136 PART 5 – 29. RECREATION (KEY: AC) ............................................................................................................ 138 PART 5 – 30. RELIGIOUS PRACTICES (KEY: AD) ............................................................................................. 142 PART 5 – 31. TELEPHONE ACCESS (KEY: AE) ................................................................................................. 145 PART 5 – 32. VISITATION (KEY: AF) ............................................................................................................... 150 PART 5 – 33. VOLUNTARY WORK PROGRAM (KEY: AG) ................................................................................ 153 SECTION VI: JUSTICE ............................................................................................................................... 155 PART 6 – 34. DETAINEE HANDBOOK (KEY: AH) ............................................................................................. 156 PART 6 – 35. GRIEVANCE SYSTEM (KEY: AI) .................................................................................................. 161 PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (KEY: AJ) ..................................................................... 164 PART 6 – 37. LEGAL RIGHTS GROUP PRESENTATIONS (KEY: AK) .................................................................. 168 SECTION VII: ADMINISTRATION & MANAGEMENT ...................................................................... 170 PART 7 – 38. DETENTION FILES (KEY: AL) ...................................................................................................... 171 PART 7 – 39. NEWS MEDIA INTERVIEWS AND TOURS (KEY: AM) .................................................................173 PART 7 – 40. STAFF TRAINING (KEY: AN) ...................................................................................................... 175 PART 7 - 41. TRANSFER OF DETAINEES (KEY: AO) ......................................................................................... 181 DOCUMENT CHECK .................................................................................................................................. 184 Page 3 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities INTRODUCTION TO THE G-324A OVER 72 HOUR FACILITY DETENTION INSPECTION WORKSHEETS The Performance-Based National Detention Standards (PBNDS 2008) were designed to better address the needs of ICE’s detainee population while maintaining a safe and secure detention environment for staff and detainees. The revised PBNDS 2008 builds on the requirements of NDS to more clearly delineate the results or outcomes to be accomplished by adherence to their requirements. The PBNDS 2008 prescribe both the expected outcomes of each detention standard and the expected practices required to achieve them. During development four new standards were added to include standards on Searches of Detainees, Sexual Abuse and Assault Prevention and Intervention, News Media Interviews and Tours, and Staff Training, while the two National Detention Standards regarding Special Management Units standards were condensed into one standard in PBNDS 2008. WHAT IS “PERFORMANCE-BASED”? Unlike “policy and procedures” that focus solely on what is to be done, performance-based policy starts with a focus on the results or outcomes that the required procedures are expected to accomplish. Each performance-based standard has been revised to produce Expected Outcomes that are clearly stated. Each standard reflects the overall mission and purpose of the agency and contributes to the goal that has been articulated. Expected Practices found in the PBNDS represent what is to be done to accomplish the Expected Outcomes that will meet the Purpose and Scope of the detention standard. WORKSHEET OVERVIEW Detention Inspection Worksheets are used to assess facility compliance with ICE detention standards. This set of worksheets is derived from the policies and procedures set forth in the PBNDS 2008. The G-324A is for use with facilities that house detainees for over 72 hours. Various line items in the worksheets have been designated as “Priority.” Priority components replace mandatory components in earlier PBNDS 2008 worksheets, and represent those PBNDS requirements that ICE deems of critical importance for ensuring adequate conditions of confinement and the safety and security of detainees and staff at all ICE authorized detention facilities. Page 4 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities WORKSHEET COMPLETION Reviewers are required to complete each item within each section of the G-324A Detention Inspection Worksheets. Worksheets are in a uniform format with three columns, with PBNDS purpose and scope stated at the top of the worksheet. Column one contains the relevant standard line item. Column two contains a dropdown menu for each row where a rating can be assigned to a given line item. In addition to rating options for “Meets Standard” and “Does Not Meet Standard,” there is an option for the review team to select “N/A.” The “N/A” rating should be used only rarely and where applicable. In addition, the remarks section for each line item should be filled out in as much detail as possible. If the review team fails to assign a rating to a given line item, the default rating and thus the assigned rating on the worksheet will show as “Not Rated.” There is also a summary remarks and rating section at the end of each standard that must be completed by the assigned reviewer. The remarks should be filled out with sufficient detail to assist the Review Authority in accurately assessing overall facility compliance to the PBNDS. Page 5 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Section I: SAFETY Emergency Plans Environmental Health and Safety Transportation (By Land) Page 6 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 1. EMERGENCY PLANS (Key: A) This Detention Standard ensures a safe environment for detainees and employees by having in place contingency plans to quickly and effectively respond to any emergency situations that arise and to minimize their severity. Components 1. 2. 3. Meets Standard Meets Standard Training file documentation confirmed that all employees receive training in emergency preparedness during their initial training and annually. Meets Standard Documentation confirmed that the facility has contingency plans for responding to emergencies. The emergency plans include a locally approved evacuation plan that is updated annually. The plan was approved on 05/19/2021. Meets Standard Documentation of "man-down" drills were inspected. Meets Standard The IGSA facility has developed contingency plans with local state and federal law enforcement. Memoranda of Understanding Agreements include Clay Community School Corporation and the City of Brazil, Indiana. The OIC reviews and approves the contingency plan at least annually. Meets Standard The Facility Emergency Plans policy includes a statement prohibiting unauthorized use. Meets Standard The Facility Emergency Plans policy addresses all items listed in the standard. (SPCs/CDFs) The facility shall set up a primary command post outside the secure perimeter that is equipped as per the Emergency Plan standard. Meets Standard In this IGSA facility, the command post is set up outside the secure perimeter of the facility in the training room at the Clay County Justice Center. At least one video camera shall be maintained in the Meets Standard The video camera was observed All staff receive training in the emergency plans during their orientation training as well as during their annual training. PRIORITY: The facility shall have in place contingency plans for responding to emergencies, including a locally approved and annually updated evacuation plan. The facility conducts emergency exercises to test specific emergency plans to assess their effectiveness. 5. (SPCs/CDFs) Each SPC and CDF shall develop contingency plans with local, State, and Federal law enforcement agencies and formalize those agreements with Memoranda of Understanding (MOUs). The facility administrator shall review and approve contingency plans at least annually. 6. Every plan that is being developed or is final must include a statement prohibiting unauthorized disclosure. 7. The facility shall establish written policy and procedures addressing, at a minimum: chain of command, command post/center, staff recall, staff assembly, emergency response components, use of force, video recording, records and logs, utility shutoff, employee conduct and responsibility, public relations, facility security, etc. 9. Remarks (1000 Char Max) Training records verified that staff are trained to identify detainee unrest to include distress and unusual behavior. Staff are trained to identify signs of detainee unrest. 4. 8. Rating Page 7 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 1. EMERGENCY PLANS (Key: A) This Detention Standard ensures a safe environment for detainees and employees by having in place contingency plans to quickly and effectively respond to any emergency situations that arise and to minimize their severity. Components Rating in the control center. The video camera was tested for operability. Control Center for use in emergency situations. 10. Emergency plans include emergency medical treatment for staff and detainees during and after an incident. 11. The FSA shall make contingency plans for providing meals to detainees and staff during an emergency, including access to community resources, which the FSA shall negotiate during the planning phase. 12. The plan shall include post-emergency procedures. Remarks (1000 Char Max) Does Not Meet Standard Emergency medical treatment for staff and detainees was not included in the emergency plan. Does Not Meet Standard Food service has no written plans for providing meals to detainees and employees during an emergency. The food service department has not developed plans to access community resources. Does Not Meet Standard Post-emergency procedures are not included in the emergency plan. 13. Written procedures cover: • Work/Food Strike • Fire • Environmental Hazard • Detainee Transportation System Emergency • ICE-wide Lockdown • Staff Work Stoppage • Disturbances • Escapes • Bomb Threats • Adverse Weather • Internal Searches Meets Standard • Facility Evacuation • Detainee Transportation System Plan • Hostages (Internal) • Civil Disturbances Emergency Plans include each contingency required by this component. PART 1 – 1. EMERGENCY PLANS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.)(5000 Character Max) Emergency Plans ensure a safe environment for detainees and employees by having in place contingency plans to quickly and effectively respond to emergency situations and to minimize their severity. The plans are considered confidential and include a statement prohibiting unauthorized disclosure. All officers receive training on the facility's emergency procedures. All contingency plans comply with detention standards for confidentiality, accountability, review, and revision. The Page 8 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 1. EMERGENCY PLANS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) emergency plans address the chain of command, staff recall during emergencies, utility shutoffs, and facility security. The OIC reviews and approves contingency plans annually. Annual review and approval of the plans are recorded on the master copy of the Emergency Plans, even if the review resulted in no change. Plans do not include procedures for assisting detainees with special needs during emergency or evacuation. In an emergency, the facility ensures detainees with disabilities and detainees who are limited in their English proficiency (LEP) will be provided with effective communication by as many means as possible. Evaluation of this standard was based on review of the Facility Emergency Plans policy, Emergency Plans, emergency response drills, training files and Memoranda of Agreements; interviews with Captain Brandon Crowley; and observation of the control center, command center and perimeter security. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 9 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B) This Detention Standard protects detainees, staff, volunteers, and contractors from injury and illness by maintaining high facility standards of cleanliness and sanitation, safe work practices, and control of hazardous substances and equipment. Components 1. 2. 3. 4. Rating Remarks (1000 Char Max) Does Not Meet Standard Environmental health and safety conditions are not always maintained at a level consistent with the recognized safety and hygiene standards of the organizations listed in this component. Specifically, sanitation levels were not consistent an some areas. Additionally, observation of fire extinguishers in several areas did not support monthly inspection, although a master monthly reports indicates otherwise. Does Not Meet Standard The captain, who is charged with overseeing the safety program at this facility, stated there is no formalized housekeeping plan. Sanitation levels were noted as inconsistant throughouut the facility. Specifically, shower and bathroom areas were not clean and free of clutter. Similarly, a property storage area was unkempt and had boxes blocking electrical panels. Does Not Meet Standard Staff state hazardous materials are not maintained within the secure perimiter of this facility; however, hazardous materials were observed in the facility in various quantities and locations, which does not support a viable chemical control program. Does Not Meet Standard The lieutenant is charged with oversight of the SDS program. Review of chemical storage areas indicated several chemicals did not have an SDS. Additionally, chemicals were observed throughout the facility in other than recognized storage areas. Emergency numbers were included in the SDS book; chemical locations were not. Environmental health and safety conditions shall be maintained at a level that meets recognized standards of safety and hygiene, including those from the: • American Correctional Association, • Occupational Safety and Health Administration, • Environmental Protection Agency, • Food and Drug Administration, • National Fire Protection Association's Life Safety Code, and • National Center for Disease Control and Prevention. A housekeeping plan will be developed for detainee living areas noted in the standards. The facility appears clean and well maintained. The facility has a system for storing, issuing, and maintaining inventories of hazardous materials The Maintenance Supervisor shall compile: • An up to date master index of all hazardous substances in the facility and their locations; • A master file of MSDSs; and • A comprehensive, up-to-date list of emergency phone numbers (fire department, poison control center, etc.). Page 10 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B) This Detention Standard protects detainees, staff, volunteers, and contractors from injury and illness by maintaining high facility standards of cleanliness and sanitation, safe work practices, and control of hazardous substances and equipment. Components 5. All personnel using flammable, toxic, and/or caustic substances follow prescribed safety procedures. 6. The MSDS are readily accessible to staff and detainees in the work areas. 7. Hazardous materials are always issued under proper supervision. Rating Remarks (1000 Char Max) Does Not Meet Standard Interviews and personal observations indicate there is no training provided to staff on chemical safety and/or use. Meets Standard Does Not Meet Standard 8. All toxic and caustic materials stored in their original containers in a secure area. 9. Excess flammables, combustibles, and toxic liquids are disposed of properly in accordance with MSDS. SDS were observed in storage and work areas. Hazardous materials were observed in various areas other than designated storage areas, suggesting a lack of adherance to issue/return procedures. Specifically, a partial five-gallon bucket of cautic stripper was stored in the control room hallway and a partial gallon of liquid labeled as poison was observed on top of a file cabintet in the ICE office. Meets Standard Chemicals were observed in original containers. Meets Standard No flammable, combustible, or toxic liquids are maintained within the facilty. Meets Standard The captain is charged with administering the safety program and he has received hazardous chemical training and OSHA training as a volunteer firefighter. He has received additional training in his current position. Does Not Meet Standard Although the captain conducts weekly fire and safety inspections for the facility, there were no discrepancies noted in any of the inspections reviewed. This condition is not supported by personal observations of the facility's cleanliness and santation, nor the reviews of operational practices during this inspection. 10. The facility program will be supervised by a person who has been trained in accordance with OSHA standards. 11. PRIORITY: A qualified departmental staff member shall conduct weekly fire and safety inspections. Page 11 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B) This Detention Standard protects detainees, staff, volunteers, and contractors from injury and illness by maintaining high facility standards of cleanliness and sanitation, safe work practices, and control of hazardous substances and equipment. Components Rating Remarks (1000 Char Max) Meets Standard The captain conducts monthly inspections of the facilty and completes a report indicating that fire extinguisher condition is good. However, an inspection of individual fire extinguishers tags indicated they had only been inspected one time in this calendar year. Meets Standard Inspection reports are maintained in the captains' office. There were no issues identified in any of the reports reviewed, hence there were no maintenance orders produced or corrective actions taken. Meets Standard The facilty has an fire prevention plan that has been approved by the local fire authority on 05/19/2021. Documentation is maintained in the captains' office. Meets Standard The fire prevention, control and evacuation plan includes all of the bulleted requirements except the required exit signs and directional arrows. A waiver, approved by Jay M. Brooks, ICE Deputy Assistant Director, Detention Management Division on 12/12/2018 regarding evacuation diagrams in areas where detainees could use the for escape purposes remains in force. A "work around" solution was developed which required evacuation plans to be posted and maintained in the facility control room and the housing unit control rooms. Meets Standard A review of fire drill documentation confirmed drills are conducted in all areas and all shifts and include the drawing of emergency keys. A drill was simulated during the review. 12. Facility maintenance (safety) staff shall conduct monthly inspections. 13. The facility maintains files of inspection reports, including corrective actions taken. 14. PRIORITY: The facility has an approved fire prevention, control, and evacuation plan. 15. The plan requires: • Monthly fire inspections. • Fire protection equipment strategically located throughout the facility. • Public posting of emergency plan with accessible building/room floor plans. • Exit signs and directional arrows. • An area-specific exit diagram conspicuously posted in the diagrammed area. 16. Fire drills are conducted and documented quarterly in all facility locations including the administrative area. Page 12 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B) This Detention Standard protects detainees, staff, volunteers, and contractors from injury and illness by maintaining high facility standards of cleanliness and sanitation, safe work practices, and control of hazardous substances and equipment. Components 17. PRIORITY: The facility administrator shall ensure licensed pest-control professionals perform monthly inspections to identify and eradicate rodents, insects and vermin, including a preventative spraying program for indigenous insects. 18. At least annually, a state laboratory shall test samples of drinking and wastewater to ensure compliance with applicable Standards. 19. Emergency power generators are tested as required by emergency plans and manufacturer’s recommendations. 20. (Medical Operations) Written procedures, to include an exposure-control plan in the event of a needle stick, regulate the handling and disposal of used needles and other sharp objects. Rating Meets Standard A review of invoices confirms licensed pest control performs monthly inspections and remediation per the issue identified. Meets Standard Water is supplied by a the City of Brazil which conducts testing of water and waste water to ensure compliance with applicable standards. Meets Standard A review of logs indicates the generator is tested as required by the manufacturers recommendations. Meets Standard Health care is provided by Quality Correctional Care, and includes a policy on needle sticks. The handling/disposal of sharps is outlined in training as indicated in training curriculum. Meets Standard Standard cleaning practices are used in the medical area. The area is cleaned daily with chemicals supplied by security staff. Meets Standard Spill kits were observed in the numerous areas and avaiable as needed. Meets Standard Medical waste is disposed of via a contract with Stericycle. Meets Standard A review of training materials confirms training is provided to staff to prevent contact with blood and other body fluids. 21. (Medical Operations) Standard cleaning practices include: • Using specified equipment; cleansers; disinfectants and detergents. • An established schedule of cleaning and follow-up inspections. 22. (Medical Operations) Spill kits are readily available. 23. (Medical Operations) A licensed medical waste contractor disposes of infectious/bio-hazardous waste. 24. (Medical Operations) Staff are trained to prevent contact with blood and other body fluids and written procedures are followed. Remarks (1000 Char Max) Page 13 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY (Key: B) This Detention Standard protects detainees, staff, volunteers, and contractors from injury and illness by maintaining high facility standards of cleanliness and sanitation, safe work practices, and control of hazardous substances and equipment. Components Rating Remarks (1000 Char Max) Does Not Meet Standard Interviews with an RN indicated inspections are performed daily and are documented on a check list. However, the documentation reflects the office is cleaned weekly with no mention of other areas in health services. There are two rooms utilized by health services and both appeared to be in need of routine cleaning and organizing. Meets Standard The captain investigates and conducts surveys of environmental health conditions if required and provides required advisory, consultive, inspections and training as necessary. Meets Standard The captain states that he reviews policy annually, or as needed, and recommends changes as needed. 25. (Medical Operations) The Health Services Administrator conducts medical-facility inspections daily. 26. A qualified staff member shall: conduct special investigations and comprehensive surveys of environmental health conditions, and provide advisory, consultative, inspection, and training services regarding environmental health conditions. 27. The assigned staff member is responsible for developing and implementing policies, procedures, and guidelines for the environmental health program. PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The safety program is administered by Captain Brandon Crowley, with some components assigned to Lieutenant Neil Taylor on a collateral basis. The captain was provided OSHA training as a former volunteer firefighter, and has completed additional OSHA training in his current position. Environmental health and safety conditions are not always maintained at a level consistent with the recognized safety and hygiene standards of the organizations listed in this component. Specifically, sanitation levels were not consistent in some areas. Toilet and shower areas in the housing units were not clean and were cluttered with various items. Several storage areas and offices were cluttered and in need of basic sanitation such as sweeping and/or mopping. Observation of fire extinguishers in several areas does not support monthly inspection although a master monthly report indicates otherwise. Two extinguishers located in the ICE office were placed on the floor and not mounted on the wall. Some fire exits as well as an evacuation diagrams were blocked throughout the inspection. Although the facility utilizes a red line to enforce that nothing be within eighteen inches of the ceiling, items were observed exceding the line in two locations. The fire prevention, control and evacuation plan includes all of the bulleted requirements except the required exit signs and directional arrows. A waiver, approved by Jay M. Brooks, ICE Deputy Assistant Director, Detention Management Division on 12/12/2018, regarding evacuation diagrams in areas where detainees could use the for escape purposes remains in force. The "work around" solution was to ensure that evacuation plans were posted and maintained in both the facility control room and housing unit control rooms. Hazardous materials were observed in various areas other than designated storage areas suggesting a lack of adherance to Page 14 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 2. ENVIRONMENTAL HEALTH AND SAFETY – Reviewer Summary (Use following format for dates: mm/dd/yyyy) issue/return procedures. Specifically, a partial five-gallon bucket of caustic stripper was stored in the control room hallway and a partial gallon of fluid marked poison was observed on top of a file cabintet in the ICE office. Interview with Stan Roark, RN, indicated inspections are performed daily in health services and are documented on a check list. However, documentation reflects the office is cleaned weekly with no mention of other areas in health services. Observation of the health services area suggests there is not a regularly scheduled cleaning program. During the evaluation of this standard Captain Brandon Crowley, Lieutenant Neil Taylor and Registered Nurse Stan Roark were interviewed; policies and logs were reviewed and the physical plant was observed. Overall Rating: Does Not Meet Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 15 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 3. TRANSPORTATION (BY LAND) (Key: C) This Detention Standard prevents harm to the general public, detainees, and staff by ensuring that vehicles are properly equipped, maintained, and operated and that detainees are transported in a secure, safe and humane manner, under the supervision of trained and experienced staff. Standard N/A I Click the above button if all ICE Transportation is handled only by the ICE Field Office or Sub-Office in control of the detainee case. (All Line Items and standard will be rated “N/A”) Components 1. The Facility Administrator shall develop and implement written policy, procedures and guidelines for the transportation of detainees. 2. Documentation indicating annual inspection of vehicles and annual inspection in accordance with state statutes is available for review. Rating Meets Standard Remarks (1000 Char Max) The Inmate Transports policy and procedures address the transportation of detainees. Does Not Meet Standard Documentation was not available to verify that annual inspections are conducted on all vehicles in accordance with state statutes. To be assigned to a bus transporting detainees, an officer must have successfully completed the ICE/ERO bus-drivertraining program or a comparable approved training program and all local state requirements for a Commercial Driver’s License (CDL). Meets Standard Documentation revealed that all bus drivers have completed the required training and have been issued current commercial driver's licenses. Supervisors maintain records for each vehicle operator. This includes certificate of completion from bus training program, most current physical exam used to obtain the CDL, and a copy of the CDL. Meets Standard The chief deputy maintains a file for documents required in this component. 5. Maximum driving time (time on the road), for CDL operators, is governed by USDOT. Meets Standard 6. The transporting officer inspects the vehicle before the start of each detail. 3. 4. 7. 8. 9. Positive identification of all detainees being transported is confirmed. The facility ensures that the number of detainees transported does not exceed the vehicle manufacturer’s occupancy level. Policies and procedures are in place addressing the use of restraining equipment on transportation vehicles. Meets Standard The Inmate Transports policy requires that vehicles are inspected before each detail. Documentation confirmed practice. Meets Standard Positive identification is confirmed with a picture of the detainee, face sheet and Form I203. Meets Standard The administrative sergeant ensures that the number of detainees transported does not exceed occupancy levels. Trip sheets confirmed practice. Meets Standard The Inmate Transports policy includes language regarding the use of restraining equipment on transportation vehicles. Page 16 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 3. TRANSPORTATION (BY LAND) (Key: C) This Detention Standard prevents harm to the general public, detainees, and staff by ensuring that vehicles are properly equipped, maintained, and operated and that detainees are transported in a secure, safe and humane manner, under the supervision of trained and experienced staff. Standard N/A I Click the above button if all ICE Transportation is handled only by the ICE Field Office or Sub-Office in control of the detainee case. (All Line Items and standard will be rated “N/A”) Components Rating 10. Meals are provided during long distance transfers. The meals meet the minimum dietary standards, as identified by dieticians utilized by ICE. Meets Standard 11. The facility administrator shall establish the procedures and schedule for sanitizing facility vehicles. Is inventoried. • Is inspected. • Accompanies the detainee. Documentation confirmed that sack meals provided meet the minimum dietary standards. Does Not Meet Standard The procedures and schedule for sanitizing facility vehicles is not available. During the inspection the procedures and schedule were developed for sanitizing vehicles. Meets Standard Documentation confirmed that personal property of a detainee transferring to another facility is inventoried, inspected and accompanies the detainee. 12. Personal property of a detainee transferring to another facility: • Remarks (1000 Char Max) PART 1 – 3. TRANSPORTATION (BY LAND) – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Detainees are transported safely and humanely under the supervision of trained staff with required qualifications. Policy requires escorting officers to properly identify the detainee they are transporting. The facility does not have a handicap accessible van to transport detainees with disabilities. The OIC would borrow a vehicle from an adjoining county if such a need would present. Meals are provided for long-distance transfers. The facility prohibits one-on-one opposite gender transports. As reported by the OIC, officers are required to secure a vehicle before leaving it unattended including removing keys from the ignition immediately upon parking the vehicle. Officers avoid parking in areas that may attract undue attention or be vulnerable to vandalism or sabotage. Transportation officers are instructed to contact local law enforcement for advice if they cannot locate parking with adequate security. Policy requires an armed officer to be posted whenever detainees enter or exit a vehicle outside a secure area. A complete set of keys for every lock located in or on the vehicle travels with the vehicle at all times in a secure place known to every transporting officer. An armed officer may not enter the secure area of the vehicle. If he/she must enter that area, the officer shall first leave the weapon(s) with another officer for safekeeping. Evaluation of this standard was based on review of the Inmate Transports policy, trip sheets, post orders, CDL's and training documents; observation of a transportation vehicle which was observed to be unclean; and interviews with Chief Deputy Josh Clarke, Sergeant Jace Glassburn and Captain Brandon Crowley. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Page 17 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 1 – 3. TRANSPORTATION (BY LAND) – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Reviewer Signature (for printed form submission): Page 18 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Section II: SECURITY Admission and Release Classification System Contraband Facility Security and Control Funds and Personal Property Hold Rooms in Detention Facilities Key and Lock Control Population Counts Post Orders Searches of Detainees Sexual Abuse and Assault Prevention and Intervention Special Management Units Staff-Detainee Communication Tool Control Use of Force and Restraints Page 19 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 4. ADMISSION AND RELEASE (Key: D) This Detention Standard protects the community, detainees, staff, volunteers, and contractors by ensuring secure and orderly operations when detainees are admitted to or released from a facility. Components 1. 2. Rating Remarks (1000 Char Max) Meets Standard The local handbook given to all detainees at intake addresses rules, policies, programs and activities. New arrivals are also shown a site specific video that describes facility policies, rules and procedures. The handbook and video are available in Spanish and English. Confirmed via review of the local handbook and detainee interviews. Meets Standard At intake detainees are pat searched and pass through a full body metal detector; their personal property and valuables are checked for contraband, inventoried, receipted and stored. Confirmed via detainee interviews. The facility has implemented written policies and procedures for the intake and reception of newly arrived detainees and provided them with information about facility policies, rules and procedures. At intake, detainees are searched, and their personal property and valuables checked for contraband, inventoried, receipted, and stored. 3. Each detainee’s identification documents are secured in the detainee’s A-file. 4. A medical screening will be conducted to protect the health of the detainee and others in the facility, and the detainee shall be given an opportunity to shower and be issued clean clothing, bedding, towels, and personal hygiene items. Meets Standard Meets Standard 5. Staff shall not routinely require a detainee to remove clothing or require a detainee to expose private parts of his or her body to search for contraband. 6. Staff shall issue those clothing and bedding items that are appropriate for the facility environment and local weather conditions. Detention officers conduct an intake screen. They will contact the RN either on-site or call them at home. The RN will contact the physician to review the screen over the phone and get orders. Detainees are required to shower prior to changing into issued color coded shirt and pants, and a wrist band noting their classification level. Clean clothing, bedding, towels, linens and gender specific items are issued during the intake process. Confirmed via detainee interviews. Meets Standard Meets Standard Page 20 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) On site inspectors confirmed that issued clothing and bedding are appropriate for the facility's environment and local climate conditions. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 4. ADMISSION AND RELEASE (Key: D) This Detention Standard protects the community, detainees, staff, volunteers, and contractors by ensuring secure and orderly operations when detainees are admitted to or released from a facility. Components 7. 8. 9. Staff shall use the documentation accompanying each new arrival for identification and classification purposes. If the classification staff is not ICE/ERO employees ICE/ERO shall provide the information needed for classification. Under no circumstances may non-ICE/ERO personnel have access to the detainees A-File. An Order to Detain or Release the detainee (Form I-203 or I-203a), bearing the appropriate ICE/ERO Authorizing Official signature, must accompany each newly arriving detainee. Rating Remarks (1000 Char Max) Meets Standard ICE classifies detainees prior to transporting them to the facility. Staff follow ICE's classification level in assigning detainee housing. The inspector examined detainee classification documents (RCA) and completed I-203 forms in eight detainee files. A-files are not kept at the facility. Meets Standard PRIORITY: Facilities shall have a method to provide ICE/ERO detainees an orientation to the facility as soon as practicable, in a language or manner that detainees can understand. Meets Standard A signed I-203 form accompanies each detainee admitted to the facility. The inspector examined signed I 203 forms in reviewed detainee files. Detainees receive a local handbook and National Detention handbook upon admission. Handbooks are available in English and Spanish and explain in detail facility rules, regulations, expected behavior and available program services. In addition, an orientation video, in both Spanish and English, is shown during intake. Confirmed via detainee and staff inteviews. 10. The facility shall issue to each newly admitted detainee a copy of the ICE National Detainee Handbook and local supplement that fully describes all policies, procedures, and rules in effect at the facility. Meets Standard Upon admission, detainees are given the ICE and local handbooks. Together, the handbooks fully describe facility policies, procedures, rules and other applicable information. Confirmed via detainee and staff inteviews. 11. All releases are coordinated with ICE. Meets Standard 12. Staff complete paperwork/forms for release as required. Meets Standard Page 21 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) The inspector interviewed the assistant jail administrator who confirmed that all paperwork/forms for release are completed as required. Reviewed detainee files also contained required release forms. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 4. ADMISSION AND RELEASE (Key: D) This Detention Standard protects the community, detainees, staff, volunteers, and contractors by ensuring secure and orderly operations when detainees are admitted to or released from a facility. Components Rating 13. The facility returns each detainee’s property upon release, and each detainee receives a receipt for personal property secured by the facility. Meets Standard 14. PRIORITY: The facility has a system to maintain accurate records and documentation for admission, orientation, and release. 15. ICE staff enter all information pertaining to release, removal, or transfer of all detainees into the Enforce Alien Detention Module (EADM) within 8 hours of action. Meets Standard Remarks (1000 Char Max) The inspector reviewed written policy requiring that all records and documents concerning a detainee's admission, orientation, and release be filed in their detention file. Meets Standard 16. All orientation material shall be provided in English, Spanish, and other language(s) as determined by the Field Office Director. Meets Standard Orientation materials are provided in English and Spanish; languages spoken by many the detainees held at the facility. The inspector reviewed the Spanish version of the detainee handbook. PART 2 – 4. ADMISSION AND RELEASE – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The facility has written policy and procedures in place related to the admissions process, which includes intake and admissions forms and screening forms. Staff members are provided with adequate training on the admissions process. Staff search efforts focus on commonly used hiding and smuggling places, such as pockets, waistbands, seams, collars, zipper areas, cuffs, and shoe exteriors and interiors, including under the inner soles. Staff also inspects all open containers, and inventories and stores factory-sealed durable goods in accordance with facility procedures. A strip search, if performed, must take place in an area that affords privacy from other detainees and from facility staff who are not involved in the search. Observation must be limited to members of the same sex. The strip search must be supported by reasonable suspicion and be documented. Before strip searching, an officer makes attempts to resolve his or her suspicions through less intrusive means, such as a thorough examination of reasonably available ICE and other law enforcement records; a pat-down search and a detainee interview. The officers also document the results of those other, less intrusive, search methods. The orientation procedures in this IGSA facility have been approvedby the ICE field office. COVID-19 safety protocols have been developed and implemented for all newly admitted detainees which included, upon entry to the intake area, detainees would be provided a mask, their body temperature would be measured and recorded, a series of questions would be asked and recorded to determine possible exposure, and they would be placed in quarantine status for fourteen days prior to assignment to general population. Detention officers would conduct an intake screening and, when indicated, would contact the RN, either on-site or at home, and provide any questionable information obtained during the intake screening. The RN would contact the physician by telephone to review the intake screening results and obtain orders if needed. In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and detainees with minor disabilities. This is achieved via bilingual staff, a translation service, or other means for LEP detainees; or Page 22 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 4. ADMISSION AND RELEASE – Reviewer Summary (Use following format for dates: mm/dd/yyyy) in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. The facility does not house detainees with significant physical or mental disabilities. Detainees requiring special housing accommodations or special care due to a disability are not assigned to this facility. Evaluation of the standard included review of written policy, the local handbook, and staff and detainee interviews. The inspector interviewed Assistant Jail Administrator Neil Taylor and ICE DSCO T. Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 23 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 5. CLASSIFICATION SYSTEM (Key: E) This Detention Standard protects the detainees, staff, contractors, volunteers, and the community from harm, and contributes to orderly facility operations, by requiring a formal classification process for managing and separating detainees that is based on verifiable and documented data. Components 1. Rating PRIORITY: SPC and CDF facilities use the required Objective Classification System. IGSAs use an objective classification system or similar system for classifying detainees. ICE classifies detainees prior to the detainee's arrival at the facility, using ICE's RCA system. The system is an objective fact based method of classifying detainees. Staff shall use facts and other objective, credible evidence documented in detainee’s A-file, criminal history checks, or work-folder during the classification process. The classification reclassification. process includes Remarks (1000 Char Max) reassessment/ Meets Standard Classification documents are transferred with detainees. Detainee housing assignments are based upon ICE's classification. The inspector confirmed the rating via interviews with the ICE and facility staff and review of detainee classification documents contained in detainee files. 2. The facility classification system includes: Classifying detainees upon arrival. • Separating individuals who cannot be classified upon arrival from the general population. • The first-line supervisor or designated classification specialist reviews every classification decision. The classification system requires that all detainees be classified upon admission prior to being assigned to a housing unit. Meets Standard Unclassified detainees are housed separately until ICE can complete their classification. An ICE supervisor reviews all classification decisions. Confirmed via staff interviews and review of written policy. 3. The intake/processing officer reviews work-folders, A-files, etc., to identify and classify each new arrival. 4. In SPCs and CDFs detainees are assigned color-coded uniforms and IDs to reflect classification levels. In IGSA’s a similar system is utilized for each level of classification. Meets Standard Meets Standard This IGSA issues orange and white striped shirt and pants and ID wrist bands to all detainees. Wrist bands note the detainee's classification level. 5. PRIORITY: Housing assignments are based on classificationlevel. Level 1 detainees may not be commingled with Level 3 detainees in housing, recreation and feeding. Meets Standard Page 24 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) Housing assignments are based on classification levels. Low security level detainees are not housed, fed or recreate with high security level detainees. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 5. CLASSIFICATION SYSTEM (Key: E) This Detention Standard protects the detainees, staff, contractors, volunteers, and the community from harm, and contributes to orderly facility operations, by requiring a formal classification process for managing and separating detainees that is based on verifiable and documented data. Components 6. PRIORITY: Level 1 detainees may not have felony convictions that included an act of physical violence, and may not be housed with any Level 2 detainee with a history of assaultive or combative behavior. Rating Remarks (1000 Char Max) Meets Standard This IGSA's policy states that low security detainees do not have a felony conviction and they are not housed with detainees who have a history of violence. ICE detainees do not work at this IGSA. 7. Detainee work assignments are based upon classification designations. N/A 8. The classification process includes reassessment/ reclassification. The first reassessment is to be completed 60 days to 90 days after the initial assessment. Meets Standard 9. (SPCs/CDFs) Subsequent classification reassessments are completed at 90 day to 120 day intervals. Special reassessments are completed within 24 hours. 10. The facility classification system shall include procedures for detainees to appeal their classification levels. 11. The Detainee Handbook or equivalent for IGSAs explains the classification levels, with the conditions and restrictions applicable to each. Meets Standard Detainees are reassessed at the IGSA facility thirty days after their arrival. Subsequent reassessments occur at sixty-day intervals. Special assessments are completed within 24 hours. Meets Standard Meets Standard All detainees are given ICE and local handbooks. The handbooks explain classification levels including conditions and restrictions applicable to each. PART 2 – 5. CLASSIFICATION SYSTEM – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Detainees are classified in accordance with the standard. The facility staff responds to a detainee request for reclassification within 72 hours. Classification staff consider institutional disciplinary history, documented violent episodes and incidents, medical information, and a history of victimization while in detention in determining classification. The completed classification paperwork is filed by ICE in the A-File (right side) and a copy is given to the facility and placed in the detainee's detention file. Detainees are offered recreational and other activities according to their classification. Detainees have an initial assessment to include health screening within twelve hours of arrival at the facility. Policy notes that medium custody detainees shall not have a behavior pattern or history of violent assaults whether convicted or not. The medium custody detainees have not been convicted of assault on a correctional officer while in custody nor have a previous institutional record suggesting a pattern of assaults while in custody. High custody detainees are considered a high-risk category and are housed in medium to maximum security housing. They are always monitored and escorted. High custody detainees at this facility may be housed with medium custody detainees. Reclassification of a detainee to high custody based on documented behavior including threats to the facility, other detainees or personnel will be approved by the classification officer within 72 hours. Reclassifications that include a reduction in custody level are referred to ICE for review and decision. All detainees placed in disciplinary or administrative segregation for violations of facility rules are not reclassified prior to being returned to the Page 25 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 5. CLASSIFICATION SYSTEM – Reviewer Summary (Use following format for dates: mm/dd/yyyy) general population. In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. Decisions regarding detainees with disabilities, LEP detainee, and/or detainees included under any SAAPI/DHS PREA protection or category will be made only after consideration of the disability, language difficulty, or SAAPI/PREA condition. Evaluation of the standard included policy review, staff and detainee interviews, and inspection of classification documents contained in a detainee's detention file. The inspector interviewed Assisstant Jail Administrator Taylor and ICE DSCO Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 26 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 6. CONTRABAND (Key: F) This Detention Standard protects detainees and staff and enhances facility security and good order by identifying, detecting, controlling, and properly disposing of contraband. Components 1. 2. 3. 4. 5. Rating PRIORITY: The facility follows a written procedure for disposition and handling contraband to include proper destruction of contraband and return of property not needed as evidence. Meets Standard The Control of Contraband/Searches policy includes the process for disposition and handling of contraband to include the destruction of contraband and the return of property not needed as evidence. Meets Standard According to the Control of Contraband/Searches policy, contraband is retained as evidence for potential disciplinary action or criminal prosecution. Contraband retained as evidence for criminal prosecution is turned over to the appropriate law enforcement authority. There has been no such contraband discovered during the inspection period. Meets Standard In this IGSA facility, the facility consults with the on-call chaplain before confiscating religious items. Meets Standard The sheriff's office has a canine unit which is used for contraband detection. The canine unit is not used in the presence of ICE detainees. The canine unit has not been deployed during the inspection period. Meets Standard Documentation confirmed that detainees receive a handbook during admission. The handbook includes contraband rules and procedures. Contraband is retained as evidence for potential disciplinary action or criminal prosecution. (SPCs/CDFs) Before confiscating religious items, the Facility Administrator or designated investigator contacts a religious authority. Facilities with canine units only use them for contraband detection and not in the presence of ICE detainees. Detainees receive notification of contraband rules and procedures in the Detainee Handbook. Remarks (1000 Char Max) PART 2 – 6. CONTRABAND – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) This facility is preserving, inventorying, controlling, and disposing of seized contraband according to standard guidelines and policy. Policy does not include contraband language regarding controlled substances not dispensed or approved by the medical Page 27 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 6. CONTRABAND – Reviewer Summary (Use following format for dates: mm/dd/yyyy) department. Medication dispensed or approved by the medical department is considered hard contraband if found in the possession of a detainee for whom it was not prescribed, or if not used as prescribed. Hard contraband, which is criminal in nature, is collected, processed and disposed of by the OIC. Hard contraband that is illegal is turned over to the sheriff's department for storage, prosecution and disposal. There has been no such seizure of contraband. Property that is not illegal under criminal statutes, and does not pose a security threat is inventoried, receipted and either mailed to a third party or stored with the detainee's other property. Contraband that is government property is retained as evidence for possible disciplinary action or criminal prosecution. A copy of the property disposal record is placed in the detainee's detention file. There has been no such discovery. Evaluation of this standard was based on review of the Control of Contraband/Searches policy, detention files, activity logs and handbook; observation of property storage room; and interviews with Captain Brandon Crowley and Lieutenant Neil Taylor. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 28 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 7. FACILITY SECURITY AND CONTROL (Key: G) This Detention Standard protects the community, staff, contractors, volunteers, and detainees from harm by ensuring that facility security is maintained and that events that pose a risk of harm are prevented. Components 1. At least one male and one female staff are on duty where both males and females are housed. 2. Comprehensive annual staffing analysis determines staffing needs and plans and is reviewed and updated annually. 3. Essential posts and positions are filled with qualified personnel. 4. 5. 6. (SPCs/CDFs) Detainees do not have access to the Control Center. Facility security and safety will be monitored and coordinated by a secure, well-equipped, and continuously staffed control center. Rating Remarks (1000 Char Max) Meets Standard The master roster confirmed that at least one male and one female is on duty at all times. The facility houses males and females. Does Not Meet Standard A staffing analysis was not available. Meets Standard Training documentation confirmed that essential posts are filled with qualified personnel. Meets Standard In this IGSA facility, post orders confirmed that detainees do not have access to the control center. Observation confirmed practice. Meets Standard The Correctional Officer Assignment policy specifies that control center is to be continuously staffed, secure and well equipped. N/A In this IGSA facility, there were no procedures in place requiring component actions. Meets Standard Documentation and observation confirmed that the front entrance officer checks the identification of everyone entering or exiting the facility. (SPCs/CDFs) The facility administrator shall establish procedures to implement the following Control Center requirements: Communications center; Maintenance of a list of the current home and cellphone number of every officer, administrative/support services staff, Situation Response Teams (SRTs), Hostage Negotiation Teams (HNTs), and law enforcement agencies. Watch calls (officer safety checks) to the Control Center by all staff ordinarily shall occur every half-hour between 6:00 P.M. and 6:00 A.M. Individual facility policy may designate another post to conduct watch calls. Any exception for staff to not make watch calls as described requires approval of the facility administrator. 7. The front-entrance officer checks the identification of everyone entering or exiting the facility. Page 29 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 7. FACILITY SECURITY AND CONTROL (Key: G) This Detention Standard protects the community, staff, contractors, volunteers, and detainees from harm by ensuring that facility security is maintained and that events that pose a risk of harm are prevented. Components 8. All visits are officially recorded in a visitor logbook or electronically recorded. 9. The facility has a secure visitor pass system. 10. Information about routine procedures, emergency situations, and unusual incidents will be continually recorded in permanent post logs and shift reports. 11. (SPCs/CDFs) Housing unit Post Orders in SPCs and CDFs shall follow the event schedule format, for example, "0515 Lights on" and shall direct the assigned officer to maintain a unit log of pertinent information regarding detainee activity. The shift supervisor shall visit each housing area and initial the log on each shift. Rating Remarks (1000 Char Max) Meets Standard Documentation and observation confirmed that all visits are officially recorded. Meets Standard Documentation and observation confirmed that the facility has a secure visitor pass system. Visitors are required to wear a badge indicating escort status. Does Not Meet Standard Documentation was not available to confirm that routine procedures, emergency situations and unusual incidents are continually recorded in permanent logs and/or shift reports. N/A In this IGSA facility, housing unit post orders do not follow the event schedule format. Meets Standard Posts are located near detainee living areas to permit officers to see or hear and respond promptly to emergency situations. The control center (tower) officer is located above the housing unit with good line of sight. Meets Standard The Inmate Movement policy and observation confirmed that detainee movement from one area to another area is controlled by staff. Meets Standard The Supervision of Inmates policy includes component language. Meets Standard Logs verified that supervisory staff visit the housing units at least weekly to observe living conditions and interact with detainees. Meets Standard The Permanent Log policy requires security inspections be conducted on each shift. 12. Security officer posts shall be located in or immediately adjacent to detainee living areas to permit officers to see or hear and respond promptly to emergency situations. 13. Detainee movement from one area to another area is controlled by staff. 14. PRIORITY: No detainee may ever be given authority over, or be permitted to exert control over, any other detainee. 15. The facility administrator, designated assistant facility administrator, security supervisors, and others designated by the facility administrator shall be required to visit all housing units at least weekly to observe living conditions and interact informally with detainees. 16. The facility has a comprehensive security inspection policy. Page 30 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 7. FACILITY SECURITY AND CONTROL (Key: G) This Detention Standard protects the community, staff, contractors, volunteers, and detainees from harm by ensuring that facility security is maintained and that events that pose a risk of harm are prevented. Components 17. Documentation of security inspections is kept on file. Rating Remarks (1000 Char Max) Meets Standard Inspection reports are filed in the administrative lieutenant's office. Does Not Meet Standard Documentation was not available to confirm perimeter checks were conducted. 18. Daily procedures include: • Perimeter alarm system tests. • Physical checks of the perimeter fence. • Documenting the results. PART 2 – 7. FACILITY SECURITY AND CONTROL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Policies are in place to protect detainees, employees, and the community from harm by initiating operating procedures and hiring a trained work force necessary to prevent events which create risk of harm and to ensure security is always maintained. While in the facility, employees must always have the identification card in their possession. For tracking the arrivals and departures of contract employees, the OIC has established policy and procedures that require all contract employees to have a contract employee identification card that must be presented upon entering and upon exiting the facility. A delivery for food service was observed during the inspection. The vendor unloaded a semi-trailer directly into an indoor sally port, which is opened by a remote control center via camera. At times during the process, both interior and exterior sally port doors were open simultaneously as the driver unloaded the trailer with some items dropped in the kitchen and others in the sally port. There is no perimeter fence at this facility and no security staff were present inside or outside. There does not appear to be any search of the goods, nor security procesing of the delivery driver or vehicle. This concern is compounded by the fact that the food service staff member receiving the order has not received any security related training. The central control center coordinates all vehicle traffic entering the sally port. However, the rear gate entrance officer does not check the driver's credentials, does not record vehicle information and does not ensure that all weapons are secured in a gun locker before entering the secure perimeter. Vehicles are not searched and escorted while inside the secure perimeter. No documentation was available to confirm that officers check the inventory of tools entering and leaving the special management unit. On 12/29/2020, a non-ICE detainee escaped from two officers while in custody at Union Hospital. The detainee threw an unknown substance in one of the officer's face and fled down the hall and out of the hospital. The non-ICE detainee was apprehended within twenty hours. To provide detainees with meaningful access to its programs and activities, the facility ensures that detainees with disabilities and detainees who are limited in their English proficiency (LEP) are provided with effective communication by as many means possible through a language line translation service. Policy requires that unannounced security inspections are conducted by housing officers on day and night shifts to control the introduction of contraband, identify and deter sexual abuse of detainees; ensure facility safety, security and good order; prevent escapes; maintain sanitary standards; and eliminate fire and safety hazards. Evaluation of this standard was based on review of the Control of Contraband/Searches policy, Security and Control policy, Page 31 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 7. FACILITY SECURITY AND CONTROL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) inspection reports and training records; observation of housing unit housekeeping practices; and interviews with Captain Brandon Crowley and Lieutenant Neil Taylor. The housing units were observed to be unclean and cluttered. Walls were observed with graffiti; dirt and grime was observed in the dayroom areas; and bunks were observed with trash and commissary debris. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 32 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 - 8. FUNDS AND PERSONAL PROPERTY (Key: H) This Detention Standard ensures that detainees’ personal property is safeguarded and controlled, specifically including funds, valuables, baggage and other personnel property, and that contraband does not enter a detention facility. Standard N/A I Click the button above (IGSA ONLY) if all ICE detainee Funds, Valuables and Property are handled only by the ICE Field Office or Sub-Office in control of the detainee case. (All Line Items and standard will be rated “N/A”) Components 1. Remarks (1000 Char Max) All detention facilities are required to have written policies and procedures to: • 2. Rating Account for and safeguard detainee property from time of admission until date of release; • Inventory and receipt detainee funds and valuables; • Inventory and receipt detainee baggage and personal property (other than funds and valuables); • Inventory and audit detainee funds, valuables and personal property; • Return funds, valuables and personal property to detainees being transferred or release; and • Provide a way for a detainee to report missing or damaged property. Meets Standard Written policies address the elements of this component. Meets Standard A secure storage room is maintained for holding large valuables. This area is only accessible to designated supervisors. The policies and procedures regarding personal property are addressed in the local handbook. All facilities, at a minimum shall provide: • A secured locker for holding large valuables, that can be accessed only by designated supervisor(s); and • A baggage and property storage area that is secured when not attended by assigned admissions processing staff. 3. The detainee handbook or equivalent shall notify the detainees of facility policies and procedures concerning personal property. Meets Standard 4. At admission, staff search and inventory detainee property only in the presence of the detainee, unless instructed otherwise by the facility administrator. Meets Standard 5. The facility administrator shall establish whether and, how much cash each detainee may have in personal possession while in detention. Meets Standard Detainees are not allowed to possess cash. 6. Identity documents, such as passports, birth certificates, are held in each detainee's A-file but, upon request, staff shall provide the detainee a copy of a document, certified by an ICE/ERO official to be a true and correct copy. Meets Standard Identity documents are removed from detainees by ICE prior to their intake into the facility. These documents are maintained in the detainees A-file. Certified copies may be obtained by the detainee upon request. Page 33 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 - 8. FUNDS AND PERSONAL PROPERTY (Key: H) This Detention Standard ensures that detainees’ personal property is safeguarded and controlled, specifically including funds, valuables, baggage and other personnel property, and that contraband does not enter a detention facility. Standard N/A I Click the button above (IGSA ONLY) if all ICE detainee Funds, Valuables and Property are handled only by the ICE Field Office or Sub-Office in control of the detainee case. (All Line Items and standard will be rated “N/A”) Components Rating Remarks (1000 Char Max) (SPCs /CDFs) Every housing area shall have lockers or other securable space for storing detainees’ authorized personal property. The amount of storage space shall correspond to the number of detainees assigned to that housing area. N/A In this IGSA, detainees are not provided a securable locker or other form of securable space for storing their personal property. 8. Property discrepancies are immediately reported to the Chief of Security or equivalent. Meets Standard 9. PRIORITY: Procedure ensures that: 7. • Detainee funds and small and large valuables are placed in a secure location; • Medical staff determine the disposition of all medicine accompanying an arriving detainee • Detainees are able to keep a reasonable amount of personal property in their possession, provided it poses no threat to detainee safety or facility security; and • Facilities return funds and valuables to detainees being transferred or released. 10. (SPCs/CDFs) For recordkeeping and accounting purposes, use of the G-589 Property Receipt form is mandatory to inventory any funds removed from a detainee’s possession, and a separate form G-589 is required for each kind of currency and negotiable instrument. Meets Standard A review of policy as well as personal observations indicated intake procedures as well as release procedures address the elements of this component. N/A In this IGSA facility, an automated, facility specific form, is used to inventory any funds removed from a detainee. Noncash negotiable instruments are only excepted for deposit into the detainees commissary fund when they are issued from another facility or in the form of certified funds or money orders. N/A In this IGSA facility, an automated, facility specific, form is used to inventory any funds removed from a detainee. Cash and negotiable instruments are inventoried, receipted (the detainee is provided a copy) and placed in a safe in the ICE office until they can be delivered to finance personnel for deposit. Large valuables are maintained in a locked cabinet in the ICE office. 11. (SPCs/CDFs) The supervisory security officer or equivalent shall remove the contents of the drop safe during his or her shift and initial the G-589 accountability log. The supervisor shall: • Verify the correctness of all G-589s; • Record the amount of cash and describe each item in the supervisors’ property log; and • Verify the proper disposition of funds and valuables by checking the sealed envelopes in the cash box, the property envelopes in the safe, and the safekeeping of all large valuables in the designated secured locked area. Page 34 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 - 8. FUNDS AND PERSONAL PROPERTY (Key: H) This Detention Standard ensures that detainees’ personal property is safeguarded and controlled, specifically including funds, valuables, baggage and other personnel property, and that contraband does not enter a detention facility. Standard N/A I Click the button above (IGSA ONLY) if all ICE detainee Funds, Valuables and Property are handled only by the ICE Field Office or Sub-Office in control of the detainee case. (All Line Items and standard will be rated “N/A”) Components Rating 12. The Facility Administrator has established quarterly audits of baggage and non-valuable property. Meets Standard Monthly audits of baggage and non-valuable property are conducted and documented. 13. All facilities shall report and turn over to ICE/ERO all detainee abandoned property. Meets Standard Abandoned or forgotten property of detainees is turned over to ICE personnel. Meets Standard Policy and procedures address the process for reporting and investigation incidents of detainee property loss or damage. Reimbursement to the detainee for property losses caused by the facility is addressed in this policy. ICE is notified by the facility of claims of this nature. 14. PRIORITY: Facilities have and follow procedures for reporting and investigating incidents of detainee property loss or damage, and for reimbursing detainees for all validated property losses caused by facility negligence. The senior contract officer immediately notifies the designated ICE/ERO officer of all claims and outcomes. Remarks (1000 Char Max) PART 2 - 8. FUNDS AND PERSONAL PROPERTY – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The evaluation of this standard was based upon personal observations of the booking area, the secure property storage room and the secure valuable storage cabinet in the ICE office. A review of policy, an examination of documents and detainee detention files was also conducted. The processes described above substantiated practices are sufficient to ensure detainee property is safeguarded and controlled under conditions that enhance the security of the property. Each detainee and their property are searched for contraband. Property and valuables are inventoried and stored in a secure area. Each detainee is treated with respect and dignity. Detainees are permitted to keep in their possession reasonable quantities of personal property if the particular items do not pose a threat to the security or good order of the facility. The local handbook notifies the detainees of the policies and procedures concerning items they may retain in their possession, rules for storing or mailing unauthorized property, the procedures for claiming property, and the procedures for filing a property claim. A detainees' abandoned or forgotten property is forwarded to ICE for final disposition or disposed of at the direction of ICE. There is a commissary where detainees may purchase store items. An Office of Detention Oversight (ODO) review conducted in November 2020, referenced several areas of concern in funds and personal property. Specifically, that the local handbook did not address the process for a detainee to acquire copies of identity documents, the local handbook did not address the process for storing or mailing property which is not allowed in their personal possession, the local handbook did not address the process a detainee would use to file a claim for lost or Page 35 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 - 8. FUNDS AND PERSONAL PROPERTY – Reviewer Summary (Use following format for dates: mm/dd/yyyy) damaged property and the local handbook did not address the process a detainee would use to withdraw funds from their commissary account to pay for legal services. A review of the local handbook during this inspection revealed these four concerns are now addressed. Although written policies and procedures do not address the audit of detainee detainee funds, valuables and personal property, monthly audits of these areas are conducted and documented. In this IGSA facility, a logbook to record funds placed into and out of the funds safe is not used; nor is an accountability logbook or a logbook to record property placed into and taken out of the property room. During the evaluation of this standard Captain Brandon Crowley, Lieutenant Neil Taylor and Sergeant Jase Glassburn were interviewed. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 36 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (Key: I) This Detention Standard ensures the safety, security, and comfort of detainees temporarily held in Hold Rooms pending further processing. The maximum aggregate time an individual may be confined in a facility’s Hold Room is 12 hours. Components 1. 2. (SPCs/CDFs) Each Hold Room shall contain sufficient seating for the maximum room-capacity but shall contain no moveable furniture. (SPCs/CDFs) Each Hold Room shall be equipped with stainless steel, combination lavatory/toilet fixtures with modesty panels, in compliance with the Americans with Disabilities Act of 1990. 3. PRIORITY: Detainees are not held in hold rooms for more than 12 hours. 4. Male and females detainees are segregated from each other at all times. 5. 6. 7. Unaccompanied minors (under 18) and parent(s) or legal guardians accompanied by minor children shall not be placed in Hold Rooms, unless they have shown or threatened violent behavior, have a history of criminal activity, or have given staff reasonable grounds to expect an escape attempt. Persons exempt from placement in a Hold Room due to obvious illness, special medical, physical and or psychological needs, or other documented reasons shall be seated in an appropriate area designated by the facility administrator outside the Hold Room, or in separate rooms, under direct supervision and control, barring an emergency. To the extent practicable in a hold room situation, detainees with known or readily apparent disabilities, including temporary disabilities, shall be housed in manner that accommodates their mental and/or physical condition(s) and provides for their safety, comfort and security. Rating Remarks (1000 Char Max) Meets Standard In this IGSA facility, hold rooms contain sufficient seating for the maximum room capacity and contain no moveable furniture. N/A In this IGSA facility, hold rooms used to process ICE detainees are equipped with a stainless-steel combination lavatory/toilet. However, hold rooms do not have modesty panels. Meets Standard Logs confirmed that detainees are not held in the hold rooms for more than twelve hours. Meets Standard According to the shift supervisor, males and females are segregated from one another. No detainees were observed in a hold room during the inspection. Meets Standard According to the shift supervisor, juvenile detainees are not housed at this facility. Meets Standard No detainees were observed in a hold room during the inspection. Detainees who are exempt from placement in a hold room, due to illness, special medical, physical or psychological needs or other documented reasons, are placed in a medical segregation cell under direct supervision guidelines. Meets Standard No detainees were observed in a hold room during the inspection. Detainees with known or readily apparent disabilities are placed in a medical segregation cell and are where they are under direct supervision. Page 37 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (Key: I) This Detention Standard ensures the safety, security, and comfort of detainees temporarily held in Hold Rooms pending further processing. The maximum aggregate time an individual may be confined in a facility’s Hold Room is 12 hours. Components 8. 9. Detainees are provided with basic personal hygiene items such as water, soap, toilet paper, cups for water, feminine hygiene items, diapers and wipes. If the hold room is not equipped with toilet facilities, an officer is posted within visual or audible range to allow detainees access to such on a regular basis. Rating Remarks (1000 Char Max) Meets Standard Detainees are provided personal hygiene items. The hygiene items were observed and found to include required items. There were no admissions during the inspection. N/A All hold rooms are equipped with toilet facilities. 10. All detainees are given a pat down search for weapons or contraband before being placed in the hold room. 11. Before placing a detainee in a room, an officer shall observe each individual to screen for obvious mental or physical problems. Meets Standard As reported by the shift supervisor, all detainees are given a pat search for weapons and contraband prior to being placed in a hold room. Additionally, detainees are observed with a full body metal detector. Meets Standard As reported by the shift supervisor, detainees are initially observed by transportation officers and then by the facility custody officers to screen for obvious mental or physical problems. Meets Standard The Reception and Orientation policy includes component requirements. Documentation confirmed that booking officers maintain a log for each detainee placed in a hold cell. Meets Standard Detainees in a hold room for more than six hours are provided a meal. There were no admissions during the inspection. Meets Standard The hold rooms were observed to be maintained at acceptable and comfortable levels. Detainees are provided blankets upon request. 12. Each detention facility maintains a detention log for each detainee placed in a hold cell. 13. Officers provide a meal to any detainee detained in a hold room for more than six hours. Pregnant women have access to snacks, milk or juice. 14. Staff shall ensure that sanitation, temperatures and humidity in Hold Rooms are maintained at acceptable and comfortable levels. Pregnant women and others with evident medical needs will have temporary access to temperature appropriate clothing and blankets. Page 38 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES (Key: I) This Detention Standard ensures the safety, security, and comfort of detainees temporarily held in Hold Rooms pending further processing. The maximum aggregate time an individual may be confined in a facility’s Hold Room is 12 hours. Components Rating Remarks (1000 Char Max) Meets Standard Observation confirmed that officers are stationed so they can hear a detainee placed in the hold rooms. Each hold room is equipped with a camera allowing staff to view activity in the room. Staff are required to make rounds to the hold rooms at least every fifteen minutes. Documentation indicated gaps in the fifteen-minute observation period. Constant surveillance is provided for any detainee exhibiting signs of hostility, depression or other unusual behavior. The OIC developed a reasonable action plan which includes a procedure to ensure that fifteen-minute checks are completed consistently. 15. PRIORITY: Officers closely supervise hold rooms through direct supervision, to ensure: • Continuous auditory monitoring, • Visual monitoring at irregular intervals at least every 15 minutes, • Constant surveillance of any detainee exhibiting signs of hostility, depression, or similar behaviors. 16. The maximum occupancy for the hold room will be posted. 17. When the last detainee has been removed, officers shall ensure the Hold Room is thoroughly cleaned and inspected. 18. (SPCs/CDFs) Evacuation procedures shall include posting the evacuation map and advance designation of the officer responsible for removing detainees from the Hold Room(s) in case of fire and/or building evacuation. Meets Standard Meets Standard Documentation confirmed that staff inspect the hold rooms and have the rooms cleaned when detainees have been removed. N/A This IGSA facility has a waiver to suspend the requirement to post the evacuation procedures. Waiver was issued 08/21/2018 and approved by Jay M. Brooks. PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Hold rooms are multiple occupancy rooms equipped with two metal bunks. The hold rooms are located within the secure perimeter of the facility and possess adequate footage for the number of detainees held in a hold room. A review of randomly selected logs verified that no detainee was kept in a hold room for over twelve hours during the inspection period. As reported by the shift supervisor detainees are issued a mattress with sheets and a blanket. Detainees identified as high risk are placed on one-on-one supervision until they are seen be mental health staff. The shift supervisor stated that whenever there is a need to enter a hold room, two officers are required to enter the room. Evaluation of this standard was based on review of the Reception and Orientation policy, Holding Room Fifteen Minute Checks logs and detention files; interviews with Captain Brandon Crowley, Lieutenant Neil Taylor and Officer Melissa Hughbanks; and observation of the hold rooms, hygiene packages and required postings. There were no admissions during the inspection. Page 39 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 9. HOLD ROOMS IN DETENTION FACILITIES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 40 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 10. KEY AND LOCK CONTROL (Key: J) This Detention Standard maintains facility safety and security by requiring that keys and locks be properly controlled and maintained. Components 1. 2. 3. 4. 5. 6. All staff shall be trained and held responsible for adhering to proper procedures for the care and handling of keys, including electronic key pads where they are used. Initial training shall be accomplished before staff is issued keys, and key control shall be among the topics covered in subsequent annual training. Each facility administrator shall establish the position of Security Officer, or at a minimum, assign a staff member the collateral security officer. The Security Officer shall have a written position description that includes duties, responsibilities, and chain of command. The Security Officer is responsible for all administrative duties, including recordkeeping, concerning keys, locks, and related security equipment. The Security Officer shall train and direct employees in key control, including electronic key pads where they are used. The facility maintains inventories of all keys, locks and locking devices. Lock shop inventories include a secure master-key cabinet containing at least one pattern key. Rating Remarks (1000 Char Max) Meets Standard Training records confirmed that all staff are trained in proper procedures for care of handling keys. The Clay County Justice Center Training Plan documents confirmed that new employees had completed the initial training on key control. The Law Enforcement Training Roster confirmed that staff participated in annual key control training. Does Not Meet Standard The position of security officer had not been established. During the inspection, the administrative lieutenant was assigned the key control responsibilities. A written position description was not available. Does Not Meet Standard No documentation was available to include recordkeeping of keys, locks and related security equipment. Meets Standard The training officer trains and directs employees on key control, including the electronic key pads. Does Not Meet Standard No documentation was available to include all keys, locks and locking devices. The facility does not have a lock shop. Security keys are maintained in a locked cabinet in the booking area. Does Not Meet Standard The Controlled Access and Use of Keys policy addresses compromised keys. There is no safe combination integrity. A safe is located in the medical room. The staff was not sure who had the combination to the safe. Facility policies and procedures address the issue of compromised keys, locks, and to ensure safe combination integrity. Page 41 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 10. KEY AND LOCK CONTROL (Key: J) This Detention Standard maintains facility safety and security by requiring that keys and locks be properly controlled and maintained. Components 7. Either deadbolts or deadlocks shall be used in detaineeaccessible areas. Grand master-keying systems are not authorized. A master-keying system may be used only in housing units where detainees have individual room keys. 8. The Security Officer shall implement a preventive maintenance program. The Security Officer shall maintain all preventive maintenance records. 9. The Security Officer shall implement procedures for identifying every key ring and every key on each key ring, and for preventing keys from being removed from key rings, once issued. 10. Emergency keys shall be on hand for every area to or from which entry or exit might be necessary in an emergency. 11. The facility has a written policy and implementation procedures to ensure key accountability. Facilities shall use standard system for the issuance and accountability of key rings. 12. The facility administrator shall establish rules and procedures for authorizing use of restricted keys. Rating Remarks (1000 Char Max) Does Not Meet Standard Grand master-keys are authorized in the facility. Detainees do not have room keys. Electronic deadlocks are used in detainee accessible areas. Does Not Meet Standard No documentation of a preventive maintenance program is available. Does Not Meet Standard It was observed that not all key rings are identifiable and provide the number of keys on the ring. Keys were easily removed on four sets of keys. Meets Standard Emergency keys are kept in the intake unit. Emergency keys were used during the simulation of a fire drill. Meets Standard Controlled Access and Use of Keys policy includes key accountability requirements. However, there is not a practice or documentation to confirm accountability. Keys were issued and not recorded as to time, date and employee issed the key ring. Does Not Meet Standard Controlled Access and Use of Keys policy includes restricted key language. However, practice is not in place to ensure restricted key accountability. Does Not Meet Standard There is no pharmacy at this facility. The keys to the medication cart are restricted. However, when observing the key issuance procedure, it was discovered that the nurse does not log the pharmacy key in and out. Practice is not in place to ensure restricted key accountability. 13. Pharmacy keys shall be strictly controlled. Page 42 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 10. KEY AND LOCK CONTROL (Key: J) This Detention Standard maintains facility safety and security by requiring that keys and locks be properly controlled and maintained. Components 14. Keys to ICE and EOIR (Executive Office for Immigration Review) office and courtroom areas shall similarly be restricted and controlled. If a key is authorized for emergency withdrawal, a copy of the Restricted Key form is to be provided to ICE. 15. Officers shall store all their weapons in individual lockers before entering the facility. The facility administrator shall develop and implement site-specific procedures for controlling gun-locker access. Rating Remarks (1000 Char Max) N/A ICE officials do not have an office. The facility does not have a courtroom. The ICE DSCO is issued an electronic key fob. He has access to the administrative areas. He keeps the key fob 24 hours a day. Meets Standard Weapons are stored in individual lockers outside the secure perimeter. Site-specific procedures for controlling gunlocker access has been implemented through sheriff's office procedures. PART 2 – 10. KEY AND LOCK CONTROL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) A review of policy, procedure, logs, staff interviews and observation confirmed that keys and locks are not properly controlled and maintained. Shift supervisor shall be responsible for the issuance of all security keys located in the master control key box. According to the Controlled Access and Use of Keys policy, the shift supervisor is responsible for the issuance of all security keys located in the key box. The standard required language (in the following paragraph) is not practiced, including, but not limited to: Evacuation keys are only issued when a complete or partial evacuation of the facility is required or if it should become necessary for assisting officers to come into the facility unaided. Operational keys are issued in the event of total or partial power outage in the facility. No two sets of operational keys shall be in any confinement area at the same time. All security keys issued shall be returned to master control before person possessing said key(s) leaves the facility. No security keys shall be passed directly from person to person without first going to the supervisor to have the key reissued. Non-security keys are maintained in a secure key box. The shift supervisor is responsible for issuing the keys. A key log is not maintained. Missing, broken, and/or malfunctioning keys shall be reported immediately to the shift supervisor. All broken or malfunctioning keys or parts thereof shall be returned to the shift supervisor who shall notify maintenance. The shift supervisor shall conduct an immediate search and/or investigation for missing key(s). If the key(s) cannot be found the shift supervisor shall notify the jail commander. Evaluation of this standard was based on review of the Controlled Access and Use of Keys policy, key logs and training records; interviews with Sergeant Jase Glassburn and Captain Brandon Crowley; and observation of the key box, key rings and issuing of keys. Observation of the key box revealed that a key was issued. No key chit was placed on the key post. No record of who was issued the key ring was documented. Observation of medication cart key issue revealed that the nurse keeps the pharmacy key in a safe in the medical room. There is no key log accounting for the key. The shift supervisor does not account for the key ring. Page 43 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 10. KEY AND LOCK CONTROL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) The policy requires key accountability. However, practice is not in place. A key control officer was assigned during the inspection. Overall Rating: Does Not Meet Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 44 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 11. POPULATION COUNTS (Key: K) This Detention Standard protects the community from harm and enhances facility security, safety, and good order by requiring that each facility have an ongoing, effective system of population counts and detainee accountability. Components 1. 2. Rating Staff conduct a formal count at least once each 8 hours (no less than three counts per day). At least one of these counts shall be a face to photo count. Each officer shall make irregular but frequent checks to verify the presence of all detainees in his or her charge. 3. The facility Control Center shall maintain a master count. 4. The control officer (or other designated position) maintains an “out-count” record of all detainees temporarily out of the facility. 5. An emergency count shall be conducted when there is reason to believe a detainee is missing, or after a major disturbance has occurred. Remarks (1000 Char Max) Meets Standard Three formal counts are conducted every 24 hours. The formal face-to-photo count is conducted daily at 11:00 p.m. Meets Standard Staff are required to make irregular checks to verify the presence of detainees. Observation confirmed practice. Meets Standard Observation confirmed that officers in the control center maintain the master count. Meets Standard The control center and booking officers maintain the official "out-count" record of all detainees temporarily out of the facility. Meets Standard According to Emergency Plans, an emergency count will be taken whenever there is reason to believe a detainee is missing or after a major disturbance. PART 2 – 11. POPULATION COUNTS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The count process accounts for all detainees and includes a daily face-to-photo count. As reported by the OIC and verified by document review, this IGSA has two shifts and conducts counts no more than eight hours apart. Documentation confirmed the count frequency, as required by the standard. During observation of the count, two officers entered each housing unit and physically observed each detainee in the cell. While conducting the count, the officer looked into showers and behind sheets on bedding to assure every detainee in the cell was counted. Detainees do not participate in the count nor the preparation of documentation of the count process. No detainee movement is allowed during the count process without the approval of the OIC or designee. The intake officer is responsible for maintaining an out count. Evaluation of this standard was based on a review of the Inmate Counts policy, training records, count sheets and JailTracker; interviews with Captain Brandon Crowley, Lieutenant Neil Taylor, Officer Little and Officer Noah Minor; and observation of count. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Page 45 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 11. POPULATION COUNTS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Reviewer Signature (for printed form submission): Page 46 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 12. POST ORDERS (Key: L) This Detention Standard protects detainees and staff and enhances facility security and good order by ensuring that each officer assigned to a security post knows the procedures, duties, and responsibilities of that post. Components 1. 2. 3. 4. The facility administrator shall ensure that: • There are written Post Orders for each security post, • Copies are available to all employees, • Written facility policy and procedures: o Provide official on-duty time for officers to read the applicable Post Orders when assigned to a post, and o Ensure that officers read those applicable Post Orders prior to assuming their posts. Supervisors shall ensure that officers understand the Post Orders, regardless of whether the assignment is temporary, permanent, or due to an emergency. Anyone assigned to an armed post qualifies with the post weapons before assuming post duty. Rating Remarks (1000 Char Max) Meets Standard Post orders are available for each security post. According to the OIC, staff are provided time to read the post orders. Staff sign a log to acknowledge reading the post orders. Documentation confirmed practice. Meets Standard Meets Standard Training records confirmed that each officer assigned to an armed post qualifies with the post weapons before assuming the position. Post Orders for armed posts, and for posts that control access to the institution perimeter, clearly state that: Any staff member who is taken hostage is considered to be under duress, and Meets Standard Any order issued by such a person, regardless of his or her position of authority, is to be disregarded. 5. 6. Specific instructions for escape attempts shall be included in the Post Orders for armed posts. Post Orders shall be kept current at all times and formally reviewed at least annually and updated as needed. Meets Standard The transportation officer post order contains specific instructions for officers in the event of escape attempts. Meets Standard Post orders were reviewed and found to be current and formally reviewed. Post orders are reviewed annually. 7. Post Orders and logbooks are confidential and must be kept secure at all times and never left in an area accessible to detainees. Meets Standard 8. The facility administrator authorizes all Post Orders and changes. Meets Standard The sheriff authorizes all post orders and changes. PART 2 – 12. POST ORDERS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Page 47 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 12. POST ORDERS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The post orders include all the information and instructions needed to ensure that each officer assigned to a security post knows the procedures, duties, and responsibilities of that post. The post orders are based on policies, facility practices and specify the hours of each post. The post orders include special instructions, and general operating procedures. Officers are required to sign the applicable post order before assuming duty. All officers are encouraged to submit a written list of suggested post order changes to the shift supervisor. The change requests are submitted to the captain for review and to the sheriff for approval. New post orders are read at the beginning of each shift by the shift supervisor. The shift supervisor then signs the post order acknowledging having read it. Evaluation of this standard was based on a review of the Post Orders policy, post orders, training records and signature sheets acknowledging receipt of the post order; observation of post orders; and interviews with Captain Brandon Crowley. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 48 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 13. SEARCHES OF DETAINEES (Key: M) This Detention Standard protects detainees and staff and enhances facility security and good order by detecting, controlling, and properly disposing of contraband. Components 1. 2. PRIORITY: The facility has written policy and procedures governing searches of detainees and housing or work areas. The policies and procedures include the requirement that staff employ the least intrusive method of body search practicable, based on security concerns involved; and conduct searches without unnecessary force and in ways that preserve the dignity of detainees. All staff who do housing or work area searches or body searches shall receive initial training regarding search procedure prior to entering on duty, and annual training in effective techniques thereafter. Rating Remarks (1000 Char Max) Meets Standard Written policy procedures govern searches of detainees and all housing, work and common areas. The reviewed policy states that searches must be conducted in a manner which avoids unnecessary force, embarrassment, or indignity to the detainee. Meets Standard Staff informed the inspector that all new staff hires receive search procedures training upon entry on duty, as well as annual refresher training thereafter. The inspector examined staff search training curriculum to confirm rating. 3. The facility shall establish procedures to ensure all housing units and work areas are searched routinely, but irregularly. 4. Staff shall maintain written documentation of each housing unit search within the individual housing unit. 5. Work areas shall be searched each workday by shop supervisors, and these inspections shall be supplemented with periodic searches by designated search teams. 6. 7. Meets Standard Meets Standard Meets Standard Staff informed the inspector that work areas are searched each day by a supervisor and periodically by a search team. Meets Standard Review of written policy confirmed that strip searches are conducted only when there is a reasonable suspicion that a detainee may be concealing contraband. The policy further notes that a supervisor must authorize the search. The inspector reviewed documents and detainee files confirming that the policy is routinely followed. Meets Standard There were no strip searches during the reporting period. Strip searches are conducted only when there is reasonable belief or suspicion that contraband may be concealed on the person, or a good opportunity for concealment has occurred, and when properly authorized by a supervisor. PRIORITY: Strip searches are performed by an officer of the same gender as the detainee. Review of written policy and post orders confirmed that housing units and work areas be searched routinely but irregularly. Page 49 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 13. SEARCHES OF DETAINEES (Key: M) This Detention Standard protects detainees and staff and enhances facility security and good order by detecting, controlling, and properly disposing of contraband. Components 8. 9. Rating Body cavity searches are conducted by designated health personnel only when authorized by the facility administrator (or acting administrator) on the basis of reasonable belief or suspicion that contraband may be concealed in or on the detainee’s person. “Dry cells” are used for contraband detection only when there is reasonable belief of concealment, with proper authorization, and in accordance with required procedures. 10. The chief of security shall have post orders for closely observing a detainee in dry cell status. Remarks (1000 Char Max) Meets Standard The inspector was informed by staff that body cavity searches are conducted by medical staff only and only when authorized by the OIC. There have been no such searches during the inspection period. Meets Standard Written policy states that the OIC may authorize the placement of a detainee in a dry cell under close staff observation when there is reasonable belief of contraband concealment. Meets Standard Written policy states that if dry cells detection is ordered a post order will be placed by the cell to assure instructions for observing the detainee held in the cell. PART 2 – 13. SEARCHES OF DETAINEES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The facility handles detainee searches in accordance with the standard. There are procedures in place to conduct dormitories and work areas searches which are primarily designed to detect contraband, prevent escapes, maintain sanitary standards, and eliminate fire and safety hazards. The procedures also include basic correctional services during lockdowns, such as delivery of food services, toilet access, medication delivery, and other vital services. The detainees at this facility are pat searched on a routine or random basis to control contraband without a threshold level of suspicion. The search includes a search of the detainee's clothing and personal effects. The post orders for staff assigned to monitor detainees that are in close observation are clear and concise. They contain all the items outlined in the standard. Detainees that are in a dry cell status for more than seven days have the prior approval of both the OIC and medical staff. In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. Decisions regarding detainees with disabilities, LEP detainee, and/or detainees included under any SAAPI/DHS PREA protection or category will be made only after consideration of the disability, language difficulty, or SAAPI/PREA condition. The facility does not house detainees with significant physical or mental disabilities. Detainees requiring special housing accommodations or special care due to a disability are transferred to an appropriate facility. This standard was evaluated via policy review, staff search training curriculm, and staff and detainee interviews The inspector interviewed Assistant Jail Administrator Taylor and Sergent Glassburn. Overall Rating: Meets Standard Page 50 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 13. SEARCHES OF DETAINEES – Reviewer Summary Reviewer Name (Printed): Inspector 2 (Use following format for dates: mm/dd/yyyy) I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 51 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (Key: N) This Detention Standard requires that facilities that house ICE/DRO detainees affirmatively act to prevent sexual abuse and assaults on detainees, provide prompt and effective intervention and treatment for victims of sexual abuse and assault, and control, discipline, and prosecute the perpetrators of sexual abuse and assault. Components 1. • Measures to prevent sexual abuse and sexual assault; • Policy and procedures for required chain-of-command reporting to the highest facility official and the ICE Field Office Director; • Measures for prompt and effective intervention to address the safety and treatment needs of detainee victims if an assault occurs; and • Investigation of incidents of sexual assault, and discipline of assailants. (SPCs/CDFs) The written policy and procedure has been approved by the Field Office Director. 3. PRIORITY: All staff are trained, during orientation and in annual refresher training, in the prevention and intervention areas required by the Detention Standard. 5. Remarks (1000 Char Max) Meets Standard The facility has a sexual abuse and assault prevention and intervention (SAAPI) program that includes, at a minimum, each of the bulleted items in this component. N/A At this IGSA facility, the written policy and procedure has been approved by the sheriff. Does Not Meet Standard This component is rated Does Not Meet Standard because no documentation was provided to confirm that staff were trained, during orientation and in annual refresher training in the prevention and intervention areas required by the standard. PRIORITY: The facility has a Sexual Abuse and Assault Prevention and Intervention Program that includes, at a minimum: 2. 4. Rating PRIORITY: Detainees are informed about the program in facility orientation and the detainee handbook (or equivalent). Meets Standard The Sexual Assault Awareness Notice is posted on all housing unit bulletin boards. Does Not Meet Standard Page 52 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) Detainees are informed about the program in the national detainee and local handbooks and during the intake orientation. This component was rated Does Not Meet Standard because the Sexual Assault Awareness Notice was not posted in the housing areas. It was posted outside of the housing unit; however, the PSA compliance manager contact information was not current. The PSA compliance manager was informed. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (Key: N) This Detention Standard requires that facilities that house ICE/DRO detainees affirmatively act to prevent sexual abuse and assaults on detainees, provide prompt and effective intervention and treatment for victims of sexual abuse and assault, and control, discipline, and prosecute the perpetrators of sexual abuse and assault. Components 6. (SPCs/CDFs) The Sexual Assault Awareness Information brochure is available for detainees. 7. Rating Remarks (1000 Char Max) Meets Standard At this IGSA facility, the information brochure has been reproduced in total in the 2016 version of the National Detainee handbook. Meets Standard Per interviews with booking personnel and the PSA compliance manager and review of detainee intake screenings, it was verified detainees are screened upon arrival for "high risk" sexual assaultive and victimization potential and housed and counseled accordingly. It was reported that detainees who are likely to become victims would be placed in the least restrictive housing that is available and appropriate. Per the PSA compliance manager, a detainee would typically be housed in pod C, which is the protective custody unit. Meets Standard Per policy review, an interview with the PSA compliance manager, and review of a detainee health care record, it was verified there would be prompt and effective intervention. Any detainee who alleges that he or she has been sexually abused or assaulted, would be immediately offered protection from the assailant and would be referred for a medical examination. Policy and procedures contain the required process for chain-of-command reporting. PRIORITY: Detainees are screened upon arrival for “high risk” sexual assaultive and sexual victimization potential and housed and counseled accordingly. Detainees who are likely to become victims will be placed in the least restrictive housing that is available and appropriate. 8. PRIORITY: There is prompt and effective intervention when any detainee is sexually abused or assaulted and policy and procedures for required chain-of-command reporting. Page 53 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION (Key: N) This Detention Standard requires that facilities that house ICE/DRO detainees affirmatively act to prevent sexual abuse and assaults on detainees, provide prompt and effective intervention and treatment for victims of sexual abuse and assault, and control, discipline, and prosecute the perpetrators of sexual abuse and assault. Components 9. Rating Remarks (1000 Char Max) Meets Standard Per policy review, an interview with the PSA compliance manager, and review of a detainee health care record, it was confirmed, when there is an alleged sexual assault, a thorough investigation would be conducted which would include the gathering and maintaining of evidence and referrals to the appropriate law enforcement agencies. Meets Standard Per interviews with the ICE detention standard compliance officer and the PSA compliance manager and review of a detainee health care record, ICE is promptly notified verbally and in writing when there is alleged or proven sexual assault. During the inspection period, there was one allegation of sexual assault and/or abuse. Meets Standard Victims of sexual abuse or assault are referred to Union Hospital located in Terre Haute, IN, for treatment and gathering of evidence by either SAFE or SANE certified personnel. Meets Standard The PSA compliance manager is responsible to ensure all records associated with claims of sexual abuse or assault are maintained, specifically logged and tracked. Per the PSA compliance manager, there was one incident during this inspection period. Meets Standard Tracking statistics and reports of the one detainee incident, were readily available for review by the inspector. When there is an alleged sexual assault, staff conduct a thorough investigation, gather and maintain evidence, and make referrals to appropriate law enforcement agencies for possible prosecution. 10. PRIORITY: When there is an alleged or proven sexual assault, the required notifications to ICE, facility management, and the appropriate law enforcement agency are promptly made. 11. Victims of sexual abuse or assault are referred to specialized community resources for treatment and gathering of evidence. 12. All records associated with claims of sexual abuse or assault is maintained, and such incidents are specifically logged and tracked by a designated staff coordinator. 13. Tracking statistics and reports are readily available for review by the inspectors. PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Page 54 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 14. SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The facility has a comprehensive, zero tolerance sexual abuse and assault prevention and intervention program in place. Approved policies and procedures ensure immediate protection to victims, including prevention of retaliation, assure medical and mental health referrals for alleged victims, specify procedures for detainees to report allegations to any staff member, specify medical employees’ responsibility to report allegations or suspicions of sexual assault to facility staff and specify procedures for evidence gathering and forensic medical exam protocols. Detainees are provided instructions on how to contact DHS/OIG or ICE to confidentially report sexual abuse or assault. Decisions regarding detainees with disabilities, LEP detainees, and/or detainees included under any SAAPI/DHS PREA protection or category would be made only after consideration of the disability, language difficulty or SAAPI/PREA condition. The facility is managed in such a manner as to protect detainees from sexual assault or abuse. The OIC has designated a Prevention of Sexual Assault (PSA) compliance manager. The program manager assists with the development of written policies and procedures and training protocols and serves as a liaison with other agencies. Employee, contractor and volunteer training includes all the topics listed in the standard. Following the intake process, detainees are educated on the SAAPI program and on topics as required in the standard. Statements from detainees claiming to be victims of sexual assaults are taken seriously and professionally responded to. Victims of sexual assault would be taken to Union Hospital where a Sexual Assault Nurse Examiner (SANE) would conduct an examination and collect forensic evidence using an approved kit; forensic evidence is secured and the chain of custody is maintained; testing is conducted for sexually transmitted diseases and infections and referrals for counseling are made, as appropriate; upon request, prophylactic treatment, emergency contraception and follow-up examinations for sexually transmitted diseases are offered; after the physical examination, a mental health professional evaluates the need for crisis intervention, counseling and long-term follow-up. During the community forensic exam, the victim may choose to have an outside advocate present. When the detainee has been transferred, the OIC is notified. There was one sexual abuse and assault allegation during this inspection period and per the PSA compliance manager, as of last week, it was still being investigated by ICE personnel. Reports related to the incident were readily available for review by the inspector. Evaluation of this standard was based on review of policy and procedures, visualization of detainee housing units and postings, review of tracking logs, training curriculum/documentation, review of one detainee health care record, and staff interviews. Interviews included, PSA Compliance Manager, Sergeant Jase Glassburn; Staff Registered Nurse (RN), Stan Roark and ICE Deportation Officer/Detention Standards Compliance Officer, Tashi F. Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 24 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 55 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components 1. Rating Written policy and procedures are in place for special management units, including Administrative Segregation and Disciplinary Segregation, as well as documenting the reason(s) for placement and periodic reviews. Meets Standard Remarks (1000 Char Max) Policies and procedures are in place for the special management housing unit (SMU), including administrative segregation and disciplinary segregation. Policy requires that employees document the reasons for placement and periodic reviews. The inspector reviewed SMU processing documents confirming adherence to the requirements of this component. 2. The number of detainees confined to each cell or room does not exceed the capacity for which it was designed. 3. Cells and rooms are well ventilated, adequately lit, appropriately heated and maintained in a sanitary condition at all times. 4. 5. Each facility shall issue guidelines concerning the privileges detainees may have in both Administrative and Disciplinary status. PRIORITY: Detainees in SMUs are personally observed at least every 30 minutes in an irregular schedule and more often when warranted. Meets Standard Meets Standard On-site inspectors confirmed that the SMU is well ventilated, adequately lit, and temperature controlled. Meets Standard Reviewed policy mandates guidelines for the privileges detainees may have in administrative and disciplinary status Meets Standard Per policy, detainees in the SMU are observed every thirty minutes at irregular intervals and more often when warranted. A review of the segregation log book confirmed the practice. Page 56 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components 6. 8. 9. Remarks (1000 Char Max) Meets Standard Reviewed policy notes that detainees are placed in protective custody status in administrative segregation only when there is documentation that it is warranted and that no reasonable alternatives are available. Detainees are placed in administrative segregation status only for non-punitive reasons, when necessary to ensure the safety of detainees or others, the protection of property, or the security or good order of the facility. Meets Standard A pre-hearing detention form detailing the reason for placing a detainee on administrative segregation status is completed and signed by the OIC prior to a detainee being placed in that status. Meets Standard Per policy and confirmed by staff interviews and record review, detainees are given a copy of the decision and justification form for each review, unless this provision would jeopardize security. Detainees are informed in writing that they have the right to appeal the decision. Meets Standard Policy addresses the requirements listed in this component PRIORITY: A detainee is placed in protective custody status in Administrative Segregation only when there is documentation that it is warranted and that no reasonable alternatives are available. A detainee is placed in Administrative Segregation only for non-punitive reasons, when necessary to ensure the safety of detainees or others, the protection of property, or the security or good order of the facility. 7. Rating The facility administrator or designee shall complete the Administrative Segregation Order (Form I-885 or equivalent), detailing the reasons for placing a detainee in Administrative Segregation, before his or her actual placement. A copy of the decision and justification for each review is given to the detainee, unless, in exceptional circumstances, this provision would jeopardize security. The detainee is given an opportunity to appeal a review decision to a higher authority within the facility. A detainee will be placed in Disciplinary Segregation only after a finding by a Disciplinary Hearing Panel that the detainee is guilty of a prohibited act or rule violation classified at a “Greatest,” “High,” or “High-Moderate” level, as defined in the Detention Standard on Disciplinary System. Page 57 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components 10. A written order shall be completed and signed by the chair of the IDP (or disciplinary hearing officer) before a detainee is placed into Disciplinary Segregation. A copy of the order shall be given to the detainee within 24 hours, unless delivery would jeopardize the safety, security, or the orderly operation of the facility or the safety of another detainee. Rating Meets Standard Remarks (1000 Char Max) Per policy and as reported by the lieutenant, a written order is completed and signed by the IDP before a detainee is placed in disciplinary segregation status. Copies of the order are given to the detainee and placed in the detention files within 24 hours, barring safety or security concerns. The inspector reviewed documents confirming adherence to this component. 11. Upon a detainee’s release from the SMU, the releasing officer attaches the entire housing unit record to the Administrative Segregation Order or Disciplinary Segregation Order and forwards it to the Supervisor for inclusion in the detainee’s detention file. Meets Standard A review of detention files verified that, upon a detainees release from SMU, the housing record is placed in the detainee's detention file. Meets Standard The SMU policy includes the requirements of the component. A review of completed administrative segregation reviews confirmed the practice. Meets Standard A review of the administrative segregation records verified that records are maintained in the SMU to record pertinent information on a detainee's admission to and release from the unit. 12. PRIORITY: There are implemented written procedures for the regular review of all detainees in Administrative Segregation. A supervisor conducts a review within 72 hours of the detainee’s placement in Administrative Segregation to determine whether segregation is still warranted. The review includes an interview with the detainee, and a written record is made of the decision and the justification. If a detainee is segregated for the detainee's protection, but not at the detainee's request, continued detention requires the authorizing signature of the facility administrator or assistant facility administrator. When a detainee has spent seven days in Administrative Segregation, and every week thereafter for the first 60 days and at least every 30 days thereafter, a supervisor conducts a similar review, including an interview with the detainee, and documents the decision and justification. 13. Permanent housing logs are maintained in SMUs to record pertinent information on detainees upon admission to and release from the unit, and in which supervisory staff and other officials record their visits to the unit. Page 58 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components Rating Remarks (1000 Char Max) Meets Standard At this IGSA, separate logs are maintained in the SMU noting the time and circumstances of all visits to the unit; documentation of the visit is placed in the detainee's file. Meets Standard An SMU housing record is maintained for each detainee held in the SMU. 14. (SPCs/CDFs) A separate log is maintained in the SMU that all persons visiting the unit must sign and record: • The time and date of the visit, and • Any unusual activity or behavior of an individual detainee, with a follow-up memorandum sent through the facility administrator to the detainee's file. 15. A Special Management Housing Unit Record is maintained on each detainee in an SMU. 16. Health care personnel are immediately informed when a detainee is admitted to an SMU to provide assessment and review as indicated by health care protocols. Meets Standard 17. PRIORITY: A health care provider visits every detainee in an SMU at least once daily, and detainees are provided any medications prescribed for them. Detainees will have access to regularly scheduled sick call regardless of housing assignment. Meets Standard Per reviewed policy, a health care provider visits each detainee in the SMU on a daily basis. Regular sick call is conducted; documentation is noted in the SMU housing record. Meets Standard Detainees in the SMU may shave and shower daily. All other basic services listed in this component are received on the same basis as general population. Any action taken is documented in a separate logbook, and the medical visit is recorded on the detainee’s SMU Housing Record (Form I-888). 18. Detainees in SMUs may shave and shower three times weekly and receive other basic services (laundry, hair care, barbering, clothing, bedding, linen) on the same basis as the general population. 19. Detainees in Administrative Segregation are provided opportunities to spend time outside their cells (over and above the required recreation periods), for such activities as socializing, watching TV, and playing board games and may be assigned to work details (for example, as orderlies in the SMU). Does Not Meet Standard This component was rated Does Not Meet Standard during the last inspection because detainees held in special housing are not afforded time outside their cells over and above the required recreation periods. This practice remains in policy. It should be noted that during this inspection there were no detainees held in special housing. This is a repeat deficiency. 20. The shift supervisor sees each segregated detainee daily, including weekends and holidays. Meets Standard 21. The facility administrator (or designee) visits each SMU daily. Meets Standard Page 59 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components Rating Remarks (1000 Char Max) Meets Standard Detainees in the SMU are provided three nutritionally adequate meals per day from the general population menu. A review of policy noted that detainees will be served three meals each day. Meets Standard Policy addresses the requirements in this component.. Meets Standard Per policy, detainees in the SMU have the same mail privileges as the general population. Meets Standard Detainees in SMU ordinarily retain visiting privileges. 26. Adequate documentation is generated for any restricted or disallowed general visits for a detainee in an SMU who violated visiting rules or whose behavior indicated the detainee would be a threat to the security or good order of the visiting room in the past year. Meets Standard Policy addresses the documentation required by this component. 27. Under no circumstances is a detainee permitted to participate in general visitation while in restraints. Meets Standard Detainees are not permitted to visit in restraints. 22. Detainees in SMUs are provided three nutritionally adequate meals per day, ordinarily from the general population menu. 23. Only for documented medical or mental health reasons are detainees denied such items as clothing, mattress, bedding, linens, or a pillow. If a detainee is so disturbed that he or she is likely to destroy clothing or bedding or create a disturbance risking harm to self or others, the medical department is notified immediately and a regimen of treatment and control instituted by the medical officer. 24. Detainees in an SMU may write and receive letters the same as the general population. 25. Detainees in an SMU ordinarily retain visiting privileges. 28. (SPCs/CDFs) Detainees in protective custody and violent and disruptive detainees are not permitted to use the visitation room during normal visitation hours. Meets Standard Staff confirmed that at this IGSA facility, detainees in protective custody status and violent and disruptive detainees are not permitted to use the visitation room during normal visiting hours, if there is reason to believe that the detainee may disrupt the visitation session. Note: due to health safety concerns there have been no contact visits since April 2020. Page 60 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components 29. (SPCs/CDFs) Violent and disruptive detainees are limited to non-contact visits and, in extreme cases, not permitted to visit. 30. Ordinarily, detainees in SMUs are not denied legal visitation. 31. Detainees in SMUs are allowed visits by members of the clergy, upon request; unless it is determined a visit presents a risk to safety, security, or orderly operations. 32. Detainees in SMUs have access to reading materials, including religious materials. In SPCs and CDFs, the Recreation Specialist offers each detainee soft-bound, nonlegal books on a rotating basis, provided no detainee has more than two books (excluding religious material) at any one time. 33. Detainees in SMUs have access to legal materials, in accordance with the Detention Standard on Law Libraries and Legal Material. Detainees are permitted to retain a reasonable amount of personal legal material in the SMU, provided it does not create a safety, security and/or sanitation hazard. Rating Remarks (1000 Char Max) Meets Standard Staff confirmed that at this IGSA facility detainees who are violent and disruptive do not receive contact visits and, in extreme cases, may have their visitation privileges suspended. Meets Standard Meets Standard Per policy, detainees may visit with clergy upon request. The visits will only be denied for security or safety concerns. Meets Standard Detainees in SMU have access to reading materials. Policy addresses the requirements of this component. Meets Standard Policy addresses all the requirements of this component. Detainee requests for access to legal material in their personal property are accommodated as soon as possible and always within 24 hours of a detainee’s request. 34. Any denial of access to the law library is always: • Supported by compelling security concerns, • For the shortest period required for security, and • Fully documented in the SMU housing logbook. ICE/ERO is notified every time law library access is denied. Meets Standard Policy addresses all the requirements of this component. The detention standards officer (DSCO), reported that ICE will be notified if a detainee is denied access to the law library. No detainees were denied law library access during this inspection period. 35. Recreation for detainees in the SMU is separate from the general population. Meets Standard 36. The facility has policy and procedures to ensure detainees who must be kept apart never participate in activities in the same location at the same time. Meets Standard Page 61 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) Policy addresses the items listed in this component. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components Rating 37. Detainees in the SMU are offered at least one hour of recreation per day, scheduled at a reasonable time, at least five days per week. Where cover is not provided to mitigate inclement weather, detainees are provided weather-appropriate equipment and attire. Meets Standard 38. The recreation privilege is denied or suspended only if it would unreasonably endanger safety or security. When a detainee in an SMU is deprived of recreation (or any usual authorized items or activity), a report of the action is forwarded to the facility administrator. 39. The case of a detainee denied recreation privileges is reviewed at least once each week, as part of the reviews required for all detainees in SMU status. The reviewer documents whether the detainee continues to pose a threat to self, others, or facility security and, if so, why. 40. Denial of recreation privileges for more than 15 days requires the concurrence of the facility administrator and the health authority. The facility notifies ICE/ERO when a detainee is denied recreation privileges for more than 15 days. Meets Standard Meets Standard 42. After seven consecutive days in Administrative Segregation, the detainee may exercise the right to appeal to the facility administrator the conclusions and recommendations of any review conducted. Per policy, recreation privileges may be denied or suspended for safety and security concerns. Such action requires a report to be submitted to the OIC. There were no such denials during this inspection period. Staff confirmed that any denial of recreation privileges would be evaluated during the seven-day review. No detainees were denied recreation privileges during this reporting period. Meets Standard Per policy, the OIC and the resident health official must approve any denial of recreational privileges lasting more than seven days. ICE is notified of the denial. Meets Standard Per reviewed policy, detainees in administrative segregation status are allowed the same telephone access as the general population. Detainees in disciplinary segregation status are provided direct free legal calls as required by this component. Calls are only denied for compelling documented security concerns. 41. Ordinarily, detainees in Administrative Segregation have telephone access similar to detainees in the general population, in a manner consistent with the special security and safety requirements of an SMU. Detainees in Disciplinary Segregation may be restricted from using telephones to make general calls as part of the disciplinary process; however, ordinarily, they are permitted to make direct and/or free and legal calls as described in the Detention Standard on Telephone Access, except for compelling and documented reasons of safety, security, and good order. Remarks (1000 Char Max) Meets Standard Page 62 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS (Key: O) This Detention Standard protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in Special Management Units (SMUs) with an Administrative Segregation section for detainees segregated for administrative reasons and a Disciplinary Segregation section for detainees segregated for disciplinary reasons. Components 43. If a detainee has been in Administrative Segregation for more than 30 days and objects to this status, the facility administrator reviews the case to determine whether that status should continue, taking into account the views of the detainee. A written record is made of the decision and the justification. A similar review is done every 30 days thereafter. 44. When a detainee has been held in Administrative Segregation for more than 30 days, the facility administrator notifies the Field Office Director. Rating Remarks (1000 Char Max) Meets Standard Per policy, if a detainee has been in administrative segregation status for more than thirty days and objects to that status, the OIC shall review the case to determine whether that status should continue. The review shall take into account the detainee’s views and the OIC shall document the decision and his justifications. A similar review shall take place every thirty days thereafter. Meets Standard The DSCO reported that ICE receives all required notifications. There were no detainees on disciplinary segregation status for more than thirty days during this inspection period. 45. A permanent log is maintained in each SMU to record all activities concerning SMU detainees (meals served, recreation, visitors, etc.). In SPCs and CDFs, the SMU log records the detainee's name, A-number, housing location, date admitted, reasons for admission, tentative release date for detainees in Disciplinary Segregation, the authorizing official, and date released. Meets Standard PART 2 – 15. SPECIAL MANAGEMENT UNITS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The evaluation of this standard was based on review of policy, detention files; interviews with the Assistant Jail Administrator Taylor and DSCO Tilman; and a tour of the SMU by the on-site inspector. The facility protects detainees, staff, contractors, volunteers, and the community from harm by segregating certain detainees from the general population in special management housing units. During the inspection there were no detainees in administrative segregation or disciplinary segregation status. All detainees housed in segregated housing receive a copy of the documentation placing them in segregation status. Per staff, each prehearing detention form detailing the reasons for placing a detainee in administrative segregation is emailed to the field office director. The SMU provides a safe housing environment for detainees who cannot live in the general population or require segregated status for disciplinary reasons. A detainee is not placed in involuntary segregation solely on the basis of age, gender identity, race, color, national origin, or Page 63 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 15. SPECIAL MANAGEMENT UNITS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) religion. Except in instances where other placements or options are not sufficient or available, detainees are not placed in segregation based on their vulnerabilities to sexual or other types of abuse or assault. Detainees are evaluated by a medical professional prior to placement into the SMU when feasible; or as soon as possible when not feasible. Seriously mentally ill detainees are given a mental health consultation within 72 hours of placement into the SMU, and are seen weekly by a mental health provider for the length of their stay in the SMU. Training in the identification and management of mentally ill detainees such as identification of signs of mental health decomposition, interacting with mentally ill detainees, and de-escalation techniques, is provided to the staff assigned to the SMU. Policy and procedures are in place to control and secure access to the SMU, contraband, tools, and food carts. Administrative segregation records are maintained and used to record specific data on detainees upon admission to and release from the unit and for supervisors to record their visits. Detainees in disciplinary segregation will have more stringent personal property restrictions and control than those in administrative segregation. Detainees housed in the SMU have the same law library access as the general population. The facility provides communication assistance to LEP detainees and detainees with disabilities. This may be achieved via bilingual staff, translation services, TTY machine, or other means for LEP detainees; or in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. Detainees are provided translation services or interpretation services while in the SMU to assist with their understanding of conditions of confinement as well as their rights and responsibilities. Detainees are provided appropriate accommodations and professional assistance, such as medical and therapeutic or mental health treatment, for special needs. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 64 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 16. STAFF-DETAINEE COMMUNICATION (Key: P) This Detention Standard enhances security, safety, and orderly facility operations by encouraging and requiring informal direct and written contact among staff and detainees, as well as informal supervisory observation of living and working conditions. It also requires the posting of Hotline informational posters from the Department of Homeland Security Office of the Inspector General. Components 1. Rating Remarks (1000 Char Max) Meets Standard Interviews with assigned ICE and facility staff and detainees confirmed that detainees have frequent informal access to and interaction with key facility and ICE personnel in languages they can understand. Interviews further confirmed that personnel make scheduled and frequent unannounced visits to all detainee housing units to monitor overall living conditions and to listen and respond to detainee concerns. Does Not Meet Standard Due to health safety concerns all ICE staff visits have been suspended. Facility staff informed the inspector that prior to the suspension all visits by ICE/ERO personnel were documented in the shift officers’ logbook. PRIORITY: ICE/ERO detainees shall have frequent informal access to and interaction with key facility staff members, in a language they can understand. Facility staff shall conduct scheduled visits to address detainees’ personal concerns and monitor living conditions. 2. 3. Each facility shall develop a method to document the unannounced visits by ICE/ERO staff. In SPCs, CDFs, and IGSAs with On-Site ICE/ERO Presence: The facility administrator or Supervisory Detention and Deportation Officer (SDDO) shall develop written schedules of weekly visits and ensure they are posted in detainee living and other appropriate areas. Each facility shall have specific procedures for documenting each visit. N/A The IGSA does not have an onsite ICE/ERO presence. The facility's ICE liaison officer conducts weekly on-site unit inspections of each detainee living quarters. The inspection is supervised by ICE/ERO staff via a remote telephonic connection. with ICE staff. The on-site inspection schedule is posted in the housing unit. Confirmed via review of inspection visit documentaton conducted by the ICE liaison officer and supervised remotely by ICE staff. Postings of the scheduled visits were also observed by the on-site SME. Page 65 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 16. STAFF-DETAINEE COMMUNICATION (Key: P) This Detention Standard enhances security, safety, and orderly facility operations by encouraging and requiring informal direct and written contact among staff and detainees, as well as informal supervisory observation of living and working conditions. It also requires the posting of Hotline informational posters from the Department of Homeland Security Office of the Inspector General. Components 4. Rating Remarks (1000 Char Max) PRIORITY: Detainees may submit written questions, requests, or concerns to ICE/ERO staff, using the detainee request form, a local IGSA form, or a sheet of paper. Each facility administrator shall: 5. 6. • Ensure that adequate supplies of detainee request forms, envelopes, and writing implements are available. • Have written procedures to promptly route and deliver detainee requests to the appropriate ICE/ERO officials by authorized personnel (not detainees) without reading, altering, or delaying. • Ensure that the standard operating procedures accommodate detainees with special assistance needs based on, for example, disability, illiteracy, or limited use of English. • Ensure that each facility provides a secure drop box for ICE detainees to correspond directly with ICE management, and that only ICE personnel have access to the drop box. In SPCs and CDFs and in IGSAs with ICE/ERO on-site presence: The staff member receiving the request shall normally respond in person or in writing as soon as possible and practicable, but no longer than within 72 hours of receipt. In IGSA facilities without ICE/ERO on-site presence, each detainee request shall be forwarded to the ICE/ERO office of jurisdiction within two business days. Meets Standard Interviews with staff and review of policy documents such as ICE officer liaison check lists and logs, confirmed that each element of this component is addressed in facility and ICE policy and/or practice. Meets Standard The IGSA facility does not have an on-site ICE/ERO presence. Detainee requests are answered in person and in writing within by the facility's ICE liaison officer working with ICE field staff within 72 hours of receipt, as confirmed by review of request logbook entries. Meets Standard Page 66 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 16. STAFF-DETAINEE COMMUNICATION (Key: P) This Detention Standard enhances security, safety, and orderly facility operations by encouraging and requiring informal direct and written contact among staff and detainees, as well as informal supervisory observation of living and working conditions. It also requires the posting of Hotline informational posters from the Department of Homeland Security Office of the Inspector General. Components 7. Rating Remarks (1000 Char Max) Meets Standard During this inspection reviewed officer's logbooks confirmed that each of items required by this component are recorded. As required by the ICE/ERO Detention Standard on Detainee Handbook, each facility’s handbook (or supplement) shall advise detainees of the procedures to submit written questions, requests, or concerns to ICE/ERO staff, as well as the availability of assistance to prepare such requests. Meets Standard The local handbook contains the information addressed in this component. The facility administrator shall ensure that OIG Hotline posters are posted at appropriate common areas (recreation areas, dining areas, processing areas, etc.) to include each housing area in SPC/CDFs. Meets Standard The on-site SME confirmed compliance with requirements of this component. All requests to ICE/ERO staff shall be recorded in a logbook (or electronic logbook) specifically designed for that purpose. At a minimum, the log shall record: • Date of receipt; • Detainee’s name; • Detainee’s A-number; • Detainee’s nationality; • Name of the staff member who logged the request; • Date the request, with staff response and action, was returned to the detainee; and • Any other pertinent site-specific information. In IGSAs, the date the request was forwarded to ICE/ERO and the date it was returned shall also be recorded. 8. 9. PART 2 – 16. STAFF-DETAINEE COMMUNICATION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Staff-detainee communications are conducted in accordance with the standard. ICE staff provides general information to detainees pertaining to the immigration court process. Detainee written request can be delivered in a sealed envelope with the name and title of the ICE official to whom it should be forwarded. Detainees are informed that they can obtain assistance from other detainees or facility staff in preparing a request form. All completed detainee requests are considered confidential and are maintained in the field office. The facility's ICE Liaison Officer and the facility's telephone service provider test all detainee phones at least weekly to verify serviceability. Staff makes random calls to pre-programmed numbers for attorney and consulate services, interview a sampling of detainees regarding telephone services, and check the TTY or other reasonable accommodation ensuring they are working and available for hearing-impaired detainees. The staff document each serviceability test and maintains them by month for three years. OIG contact information posters are in the housing units. The facility provides communication assistance to LEP detainees and detainees with disabilities. This includes bilingual staff, translation services, or other auxiliary aids for detainees with disabilities, including but not limited to, those aids listed in the Page 67 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 16. STAFF-DETAINEE COMMUNICATION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Standard. In evaluating the standard, facility staff and detainees were interviewed; ICE officer liaison check lists and telephone serviceability check lists were examined. The inspector interviewed four detainees. Each of the detainees told the inspector that they felt safe and had not had any adverse physical or verbal confrontation when interacting with facility or ICE staff. Each of the detainees interviewed voiced complaints concerning their interaction with other non-ICE detainees; stating they were harrassed and "bullied" by the other non-ICE detainees. All but one of the detainees stated that they did not report their situation to facility or ICE staff fearing repriasals. One detainee stated that he did report the situation to a facility officer who spoke to the other detainees warning them that they needed to curtail their behavior. The inspector interviewed ICE Liaison Officer Glassburn and Officer Little. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 68 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 17. TOOL CONTROL (Key: Q) This Detention Standard protects detainees, staff, contractors, and volunteers from harm and contributes to orderly facility operations by maintaining control of tools, culinary utensils, and medical and dental instruments, equipment, and supplies. Components 1. Rating The use of tools, keys, medical equipment and culinary equipment is controlled. Does Not Meet Standard Remarks (1000 Char Max) Inventory of medical equipment was conducted and observed to be inaccurate. Suture removal kits most recent count was conducted on 02/11/2021 and reflected there were ten kits. Inspector and staff RN count conducted count during the inspection period and noted there were nine; not ten kits in stock. The most current 23 gauge, one inch needle count was conducted on 03/05/2020. Count completed by staff RN during this inspection reflected that the actual count was off by five syringe needles. In the maintence office, tool inventory for the "tool bucket" was not available. The tools are located in a maintence office within the secure perimeter. Culinary equipment inventory was not accurate. A broken tool was observed laying in the bottom of the tool cabinet. Two "seat belt cutters" were observed in the key control cabinet and were not logged in any inventory. 2. 3. PRIORITY: There is an individual who is responsible for developing a tool control procedure and an inspection system to insure accountability. PRIORITY: Each facility administrator shall develop and implement a written tool control and storage system to include a tool classification system, and there are policies and procedures in place to ensure that all tools are properly marked and readily identifiable. Meets Standard There is no individual responsible for developing a tool control procedure. During the inspection, the captain assigned the administrative sergeant to the tool control officer responsibilities. Meets Standard The Tools and Equipment and Supplies policy includes a written tool control and storage system. Page 69 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 17. TOOL CONTROL (Key: Q) This Detention Standard protects detainees, staff, contractors, and volunteers from harm and contributes to orderly facility operations by maintaining control of tools, culinary utensils, and medical and dental instruments, equipment, and supplies. Components 4. 5. 6. 7. The facility has developed and implemented a tool classification system. Rating Does Not Meet Standard Does Not Meet Standard Tool inventories were not readily available in the maintenance department. The food service inventory was incomplete. Broken tools were not logged. There is no electronics shop, recreation department, or armory Does Not Meet Standard Tool inventories were not conspicuously posted on the "tool bucket" used by the maintenance empoyees. Tool inventories are required for: • Facility Maintenance Department • Medical Department • Food Service Department • Electronics Shop • Recreation Department • Armory Tool Inventories are conspicuously posted on all tool boards, tool boxes and tool kits. (SPCs/CDFs) The new tools shall be issued only after the Tool Control Officer has marked and inventoried them. Inventories that include any portable power tools shall provide brand name, model, size, description, and inventory control/AMIS number. 8. The facility administrator shall schedule, and establish procedures for, the quarterly inventorying of all tools. 9. (SPCs/CDFs) Tool inventories shall be numbered and posted conspicuously on all corresponding shadow boards, toolboxes, and tool kits. While all posted inventories must be accurate, only the Master Tool Inventory Sheet in the office of the chief of security requires the certifiers' signatures. 10. The facility administrator shall develop and implement procedures governing lost tools. Remarks (1000 Char Max) The facility has developed a classification system in policy. However, the tool classification system has not been implemented. N/A Does Not Meet Standard In this IGSA facility, policy does not address this component. No documentation was provided to confirm the completion of quarterly inventorying of tools. N/A In this IGSA facility, policy does not address this component. Does Not Meet Standard The Tools and Equipment and Supplies policy includes procedures governing lost tools. However, no documentation of implementation was provided. Page 70 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 17. TOOL CONTROL (Key: Q) This Detention Standard protects detainees, staff, contractors, and volunteers from harm and contributes to orderly facility operations by maintaining control of tools, culinary utensils, and medical and dental instruments, equipment, and supplies. Components Rating Remarks (1000 Char Max) 11. (SPCs/CDFs) When a restricted or non-restricted tool is missing or lost, staff shall notify the chief of security in writing as soon as possible. When the tool is a restricted (Class “R”) tool, staff shall inform the shift supervisor orally immediately upon discovering the loss. Any detainee(s) who may have had access to the tool shall be held at the work location pending completion of a thorough search. N/A In this IGSA facility, policy does not address this component. The facility administrator shall implement quarterly evaluations of lost/missing tool files. 12. All visitors, including repair and maintenance workers who are not ICE/ERO or facility employees, shall submit to an inspection and inventory of all tools, tool boxes, and equipment that could be used as weapons before entering and leaving the facility. The contractor shall maintain a copy of the tool inventory with them while inside the facility. Does Not Meet Standard The Tools and Equipment and Supplies policy requires that the workers submit to an inspection and inventory of tools. Documentation was not available to support practice. The maintenance worker advised that "he always takes the same tool bucket into the facility." Security officers do not inspect the tools prior to entering the housing unit or departing housing unit. PART 2-17. TOOL CONTROL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) A review of all relevant material confirmed that the facility has not implemented procedures to ensure that tools are properly accounted for. Documentation confirmed that tool inventories are not conducted daily, monthly and quarterly. During the inspection, the administrative sergeant was assigned the responsibilty for tool control. The tool classification system is not in place. All new tools are not labeled and inventoried before being issued. Policy requires that all visitors bringing tools into the facility must have an accurate inventory before being granted entry and must keep the inventory with them at all times while inside the facility. No documentation was available to support the practice. Practices are not in place for the following: Policy requires that when a tool is missing or lost, staff shall notify the chief of security in writing as soon as possible. When the tool is a restricted tool, staff shall inform the shift supervisor orally immediately upon discovering the loss. Any detainee(s) who may have had access to the tool shall be held at the work location pending completion of a thorough search. When a tool or equipment in the medical department is missing or lost, staff shall immediately inform the medical staff who will immediately verbally notify the chief of security or shift supervisor and submit a written notification to the facility administrator. The shift supervisor's office shall maintain a lost-tool file, monitor the individual reports for accuracy, ascertain any unusual patterns or occurrences of loss in one or more shops, document search efforts, and send written notification to the captain. According to the Tools and Equipment and Supplies policy, it is the responsibility of security staff to ensure that knives and Page 71 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2-17. TOOL CONTROL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) other kitchen implements are not concealed and taken to the housing units. At the conclusion of inmate workers shifts, they will be searched before being returned to housing unit. However, observation did not confirm this practice. The medical area does not permit unsupervised access to inmates/detainees therefore, they do not have access to medical equipment. Evaluation of this standard was based on review of the Tools and Equipment and Supplies policy, tool logs, inventories and tool reports; observation of inaccurate tool inventories, tools that were not etched and tools that were not on an inventory; and interviews with Maintenance Workers Wayne Payne and Tony Bowles, Captain Brandon Crowley and Sergeant Jase Glassburn. Overall Rating: Does Not Meet Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 72 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 18. USE OF FORCE AND RESTRAINTS (Key: R) This Detention Standard authorizes staff to use necessary physical force, after all reasonable efforts to otherwise resolve a situation have failed, and only for protection of self, detainees, or others, for prevention of escape or serious property damage, or to maintain the security and orderly operation of the facility. Components 1. 2. Remarks (1000 Char Max) Meets Standard The Reporting Use of Force and Weapons/Physical Force policy includes the component language. There were three immediate use-of-force incidents during the inspection period. The use-of-force packet included one incident report. No documentation was included to confirm that confrontation avoidance techniques and useof- force continuum was employed. During the inspection, the captain executed a plan of action to include remedial training for the use-of-force report documentation. Meets Standard The Reporting Use of Force and Weapons/Physical Force policy includes the component language. Meets Standard Training records confirmed training. Meets Standard The Reporting Use of Force and Weapons/Physical Force policy does not include component requirements. The captain advised that the requirements will be added to the policy and practice. PRIORITY: Staff use physical force only as a last resort after all reasonable efforts to otherwise resolve a situation have failed, and use only the degree of force necessary to gain control of the situation, employing confrontation avoidance techniques and the use-of-force continuum. Staff: • Does not use force as punishment. • Attempts to gain the detainee's voluntary cooperation before resorting to force. • Uses only as much force as necessary to control the detainee. • Uses restraints only when other non-confrontational means, including verbal persuasion, have failed or are impractical. 3. PRIORITY: All officers receive training in self-defense, confrontation avoidance techniques and the use of force to control detainees. Specialized training is given to officers ensuring they are certified in all devices including chemical agents, approved for use. 4. Rating PRIORITY: Staff will consult with medical staff prior to a calculated use of force regarding the following: • Use of pepper spray/non-lethal weapons. • Pregnant detainees. • Detainees with wounds or cuts. • Detainees with special medical or mental health needs. Page 73 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 18. USE OF FORCE AND RESTRAINTS (Key: R) This Detention Standard authorizes staff to use necessary physical force, after all reasonable efforts to otherwise resolve a situation have failed, and only for protection of self, detainees, or others, for prevention of escape or serious property damage, or to maintain the security and orderly operation of the facility. Components 5. Special precautions are taken when restraining pregnant detainees. Rating Remarks (1000 Char Max) Meets Standard The Use of Force policy includes component requirements. Medical personnel are consulted. 6. Intermediate force weapons, when not in use, are stored in areas where access is limited to authorized personnel and to which detainees have no access. Meets Standard Intermediate force weapons are stored in the captain's office, a restricted access area. 7. When the detainee is in an area that is or can be isolated (e.g., a locked cell, a range), posing no direct threat to the detainee or others, staff must try to resolve the situation without resorting to force. Meets Standard The Use of Force policy includes component requirements. Meets Standard The Use of Force policy includes component requirements. Meets Standard According to the Use Of Force policy, if time permits and there is not an immediate danger for the security or safety staff use the use-of-force team (Detention Response Team) technique. Meets Standard Training documents confirmed component requirements. Meets Standard Policy requires that all use-offorce incidents are audio-visually documented and reviewed by the captain and lieutenant. According to policy, documentation includes the medical examination through the conclusion of the incident. There were three immediate useof-force incidents during this inspection period. The use-of force-packet did not include audio visual documentation, medical reports or witness statements. The captain advised that the requirements will be added to the policy and practice. Meets Standard The video recorder was observed in the control center, fully powered and maintained in a secure area. 8. The facility subscribes to the prescribed confrontation avoidance procedures. The ranking detention official, health professionals, and others confer before every calculated use of force. 9. When a detainee must be forcibly moved and/or restrained and there is time for a calculated use of force, staff use the use of force team technique. 10. Staff members are trained in the performance of the useof-force team technique. 11. PRIORITY: All use of force incidents are documented and reviewed. All use of force incidents are properly audio-visually documented and forwarded for review. Use of Force documentation at a minimum, shall include the medical examination through the conclusion of the incident. All calculated uses of force incidents must be audio-visually recorded in its entirety from the beginning of the incident to its conclusion. 12. Staff shall store and maintain audio-visual recording equipment under the same conditions as “restricted” tools. Page 74 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 18. USE OF FORCE AND RESTRAINTS (Key: R) This Detention Standard authorizes staff to use necessary physical force, after all reasonable efforts to otherwise resolve a situation have failed, and only for protection of self, detainees, or others, for prevention of escape or serious property damage, or to maintain the security and orderly operation of the facility. Components Rating Remarks (1000 Char Max) Does Not Meet Standard This facility utilizes the restraint chair. Policy does not address the component requirements. Does Not Meet Standard The Use of Force policy requires officers to contact medical staff once the detainee is under control. Documentation did not confirm that medical staff were contacted after the immediate use-of-force incidents. Meets Standard This facility utilizes the restraint chair. Policy addresses component requirements. Meets Standard This facility utilizes the restraint chair. Policy addresses component requirements. 13. Standard procedures associated with using four/five point restraints include: • Soft (nylon/leather) restraints. • Dressing the detainee appropriately for the temperature. • A bed, mattress, and blanket/sheet. • Checking the detainee at least every 15 minutes. • Logging each check. • Repositioning detainee often enough to prevent soreness or stiffness. • Medical evaluation of the restrained detainee twice per eight-hour shift. When qualified medical staff are not immediately available, staff position the detainee "face-up." 14. In immediate use of force situations, officers contact medical staff once the detainee is under control. 15. The shift supervisor monitors position/condition every two hours. the detainee's He/she allows the detainee to use the restroom at these times under safeguards. 16. All detainee checks are logged. 17. When any detainee is restrained for more than eight hours, the facility administrator shall telephonically notify the Assistant Field Office Director and provide updates every eight hours until the restraints are removed. 18. It is standard practice to review any use of force and the non-routine application of restraints. 19. In SPCs, the use of force form is used. In other facilities (IGSAs / CDFs) this form or its equivalent is used. Does Not Meet Standard This facility utilizes the restraint chair. Policy does not address the component requirement. Does Not Meet Standard No documentation was available to confirm that use-of-force incident reports are routinely reviewed. Does Not Meet Standard In this IGSA facility, an incident report is used. The form is not an equivalent. PART 2 – 18. USE OF FORCE AND RESTRAINTS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Page 75 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 2 – 18. USE OF FORCE AND RESTRAINTS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) During the inspection period, there were three immediate use-of-force incidents involving ICE detainees. Each use-of-force "packet" included one incident report. Reports written by officers witnessing or involved in each event were not provided/available, as required by the standard. Medical assessments for staff and/or detainees were not provided/available. Audio visual documentation was not provided/available. On 10/20/2020, an ICE detainee housed in the padded cell "charged out of the padded cell" during an attempt to serve his meal. The officers gave the detainee multiple orders to comply prior to placing the detainee in the restraint chair. One incident report was provided. No after-action report was available. No medical report was provided. No audio visual documentation was provided. On 11/08/2020, an ICE detainee refused escort from a holding cell to the multipurpose housing. Officers used open hand and pressure point techniques to gain compliance. Detainee refused to comply and continued to push back to officers. The sergeant deployed her Taser. Detainee continued to push back the officers. After the struggle, detainee was placed in the restraint chair. One incident report was provided. No after-action report was available. No medical report was provided. No audio visual documentation was provided. On 03/23/2021, officers were monitoring an ICE detainee for withdraw of alcohol protocol. The intake control officer observed sheets and blankets in the holding cell that appeared to replicate suicide materials. Officers entered the padded cell, a struggle with the detainee began, and a Taser was deployed. One incident report was provided. No after-action report was provided. No medical report was provided. No audio visual documentation was provided. All staff receive use-of-force training during their initial training prior to assuming duty and then receive 24 hours use-of-force training as part of their basic training. Documentation of Taser inventory was incomplete. Oleoresin Capsicum/pepper spray (OC) is the only chemical agent approved for use. The following acts and techniques are not specifically prohibited: chokeholds, carotid control holds, and other neck restraints. Batons are not used at this facility. Per policy, restraints are prohibited to be used on a female detainee that is pregnant or in post-delivery recuperation unless directed by a medical authority for purpose of their safety. Whenever restraints are used on a pregnant detainee follow-up of medical attention if necessary is required. Evaluation of this standard was based on review of the Use of Force policy, Use of Restraint Chair policy, Use of Restraints policy, use-of-force incident reports and logs; interviews with Captain Brandon Crowley and Lieutenant Neil Taylor; and observation of the restraint chair. Overall Rating: Does Not Meet Standard Reviewer Name (Printed): Inspector 3 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 76 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Section III: ORDER Disciplinary System Page 77 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 3 – 19. DISCIPLINARY SYSTEM (Key: S) This Detention Standard promotes a safe and orderly living environment for detainees by expecting detainees to comply with facility rules and regulations and imposing disciplinary sanctions to control the behavior of those who do not. Components 1. 2. 3. 4. 5. 6. PRIORITY: The facility has a written disciplinary system using progressive levels of reviews and appeals. Written disciplinary policy and procedures shall clearly define detainee rights and responsibilities. The policy, procedures, and rules shall be reviewed at least annually. Detainees will receive translation or interpretation services throughout the investigative, disciplinary, and appeal process, including accommodation for the hearing impaired. The facility shall not hold a detainee accountable for his or her conduct if a medical authority finds him or her mentally incompetent. PRIORITY: Time in disciplinary segregation or withholding of privileges imposed for disciplinary violations do not generally exceed 60 days per violation. Staff do not impose or allow imposition of the following sanctions: corporal punishment; deprivation of food services (to include use of Nutraloaf or “food loaf”); deprivation of clothing, bedding, or items of personal hygiene; deprivation of correspondence privileges; deprivation of legal access and legal materials; or deprivation of physical exercise, unless such activity creates a documented unsafe condition. PRIORITY: The facility supplemental handbook issued to each detainee upon admittance, shall provide notice of the facility’s rules of conduct and prohibited acts, the sanctions imposed for violations of the rules, the disciplinary severity scale, the disciplinary process and the procedure for appealing disciplinary findings. Copies of the rules of conduct, rights, and disciplinary sanctions shall be provided to all detainees and posted in English, Spanish, and/or other languages spoken by significant numbers of detainees, as follows: • Disciplinary Severity Scale • Prohibited Acts • Sanctions All facilities shall have graduated scales of offenses and disciplinary consequences as provided in this section. Rating Remarks (1000 Char Max) Meets Standard Per reviewed policy, the facility uses progressive levels of reviews and appeals. The policy clearly defines detainee rights and responsibilities. The policy, procedures, and rules are reviewed annually by the OIC. Meets Standard As reported by staff, detainees are provided translation or interpretation services for each phase of the disciplinary process. Detainees are not held accountable for their conduct if a medical authority finds them mentally incompetent. Meets Standard Per reviewd policy, time in disciplinary segregation, or the withholding of privileges imposed for disciplinary violations, does not exceed thirty days per violation, except under extraordinary circumstances. Staff does not impose or allow the imposition of any of the sanctions prohibited by this standard unless the activity creates a documented unsafe condition. Meets Standard A review of the local handbook confirmed it includes the required information on the facility's rules of conduct and the referenced information in the component. Meets Standard Meets Standard Page 78 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) The facility uses a graduated scale of offenses and consequences. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 3 – 19. DISCIPLINARY SYSTEM (Key: S) This Detention Standard promotes a safe and orderly living environment for detainees by expecting detainees to comply with facility rules and regulations and imposing disciplinary sanctions to control the behavior of those who do not. Components 7. 8. 9. PRIORITY: Incident reports are investigated within 24 hours of the incident by an officer who had no involvement in the incident. Low or moderate infractions are adjudicated by a Unit Disciplinary Committee (UDC). Unresolved cases and cases involving serious charges are forwarded by the UDC to the Institution Disciplinary Panel (IDP) for adjudication. A staff representative is available if requested for a detainee facing an IDP disciplinary hearing. The facility permits hearing postponements or continuances when conditions warrant such a continuance. Reasons are documented. 10. Written procedures govern the handling of confidentialsource information. Procedures include criteria for recognizing "substantial evidence." 11. All forms relevant to the incident, investigation, committee/panel reports, etc., are completed and distributed as required. Rating Remarks (1000 Char Max) Meets Standard Per reviewd policy, the facility uses progressive levels of reviews and appeals. The policy clearly defines detainee rights and responsibilities. The policy, procedures, and rules are reviewed annually by the OIC. Meets Standard Staff representatives are available, if requested, for a detainee to confer when facing an IDP hearing. Meets Standard Per reviewed policy and as reported by the disciplinary sergeant, postponements are allowed for case preparation and health and security related issues. Meets Standard Policy governs handling confidential information and provides procedures for recognizing substantial evidence. Meets Standard A review of records verified that all forms relevant to the incident, investigation, committee/panel reports, etc. are completed and distributed as required. PART 3 – 19. DISCIPLINARY SYSTEM – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The evaluation of this standard was based on review of policy, the local handbook, and reports; and staff interviews with the Assistant Jail Administrator Taylor and Sergent Glassburn. The facility uses progressive levels of appeals and reviews. Policy clearly defines detainee rights and responsibilities. The policy indicates that detainees will not spend over thirty days in segregation for a single infraction. Upon arrival at the facility, detainees receive a local handbook that provides notice of the rules of conduct, sanctions, disciplinary severity scale, the disciplinary process, and the procedure to appeal the disciplinary finding. Incidents are reviewed within 24 hours and are referred to the UDC or IDP, depending on the severity of the incident. This facility has a comprehensive disciplinary process that affords detainees their due process rights and levels of appeals. Detainees with LEP and disabilities are provided assistance and/or accommodations to ensure that they can meaningfully participate in all aspects of the disciplinary process. When a detainee has a diagnosed mental illness or mental disability or demonstrates symptoms of mental illness or mental disability, a mental health professional, preferably the treating clinician, shall be consulted. The mental health professional will provide input as to the detainee’s competence to participate in the disciplinary hearing, any impact the detainee’s mental illness may have had on his or her responsibility for the charged Page 79 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 3 – 19. DISCIPLINARY SYSTEM – Reviewer Summary (Use following format for dates: mm/dd/yyyy) behavior, and information about any known mitigating factors regarding the behavior. The disciplinary process is adjusted according to the mental competence of a detainee, as diagnosed or directed by an appropriate health care professional. The disciplinary policy guides disciplinary hearing adjustments including, but not limited to, the provision of assistance to the detainee throughout all phases of the process; mitigation of certain behaviors; imposition of or relief from certain sanctions; ruling a detainee incompetent due to the inability to assist in their defense or the inability to distinguish right from wrong; and postponement of a hearing. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 80 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Section IV: CARE Food Service Hunger Strikes Medical Care Personal Hygiene Suicide Prevention and Intervention Terminal Illness, Advance Directives, and Death Page 81 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 20. FOOD SERVICE (Key: T) This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation. Components 1. 2. • Planning, controlling, directing, managing, and evaluating food service; • Managing budget resources; • Establishing standards of sanitation, safety and security; • Developing nutritionally adequate menus and evaluating detainee acceptance of them; • Developing specifications for the procurement of food, equipment, and supplies; and • Establishing a training program that ensures operational efficiency and a high quality food service program. The knife cabinet must be equipped with an approved locking device. Knives must be physically secured to workstations for use outside a secure cutting room. Any detainee using a knife outside a secure area must receive direct staff supervision. Special procedures govern the handling of food items that pose a security threat. 4. The FSA annually reviews detainee-volunteer job descriptions to ensure they are accurate and up-to-date. 6. Remarks (1000 Char Max) Meets Standard The head cook (HC) has fifteen years of food service experience and is ServSafe certified. She is responsible for each of the components listed. Meets Standard The food service knife cabinet was secured with a handle lock and a padlock. Knives are secured to the workstation when in use. Knives are used under food service personnel supervision. Meets Standard Food items which could pose a security threat were observed secured in a locked cabinet. Meets Standard The HC develops and reviews detainee job descriptions annually. ICE detainees do not work at this facility. Meets Standard A review of training records of non-ICE detainees workers confirmed the elements of this components are addressed during training. Meets Standard Training records are maintained for all non-ICE detainee workers. The records were reviewed during the inspection. PRIORITY: The food service program shall be under the direct supervision of an experienced food service administrator (FSA) who is responsible for: 3. 5. Rating During orientation and training session(s), the cook supervisor or equivalent explains and demonstrates: • Safe work practices and methods. • Safety features of individual products/ pieces of equipment. • Training covers the safe handling of hazardous material[s] the detainee are likely to encounter in their work. The cook supervisor documents all training. Page 82 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 20. FOOD SERVICE (Key: T) This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation. Components 7. Detainees assigned to the food service department shall have a neat and clean appearance. 8. Detainees are served three meals every day, at least two of which are hot meals. No more than 14 hours elapse between the last meal served and the first meal of the following day. Rating Remarks (1000 Char Max) Meets Standard Non-ICE detainee workers were observed to be neat and clean while at work. Meets Standard Per the HC and a review of the menus, three meals are provided each day; two of which are hot meals. The feeding schedule reflected fewer than fourteen hours between the evening meal and the following days' breakfast. Does Not Meet Standard Meals were trayed without staff supervision and placed in the corridor for delivery without staff supervision. Meals are served on insulated trays, but not transported in locked carts. Trays were under staff supervision when delivered to the living areas. Meets Standard Random temperatures were taken on the prep line as well as on completed trays. All temperatures were within required parameters. Does Not Meet Standard Servers utilized food grade gloves, hats, and masks. However, no utensils were used during the traying process. Hamburger patties and french fries were placed in the tray by hand. Does Not Meet Standard The thermometer used to assure food temperatures was not cleaned between uses. 13. If the facility does not have enough equipment to maintain the minimum or maximum temperature required for food safety, the affected items (for example, salad bar staples such as lettuce, meat, eggs, cheese) must be removed and discarded after two hours at room temperature. Meets Standard Food is trayed and served within required time frames. The HC indicated food would be disgarded after two hours at room temperature. 14. Food shall be delivered from one place to another in covered containers. Meets Standard Trays are transported to the housing units in covered carts. 9. Meals shall always be prepared, delivered, and served under staff supervision. 10. PRIORITY: Before and during the display, service and transportation of food, sanitary guidelines are observed, with hot foods maintained at a temperature of at least 140 F degrees (120 degrees in food trays) and foods that require refrigeration maintained at 41 F degrees or below. 11. Servers must wear food grade plastic gloves and hair nets whenever there is direct contact with a food or beverage. Serving food without use of utensils is strictly prohibited. 12. Utensils shall be sanitized as often as necessary to prevent cross-contamination and other food-handling hazards during food preparation and service. Page 83 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 20. FOOD SERVICE (Key: T) This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation. Components 15. If food carts are delivered to housing units by detainees, they must be locked unless they are under constant supervision of staff. All food safety procedures (sanitation, safe-handling, storage, etc.) apply without exception to food in transit. Rating Remarks (1000 Char Max) Does Not Meet Standard Meals were trayed without staff supervision and placed in the corridor for delivery without staff supervision. Meals are served on insulated trays, but not transported in locked carts. Trays are passed out by officers once they are delivered to the housing unit. 16. PRIORITY: A registered dietitian shall conduct a complete nutritional analysis that meets U.S. Recommended Daily Allowances (RDA), at least annually, of every master-cycle menu planned by the FSA. The dietitian must certify menus before they are incorporated into the food service program. Meets Standard A registered dietician approves master cycle menus. The most recent analysis was conductd 05/10/2021. The analysis was docmented in a memorandum. 17. The FSA has established procedures to ensure that items on the master-cycle menu are prepared and presented according to approved recipes. Meets Standard Master recipes were present and reviewed. Food is prepared per the recipes per the HC. 18. The FSA or designee has the authority to change menu items if necessary, documenting each substitution, along with its justification, with a copy to the FSA. Menu substitutions will be in accordance with dietician approved substitution guidelines. Meets Standard The HC makes menu changes with equal items and documents these changes. 19. Food service staff and detainee workers involved in cooking shall ensure that potentially hazardous foods are cooked at the required safe temperatures, as listed in the Detention Standard on Food service. Meets Standard Per the HC, temperatures are checked and confirmed by food service staff prior to serving. Meets Standard The HC states they have not experienced a religious diet, but would purchase any special meals required. Meets Standard In this IGSA they do not issue a duplicate special diet identification. Special diets are notated with the detainee's name on a different colored tray. No religious diets are currently being served at this facility. 20. Facilities are required to provide detainees requesting a religious diet a reasonable and equitable opportunity to observe their religious dietary practice by offering a Common Fare Menu. Detainees whose religious beliefs require the adherence to particular religious dietary laws are referred to the Chaplain or FSA. 21. (SPCs/CDFs) Once a religious diet has been approved, the FSA shall issue, in duplicate, a special-diet identification card. Page 84 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 20. FOOD SERVICE (Key: T) This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation. Components 22. The common fare menu shall be based on a 14 day cycle. The menus must be certified as exceeding minimum daily nutritional requirements. Hot entrees shall be offered at least three times a week. 23. The chaplain, in consultation with local religious leaders if necessary, shall develop the ceremonial meal schedule for the following calendar year and provide it to the facility administrator. 24. The Common Fare Program shall accommodate detainees abstaining from particular foods or fasting for religious purposes at prescribed times of the year, such as Ramadan, Passover, and Lent. 25. Detainees with certain conditions – chronic or temporary; medical, dental, and/or psychological – shall be prescribed special diets as appropriate. Rating Remarks (1000 Char Max) Does Not Meet Standard This facility does not have a fourteen-day common fare menu. Interviews with the HC indicated commercial meals would be purchased if required for common fare. Does Not Meet Standard A ceremonial meal schedule has not been developed at this facilty. Does Not Meet Standard This facility does not have a common fare menu. Interviews with the head cook indicate commercial meals would be purchased if required for common fare. Meets Standard Medical diets are served as prescribed by health services. 26. The sanitary standards, including proper temperature maintenance, are required in the food service department also apply to satellite meals, from preparation to actual delivery. Meets Standard Sanitation standards, including proper temperature maintenance, are maintained from preparation to serving. 27. Food for satellite meals must be prepared and held at the proper temperatures until served. Satellite tray meals must be delivered and served within two hours of food being plated. Meets Standard Food is prepared, delivered and served within two hours. Meets Standard Detainees in segregation are served meals identical to that of the general population. However, this facilty does utilize "nutri-loaf" meals for disruptive non-ICE detainees. Policy does not allow these types of meals for ICE detainees Meets Standard Sack meals are provided as needed and are approved by a dietician per the HC. 28. In segregation units, food rations shall not be reduced or changed or otherwise used as a disciplinary tool. 29. Sack meals shall be provided for detainees being transported from the facility, and detainees arriving or departing between scheduled meal hours, and detainees in the SMU, as provided in the standard. Sack meals shall be of the same nutritional quality as other meals prepared by the food service. Page 85 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 20. FOOD SERVICE (Key: T) This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation. Components Rating Remarks (1000 Char Max) Meets Standard Personal observation indicated non-ICE detainee kitchen workers are trained in all aspects outlined in this component and acknowlege this training in writing. Meets Standard Health services confirms non-ICE detainees working in food service receive a physical and TB test prior to their work assignment. Physical results are maintained in health services, while TB results are contained within the detainee's file in food service. Workers are inspected upon arrival by food service staff. Food service personnel are only required to have a TB test. A review of documentation indicated the three food service staff members had current TB test. Meets Standard The food service department complies with food safety standards. The Clay County Health Department inspects the foof service operation annually. The most recent inspection was conducted 05/10/2021. 30. The food service staff instruct detainee volunteers on: • Personal cleanliness and hygiene; • Sanitary techniques for preparing, storing, and serving food, and; • The sanitary operation, care, and maintenance of equipment. 31. All food service personnel, including staff and detainees, shall receive a pre-employment medical examination. The Cook Foreman or detention staff assigned to food service shall inspect all detainee food service workers on a daily basis at the start of each work period. Detainees who exhibit signs of illness, skin disease, diarrhea (admitted or suspected), or infected cuts or boils shall be removed from the work assignment and immediately referred to Health Services for determination of duty fitness. 32. The food service department complies with food safety and sanitation requirements as prescribed by the governing health inspection authority, applicable laws and contract provisions. 33. All facilities shall meet environmental standards for safety and sanitation. Meets Standard 34. The FSA shall develop a schedule for the routine cleaning of equipment consistent with the information obtained from manufacturers or local distributors, the National Sanitation Foundation International (NSF) standards or equivalent standards of other agencies about the operation, cleaning, and care of equipment. Meets Standard 35. Spray or immersion dishwashers or devices – including automatic dispensers for detergents, wetting agents, and liquid sanitizer – shall be maintained in good repair. Utensils and equipment placed in the machine must be exposed to all cycles. Meets Standard Page 86 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) The HC has developed a cleaning schedule which appears to be very effective as evidenced by the cleanliness of and sanitation level of the area. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 20. FOOD SERVICE (Key: T) This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation. Components 36. Adequate, sanitary, properly equipped, and conveniently located toilet facilities shall be provided for all food service staff and detainee workers. 37. The FSA is responsible for pest control in the food service department. Air curtains or comparable devices shall be used on outside doors where food is prepared, stored, or served to protect against insects and other rodents. 38. The facility shall implement written procedures requiring administrative, medical, and/or dietary personnel to conduct the weekly inspections of all food service areas, including dining, storage, equipment, and foodpreparation areas. Rating Meets Standard There are separate restroom facilities for non-ICE detainee workers and kitchen staff. Both of which were observed to be properly equipped. Meets Standard There are no doors in food service area where an air curtain would be required. The facility utilizes a licensed pest control vendor to protect against pest/vermin. Meets Standard An interview with the HC indicated daily safety and sanitation inspections are made by the HC but not documented. Personal observation of the food service area and equipment found them to be clean and well organized. Meets Standard Temperature logs were reviewed and confirm staff check temperatures of the dish washer, refrigerators and freezer, twice daily. The HC inspects the area daily and takes action as required. The kitchern was insected by the Clay County Health Department on 05/10/2021 with no findings noted. Meets Standard A cleaning schedule for each area of the food service area is posted for easy reference. Meets Standard The HC has established procedures for the storage, receiving and inventorying of food. Meets Standard Personal observations indicated food products were stored appropriatly. Meets Standard A review of logs and thermometers confirm proper temperatures are maintained for the storage of cold and frozen items. 39. PRIORITY: Staff shall check refrigerator and water temperatures daily and record the results. The FSA or designee will verify and document requirements of food and equipment temperatures. The FSA or CS shall inspect food service areas at least weekly. An independent, external inspector shall conduct annual inspections to ensure that the food service facilities and equipment meet governmental health and safety codes. 40. The FSA shall develop a cleaning schedule for each food service area and post it for easy reference. 41. Each FSA shall establish procedures for storing, receiving, and inventorying food. 42. Store all products at least six inches from the floor and sufficiently far from walls to facilitate pest-control measures. 43. Perishables shall be stored at 35-40 F degrees to prevent spoilage and other bacterial action, and maintain frozen foods at or below zero degrees. Remarks (1000 Char Max) Page 87 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 20. FOOD SERVICE (Key: T) This Detention Standard ensures that detainees are provided a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation. Components Rating 44. Inventory levels are established, monitored and periodically adjusted to correct excesses or shortages. Remarks (1000 Char Max) Inventory levels are maintained as required. The facility maintains two weeks supply of food on hand. Meets Standard PART 4 – 20. FOOD SERVICE – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Food service is managed by Tammie Fagg, Head Cook, and three part time staff. Non-ICE detainee workers assists with food service operations. The HC and the three part-time staff are ServSafe certified. Food service operations were observed during a noon meal. During the meal non-ICE detainees were observed traying the meal without constant supervision, and were not utilizing serving utensils. Once trayed, the meals were placed by the workers onto open carts, and again were unsupervised. The meals were transported to the housing area where security staff supervised the meal distribution. The refrigerator, freezer and dry storage areas were unsecured during the observation period despite posted signs to keep them secured when not in use. Food service utizes a five-week meal cycle and menus were approved by a registered dietician. Review of the tools maintained in the kitchen confirmed knives were secured by a padlock and hasp. While the cabinet frame is metal, the actual doors to the cabinet appear to be plexiglass and could be compromised. An approximately six-inch set of broken shears was observed stored within the cabinet and not inventoried or otherwise accounted for. Temperatures and logs confirm food is maintained/prepared within appropriate parameters. However, the head cook used the same thermometer to check numerous food items without appropriate sanitizing. The kichen appeared clean and well organized. Several non-ICE detainee workers commented on the quality of meals. A delivery for food service was observed during the inspection. The vendor unloaded a semi trailer directly into an indoor sallyport which is opened remotely by the control center. At times during the process, both interior and exterior sallyport doors are open simultaneously as the driver unloaded the trailer with some items dropped in the kitchen and others in the sallyport. There is no perimeter fence at this facility and no security staff present inside or outside. There does not appear to be a search of the goods, nor security procesing of the delivery driver or vehicle. This concern is compounded by the fact that food service staff personnel receiving the order have not received security related training. Evaluation of this standard was based on interviews with the Tammie Fagg, Head Cook; observation of meal traying operations; review of temperature logs, menus, training files; observation of food service kitchen and storage areas. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 88 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 21. HUNGER STRIKES (Key: U) This Detention Standard protects detainees’ health and well-being by monitoring, counseling and, when appropriate, treating any detainee who is on a hunger strike. Components 1. 2. 3. Rating Remarks (1000 Char Max) Does Not Meet Standard This component was rated Does Not meet Standard because there was no documentation verifying that all staff received initial and annual training on recognizing the signs of a hunger striker and on the procedures for referral for medical assessment. There was no verification that medical staff had received training in hunger-strike evaluation and treatment. Meets Standard Review of policy and procedures include procedures for identifying and referring hunger strikers to medical personnel. Any detainee who does not eat for 72 hours and/or refuses beverages for twenty four hours, would be referred to the medical department for evaluation and treatment. Per an interview with a staff RN, it was confirmed a referral to mental health would also be initiated to assess whether the detainee's actions were reasoned and deliberate or the manifestation of a mental illness. Meets Standard Per interviews with medical personnel and the designated ICE detention standards compliance officer, hunger strikes are immediately reported to ICE via the facility chain-of-command. All staff receive initial and annual training on recognizing the signs of a hunger striker and on the procedures for referral for medical assessment. Medical staff receive training in hunger-strike evaluation and treatment and remain up-to-date on these techniques. Procedures for identifying and referring to medical staff a detainee suspected or announced to be on a hunger strike shall include obtaining from qualified medical personnel an assessment of whether the detainee’s action is reasoned and deliberate or the manifestation of a mental illness. PRIORITY: Facility immediately reports via the chain of command a hunger strike to ICE/ERO. Page 89 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 21. HUNGER STRIKES (Key: U) This Detention Standard protects detainees’ health and well-being by monitoring, counseling and, when appropriate, treating any detainee who is on a hunger strike. Components 4. 5. Rating Remarks (1000 Char Max) Meets Standard Per review of policy and medical staff interviews, any detainee observed not eating would be referred to medical and mental health personnel at 24-hours, 48hours and 72-hours. At 72hours, an official hunger strike would be declared and medical/mental health evaluations and monitoring would commence. Meets Standard Per review of policy and procedures and an interview with a staff RN, it was confirmed, during the initial evaluation of a hunger striker, medical personnel perform all the bulleted tasks listed in this component and repeat other procedures as medically indicated, at least once every 24hours. All examination results would be documented in the detainee's medical file. If a hunger strike was noted over the weekend, the staff RN would have to come to the facility to perform the required 24-hour monitoring and documentation. Meets Standard Per review of policy and medical records, written informed consent is obtained from detainees during the intake process. Additional procedurespecific consents are obtained as needed. PRIORITY: Staff shall consider any detainee observed to have not eaten for 72 hours to be on a hunger strike, and shall refer him or her to the clinical medical authority for evaluation and management. During the initial evaluation of a detainee on a hunger strike, medical staff shall: • Measure and record height and weight; • Measure and record vital signs; • Perform urinalysis; • Conduct psychological/psychiatric evaluation; • Examine general physical condition; and • If clinically indicated, proceed with other necessary studies. Medical staff record the weight and vital signs and repeat other procedures as medically indicated of a hungerstriking detainee at least once every 24 hours. Medical staff shall record all examination results in the detainee's medical file. 6. All physical and mental examinations, treatments, and other medical procedures require the documented informed consent of the detainee. Page 90 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 21. HUNGER STRIKES (Key: U) This Detention Standard protects detainees’ health and well-being by monitoring, counseling and, when appropriate, treating any detainee who is on a hunger strike. Components 7. 8. 9. A signed Refusal of Treatment form is required of every detainee who rejects medical evaluation or treatment. If the detainee will not cooperate by signing, staff shall note this on the "Refusal of Treatment" form. Any detainee refusing medical treatment will be monitored by medical staff to evaluate whether the hunger strike poses a risk to the detainee’s life or permanent health. Rating Remarks (1000 Char Max) Meets Standard Per review of policy and detainee health records, a signed refusal of treatment form is completed any time a detainee refuses an evaluation or treatment. Should the detainee refuse to sign the form, it would be noted on the refusal of treatment form and witnessed by two employees. The detainee would continue to be monitored by medical personnel to evaluate whether the hunger strike posed a risk to the detainee's life or permanent health. Meets Standard Per medical staff interviews and review of policy, at the conclusion of a hunger strike, medical personnel would provide appropriate medical and mental health follow-up care. Per policy, only the clinical director/provider, in consultation with the mental health provider/psychiatrist, can order a detainee's release from hunger strike treatment, and that written order would be documented in the detainee's medical record. A notation would be made in the detention file when a detainee has ended a hunger strike. There have been no reported hunger strikes during this inspection period. Meets Standard Per review of policy and medical staff interviews, when it is determined that it would be beneficial to measure and record a detainee's food and water intake and output an equivalent IHSC hunger strike monitoring form would be used to document the information required by the standard. After the hunger strike, medical staff shall provide appropriate medical and mental health follow-up care. Only the clinical medical authority may order a detainee's release from hunger strike treatment and shall document that order in the detainee’s medical record. A notation will be made in the detention file when the detainee has ended the hunger strike. After consultation with the clinical medical authority, the facility administrator may require staff to measure and record food and water intake and output until terminated by the clinical medical authority. An IHSC Hunger Strike Form or equivalent must be used. Page 91 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 21. HUNGER STRIKES (Key: U) This Detention Standard protects detainees’ health and well-being by monitoring, counseling and, when appropriate, treating any detainee who is on a hunger strike. Components 10. Unless otherwise directed by the medical authority, staff physically deliver three meals per day to the detainee's room, regardless of the detainee's response to a verbally offered meal and document those meal offers. Rating Remarks (1000 Char Max) Meets Standard Per policy and procedure review, and medical staff interviews, it was confirmed, regardless of the detainee's response to a verbal offer of a meal, staff are required to deliver three meals per day to the detainee's cell and complete the applicable documentaiton per the standard requirements. Meets Standard Per review of facility policy and procedures, staff members are to provide an adequate supply of drinking water and other beverages to the detainee. Beverages are provided on each meal tray and are offered by staff between meal deliveries. Meets Standard No food items are permitted in the hunger striker's cell other than food approved by the CMA, who is a physician. Meets Standard Per an interview with medical personnel and the ICE detention compliance manager and review of policy, before involuntary medical treatment would be administered, staff would make reasonable efforts to educate and encourage the detainee to accept treatment voluntarily. Involuntary medical treatment would be administered in accordance with established guidelines and applicable laws and only after the physician had determined the detainee's life or health would be at risk. Involuntary treatment would not be performed onsite; instead the detainee would be transported to either Union Hospital, Regional hospital or to a detention facility appropriately equipped for such treatment. 11. Provide an adequate supply of drinking water or other beverages. 12. Remove from the detainee’s room all food items not authorized by the clinical medical authority. 13. Before involuntary medical treatment is administered, staff shall make reasonable efforts to educate and encourage him or her to accept treatment voluntarily. Involuntary medical treatment shall be administered in accordance with established guidelines and applicable laws and only after the clinical medical authority determines the detainee’s life or health is at risk. Page 92 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 21. HUNGER STRIKES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) During initial referral, medical personnel document the reasons for placing a detainee in a single occupancy observation room. This decision is reviewed every 72 hours. Medical personnel make the decision regarding appropriate housing placement when food and liquid intake/output is measured. If a detainee engaging in a hunger strike has been previously diagnosed with a mental health condition, or is incapable of giving informed consent due to age or illness, appropriate medical/administrative action would be taken in the best interest of the detainee. Only qualified medical personnel modify or augment standard treatment protocols. If medically necessary, detainees are transferred to a community hospital or a detention facility appropriately equipped for treatment. Detainees refusing to accept treatment are counseled by medical personnel regarding the medical risks associated with refusal of treatment. When clinical assessment and laboratory results indicate a detainee's weakening condition threatens the life or long-term health of the detainee, a physician recommends involuntary treatment. The OIC notifies ICE if a detainee is refusing treatment, and the staff RN notifies the IHSC managed care coordinator in writing of any proposed plan to involuntarily feed the detainee. Any involuntary medical treatment is approved by ICE. The FOD, in consultation with the physician, contacts the respective ICE Office of Chief Counsel and the U.S. Attorney's Office and discusses any impending involuntary medical treatment and makes recommendations regarding pursuing a court order. Medical personnel continue clinical and laboratory monitoring as necessary until the detainee's life or health is out of danger and continue medical and mental health follow-up as necessary. Written policy, procedures and practice for the identification and management of hunger strikers are in place. Since the last inspection, there have been no hunger strikes. Evaluation of the standard was determined following a review of policy and procedures, medical treatment protocols, training outlines and records and interviews with the medical staff RN, Stan Roark; ICE Compliance Officer, Tashi F. Tillman and Sergeant Taylor for training documentation. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 24 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 93 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 1. 2. Rating Remarks (1000 Char Max) Meets Standard Initial medical, mental health, and dental screening are performed by detention officers. Primary medical and mental health care is provided by contractual staff provided through a comprehensive contractual agreement with Quality Correctional Care. Dental services are provided at all times by Urgent Dental Care, in Indianapolis, IN. Emergency, specialty health care and hosptalization as needed would be provided by either Union or Regional hospital, located in Terre Haute, IN. Does Not Meet Standard This component was rated Does Not Meet Standard because the administrative health authority is not a physician, health services administrator, or a health agency as the standard requires. The sheriff was designated as the administrative health authority, by the clinical medical authority (CMA) in July of 2020. The CMA is a licensed physician and per policy, has final clinical judgement with respect to medical decisions. Clinical decisions are made by qualified clinicians. Every facility shall directly or contractually provide its detainee population: • Initial medical, mental health, and dental screening, • Primary medical and dental care, Emergency care, Specialty health care, • Timely responses, Mental health care, and • Hospitalization as needed within the local community. A designated administrative health authority shall have overall responsibility for health care services pursuant to a written agreement, contract, or job description. The administrative health authority is a physician, health services administrator, or health agency. When the administrative health authority is other than a physician, final clinical judgment shall rest with the facility’s designated clinical medical authority. In no event should clinical decisions be made by non-clinicians. Page 94 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 3. 4. 5. Rating Remarks (1000 Char Max) Does Not Meet Standard This component was rated Does Not Meet Standard because on the last day of the inspection, 05/20/2021, the staff RN provided this inspector a signed document reflecting the annual staffing plan was reviewed by the sheriff , who is the assigned administrative health authority, on 05/20/2021. Prior to this documentation there was no evidence of annual staffing plan reviews being conducted by the administrative health authority. Medical personnel are not on site at all times. Per review of the stafffing plan and information provided by medical personnel, it was determined the facility does not provide sufficient staff and support personnel to meet the requirements of the standard. Meets Standard Review of health care staff licensing, certifications and credentials found the credentials and certifications for the certified clinical medical assistant (CCMA) were not available; rather she was certified as a nurses aid and that certification had expired as of 12/5/2014. The staff RN was able to verify proper current certification and credentials through an online source to correct the problem during this inspection period. Meets Standard Informal agreements are in place with community hospitals and numerous multidisciplinary physicians to provide health care services not available within the facility. Detention personnel have been identified to transport and remain with detainees for the duration of any off-site treatment including hospitalization if necessary. PRIORITY: All facilities shall provide a medical staff and sufficient support personnel to meet these Standards. A staffing plan, which is reviewed at least annually by the administrative health authority, identifies the positions needed to perform the required services. PRIORITY: All health care staff must be verifiably licensed, certified, credentialed, and/or registered in compliance with applicable state and federal requirements. Health care personnel only perform duties for which they are credentialed by training, licensure, certification, job descriptions, and/or written standing or direct orders by personnel authorized by law to give such orders. The facility administrator, in collaboration with the clinical medical authority and administrative health authority, negotiates and maintains arrangements with nearby medical facilities or health care providers to provide required health care not available within the facility, as well as identifying custodial officers to transport and remain with detainees for the duration of any off-site treatment or hospital admission. Page 95 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 6. Rating Remarks (1000 Char Max) Meets Standard Established written plans address the management of infectious and communicable diseases. The written plans include all of the bulleted procedural requirements listed in this component. The staff RN is responsible for reporting to state, local and federal agencies and to ICE. During the inspection there were eighteen detainees in quarantine for COVID-19. The quarantine was scheduled to end on 05/20/2021. Meets Standard Review of health records, intake screening forms and medical staff interviews confirmed all detainees receive symptomatic screening for TB during the intake process. Detainees arriving without recent evidence of testing receive a TB skin test or a chest x-ray, when indicated. Per the staff RNs, if this would occur on the weekend, the staff RNs would be contacted to arrange/provide the required testing. PRIORITY: Each facility shall have written plans that address the management of infectious and communicable diseases, including prevention, education, identification, surveillance, immunization (when applicable), treatment, follow-up, isolation (when indicated), and reporting to local, state, and federal agencies. Plans shall include: • 7. Coordination with public health authorities; • Ongoing education for staff and detainees; • Control, treatment and prevention strategies; • Protection of individual confidentiality; • Media relations; • Procedures for the identification, surveillance, immunization, follow-up and isolation of patients; • Manage infectious diseases and report them to local and/or state health departments in accordance with established guidelines and applicable laws; and • Management of bio-hazardous waste and decontamination of medical and dental equipment that complies with applicable laws and Detention Standard on Environmental Health and Safety. PRIORITY: All new arrivals shall receive TB screening within 12 hours of intake and using methods in accordance with CDC guidelines for non-minimal risk detention facilities. Page 96 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 8. 9. Detainees with symptoms suggestive of TB shall be placed in a functional airborne infection isolation room with negative pressure ventilation and promptly evaluated for TB disease. Suspected and confirmed active TB patients shall be placed in a functional airborne infection isolation room with negative pressure ventilation (on- or off-site) until determined by a qualified provider to be noninfectious in accordance with CDC guidelines for nonminimal risk detention facilities. Rating Meets Standard Detainees with symptoms of active TB infection would be placed in one of two negative pressure respiratory isolation cells in the intake area. They would remain in isolation until proper medical evaluation/testing could be accomplished by a qualified medical care provider. No suspected TB cases were identified duing this inspection period. Meets Standard There were no confirmed/suspected active TB cases during this inspection period. If an active case was identified, per policy and confirmed by the RN and the ICE deportation officer/detention standards compliance officer, the bulleted reporting requirements listed in this component would be completed. Meets Standard Per written policy and procedures, and interviews with the staff RN and ICE deportation officer/detention standards compliance officer, all nationally notifiable infectious diseases would be reported to the IHSC Public Health, Safety and Preparedness Unit via the ICE chain of command. Meets Standard The facility has a written plan to ensure the highest degree of confidentiality regarding HIV status and medical condition. The plan includes that medical and detention staff are trained in HIPPA which emphasizes the need for confidentiality related to a detainee's medical diagnosis and/or conditions. For all confirmed and suspected active tuberculosis cases, designated medical staff shall report: • All cases to local and/or state health departments within one working day of meeting reporting criteria and in accordance with established guidelines and applicable laws. • All cases to the ICE HQ Epidemiology Unit within one working day. • Any movement of TB patients, including hospitalizations, facility transfers, releases, or removals/deportations to the local and/or state health department and the ICE HQ Epidemiology Unit. 10. PRIORITY: Designated medical staff shall report to the ICE Epidemiology Unit all cases of nationally notifiable infectious diseases as per the CDC guidelines, including, but not limited to: TB, varicella (herpes zoster [shingles], chicken pox), and recent exposures of varicella among non-immune contacts. Remarks (1000 Char Max) 11. Facilities must develop a plan to ensure the highest degree of confidentiality regarding HIV status and medical condition. Page 97 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 12. When current symptoms are suggestive of HIV infection, clinical evaluation shall determine the medical need for isolation. 13. Each facility shall establish a plan to address exposure to blood-borne pathogens, including reporting. 14. The facility shall provide each detainee, upon admittance, a copy of the detainee handbook and local supplement, in which procedures for access to health care services are explained; access to health care services, sick call and a medical grievance process shall be included in the orientation curriculum for newly admitted detainees. 15. PRIORITY: Medical, dental, and mental health interviews, examinations, and procedures shall be conducted in settings that respect detainee’s privacy. Rating Meets Standard Per policy and the staff RN, detainees who are diagnosed with HIV are only placed in medical isolation based on clinical evaluation that would indicate a need for isolation. Meets Standard Per review of the current bloodborne pathogen plan, it was confirmed that the plan met the standard requirements, including reporting procedures. Meets Standard The facility provides each detainee a copy of the detainee handbook and local supplement during the intake process. The handbook contains the procedures to access health care services, sick call and the medical grievance process. Meets Standard Per nursing staff, it was confirmed all medical, dental and mental health interviews, examinations and procedures are conducted in settings that respect detainee privacy. Meets Standard The waiting area is in the hallway outside of the examination/interview room. It consists of a bench with seating for two detainees. Detainees are under direct supervision of a correctional officer while in the waiting area. Detainees have access to a toilet and to drinking water. Meets Standard Medical records are kept separate from detainee detention records and are stored in a file cabinet within the medical unit. 16. A holding/waiting area shall be located at the entrance to the medical facility that is under the direct supervision of custodial officers. A detainee toilet and drinking fountain shall be accessible from the holding/waiting area. 17. Medical records shall be kept separate from detainee detention records and stored in a securely locked area within the medical unit. Remarks (1000 Char Max) Page 98 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) N/A The medical department does not include an infirmary, shortstay or medical observation unit. Does Not Meet Standard The component was rated Does Not Meet Standard because practice, as observed during the inspection, was inconsistent with policy, in that, there was no emergency stocked medication inventory, disposal of medications were not being witnessed by two persons, narcotic controlled substances were not being counted and verified by two persons, sharps inventories were not accurate, on two different occasions during the inspection keys to the medication cart were found unattended/unsecured on the desk and counters in the medical area, and the medication cart and sharps storage area were not secured when unattended by medical personnel. Written pharmacy policy and procedures address the management of pharmaceuticals and included the requirements of the component. 18. If there is a specific area, separate from other housing areas, where detainees are admitted for health observation and care under the supervision and direction of health care personnel, the following minimum standards shall be met: • Clearly defined scope of care services available; • Physician on call or available 24 hours per day; • Health care personnel are on duty 24 hours per day when patients are present; • All patients within sight or sound of a staff member; • Housing record that is a separate and distinct section of the complete medical record; and • Compliance with all established guidelines and applicable laws. Facilities are expected to provide detainees in medical housing access to other services such as telephone, legal access and materials consistent with their medical condition. 19. PRIORITY: Each facility shall have written policy and procedures for the management of pharmaceuticals that include procurement, inventory, prescription, dispensing, and secure storage and disposal of all prescription and nonprescription medicines. Page 99 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 20. The facility administrator and administrative health authority shall jointly approve any non-prescription medications that are available to detainees outside of health services and they shall jointly review the list annually. Rating Remarks (1000 Char Max) Meets Standard The administrative health authority and clinical medical authority have developed and approved a list of nonprescription medications available through commissary for purchase by detainees. The last review was dated 03/12/2021. Does Not Meet Standard This component was rated Does Not Meet Standard because, while the initial medical, dental and mental health screenings were being conducted well within the twelve hour requirement, there was no documentation confirming the detention officers performing the intake screening had been appropriately trained to perform this function as required by the standard. 21. PRIORITY: Initial medical, dental, and mental health screening shall be done within 12 hours of arrival by a health care provider or a detention officer specially trained to perform this function. The screening shall inquire into the following: • Any past history of serious infectious or communicable illness, and any treatment or symptoms; • Current illness and health problems, including communicable diseases; • Pain assessment; • Current and past medication; • Allergies; • Past surgical procedures; • Symptoms of active TB or previous TB treatment; • Dental problems; • Use of alcohol and other drugs; • Possibility of pregnancy; • Other health programs designated by the responsible clinical medical authority; • Observation of behavior, including state of consciousness, mental status, appearance, conduct, tremor, sweating; • Observation and interview items related to the detainee’s potential suicide risk and possible mental disabilities, including mental illness; • History of suicide attempts or suicidal/homicidal ideation or intent; • Observation of body deformities and other physical abnormalities; • Questions and an assessment regarding past or recent sexual victimization. current Page 100 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 22. If screening is performed by a detention officer, the facility shall maintain documentation of the officer’s special training, and the officer shall have available for reference the training syllabus, to include education on patient confidentiality of disclosed information. Rating Remarks (1000 Char Max) Does Not Meet Standard This component was rated Does Not Meet Standard because there was no documentation of detention officer special training to perform the intake screenings. Meets Standard Detention staff perform the initial screening. If there is an indication of need, or request for mental health services, the CMA would be notified within twentyfour hours and would ensure a full mental health evaluation would be done, by a qualified mental health clinician if indicated. Mental health personnel are onsite twice monthly and are available on call at all times. Mental health clinicians can interview and evaluate detainees through telemedicine when they are not on-site. Meets Standard Policy requires the initial health screening and assessment are documented. A random review of detainee medical records confirmed this practice. 23. PRIORITY: If at any time during the screening process there is an indication of need, or request for, mental health services, the health authority must be notified within 24 hours. The clinical medical authority will ensure a full mental health evaluation if indicated. 24. All facilities shall have policies and procedures to ensure the initial health screening and assessment is documented. Page 101 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Meets Standard Per an interview with the staff RN and detention staff, and review of detainee health care records, it was confirmed detention staff complete the initial in-processing health screen. Upon completion, the inprocessing health screening form is forwarded to the staff RN for appropriate action. Within 24hours of completion, the staff RN on duty contacts the CMA to review the health screening forms and determine the priority for treatment. This review requires the staff RN to be contacted on weekends when not on duty to contact the physician and/or the mental health provider to review the intake screenings and arrange for any needed treatment and or medications. Meets Standard The facility has access to Lyon Bridge translation services, which provides non-english speaking detainees telephonic translation services. The facility has a verified working talk to text (TTY) machine to provide services to detainees who are deaf and/or hard of hearing. Meets Standard The clinical medical authority (CMA) has developed and implemented guidelines for the evaluation and treatment of new arrivals who require detoxification. 25. PRIORITY: Upon completion, the in-processing health screening form shall be forwarded to the facility medical staff for appropriate action. The clinical medical authority shall be responsible for review of all health screening forms within 24 hours or next business day to assess the priority for treatment (for example, Urgent, Today, or Routine). 26. PRIORITY: Non-English speaking detainees and detainees who are deaf or hard of hearing will be provided interpretation or translation services or other assistance as needed for medical care activities. Language assistance may be provided by another staff member competent in the language or by a professional service, such as a telephone translation service. 27. The clinical medical authority shall establish guidelines for evaluation and treatment of new arrivals who require detoxification. Page 102 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 28. PRIORITY: Each facility’s health care provider shall conduct a health appraisal including a physical examination on each detainee within 14 days of the detainee’s arrival unless more immediate attention is required due to an acute or identifiable chronic condition, in accordance with the most recent ACA Adult Local Detention Facility standards for Health Appraisals. If there is documentation of one within the previous 90 days, the facility health care provider upon review may determine that a new appraisal is not required. 29. Detainees will be provided same sex chaperones as appropriate or as requested. Rating Meets Standard Per policy and the staff RN, a detainee receives a comprehensive physical examination/assessment, conducted by an RN within fourteen days of admission. Review of completed physical examinations verified practices consistent with this component and meets the standards and facility policy. Meets Standard Policy requires provision of chaperones of the same gender as the detainee as appropriate or as requested. Practice was confirmed by the staff RN. Does Not Meet Standard This component is rated Does Not Meet Standard because there was no documentation detention personnel have been trained to perform an intake medical/mental health screening. Per medical record review and staff interviews, it was confirmed that detainees receive a mental health intake screening, conducted by detention staff, as part of the intake health screening process. Policy requires referral to and follow-up by mental health personnel when a mental health concern is identified. The mental health screening includes the items listed in this component. Detainees are transferred to a community hospital or a mental health facility when care exceeds the capability of the facility. 30. PRIORITY: The facility performs mental health intake screening, as well as mental health evaluations based on screening results, medical documentation, or subsequent observations, that include prior history of mental health treatment, medications, drug use, suicidal tendencies, and abuse, observations of current physical and intellectual condition, and recommendations for any appropriate medical or custodial treatment. Detainees are appropriately referred to a mental health provider for diagnosis, treatment, and/or intervention, and transferred to licensed mental health facilities where detainee mental health needs exceed the capabilities of the facility. Remarks (1000 Char Max) Page 103 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Meets Standard When a detainee is referred for mental health treatment, he/she would receive a comprehensive evaluation by a licensed mental health professional within fourteen days and a treatment plan would be developed. If the detainee's mental health illness or developmental disability needs exceed the capability of the facility, the plan may include transfer to a mental health facility that can meet the detainees needs. Review of selected medical records confirmed a comprehensive mental health evaluation was conducted within fourteen days of the referral. Meets Standard Policy and medical staff interviews confirmed, under the authority of the CMA, any staff member can place any detainee who is exhibiting violent behavior in medical isolation. Daily reassessment by medical personnel is required which may include the staff RNs reporting to the facility when they are off duty on the weekends. Meets Standard Written policies and procedures for restraints for medical or mental health purposes included each of the bulleted items listed in this component. 31. PRIORITY: Any detainee referred for mental health treatment shall receive a comprehensive evaluation by a licensed mental health provider as clinically necessary, but no later than 14 days of the referral. The provider shall develop an overall treatment/management plan that may include transfer to a mental health facility if the detainee’s mental illness or developmental disability needs exceed the treatment capability of the facility. 32. The clinical medical authority may place in medical isolation a detainee who is at high risk for violent behavior because of a mental health condition. The clinical medical authority must provide for reassessment on a daily basis the need for continued medical isolation for the health and safety of the detainee. 33. PRIORITY: The facility shall have written procedures for restraints for medical or mental health purposes that specify: • The conditions under which restraints may be applied; • The types of restraints to be used; • The proper use, application, and monitoring of restraints; • Requirements for documentation, including efforts to use less restrictive alternatives; and • After-incident review. Page 104 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Meets Standard Written guidelines addressed all of the bulleted requirements listed in this component. Per the staff RN, involuntary administration of psychotropic medications would not be performed in the facility. If involuntary administration of psychotropic medications were necessary, the detainee would be referred to ICE and transferred to a qualified community health care center for observation and treatment as needed. Meets Standard Per the staff RN and per written policy, detainees in ICE custody for over a year would receive age and gender appropriate physical examinations including rescreening for tuberculosis. Meets Standard Review of health records confirmed dental screening exams are performed by the staff RN and/or the CMA as part of the fourteen-day comprehensive physical assessment. If necessary detainees are referred to an offsite dental clinic for evaluation and treatment by a qualified dental clinician. 34. PRIORITY: Involuntary administration of psychotropic medications to detainees shall comply with established guidelines and applicable laws and only pursuant to the specific, written and detailed authorization of a physician. When psychotropic medication is involuntarily administered, it is required that the administrative health authority contact ERO Management, who shall contact respective DHS/ICE Chief Counsel. The authorizing physician shall: • Review the medical record of the detainee and conduct a medical examination; • Specify the reasons for and duration of therapy and whether the detainee has been asked if he or she would consent to such medication; • Specify the medication to be administered, the dosage, and the possible side effects of the medication; • Document that less restrictive intervention options have been exercised without success; • Detail how the medication is to be administered; • Monitor the detainee for adverse reactions and side effects; and • Prepare treatment plans for alternatives as soon as possible. less restrictive 35. A detainee that is in ICE custody for over a year shall receive health examinations on an annual basis. Detainees shall have access to age and gender appropriate exams annually, including rescreening for tuberculosis. 36. An initial dental screening exam shall be performed within 14 days of the detainee’s arrival. • Emergency dental treatment shall be provided for immediate relief of pain, trauma and acute oral infection. • Routine dental treatment may be provided to detainees in ICE custody for whom dental treatment is inaccessible for prolonged periods because of detention for over six (6) months. Page 105 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Does Not Meet Standard This component was rated Does Not Meet Standard because medical personnel are only on site Monday through Friday and, as a result, cannot ensure that all sick call requests are received and triaged within 48-hours after a detainee submits a request. Written sick call procedure allows detainees the unrestricted opportunity to freely request health care, mental health and dental services which are provided by qualified personnel. The procedure addresses the bulleted points listed in this component with the exception of the last bulleted requirement. All detainees, regardless of classification, have access to sick call. Detainees have the option to request medical services either electronically via the housing unit kiosk system or by submitting a paper request. Paper requests are to be collected and triaged by medical personnel each morning, Monday through Friday. Meets Standard Paper sick call requests were printed in English and Spanish and, per observation, were readily available. Non-English speaking detainees would be provided assistance in completing a request slip through use of a telephone translation service. Deaf or hard of hearing detainees would be provided assistance through use of an on site TTY device. 37. PRIORITY: Each facility shall have a sick call procedure that allows detainees the unrestricted opportunity to freely request health care services (including mental health and dental services) provided by a physician or other qualified medical staff in a clinical setting. This procedure shall include: • Clearly written policies and procedures; • Sick call process will be communicated in writing and verbally to detainees during their orientation; • Regularly scheduled “sick call” times will be established and communicated to detainees; • All facilities must have an established procedure in place to ensure that all sick call requests are received and triaged by appropriate medical personnel within 48 hours after the detainee submits the request. In an urgent situation, the housing unit officer shall notify medical personnel immediately. All detainees, including those in Special Management Units, regardless of classification, shall have access to sick call. 38. If the procedure uses a written request slip, they shall be provided in English and the most common languages spoken by the detainee population of that facility. NonEnglish speaking detainees and detainees who are deaf or hard of hearing will be provided interpretation/translation services as needed or other assistance as needed to complete a request slip. Page 106 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) 39. PRIORITY: Each facility shall have a written emergency services plan for the delivery of 24-hour emergency health care. A plan shall be prepared in consultation with the facility's clinical medical authority or the administrative health authority. The plan will include the following: • An on-call physician, dentist, and mental health professional, or designee, that are available 24 hours per day; • A list of telephone numbers for local ambulances and hospital services available to all staff; • An automatic external defibrillator (AED) will be maintained for use at each facility and accessible to staff; • All detention staff shall receive cardio pulmonary resuscitation (CPR, AED) , and emergency first aid training annually; • Security procedures that ensure the immediate transfer of detainees for emergency medical care. Does Not Meet Standard This component was rated Does Not Meet Standard because there was no documentation verifying that detention staff have received annual training in CPR, AED and emergency first aid. All other bulleted items in this component were met per the standard requirments. Meets Standard Per the staff RN, medical staff collect and triage sick call requests each morning, Monday through Friday, and determine when the detainee should be seen. Each sick call request is placed in the detainees medical file as a permanent record. The facility does not meet the requirements of the standard which requires collection and triage of requests within 48hours of submission by the detainee, and medical personnel are only on site Monday through Friday. 40. Medical personnel shall review the request slips and determine when the detainee will be seen. All facilities shall maintain a permanent record of all sick call requests. Page 107 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Does Not Meet Standard This component was rated Does Not Meet Standard because there was no documentation provided to verify that training for detention and health care personnel was occurring at least annually by a responsible medical authority in cooperation with the facility administrator. 41. PRIORITY: Training is provided to all detention and health care personnel at least annually by a responsible medical authority in cooperation with the facility administrator, and includes: • Responding to health-related situations within four (4) minutes; • Recognizing of signs of potential health emergencies and the required responses; • Administering first resuscitation (CPR); • Obtaining emergency medical assistance through the facility plan and its required procedures; • Recognizing signs and symptoms of mental illness, suicide risk, retardation, and chemical dependency; • The facility’s established plan and procedures for providing emergency medical care including, when required, the safe and secure transfer of detainees for appropriate hospital or other medical services, including by ambulance when indicated. aid and cardiopulmonary 42. The designated health authority and facility administrator shall determine the contents, number, location(s), use protocols, and procedures for monthly inspections of first aid kits. N/A Per the staff RN, there were no first aid kits in the facility. Does Not Meet Standard This component was rated Does Not Meet Standard because, in the absence of on site medical personnel, detention personnel distribute/administer medication, and no documentation was provided verifying detention personnel have been appropriately trained to distribute/administer medication. The facility uses an electronic medication administration record (E-MAR) by Sapphire, and personnel document each dose of medication administered or refused at the time of administration. Per reviewed policy, detainees are not permitted to deliver or administer medications. 43. Distribution of medication shall be in accordance with specific instructions and procedures established by the administrative health authority. Written records of all medication given to detainees shall be maintained. Detainees may not deliver or administer medications to other detainees. Page 108 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Does Not Meet Standard This component was rated Does Not Meet Standard because, in the absence of on site medical personnel, detention staff distribute/administer medication, and there was no documentation verifying detention personnel had been appropriately trained to distribute/administer medication. Additionally, detention personnel did not have available for reference the training syllabus or other guide or protocol provided by the health authority. Meets Standard Per the staff RN and review of sample informational/educational brochures, it was determined qualified medical staff provided detainee health education and wellness information as needed. Meets Standard Per staff interviews, it was confirmed appropriate facility personnel and ICE were notified by telephone and email of any detainee identified as having special needs. Meets Standard Per the staff RN and ICE deportation/detention standards compliance officer, if a detainee requires close medical supervision, including chronic and convalescent care, he/she would be transferred to an appropriate detention center that could meet the detainee's needs. 44. If medication must be delivered at a specific time when medical staff is not on duty, it may only be distributed by detention officers who have received proper training by the administrative health authority. The facility shall maintain documentation of the training given any officer required to distribute medication, and the officer shall have available for reference the training syllabus or other guide or protocol provided by the health authority. 45. The health authority shall provide detainees health education and wellness information. 46. The health administrative authority for each facility must have a plan to notify ICE for any detainee with special needs. The written notification must become part of the detainee’s health record file. 47. PRIORITY: When a detainee requires close medical supervision, including chronic and convalescent care, a written treatment plan that includes access to health care and other personnel regarding care and supervision, shall be developed and approved by the appropriate physician, dentist, or mental health practitioner, in consultation with the patient, with periodic review. The written treatment plan will conform to NCCHC and TJC requirements. Page 109 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components 48. PRIORITY: Female detainees shall have access to pregnancy testing and pregnancy management services that include routine prenatal care, addiction management, comprehensive counseling and assistance, nutrition, and postpartum follow-up. 49. Detainees shall have access to age- and genderappropriate examinations. Rating Remarks (1000 Char Max) Meets Standard Per the staff RN, female detainees have access to each of the services detailed in this component. At the time of the inspection, two female detainees were being housed in the facility. During the inspection period, there were no pregnant detainees housed in the facility. Meets Standard Per the staff RN and written policy, detainees have access to age and gender appropriate examinations. Meets Standard Per review of policy, there was a plan to ensure continuity of medical care in the event of a change in detention placement or status. A transfer summary form listing any acute or chronic medical, dental or mental health conditions, allergies and current medications was completed and provided for each detainee at the time of removal. If indicated, at least a seven-day supply, or in the case of TB and HIV medication, a thirty-day supply of medication was provided. Meets Standard Per review of detainee health care records, it was confirmed a general informed consent to treatment was obtained during the intake process. Procedure specific consent is obtained as needed. The medical risks associated with refusing recommended treatment are explained to a detainee and thoroughly documented in the detainee's medical file. 50. The facility administrative health authority must ensure that a plan is developed that provides for continuity of medical care in the event of a change in detention placement or status. Upon transfer to another facility or release, the medical provider shall ensure that all relevant medical records and at least 7 days (or, in the case of TB medications, 15 days) supply of medication shall accompany the detainee. 51. PRIORITY: Documented informed consent, consistent with standards of the jurisdiction, is obtained from a detainee before medical treatment is administered. If a detainee refuses consent to treatment, medical staff explain the medical risks if treatment is declined and document their efforts in the detainee’s medical record. Page 110 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Meets Standard Per medical staff interviews and an interview with the ICE compliance officer, ICE personnel would be notified if a detainee was refusing necessary treatment or evaluation. Included in the discussion would be an appropriate plan of action. Involuntary treatment, if indicated, would meet ICE protocols and would be performed at an appropriate medical facility. Meets Standard A complete medical record is maintained on each detainee, and it is kept separate from detention records. The facility utilizes a paper medical record to document health care services and information. Access to medical records is restricted to medical personnel and practitioners for the provision and documentation of health care and mental health care treatments and services. The health care records are stored in a file cabinet located in the medical department. Copies of health records are not placed in detention files. Does Not Meet Standard This component was rated Does Not Meet Standard because documentation verifying staff training in the requirements of this component could not be provided. Per review, policy required all staff to be trained to protect the privacy of a detainee's medical information in accordance with established guidelines and applicable laws. 52. If a detainee refuses treatment and the clinical medical authority determines that the treatment is necessary, ICE/ERO shall be consulted in determining whether involuntary treatment shall be pursued. Involuntary treatment is a decision made only by medical staff under strict legal restrictions. Prior to any contemplated action involving involuntary medical treatment, DHS/ICE respective Chief Counsel will be consulted. 53. PRIORITY: The administrative health authority shall maintain a complete health record on each detainee that is: • Organized uniformly in accordance with recognized medical records standards; • Available to all practitioners and used by them for health care documentation; • Properly maintained and safeguarded in a securely locked area within the medical unit separately from other detention records. 54. All medical providers shall protect the privacy of detainees’ medical information in accordance with established guidelines and applicable laws. These protections apply, not only to records maintained on paper, but also to electronic records where they are used. Staff training must emphasize the need for confidentiality and procedures must be in place to limit access to health records to only authorized individuals and only when necessary. Page 111 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Meets Standard The administrative health authorty is the sheriff. The sheriff provides designated staff information that is necessay and in accordance with the bulleted items in this component. Meets Standard Per reviewed policy, upon receipt of a written authorization that complies with HIPAA from a detainee, copies of health records can be released by medical personnel directly to the detainee/designee at no cost. The written authorization for the release of health records/information would be maintained in the detainee's medical file as a permanent record. Meets Standard Per the staff RN and policy review, it was confirmed a detainee wishing to obtain a copy of his/her medical record would be provided the appropriate request form. Detainees are provided assistance as needed to complete and transmit the written request. Meets Standard Per the staff RN and ICE officer, when it has been determined that a detainee's medical or psychiatric condition meets the requirements of the two bulleted points listed in this component, the OIC and ICE officer would be notified in writing electronically and transmitted through the chain of command. 55. The administrative health authority shall provide the facility administrator and designated staff information that is necessary: • To preserve the health and safety of the detainee, other detainees, staff, or any other person. • For administrative and detention decisions such as housing, voluntary work assignments, security, and transport. • For management purposes such as audits and inspections. 56. Copies of health records shall be released by the administrative health authority directly to a detainee or their designee, at no cost to the detainee, upon receipt by the administrative health authority of a written authorization from the detainee that complies with the Health Insurance Portability and Accountability Act (HIPAA). 57. Detainees who indicate they wish to obtain copies of their medical records shall be provided with the appropriate request form. ICE/ERO, or the facility administrator, shall provide non-English speaking detainees and detainees who are deaf or hard of hearing with interpretation or translation services or other assistance as needed to make the written request and assist in transmitting the request to the facility administrative health authority. 58. PRIORITY: Medical staff shall notify the facility administrator in writing, when they determine that a detainee’s medical or psychiatric condition requires: • Clearance by the medical staff prior to release or transfer, or • Medical escort during removal, deportation, or transfer. Page 112 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Meets Standard Per interviews with staff RN and ICE officer, review of written policy and procedure, and review of detainee health care records, it was confirmed, generally, twelve hours advance notice is provided by ICE prior to the release, transfer or removal of a detainee. A transfer summary is completed for each detainee which includes each of the bulleted items listed in this component. Completed transfer summaries are provided for each detainee and packaged in an envelope marked "confidential medical records". Meets Standard With the exception of approved clinical trials that may be warranted for a specific detainee's diagnosis or treatment when recommended and approved by the treating physician and ICE and following documented detainee informed consent, detainees do not participate in medical, pharmaceutical or cosmetic research. 59. PRIORITY: The administrative health authority shall be given advance notice prior to the release, transfer, or removal of a detainee, so that medical staff may determine and provide for any medical needs associated with the transfer or release. A summary of the detainee’s medical care (transfer summary) shall be marked “CONFIDENTIAL MEDICAL RECORDS” and shall accompany the detainee who is being transferred. A transfer summary must include: • TB clearance, including PPD and Chest x-ray results, with the test dates; • Current mental and physical health status, including all significant health issues; • Current medications, with specific instructions for medications that must be administered en route; and • The name and contract information of the transferring medical facility. 60. Detainees will not participate in medical, pharmaceutical or cosmetic research while under the care of ICE detention facilities. This does not preclude the use of approved clinical trials that may be warranted for a specific inmate’s diagnosis or treatment when recommended and approved by the clinical medical director. Such measures require documented informed consent. Page 113 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE (Key: V) This Detention Standard ensures that detainees have access to a continuum of health care services, including prevention and health education, so that their health care needs are met in a timely and efficient manner. Components Rating Remarks (1000 Char Max) Meets Standard The staff RN has implemented a system of internal review and quality assurance, titled Continuous Quality Improvement (CQI), that includes data anaylsis, a multidisciplinary committee with regular monitoring of heath service outcomes and assessment of ongoing education and training needs. The committee meets quarterly and written documentation of topics discussed are maintained by the staff RN. Quarterly documentation was readily available for review. The last meeting was held 4/14/2021. Does Not Meet Standard This component was rated Does Not Meet Standard because there was no documented implementation of an intraorganizational external peer review program for all independently licensed medical professionals. 61. PRIORITY: The administrative health authority shall implement a system of internal review and quality assurance that includes data analysis, a multidisciplinary committee with regular monitoring of health service outcomes, and assessment of ongoing education and training needs. 62. The administrative health authority shall implement an intra-organizational, external peer review program for all independently licensed medical professionals. Reviews are conducted at least every two years. PART 4 – 22. MEDICAL CARE – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) When TB treatment is indicated, multi-drug, anti-TB therapy is administered using directly observed therapy (DOT). Active TB disease is ruled out before treatment for latent TB infection is initiated. International referrals are coordinated with the IHSC Public Health, Safety and Preparedness Unit and local/state health departments. There is a written plan to address the management of hepatitis A, B and C and HIV infection. Detainees may request hepatitis and HIV testing at any time. Medical personnel provide all detainees diagnosed with HIV/AIDS medical care consistent with national recommendations and guidelines. Medical and pharmacy personnel ensure that all FDA medications currently approved for the treatment of HIV/AIDS are accessible per the ICE formulary. Detainees with active tuberculosis are evaluated for possible HIV infection. a new HIV positive diagnosis would be reported to government bodies according to state and local laws and requirements; the HSA is responsible for ensuring that all applicable state requirements are met. Pharmaceutical management policy includes: a formulary, obtaining non-formulary medications, prescription practices, perpetual inventory, medication administration error reports, training and storage in a secure area (secure perimeter, limited access, solid walls from floor to true ceiling and a solid ceiling, solid door with high security lock, secure medication storage area). Mental health evaluations and screenings include: reason for referral, mental health history, drug/alcohol use history, suicide attempts, current suicidal/homicidal ideation; medications; intellectual functioning; history of abuse, pertinent physical Page 114 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 22. MEDICAL CARE – Reviewer Summary condition and treatment recommendations. (Use following format for dates: mm/dd/yyyy) The emergency medical services plan includes provisions for expedited entrance to and exit from the facility. Non-medical personnel contact medical personnel when questioning the need for emergency care. Detainees who arrive with prescribed medications or who report being on such medications are evaluated by a qualified health care professional as soon as possible but not later than 24 hours after arrival, and provisions are made to secure medically necessary medications. Detainees are not charged for any medical services to include pharmaceuticals dispensed by medical personnel. Separate informed consent is obtained for use of psychotropic medications. Detainee treatment questions are answered by medical personnel. Detainees sign a refusal for treatment when appropriate. Refusals are reviewed to determine reasons for refusal. Detainees request an independent health examination by submitting a written request to the FOD. The cost of the exam is at the detainee’s expense. The facility does provide for the use of mental health tele-medicine by the licensed mental health provider. Decisions regarding detainees with disabilities, LEP detainees, and/or detainees included under any SAAPI/DHS PREA protection or category would be made only after consideration of the disability, language difficulty or SAAPI/PREA condition. The facility provides timely access to medical, dental and mental health services through appropriately licensed medical personnel for routine care and chronic and emergency conditions. Medical personnel are on site fourteen hours a day, Monday through Friday. RNs perform the required fourteen-day physical assessments. Per review of ICE detainee medical records available at the time of the inspection, medical intake screenings and tuberculosis screening are consistently completed timely. The detainee medical record review indicated the fourteen-day physical examinations and assessments are consistently completed within the required timeframe and are reviewed and signed by the physician. Detainees requesting sick call appointments receive appropriate medical care; however, it cannot always be provided in a timely manner related to no medical coverage on-site during the weekend. The facility has two negative pressure respiratory isolation rooms. Written medical treatment consent is consistently obtained prior to treatment. Detainees with chronic illnesses are medically monitored and provided appropriate medical treatment. All needed health care not available on-site is provided through the use of community health care providers and services. ICE is notified if the medical condition of a detainee already housed in the facility deteriorates and requires a level of medical care beyond the capabilities of the facility. Evaluation of the standard was determined following a review of policy, medical records, training outlines and files, and interviews with the staff RNs Stan Roark and Jackie Rominger; ICE Deportation Officer/Detention Standards Compliance Officer, Tashi F. Tillman, and Lieutenant Taylor for training documentation. Overall Rating: Does Not Meet Standard Reviewer Name (Printed): Inspector 24 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 115 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 23. PERSONAL HYGIENE (Key: W) This Detention Standard ensures that each detainee is able to maintain acceptable personal hygiene practices through the provision of adequate bathing facilities and the issuance and exchange of clean clothing, bedding, linens, towels, and personal hygiene items. Components 1. 2. 3. 4. 5. 6. Each detention facility shall have a written policy and procedures for the regular issuance and exchange of clothing, bedding, linens, towels, and personal hygiene items. Rating Meets Standard Written policy establishes procedures for the issuance and exchange of clothing, bedding, linens, towels, and personal hygiene items. Meets Standard Policy review and interview with the sergeant in charge of property, confirmed that detainees are able to complete a property request form in order to exchange/replace any clothing that is worn out, indelibly stained, or bears offensive or otherwise unauthorized markings. Meets Standard During admission, detainees, at no cost, are issued clean, indoor/outdoor temperatureappropriate, size appropriate presentable clothing. Clothing that is worn out, indelibly stained, or bears offensive or otherwise unauthorized markings should be discarded and replaced as soon as practicable. All new detainees shall be issued clean, indoor/outdoor temperature-appropriate, size appropriate, presentable clothing during in-processing at no cost to the detainee. Each detainee assigned to a special work area shall be clothed in accordance with the requirements of the job and, when appropriate, provided protective clothing and equipment. N/A Staff shall provide male and female detainees personal hygiene items appropriate for their gender and shall replenish supplies as needed. The distribution of hygiene items shall not be used as reward or punishment. Razors must be strictly controlled. Disposable razors will be provided to detainees on a daily basis. Razors will be issued and collected daily by staff. Remarks (1000 Char Max) Detainees are not assigned to any work areas. Meets Standard Per interview with the sergeant, at no cost, detainees are initially provided personal hygiene items which are replenished twice weekly. The distribution of hygiene items is not used as reward or punishment. Female detainees are housed at this facility; there were two present at the time of the inspection. Personal hygiene items issued to male and female detainees are consistent with the standard requirements Meets Standard Inspector reviewed written logs containing issuance and collection of disposable razors and confirmed this component is being met per the standard requirements. Page 116 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 23. PERSONAL HYGIENE (Key: W) This Detention Standard ensures that each detainee is able to maintain acceptable personal hygiene practices through the provision of adequate bathing facilities and the issuance and exchange of clean clothing, bedding, linens, towels, and personal hygiene items. Components 7. Rating Female detainees shall be issued and may retain feminine hygiene items as needed. Meets Standard 8. 9. Detainees shall be provided an adequate number of toilets 24 hours per day that can be used without staff assistance when detainees are confined to their cells or sleeping areas. There were two female detainees housed in the facility at the time of the inspection. Female detainees are issued feminine hygiene items which they can retain as needed. Hygiene items are replenished twice a week. Does Not Meet Standard This component was rated Does Not Meet Standard at the last inspection due to there not being an adequate number of toilets in housing units C and E. Those units have four individuals to a cell with only one toilet. The standard states, "All housing units with three or more detainees must have at least two toilets". This is a repeat deficiency that was found to be deficient a third time, during this inspection. Meets Standard An adequate number of washbasins with temperature controlled hot and cold running water are available 24 hours per day. Inspector review of temperature control logs, that are maintained by the maintenance department and was able to confirm temperatures were being measured per the standard and ranged between 110-120 degress Farenheit.. Meets Standard A review of housing unit water temperature logs verified water temperatures between 110 degrees Fahrenheit and 120 degrees Fahrenheit. An adequate number of washbasins with temperature controlled hot and cold running water 24 hours per day. 10. Operable showers that are thermostatically controlled to temperatures between 100 and 120 degrees Fahrenheit, to ensure safety and promote hygienic practices. Remarks (1000 Char Max) Page 117 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 23. PERSONAL HYGIENE (Key: W) This Detention Standard ensures that each detainee is able to maintain acceptable personal hygiene practices through the provision of adequate bathing facilities and the issuance and exchange of clean clothing, bedding, linens, towels, and personal hygiene items. Components 11. Detainees with disabilities shall be provided the facilities and support needed for self-care and personal hygiene in a reasonably private environment in which the individual can maintain dignity. Rating Remarks (1000 Char Max) Meets Standard Per the ICE deportation officer and detention standards compliance manager, detainees with disabilities would not be housed in this facility; they would be transferred to another detention facility that was equipped to meet disability requirements. Meets Standard The initial issuance of clothing items meet the bulleted items listed in this component and fullfills the standard requirements. 12. PRIORITY: Detainees shall be provided with clean clothing, linen and towels on the following basis: • A daily change of socks and undergarments. An additional exchange of undergarments shall be made available to detainees if necessary for health or sanitation reasons. • At least twice weekly exchange of outer garments (with a maximum of 72 hours between changes). An additional exchange of outer garments shall be made available to detainees if necessary for health or sanitation reasons. • At least weekly exchange of sheets, towels, and pillowcases. More frequent exchanges of outer garments may be appropriate, especially in hot and humid climates. PART 4 – 23. PERSONAL HYGIENE – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The facility maintains an excess clothing inventory of at least two hundred percent of the maximum funded detainee capacity. Personal items of clothing are not permitted. Personal hygiene items from other sources are not permitted. Detainees are provided with a reasonable private environment in accordance with safety and security needs. Challenged detainees who cannot perform activities of daily living are not housed at this facility. Each detainee is able to maintain acceptable personal hygiene practices through the provision of adequate bathing facilities and the issuance and exchange of clean clothing, bedding, linens, towels and personal hygiene items. There is an inadequate number of toilets in housing units C and E. These units contain four-person cells with only one toilet, and the standard requires two toilets. This was a repeat deficiency in the last inspection and remains a deficiency during this inspection. Evaluation of the standard was determined following a review of provided policy, review of detainee handbook, inspector visit to the housing units and interviews with the ICE compliance officer, Tashi F. Tillman, and Staff RN, Stan Roark. Overall Rating: Meets Standard Page 118 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 23. PERSONAL HYGIENE – Reviewer Summary Reviewer Name (Printed): Inspector 24 (Use following format for dates: mm/dd/yyyy) I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 119 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X) This Detention Standard protects detainees’ health and well-being by training staff to prevent suicide by recognize potential signs and situations of risk and to intervene with appropriate sensitivity, supervision, referral, and treatment. Components 1. Rating Remarks (1000 Char Max) Meets Standard The suicide intervention and prevention policy is reviewed annually, approved and signed by the medical authority, the administrative health authority, the sheriff, who is also the OIC.The program addresses each of the bulleted items listed in this component. PRIORITY: The facility has a written suicide prevention and intervention program that is reviewed and approved by the clinical health authority, approved and signed by the administrative health authority and Facility Administrator and reviewed annually. At a minimum, the Program shall include procedures to address suicidal detainees. Key components of this program include: 2. 3. • Staff training, • Identification, • Referral, • Evaluation, • Treatment, • Housing, • Monitoring, • Communication, • Intervention, • Notification and reporting, • Review, and • Debriefing. Every new staff member receives suicide-prevention training. Suicide-prevention training occurs during the employee orientation and annual training. Does Not Meet Standard If a detainee is identified as being suicidal, the detainee is removed from general population, placed on suicide precautions, and is referred immediately to qualified medical staff. Meets Standard Page 120 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) This component is rated Does Not Meet Standard because there was no documetation of staff training related to suicide prevention and intervention. Per medical staff interviews, it was confirmed that a detainee identified as being suicidal would be placed on suicide precautions, housed in one of four observation cells in the booking area or in one padded observation room, located in the booking area. The detainee would immediately be referred to mental health personnel. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X) This Detention Standard protects detainees’ health and well-being by training staff to prevent suicide by recognize potential signs and situations of risk and to intervene with appropriate sensitivity, supervision, referral, and treatment. Components 4. 5. Rating Remarks (1000 Char Max) PRIORITY: All facility staff who interact with and/or are responsible for detainees are trained at least annually on the facility’s Suicide Prevention and Intervention Program, to include: • Identifying the warning signs and symptoms of impending suicidal behavior, • Demographic, cultural, and precipitating factors of suicidal behavior, • Responding to suicidal and depressed detainees, • Communication between correctional and health care personnel, • Referral procedures, • Housing observation procedures, and • Follow-up monitoring of detainees who have attempted suicide. and suicide-watch Does Not Meet Standard This component is rated Does Not Meet Standard because there was no documetation of annual staff training. level PRIORITY: Detainees who are identified as being “at risk” for suicide shall immediately be referred to the mental health provider or other appropriately trained medical staff member for evaluation. Appropriately trained and qualified medical staff shall evaluate the detainee within 24 hours of the referral, and re-evaluate any detainee placed on suicide watch on a daily basis. All evaluation is documented in the detainee’s medical record. Only the mental health professional, clinical medical authority, or designee may terminate a suicide watch after a current suicide risk assessment is completed. Meets Standard Page 121 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) A detainee identified as at risk would be immediately referred to mental health personnel for evaluation. Per policy, the detainee must be evaluated at the mental health provider's next regularly scheduled on-site visit with the results thoroughly documented in the detainee's medical record. Only the physician or mental health professional are authorized to release a detainee from suicide watch and only after the completion of a suicide risk assessment. Currently, the mental health professional is onsite every two weeks and is available for calls when not onsite or by telehealth. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X) This Detention Standard protects detainees’ health and well-being by training staff to prevent suicide by recognize potential signs and situations of risk and to intervene with appropriate sensitivity, supervision, referral, and treatment. Components 6. 7. Rating Remarks (1000 Char Max) Meets Standard A detainee determined to be at risk for suicide would be evaluated by a medical/mental health provider. The evaluation would include each of the bulleted items listed in this component and would be documented in the detainee's medical record. Mental health personnel included one part-time licensed mental health counselor (MHC) who is on-site every two weeks and available on call by telehealth when not on-site.. Meets Standard Per medical personnel, a detainee on suicide watch would be evaluated by the physician and/or the MHC when he is next on-site with documentation in the medical record. All other days the MHC would contact the facility by telephone for updates. Per policy, nursing personnel would evaluate a detainee daily. Only the mental health professional and physician have the authority to remove a detainee from suicide watch and only following the completion of a suicide risk assessment. Per policy, a detainee cannot return to general population until completion of the assessment. Review of selected medical records documentation verified practice. Evaluation by a mental health provider of detainees who are identified as being “at risk” for suicide will be documented in the medical record and include: • Relevant history, • Environmental factors, • Lethality of suicide plan, • Psychological factors, • A determination of level of suicide risk, • Level of supervision needed, • Referral/transfer for inpatient care (if needed), • Instructions to medical staff for care, and • Reassessment time frames. Detainees who are placed on suicide watch are to be reevaluated by appropriately trained and qualified medical staff on a daily basis and this re-evaluation is documented in the detainee’s medical record. Only the mental health professional, clinical medical authority, or designee may terminate a suicide watch after a current suicide risk assessment is completed. A detainee may not be returned to the general population until this assessment has been completed. Page 122 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X) This Detention Standard protects detainees’ health and well-being by training staff to prevent suicide by recognize potential signs and situations of risk and to intervene with appropriate sensitivity, supervision, referral, and treatment. Components 8. 9. Rating Remarks (1000 Char Max) Meets Standard Suicidal detainees are housed in one of five designated suicide watch cells located in the booking department or one of two respiratory negative pressure rooms. Detainees are under camera observation, as well as direct observation by security personnel outside the door for a level one suicide watch. Per provided policy and prior to placement, security personnel inspect the cell for safety concerns with the inspection documented. Meets Standard Per medical personnel, a detainee on a level one suicide watch would be clothed in a suicide-resistant smock and provided a suicide-resistant blanket and mattress. Items can be added or taken away as deemed appropriate by the mental health professional or physician. Meets Standard Level one suicide watch detainees are maintained on constant one-to-one detention officer observation. The assigned detention officer makes and documents behavioral observations at least every fifteen minutes. Meets Standard Per staff interviews, it was confirmed security staff would initiate and continue life-saving measures until relieved by medical personnel. They also have access to cut-down equipment that can be used if a detainee attempts suicide by hanging. PRIORITY: Suicidal detainees should be housed in a room that has been made as suicide resistant as possible. Security staff shall ensure that the area for suicide observation is initially inspected so that there are no objects that pose a threat to the detainee’s safety. When standard-issue clothing presents a security or medical risk, the detainee is to be provided an alternative garment that promotes detainee and staff safety, while preventing the humiliation and degradation of the detainee. The clinical medical authority or designee will determine appropriate clothing. 10. Suicidal detainees will be monitored by assigned security officers who maintain constant one-to-one visual observation, 24 hours a day, until the detainee is released from suicide watch. The assigned security officer makes a notation every 15 minutes on the behavioral observation checklist. 11. Following a suicide attempt, security staff shall initiate and continue appropriate life-saving measures until relieved by arriving medical personnel. Page 123 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION (Key: X) This Detention Standard protects detainees’ health and well-being by training staff to prevent suicide by recognize potential signs and situations of risk and to intervene with appropriate sensitivity, supervision, referral, and treatment. Components Rating Remarks (1000 Char Max) Meets Standard Per review of policy, a detainee medical file, and staff interviews, it was confirmed, that in the event of a suicide attempt or completed suicide, ICE and IHSC officials would be notified. ICE personnel would be responsible for notifying the family and outside authorities. Medical personnel are required to complete an incident report within 24 hours. Meets Standard A completed suicide or serious suicide attempt would be subject to a mortality review. A critical incident debriefing would be provided to affected personnel and detainees. 12. In the event of a suicide attempt or a completed suicide, all appropriate ICE and IHSC officials shall be notified through the chain of command. The victim’s family and appropriate outside authorities, as appropriate, shall also be immediately notified. Medical staff shall complete an Incident Report Form within 24 hours. 13. Every completed suicide and serious suicide attempt shall be subject to a mortality review process. A critical incident debriefing shall be provided to all affected staff and detainees. PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) There was one interupted suicide attempt during this inspection period involving a detainee who was housed in an observation area in booking. The detainee was observed tying a noose and hanging it over a door. Officers noticed the action and immediately entered the cell and interupted the attempt. The detainee was placed on level one suicide watch. Detainees receive an initial mental health screening by detention staff within twelve hours of admission. Results of the screening are documented on an approved intake screening form which includes observation and interview items related to potential suicide risk. The intake screening becomes a permanent part of the detainee's medical record. Detainees may be identified as being at risk for suicide at any time while in ICE custody. This identification may be through self-referral or through daily observation and/or interaction with medical, security or ICE personnel. An at-risk detainee referred for an evaluation would be placed in a secure environment on observation until the evaluation was completed. Based on the evaluation, mental health personnel would develop a treatment plan which would address the environmental, historical and psychological factors that contributed to the detainee's suicidal ideation. The plan would include strategies and interventions to be followed by employees and the detainee if suicidal ideation reoccurred and strategies for improved functioning and regular follow-up appointments based on level of acuity. The treatment plan would be documented in the detainee's medical record. All detainees discharged from suicide watch are re-assessed by an appropriately trained and qualified mental health provider or medical personnel at intervals consistent with the level of acuity. The facility uses three levels of suicide watch status as follows: level one requires one-to-one observation with fifteen-minute documentation and the detainee clothed in a suicide smock; level two requires staggered fifteen-minute documentation, and the detainee can be clothed in regular facility issued clothing; and, at level three, the detainee can be in general population with 24, 48 and 72 hours follow-up with additional evaluations at two weeks and thirty days. When medical personnel determine a detainee is at imminent risk of bodily injury or death, medical personnel would make a recommendation to place the detainee in an observation cell designated for the purposes of evaluation and/or treatment. If the detainee is mentally competent and refuses, ICE counsel would be consulted as to appropriate further action such as Page 124 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 24. SUICIDE PREVENTION AND INTERVENTION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) petitioning the appropriate federal court to intervene against the detainee's refusal for purposes of his potential hospitalization and treatment. In the event of a suicide attempt, medical personnel arriving on the scene perform the appropriate medical evaluation and intervention. The physician/medical director would be notified when referral to the emergency room of the local hospital was required. In the event of a detainee death, the DHS Office of Inspector General would be notified within 48 hours, and all personnel who came into contact with the victim prior to the incident would submit a statement including their knowledge of the detainee and the incident. Consistent communication is maintained between medical, mental health and correctional personnel through a variety of mechanisms including intake forms, daily briefings, shift change briefings, medical progress notes, special needs forms, medical/psychiatric alerts and transfer summaries. Suicide prevention policy and procedures protect the detainee's health and well-being. No training documentation was available to confirm the requirement of staff training. Since the last inspection, there were no serious suicide attempts or suicides. Evaluation of this standard was determined following a review of policy, training records, and curriculum; a detainee medical record, and interviews with Staff RNs Stan Roark and Jackie Rominger; Ice Deportation and Detention Standards Compliance Officer Tashi F. Tillman and Lieutenant Taylor. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 24 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 125 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y) This Detention Standard ensures that each facility’s continuum of health care services addresses terminal illness, fatal injury, and advance directives and provides specific guidance in the event of a detainee’s death. Standard N/A I Click the above button if the facility does not accept ICE detainees who are severely or terminally ill. ALWAYS complete all references to detainee death and related notifications. (All Line Items and standard will be rated “N/A”) Components 1. 2. 3. Detainees, who are chronically or terminally ill, are transferred to an appropriate off-site medical facility, if necessary. Immediately notify the facility administrator and/or ICE/ERO Field Office Director (FOD) of the detainee's condition by phone or in person and document the detainee's condition in a memorandum to the facility administrator that briefly describes the illness and prognosis. The FOD or designee shall immediately notify (or make reasonable efforts to notify) the detainee’s next-of-kin of the medical condition and status, the detainee's location, and the visiting hours and rules at that location, in a language or manner which they can understand. Remarks (1000 Char Max) Meets Standard Per the staff RN and ICE officer, the facility does not accept or continue to house detainees who are chronically or terminally ill. Such detainees would be transferred to an appropriate offsite medical facility as needed. Administration and ICE are notified of the detainee's status by telephone and in writing electronically which briefly describes the illness and prognosis. Meets Standard ICE is responsible for notifying the detainee's next-of-kin as to his/her medical condition, location, visiting hours and rules. Per ICE, the notification would be in a language or manner which the next-of-kin could understand. Meets Standard The facility uses the state of Indiana advance directive form. Per the RN, it is the expectation that personnel at an off-site medical facility would assist a detainee in completing an advance directive and/or living will. Meets Standard When the terms of an advance directive must be implemented, ICE would be contacted to coordinate and supervise the implementation. At the time of the inspection, no detainees had implemented an advance directive. When the detainee is at an off-site facility, that facility is expected to assist the detainee in completing an Advance Directive and/or Living Will. All facilities shall use the State Advance Directive form (in which the facility is located) for implementing Living Wills and Advance Directives. 4. Rating When the terms of the advanced directive must be implemented, the medical professional overseeing the detainee’s care will contact the ICE/ERO FOD or designee and the respective ICE Chief Counsel. Page 126 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y) This Detention Standard ensures that each facility’s continuum of health care services addresses terminal illness, fatal injury, and advance directives and provides specific guidance in the event of a detainee’s death. Standard N/A I Click the above button if the facility does not accept ICE detainees who are severely or terminally ill. ALWAYS complete all references to detainee death and related notifications. (All Line Items and standard will be rated “N/A”) Components Rating Remarks (1000 Char Max) Meets Standard DNR procedures are contained in policy and, per the staff RN, are consistent with state laws. At the time of the inspection, no detainee had requested a DNR order. Meets Standard Per the staff RN, If a detainee has a DNR order, health care would continue to be provided consistent with with the DNR order. The detainee would receive all therapeutic efforts short of resusitation. Meets Standard Per policy, a detainee's medical record would include documentation validating the DNR order. Meets Standard Per policy and an interview with staff RN, the staff RN on duty would inform all medical and mental health personnel verbally and by email of a DNR order. Meets Standard The facility has a policy that addresses organ donation. 10. Each facility shall have written policy and procedures that are followed to notify ICE/ERO officials, next-of-kin, and consulate officials of a detainee's death while in custody. Meets Standard Per policy, ICE is notified and is responsible to notify next-of-kin and consulate officials of a detainee's death while in custody. 11. The facility has a policy and procedure to address the death of a detainee while in transport. Meets Standard Written policy and procedure address the death of a detainee while in transport. Meets Standard Per policy and an interview with the ICE officer, the deceased would be transferred to the medical examiner in the jurisdiction where the death occurred. This process would be coordinated with ICE. 5. 6. 7. 8. 9. Each facility holding detainees shall establish written policy and procedures governing DNR orders in accordance with the laws of the state in which the facility is located. Health care will continue to be provided consistent with the DNR order. The detainee's medical file shall include documentation validating the DNR order. The facility shall follow written procedures for notifying attending medical staff of the DNR order. The facility has written procedures to address the issues of organ donation by detainees. 12. The body must be transferred to the local coroner or medical examiner in the jurisdiction where the death occurred. Page 127 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y) This Detention Standard ensures that each facility’s continuum of health care services addresses terminal illness, fatal injury, and advance directives and provides specific guidance in the event of a detainee’s death. Standard N/A I Click the above button if the facility does not accept ICE detainees who are severely or terminally ill. ALWAYS complete all references to detainee death and related notifications. (All Line Items and standard will be rated “N/A”) Components 13. The Chaplain shall telephone the person named as the next-of-kin in the United States to communicate the circumstances surrounding the death. Rating Meets Standard Policy states the chaplain/designee, in coordination with ICE, would contact next-of-kin living in the United States to provide notification of the death. Meets Standard Per ICE, the family would have the opportunity to claim the remains within seven calendar days of the date of notification. ICE may assist the family in transporting the remains to a designated location in the U.S. ICE provides detainee property within two weeks of the detainee death. Meets Standard ICE is responsible for contacting the consulate in the event the family cannot be located or declines the remains. Meets Standard ICE is responsible for the proper distribution of death certificates. Meets Standard Written policy and procedures address each of the bulleted items listed in this component. 14. Within seven calendar days of the date of notification (in writing or in person), the family shall have the opportunity to claim the remains. 15. If family members cannot be located or decline orally or in writing to claim the remains, ICE/ERO shall notify the consulate. 16. The facility administrator shall specify policy and procedures regarding responsibility for proper distribution of the death certificate. Remarks (1000 Char Max) 17. The facility’s written procedures shall address, at a minimum: • Contacting the local coroner or medical examiner, in accordance with established guidelines and applicable laws; • Scheduling the autopsy; • Identifying the person who will perform the autopsy; • Obtaining the official death certificate; and • Transporting the body to the coroner or medical examiner’s office. Page 128 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (Key: Y) This Detention Standard ensures that each facility’s continuum of health care services addresses terminal illness, fatal injury, and advance directives and provides specific guidance in the event of a detainee’s death. Standard N/A I Click the above button if the facility does not accept ICE detainees who are severely or terminally ill. ALWAYS complete all references to detainee death and related notifications. (All Line Items and standard will be rated “N/A”) Components Rating 18. Medical staff shall arrange for the approved autopsy to be performed by the local coroner or medical examiner in accordance with established guidelines and applicable laws. Meets Standard Remarks (1000 Char Max) Interviews with staff RN and ICE officer confirmed, in coordination with ICE, medical personnel would make arrangements for an autopsy by the medical examiner in accordance with established guidelines and consistent with applicable law. PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) When a detainee is hospitalized, the regional IHSC managed care coordinator and the HSA follow up on a daily basis to receive information about major developments. In conjunction with medical providers, ICE provides family members and any others as much opportunity for visitation as possible in keeping with the safety, security and good order of the facility. Advance directive guidelines include having a living will other than the generic form made available by medical personnel; appointing another individual to make advance decisions for him/her; and having a private attorney prepare the documents at the detainee's expense. DNR policy complies with the following stipulations: a DNR order written by a staff physician is approved by the CMA; it protects basic patient rights and complies with state requirements; a decision to withhold resuscitative services is considered only under specified conditions (the detainee has a terminal illness, the detainee has requested and signed the order, the decision is consistent with sound medical practice and is not in any way associated with any measures to hasten death); the medical file includes explicit directions regarding the DNR and forms and memoranda regarding diagnosis and prognosis, the express wishes of the detainee, the immediate family's wishes, consensual decisions and recommendations of medical professionals identified by name and title, the mental competency evaluation and informed consent; and the clinical director or nursing personnel notify the IHSC medical director and the ICE Office of Chief Counsel of the basic circumstances of any detainee with a DNR order. If neither the family nor consulate claim the remains, ICE would schedule an indigent's burial after contacting the Department of Veterans Affairs to determine burial benefits. The chaplain may advise the OIC about religious considerations in remains disposition. ICE does not authorize cremation or donation of the remains for medical research. Written policy and procedures on autopsies include: the ICE Office of Chief Counsel is consulted, and a written copy of the autopsy is forwarded to the ICE Office of Chief Counsel. While an autopsy decision is pending, no actions are taken that could affect the validity of the results. The FOD verifies and accommodates the detainee's religious preference prior to autopsy or embalming. The chaplain was not involved in formulation of the policy and procedures. It is established practice to notify ICE if the medical condition of a detainee already housed in the facility deteriorates and requires a level of medical care beyond the onsite health care capabilities. The detainee would be transported to an outside medical facility for emergency and/or impatient medical care as needed pending transfer or removal by ICE. Since the last inspection, there have been no reported deaths, no requests submitted for DNR orders or advance directives. Page 129 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 4 – 25. TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Evaluation of this standard was determined following a review of policy, and interviews with Staff RN Stan Roark and ICE Deportation Officer and Detntion Standards Compliance Officer, Tashi F. Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 24 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 130 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Section V: ACTIVITIES Correspondence and Other Mail Escorted Trips for Non-Medical Emergencies Marriage Requests Recreation Religious Practices Telephone Access Visitation Voluntary Work Program Page 131 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (Key: Z) This Detention Standard ensures that detainees will be able to correspond with their families, the community, legal representatives, government offices, and consular officials consistent with the safe and orderly operation of the facility. Components 1. Each facility shall have written policy and procedures concerning detainee correspondence and other mail. 2. PRIORITY: A detainee is considered "indigent" if he or she has less than $15.00 in his or her account. Indigent detainees will be permitted to mail a reasonable amount of mail each week at government expense, as determined by the Facility Administrator, including the following: 3. 4. 5. • At least five pieces of special correspondence or Legal Mail. • Three pieces of general correspondence. • Packages as deemed necessary by ICE. The facility shall notify detainees of its rules on correspondence and other mail through the Detainee Handbook, or supplement, provided to each detainee upon admittance. The facility shall provide key information to detainees in languages spoken by any significant portion of the facility's detainee population. Rating Meets Standard Meets Standard Incoming correspondence shall be distributed to detainees within 24 hours (one business day) of receipt by the facility. • Outgoing correspondence shall be delivered to the postal service no later than the day after it is received by facility staff or placed by the detainee in a designated mail depository, excluding weekends and holidays. The local handbook states that ICE detainees are considered indigent if they have less than $15.00 in their commissary account for thirty days. Each of the items listed in this component are satisfied through written policy and practice. Meets Standard Rules for correspondence and other mail are noted in the local handbook which is given to each detainee during the admissions process. Meets Standard The local handbook which provides key information to detainees is available in Spanish and English; languages spoken by the majority of the detainees held at the facility. Meets Standard Review of policy and the local handbook confirmed that incoming general correspondence and other mail is delivered to the detainee within one business day of its receipt at the facility. Outgoing correspondence and other mail are delivered to the U.S. postal service within one business day of it entering the facility mail system. Mail is picked up Monday through Saturday, from the housing units, by security personnel. PRIORITY: Detainee correspondence and other mail shall be delivered to the detainee and to the postal service on regular schedules. • Remarks (1000 Char Max) Rules and regulations governing detainee correspondence are provided in the local handbook. Page 132 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (Key: Z) This Detention Standard ensures that detainees will be able to correspond with their families, the community, legal representatives, government offices, and consular officials consistent with the safe and orderly operation of the facility. Components 6. Rating All facilities shall implement procedures for the inspection of all incoming general correspondence and other mail (including packages and publications) for contraband. Meets Standard Remarks (1000 Char Max) Reviewed policy issuances dictate procedures for inspection for all incoming general correspondence and other mail for the presence of contraband. Confirmed via staff and detainee interviews. 7. All facilities shall implement procedures for inspecting special correspondence and legal mail for contraband in the presence of the detainee. Detainees shall sign a logbook upon receipt of special correspondence and/or legal mail to verify that the special correspondence or legal mail was opened in their presence. Meets Standard Written policy and post orders require that special correspondence and legal mail be opened in the detainee's presence. The detainee signs a logbook indicating that the mail was opened in his presence. Confirmed via detainee interviews. 8. Outgoing special correspondence and legal mail shall not be opened, inspected, or read. 9. All facilities shall implement policies and procedures addressing acceptable and non-acceptable mail. Meets Standard Reviewed correspondence policy issuances address the requirements of this component. 10. When an officer finds an item that must be removed from a detainee’s mail, he or she shall make a written record. Meets Standard Reviewed correspondence policy issuances address the requirements of this component. Meets Standard The local handbook explains the process by which discovered prohibited items will be handled; the process discribed in the handbook is in accordance with the requirements of this component. Meets Standard The local handbook notes that detainees may purchase postage. Meets Standard 11. Prohibited items discovered in the mail shall be handled as follows: • • A receipt shall be issued to the detainee for all cash, which shall be safeguarded and credited to the detainee’s account in accordance with the Detention Standard on Funds and Personal Property. Identity documents, such as passports, birth certificates, etc., shall be placed in the detainee's Afile. Upon request, the detainee shall be provided with a copy of the document, certified by an ICE/ERO officer to be a true and correct copy. 12. The facility shall provide a postage allowance at government expense to all detainees, if the facility does not have a system for detainees to purchase stamps. 13. The facility shall provide writing paper, envelopes, and pencils at no cost to ICE detainees. Meets Standard Staff informed the inspector that writing paper, envelopes and writing implements are given to detainees free of charge. Confirmed via detainee interviews. Page 133 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 26. CORRESPONDENCE AND OTHER MAIL (Key: Z) This Detention Standard ensures that detainees will be able to correspond with their families, the community, legal representatives, government offices, and consular officials consistent with the safe and orderly operation of the facility. Components 14. All facilities shall have written policy and procedures regarding mail privileges for detainees housed in a Special Management Unit. Rating Remarks (1000 Char Max) Meets Standard Policy notes that detainees in special management units shall have the same mail privileges as those in the general population. There were no detainees held in special housing during the inspection. PART 5 – 26. CORRESPONDENCE AND OTHER MAIL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The facility has written policy and procedures concerning detainee correspondence and other mail. The rules for correspondence and other mail, which are provided to detainees in the handbook and are posted in the housing units, address all information required by the standard. The quantity of correspondence a detainee may send or receive at his own expense is not limited. Incoming priority mail, overnight mail, certified mail and deliveries from a private package service are recorded in a logbook. Packages and publications are subject to certain restrictions. Detainees are not permitted to send or receive packages without the prior approval of the OIC. Detainees must pay postage for packages, unless deemed necessary by the OIC, which includes oversized or overweight mail. Inspection of the mail is for detecting contraband and to maintain security. Incoming general correspondence is opened, but not read, and inspected for contraband before it is delivered to the detainee. Incoming special correspondence is opened in the presence of the detainee but not read. Outgoing general correspondence is inspected if it is addressed to another detainee or there is reason to believe that it may present a threat to the facility or others. Rejected mail is considered contraband and is handled in accordance with the contraband standard. Detainees may appeal rejection of correspondence through the detainee grievance system. Upon approval of the OIC, soft contraband is returned to the sender. The security captain insures that the records of the discovery and disposition of contraband are accurate and current. Correspondence to/from the news media is considered special correspondence if properly identified as such. In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. Detainees may not receive compensation or anything of value for correspondence with the media and may not act as a reporter or publish under a byline. The facility aids any detainee without legal representation who requests certain services in connection with a legal matter (notary public, certified mail, etc.) if the detainee has no family member, friend, or community organization able to provide assistance. When timely communication through the mail is not possible, a reasonable amount of communication by means of a facsimile device between the detainee and designated legal representative is permitted. The evaluation of this standard included review of policy, and interviews with staff and detainees. The inspector interviewed Assistant Jail Administrator Taylor and ICE Liaison Officer Glassburn. . Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 134 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 27. ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES (Key: AA) This Detention Standard permits detainees to maintain ties with their families and the community by providing detainees emergency staff-escorted trips into the community to visit critically ill members of the immediate family or to attend their funerals. Standard N/A I Click the above button if all ICE Non-Medical Emergency Escorted Trips are handled only by the ICE Field Office or Sub-Office in control of the detainee case. (All Line Items and standard will be rated “N/A”) Components 1. 2. 3. Rating On a case-by-case basis, and with approval of the respective Field Office Director, the facility administrator may allow a detainee, under ICE/ERO staff escort: • To visit a critically ill member of his or her immediate family. • To attend an immediate-family member's funeral. Remarks (1000 Char Max) N/A The facility notifies ICE of all detainee requests for nonmedical escorts. Each recommendation addresses the individual's suitability for travel, e.g., the kind of supervision required. The Field Office Director is the approving official for all non-medical escorted trips. N/A Escorts shall ensure that detainees with physical disabilities are provided reasonable accommodations in accordance with security and safety concerns. N/A PART 5 – 27. ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) All escorted trips for non-medical emergencies are conducted by ICE officers. Overall Rating: N/A Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 135 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 28. MARRIAGE REQUESTS (Key: AB) This Detention Standard ensures that each marriage request from an ICE/DRO detainee receives a case-by-case review and based on internal guidelines for approval of such requests. Components 1. 2. Rating All facilities shall have in place policy and procedures to enable eligible ICE/ERO detainees to marry. The Field Office Director or Facility Administrator considers detainee marriage requests on a case-by-case basis. 4. The facility administrator or designated Field Office staff shall notify the detainee in a timely manner of a time and place for the ceremony. 5. Meets Standard Meets Standard Detainees may submit a request to marry to facility personnel or directly to ICE. Any request submitted to the facility is forwarded directly to ICE. The decision to approve the request to marry rest only with ICE. Should ICE approve the request to marry the detainee would be moved to another location for the ceremony. The sheriff does not allow detainees in this facility to marry. There have been no requests to marry by ICE detainees during this inspection period. Meets Standard Per ICE personnel, each request to marry is considered on a caseby-case basis. Meets Standard Per ICE personnel, should a detainee request permission to marry, he/she would be notified in a timely manner of a time and place for the ceremony. Meets Standard Per ICE personnel, copies of all documentation pertaining to the marriage request and marriage would be maintained in the detainees' A-file and the detainees' detention file. A detainee, or his or her legal representative, may submit the request for permission to marry to the facility administrator or Field Office Director in writing. 3. Once the marriage has taken place, the facility administrator shall forward original copies of all documentation to the detainee’s A-file and maintain copies in the facility’s detention File. Remarks (1000 Char Max) The sheriff does not allow detainees, ICE or non-ICE, to marry in this facility. Should ICE approve a detainees' request to marry, the detainee would be moved to another location for the ceremony. There have been no request to marry by ICE detainees in this inspection period. PART 5 – 28. MARRIAGE REQUESTS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Page 136 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 28. MARRIAGE REQUESTS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) There have been no requests to marry by ICE detainees in this inspection period. A review of policy, interviews with facility personnel and an interview with the sheriff indicated that detainees are not allowed the opportunity to marry while detained in this facility. Any request to marry is immediately forwarded to ICE for processing. Should the request be approved the detainee will be moved to a facility where marriages can be held. This move is the responsibility of ICE. Requests are considered on a case-by-case basis. Detainees may seek legal assistance throughout the marriage application process. Guidelines for denying a detainee's marriage request includes the following: the detainee is not legally eligible to be married; the detainee is not mentally competent, as determined by a qualified medical practitioner; the intended spouse has not affirmed, in writing, his/her intent to marry the detainee; the marriage would present a threat to the security or orderly operation of the facility; or there are compelling government interests for denying the request. A detainee may file an appeal to the FOD if the request is denied. When a request is approved, after the detainee has been moved, the following guidelines are followed: the detainee, legal representative or other individual acting on the detainee's behalf will make all the marriage arrangements including, but not limited to, blood tests, obtaining marriage license, and retaining an official to perform the marriage ceremony. ICE personnel do not participate in making marriage arrangements nor serve as witnesses in the ceremony. The marriage does not interrupt nor stay any hearing, transfer to another facility or removal from the United States. Transfers do not occur solely to prevent a marriage. All arrangements are consistent with the security and orderly operation of the facility according to the following stipulations: the ceremony may take place inside the facility; all expenses relating to the marriage are borne by the detainee or person acting on the detainee's behalf; and the ceremony is private with no media publicity and only individuals essential for the marriage ceremony attend. The ICE OIC has the right of final approval concerning the time, place and manner of all arrangements. There have been no marriage requests processed during the inspection period. The evaluation of this standard was based on a review of documentation, reports and interviews with Clay County Sheriff Paul Harden, Captain Brandon Crowley and Detention Standards Compliance Officer Tashi Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 137 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 29. RECREATION (Key: AC) This Detention Standard ensures that each detainee has access to recreational and exercise programs and activities, within the constraints of safety, security, and good order. Components 1. The facility provides an indoor recreation program. 2. The facility provides an outdoor recreation program. 3. 4. PRIORITY: If outdoor recreation is available at the facility, each detainee shall have access for at least one hour daily, at a reasonable time of day, weather permitting. Detainees shall have access to clothing appropriate for weather conditions. If only indoor recreation is available, detainees shall have access for at least one hour each day to a large recreation room with exercise equipment and access to natural sunlight. All detainees participating in outdoor recreation shall have access to drinking water and toilet facilities. If a detainee is housed for more than 45 days in a facility that provides neither indoor nor outdoor recreation, he or she may be eligible for a voluntary transfer to a facility that does provide recreation. Likewise, if a detainee is housed for more than six months in a facility that provides only indoor recreation, he or she may be eligible for a voluntary transfer to a facility that also provides outdoor recreation. 5. PRIORITY: All facilities shall have an individual responsible for the development and oversight of the recreation program. In SPCs/CDFs, a recreational specialist (for facilities with more than 350 detainees) assesses the needs and interests of the detainees. 6. All facilities shall provide recreational opportunities for detainees with disabilities. 7. Exercise areas shall offer a variety of equipment. Weight training, if offered, must be limited to fixed equipment. Free weights are prohibited. 8. Cardiovascular exercise shall be available to detainees for whom outdoor recreation is unavailable. Rating Remarks (1000 Char Max) Meets Standard An indoor recreation area, separate from the detainee housing units, is available for use. Does Not Meet Standard This component was rated as Does Not Meet Standard in the last inspection because outdoor recreation is not provided. Outdoor recreation is not available at this facility. This is a repeat deficiency. Meets Standard Detainees have access to a multipurpose room for recreation purposes. This room has access to natural light and weight equipment fixed to the floor. Access to drinking water and toilet facilities is available. Meets Standard Detainees housed in this facility for more than six months are eligible for a voluntary transfer to a facility which provides outdoor recreation. Meets Standard In this IGSA, the captain is ultimately responsible for ensuring detainees have access to recreational activities outside their housing unit. The detainee population is less than 350. N/A Detainees with disabilities are not held in this facility. Meets Standard Fixed to floor weight equipment is available in the indoor recreation (multi-purpose) room. Meets Standard Detainees may walk around the perimeter of the indoor recreation (multi-purpose) room for cardiovascular exercise. Page 138 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 29. RECREATION (Key: AC) This Detention Standard ensures that each detainee has access to recreational and exercise programs and activities, within the constraints of safety, security, and good order. Components 9. Rating Remarks (1000 Char Max) PRIORITY: Dayrooms in general population housing units shall offer board games, television, and other sedentary activities. Meets Standard 10. Recreational activities shall be based on the facility’s size and location. With the facility administrator’s approval, recreational activities may include limited-contact sports, such as soccer, basketball, volleyball, and table games, and may extend to intramural competitions among units. Detention personnel shall supervise dayroom activities, distributing games and other recreation materials daily. Meets Standard 11. Recreation areas shall be under continuous supervision by staff equipped with radios or other communication devices to maintain contact with the Control Center. Meets Standard The indoor recreation area is under continuous video supervison by the control center. Meets Standard Detainees housed in the SMU, either administratively or as disciplinary sanctions, are provided one hour of out of cell recreation each day of the week. This opportunity is provided at a reasonable time. The area is climate controlled. Weather appropriate clothing is not required. Meets Standard Should a detainee be deprived of recreation or any other authorized item or activity, a written report would be forwarded to the captain and ICE would be notified of the denial and the reasons for the denial. Per the lieutenant, no detainees have been denied their recreation opportunities. Meets Standard Should a detainee be deprived of recreation, the detainee would be provided written notification of the denial which includes the reason for the denial and the conditions which must be met before the priviledge is restored. Per the lieutenant, no detainees have been denied their recreation opportunities. 12. PRIORITY: Recreation for detainees housed in the SMU shall be separate from the general population. Detainees in the SMU shall be offered at least one hour of recreation per day, outside their cells and scheduled at a reasonable time, at least five days per week. Where cover is not provided to mitigate inclement weather, detainees shall be provided weather-appropriate equipment and attire. 13. When a detainee in an SMU is deprived of recreation (or any usual authorized items or activity), a written report of the action is forwarded to the facility administrator. Denial of recreation must be evaluated daily by a shift supervisor. 14. When recreation privileges are suspended, the disciplinary panel or facility administrator shall provide the detainee written notification, the reason for the suspension, any conditions that must be met before restoration of privileges, and the duration of the suspension provided the requisite conditions are met for its restoration. Page 139 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) Dayrooms provide sedentary recreation in the form of television and board games. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 29. RECREATION (Key: AC) This Detention Standard ensures that each detainee has access to recreational and exercise programs and activities, within the constraints of safety, security, and good order. Components 15. The case of a detainee denied recreation privileges shall be reviewed at least once each week as part of the reviews required for all detainees in SMU status. Rating Remarks (1000 Char Max) Meets Standard Should a detainee be denied recreation, the denial would be reviewed at least once each week. Per the lieutenant, no detainees have been denied their recreation opportunities. Meets Standard Should a detainee be denied recreation priviledges for more than fifteen days, the concurrence of the captain and health care personnel would be required. Per the captain, ICE personnel would be consulted should this circumstance occur. Per the lieutenant, no detainees have been denied their recreation opportunities. Meets Standard ICE is notified when a detainee is placed in the SMU for any reason and would be notified should a detianee be denied recreation priviledges for fifteen days or more. Per the lieutenant, no detainees have been denied their recreation opportunities. 16. Denial of recreation privileges for more than 15 days requires the concurrence of the facility administrator and a health care professional. 17. The facility shall notify the ICE/ERO Field Office in writing when a detainee’s denied recreation privileges exceeds 15 days. PART 5 - 29. RECREATION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Detainees have access to indoor recreational and exercise programs and activities within the constraints of safety and security. Facility personnel are aware of the detainees right to request a transfer to a facility which provides outdoor recreation after they have been in this facility for six months or more. Indoor recreation is under constant video surveillance. The captain is responsible for ensuring programs are operated in an orderly, safe and secure manner. Detainees are not required to forgo basic law library privileges for recreation privileges. Officers search the recreation areas before and after each use to detect altered or damaged equipment, hidden contraband and security breaches. All recreational issued equipment is checked for damage and general condition by officers. COVID-19 restrictions have decreased the number of detainees that can recreate at one time. Intramural competitions and tournaments are currently not offered. Evaluation of this standard was based on a review of policy, documentation, personal observations and an interview with Lieutenant Neil Taylor. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Page 140 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 - 29. RECREATION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Reviewer Signature (for printed form submission): Page 141 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 30. RELIGIOUS PRACTICES (Key: AD) This Detention Standard ensures that detainees of different religious beliefs are provided reasonable and equitable opportunities to participate in the practices of their respective faiths, constrained only by concerns about safety, security, the orderly operation of the facility, or extraordinary costs associated with a specific practice. Components 1. 2. PRIORITY: Detainees have opportunities to engage in practices of their religious faiths (including observance of important holy days, observance of special diets, and use of personal religious property) consistent with safety, security, and the orderly operation of the facility. Attendance at all religious activities is voluntary. • 4. Remarks (1000 Char Max) Meets Standard Policy and procedures are in place that provide detainees with the opportunity to engage in practices of their religious faiths, consistent with the safety, security, and the orderly operation of the facility. However, due to COVID-19 restrictions, detainees are not allowed to congregate other than in the housing units in small groups. Participation in all religious activities is voluntary. Meets Standard Detainees are allowed to practice their religious beliefs in a manner that does not affect other detainees not involved in the practices. Detainees are not required to participate in or attend a religious activity in order to receive a service of the facility. Due to COVID-19 restrictions, detainees are limited to meeting in smaller groups within their housing units. Meets Standard Notations on the religious services schedule addressed the limitation of religious services provided by religious volunteers due to COVID-19 restrictions. Meets Standard Religious activities are managed and coordinated by a lieutenant. Prior to restrictions due to COVID-19, five religious programs, led by approximately ten religious volunteers, were available to detainees each weekday evening. Religious activities shall be open to the entire detainee population, without discrimination based on a detainee’s race, ethnicity, religion, national origin, gender, sexual orientation, or disability. • 3. Rating The facility chaplain shall endeavor to provide opportunities for religious practice in major languages spoken by the residents. Accommodations will be provided to residents who are deaf or hard of hearing to provide them access to the service should they wish to participate. Facility records shall reflect the limitation or discontinuance of a religious practice along with the reason for such limitation or discontinuance. PRIORITY: A facility religious services coordinator manages and coordinates religious activities for detainees, which are augmented and enhanced by community clergy, contractors, volunteers, and groups that provide individual and group assembly religious services and counseling that the facility religious services coordinator cannot personally deliver. Page 142 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 30. RELIGIOUS PRACTICES (Key: AD) This Detention Standard ensures that detainees of different religious beliefs are provided reasonable and equitable opportunities to participate in the practices of their respective faiths, constrained only by concerns about safety, security, the orderly operation of the facility, or extraordinary costs associated with a specific practice. Components 5. The chaplain or other religious coordinator shall have physical access to all areas of the facility to minister to detainees and staff. 6. All facilities shall designate space for religious activities. 7. When recruiting citizen volunteers, the chaplain and other staff shall be cognizant of the need for representation from all cultural and socioeconomic parts of the community. 8. Detainees who are members of faiths not represented by clergy may conduct their own services, provided they do not interfere with facility operations. 9. If requested by a detainee, the chaplain or designee shall facilitate arrangements for pastoral visits by a clergyperson or representative of the detainee’s faith. Rating Remarks (1000 Char Max) Meets Standard The facility has a chaplain who also serves as the sheriffs' office chaplain. The chaplain provides religious counseling upon request of a detainee. The chaplain has access to all areas of the facility. Meets Standard Prior to restrictions as a result of COVID-19, religious services were held in a multi-purpose room. Meets Standard Citizen volunteers, when they were allowed into the facility, represented the cultural and socioeconomic parts of the community. Meets Standard Meets Standard 10. Detainees may make a request for the introduction of a new component to the Religious Services program (schedule, meeting time and space, religious items and attire) to the chaplain. The chaplain shall ask the detainee to provide additional information to use in deciding whether to include the practice. Meets Standard 11. Each facility shall have written policy and procedures to facilitate detainee observance of important holy days, consistent with maintaining safety, security and orderly operations, and the chaplain shall work with detainees to accommodate proper observances. Does Not Meet Standard 12. Each facility administrator shall allow detainees access to personal religious property, as is consistent with safety, security and orderly operation of the facility. Meets Standard Page 143 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) Pastoral telephonic visits, by a clergyperson or representative of the detainees' faith, can be arranged when requested by the detainee. Policy and procedures do not address the observance of important holy days. Detainees are allowed access to personal religious property which does not pose a threat to the safe, secure and orderly operation of the facility. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 30. RELIGIOUS PRACTICES (Key: AD) This Detention Standard ensures that detainees of different religious beliefs are provided reasonable and equitable opportunities to participate in the practices of their respective faiths, constrained only by concerns about safety, security, the orderly operation of the facility, or extraordinary costs associated with a specific practice. Components 13. When a detainee’s religion requires special food services, daily or during certain holy days or periods that involve fasting, restricted diets, etc., staff shall make all reasonable efforts to accommodate those requirements (for example, modifying menus to exclude certain foods or food combinations, or providing meals at unusual hours). Rating Remarks (1000 Char Max) Meets Standard Per the captain and a review of policy, all reasonable efforts are made to accommodate a detainees' religious requirements for special food service, fasting, restricted diets, etc. There have been no requests for a religious diet made by a detainee in this inspection period. 14. The chaplain shall develop the religious fast schedule for the calendar year and provide it to the facility administrator or designee. Does Not Meet Standard A religious fast schedule for the calendar year has not been developed, hence not provided to the captain or designee. The captain indicated they had not had any detainees observing Ramadan, of which the observance period recently ended. PART 5 – 30. RELIGIOUS PRACTICES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Under normal circumstances, religious programming has been offered multiple times each week. The services have been led by a contingent of volunteers from five different religious community organizations. Religious activities were coordinated by the lieutenant prior to COVID-19 restrictions. Religious activities, including participation by religious volunteers, have been curtailed over the past months due to COVID-19 restrictions. Detainees can designate any or no religious preference during admission. With a written request to the OIC, a detainee can request to change this designation at any time, and the change will be reviewed by the lieutenant or the captain and effected in a timely manner. In the interest of maintaining the safe, secure and orderly operation of the facility and to prevent abuse or disrespect by detainees of religious practices or observances, the lieutenant, acting as the religious services coordinator, monitors patterns of changes in declarations of the detainee's religious preference. When the facility is determining whether to allow a detainee to participate in specific religious activity, the lieutenant, refers to the information contained in the initial classification and the detainee’s religious designation. Detainees showing "No Preference" can be restricted from participating in those activities deemed appropriate for members only. Religious diet requests are forwarded to the lieutenant or captain for review and approval. When approved, the request is forwarded to the food service manager. Evaluation of this standard was based upon interviews with Lieutenant Neil Taylor, Captain Brandon Crowley and Sergeant Jase Glassburn; and a review of policy. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 144 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 31. TELEPHONE ACCESS (Key: AE) This Detention Standard ensures that detainees may maintain ties with their families and others in the community by providing them reasonable and equitable access to telephone services. Components 1. 2. 3. 4. Rating Remarks (1000 Char Max) Meets Standard Interviews with staff confirmed that each housing unit has a ratio of telephones to detainees better than that required by this component. The rating was also confirmed via detainee interviews. Meets Standard The inspector was informed that the facility has a contract with a nationally recogonized telephone service provider who adheres to all state and federal regulations. Telephone rates are reasonably priced and comparable to the public telephone rates. Meets Standard Reviewed ICE officer's telephone serviceability logs document that telephones are maintained in working order, and that out of order phones are promptly repaired or replaced. Meets Standard Reviewed telephone serviceability logs document that telephones are routinely checked for operability. The logs also document that inoperable telephones are reported to maintainenance for repair. To ensure sufficient access, each facility shall provide at least one operable telephone for every 25 detainees. PRIORITY: Each facility shall ensure that detainees have access to reasonably priced telephone services. Contracts for such services shall comply with all applicable state and federal regulations and be based on rates and surcharges commensurate with those charged to the general public. Any variations shall reflect actual costs associated with the provision of services in a detention setting. Each facility shall maintain detainee telephones in proper working order. Designated facility staff shall inspect the telephones daily, promptly report out-of-order telephones to the repair service and ensure that required repairs are completed quickly. This information will be logged. Facility staff is responsible for ensuring on a daily basis that telephone systems are operational. Any problems identified must immediately be logged and reported to the appropriate facility and ICE staff personnel. Page 145 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 31. TELEPHONE ACCESS (Key: AE) This Detention Standard ensures that detainees may maintain ties with their families and others in the community by providing them reasonable and equitable access to telephone services. Components 5. Rating Each facility shall have a written policy on the monitoring of detainee telephone calls. If telephone calls are monitored, the facility shall include a recorded message on its phone system stating that all telephone calls are subject to monitoring. At each monitored telephone, place a notice that states that detainee calls are subject to monitoring. A detainee’s call to a court, a legal representative, OIG, or CRCL, or for the purposes of obtaining legal representation, may not be electronically monitored. Meets Standard Remarks (1000 Char Max) The local handbook addresses telephone monitoring. The inspector confirmed that each housing unit telephone has a placard mounted on the telephone casing stating telephone calls are subject to monitoring and a similar announcement is made through the receiver prior to each call connection. The handbook notes that special/legal telephone calls to a court, a legal representative, OIG, CRCL or for the purpose of obtaining legal representation are not monitored. The on-site SME was able to reach the OIG Hot Line using the direct dial number programmed in a housing unit telephone. . 6. Each facility shall provide telephone access rules in writing to each detainee upon admission, and also shall post these rules where detainees may easily see them in a language they can understand. Updated telephone and consulate lists shall be posted in the detainee housing units. Translation and interpretation services shall be provided as needed. Meets Standard The local handbook addresses each of the items listed in this component. Each facility administrator shall establish and oversee rules and procedures that provide detainees reasonable and equitable access to telephones during established facility “waking hours.” Meets Standard Reviewed policy and the local handbook prescribe detainee telephone usage rules 8. Detainees are afforded a reasonable degree of privacy for legal phone calls. Meets Standard 9. A procedure exists to assist a detainee who is having trouble placing a confidential call. 7. Meets Standard ICE liaison staff informed the inspector that they routinely allow detainees use of private land line telephones to make a confidential call. Confirmed via detainee interviews. Page 146 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 31. TELEPHONE ACCESS (Key: AE) This Detention Standard ensures that detainees may maintain ties with their families and others in the community by providing them reasonable and equitable access to telephone services. Components Rating Remarks (1000 Char Max) Meets Standard The inspector confirmed that special access speed dial numbers affording detainees the ability to make non-collect calls are programmed into the telephone system. 10. The facility provides the detainees with the ability to make non-collect (special access) calls. 11. Even if telephone service is generally limited to collect calls, each facility shall permit detainees to make direct or free calls to the offices and individuals listed below. Updated lists need to be posted in the detainee housing units. 12. If detainees are required to complete request forms to make direct or free calls, facility staff must assist them as needed, especially illiterate or non-English speaking detainees. 13. PRIORITY: All detainees are able to call their consulate, the DHS Office of the Inspector General, and any organization on the ICE/ERO-provided list of free legal service providers at no charge to the detainee or receiving party. The FOD will ensure that all information is kept current and provided to each facility. Updated contact lists are posted in the detainee housing units. Meets Standard Meets Standard This IGSA does not require detainees to complete request forms in order to make a free or direct call. Instructions on how to request assistance in making such a call are included in the local handbook. The on-site SME observed the required postings in each housing unit. Meets Standard Indigent detainees are afforded the same telephone access and privileges as detainees in the general population. The indigent detainee may also request a free call to immediate family or others in personal or family emergencies or for a compelling need (to be interpreted liberally). 14. A facility may neither restrict the number of calls a detainee places to his/her legal representatives nor limit the duration of such calls by rule or automatic cut-off, unless necessary for security purposes or to maintain orderly and fair access to telephones. Meets Standard 15. The facility has a system for taking and delivering emergency detainee telephone messages. Meets Standard Page 147 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) The local handbook explains that indigent detainees are afforded the same telephone access as other detainees; and that they are also assisted in calling family or others in an emergency at no cost to either party. Reviewed written policy addresses the requirements of this component. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 31. TELEPHONE ACCESS (Key: AE) This Detention Standard ensures that detainees may maintain ties with their families and others in the community by providing them reasonable and equitable access to telephone services. Components 16. The facility shall take and deliver telephone messages to detainees as promptly as possible. When facility staff receive an emergency telephone call for a detainee, the caller’s name and telephone number will be obtained and given to the detainee as soon as possible. The detainee shall be permitted to return the emergency call as soon as reasonably possible within the constraints of security and safety. The facility shall enable indigent detainees to make a free return emergency call. 17. The facility shall provide a TTY device or Accessible Telephone (telephones equipped with volume control and telephones that are hearing-aid compatible for detainees who are deaf or hard of hearing). Detainees who are hard of hearing will be provided access to the TTY on the same terms as hearing detainees. Rating Remarks (1000 Char Max) Meets Standard Reviewed ICE officer request logs document that detainee telephone messages are delivered to detainees in a timely manner. Detainee interviews confirmed that detainees are allowed to make a free return emergency call. Meets Standard The local handbook address each of the items required by this component. Meets Standard Written policy address the requirements noted in this component. 19. Generally, detainees in administrative segregation should receive the same privileges that are available to detainees in the general population, subject to any safety and security considerations that may exist. Meets Standard Per policy detainees in administrative segregation have similar telephone privileges as those in the general population. 20. Upon a detainee’s request, facility staff shall make special arrangements to permit the detainee to speak by telephone with an immediate family member detained in another facility. Meets Standard Accommodations shall also be made for detainees with speech disabilities. 18. Detainees in Disciplinary Segregation may be restricted from using telephones to make general calls as part of the disciplinary process. Even in Disciplinary Segregation, however, detainees shall have some access for special purposes. 21. LYON AGREEMENT: When a detainee requests a direct or free Legal Call to an attorney, court, or government agency or demonstrates a compelling need for other direct or free calls, access is granted within 24 hours of the request and ordinarily within 8 facility waking hours. Further delays may be justified by extraordinary circumstances. Meets Standard 22. LYON AGREEMENT: The facility documents and reports to ICE/ERO any delays in responding to requests for free or direct Legal Calls beyond 8 facility waking hours. Meets Standard 23. LYON AGREEMENT: Detainees are provided private settings for Legal Calls such that calls cannot be overheard by officers, other staff, or other detainees. Meets Standard The ICE liaison officer routinely allows detainees use of their office land line telephones to make a confidential call. Confirmed via detainee interviews. The ICE liaison officer routinely allows detainees the use of a private telephone to make a confidential call. Confirmed via detainee interviews. Page 148 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 31. TELEPHONE ACCESS (Key: AE) This Detention Standard ensures that detainees may maintain ties with their families and others in the community by providing them reasonable and equitable access to telephone services. Components Rating Remarks (1000 Char Max) 24. LYON AGREEMENT: The facility has a system for taking and delivering telephone messages to detainees, including but not limited to attorney messages, other messages related to a detainee’s legal case, and emergency messages, and ensures the timeliness of such message delivery. Meets Standard Written policy address the requirements noted in this component. 25. LYON AGREEMENT: The facility provides translation and interpretation services to detainees who are unable to read written telephone access rules in the languages provided. Meets Standard Written policy address the requirements noted in this component. 26. LYON AGREEMENT: Detainees in segregation or other environments with limited physical access to telephones have reasonable and equitable access to telephones during waking hours (i.e., they can request telephone calls and receive them in a timely manner). Meets Standard Written policy address the requirements noted in this component. PART 5 – 31. TELEPHONE ACCESS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Telephone access is handled in accordance with the standard. ICE/ERO staff test phones for detainees at least weekly to verify serviceability. They also make random calls to pre-programmed numbers for attorney and consulate services; interview a sampling of detainees regarding telephone services, and review written detainee complaints regarding telephones. In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. Evaluation of this standard included reviewing policy, procedures, and the local handbook; on site examiniation of information posters in detainee housing units; and interviewing staff and detainees. The inspector interviewed ICE Liaison Officer Glassburn. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 149 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 32. VISITATION (Key: AF) This Detention Standard ensures that detainees will be able to maintain ties through visitation with their families, the community, legal representatives, and consular officials, within the constraints of safety, security, and good order. Components 1. There is a written visitation procedure, schedule, and hours for general visitation. 2. Each facility administrator shall decide whether to permit contact visits, as is appropriate for the facility’s physical plant and detainee population. 3. A facility administrator may temporarily restrict visiting when necessary to ensure the security and good order of the facility. Each restriction or denial of visits shall be documented in writing, including the duration of and reasons for the restriction. 4. 5. Rating Remarks (1000 Char Max) Meets Standard The local detainee handbook lists visitation hours, schedules and procedures. Meets Standard Due to health safety concerns all general visitation is conducted via video. Written policy addresses the requirements of this component. Meets Standard Meets Standard Visiting rules and hours are available by telephone and on the facility's website. The inspector also noted that similar information is also posted in English and Spanish in the visitor's waiting room. Meets Standard Due to health safety concerns all general visitation is conducted via video. Detainees may visit with family and friends a minimum of thirty minutes each week via a video telephone connection located in their housing unit. The video visits are permitted during waking hours 8:00 a.m. - 8:00 p.m. - seven days a week including holidays. Each facility shall: • Make the schedule and procedures available to the public, both in written form and telephonically. • Post that information in the visitor waiting area in English, Spanish, and other major languages spoken in the facility. PRIORITY: General visitation is permitted during set hours on Saturdays, Sundays, and holidays, and, to the extent practicable, the facility accommodates the scheduling needs of visitors for whom weekends and holidays pose a hardship. The number of visitors a detainee receives and the length of visits are limited only by reasonable constraints of space, scheduling, staff availability, safety, security, and good order. The minimum duration for a visit is 30 minutes. 6. Each facility shall maintain a log of all general visitors, and a separate log of legal visitors. Meets Standard 7. If the facility establishes and maintains a dress code for visitors, it shall be made available to the public. Meets Standard 8. The facility’s visiting areas shall be appropriately furnished and arranged, and as comfortable and pleasant as practicable. Meets Standard 9. The facility’s written rules shall specify time limits for visits. The minimum time limit is 30 minutes. 10. At facilities where there is no provision for visits by minors, ICE arranges for visits by children and stepchildren, on request, within the first 30 days. Due to health safety concerns all general visitation is conducted via video. The dress code is noted in the facility's web page. Meets Standard The local handbook notes that visits last a minimum of thirty minutes. Meets Standard Per policy minors are permitted to visit at this facility. Page 150 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 32. VISITATION (Key: AF) This Detention Standard ensures that detainees will be able to maintain ties through visitation with their families, the community, legal representatives, and consular officials, within the constraints of safety, security, and good order. Components Rating Remarks (1000 Char Max) 11. Written procedures shall detail the limits and conditions of contact visits in facilities permitting them. Meets Standard Written policy addresses the requirement of this component. 12. Anytime a visit is denied, to either a general population detainee or SMU detainee, the denial is documented. Meets Standard Per policy all visitation denials must be documented. Meets Standard Written policy states that baring security concerns detainees held in special housing units will have similar visiting privileges. Meets Standard Per policy legal visits are permitted seven days a week, including holidays, twelve hours per day. Meets Standard The on-site SME observed private rooms where a detainee may meet with their legal representative and exchange legal documents. Meets Standard Staff informed the inspector that legal representatives and their assistants must clear a metal detector and have their belongings searched prior to their visit. Meets Standard The on-site SME inspector found the required postings in each housing. Meets Standard Reviewed written policy addresses the requirements of this component. 19. Facility visitation procedures shall cover law enforcement officials requesting interviews with detainees. Facilities will notify and seek approval from ICE ERO of any proposed law enforcement officer visit with a detainee. Meets Standard Staff informed the inspector that interviews of detainees by law enforcement officials must be approved by ICE prior to the visit. 20. Former ICE/ERO detainees, individuals with criminal records and individuals in deportation proceedings shall not be automatically excluded from visiting. Individuals in any of these categories must so notify the facility administrator before registering for visitation privileges. Meets Standard 13. While in administrative or disciplinary segregation status, a detainee ordinarily retains visiting privileges. 14. PRIORITY: Legal visitation is available seven (7) days a week, including holidays. Legal visitation hours provide for a minimum of eight (8) hours per day on regular business days, and a minimum of four (4) hours per day on weekends and holidays. 15. Private consultation rooms are available for attorney meetings. There is a mechanism for the detainee and his/her representative to exchange documents. 16. Legal representatives and assistants are subject to a nonintrusive search such as a pat-down search of the person or a search of the person’s belongings – at any time for the purpose of ascertaining the presence of contraband. 17. The current list of pro bono legal organizations is posted in the detainee housing areas and other appropriate areas. 18. All requests by NGOs and other organizations to send representatives to visit detainees must be submitted in advance and in writing to the ICE/ERO facility administrator or ICE/ERO Field Office supervising the contract, state or local facility. The written request must state the number of visitors, exact reason for the visit and issues to be discussed. Page 151 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 32. VISITATION – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The facility handles visitation in accordance with the standard. The facility maintains a general visitors log which contains the name and alien-registration number (A-number) of the detainee visited, the visitor’s name and address, the visitor’s immigration status, the visitor’s relationship to the detainee, the date, time in and time out. The facility has written procedures regarding incoming property and money for detainees during visitation. Staff verifies each adult visitor's identity before admitting him or her to the facility. Interpreters can accompany legal representatives. The facility permits messengers who are not legal representatives or legal assistants to deliver documents to and from the facility, but not to visit detainees. Legal representatives must present a State bar card and proper identification such as a driver’s license. A separate log is maintained for all legal visitors, including those denied access. The logs include the reason(s) for denying access. The facility has written procedures for legal representatives and assistants to contact ICE in advance of a visit to determine whether an individual is detained there. The procedures also include guidelines for pre-representation meetings. This facility has procedures in place that liberally allow the opportunity for consultation visitation for detainees subject to expedited removal in accordance with this standard. These visits are conducted in person or by telephone similar to legal visits. Detainees can receive visits by representatives of community service organizations, including civic, religious, cultural, therapeutic, and other groups. All visitors are required to comply with visitation rules. Due to health safety concerns as of April 2020 all general visitation is conducted via video. Detainees may visit with family and friends a minimum of thirty minutes each week via a video telephone connection available in their housing unit. The video visits are permitted during waking hours - 8:00 a.m. - 8:00 p.m. - seven days a week including holidays. Detainee visits with their legal representatives remain as noted above. The facility has established procedures governing whether and, if so, under what circumstances animals may accompany human visitors onto or into facility property. During the evaluation of this standard, visitation procedures in written policy and the local handbook were reviewed, and employees and detainees were interviewed The inspector interviewed Assistant Jail Administrator Taylor and ICE DSCO Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 152 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 33. VOLUNTARY WORK PROGRAM (Key: AG) This Detention Standard provides detainees opportunities to work and earn money while confined, subject to the number of work opportunities available and within the constraints of safety, security, and good order. While not legally required to do so, ICE/DRO affords working detainees basic Occupational Safety and Health Administration (OSHA) protections. Standard N/A I Click the above button if ICE detainees are not authorized to work at the IGSA facility. (All Line Items and standard will be rated “N/A”) Components Rating 1. Detainees who are physically and mentally able to work shall be provided the opportunity to participate in any voluntary work program. N/A 2. The detainee’s classification level shall determine the type of work assignment for which he/she is eligible. Level 3 detainees shall not be given work opportunities outside their housing units/living areas. N/A 3. ICE detainees may not work outside the secure perimeter of local jails and facilities used under Intergovernmental Service Agreements. N/A 4. The facility administrator shall develop site-specific rules for selecting work detail volunteers in a facility procedure that will include a voluntary work program agreement. N/A 5. Detainees shall not be denied voluntary work opportunities on the basis of such factors as a detainee's race, religion, national origin, gender, sexual orientation or disability. N/A While medical or mental health restrictions may prevent some physically or mentally challenged detainees from working, those with less severe disabilities shall have the opportunity to participate in the voluntary work program in appropriate work assignments. N/A 7. Detainees who participate in the volunteer work program are required to work according to a fixed schedule. N/A 8. Detainees shall receive monetary compensation for work completed in accordance with the facility’s standard policy. N/A 9. The facility administrator shall establish procedures for informing detainee volunteers about on-the-job responsibilities and reporting procedures. N/A 10. When a detainee is removed from a work detail, staff place the written justification for the action in the detainee’s detention file. N/A 11. All detention facilities shall comply with all applicable health and safety regulations and standards, to include training. N/A 6. Page 153 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) Remarks (1000 Char Max) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 5 – 33. VOLUNTARY WORK PROGRAM (Key: AG) This Detention Standard provides detainees opportunities to work and earn money while confined, subject to the number of work opportunities available and within the constraints of safety, security, and good order. While not legally required to do so, ICE/DRO affords working detainees basic Occupational Safety and Health Administration (OSHA) protections. Standard N/A I Click the above button if ICE detainees are not authorized to work at the IGSA facility. (All Line Items and standard will be rated “N/A”) Components Rating 12. The facility administrator shall ensure that all department heads, in collaboration with the facility’s safety/training officer, develop and institute appropriate training for all detainee workers. N/A 13. Upon a detainee’s assignment to a job or detail, the supervisor shall provide thorough instructions regarding safe work methods and, if relevant, hazardous materials. N/A 14. The facility shall provide detainees with safety equipment that meets OSHA and other standards associated with the task performed. N/A 15. The facility administrator shall implement procedures for immediately and appropriately responding to on-the-job injuries, including immediate notification of ICE/ERO. N/A Remarks (1000 Char Max) PART 5 – 33. VOLUNTARY WORK PROGRAM – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Detainees do not work at this facility. Overall Rating: N/A Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 154 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Section VI: JUSTICE Detainee Handbook Grievance System Law Libraries and Legal Material Legal Rights Group Presentations Page 155 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 34. DETAINEE HANDBOOK (Key: AH) This Detention Standard requires that, upon admission, every detainee be provided comprehensive written orientation materials that describe such matters as the facility’s rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in English, Spanish, and other languages and that detainees acknowledge receipt of those materials. Components 1. 2. 3. 4. 5. PRIORITY: Upon admission to a facility, as part of the orientation program, each detainee shall be provided a copy of the ICE National Detainee Handbook and that facility’s local supplement to the handbook. The facility administrator shall ensure that the local supplement is translated into Spanish and any other language spoken by significant numbers of detainees in that facility. Staff shall require each detainee to verify, by signature, receipt of the handbook and maintain that acknowledgement in the detainee’s detention file. If a detainee cannot read or does not understand the language of the handbook, the facility administrator shall arrange for the orientation materials to be read to the detainee, provide the material using audio or video tapes in a language the detainee does understand, or provide a translator. The facility administrator shall provide a copy of the ICE National Detainee Handbook and the local supplement to every staff member who has contact with detainees, and cover its contents in initial and annual staff training. Rating Remarks (1000 Char Max) Meets Standard The ICE National Detainee Handbook as well as the Clay County Justice Center Local ICE Detainee Handbook (local handbook) is issued to each detainee upon processing into the facility. Each detainee signs for the receipt of both handbooks. Meets Standard The local handbook is translated into Spanish. Interpretive assistance would be provided to a detainee who did not communicate in English or Spanish. The ICE National Detainee Handbook is available in a variety of languages. Meets Standard Detainees verify, by signature, their receipt of both handbooks. Documentation is maintained in each detainees detention file and was verified during the inspection. Meets Standard The local handbook is translated into Spanish. Interpretive assistance would be provided to a detainee who did not communicate in English or Spanish. The ICE National Detainee Handbook is available in a variety languages. Meets Standard Jail personnel are provided a personal copy of the local handbook. The local handbook is also available for review in various locations in the facility. Contents of the local handbook are reviewed during initial and annual refresher training. Page 156 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 34. DETAINEE HANDBOOK (Key: AH) This Detention Standard requires that, upon admission, every detainee be provided comprehensive written orientation materials that describe such matters as the facility’s rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in English, Spanish, and other languages and that detainees acknowledge receipt of those materials. Components 6. 7. The facility administrator shall appoint a committee to review the local supplement annually and recommend changes. While the handbook does not have to be immediately revised and reprinted to incorporate every change, the facility administrator shall establish procedures for immediately communicating such changes to staff and detainees. Rating Remarks (1000 Char Max) Meets Standard Per the jail commander, the local handbook is reviewed annually. The review date on the handbook is 01/28/2020, a memorandum from the jail commander indicates the local handbook was most recently reviewed 05/18/2021. No revisons were made. Procedures are in place to ensure the immediate communication of changes to staff and detainees. Meets Standard The local handbook addresses the elements of this component. The local handbook addresses this component. The detainee handbook (local supplement) address the following issues: • Personal Items permitted to be retained by the detainee. • Initial issue of clothes, bedding and personal hygiene items. • How to access care. 8. The detainee handbook (local supplement) states in clear language basic detainee responsibilities. Meets Standard 9. The handbook (local supplement) clearly outlines the methods for classification of detainees, explains each level, and explains the classification appeals process. Meets Standard 10. The handbook (local supplement) states when a medical examination will be conducted. Meets Standard 11. The handbook (local supplement) describes the facility, housing units, dayrooms, In-dorm activities and special management units. Meets Standard 12. The handbook (local supplement) describes official count times and count procedures, meal times, feeding procedures, procedures for medical or religious diets, smoking policy, clothing exchange schedules and if authorized, clothes washing and drying procedures and expected personal hygiene practices. Meets Standard The local handbook addresses the elements of this component. Meets Standard The process for obtaining a razor is explained in the handbook as well as the process for obtaining a razor to use prior to a court appearance. 13. The handbook (local supplement) describes times and procedures for obtaining disposable razors and explains that detainees attending court will be afforded the opportunity to shave first. Page 157 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 34. DETAINEE HANDBOOK (Key: AH) This Detention Standard requires that, upon admission, every detainee be provided comprehensive written orientation materials that describe such matters as the facility’s rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in English, Spanish, and other languages and that detainees acknowledge receipt of those materials. Components 14. The handbook (local supplement) describes barber hours and hair cutting restrictions. 15. The handbook (local supplement) describes; the telephone policy, debit card procedures, direct and frees calls; locations of telephones; policy when telephone demand is high; and policy and procedures for emergency phone calls. 16. The handbook (local supplement) addresses religious programming. 17. The handbook (local supplement) states times and procedures for commissary or vending machine usage (where available). 18. The handbook (local supplement) describes the detainee voluntary work program. Rating Remarks (1000 Char Max) Meets Standard Barbering hours and hair cutting procedures are addressed in the handbook. Restricitions and sanitation guidelines are also addressed in the document. Meets Standard The elements of this component are addressed in the local handbook. Meets Standard Religious programming and the process for accessing a religious diet are addressed in the local handbook. Meets Standard Meets Standard The local handbook informs detainees that they will not be allowed to participate in the volunteer work program. Meets Standard The law library procedures and schedules are addressed. General library services are provided through the use of a library cart which can be accessed during recreation hours. 20. The handbook (local supplement) describes: attorney and regular visitation hours, policies, and procedures, location of the list of pro bono legal organizations; group legal rights presentations schedule and sign up procedures. Meets Standard The elements of this component are addressed in the local handbook. 21. The handbook (local supplement) provides local ICE contact information. Meets Standard 22. The handbook (local supplement) describes the facility contraband policy. Meets Standard The contraband policy is addressed in the local handbook. 23. The handbook (local supplement) describes the facility visiting hours and schedule and visiting rules and regulations. Meets Standard Visiting hours, scheduling, rules and regulations are addressed in the local handbook. 24. The handbook (local supplement) describes correspondence policy and procedures. Meets Standard 19. The handbook (local supplement) describes the library location and hours of operation and law library procedures and schedules. the Page 158 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 34. DETAINEE HANDBOOK (Key: AH) This Detention Standard requires that, upon admission, every detainee be provided comprehensive written orientation materials that describe such matters as the facility’s rules and sanctions, disciplinary system, mail and visiting procedures, grievance system, services, programs, and medical care, in English, Spanish, and other languages and that detainees acknowledge receipt of those materials. Components 25. The handbook (local supplement) describes the detainee disciplinary policy and procedures, including: Prohibited acts and severity scale sanctions. • Time limits in the Disciplinary Process. • Summary of Disciplinary Process. 26. The grievance section of the handbook (local supplement) explains all steps in the grievance process, including informal (if used) and formal grievance procedures. Rating Remarks (1000 Char Max) Meets Standard Disciplinary policy and procedures to include prohibited acts and severity scale of sanctions are addressed in the local handbook. Meets Standard An in-depth explanation of the grievance system and the process for filing informal and formal grievances is addressed. The appleal process is addressed as well as the detainees' right to file an appeal directly to ICE. 27. The handbook (local supplement) describes the medical sick call procedures for general population and segregation. Meets Standard 28. The handbook (local supplement) describes the facility recreation policy. Meets Standard 29. The handbook (local supplement) describes the detainee dress code for daily living; and work assignments and the meaning of color-coded uniforms. 30. The handbook (local supplement) specifies the rights and responsibilities of all detainees. Meets Standard The local handbook addresses the detainee dress code for daily living. Detainees do not participate in the volunteer work program. ICE detainees are all dressed in orange and white striped uniforms; their classification is noted by the color of their identification wrist bands. Meets Standard Rights and responsibilities of detainees are addressed in the local handbook. PART 6 - 34. DETAINEE HANDBOOK – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) The local handbook serves as an overview of and guide to the policies, procedures and rules of the facility. It is available in English and Spanish. In addition, an orientation video is provided for review by detainees while in the holding area and translation services are utilized to interpret the information into other foreign languages as needed. The handbook and the ICE National Detainee Handbook inform the detainee in detail as to how to report allegations of abuse and civil rights violations, along with violations of staff misconduct, directly to ICE headquarters or the DHS OIG. The local handbook is free from derogatory or insensitive statements about detainee religion or culture and describes the facility's rules, programs, procedures and requirements for detainees during their detention. Page 159 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 - 34. DETAINEE HANDBOOK – Reviewer Summary (Use following format for dates: mm/dd/yyyy) The facility provides communication assistance to detainees with disabilities and detainees who are limited in their English proficiency (LEP). The facility provides detainees with disabilities with effective communication, which may include the provision of auxiliary aids, such as readers, telecommunications devices for deaf persons (TTYs), and interpreters, as needed. The facility provides detainees who are LEP with language assistance, including bilingual staff or professional interpretation and translation services. The evaluation of this standard was based upon a review of policy, a review of the local handbook and an interview with Captain Brandon Crowley and Lieutenant Neil Taylor. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 160 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 35. GRIEVANCE SYSTEM (Key: AI) This Detention Standard protects detainees’ rights and ensures they are treated fairly by providing a procedure by which they may file formal grievances and receive timely responses. Components 1. 2. Rating Remarks (1000 Char Max) Meets Standard Policy and procedures address the elements of this component. Meets Standard Per policy, detainees are issued the local handbook which addresses the informal and formal grievance system. PRIORITY: Each facility shall have written policy and procedures for a detainee grievance system that: • Establishes a procedure for any detainee to file a formal grievance; • Establishes a procedure to track or log all formal grievances; • Establishes reasonable time limits for: o Processing, investigating, and responding to grievances, including medical grievances; o Convening a grievance committee (or actions of a single designated grievance officer) to review formal complaints; and o Providing written responses to detainees who filed formal grievances, including the basis for the decision. • Ensures a procedure in which all medical grievances are received by the administrative health authority within 24 hours or the next business day; • Establishes a special procedure for time-sensitive, emergency grievances; • Ensures each grievance receives supervisory review; • Provides at least one level of appeal; • Includes guarantees against reprisal; and • Ensures information, advice, and directions are provided to detainees in a language or manner they can understand, or that interpretation/translation services are utilized. Illiterate, disabled, or non-English speaking detainees shall be provided additional assistance, upon request. Written procedures require that detainees are informed about the facility’s informal and formal grievance system. 3. The grievance section of the handbook explains all steps in the grievance process. Meets Standard 4. Written procedures provide for the informal resolution of oral grievances. Meets Standard Page 161 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 35. GRIEVANCE SYSTEM (Key: AI) This Detention Standard protects detainees’ rights and ensures they are treated fairly by providing a procedure by which they may file formal grievances and receive timely responses. Components 5. The facility administrator, or designee, shall allow a detainee to submit a formal, written grievance to a single designated grievance officer or the facility's grievance committee and shall be given the opportunity to obtain preparation assistance from another detainee or facility staff. Rating Remarks (1000 Char Max) Meets Standard Detainees submit formal grievances directly to the facility's ICE coordinator/ grievance sergeant. They may obtain assistance in the preparation of grievances from other detainees, facility personnel, family and/or their attorney. Medical grievances are forwarded directly to medical personnel Meets Standard Emergency grievances are defined and identified in policy and described in the local handbook Meets Standard Officers are trained to respond to emergency grievances in an expeditious manner. Meets Standard Detainees are provided two levels of appeal to their grievances and may file a grievance directly to ICE at any time. Per the grievance sergeant, written responses are provided to detainee grievances within reasonable and specified time frames. There have been no general grievances filed by detainees in this inspection period. There have been two medical grievances filed by detainees in this inspection period. Meets Standard Separate automated grievance logs are maintained which contain requirements for proper tracking. Per policy, a copy of the completed grievance, to include the final disposition, is placed in the detainees detention file and provided to the detainee. Medical grievances are maintained in the detainees'medical file. Formal written grievances regarding medical care shall be submitted directly to medical personnel designated to receive and respond to medical grievances at the facility. 6. Each facility shall implement written procedures for identifying and handling a time-sensitive emergency grievance that involves an immediate threat to a detainee's health, safety or welfare. 7. All staff will be trained to appropriately respond to emergency grievances in an expeditious matter. 8. The facility’s established grievance system protocol must provide for at least one level of appeal but may establish more than one. In all instances detainees must receive written decisions about their appeals within reasonable and specified time limits. 9. PRIORITY: Each facility shall devise a method for documenting detainee grievances, at a minimum, a Detainee Grievance Log. The documentation shall include the date of the grievance, nature of the grievance in detail, and the date the grievance was resolved. A copy of the grievance disposition shall be placed in the detainee’s detention file and provided to the detainee. Medical grievances are maintained in the detainee’s medical file. Page 162 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 35. GRIEVANCE SYSTEM (Key: AI) This Detention Standard protects detainees’ rights and ensures they are treated fairly by providing a procedure by which they may file formal grievances and receive timely responses. Components 10. PRIORITY: Staff must forward all detainee grievances containing allegations of staff misconduct to a supervisor or higher-level official in the chain of command. While such grievances are to be processed through the facility’s established grievance system, CDFs and IGSA facilities must also forward a copy of any grievances alleging staff misconduct to ICE/ERO. 11. Staff shall not harass, discipline, punish, or otherwise retaliate against a detainee who files a complaint or grievance or who contacts the Inspector General or the Office for Civil Rights and Civil Liberties. Rating Remarks (1000 Char Max) Meets Standard Per policy, any grievance alleging staff misconduct is forwarded to supervisory personnel and ICE is provided a copy of the grievance. The grievance will be processed through the facility's established grievance system. Meets Standard Per policy, staff are prohibited from treating a detainee unfairly who files a complaint or grievance or who contacts the Inspector General or the Office for Civil Rights and Civil Liberties. PART 6 – 35. GRIEVANCE SYSTEM – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Policies and procedures are in place that protect detainee rights and ensure detainees are treated fairly by providing an avenue to file informal and/or formal grievances and to receive timely responses to those complaints. There have been no general grievances and two medical grievances filed by detainees in this inspection period. Written procedures are in place for handling emergency grievances and urgent access to legal counsel and the law library. Translation and interpretation services are available as needed. Formal grievance procedures are communicated to detainees in a language and manner they understand. All materials are translated into Spanish, or other languages if significant segments of the detainee population have the need. Separate automated grievance logs, one for general grievances and one for medical grievances, collect the information required by the standard and is used to track and document grievances. The facility provides communication assistance to detainees with disabilities and detainees who are limited in their English proficiency (LEP). The facility can provide, if necessary, effective communication to detainees with disabilities, which may include the provision of auxiliary aids, such as readers, telecommunications devices for deaf persons (TTYs), and interpreters via a telephonic language line service. The facility can provide, if necessary, detainees who are LEP with language assistance, including bilingual staff or professional interpretation and translation services. The evaluation of this standard was based on a review of the grievance policy and the grievance logs, interviews with detainees and interviews with Captain Brandon Crowley, Lieutenant Neil Tayor and Registered Nurse Stan Roark. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 163 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (Key: AJ) This Detention Standard protects detainees’ rights by ensuring their access to courts, counsel, and legal materials. Components 1. 2. 3. Each facility shall provide a properly equipped law library in a designated, well-lit room that is reasonably isolated from noisy areas and large enough to provide reasonable access to all detainees who request its use. It shall be furnished with a sufficient number of tables and chairs to facilitate detainees’ legal research and writing. PRIORITY: Each detainee shall be permitted to use the law library for a minimum of five hours per week and may not be forced to forego his or her minimal recreation time to use the law library, consistent with the security needs of the institution and the detainee. Rating Remarks (1000 Char Max) Meets Standard The inspector examined photographs of the law library and noted that the library is: in a private room; well equipped; reasonably isolated from other areas of the facility. The library also has a sufficient number of work stations with an adequate number of chairs, and table space affording detainees with a suitable environment to conduct their legal research. Meets Standard The inspector confirmed that: detainees may use the law library one hour each day Monday through Friday: and they do not have to forego recreation time to use the library. Rating based on review of the local handbook and detainee interviews. PRIORITY: The law library shall provide an adequate number of computers with printers, access to one or more photocopiers and sufficient writing implements, paper, and related office supplies to enable detainees to prepare documents for legal proceedings. Typewriters, carbon paper, and correction tape may be substituted for computers and printers only if approved by ICE/ERO. Each facility administrator shall designate an employee to inspect the equipment at least weekly and ensure it is in good working order and to stock sufficient supplies. Meets Standard 4. Detainees are provided with the means to save legal work in a private electronic format for future use. Meets Standard 5. The facility subscribes to updating services where applicable and legal materials requiring updates are current. 6. Each facility administrator shall designate a facility law library coordinator to be responsible for updating legal materials, inspecting them weekly, maintaining them in good condition and replacing them promptly as needed. The law library has two computer work stations; each computer is defaulted to a printer. The facility's library has sufficient office supplies to help detainees prepare documents for legal proceedings. Staff is responsible for inspecting the library's equipment and supplies. Meets Standard The LexisNexis applications on the library's computes is routinely updated and is current during this inspection. Meets Standard Page 164 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (Key: AJ) This Detention Standard protects detainees’ rights by ensuring their access to courts, counsel, and legal materials. Components 7. 8. 9. PRIORITY: The law library contains all materials listed in the “Law Libraries and Legal Materials” Standard, Attachment A. As an alternative to obtaining and maintaining the paper-based publications in Attachment A, a facility may substitute the Lexis/Nexis publications on CD ROM. Any materials listed in Attachment A which are not loaded onto the Lexis/Nexis CD ROM must be maintained in paper form. Rating Remarks (1000 Char Max) Meets Standard The inspector confirmed that LexisNexis software is installed on each of the library computers and contains the materials required by this component. The assigned ICE DSCO informed the inspector that any additional law materials asked for may be obtained by a detainee making a request to facility or ICE staff. Meets Standard ICE's on site assigned staff verified that the required certifications and field office validation are in place. The facility administrator must certify to the respective Field Office Director – and the Field Office Director must verify – that the facility provides detainees sufficient: • Operable computers that are capable of running the Lexis/Nexis CEROM, • Operable printers, • Supplies for both, and • Instructions for detainees on the basic use of the system. Outside persons and organizations may submit published or unpublished legal material for inclusion in a facility’s law library. If the material is in a language other than English, an English translation must be provided. Outside published material is forwarded and reviewed by the ICE prior to inclusion. 10. Detainees who require legal material not available in the law library may make a written request to the facility law library coordinator, who shall inform the Field Office of the request as soon as possible. 11. The facility shall ensure that detainees can obtain photocopies of legal material when such copies are reasonable and necessary for a legal proceeding involving the detainee. 12. The facility permits detainees to assist other detainees, voluntarily and free of charge, in researching and preparing legal documents. Meets Standard Meets Standard The local handbook states that detainees may refer a request for legal materials not available in the law library to ICE. If approved, the requests are addressed in a timely manner. Meets Standard The handbook states that staff will assist detainees in photocopying legal materials necessary for their legal proceedings. Meets Standard The local handbook states that detainees may assist one another in researching or preparing legal documents. It further states that the assistance must be voluntary and free of charge. Page 165 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL (Key: AJ) This Detention Standard protects detainees’ rights by ensuring their access to courts, counsel, and legal materials. Components Rating 13. Unrepresented illiterate or non-English speaking detainees who wish to pursue a legal claim related to their immigration proceedings or detention, and who indicate difficulty with the legal materials, must be provided with more than access to a set of English-language law books. To the extent practicable and consistent with the good order and security of the facility, all efforts will be made to assist disabled persons in using the law library. Meets Standard 14. The facility shall permit a detainee to retain all personal legal material upon admittance to the general population or Administrative Segregation or Disciplinary Segregation units, unless this would create a safety, security, or sanitation hazard. Stored legal materials are accessible within 24 hours of a written request. Remarks (1000 Char Max) Meets Standard The local handbook states that detainees may keep a reasonable amount of legal materials with them in their housing unit or in special housing baring security concerns. Meets Standard Review of written policy found that detainees in administrative and disciplinary segregation are permitted the same law library access as those in the general population, unless there is a threat to safety. Written policy also states that any denial or restriction of detainee law library access must be documented. Meets Standard Written policy states that all restrictions or denials of detainee law library access must be documented. Such actions must be justifiable; the restriction must be for a limited period and periodically reviewed. Copies of the documentation must be sent to the ICE field office and placed in the detainee's detention file. 17. The facility shall provide assistance to any unrepresented detainee who requests a notary public, certified mail, or other such services to pursue a legal matter, if the detainee is unable do so through a family member, friend, or community organization. Meets Standard Staff informed the inspector that the referenced requests are referred to ICE. 18. Staff shall not permit a detainee to be subjected to reprisals, retaliation, or penalties because of a decision to seek judicial or administrative relief or investigation of any matter. Meets Standard 15. Detainees housed in Administrative Segregation and Disciplinary Segregation units have the same law library access as the general population, unless compelling security concerns require limitations. 16. Denial of access to the law library must be: • Supported by compelling security concerns, • For the shortest period required for security, • Fully documented in the Special Management Unit housing logbook, and • The reason should be documented and placed in the detention file. The facility shall notify the Field Office every time access is denied and send a copy of the proper documentation. PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Page 166 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 36. LAW LIBRARIES AND LEGAL MATERIAL – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Law library and legal materials are handled in accordance with the standard. The facility has procedures in place that effectively prevent detainees from damaging, destroying or removing equipment, materials or supplies from the law library. Staff accommodates detainee requests for additional law library time to the extent that is consistent with the orderly and secure operation of the facility. Special priority access to the library is given to requests from a detainee who is facing a court deadline. The facility provides indigent detainees with free envelopes and stamps for mail related to a legal matter, including correspondence to a legal representative, a potential legal representative or any court. Requests to send international mail are honored as is reasonable. The detainee handbook outlines the rules and procedures governing access to legal materials and the procedures are also posted in the law library along with a list of the law library's holdings. In order to enhance the provision of access to legal materials and services, the facility provides communication assistance to LEP detainees and detainees with disabilities. This is achieved via bilingual staff, translation services, or other means for LEP detainees; or in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. ICE officers routinely provide updated LexisNexis software for installation on the library's computers. The last update was installed January, 2021. Evaluation of the standard included review of policy, and; interviews with detainees, ICE and facility staff members. The inspector interviewed Assistant Jail Administrator Taylor and DSCO Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 167 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 37. LEGAL RIGHTS GROUP PRESENTATIONS (Key: AK) This Detention Standard protects detainees’ rights by ensuring their access to information presented by authorized persons and organizations for the purpose of informing them of U.S. immigration law and procedures. Standard N/A I Click the above button if No Group Presentations were conducted within the past 12 months. (All Line Items and standard will be rated “N/A”) Components 1. 2. If upon notification by the Field Office Director that a group presentation on legal rights has been approved, the facility administrator shall telephone the listed contact person to arrange a mutually acceptable date and time for the presentation according to the standard. Rating N/A PRIORITY: At least 48 hours before a scheduled presentation, facility staff shall in each housing unit prominently display the informational posters provided by the presenter, and provide a sign-up sheet for detainees who plan to attend. The facility shall ensure that presentations are open to all detainees, regardless of the presenter’s intended audience, except when a particular detainee’s attendance would pose a security risk. If a detainee in segregation cannot attend for this reason, facility staff shall make alternative arrangements, if the detainee or the presenter so request. N/A 3. One or more legal assistants may help with a presentation. N/A 4. The presenters ordinarily will have at least one hour for the presentation and additional time for a question-andanswer session ICE/ERO and/or facility staff may observe and monitor presentations, assisted by interpreters as necessary. ICE/ERO and facility personnel will not interrupt a presentation, except for security purposes or if the allotted time has expired. N/A If approved in advance by ICE/ERO, presenters may distribute brief written materials that inform detainees of U.S. immigration law and procedure. The request for approval of a presentation must list any published or unpublished materials proposed for distribution, and the requestor must provide a copy of any unpublished material, with a cover page. N/A Following a group presentation, the facility shall permit presenters to meet with small groups of detainees to discuss their cases as long as meetings do not interfere with facility security and orderly operations. N/A 5. 6. Remarks (1000 Char Max) Page 168 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 6 – 37. LEGAL RIGHTS GROUP PRESENTATIONS (Key: AK) This Detention Standard protects detainees’ rights by ensuring their access to information presented by authorized persons and organizations for the purpose of informing them of U.S. immigration law and procedures. Standard N/A I Click the above button if No Group Presentations were conducted within the past 12 months. (All Line Items and standard will be rated “N/A”) Components 7. 8. Rating Remarks (1000 Char Max) The facility may discontinue or temporarily suspend group presentations by any or all presenters, if they: • Pose an unreasonable security risk; • Interfere substantially with the facility’s orderly operation; • Deviate materially from approved presentation material, procedures or presenters; or if • The facility is operating under emergency conditions. PRIORITY: If ICE/ERO approves an electronic presentation submitted by qualified individuals or organizations, the facility shall provide regularly scheduled and announced opportunities for detainees in the general population to view or listen to the electronic presentation(s). N/A N/A Each facility shall present only ICE/ERO-approved electronic presentations on detainee legal rights. 9. The facility shall maintain electronically-formatted presentations and equipment in good condition. N/A PART 6 - 37. LEGAL RIGHTS GROUP PRESENTATIONS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) There have been no legal rights presentations conducted at this facility in the past twelve months. The inspector interviewed Assistant Jail Administrator Taylor. Overall Rating: N/A Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 169 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities Section VII: ADMINISTRATION & MANAGEMENT Detention Files News Media Interviews and Tours Staff Training Transfer of Detainees Page 170 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 38. DETENTION FILES (Key: AL) This Detention Standard contributes to efficient and responsible facility management by maintaining for each detainee booked into a facility for more than 24 hours a file of all significant information about that person. Components 1. 2. 3. 4. 5. 6. Rating For every new arrival whose stay will exceed 24 hours, a designated officer shall create a detainee detention file. The detainee detention file contains either originals or copies of documentation and forms generated during the admissions process. The detention files are located and maintained in a secured area. Each detention file remains active during the detainee’s stay. When the detainee is released from the facility, staff add copies of completed release documents, the original closed-out receipts for property and valuables, the original I-385 or equivalent and other documentation. Remarks (1000 Char Max) Meets Standard Interviews with facility staff confirmed that detention files are created for every new admission during intake. Meets Standard Review of detainee files (eight) confirmed that detention files contain documentation and forms generated during the admissions process. Meets Standard The inspector examined photographs of the lockable cabinets located in a secure area of the facility where detainee files are located. Staff informed the inspector that active files are maintained and closed in accordance with the requirements of this component Meets Standard The inspector examined detainee files that had been marked "closed" and found copies of the close out documents referenced in the component. At a minimum, a logbook entry recording the file’s removal from the cabinet shall include: • The detainee’s name and A-File number; • Date and time removed; • Reason for removal; • Signature of person removing the file, including title and department; • Date and time returned; and • Signature of person returning the file. Meets Standard Electronic record-keeping systems and data are protected from unauthorized access. Meets Standard The inspector was informed that all facility "e" files are password protected. PART 7 – 38. DETENTION FILES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Page 171 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 38. DETENTION FILES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Detention files are handled in accordance with the standard. The facility has procedures in place to ensure that intake officers always have the necessary supplies, that equipment is maintained in good working order, including photocopier(s) and paper and the equipment has the capacity to handle the volume of work generated. The officer closing the detention files makes a notation that the file is complete and ready for archiving. The closed file is not transferred with the detainee to another facility. Detention files are handled in accordance with the provisions of the Privacy Act and records are only released following those guidelines. Evaluation of the standard included review of policy, examination of ten active detainee files and one archived filed, and staff interviews. The inspector interviewed Assistant Jail Administrator Taylor and Sargent Glassburn. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 172 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 39. NEWS MEDIA INTERVIEWS AND TOURS (Key: AM) This Detention Standard ensures that the public and the media are informed of events within the facility’s areas of responsibility through interviews and tours. Components 1. 2. 3. 4. 5. Rating Remarks (1000 Char Max) Interviews by reporters, other news media representatives, academics and parties not included in other visitation categories in the Detention Standard on Visitation shall be permitted access to facilities only by special arrangement and with prior approval of the respective ICE/ERO Field Office Director. Meets Standard Interviews with ICE and facility staff confirmed that requests to interview a detainee are referred to ICE for approval. News media organizations shall abide by the policies and procedures of the facility being visited or toured. Media representatives must obtain advance permission from the facility administrator and FOD before taking photographs in or of any facility. The facility administrator shall advise both media representatives and detainees that use of any detainee's name, identifiable photo, or recorded voice requires his or her prior permission. Meets Standard Staff interviews confirmed that the requirements of this standard are complied with. Media representatives shall obtain a signed release from the detainee before photographing or recording his or her voice. The original of the form is to be filed in the detainee’s A-file with a copy in the facility’s Detention File. Meets Standard Staff interviews confirmed that the requirements of this standard are complied with. Meets Standard The assigned ICE staff confirmed that the Field Office is consulted regarding any issues concerning the case of a high-profile detainee. Meets Standard ICE personnel confirmed that an ICE public information officer would coordinate with the Field Office Director to ensure that press pool protocols for accommodating a large volume of interview requests were followed. When the alien is the center of a controversy or of a special interest or high profile case, the Field Office Director shall consult with the Headquarters Deputy Assistant Director, Detention Management Division, before deciding whether to allow the interview. A press pool may be established when the Field Office Director and facility administrator determine that the volume of interview requests warrants such action. The facility administrator shall notify all media representatives with pending or requested interviews, tours, or visits that, effective immediately and until further notice, all media representatives must comply with the press pool guidelines established by the Field Office Director. PART 7 - 39. NEWS MEDIA INTERVIEWS AND TOURS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) There are written policy and procedures in place that ensure that a media request does not delay or otherwise interfere with the admission in-processing or departure of a detainee. The privacy of detainees and staff, including the right of a detainee not be photographed or recorded, is protected. Media representatives, media visitors, tours, personal interviews, press pools and visits by NGOs are all coordinated and approved by ICE officials. Access is not denied based on the political or editorial viewpoint of the requestor. Prior to the tour, the OIC or designee explains the terms and guidelines of the tour to the visitors. During the evaluation of this standard, policy and procedures were reviewed, ICE staff were interviewed and documents referencing a recent media tour of the facility were reviewed. Page 173 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 - 39. NEWS MEDIA INTERVIEWS AND TOURS – Reviewer Summary (Use following format for dates: mm/dd/yyyy) The inspector interviewed Assistant Jail Administrator Taylor and ICE DSCO Tillman. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 174 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 40. STAFF TRAINING (Key: AN) This Detention Standard ensures that staff, contractors, and volunteers are competent in their assigned duties by requiring that they receive initial and ongoing refresher training. Components 1. 2. The amount and content of training is consistent with the duties and function of each individual and the degree of direct supervision that individual receives. 3. At least one qualified individual with specialized training for the position coordinates and oversees the staff development and training program. At a minimum, fulltime training personnel complete a 40-hour training-fortrainers course. 4. Rating Remarks (1000 Char Max) Does Not Meet Standard Per Indiana regulations, new corrections officers must complete the State of Indiana Law Enforcement/Police Academy - Jail School training within their first year of employment. This training is provided at county jails around the state, including this facility on occasion. In addition, new Clay County jail employees must complete a forty hour on-the-job training program prior to working a post alone. A fortyhour annual refresher training is provided and documented to corrections personnel. Interviews with the lieutenant and a review of documentation indicated volunteers and county maintenance personnel are not provided appropriate training. The facility conducts appropriate orientation, initial training, and annual training for all staff, contractors, and volunteers with appropriate assessment measures. Training is governed and guided by a training plan that is reviewed and approved annually by the facility administrator. 5. Training shall be conducted by trainers certified in the subject matter. 6. Each trainee shall be required to pass a written or practical examination to ensure the subject matter has been mastered. Meets Standard Meets Standard The forty-hour jail school training is provided by certified trainers. The captain and lieutenant are not full-time training personnel; however, they provide training to facility personnel. Each has completed a leadership training program. Meets Standard The training plan is presented as the required topics covered in the annual refresher plan. The training is presented by the captain, who serves as the facility administrator. Meets Standard Meets Standard Page 175 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) Written or practical examinations are administered after training sessions to ensure the subject matter is understood. G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 40. STAFF TRAINING (Key: AN) This Detention Standard ensures that staff, contractors, and volunteers are competent in their assigned duties by requiring that they receive initial and ongoing refresher training. Components 7. The formal training received by each trainee shall be fully documented in permanent training records. 8. Each new employee, contractor, and volunteer is provided an orientation prior to assuming duties. While tailored specifically for staff, contractors, and volunteers, the orientation programs include, at a minimum: 9. • ICE/ERO National Detention Standards • Working conditions • Cultural diversity for understanding staff and detainees • Requirements of special-needs detainees • Code of ethics • Personnel policy manual • Employees' rights and responsibilities • Drug-free workplace • Health-related emergencies • Signs of suicide risk, suicide precautions, prevention, and intervention • Hunger strikes • Use of force • Key and lock control • Overview of the criminal justice system • Tour of the facility • Facility goals and objectives • Facility organization • Staff rules and regulations • Sexual harassment/sexual misconduct awareness • Hostage situations and staff conduct if taken hostage • Program overview. Clerical/support employees who have minimal detainee contact receive the facility initial training and training specific to their job duties. Rating Remarks (1000 Char Max) Meets Standard Does Not Meet Standard County maintenance personnel and volunteers are not provided orientation training which address at a minimum the elements of this component. County maintenance personnel are not members of jail staff but are in the facility frequently and have interaction with detainees. Interviews with the lieutenant indicated religious volunteers were not trained prior to providing services available to detainees and non-ICE detainees. Although volunteers are not currently allowed in the facility due to COVID-19 restrictions, policy does not address the required training they must receive. N/A There are no clerical and/or support personnel who have minimal contact with detainees. Page 176 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 40. STAFF TRAINING (Key: AN) This Detention Standard ensures that staff, contractors, and volunteers are competent in their assigned duties by requiring that they receive initial and ongoing refresher training. Components Rating Remarks (1000 Char Max) Meets Standard There are no clerical and/or support personnel who have minimal contact with detainees. Professional personnel receive training which addresses the elements of this component. 10. Professional and support employees (including contractors) who have regular or daily detainee contact will receive training on the following subjects, at a minimum: • ICE/ERO National Detention Standards update • Security procedures and regulations • Code of Ethics • Health-related emergencies • Drug-free workplace • Supervision of detainees • Signs of hunger strike • Signs of suicide risk, suicide precautions, prevention, and intervention • Use-of-force regulations and tactics • Hostage situations and staff conduct if taken hostage • Report writing • Detainee rules and regulations • Key and lock control • Rights and responsibilities of detainees • Safety procedures • Emergency plan and procedures • Interpersonal relations • Social and cultural lifestyles of the detainee population • Cultural diversity for understanding staff and detainees • Communication skills • Cardiopulmonary resuscitation (CPR)/First aid • Counseling techniques • Sexual harassment and sexual misconduct awareness Page 177 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 40. STAFF TRAINING (Key: AN) This Detention Standard ensures that staff, contractors, and volunteers are competent in their assigned duties by requiring that they receive initial and ongoing refresher training. Components Rating Remarks (1000 Char Max) Does Not Meet Standard There was no documentation provided to indicate full-time health care personnel receive forty hours of formal orientation training which addresses the elements of this component. 11. Full-time health care employees receive at least 40 hours of formal orientation before undertaking their assignments. In addition to the training areas above, the health-care employee orientation program includes instruction in the following: • ICE/ERO National Detention Standards update • The purpose, goals, policies, and procedures for the facility and parent agency security and contraband regulations • Key and lock control; appropriate conduct with detainees • Medical grievance procedures and protocols • Emergency medical procedures • Requirements of special-needs detainees • Code of ethics • Drug-free workplace • Responsibilities and rights of employees • Standard precautions • Occupational exposure • Personal protective equipment • Bio-hazardous waste disposal • Overview of the detention operations • Hostage situations and staff conduct if taken hostage Page 178 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 40. STAFF TRAINING (Key: AN) This Detention Standard ensures that staff, contractors, and volunteers are competent in their assigned duties by requiring that they receive initial and ongoing refresher training. Components Rating Remarks (1000 Char Max) Meets Standard During the previous inspection, this component was rated Does Not Meet Standard because there was insufficient documentation that security staff were consistently receiving training in each of the subjects listed in this component. Training provided to officers is in compliance with Indiana state law and covers the required topics of this component. Documentation was not available to indicate security personnel receive the minimum training required in the component. During this inspection, documentation was provided and reviewed which indicated the required training has been provided. N/A The facility does not have a situation response team. Should this type of assistance be required patrol deputies would be called in to assist jail personnel. Meets Standard The captain and lieutenant have received leadership training. Documentation of the training was reviewed during the inspection. 12. Security personnel (including contractors) will receive training on the following subjects, at a minimum: • ICE/ERO National Detention Standards update • Security procedures and regulations • Supervision of detainees • Searches of detainees, housing units, and work areas • Signs of suicide risk, suicide precautions, prevention, and intervention • Indicators of hunger strike • Code of Ethics • Health-related emergencies • Drug-free workplace • Self-defense techniques • Use-of-force regulations and tactics • Hostage situations and staff conduct if taken hostage • Report writing • Detainee rules and regulations • Key and lock control • Rights and responsibilities of detainees • Safety procedures • Emergency plans and procedures • Interpersonal relations • Social/cultural lifestyles of the detainee population • Cultural diversity for detainees and staff • Communication skills • Cardiopulmonary resuscitation (CPR) and first aid • Counseling techniques • Sexual abuse and assault awareness 13. Situation Response Teams (SRTs) receive: • Specialized training assignments. before undertaking their 14. Facility management and supervisory staff receive Management and Supervisory training. Page 179 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 – 40. STAFF TRAINING (Key: AN) This Detention Standard ensures that staff, contractors, and volunteers are competent in their assigned duties by requiring that they receive initial and ongoing refresher training. Components 15. PRIORITY: Personnel authorized to use firearms receive training that covers their use, safety, and care and constraints on their use – before being assigned to a post involving their possible use. Rating Remarks (1000 Char Max) Meets Standard Personnel authorized to use firearms are provided training which addresses the requirements of this component. Competency in the use of the firearm is required annually. Meets Standard Not all jail personnel are authorized to use chemical agents. Those that are authorized to use chemical agents are provided training which addresses the requirements of this component. The training includes the trainees exposure to the chemical agent so the trainee will have a clear understanding of the effects of its use. The training also includes the decontamination of individuals exposed to the chemical. All personnel authorized to use firearms demonstrate competency in their use at least annually. 16. PRIORITY: Personnel authorized to use chemical agents receive training in the use of chemical agents and in the treatment of individuals exposed to a chemical agent before being assigned to a post involving their possible use. PART 7 – 40. STAFF TRAINING – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Evaluation of this standard was based on review of the training plan, training policy, sign-in documents and interviews with the captain and lieutenant. There is no certified trainer assigned to the facility. Training is provided by certified trainers assigned to the Clay County Sheriff's Office. As noted above volunteers, when allowed into the facility, are not provided an orientation training as required by the standard. Maintenance is provided by county maintenance personnel, which are not jail personnel nor are they county personnel assigned permanently to the jail. These maintenance personnel do willingly adhere to safety and security protocols of the jail. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 29 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 180 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 - 41. TRANSFER OF DETAINEES (Key: AO) This Detention Standard ensures that transfers of detainees from one facility to another are professionally and responsibly managed in regard to notifications, detainee records, safety and security, and protection of detainee funds and personal property. Components 1. 2. 3. Rating Remarks (1000 Char Max) Meets Standard The inspector was informed by ICE staff that: transfer notifications are processed by the local ICE field officer; and detainee transfer plans are not discussed prior to a detainee's transfer so the detainee would not be able to call or tell another detainee in the general population about the pending transfer. Facility policy mandates that: • Times and transfer plans are never discussed with the detainee prior to transfer. • The detainee is not notified of the transfer until immediately prior to departing the facility. • The detainee is not permitted to make any phone calls or have contact with any detainee in the general population. A detainee may not be removed from any facility without a Form I-203 or I-203A or equivalent authorizing the removal of the detainee the facility. The facility health care provider shall be notified sufficiently in advance of the transfer that medical staff may determine and provide for any associated medical needs. Meets Standard Meets Standard ICE and facility staff informed the inspector that I-203 forms authorize detainee removals The inspector also examined I203 forms contained in closed detainee files. The inspector was informed that health care providers are given notice of upcoming detainee transfers. The medical SME confirmed adherence to the requirements of this component. 4. 5. The sending facility's medical staff shall prepare a Transfer Summary that must accompany the transferee. Either the USM 553 Form or a facility-specific form may be used, provided it shows: • TB clearance, including PPD and Chest x-ray results, with the test dates; • Current mental and physical health status, including all significant health issues; • Current medications, with specific instructions for medications that must be administered en route; and • The name and contact information of the transferring medical official. Transportation staff may not transport a detainee without the required Transfer Summary, which is essential for detainee safety while in transit. Meets Standard Interviews with ICE staff confirmed that the facility is in compliance with each of the requirements of this component. Meets Standard Page 181 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 - 41. TRANSFER OF DETAINEES (Key: AO) This Detention Standard ensures that transfers of detainees from one facility to another are professionally and responsibly managed in regard to notifications, detainee records, safety and security, and protection of detainee funds and personal property. Components 6. Rating Medical staff shall notify the facility administrator when they determine that a detainee’s medical or psychiatric condition requires: • Clearance by the medical staff prior to transfer, or • Medical escort during transfer. Meets Standard Remarks (1000 Char Max) Facility staff informed the inspector that medical personnel will advise the facility administrator when a detainee's medical or psychiatric condition requires clearance prior to transfer or a medical escort is required during the transfer. The medical SME confirmed adherence to the requirements of this component. 7. PRIORITY: Prior to transfer, medical personnel shall provide the transporting officers instructions and, if applicable, medication(s) for the detainee’s care in transit. Detainees shall be transferred with, at a minimum, 7 days worth of prescription medications (TB medications, a 15 days supply) to ensure continuity of care throughout the transfer and subsequent intake process. Medications shall be: 8. 9. • Placed in a property envelope with the detainee's name and A-number on it, • Accompany the transfer, and • If unused, be turned over to an officer at the receiving Field Office. Before transfer, the sending facility shall return all funds and small valuables to the detainee and close out all forms G-589 (or local IGSA funds and valuables receipts) in accordance with the Detention Standard on Funds and Personal Property. Within 24 hours of arrival at the final transfer destination all detainees should be given the opportunity to make a phone call. Any indigent detainee shall be permitted a single domestic phone call at the Governments expense, ordinarily using a PCS Emergency Card or equivalent. Meets Standard Reviewed policy issuances confirmed that each element of this component is addressed. Interviews with staff confirmed that the policy is also followed in practice. Meets Standard Interviews with ICE staff confirmed that the facility is in compliance with the requirements of this component. Meets Standard Facility staff informed the inspector that detainees arriving at this IGSA are provided the opportunity to place a telephone call within 24 hours, free of charge. PART 7 - 41. TRANSFER OF DETAINEES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) Overall Remarks: (Record significant facts, observations, other sources used, etc.) (5000 Character Max) Transfers are approved and facilitated with consideration for the safety and security of the staff, detainees and the public. Policy and procedures address notifications, detainee records and the protection of detainee funds and property. ICE officers informed the inspector that indigent detainees being transferred will be authorized a single domestic phone call at the government's expense upon arrival at their destination. Non-indigent detainees have access to make calls at their own expense pursuant to the Detainee Telephone Access standard. Page 182 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities PART 7 - 41. TRANSFER OF DETAINEES – Reviewer Summary (Use following format for dates: mm/dd/yyyy) In order to provide access to programs and services, the facility provides communication assistance to LEP detainees and detainees with disabilities. This may be achieved via bilingual staff, translation services, or other means for LEP detainees; or in the form of auxiliary aids for detainees with disabilities including, but not limited to, those aids listed in the standard. To evaluate this standard, policy was reviewed and Assistant Jail Administrator Taylor and Sergeant Glassburn were interviewed. Overall Rating: Meets Standard Reviewer Name (Printed): Inspector 2 I Completion Date: 5/20/2021 Reviewer Signature (for printed form submission): Page 183 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 Performance-Based National Detention Standards 2008 Inspection Worksheet for Over 72 Hour Facilities DOCUMENT CHECK The document check should be run upon completion of the review form and PRIOR to submission to DHS-ICE. This check will help ensure the form is ready for upload to DHS-ICE systems. Errors indicate issues were found with specific data entered into the form. Items Not Rated indicate there were line items found on the form which remain in a “Not Rated” status. This action will also update the table of contents. The check will take several minutes to complete, during which the screen will flash. Review Document Issue Summary Check Document: Errors: Run Check I Ratings check complete. Error(s) Found: 0 Items Not Rated: No Errors Found Items Not Rated: All Items Rated Run Indicator: Page 184 of 184 FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) G-324A PBNDS 2008 Detention Inspection Worksheet - Rev: 05/09/2017 – Form Key 27 0
