ICE’s Inspections and
Monitoring of Detention
Facilities Do Not Lead to
Sustained Compliance or
Systemic Improvements

June 26, 2018
OIG-18-67

DHS OIG HIGHLIGHTS

ICE’s Inspections and Monitoring of
Detention Facilities Do Not Lead to Sustained
Compliance or Systemic Improvements


June 26, 2018

What We Found

Why We
Did This
Inspection

ICE uses two inspection types to examine
detention conditions in more than 200 detention
facilities. ICE contracts with a private company
and also relies on its Office of Detention Oversight
for inspections. ICE also uses an onsite
monitoring program. Yet, neither the inspections
nor the onsite monitoring ensure consistent
compliance with detention standards, nor do they
promote comprehensive deficiency corrections.
Specifically, the scope of ICE’s contracted
inspections is too broad; ICE’s guidance on
procedures is unclear; and the contractor’s
inspection practices are not consistently
thorough. As a result, the inspections do not fully
examine actual conditions or identify all
deficiencies. In contrast, ICE’s Office of Detention
Oversight uses effective practices to thoroughly
inspect facilities and identify deficiencies, but
these inspections are too infrequent to ensure the
facilities implement all deficiency corrections.
Moreover, ICE does not adequately follow up on
identified deficiencies or consistently hold
facilities accountable for correcting them, which
further diminishes the usefulness of inspections.
Although ICE’s inspections, follow-up processes,
and onsite monitoring of facilities help correct
some deficiencies, they do not ensure adequate
oversight or systemic improvements in detention
conditions, with some deficiencies remaining
unaddressed for years.

U.S. Immigration and
Customs Enforcement
(ICE) inspects and
monitors just over 200
detention facilities
where removable aliens
are held. In this review
we sought to determine
whether ICE’s
immigration detention
inspections ensure
adequate oversight and
compliance with
detention standards. We
also evaluated whether
ICE’s post-inspection
follow-up processes
result in correction of
identified deficiencies.

What We
Recommend
We made five
recommendations to
improve inspections,
follow-up, and
monitoring of ICE
detention facilities.
For Further Information:
Contact our Office of Public Affairs
at (202) 254-4100, or email us at
DHS-OIG.OfficePublicAffairs@oig.dhs.gov

ICE Response
ICE officials concurred with all five
recommendations and proposed steps to update
processes and guidance to improve oversight over
detention facilities.

www.oig.dhs.gov

OIG-18-67


OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Washington, DC 20528 / www.oig.dhs.gov

-XQH
MEMORANDUM FOR: 	 Thomas D. Homan
Deputy Director and Senior Official Performing the
Duties of the Director
U.S. Immigration and Customs Enforcement
FROM: 	

John V. Kelly
Acting Inspector General

SUBJECT: 	

ICE’s Inspections and Monitoring of Detention Facilities
Do Not Lead to Sustained Compliance or Systemic
Improvements

Attached for your information is our final report, ICE’s Inspections and
Monitoring of Detention Facilities Do Not Lead to Sustained Compliance or
Systemic Improvements. We incorporated the formal comments from the ICE
Office of Custody Management and Office of Detention Oversight in the final
report.
Consistent with our responsibility under the Inspector General Act, we will
provide copies of our report to congressional committees with oversight and
appropriation responsibility over the Department of Homeland Security. We will
post the report on our website for public dissemination.
Please call me with any questions, or your staff may contact Jennifer Costello,
Chief Operating Officer, at (202) 254-4100.
Attachment

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security


Table of Contents

Background .................................................................................................... 1 

Results of Inspection....................................................................................... 4 

Nakamoto Inspections Are Significantly Limited and Office of Detention 

Oversight Inspections Are Not Frequent Enough .................................... 5 

Inadequate Inspection Follow-up Leads to Continuing Deficiencies ...... 11 

Onsite Detention Service Managers Face Challenges in Improving 

Compliance ......................................................................................... 14 

Conclusion ................................................................................................... 15 

Recommendations......................................................................................... 15 


Appendixes
Appendix A: Objective, Scope, and Methodology .................................. 19
Appendix B: Management Comments to the Draft Report ..................... 20
Appendix C: National Detention Standards (NDS) and 

Performance-Based National Detention Standards 

(PBNDS 2008 and PBNDS 2011) .......................................................... 24
Appendix D: Core Standards ICE Office of Professional Responsibility’s 

Office of Detention Oversight Uses to Assess Detention Conditions ...... 26
Appendix E: Office of Inspections and Evaluations Major 

Contributors to This Report………. ....................................................... 27
Appendix F: Report Distribution. ......................................................... 28

Abbreviations
ADP
DSCU
DSM
ERO
FOD
ICE
IGSA
NDS
ODO
OIG
PBNDS
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average daily population
Detention Standards and Compliance Unit
Detention Service Manager
Enforcement and Removal Operations
Field Office Director
U.S. Immigration and Customs Enforcement
Inter-governmental Service Agreement
National Detention Standards
Office of Detention Oversight
Office of Inspector General
Performance-Based National Detention Standards
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SOW
UCAP

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Statement of Work
Uniform Corrective Action Plan

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Background
U.S. Immigration and Customs Enforcement (ICE) Enforcement and Removal
Operations (ERO) apprehends removable aliens, detains these individuals when
necessary, and removes them from the United States. All ICE detainees are
held in civil, not criminal, custody. ICE detention is administrative in nature,
aimed to process and prepare detainees for removal. At the end of fiscal year
2017, ICE held nearly 38,000 detainees in custody, with more than 35,000
detainees in the facilities that undergo ICE inspections discussed in this report.
Table 1 lists the types and numbers of facilities ICE uses to detain removable
aliens as well as the average daily population (ADP) at the end of FY 2017.
Table 1: Types of Facilities ICE Uses for Detention
Facility Type

Description

Number of
Facilities

FY 17 Year
End ADP

Service Processing
Center
(SPC)

Facilities owned by the
Department of Homeland
Security and generally operated
by contract detention staff

5

3,263

8

6,818

Contract Detention Facilities owned and operated
by private companies and
Facility
contracted directly by ICE
(CDF)
Intergovernmental
Service
Agreement
(IGSA)

Facilities, such as local and county
jails, housing ICE detainees (as well
as other inmates) under an IGSA
with ICE

87

8,778

Dedicated Intergovernmental
Service
Agreement
(DIGSA)

Facilities dedicated to housing
only ICE detainees under an IGSA
with ICE

11

9,820

U.S. Marshals
Service Intergovernmental
Agreement
(USMS IGA)

Facilities contracted by the U.S.
Marshals Service that ICE also
agrees to use

100

6,756

211

35,435

Total:
Source: ICE data

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ICE began operating its detention system under the National Detention
Standards (NDS), which it issued in 2000 to establish consistent conditions of
confinement, program operations, and management expectations in its
detention system. Along with stakeholders, ICE revised the NDS and developed
Performance-Based National Detention Standards 2008 (PBNDS 2008) to
improve safety, security, and conditions of confinement for detainees. With its
Performance-Based National Detention Standards 2011 (PBNDS 2011), ICE
aimed to enhance immigration detention conditions while maintaining a safe
and secure detention environment for staff and detainees. Contracts and
agreements with facilities that hold ICE detainees include either NDS, PBNDS
2008, or PBNDS 2011.1 Appendix C lists the standards included in each set.
As part of its layered approach, various ICE offices manage the oversight and
monitoring of detention standards and have different roles and responsibilities.
Specifically, ICE uses the following inspections2 and onsite monitoring program
to determine whether facilities comply with applicable detention standards.3
x Inspections by Nakamoto Group, Inc. (Nakamoto): ICE ERO Custody
Management, which manages ICE detention operations and oversees the
administrative custody of detained aliens, contracts with Nakamoto4 to
annually or biennially inspect facilities that hold ICE detainees more than
72 hours.5 Nakamoto inspects about 100 facilities per year to determine
compliance with 39 to 42 applicable detention standards.6 Nakamoto
inspected or re-inspected 103 facilities in 2015, 83 facilities in 2016, and
116 facilities in 2017. ICE uses Nakamoto to inspect all types of facilities
listed in table 1.

ICE also uses Family Residential Standards for Family Residential Centers holding families
and juveniles; we did not examine oversight of these facilities in this review.
2 The inspection types evaluated in this report inspect facilities holding detainees more than 72
hours because about 99 percent of ICE detainees are in such facilities.
3 ICE also has procedures for operational review self-assessments, which allow facilities with
an average daily population of fewer than 10 detainees or those designated as short-term
facilities that house detainees under 72 hours to conduct their own inspections, under the
guidance of the local ICE ERO field office. We did not assess these operational review selfassessments.
4 ICE ERO has been contracting with Nakamoto since 2007; ICE ERO last re-competed and reawarded the contract in 2016.
5 Nakamoto also conducts quality assurance reviews, technical assistance reviews, follow-up
inspections, special assessments, and pre-occupancy inspections; we only assessed
Nakamoto’s annual/biennial inspections. Nakamoto also inspects a few facilities holding
detainees less than 72 hours.
6 As shown in appendix C, the number of standards inspected depends on whether the facility
operates under NDS or PBNDS.
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x	 Inspections by the Office of Detention Oversight (ODO): ODO is unit of
the ICE’s Office of Professional Responsibility, Inspections and Detention
Oversight Division. ODO is institutionally separate from ERO. As such, ODO
inspections aim to provide ICE executive leadership with an independent
assessment of detention facilities. About once every 3 years, ODO also
inspects detention facilities that hold ICE detainees more than 72 hours
(and have an average daily population of more than 10 detainees). ODO
adjusts its inspection schedule based on perceived risk, ICE direction, or
national interest. ODO leadership determines the facilities to review each
year based on staffing budget, agency priorities, and special requests by ICE
leadership. Contract staff from Creative Corrections, LLC support ODO
teams. ODO inspects facilities to determine compliance with 15 to 16 “core”
standards, identified in appendix D. ODO inspected 23 facilities in FY 2015,
29 in FY 2016, and 33 in FY 2017. ODO also inspects all types of facilities
listed in table 1, but less frequently.
x	 Monitoring by the Detention Service Managers (DSM): ICE ERO Custody
Management also has a Detention Monitoring Program through which onsite
DSMs at select facilities, covering each facility type listed in table 1,
continuously monitor compliance with ICE detention standards. In
December 2017, 35 DSMs monitored compliance with ICE detention
standards at 54 facilities holding more than 70 percent of detainees. Both
Nakamoto and ODO still inspect facilities that have DSMs as the inspection
processes are separate from the onsite monitoring.
The responsibility for monitoring follow-up and corrective actions resulting
from ICE’s detention oversight falls to the Detention Standards and Compliance
Unit (DSCU), also within ICE ERO Custody Management, and to ICE ERO field
offices. Detention facilities develop Uniform Corrective Action Plans (UCAP)
when either Nakamoto or ODO inspections find instances of noncompliance.
DSCU and ICE ERO field office managers work with facilities to resolve the
issues.
We evaluated policies, procedures, and inspection practices, and we observed
Nakamoto and ODO inspections of detention facilities. Between April and
August 2017, we observed Nakamoto inspections at Irwin County Detention
Center in Ocilla, Georgia, and at Johnson County Detention Center in
Cleburne, Texas. We observed ODO inspections at Eloy Detention Center in
Eloy, Arizona, and at Stewart Detention Center in Lumpkin, Georgia. We also
reviewed a sample of Nakamoto and ODO inspection reports and UCAPs to
evaluate how ICE reports on and corrects identified deficiencies. For our
observations, we used a limited judgmental sample and relied on our
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professional judgment as inspectors to draw conclusions when we observed
practices of Nakamoto and ODO inspection teams. We also interviewed nine
DSMs from various types of facilities. In this review we sought to determine the
effectiveness of both ICE’s immigration detention inspection and follow-up
processes as well as its monitoring of detention facilities.

Results of Inspection
Neither type of inspection ICE uses to examine detention facilities ensures
consistent compliance with detention standards or comprehensive correction of
identified deficiencies. Specifically, because the Nakamoto inspection scope is
too broad, ICE’s guidance on procedures is unclear, and Nakamoto’s inspection
practices are not consistently thorough, its inspections do not fully examine
actual conditions or identify all compliance deficiencies. In contrast, ODO uses
effective methods and processes to thoroughly inspect facilities and identify
deficiencies, but the inspections are too infrequent to ensure the facilities
implement all corrections. Moreover, ICE does not adequately follow up on
identified deficiencies or systematically hold facilities accountable for correcting
deficiencies, which further diminishes the usefulness of both Nakamoto and
ODO inspections. In addition, ICE ERO field offices’ engagement with onsite
DSMs is inconsistent, which hinders implementation of needed changes.
Although ICE’s inspections, follow-up processes, and DSMs’ monitoring of
facilities help correct some deficiencies, they do not ensure adequate oversight
or systemic improvements in detention conditions; certain deficiencies remain
unaddressed for years.
As some of our previous work indicates, ICE’s difficulties with monitoring and
enforcing compliance with detention standards stretch back many years and
continue today. In 2006, the Office of Inspector General (OIG) identified issues
related to ICE detention facility inspections and implementation of corrective
actions. In our 2006 report, we recommended that ICE “improve the inspection
process and ensure that all non-compliance deficiencies are identified and
corrected.”7 In a December 2017 report, which related to OIG’s unannounced


Treatment of Immigration Detainees Housed at Immigration and Customs Enforcement
Facilities, OIG-07-01, December 2006
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inspections of five detention facilities, we identified problems in some of the
same areas noted in the 2006 report.8

Nakamoto Inspections Are Significantly Limited and Office of
Detention Oversight Inspections Are Not Frequent Enough
After observing Nakamoto and ODO inspections in detention facilities and
evaluating their inspection methods, practices, and reports, we determined that
ICE detention facility compliance enforcement is lacking because Nakamoto’s
inspection scope is too broad; ICE does not provide clear guidance on
procedures; and the Nakamoto inspectors are not always thorough. In contrast,
ODO’s inspections are better scoped and more comprehensive, but are too
infrequent to ensure compliance and effect regular and consistent changes in
detention conditions. Both sets of inspections have value, but their weaknesses
render them inadequate to promote effective oversight. In the following
paragraphs we detail the inspections’ strengths and weaknesses.
Pre-inspection: ICE only requires the Nakamoto teams to review previous
oversight reports and inspection results for a facility during pre-inspection
research. Therefore, Nakamoto inspectors typically limit their pre-inspection
research to reviewing previous Nakamoto inspection reports and UCAPs for the
inspected facility. Prior to each inspection, according to a Nakamoto manager,
an introductory letter, inspection notification letter, and a blank facility
incident form are sent to the detention facility. When applicable, the detention
facilities complete the incident form, detailing any incident that may have
occurred during the year between inspections.
In contrast, before visiting a detention facility, ODO policies direct ODO
inspection teams to research and compile information from the facility and the
relevant ERO field office.9 We reviewed ODO’s pre-inspection packages, which
included documents from the facility and ICE ERO, such as contracts, facility
records, local ERO policies and procedures, complaints the ICE Joint Intake
Center received about the facility, and any detainee death reports. The preinspection materials also included policies on emergency response, safety
inspections, and use of force. Through this research, ODO teams check for
potential deficiencies before they arrive at the facility, which allows more time
on site to assess detention conditions instead of reviewing policies and
procedures.

Concerns about ICE Detainee Treatment and Care at Detention Facilities, OIG-18-32, December
2017
9 ICE ERO has 24 field offices that manage detention operations in their geographic area.
8

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Scope: The Nakamoto inspection scope is too broad to be completed by a small
team in a short timeframe. Under its Statement of Work (SOW) with ICE,
Nakamoto must determine compliance with all 39 to 42 applicable detention
standards by examining more than 650 elements of the standards at more than
100 facilities a year. Typically, three to five inspectors have only 3 days to
complete the inspection, interview 85 to 100 detainees, brief facility staff, and
begin writing their inspection report for ICE. Even with a full 5-member
inspection team, each of four inspectors has to evaluate compliance with about
10 standards. The fifth inspector completes a Quality of Medical Care
Assessment,10 when applicable, which includes using 20 checklists, each
requiring review of 10 to 20 patient records. Nakamoto inspectors also told us
that it was difficult to complete their work in the allotted time.
Under ODO’s guidance, ODO teams assess compliance with 15 or 16 “core”
standards selected because deficiencies in these standards could most
significantly impact a detainee’s health, safety, civil rights, and civil liberties.11
Hence, ODO inspections appear to be appropriately scoped for the size of the
teams performing the work. A typical ODO team has six or seven inspectors,
consisting of three ODO employees and three or four contractors from Creative
Corrections, LLC. Each member of the ODO team has 3 days to assess
compliance with either two or three detention standards. We observed an
adequate number of ODO inspectors and contractors, who appeared to have a
reasonable workload and enough time to thoroughly inspect facilities, as well
as observe and validate actual detention conditions. However, although it helps
to narrow the scope, by limiting its inspections to assessing just the “core”
standards, ODO is scrutinizing compliance with fewer than half of the NDS or
PBNDS standards.
Guidance and Inspection Practices: ICE provides Nakamoto with detention
review summary forms and inspection checklists to determine compliance with
detention standards, but it does not give Nakamoto clear procedures for
evaluating detention conditions. In general, the Nakamoto inspection practices
we observed fell short of the SOW requirements. Specifically, we saw some
inspectors observing and validating “the actual conditions at the facility,” per
the SOW, but other Nakamoto inspectors relied on brief answers from facility

In 2016, ICE added a Quality of Medical Care Assessment to Nakamoto’s inspection of “over72 hour” facilities. ICE Health Service Corps and the DHS Office for Civil Rights and Civil
Liberties developed a standardized quality of care audit toolkit. Most of the measures are not
detention standard requirements.
11 ODO may review standards outside of the “core” standards based on conditions at the facility
or at the request of ICE leadership. Appendix D contains details on the core standards.
10

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staff and merely reviewed written policies and procedures instead of observing
and evaluating facility conditions. Some inspectors did not consistently look at
documentation to substantiate responses from staff or ensure the facility was
actually implementing the policies and procedures.12 For example:
x An inspector documented that A-files13 contained required identification 

documents without checking the actual files. 

x Facility staff told inspectors that drivers had commercial driving licenses 

as required, but the inspectors did not review records to confirm. 

x	 An inspector encountered two detainees held in administrative
segregation14 because, according to the facility officer, they arrived late the
night before and no space was available in the general population area of
the facility. The inspector did not follow up to ensure the placement in
administrative segregation was properly documented as required.
x	 Some Nakamoto inspectors relied on responses from facility employees who
were not responsible for the areas and functions the inspectors were
inquiring about, such as asking a classification officer responsible for
admissions about the standards relating to Visitation and Law Library,
instead of asking staff responsible for those areas.
In contrast, ODO has developed clear procedures and effective tools to help
inspectors thoroughly inspect facilities. During the two inspections we
observed, each ODO inspector used the checklist to determine “line-by-line”
compliance with two or three detention standards. In addition, the inspectors
devoted most of their time to observing facility practices, validating
observations through records review, and interviewing ICE and facility
employees and detainees.
ODO teams consistently identify more deficiencies than Nakamoto when the
two groups inspect the same facilities. For example, in FY 2016, for the same

Several ICE employees in the field and managers at ICE ERO headquarters commented that
Nakamoto inspectors “breeze by the standards” and do not “have enough time to see if the
[facility] is actually implementing the policies.” They also described Nakamoto inspections as
being “very, very, very difficult to fail.” One ICE ERO official suggested these inspections are
“useless.”
13 A-file refers to an Alien File, a file that identifies a non-citizen by unique personal identifier
called an Alien Registration Number. A-Files are official files for all immigration and
naturalization records.
14 Detention facility staff sometimes segregate detainees from a detention facility’s general
population using two types of segregation disciplinary and administrative. Although separated
from other detainees, detainees in segregation are permitted daily contact with detention and
medical staff, as well as time for recreation, library, and religious activities.

12

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29 facilities ODO and Nakamoto inspected, ODO’s teams found 475
deficiencies while Nakamoto teams reported 209 deficiencies. Given that ODO
looks at 15 to 16 standards and Nakamoto inspects 39 to 42 standards, the
much larger number of deficiencies identified by ODO is surprising.
Detainee Interviews: For the two inspections we observed, Nakamoto reported
interviewing between 85 and 100 detainees, but the interviews we saw during
these two inspections did not comply with the SOW and we would not
characterize them as interviews. The SOW requires detainee interviews to
include “private conversations with individual detainees (in a confidential
area),” but we did not see any interviews taking place in private settings.
Instead, inspectors had brief, mostly group conversations with detainees in
their detention dorms or in common areas in the presence of detention facility
personnel, generally asking four or five basic questions about treatment, food,
medical needs, and opportunities for recreation. Describing these discussions
between Nakamoto inspectors and detainees as “interviews” is not consistent
with the SOW requirements.
The SOW also requires Nakamoto inspectors to interview detainees who do not
speak English, but we did not observe any interviews Nakamoto inspectors
conducted in a language other than English, nor any interviews in which
inspectors used available DHS translation services. In fact, inspectors selected
detainees for interviews by first asking whether they spoke English. During one
inspection, a facility guard translated for a detainee. Inspectors did not
consistently follow up with the facility or ICE staff on issues detainees raised.
Conversely, we observed ODO teams closely following ODO guidance on
interviewing a representative sample of detainees, in confidential settings, and
in languages detainees understand. ODO teams used an interview form that
included a wide range of questions about the living conditions, safety, and wellbeing of detainees and elicited candid responses and insight on facility
conditions. According to ODO policy, depending on the size of the facility,
inspectors interview between 10 and 40 detainees, including all detainees in
segregation. We observed ICE ODO staff interviewing about 30 detainees oneon-one in a confidential setting, separate from facility staff and ICE employees.
We also observed ODO inspectors interviewing every detainee in segregation.
Inspectors selected detainees to interview based on a number of factors, such
as length of detention, age, medical history, and the detainee’s country of
origin. ODO used the DHS language telephone line for translation and
interviewed some detainees in Spanish and other languages. ODO teams
discussed every issue raised during these interviews with facility and ICE
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officials and identified a number of deficiencies that may have gone undetected
without these interviews.
Onsite Briefings: Both Nakamoto and ODO inspectors briefed facility staff at
the end of each day. As a result, we identified some deficiencies that were
corrected while inspectors were onsite, such as discontinuing the practice of
charging ICE detainees for medical co-payments, requiring more privacy for
medical examinations, repairing inoperable telephones, and updating facility
handbooks. Although Nakamoto does not track such onsite corrective actions,
ODO does — for example, in FY 2016, ODO recorded 106 onsite corrections to
475 identified deficiencies at 29 facilities. Initiating onsite corrections is a good
practice.
Reporting: Following each inspection, Nakamoto sends ERO a completed
checklist with an assessment of each element of the evaluated standards and a
summary of the inspection. We identified inaccuracies in Nakamoto’s summary
reports and checklists we selected for our sample. In some instances,
Nakamoto’s reports misrepresented the level of assurance or the work
performed in evaluating the actual conditions of the facility and the information
in the reports was inconsistent with what we observed during inspections. For
example:
x	 Nakamoto reported “Detainees were familiar with ICE officers and
understood how to obtain assistance from ICE officers and the case
managers. Interviews yielded positive comments regarding access to library
services, access to case managers and visiting opportunities.” However, we
heard detainees tell inspectors they did not know the identity of their ICE
deportation officer or how to contact the officer. We did not observe
inspectors asking any detainees about law library services or visiting
opportunities.
x	 At one facility, we discovered it was impossible to dial out using any tollfree number, including the OIG Hotline number, due to telephone company
restrictions on the facility. We alerted the facility, which started working to
correct this facility-wide issue by modifying the directions for dialing tollfree numbers. Although the issue was not corrected until the third day of
the inspection, a Nakamoto inspector wrote on a checklist that an
inspector could reach the OIG Hotline from several units on the second day
of the inspection.
x	 At another facility, Nakamoto inspectors questioned an ICE employee
about the facility’s correction officer duties, instead of actually interviewing
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correction officers. Yet, Nakamoto inspectors concluded in the summary
report that “[correction] officers … exhibited an understanding of the
detention standards and civil detention.”
ODO teams also issue compliance inspection reports to various ICE
stakeholders and the public, detailing their findings, as well as any immediate
remedial actions facilities initiated or completed in response to identified
deficiencies. We did not identify any inconsistencies between what ODO
inspectors discovered at the facilities during the inspections we observed and
what they then reported. However, ICE ERO officials remarked that
occasionally ODO reports are not timely.
Frequency: Based on our analysis, Nakamoto inspections target about 100
facilities a year, thus reaching a large number of the facilities ICE uses. ODO
teams only inspect about 30 facilities per year.15 The infrequency of ODO
inspections limits the ability to produce regular improvements in detention
conditions. Although ODO thoroughly assesses and reports on a facility’s
deficiencies and compliance, the deficiencies may go unnoticed or unreported
for 3 years, and ODO cannot evaluate whether a facility has corrected them
until its next inspection. ODO officials suggested more frequent potential
follow-up visits to facilities that perform very poorly during inspections, but
said this might be difficult with current staffing. Also, all Nakamoto and ODO
inspections are scheduled in advance and announced to the facilities, which,
according to ICE field staff, allows facility management to temporarily modify
practices to “pass” an inspection.
Quality Control: Although Nakamoto inspections have clear weaknesses, ICE
ERO does not exercise enough quality control over these contracted inspections
to evaluate or improve Nakamoto’s performance. Specifically, we could not find
evidence that ICE ERO performed quality assurance visits in the past 4 years.
An ICE ERO headquarters employee said that, in the past, ERO quality
assurance visits with Nakamoto inspectors took place two to three times a year,
but ICE could not provide documentation of any visits in 2014 or 2015. ICE
ERO officials in Custody Management admitted they were unable to perform
any quality assurance visits during FY 2016 and that there were no planned
visits for FY 2017 because ERO does not have “the right tools” to evaluate
Nakamoto performance.


ODO leadership determines the number of facilities to review each FY based on staffing,
budget, and agency priorities or special requests by ICE leadership.

15

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ODO internal guidance requires that Section Chiefs join teams inspecting
detention facilities once a quarter and the Division Chief has to accompany
ODO inspectors at least twice a year. We reviewed records that confirmed ODO
has conducted supervisory visits over the past 3 years. Also, the ODO Section
Chief and Division Chief were present at ODO inspections we observed.

Inadequate Inspection Follow-up Leads to Continuing
Deficiencies
The usefulness of ICE inspections is further diminished by ICE’s failure to
ensure that identified deficiencies are consistently corrected.
When Nakamoto and ODO inspections find instances of noncompliance, the
Detention Standards and Compliance Unit in ICE ERO Custody Management
develops a UCAP for the facility. A UCAP typically lists the applicable
standards, indicates how the facility did not comply with the standards
(resulting in a deficiency), and provides blank columns for the facility or the
ICE ERO field office to propose corrective actions. ERO field office officials must
return the UCAP containing proposed or competed corrective actions within 55
days to DSCU for tracking and verification. In limited circumstances, ICE will
grant waivers for components within detention standards, in essence
exempting the facility from compliance.16 We identified problems with these
corrective measure procedures, which have led to ongoing deficiencies:
Inadequate Response to UCAPs: ERO field offices do not always respond to
DSCU with proposed corrections; some respond late, submit incomplete
responses, or report that facility deficiencies will continue due to local policies
or conditions. For example, our document review revealed that in FY 2015 and
FY 2016, ERO field offices only responded to 8 of 20 and 12 of 25 ODO
inspection UCAPs, respectively. Further, in 2015 and 2016, some field offices
sent UCAPs to DSCU from 2 to 6 months past the 55-day deadline.
Submitted UCAPs from some facilities did not have proposed corrective actions
for a number of identified deficiencies and contained responses with
corrections only for certain deficiencies. In addition, rather than proposing
corrective actions, some facilities indicated that deficient practices would
continue because of local policies or conditions, which essentially amounts to

is currently reviewing ICE’s processes for granting waivers, including ICE’s specific
authority to do so. 

16OIG

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an intent to continue not complying with standards. Such practices are not
consistent with the detention standards for civil custody, which facilities agree
to comply with when entering into contracts with ICE. For example:
x	 A detention standard requires the facility to allow detainees to help other
detainees voluntarily and free-of-charge prepare legal documents. In
addressing a deficiency in this area, the facility responded that it did not
permit such assistance, stating, “It is the policy of the [facility] not to allow
inmates/detainees to assist others with their legal issues.... The [facility]
chooses not to change its policy regarding the issues noted.”
x	 A detention standard requires that the facility handbook describe official
population count times and procedures. One facility had a deficiency in
this area because the handbook did not include the count times. In its
response, the facility asserted that it would not be adding exact count
times to the handbook.
Inconsistent Implementation of Corrective Actions: ICE does not
consistently enforce compliance with detention standards. ICE DSCU
sometimes receives follow-up documentation, such as updated policies or
photos of corrections, supporting implementation of corrective actions, but ICE
does not require, and many field offices do not send, such evidence. Although
ICE ERO has 24 Field Office Directors (FOD)17 whose staff are supposed to
work with DSCU to ensure that deficiencies are actually corrected, we found
that ERO field offices’ engagement in detention oversight varies widely. ICE
does not appear to have a comprehensive process to verify whether facilities
implemented all the corrective actions until the next Nakamoto or ODO
inspection.
The frequency of repeat deficiencies in the same facilities,18 and the high
number of deficiencies inspectors identify at facilities expose the problems
associated with ICE’s inability to consistently follow up on corrective actions.
Even well documented deficiencies that facilities commit to fixing routinely
remain uncorrected for years. For example, several facilities continue to strip
search all incoming detainees without establishing reasonable suspicion, as
required by detention standards.19 Even when inspections documented this as

FODs are responsible for managing detention operations in their geographic area.

A repeat deficiency is any deficiency identified in 2 or more consecutive years of annual 

inspections by the same inspection entity (i.e., Nakamoto or ODO). 

19 According to PBNDS 2008 and 2011, strip searches are conducted only when there is

reasonable belief or suspicion that contraband may be concealed on the person, and when 

properly authorized.

17
18

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a deficiency, the facilities continued routine strip searches of detainees during
intake without proper documentation. Other examples of repeat deficiencies
include facilities failing to notify ICE about alleged or proven sexual assaults.
We also found less egregious repeat deficiencies such as instances where
officers open incoming general correspondence without the presence of the
addressed detainee or do not allow detainees to participate in recreation for the
maximum time required by the standard.
Our review of 10 Nakamoto inspection reports from 2015 and 2016 showed
that 6 of the 10 included at least 1 repeat deficiency, as shown in the preceding
examples. Further, in 2015, ODO identified 18 repeat deficiencies during 23
inspections, and in 2016, ODO teams identified 21 repeat deficiencies during
29 inspections. Under current ICE ERO practices, these repeat deficiencies
may be present for the entire 3-year period between ODO inspections.
Inappropriate Use of Waivers: Granting waivers that allow some facilities to
opt out of complying with particular standards may be appropriate in some
cases. However, we identified examples in which the repeated use of waivers
allowed facilities to exempt themselves from standards that ICE deems
critically important, including those related to health, safety, and security.20
For example:
x	 In one facility, ICE granted a waiver to allow the comingling of detainees of
different custody classification levels. The standard requirement is to avoid
comingling of low-custody detainees, who have minor, non-violent criminal
histories or only immigration violations, with high-custody detainees, who
have histories of serious criminal offenses. The facility asserted that “a
corrective plan of action is not readily available due to overwhelming
expense, time and space limitations associated with full compliance with
the standards.... Separation of detainees by classification levels … may
prove to be an undue burden upon the facility.”
x	 At another facility, ICE granted a waiver for the fire prevention, control, 


and evacuation planning standard, which requires the posting of 

emergency plans. The facility “expressed safety concerns regarding the 

posting of such detailed and specific exit diagrams within its detention 

facility.” 



These standards are called “Priority Components” on inspection checklists. ICE selects
Priority Components from a range of detention standards, based on their importance to factors
such as health and life safety, facility security, detainee rights, and quality of life in detention.

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Other common examples of waivers range from those allowing strip searches of
detainees to barbershop availability and reducing the frequency of razor
distribution. Granting waivers after inspections identify discrepancies negates
the effectiveness of the inspections process and allows inherently deficient
practices to continue.

Onsite Detention Service Managers Face Challenges in
Improving Compliance
In addition to oversight provided by the Nakamoto and ODO inspections, in
2010, ICE ERO established the Detention Monitoring Program and placed
DSMs in 52 detention facilities. The program goals were to monitor compliance
with applicable detention standards, enable “on the spot” resolution of facility
issues, ensure regular inspection checks, and enhance collaboration with ERO
field offices and facility staff to address concerns. Although DSMs are meeting
these goals, their effectiveness is sometimes limited by a lack of support from
ERO field office management.
In the facilities they monitor, DSMs provide a needed service for ICE ERO
Custody Management by assessing compliance with standards nearly daily or
weekly. DSMs we interviewed described duties such as monitoring food services
and kitchen operations, observing housing units for cleanliness, checking the
status of detainees’ medical requests, looking at special management units
(segregation), reviewing grievances, and talking to detainees and addressing
their concerns. DSMs also identify deficiencies independent of Nakamoto and
ODO inspections and correct deficiencies “on the spot.” For example, DSMs
noted 6,216 and resolved 4,331 deficiencies in FY 2017. In addition, DSMs
provide technical guidance to the facilities on implementing corrective action
plans.
Although DSMs keep ERO Custody Management officials informed about
conditions at more than 50 facilities and address detention issues, their results
in improving detention conditions are mixed. To correct instances of
noncompliance, DSMs typically must rely on local ERO field office assistance
because corrective actions are a field office responsibility. Thus, DSMs have the
expertise to propose appropriate corrective actions, but not the authority to
implement them. According to some DSMs, when the ERO field office supports
them, correcting identified deficiencies is collaborative and productive. In
contrast, when ERO field office management does not support and collaborate
with the DSM, facility compliance is challenging. Specifically, DSMs at a few
facilities portrayed local ERO management as “disengaged” or “reluctantly
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responsive” in detention issues; they described the relationship between DSMs
and ERO field management as “not very productive.” One Custody Management
supervisor said that some ERO field office managers are “hands off” and
consider DSMs “a nuisance.”
ICE ERO headquarters officials explained that DSMs’ influence is directly
related to their respective ERO field office’s commitment to improving
compliance and facility conditions. Officials added that Nakamoto and ODO
inspections tend to reveal fewer problems at facilities where ERO field offices’
leadership demonstrates understanding and concern about detention
conditions. We found that ERO field offices with ICE ERO Field Office
Compliance teams21 were more engaged in detention issues.

Conclusion
To detain approximately 38,000 removable aliens at more than 200 facilities,
ICE Custody Operations receives about $2.3 billion of ERO’s total operations
budget of about $3.2 billion. Given ICE’s investment in detention operations, a
potentially rising number of detainees and facilities, and the issues we
identified during this review, ICE needs to comprehensively examine and
assess its inspections process, improve its follow-up procedures for corrective
actions, and ensure ERO field offices more consistently engage in overseeing
detention operations. Taking such actions will help limit and correct persistent
deficiencies, as well as effect long-lasting changes and systemic improvements
in ICE detention facilities.

Recommendations
We recommend the Assistant Director for ICE ERO Custody Management:
Recommendation 1: Revise the inspection scope and methodology for annual
and biennial contracted inspections to ensure that the inspection procedures
are adequate to evaluate actual conditions at facilities.
Recommendation 2: Reinstate a quality assurance program for contracted
inspections of detention facilities to ensure the reported inspection results are
thorough and accurate. Document all quality assurance conclusions.

Field Office Compliance teams consist of ICE ERO compliance officers who receive training
on the detention standards and ensure standards are followed in their respective facilities.
Compliance officers are ICE ERO field office employees and keep ICE ERO field management
informed of compliance concerns.

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We recommend the Associate Director for ICE Office of Professional
Responsibility:
Recommendation 3: Develop a follow-up inspection process for select facilities
where the Office of Detention Oversight identifies egregious or numerous
deficiencies. Consider the feasibility and appropriateness of making some of
such visits unannounced.
We recommend the Executive Associate Director for ICE ERO and the Assistant
Director for ICE ERO Custody Management:
Recommendation 4: Update and enhance current procedures to ensure
verification of all corrective actions for identified deficiencies. Track all
corrective actions by facility, responsible field office, and status of resolution.
Recommendation 5: Develop protocols for ERO field offices to require facilities
to implement corrective actions resulting from Detention Service Managers’
identification of noncompliance with detention standards.

Management Comments and OIG Analysis
ICE concurred with all recommendations. Appendix B contains a copy of ICE
management comments in their entirety. We also received technical comments
and incorporated them in the report where appropriate. We consider all
recommendations to be resolved and open. A summary of ICE’s responses and
our analysis follows.
ICE Response to Recommendation 1: ICE concurred with the
recommendation. ICE will re-evaluate the existing inspection scope and
methodology in the statement of work for annual and biennial contracted
inspections to ensure that inspection procedures are adequate and
appropriately resourced to fully evaluate detention conditions at facilities. ICE
anticipates these actions to be complete by July 30, 2019.
OIG Analysis: We consider these actions responsive to the recommendations,
which is resolved and open. We will close this recommendation when we
receive the new inspection scope and methodology for annual and biennial

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contracted inspections that ensure inspection procedures are adequate and
appropriately resourced to fully evaluate detention conditions at facilities.
ICE Response to Recommendation 2: ICE concurred with the
recommendation. ICE has initiated steps to bolster the quality assurance
process for contracted inspections. ICE is in the process of hiring additional
federal staff with subject matter expertise in ICE detention and facility
inspections to conduct on-site quality assurance reviews of ICE’s contract
inspectors. ICE anticipates these employees will start by October 30, 2018. ICE
also has directed officers from the DSCU to attend all out-briefings by the ICE
inspections contractor to ERO field offices, starting this quality assurance
element by June 30, 2018. In addition, starting in July 2018, the existing
monthly meetings with the ICE inspections contractor will include quality
assurance-related input by the ICE Contracting Officer and Contracting
Officer’s Representatives. ICE’s Mission Action Plan, due to the OIG within 90
days of the issuance of this report, will outline additional actions to address
this recommendation. ICE anticipates all actions responsive to this
recommendation be completed by July 30, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation when we
receive documentation that the proposed actions are completed or occurring
regularly, as appropriate.
ICE Response to Recommendation 3: ICE concurred with the
recommendation. ICE OPR has already planned for the ODO to conduct at
least two follow-up inspections during FY 2018. During these more targeted
inspections, ODO will focus on either where ODO identified deficiencies during
most recent compliance inspection of the facility or in response to concerns
that may be identified by agency leadership or third parties. Additionally, the
ODO has decreased the amount of advanced notice to facilities in preparation
for an ODO inspection. Although ODO continues to consider conducting some
unannounced inspections in FY 2019, ODO’s significant pre-inspection
documentation review makes conducting unannounced inspections difficult.
ICE requests that OIG consider this recommendation resolved and closed.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation when we
receive documentation that ODO developed a follow-up inspection process and
conducted the follow-up inspections using a more targeted approach with a
more specific focus.

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ICE Response to Recommendation 4: ICE concurred with the
recommendation. ICE stakeholders are working together to improve the
existing corrective action process, and have initiated new steps, such as:
1) requiring ERO field offices to provide validating documentation to the DSCU
to confirm that corrective actions have been implemented and for DSCU to
track them; 2) directing the DSCU to provide copies of completed UCAPs to onsite federal DSMs for validation that corrective actions have been implemented
by management at their facilities; 3) directing DSMs to monitor that the
implemented changes are being maintained between inspections; 4) directing
the DSCU to provide copies of completed UCAPs and the contractor
inspections’ most recent findings to ODO for each facility scheduled for an
ODO compliance inspection; and 5) updating the existing Detention
Management Control Program (DMCP) directive. On June 12, 2018, an ERO
Headquarters working group began meeting weekly to update the program
directive and incorporate any new compliance-related and quality assurance
program changes. Once finalized, a copy of the new directive will be distributed
to ERO field offices to enhance facilities’ compliance with ICE detention
standards. ICE anticipates all actions responsive to this recommendation be
completed by July 30, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation when we
receive adequate supporting documentation demonstrating that the proposed
actions are completed.
ICE Response to Recommendation 5: ICE concurred with the
recommendation. On June 12, 2018, an ERO Headquarters working group
began meeting weekly to update the DMCP directive and explore various
options to enhance collaboration and support between field offices, facility
staff, and on-site DSMs. The directive will include guidelines and requirements
on how ERO field office staff will work with on-site DSMs. ICE’s Mission Action
Plan, due to the OIG within 90 days of the issuance of this report, will outline
additional actions to address this recommendation. ICE anticipates all actions
responsive to this recommendation be completed by July 30, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation when we
receive the new DMCP directive and evaluate the proposed protocols on how
ERO field office staff will work with on-site DSMs.

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Appendix A
Objective, Scope, and Methodology
DHS OIG was established by the Homeland Security Act of 2002 (Public Law
107ï296) by amendment to the Inspector General Act of 1978. In this review,
we sought to determine whether ICE’s inspection process ensures adequate
oversight of detention facilities, compliance with detention standards, and
correction of deficiencies.
To answer the objective, we reviewed ICE’s policies and procedures for
performing immigration detention inspections. We reviewed whether the
methodology ICE uses for its various inspections is conducive to thorough and
independent oversight. We reviewed the contract and SOW between ICE and
the contractor (Nakamoto) performing detention facility inspections to
understand the role, requirements, and responsibilities of the contractor.
Using ICE data, we selected four ICE detention facilities to visit and observe
inspections, based on a range of factors including facility type and detention
standards governing the facility. We observed ICE ODO inspections of two
detention facilities (Eloy Detention Center in Eloy, Arizona, and Stewart
Detention Center in Lumpkin, Georgia) and observed ICE ERO contractor
(Nakamoto) inspections of two facilities (Irwin County Detention Center in
Ocilla, Georgia, and Johnson County Detention Center in Cleburne, Texas).
To determine the thoroughness and accuracy of detention inspections, we
reviewed ICE documentation of the inspection results and interviewed ICE
officials, including both ICE staff and contract personnel working in the
detention facilities. To assess the process for correcting deficiencies identified
by ICE inspections, we reviewed ICE processes and procedures for correcting
deficiencies. We interviewed ICE officials responsible for tracking, analyzing,
and making remedial decisions about identified issues. We reviewed UCAPs for
deficiencies identified in both Nakamoto and ODO inspections.
We also met with staff from DHS’ Office for Civil Rights and Civil Liberties to
discuss the adequacy of ICE immigration detention oversight.
We conducted this review between April and October 2017 pursuant to the
Inspector General Act of 1978, as amended, and according to the Quality
Standards for Inspection and Evaluation issued by the Council of the Inspectors
General on Integrity and Efficiency. We believe that the evidence obtained
provides a reasonable basis for our findings and conclusions based upon our
objectives.
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Appendix B
Management Comments to the Draft Report

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Appendix C
National Detention Standards (NDS) and Performance-Based
National Detention Standards (PBNDS 2008 and PBNDS 2011)
Number

NDS 2000

PBNDS 2008 / PBNDS 2011*

1.

Access to Legal Materials
Admission and Release
Correspondence and Other Mail
Classification System
Detainee Handbook
Food Service
Funds and Personal Property
Detainee Grievance Procedures
Group Legal Rights Presentations

Emergency Plans
Environmental Health and Safety
Transportation
Admission and Release
Custody Classification System
Contraband
Facility Security and Control
Funds and Personal Property
Hold Rooms in Detention Facilities

Issuance and Exchange of Clothing,
Bedding, and Towels
Marriage Requests
Non-Medical Emergency Escorted
Trips
Recreation
Religious Practices

Key and Lock Control

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.

Detainee Telephone Access
Visitation
Voluntary Work Program
Hunger Strikes
Access to Medical Care
Suicide Prevention and Intervention
Terminal Illness, Advanced
Directives, and Death
Contraband
Detention Files

25.

Disciplinary Policy
Emergency (Contingency) Plans

26.

Environmental Health and Safety

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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
Disciplinary System
Food Service
Hunger Strikes
Medical Care
Medical Care – Women (as
applicable)
Personal Hygiene
Significant Self-Harm and Suicide
Prevention and Intervention
Terminal Illness, Advanced
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27.

Hold Rooms in Detention Facilities
Key and Lock Control
Population Counts
Post Orders
Security Inspections
Special Management Unit
(Administrative Segregation)

Correspondence and Other Mail
Trips for Non-Medical Emergencies
Marriage Requests
Recreation
Religious Practices
Telephone Access

33.

Special Management Unit
(Disciplinary Segregation)

Visitation

34.

Tool Control
Transportation
Use of Force
Staff Detainee Communications
Detainee Transfer Standard
Sexual Abuse and Assault
Prevention and Intervention

Voluntary Work Program
Detainee Handbook
Grievance System
Law Libraries and Legal Materials
Legal Rights Group Presentations
Detention Files

28.
29.
30.
31.
32.

35.
36.
37.
38.
39.
40.

Interviews and Tours
Staff Training
Detainee Transfers

41.
42.
Source: ICE ERO

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Appendix D
Core Standards ICE Office of Professional Responsibility’s
Office of Detention Oversight Uses to Assess Detention
Conditions
Number

NDS (2000)

PBNDS (2008)

PBNDS (2011)

1

Access to Legal
Materials
Admission and
Release
Detainee
Classification System
Detainee Grievance
Procedures
Detainee Handbook

Law Libraries and
Legal Material
Admission and Release

Grievance System

Law Libraries and
Legal Material
Admission and
Release
Custody Classification
System
Grievance System

Detainee Handbook

Detainee Handbook

Environmental
Health and Safety
Food Service

Environmental Health
and Safety
Food Service

Environmental Health
and Safety
Food Service

Funds and Personal
Property
Medical Care

Funds and Personal
Property
Medical Care

Funds and Personal
Property
Medical Care

Special Management
Unit (Administrative
Segregation)
Special Management
Unit (Disciplinary
Segregation)
Staff-Detainee
Communication
Suicide Prevention
and Intervention

Special Management
Units

Medical Care (Women)

Staff-Detainee
Communication

Special Management
Units

Suicide Prevention and
Intervention
Telephone Access

Staff-Detainee
Communication
Significant Self-Harm
and Suicide
Prevention and
Intervention
Telephone Access

2
3
4
5
6
7
8
9
10
11
12
13

14

Telephone Access

15

Use of Force

16

Sexual Abuse and
Assault Prevention
and Intervention

Classification System

Use of Force and
Restraints
Sexual Abuse and
Assault Prevention and
Intervention
Not Applicable

Use of Force and
Restraints
Sexual Abuse and
Assault Prevention
and Intervention

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Appendix E
Office of Inspections and Evaluations Major Contributors to
This Report
Tatyana Martell, Chief Inspector
Ayana Henry, Senior Inspector
Kimberley Lake de Pulla, Senior Inspector
Jason Wahl, Senior Inspector
Erika Algeo, Inspector
James Johnson, Inspector
Kelly Herberger, Communications and Policy Analyst
Jennifer Berry, Independent Referencer

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Appendix F
Report Distribution
Department of Homeland Security
Secretary
Deputy Secretary
Chief of Staff
General Counsel
Executive Secretary
Director, GAO/OIG Liaison Office
Assistant Secretary for Office of Policy
Assistant Secretary for Office of Public Affairs
Assistant Secretary for Office of Legislative Affairs
ICE Liaison
Office of Management and Budget
Chief, Homeland Security Branch
DHS OIG Budget Examiner
Congress
Congressional Oversight and Appropriations Committees

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Additional Information and Copies
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