Lives in Peril:
How Ineffective Inspections
Make ICE Complicit in
Immigration Detention Abuse

The Immigration
Detention
Transparency
and Human
Rights Project
October 2015 Report

immigrantjustice.org

detentionwatchnetwork.org

About the National Immigrant Justice Center
With offices in Chicago, Indiana, and Washington, D.C., Heartland Alliance’s National Immigrant
Justice Center (NIJC) is a nongovernmental organization dedicated to ensuring human rights
protections and access to justice for all immigrants, refugees, and asylum seekers through a
unique combination of direct services, policy reform, impact litigation and public education.
Visit immigrantjustice.org

About the Detention Watch Network
The Detention Watch Network works through the collective strength and diversity of its members to
expose and challenge injustices of the U.S. immigration detention and deportation system and
advocate for profound change that promotes the rights and dignity of all persons.
Visit detentionwatchnetwork.org

Acknowledgements
This report was a collaborative effort of NIJC and DWN. Primary contributors were: Claudia
Valenzuela, Tara Tidwell Cullen, Jennifer Chan, and Royce Bernstein Murray of NIJC; and Mary
Small, Carol Wu, and Silky Shah of DWN. Additional thanks to Assistant Professor John Eason,
Professor Pat Rubio Goldsmith, and their team at the Texas A&M Department of Sociology and
Professor David Hernández at Mount Holyoke College whose review of thousands of pages of
documents and feedback were critical to this report.
NIJC staff and interns also contributed crucial research, editing, and design support: Mark Fleming,
Catherine Matthews, Mary Meg McCarthy, Kathleen O’Donovan, Katherine Rivera, and Julia Toepfer.
Sincere thanks to pro bono attorneys at Dentons US LLP, who represented NIJC through more than
three years of Freedom of Information Act litigation to obtain the inspections documents analyzed for
this report.

Cover Images: La Vision, Detention Watch Network, Will Coley, National Immigrant Justice Center

© October 2015 Detention Watch Network and Heartland Alliance’s National Immigrant Justice Center

The Immigration Detention Transparency and Human Rights Project
October 2015 Report

Table of Contents
I. Executive Summary .......... 2
II. Navigating the Inspection Reports .......... 7
III. Ineffective Inspections .......... 10
IV. In Focus: Six Case Studies of Facilities
with Known Conditions Problems, 2007-2012 .......... 16
V. Conclusion and Recommendations .......... 29
Eloy Federal Contract Facility, Arizona ..... Page 17
Baker County Detention Center, Florida ..... Page 19
Etowah County Detention Center, Alabama ..... Page 21
Houston Processing Center, Texas ..... Page 23
Stewart Detention Center, Georgia ..... Page 25
Pulaski County Jail, Illinois (formerly named Tri-County Detention Center) ..... Page 27
VI. Endnotes .......... 30

Read this report and download inspections and other cited documents
at immigrantjustice.org/TransparencyandHumanRights

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

I. Executive Summary
In the aftermath of September 11, 2001, when the immigration detention system began its unprecedented growth, the world slowly began to hear about the troubling conditions of detention that immigrants confronted in government custody while facing removal from the United States. Years later,
the Obama administration would inherit a sprawling, broken immigration detention system with little
oversight or accountability. In 2015, as the Obama administration winds down, its early promises of
immigration detention reform have failed to materialize. The U.S. Immigration and Customs Enforcement (ICE) immigration detention inspections process—a key target of the Obama administration’s
reform plan—remains non-transparent and ineffective at identifying pervasive and troubling conditions
in detention. Instead, the inspections process remains a “checklist culture,” in which inspectors—employed by ICE directly or via subcontracts—engage in pre-planned, perfunctory reviews of detention
facilities that are designed to result in passing ratings and to ensure local counties and private prison
corporations continue to receive government funds.
A review of five years of ICE inspections for 105 of the largest immigration detention centers confirms
that ICE’s oversight practices under the Obama administration remain fundamentally unchanged
and unreformed. Public and private contractors who run detention facilities continue to make money
without adequate oversight, and troubling conditions of detention persist for the more than 400,000
individuals who pass through ICE custody each year. In fact, detailed reviews of six facilities known
to have troubling human rights records suggest that in some cases, ICE inspections allow facilities
to obscure severe conditions problems and their inability to protect the rights and lives of detained
immigrants.

Immigration Detention Oversight Under the
Obama Administration
The transition from the Bush to the Obama administration was accompanied by a tide of high-profile reports by
journalists and advocates chronicling human rights abuses and unexplained deaths of people in ICE custody. In
groundbreaking exposés in 2008, both The Washington
Post1 and The New York Times2 examined allegations of
negligent medical care and revealed that at least 83 people3 had died in ICE custody between 2003 and 2008.
That same year, a report4 about the Northwest Detention
Center in Tacoma, Washington, described inadequate
medical care and food, deplorable daily living conditions,
and impediments to legal information—conditions similar
to what individuals in ICE custody experienced around
the country. In 2009, advocates published ICE detention
documents obtained in litigation, and concluded that the
inspections process had failed.5
This public scrutiny prompted congressional inquiries
into the sprawling system whose population had quadrupled within a span of 14 years.6 Congress passed a 2009
Department of Homeland Security (DHS) appropriations
bill which included a provision that ICE cannot expend
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funds to immigration detention facilities that fail two consecutive inspections. On August 6, 2009, the
Obama administration also responded by announcing a series of reforms which it said would create
a more civil detention system.7 Among the reforms was a revamp of ICE’s compliance monitoring
procedures and the establishment of the Office of Detention Oversight (ODO) to inspect immigration
detention facilities and investigate the deaths of individuals in ICE custody.8
In addition to changes to the immigration detention system, in 2009 President Obama promised transparency across the federal government. On January 21, 2009, the president directed the heads of all
federal agencies to “adopt a presumption in favor of disclosure … and to usher in a new era of open
Government.” In a memorandum, he said, “The presumption of disclosure also means that agencies
should take affirmative steps to make information public.”9 Nonetheless, such proactive transparency
and commitment to open government failed to materialize in the immigration context. The ICE inspections regime is shrouded in secrecy. Information regarding facilities’ compliance with ICE’s detention
standards has largely been hidden from the public. Since ICE released its first and only semiannual
report on compliance with its national detention standards in 2007, information about how ICE oversees detention facilities, and what that oversight uncovered, has largely come from Freedom of Information Act (FOIA) requests and litigation.10 The inspections released with this report were not made
available voluntarily by DHS, but as the result of FOIA requests by the National Immigrant Justice
Center (NIJC) and a federal court order following three years of litigation.
NIJC has released all inspections from 2007 to 2012 obtained through the FOIA litigation at
immigrantjustice.org/TransparencyandHumanRights.

Overview of Findings
NIJC and Detention Watch Network (DWN) reviewed ICE detention facility inspections dating from
2007 to 2012, most of which were previously unreleased. A close analysis of the inspections, along
with additional human rights reports that elucidate conditions in specific facilities, reveals that the
Obama administration has done little to improve oversight or gain control over the sprawling immigration detention system and the conditions approximately 34,000 immigrants face in custody every
night.
The documents released include:
•

Annual facility inspections by the ICE Office of Enforcement and Removal Operations
(ERO). Under the 2009 DHS Appropriations Act, these are the inspections that determine whether detention facilities are allowed to maintain their contracts with ICE.

•

Facility inspections by the ODO, the office under the ICE Office of Professional Responsibility purportedly created to ensure better monitoring compliance.11

•

The deposition of the chief of ICE’s Detention Monitoring Unit, which provides an overview of the immigration detention inspections process.12

This report contains an evaluation of the ERO and ODO inspections process itself as gleaned from
the documents and a focused analysis of six detention facilities known to have detention conditions
violations during the study period.
While the most recent inspections covered in this report are from 2012, there is no indication that any
of the shortcomings identified have changed. Three years later, advocates and non-governmental
organizations (NGOs) continue to raise complaints of systemic human rights13 and due process vioPage 3

Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

lations14 in the immigration detention system. In the first nine months of 2015 alone, ICE reported six
deaths in detention.15
Based on the review of the inspection reports, NIJC and DWN found:
1. ICE’s Culture of Secrecy Persists
•

Neither information nor documents which would help the public to understand
ICE’s inspections and oversight processes are readily available.

•

There is a lack of independent oversight because both entities which conduct
inspections are paid and vetted—either through contracts or as direct employees—by ICE.

2. ICE Inspections Fail to Adequately Assess the Conditions Detained Immigrants Experience
•

Both ERO and ODO inform facilities of inspections in advance.16

•

There are significant inconsistencies within and between inspection reports for
individual facilities, as well as between ODO and ERO inspections, raising questions about the reliability of either inspections process.

•

As of FY 2012, most ICE detention facilities continued to be inspected using outdated standards.

•

Inspectors fail to apply 2008 and 2011 Performance-Based National
Detention Standards language that was intended to improve oversight of facilities
that detain immigrants for ICE under contracts called Intergovernmental Service
Agreements (IGSAs).

•

ERO and ODO inspection reports are not designed to capture actual conditions
of detention for the population at a given facility.

3. Inspections are Designed to Facilitate Passing Ratings for Facilities, Not Identify or Address
Violations
•

Even where human rights violations and unexplained deaths have been publicly
documented, facilities rarely fail ERO inspections.

•

Inspection reports may be edited before they are finalized and submitted to ICE’s
Detention Monitoring Unit by the inspections contractor.

•

The checklist ERO inspectors use during their reviews does not include all components of the detention standards.

(For a better understanding of the ICE offices involved in the detention center inspections system,
see page 6 of this report.)

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Recommendations
NIJC and DWN call on DHS and ICE to:
1. Increase Transparency and Oversight of the Inspections Process
A. Make ERO and ODO inspections available to the public in a timely manner. To date, ICE
has released its inspections to the public only as a result of FOIA requests. FOIA requests
are unnecessarily time-consuming and expensive obstacles to accessing information about
how the federal government treats thousands of people in its custody and spends billions of
taxpayer dollars. Instead, this information should be freely available.
B. Provide public reporting on suicide attempts, hunger strikes, work program stoppages, use
of solitary confinement, use of force, and other significant events at detention centers.
C. Submit quarterly reporting to Congress on inspection and oversight activities of detention
facilities, to be made available to the public.
2. Improve the Quality of Inspections
A. Establish a DHS ombudsman outside of ICE to conduct unannounced inspections of immigration detention facilities at least once per year, with complete findings made available to
the public. These third-party inspections should examine compliance with applicable detention standards and determine whether contracts will be renewed in accordance with congressional appropriations requirements.
B. Prohibit facilities from taking an “à la carte” approach to compliance and make all detention
standards provisions mandatory during inspections. ICE must stop permitting some facilities to opt out of detention standards they have been contracted to apply. If a facility cannot
abide by detention standards in their entirety then it should not be permitted to enter into or
continue a contract with ICE.
C. Ensure that inspections involve more than checklists. Inspectors must rely on more than
assurances by jail administrators of compliance with detention standards and instead seek
and document proof of their effective implementation.
D. Engage detained immigrants during inspections, as well as other stakeholders such as legal
service providers and those who regularly conduct visitation, in order to capture the range of
concerns at a facility that may not be reported through formal institutional channels. Inspectors should document the content of those interviews.
3. Institute Consequences for Failed Inspections
A. Place detention facilities on probation and subject them to more intensive inspections after
the first finding of substantial non-compliance.
B. Terminate contracts within 60 days for those facilities with repeat findings of substantial
non-compliance, including inadequate or less than the equivalent median score in two consecutive inspections.

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

ICE Offices Involved in
Detention Center Inspections
Department of Homeland Security (DHS)

U.S. Immigration and Customs Enforcement (ICE)

Enforcement and Removal
Operations (ERO)

ERO Field
Offices

Office of Detention
Policy and Planning
The office formed in
2009 to oversee ICE’s
detention reforms.

Also sometimes referred to as
the Custody and Management
Division.

Also sometimes referred to
as the Detention Compliance
Oversight Program, this office
ensures that ICE detention
facilities adhere to detention
standards.

Office of Detention
Oversight (ODO)
Conduct inspections on
an as-needed basis with
a focus on key
standards which have
been identified as areas
where a facility may not
be in compliance.

Detention Management
Division

Detention Monitoring Unit

Office of Professional
Responsibility

Detention Standards
Compliance Unit
Interprets the detention
standards on which the
inspections are based.

The Nakamoto Group
Maryland-based government
management company contracted to
conduct ERO inspections. Prior to about
2009, the government contracted with
other companies including MGT of
America, Inc., and Creative Corrections.

Contract Technical
Representative
Detention Service
Managers
Officers stationed at 54
detention facilities to monitor
day-to-day compliance with
ICE detention standards.

The ICE representative with
delegated limited authority
to bind ICE to contracts.
Reviews and finalizes ERO
inspection reports and
determines final ratings.

Lead Compliance Inspector
The individual who oversees inspections
by reviewers with subject-matter
expertise at ICE detention facilities.
Prior to about 2009, this individual was
called the Reviewer-in-Charge (RIC).

Sources: January 2014 deposition in NIJC v. DHS of the head of the ICE Detention Monitoring Unit;
ICE website; and Government Accountability Office October 2014 report
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II. Navigating the Inspection Reports
Each immigration detention facility is inspected according to a specific set of detention standards promulgated by ICE. Currently, three sets of detention standards primarily are in use: the 2000 National
Detention Standards (NDS)17 and the Performance-Based National Detention Standards (PBNDS)
issued in 200818 and 2011.19
Even when facilities are inspected according to the same set of standards, the type of contract each
facility holds determines exactly which specific requirements of each standard (called “components”
on the inspection worksheets, see Fig. 1) apply during an inspection. Facilities run by local governments, which ICE contracts through Intergovernmental Service Agreements (IGSAs), are permitted
to adapt certain components.20 If a local government contractor subcontracts a jail’s operations to a
private prison company, that company retains the ability establish alternatives to some components.21
In contrast, Service Processing Centers (or SPCs, facilities owned and operated by ICE) and Contract Detention Facilities (or CDFs, those owned and operated by private companies) are not allowed
such loopholes.
While the PBNDS contain more robust protections for detained immigrants, the ICE inspections
process does not apply the same weight to all standards. Both the 2008 and 2011 PBNDS inspections checklists designate some components as “mandatory.” (See Fig. 1) For example, the 2008
PBNDS checklist includes 41 standards, which are broken down into a total of 889 components. Only
40 of these components are labeled “mandatory.” The introduction to the inspection form explains
that mandatory items “typically represent life safety issues. A ‘Does Not Meet Standards’ on one of
these components is very serious.”22 Failure to meet any mandatory component will cause the facility to receive an overall deficient rating. But ICE only takes a small number of these components so
seriously. Some critical components, such as those covering facilities’ response to hunger strikes or
guaranteeing detained individuals have 24-hour access to emergency care, are not marked as mandatory. Many of these mandatory components ensure that there are written policies and plans in place
for emergencies, but they do not reflect or even check for implementation. As much as the standards
were purported to be written “with a focus on the results or outcomes that the required procedures are
expected to accomplish,”23 there remains a gap in truly evaluating efficacy.
There are three types of inspections:
1. ERO Inspections
Facilities that hold 50 or more people are subject to inspections conducted by ERO’s Detention
Management Division. 24 The ERO inspections are conducted by private contractors on an annual
basis. 25 Inspectors use a checklist of applicable national detention standards and each standard’s
components (ICE Form G-324A). The ERO ratings system consists of three tiers: the components
of each standard receive ratings, which determine the rating for each standard, which in turn inform the overall rating for the facility. (See Figs. 2-4) Facilities inspected under the 2008 and 2011
PBNDS are rated simply as “meets standards” or “does not meet standards.” Facilities inspected
under the 2000 NDS can be rated “superior,” “good,” “acceptable,” “deficient,” or “at risk.” There is
space for notes next to each of the components and for concluding remarks to summarize the full
inspection, but the quality of comments varies greatly from inspector to inspector.
2. ODO Inspections
Facilities with average daily populations of 50 or more people may also be subject to ODO inspections. ODO inspectors, who may be ICE employees or contractors, focus on key standards which
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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

Fig. 1: Inspection checklist excerpt
from Eloy Federal Contract Facility 2012 ERO inspection

• Summary of standard

• List of components that
comprise the standard

• Some components are
marked as “mandatory.”
A rating of “Does Not Meet
Standards” or “Deficient”
on one of these components
should result in failure of the
overall inspection.

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The Immigration Detention Transparency & Human Rights Project - October 2015 Report

Fig. 2:
First tier to the ERO
checklist is a rating of
individual components
within a given
standard. Taken
from the Tri-County
Detention Center’s
2012 ERO inspection.

Fig. 3:
Second tier to the ERO
checklist is a rating for
an overall standard,
which is based on the
ratings of individual
components. Taken
from the Tri-County
Detention Center’s
2012 ERO inspection.

Fig. 4:
Third tier to the ERO
checklist is a rating for
the overall facility, which
is based on the ratings
given to standards.
Taken from the
Tri-County Detention
Center’s 2012 ERO
inspection.

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

have been identified as areas where a facility may not be in compliance. For their inspections, the
ODO inspectors collect and analyze “relevant allegations, complaints and detainee information
from multiple ICE databases”26 and gather “facility facts and inspection-related information from
ERO [headquarters] staff to prepare for the site visit.”27
3. Self Assessments:
Facilities that only hold immigrants for less than 72 hours at a time, or that hold 50 or fewer immigrants for more than 72 hours, are subject only to the Organizational Review Self-Assessment
(ORSA) process.28 ORSA inspections were not included in NIJC’s FOIA litigation, which focused
on the largest 100 immigration detention facilities.

III. Ineffective Inspections
Why ICE Inspections Matter
ICE’s ERO inspections generate the ratings that determine, under DHS Appropriations Act requirements, whether the government continues funding a local government or private entity to detain immigrants. As early as 2007, Congress expressed concerns about the lack of compliance with detention
standards in facilities managed by ICE as well as contractors, and directed ICE to improve the quality
and frequency of oversight.29 One year later, Congress added specific language to the FY 2009 DHS
appropriations law prohibiting ICE from expending funds to facilities that are found deficient in two
consecutive inspections. That bill stated:
Provided further, That effective April 15, 2009, none of the funds provided under this
heading may be used to continue any contract for the provision of detention services if
the two most recent overall performance evaluations received by the contracted facility
are less than ‘‘adequate’’ or the equivalent median score in any subsequent performance evaluation system.30
This mandate signaled congressional intent that immigration detention facilities be monitored for adherence to humane standards of detention, and ICE subsequently acknowledged its understanding of
this obligation. According to 2010 congressional testimony by former ICE Director John Morton, eight
facilities had been closed because they had failed to achieve acceptable ratings. 31 However, because
ICE does not share information publicly about which facilities it uses or contracts with at any given
time, it is unknown which facilities Director Morton was referring to or how many additional facilities,
if any, have since had contracts terminated on the basis of failure to meet adequate standards. This
lack of transparency makes it difficult for taxpayers or members of Congress to ascertain whether ICE
is indeed adhering to the intent encompassed in the Appropriations Act language. Further, passing
ratings based on cursory checklists cannot be what Congress intended as a condition for expending
taxpayer money to subsidize the detention of immigrants.

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Findings Regarding the ERO and ODO Inspections Process:
1. ICE’s Culture of Secrecy Persists
•

Neither information nor documents which would help the public to understand ICE’s inspections and oversight processes are readily available. ICE
does not publicly post inspection reports as a matter of practice. Rather, it took
years of resource-intensive litigation for NIJC to obtain inspection reports. This
record undermines President Obama’s early promises of open government.

•

There is a lack of independent oversight because both entities which conduct inspections are paid and vetted—either through contracts or as direct
employees—by ICE. The ODO is housed within ICE’s Office of Professional Responsibility, and ERO inspectors are employed by private companies contracted
by ICE. While government agencies routinely are permitted to keep themselves
accountable, the problems apparent in the inspections reviewed for this report
show this is not sound practice, especially within the detention system which has
been persistently plagued by sub-standard conditions and frequent reports of
abuse.

2. ICE Inspections Fail to Adequately Assess the Conditions Detained Immigrants Experience
•

Both ERO and ODO inform facilities of inspections in advance.32 This warning provides ample time for facilities to prepare and “clean up” before inspectors
arrive, seriously hampering the ability of inspectors to make honest and accurate
assessment of the typical conditions under which detained individuals are held
on a typical day.

•

There are significant inconsistencies within and between inspection reports for individual facilities, as well as between ODO and ERO inspections,
raising questions about the reliability of either inspections process. Such
inconsistencies were identified for all five facilities for which DWN and NIJC conducted in-depth reviews of 2011 and 2012 ERO and ODO inspections (the sixth
facility reviewed in this report has never been inspected by ODO). In October
2014, the Government Accountability Office (GAO) released a report criticizing
the variation between inspections carried out by ERO and ODO during roughly
the same time period for the same facilities.33 Out of 35 facilities inspected by
both ERO and ODO in fiscal year 2013, the findings between the two entities differed substantially for 29 facilities. The GAO’s findings substantiate those which
NIJC and DWN found in 2011 and 2012 inspections, and bring into question the
credibility of the entire review system. The ERO and ODO inspections consistently fail to account for or acknowledge egregious human rights concerns raised in
independent reports published by NGOs.

•

As of FY 2012, most ICE detention facilities continued to be inspected
using outdated standards. (See Fig. 5) Sixty-five of the 103 detention facilities
for which NIJC obtained 2012 or 2011 inspections were still inspected against
the least-rigorous 2000 NDS. Thirty percent of the population represented by the
84 inspections NIJC obtained for FY 2012 were in facilities still being inspected
under 2000 NDS. Even the GAO, in its 2014 report, requested clarity regarding why ICE continued to contract with facilities operating on a 14-year-old set
of standards.34 Not only are the 2000 NDS irrelevant to the times, they are also
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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

Fig. 5: Standards applied for most
recent inspection obtained

*The ERO PBNDS inspections worksheet does not distinguish
between 2008 and 2011 standards, therefore when available
the most recent ODO inspection was used to clarify which
version of PBNDS the facility is being inspected to.

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largely irrelevant to the needs of detained
individuals. In fact, one of the 2000 NDS
states that a facility is in compliance if the
law library is adequately equipped with
typewriters.35 Nonetheless, while the 2008
and 2011 PBNDS contain more robust
protections than the 2000 NDS, including
sexual assault prevention guidelines and
more detailed standards governing solitary
confinement and hunger strike response,
they too are problematic. Like the 2000
NDS, the PBNDS are derived from prison standards created within the criminal
justice context, and therefore replicate
many of the deplorable conditions and
troubling human rights failings endemic to
that system.
•
Inspectors fail to apply 2008 and
2011 PBNDS language that was intended to improve oversight. The inspection
form for the 2000 NDS states that some
components are applicable only to Service Processing Centers and Contract
Detention Facilities. IGSAs, which hold
the majority of detained immigrants, are
encouraged to use these components as
guidelines but are not rated on them. For
example, in IGSA facilities under the 2000
NDS, people placed in solitary confinement
do not have a right to appeal that decision
and their placement is not reviewed regularly by a supervisory agent.36 Within these
facilities, medical staff are not required to
conduct daily check-ins with people on
hunger strikes.37 Even under 2008 PBNDS
guards may read incoming mail without a
warden’s prior written approval and out of
the detained individual’s presence. This
practice threatens attorney-client confidentiality and can make the difference in
whether or not detained individuals can
safely report complaints to their attorneys
and seek redress without facing retribution.
Language holding IGSAs to higher standards was strengthened in the 200838 and
2011 PBNDS39 to require IGSAs to “adopt,
adapt, or establish alternatives, provided
they meet or exceed the intent represented
by these procedures,” but many inspectors

The Immigration Detention Transparency & Human Rights Project - October 2015 Report

continue to mark these components Fig. 6: Failed inspections, 2007-2012
as “not applicable” for IGSAs being
inspected under the PBNDS. The
PBNDS were written to strengthen protections for immigrants detained at IGSAs, but inspectors
have failed to uphold that intent.
•

ERO and ODO inspection reports are not designed to capture actual conditions of detention for the population at a given
facility. While there is an emphasis
in both ERO and ODO inspections
on the security of a facility and
ensuring that detained individuals
stay locked up, there is a de-emphasis on the humane treatment
and protection of people imprisoned for their immigration status.
As focused reviews of inspections
at six detention facilities revealed
(see Section IV), inspectors track
whether or not policies exist rather
than inquire into their implementation or effectiveness. Inspectors
often take facility administrators at
their word regarding issues such as
the adequacy of medical staff, the
efficacy of grievance procedures,
or even basic and easily verifiable safety mechanisms such as
whether fire alarms are functional.
The checklist-driven inspections
process obscures the conditions
immigrants actually face in detention centers and whether standards
are being implemented to their full
intent. Even when critical aspects
are included in the standards, they
often are segmented into sterile
lists of mundane details that are
easy to check off because they
do not immediately appear to be
connected to anything important.
For example, all three sets of
detention standards include guidelines for telephone access, but are
extremely limited in their provision
of free phone calls. They fail to

View a full-size version of charts at
immigrantjustice.org/
TransparencyandHumanRights

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acknowledge that in many facilities, the high cost of telephone calls inhibit individuals’ ability to communicate with lawyers, family, and other support systems.
Telephone contact is critical to preserve due process and prevent isolation, but
the inspections process provides no means for inspectors to document or even
detect the financial hurdles that block immigrants from making calls in some
facilities. ERO inspections rarely cite interviews with individuals in custody, and
ODO inspections treat such interviews as footnotes. Therefore inspectors are
able to check that a facility meets standards because “No restrictions are placed
on detainees attempting to contact attorneys and legal service providers who
are on the approved ‘Free Legal Services List,’” even when a short conversation
with the detained immigrants who have tried to use those phones would reveal
otherwise. The checklist culture also leads to absurd interpretations of standards,
a reality perhaps best demonstrated by the repeat finding that indoor rooms with
windows count as providing outdoor recreation because air from the outside can
enter the room.
3. Inspections Prioritize Facilities’ Interests
•

Even where human rights violations have been publicly documented, facilities rarely fail ERO inspections. (See Fig. 6 and Section IV) The number of
failed facilities dropped significantly since 2009, when Congress implemented the
appropriations requirement that ICE not expend funds to facilities with two consecutive failed inspections. No detention centers failed ERO inspections in 2010
or 2012, and only four failed in 2011. ICE has not failed any facility twice in a row
since the 2009 law took effect.

•

Inspection reports may be edited before they are finalized and submitted
to ICE’s Detention Monitoring Unit by the inspections contractor. The ICE
Detention Services Management director explained during his litigation deposition that both inspections contractors and ICE personnel may edit the findings
and ratings in a report before it is submitted to the facility’s file. These edits are
not tracked, and ICE has no knowledge of the frequency or types of edits that
occur between an initial inspection and when the inspections contractor submits
the inspection report.

•

The checklist ERO inspectors use during their reviews does not include all
components of the detention standards. As the focused review of inspections
from Arizona’s Eloy Detention Center reveals (see Section IV), such discrepancies could obscure important details of daily operations, such as medical care
staffing, which are critical to ensuring detained immigrants’ basic human rights.

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

“The contractor has latitude to get
to the final result”
— ICE Detention Monitoring Unit Director,
January 2014 deposition in NIJC v. DHS

IV. In Focus: Six Case Studies of Facilities with
Known Conditions Problems, 2007-2012
The peculiarities and efficacy of the ICE inspections system are best understood through a focused
review of facilities where human rights and due process conditions have been publicly documented,
providing a basis for comparison with inspectors’ observations. For this deep-dive approach, DWN
and NIJC selected six detention centers which have been subjects of media reports, human rights
investigations, and congressional inquiries. All but Eloy were included in DWN’s 2012 Expose & Close
(E&C) reports which surveyed immigrants detained at some of the worst immigration detention facilities in the United States.

Featured Facilities:
Eloy Federal Contract Facility, Arizona ..... Page 17
Baker County Detention Center, Florida ..... Page 19
Etowah County Detention Center, Alabama ..... Page 21
Houston Processing Center, Texas ..... Page 23
Stewart Detention Center, Georgia ..... Page 25
Pulaski County Jail, Illinois
(formerly named Tri-County Detention Center) ..... Page 27
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Eloy Federal Contract Facility, Arizona:
Detention Standards (as of 2012):
Facility Type:
Private Contractor:
2012 ICE Average Daily Population:
2011 ERO
Private Contract
Inspector:
Rating:
Deficient
Standards:
Deficient
Components:

MGT

Meets
Standards
0
3

2008 PBNDS
IGSA
CCA
1479

2011 ODO
Private Contract MGT
Inspector:

2012 ERO
Private Contract Nakamoto
Inspector:

Rating:

N/A

Rating:

Deficient
Standards:
Deficient
Components:

0

Deficient
Standards:
Deficient
Components:

13

Meets
Standards
0
9

Eloy Federal Contract Facility in Arizona has the highest number of known deaths of any detention
facility, including at least six suicides since 2003. Eloy is also the source of frequent reports of sexual
assault, and the subject of an investigation launched by Rep. Raúl Grijalva (D-AZ) in June 2015.40 Under these circumstances, it was expected that the facility’s inspection reports would reveal a troubling
history of failure to meet standards regarding medical care, suicide prevention, and sexual assault
prevention. Instead, the inspection reports reveal ICE’s complicity in obscuring the facility’s failure
to meaningfully address its violations. Based on the inspection reports NIJC received, Eloy has not
failed an ERO inspection since 2006.41 However, ICE did not provide the 2010 ERO inspection for
Eloy. It is unclear whether this omission is because the facility was not inspected that year or because
ICE failed to fully comply with the federal court order in NIJC’s FOIA litigation to obtain the documents.

Suicide prevention
The lack of accountability under the 2008 PBNDS Suicide Prevention and Intervention standard is
apparent in Eloy’s 2012 ERO inspection. Eloy passed on the overall suicide prevention standard despite failing to comply with one of its major components: the suicide watch room was found to contain
“structures or smaller objects that could be used in a suicide attempt,”42 including grates and a sprinkler head. Instead of questioning the judgment of the medical staff who signed off on the room’s use,
the inspector marked Eloy as compliant with the next component, which requires that “Medical staff
have approved the room for this purpose.” The inspector went on to minimize the concerns about
the safety of the suicide isolation room by explaining that “a detainee placed on suicide watch would
be under constant observation by a security officer sitting outside the room” but failed to address the
requirement that medical or detention staff monitor individuals on suicide watch every 15 minutes. In
2015, questions regarding whether jail staff adequately monitor individuals at risk of suicide became a
major focus of the investigation Rep. Grijalva demanded after an autopsy raised questions about the
circumstances surrounding the suicide of 31-year-old Mexican immigrant Jose de Jesus Deniz-Sahagun.
The inspections documents raise additional concerns regarding Eloy’s suicide prevention efforts and
ICE’s attempts to cover up or diminish the facility’s deficiencies over time. One suicide, that of EmPage 17

Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

manuel Owusu in October 2008, seems to have been hidden by ICE for years. In a 2010 story about
Mr. Owusu’s death in The New York Times, there is no indication the reporter was informed he had
committed suicide.43 A list of in-custody deaths released by ICE in 201244 lists Mr. Owusu’s cause of
death as “Acute Cerebrovascular Accident,” a medical term for stroke, but a list released in 201345
and updated in 201546 says Mr. Owusu died from suicide by hanging. The 2009 ERO inspection report does not mention Mr. Owusu’s death at all aside from a tally in the “significant incident summary
worksheet,” where two deaths are attributed to “illness.”47 There also is no indication that the circumstances surrounding Mr. Owusu’s death played into the determination of Eloy’s rating on the medical
care or suicide prevention standards. Notably, the Reviewer-in-Charge Assurance Statement, where
inspectors discuss deaths on other inspection reports, is heavily redacted in the 2009 inspection.48

Medical Care
The checklist ERO inspectors use during their reviews does not include all components of the detention standards, a discrepancy that could obscure important details of daily operations which are
critical to ensuring humane treatment of those in custody. At Eloy, the ERO inspection failed to recognize that medical screenings and physical exams rarely were reviewed by physicians. According
to an article in The Arizona Republic following a July 2015 media tour, Eloy has no doctors on staff.49
The February 2011 ERO inspection rated Eloy as compliant on all components of the Medical Care
standard, but the ODO inspection two months later found the facility was deficient on two points that
are not even covered in the ERO checklist: the requirement that a “clinical medical authority,” which
the ODO interprets to mean a physician, reviews the medical screenings50 individuals undergo within 24 hours of arriving at the facility and the physical examinations51 people have within their first 14
days there. These exams determine individuals’ priority for treatment. The ODO reviewed forms from
30 screenings conducted by registered nurses, nurse practitioners, or advanced practice nurses and
found none had been reviewed by a physician; of 30 physical examinations within 14 days of arrival, only one had been reviewed by a physician.52 The ERO findings regarding individuals’ access to
medical care also come into question in light of an October 2010 report by the Women’s Refugee
Commission, in which one woman who suffered from multiple sclerosis reported she made repeated
requests to see a physician but was forced to wait two months to see a doctor about her condition. 53

Sexual Assault
The 2011 ERO inspection was the first time Eloy was in compliance with the sexual assault prevention and intervention standards. This inspection report is notable because at least two sexual assaults
(which later would become highly publicized) took place at Eloy in the 14 months prior to the inspection.54 Unfortunately, inclusion of the standard does not guarantee that a facility is held accountable
for preventing sexual assault. The ERO inspector notes 10 allegations regarding sexual assaults at
Eloy in the past year, then dismisses them all as “unfounded or unsubstantiated” and refers the reader to a database for additional statistics.55
ERO’s failure to ensure compliance with the sexual assault standards means facilities are not held
accountable and those in custody remain at risk. Tanya Guzman, a transgender woman who was
held in an all-male pod at Eloy, was assaulted in December 2009 by a guard who later was convicted. Despite the first assault and Ms. Guzman’s frequent complaints of harassment and abuse, Eloy
continued to detain her in the male pod and she was assaulted by another detainee in April 2010.
She reported the assault to the police a week and a half later, saying she waited because she feared
retaliation. She was released from ICE custody soon after making the report—likely the reason her
claim was not substantiated in the records the ERO inspector reviewed. In December 2012 the ACLU
of Arizona filed a lawsuit on Ms. Guzman’s behalf against ICE, Corrections Corporation of America,
and the City of Eloy regarding the 2009 assault.56

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The Immigration Detention Transparency & Human Rights Project - October 2015 Report

Baker County Detention Center, Florida:
Detention Standards (as of 2012):
Facility Type:
2012 ICE Average Daily Population:
2011 ERO
Private Contract
MGT
Inspector:
Rating:
Good
Deficient
0
Standards:
Deficient
14
Components:

2000 NDS
IGSA
252

2011 ODO
Private Contract
MGT
Inspector:
Rating:
Acceptable
Deficient
0
Standards:
Deficient
4
Components:

2012 ERO
Private Contract
Nakamoto
Inspector:
Rating:
Acceptable
Deficient
0
Standards:
Deficient
5
Components:

Although the Baker County Detention Center in Macclenny, Florida, has been cited as one of the
worst immigration detention centers in the United States, it continues to detain a daily average of 228
individuals who have no access to outdoor recreation, no exercise equipment, no volunteer work program, and are forced to attend court hearings via video-conferencing (because the immigration court
is 200 miles away) while dressed in jump suits and shackled.57

Detention Watch Network

Nonetheless, in its 2011 inspection, ERO rated this facility as
“good,” one standard below the highest rating of “superior.”58
This is despite the fact that inspectors identified 14 specific
deficient components (although no overall standards were
found deficient)59 and despite the ODO’s inspectors rating
the facility as “acceptable”60 that same year. In the following
year,61 the ERO inspectors found only five deficient components (two of which were repeat offenses) and rated the
facility as “acceptable.”62 The different ratings assigned by
the ERO’s and ODO’s 2011 inspections already raise suspicions, but the downgrade from good to acceptable when
there were fewer identified deficiencies brings into question
the rigor and reliability of inspections. (For an explanation of
the ERO’s three-tiered ratings approach, see Figs. 2-4.)

As with many of the ERO inspections, most of the deficiencies that were identified in the 2011 and 2012 inspections
concerned the finer points of administration and security,
including the absence of written policies regarding barbershop hours, head counts, and other similar
procedures. The two repeat deficiencies referred to the policy of opening detained individuals’ mail
without appropriate protocols and the absence of a separate area for the barbershop (currently in the
facility’s common space).63 DWN’s E&C report conveyed concerns about the facility’s physical isolation, the exorbitant cost of phone cards, and how visitors who traveled a great distance to the facility
were only allowed to see their loved ones through a video feed upon arrival, yet ICE’s standards (old
and new) fail to check for these concerns.

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

Recreation
DWN’s E&C report notes that a lack of access to fresh air and sunlight is an issue at Baker because
the “area for recreation is a room with concrete walls, floor, and a roof. The room’s only window is
high on a side wall and is covered with mesh to allow in fresh air.” The 2012 ERO inspectors, contrary
to common understanding of what these words mean, found that
… each of the two housing pods includes an outdoor recreation area64 with access to fresh air and natural light through a 12-foot long by 3-foot high security
screen. The design of the rooms allow for a substantial amount of natural light
and fresh air to enter the recreation areas. The natural light and the exchange of
free flowing outdoor air reflect the outside climate and the time of day [emphasis
added].65
Equally unacceptable, the standard for outdoor recreation can also be satisfied if the facility provides
the option for a detained person to be transferred after 180 days to a facility with an actual outside
recreation area.66

Telephone Access
Another standard requires the Office of Inspector General (OIG) phone number to be programmed
into the facility’s phone system (and the number to be checked during the inspection). The 2012 ERO
inspectors wrote, “[c]alls placed to the OIG hotline were connected. The caller was not able to reach
an actual person.” Nevertheless, this was marked as complying with the standard—yet another example of the checklist culture that creates simplified shortcuts and fails to take into account the actual
experience of detained individuals.

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The Immigration Detention Transparency & Human Rights Project - October 2015 Report

Etowah County Detention Center, Alabama:
Detention Standards (as of 2012):
Facility Type:
2012 ICE Average Daily Population:
2011 ERO
Private Contract
MGT
Inspector:
Rating:
Acceptable
Deficient Stan0
dards:
Deficient Compo9
nents:

2000 NDS
IGSA
333

2012 ERO
2012 ODO
Private Contract Nakamoto Private Contract Creative
Inspector:
Inspector:
Corrections
Rating:
Acceptable
Rating:
N/A
Deficient
0
Deficient
0
Standards:
Standards:
Deficient
0
Deficient
8
Components:
Components:

In 2010, ICE planned to close the Etowah County Detention Center (ECDC) in Gadsden, Alabama,
because of the facility’s poor conditions and because its remote location made it difficult for detained
immigrants to obtain legal counsel or stay connected with their families and communities.67 However,
arguing that the facility was an important part of the local economy, Representative Robert Aderholt
(R-AL), Senator Richard Shelby (R-AL), and other members of Congress pressured ICE into keeping
the facility open by threatening DHS’s budget.68
Despite previous censure of the facility, oversight and accountability did not improve, leading to
five separate hunger strikes within the facility in the year preceding the 2012 ERO inspection.69 The
breadth of discrepancies from sequential years, different inspectors, and different oversight agencies
are an ongoing problem in the ECDC inspections. In 2011 and 2012, ERO’s inspectors (MGT and
Nakamoto, respectively) rated the facility as “acceptable” (two levels below the “superior” rating) even
though the 2012 inspection identified zero deficiencies. In fact, as explained below, a 2011 deficiency
was remedied in 2012 through re-interpretation of the standards, meaning that the problem was not
actually addressed, but that the standards were lowered to cure the problem.
Beyond inconsistencies between ERO inspections, the 2012 ODO inspection identified eight deficiencies within five standards. Some of the ODO’s major concerns included a lack of policies concerning
an emergency grievance procedure which “involves an immediate threat to detainee safety or welfare”70 and the procedure for requesting ICE-certified copies of identity documents (e.g., passports,
birth certificates) that are essential to legal cases. Both the 2011 and 2012 ERO inspections identify
these standards as having been met.

Recreation
ECDC’s indoor recreation room was counted by inspectors as offering outdoor recreation, because a
window with bars qualified as providing access to sunlight and free-flowing air. The 2012 ERO inspectors wrote, “[t]his component was rated deficient during the last inspection because the facility
did not offer outdoor recreation. During this inspection, the designated outdoor recreation facilities
were found to be enclosed areas with secure openings that allow natural lighting and air circulation.”71
The inspectors explicitly concluded that “outdoor recreation is provided at this facility.”72 DWN’s E&C
report describes the recreation area as “a cement room…the size of half a basketball court. Near the
top of one or two of the walls, very high up, are relatively small windows with bars that allow outside air to enter the area. It is impossible to see anything out of these windows. People refer to it as
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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

‘the sweatbox.’”73 The fact that indoor spaces are routinely counted as providing outdoor recreation
demonstrates that the interpretation of the standards are a sham and again points to a checklist
culture focused on technicalities that permit facilities to maintain their contracts, rather than upholding
the intent of the standards.

Legal Orientation Programs
All three inspections also found the standard regarding legal orientation programs was met despite
the fact that a legal orientation program had not been offered at the facility at any time during the past
12 months. Because individuals in ICE custody do not have the right to appointed counsel, basic legal
orientation programs are the only chance many have to understand what is happening to them and
how they might represent themselves in court. Amazingly, this standard is considered to have been
met as long as the facility has an appropriate written policy. The 2000 NDS checklist states that if “No
group presentations were conducted within the past 12 months. Mark standard as acceptable overall.”74 In comments, the 2011 ERO inspector writes, “Although there have been no group legal rights
presentations in the past 12 months or any requests to do so received, the facility does have a comprehensive written policy to address group presentations if any requests are received.”75

Visitation and Programming

Hannah Rappleye

In DWN’s E&C report, detained individuals also reported difficulties in accessing phones (citing restrictive hours) and problems with the visitation policies. Although all of the relevant standards were
rated as acceptable in the available inspections, it is striking that contact visitations are not permitted despite the distance of the facility from the nearest major metropolitan area (2.5 hour drive from
Atlanta). The video visits (which still
require in-person visits to the facility)
are limited to 30 minutes, require prior
ICE approval, and offer no privacy.
ECDC claims to offer a wide range of
programs for detained people. These
programs include the “World Aquaculture Program,” “Puppies without Borders,” and “Adventure Programming.”
Individuals interviewed for DWN’s E&C
report who were detained at Etowah
said these programs were effectively
nonexistent and in reality the facility
had nothing more than a broken fish
tank and a rock-climbing wall in a
room the size of a cell.76

The inconsistent inspection findings and ignorance of detained individuals’ publicly documented concerns underpin the necessity for increased independent oversight and meaningful responses when
deficiencies are found. It is not enough to reinterpret standards by lowering the bar and allowing for
subpar conditions to continue.

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The Immigration Detention Transparency & Human Rights Project - October 2015 Report

Houston Processing Center, Texas:
Detention Standards (as of 2012):
Facility Type:
Private Contractor:
2012 ICE Average Daily Population:
2011 ERO
Private Contract
MGT
Inspector:
Rating:
Meets
Standards
Deficient
0
Standards:
Deficient
6
Components:

2008 PBNDS
CDF
CCA
832.6

2011 ODO
Private Contract
Inspector:
Rating:
Deficient
Standards:
Deficient
Components:

None
N/A
0
1

2012 ERO
Private Contract Nakamoto
Inspector:
Rating:
Meets
Standards
Deficient
0
Standards:
Deficient
4
Components:

In 1984, the Houston Processing Center (HPC), located in Houston, Texas, became the first private
prison ever built in the United States. It is owned and operated by Corrections Corporation of America
(CCA), the nation’s largest private prison company.77 A 2012 DWN E&C report highlighted HPC as
one of the worst immigration detention facilities,78 but its 2011 and 2012 ERO inspections and 2011
ODO inspection reveal few deficiencies and paint a picture of a facility that seems to be in compliance
with standards.

Health Care and Solitary Confinement
For example, detained immigrants interviewed for DWN’s E&C report described long delays in accessing medical care and the inappropriate use of solitary confinement79 for individuals with mental
health issues. Two people died at the facility in 2011—including a 31-year-old man who died at a local
hospital after only six days in detention, three of which he had spent vomiting.80 None of the inspections noted deficiencies or concerns within the Medical Care standard. The ERO inspectors explicitly
mention reviewing medical records but they did not interview detained individuals about their experiences or follow up on any complaints or grievances. For example, one mandatory component under
the special management unit (SMU) standard requires health care personnel to provide assessments
and reviews for every detained individual placed in the SMU (also known as segregation or solitary
confinement). The ERO inspectors reviewed medical records but failed to interview detained individuals. If they had, they might have heard about David Jameson, whose story a friend conveyed to DWN
in July 2012. At that point, Mr. Jameson had been in solitary confinement at HPC for nine months,
despite being diagnosed with schizophrenia and prone to panic attacks. In Mr. Jameson’s case, either
HPC failed to fully document his circumstances or the 2012 inspectors ignored basic health care standards; either explanation is alarming. By the time of DWN’s visit, Mr. Jameson’s psychological problems had caused him to refuse to bathe for nearly four months.81

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

© 2015 Google

Food and Grievances
The rather stark contrasts between DWN’s E&C report and the inspections continue with 2012 ERO
inspectors describing the food as “nutritious and attractively presented meals” 82 and that the “facility
menu has been certified by a registered dietician, and has been analyzed with a daily average calorie
count of 3100 calories.”83 Individuals interviewed for the DWN report described the food as “insufficient to maintain one’s health” and unappetizing.84 The E&C report goes on to describe a toxic environment where people had given up on filing complaints because they never received responses or
because they feared retaliation, and in which guards verbally abused and threatened individuals with
solitary confinement if they complained.85

Telephone Access
The impact of designating some components as “non-mandatory” also is evident at HPC, where the
requirement to afford detained people “a reasonable degree of privacy for legal calls” is met by taking them to “the shift commanders’ or unit managers’ office to place legal calls,”86 This arrangement
seems to assume that the requirement for privacy is only meant to protect conversations from being
overheard by other detained people, rather than by facility staff, and even that protection is easily
overridden. Even these phone calls can be monitored as long as “notification is posted by detainee
telephones.”87 Although the standard is “met,” any real hope for attorney-client confidentiality is eliminated.

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The Immigration Detention Transparency & Human Rights Project - October 2015 Report

Stewart Detention Center, Georgia:
Detention Standards (as of 2012):
Facility Type:
Private Contractor:
2012 ICE Average Daily Population:
2011 ERO
Private Contract
MGT
Inspector:
Rating:
Meets
Standards
Deficient
0
Standards:
Deficient
2
Components:

2008 PBNDS
IGSA
CCA
1632

2011 ODO
Private Contract MGT
Inspector:
Rating:
N/A
Deficient
Standards:
Deficient
Components:

0
25

2012 ERO
Private Contract Nakamoto
Inspector:
Rating:
Meets
Standards
Deficient
0
Standards:
Deficient
3
Components:

Stewart Detention Center (SDC) in Lumpkin, Georgia, is one of the largest immigration detention
facilities in the United States with the capacity to jail 2,000 people. Although the facility is owned by
Stewart County and is contracted as an IGSA, the facility is actually operated by CCA. In 2012, SDC
was inspected under the 2008 PBNDS, but because there are certain standards that only apply to
CDFs and SPCs, CCA was provided leniency in its compliance with certain standards under Stewart
County’s IGSA contract. Out of 889 components, 144 were marked as non-applicable because the
facility is an IGSA.88
Considerable discrepancies between the 2011 ERO and ODO inspections again bring into question
their value and credibility. While the 2011 ERO inspection noted only two deficient components and
zero deficient standards, the 2011 ODO inspection found 25 deficiencies in 12 standards. Among
the most egregious deficits: Stewart lacked a written policy to ensure that medical grievances were
received by the next business day,89 ICE staff was reported to be generally inaccessible and failed
to respond to the majority of detainee requests,90 and the ODO inspection team witnessed a male
detainee changing in full view of a female corrections officer.91 The ERO inspection ignores or only
cursorily examines other major deficiencies, and in some cases provides comical justifications. For
example, the 2012 ERO inspector cites the use of floppy discs—technology that otherwise had been
largely obsolete for at least a decade—as compliant with a standard requiring that detained individuals be allowed to store legal work in private electronic form.92

Medical Care
Both ERO and ODO inspections managed to identify one major deficit regarding medical care: intake
examinations were not reviewed by physicians or mid-level practitioners by the following business
day. In fact, it sometimes took months before the examinations were reviewed by a doctor.93 According to the 2012 DWN E&C report, SDC had only one doctor and seven nurses to provide medical care
for over 1,500 detained men.94 Several of the concerns raised by the DWN report were underscored
by the 2012 ACLU of Georgia report, Prisoners of Profit: Immigrants and Detention in Georgia, which
highlighted the death of Roberto Medina Martinez, who died from a treatable heart condition in 2009
after being detained for two months at SDC.95 Nonetheless, ERO and ODO inspections stated that
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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

La Vision
La Vision
Will Coley
the medical staffing was adequate at SDC, even with five vacant positions in 2011 and 2012 (two of
which had been vacant for more than two years).96 These staffing issues may explain why, according
to the ERO inspection, SDC referred more than 775 people for outside medical care in 2012.97

Sexual Assault
The 2012 ERO inspection mentions six allegations of sexual assault or abuse, and then proceeds
to methodically dismiss or minimize them. Two were downgraded to verbal harassment, and another was relabeled as physical assault, despite the clear sexual nature of the incident: the victim was
severely beaten after refusing to provide sexual favors for another detained person. The remaining
three were found to be unsubstantiated,98 though the slow nature of investigations—sometimes taking
weeks or even months—means that witnesses, perpetrators and victims may have been transferred,
deported, or released.

Legal Rights Access and Visitation
SDC’s remote location is a hindrance to attracting and retaining adequate medical staff, but it also
creates barriers to visitation from attorneys and family members. Attorneys in the region told DWN in
2012 that visitation rooms at SDC were inadequate because they were forced to speak with their clients through a phone and Plexiglas, making it difficult to prepare for court and to provide clients confidential documents.99 People detained at SDC in 2012 also claimed that they were allowed infrequent
access to the law library and had unreliable phone access. None of these concerns were reflected in
the ERO and ODO inspections.

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The Immigration Detention Transparency & Human Rights Project - October 2015 Report

Pulaski County Jail, Illinois
(formerly named Tri-County Detention Center):
Detention Standards (as of 2012):
Facility Type:
2012 ICE Average Daily Population:
2011 ERO
Private Contract
Inspector:
Rating:
Deficient Standards:
Deficient
Components:

MGT
Meets
Standards
0
8

2008 PBNDS
IGSA
224
2012 ERO
Private Contract
Nakamoto
Inspector:
Rating:
Does Not
Meet Standards
Deficient Standards:
1
Deficient
9
Components:

The lack of consistency and accountability in the ERO inspections process is apparent in its 2011
and 2012 inspections of the Tri-County Detention Center (since renamed Pulaski County Jail) in Ullin,
Illinois.100 According to the 2012 E&C report by DWN and NIJC, grievances were largely ignored, essential medical care was delayed, and general overcrowding was exacerbated by inadequate medical
staffing.101
In 2011, the ERO inspection marked the facility as having met its obligations under the 2008 PBNDS. However, internal inconsistencies raise concerns as to how meticulous the inspectors were in
conducting their reviews. For example, although the hold rooms standard and its components were
marked as N/A (not applicable), it was checked off as having met standards in the final summary of
the inspectors’ findings.102 In comments, the inspectors also noted that there were no canines at the
facility103 yet in one of their comments (a portion of which has been redacted), they wrote that “[a]t this
time there was a minor altercation between the canine and an ICE detainee which did not result in
any serious injury.”104

Medical Care and Lack of Accountability
If internal inconsistencies were unsettling in the 2011 inspection, they intensified in the 2012 ERO
inspection. Despite the Tri-County Detention Center receiving a “does not meet standards” rating
according to the lead compliance inspector’s recommended rating at the conclusion of the 2012
inspection worksheet,105 the memorandum addressed to Field Office Director Ricardo Wong on May
29, 2012, which is affixed at the beginning of the inspection file, reflects an unexplained change in the
final determination. The memo states that according to its final rating, the facility “meets standards.”106
The lead compliance inspector attributes the deficient finding to the detention center’s failure to comply with a mandatory component under the Medical Care standard, specifically concerning oversight
over needles. The 2012 inspectors wrote, “[o]nce needles and syringes are placed in the medication
cart, no further accountability is maintained. While the current inventory of the bulk stock was inaccurate, the HSA [Health Services Administrator] had conducted an inventory two days ago which
showed significant discrepancies in the inventories of Insulin syringes, 5cc syringes with needles, and
3cc syringes with needles.”107

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NIJC

NIJC

Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

NIJC
The facility also believed its medical staff to be adequate to serve its population, despite the fact that
185 medical cases were referred for outside medical care in 2011 and 411 were referred in 2012. The
ERO inspections provide no analysis of whether the medical staff were meeting the actual needs of
the individuals detained at Tri-County.

Environmental Health and Safety
Additionally problematic in the 2012 ERO inspection are the various components which were not
found deficient but should have required follow-up before being marked as having met standards.
In particular, a new fire alarm system had been recently installed but had yet to be inspected by the
fire marshal and emergency generators did not cover critical areas such as administration, medical,
booking, and food service.108 But because facility staff indicated that they had plans to address these
problems, the environmental health and safety standard was preemptively marked as having been
fulfilled.

Telephone Access
Collectively, the inspection reports for Tri-County present a puzzling picture of the reality in the facility.
In early 2012, Senator Richard Durbin (D-IL) visited the facility and expressed his shock at the conditions—particularly referencing the high price of phone calls and inoperable telephones109—yet the
2011 and 2012 ERO inspections reflect no issues with the telephone system, finding that the standard
was met and even exceeded.110 Of course, as discussed earlier, the ERO inspections process leaves
no room to even consider whether the exorbitant cost of phone calls undermines the PBNDS’s phone
access requirements.

Grievance Procedures
Also troubling are the facility’s grievance procedures. In the 2011 inspection, a component regarding
the absence of a secure box through which detained individuals could drop in written comments to
communicate with ICE staff was marked deficient but was subsequently remediated later that year.
Prior to the box’s existence, “ICE Staff receive[d] all requests from facility staff.” With this lack of confidentiality, it is not surprising that there were only six grievances in 2011 and 10 in 2012.111

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The Immigration Detention Transparency & Human Rights Project - October 2015 Report

V. Conclusion and Recommendations
These six case studies demonstrate that the ICE inspections system is inadequate and has failed to
resolve the substantial and pervasive human rights violations detained immigrants face in ICE custody. In many cases, the poor conditions and mistreatment individuals suffer are explicitly prohibited
under ICE detention standards. Instead of reporting on these violations, the inspectors focus on completing checklists and fail to engage with detained immigrants or follow up on issues raised in public
reports. It is easy for facilities to pass inspections without actually upholding the standards’ intent.
According to the 2009 congressional mandate, the ICE inspections process creates a threshold which
determines whether or not ICE can continue to contract with local governments and private prison
companies to run immigration detention facilities. Unfortunately, NIJC and DWN found that ICE’s
inspections mechanisms whitewash problems and ensure that even the worst detention facilities pass
inspections and maintain contracts. Without a credible system of oversight, there is no humane way
to incarcerate immigrants.

Based on the findings of this report, NIJC and DWN call on DHS and ICE to:
1. Increase Transparency and Oversight of the Inspections Process
A. Make ERO and ODO inspections available to the public in a timely manner. To date, ICE
has released its inspections to the public only as a result of FOIA requests. FOIA requests
are unnecessarily time-consuming and expensive obstacles to accessing information about
how the federal government treats thousands of people in its custody and spends billions of
taxpayer dollars. Instead, this information should be freely available.
B. Provide public reporting on suicide attempts, hunger strikes, work program stoppages, use
of solitary confinement, use of force, and other significant events at detention centers.
C. Submit quarterly reporting to Congress on inspection and oversight activities of detention
facilities, which should be made publicly available.
2. Improve the Quality of Inspections
A. Establish a DHS ombudsman outside of ICE to conduct unannounced inspections of immigration detention facilities at least once per year, with complete findings made available to
the public. These third-party inspections should examine compliance with applicable detention standards and determine whether contracts will be renewed in accordance with congressional appropriations requirements.
B. Prohibit facilities from taking an “à la carte” approach to compliance and make all detention
standards provisions mandatory during inspections. ICE must stop permitting some facilities to opt out of detention standards they have been contracted to apply. If a facility cannot
abide by detention standards in their entirety then it should not be permitted to enter into or
continue a contract with ICE.
C. Ensure that inspections involve more than checklists. Inspectors must rely on more than assurances by jail administrators of compliance with detention standards and instead seek and
document proof of their effective implementation.
D. Engage detained immigrants during inspections, as well as other stakeholders such as legal

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

service providers and those who regularly conduct visitation, in order to capture the range of
concerns at a facility that may not be reported through formal institutional channels. Inspectors should document the content of those interviews.
3. Institute Consequences for Failed Inspections
A. Place detention facilities on probation and subject them to more intensive inspections after
the first finding of substantial non-compliance.
B. Terminate contracts within 60 days for those facilities with repeat findings of substantial
non-compliance, including inadequate or less than the equivalent median score in two consecutive inspections.

VI. Endnotes
1. Goldstein, Amy & Dana Priest, “Careless Detention:
Series Introduction,” The Washington Post (May 9,
2008), http://www.washingtonpost.com/wp-dyn/content/video/2008/05/09/VI2008050902424.html.
2. Nina Bernstein, “Few Details on Immigrants Who
Died in Custody,” The New York Times (May 5, 2008),
http://www.nytimes.com/2008/05/05/nyregion/05detain.html?_r=0.
3. “A Closer Look at 83 Deaths,” The Washington
Post (May 10, 2008), http://www.washingtonpost.com/
wp-srv/nation/specials/immigration/map.html.
4. Seattle University School of Law, Voices from
Detention: A Report on Human Rights Violations at
the Northwest Detention Center (July 2008), https://
weareoneamerica.org/sites/default/files/OneAmerica_Detention_Report.pdf.
5. National Immigration Law Center, A Broken System: Confidential Reports Reveal Failures in U.S.
Immigrant Detention Centers (July 2009), http://www.
nilc.org/document.html?id=9.
6. Dora Schriro, Department of Homeland Security
Immigration and Customs Enforcement, Immigration
Detention Overview and Recommendations (Oct. 6,
2009), http://www.ice.gov/doclib/about/offices/odpp/
pdf/ice-detention-rpt.pdf.
7. U.S. Immigration and Customs Enforcement, “2009
Immigration Detention Reforms” (Aug. 6, 2009), http://
www.ice.gov/factsheets/2009detention-reform.

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8. For more information about the creation of the
ODO, see Department of Homeland Security, Written testimony of U.S. Immigration and Customs
Enforcement Office of Detention Policy and Planning Assistant Director Kevin Landy for a House
Committee on the Judiciary, Subcommittee on Immigration Policy and Enforcement hearing on Performance-Based National Detention Standards (PBNDS)
2011 (Mar. 27, 2012), available at http://www.dhs.
gov/news/2012/03/27/written-testimony-us-immigration-and-customs-enforcement-house-judiciary.
9. U.S. President, Memorandum, “Freedom of Information Act,” Federal Register 74, no. 15 (Jan. 26,
2009): 4683, http://www.justice.gov/sites/default/files/
oip/legacy/2014/07/23/presidential-foia.pdf.
10. U.S. Immigration and Customs Enforcement Office of Detention and Removal Operations, Semiannual Report on Compliance with ICE National Detention
Standards January – June 2007 (May 9, 2008), http://
www.ice.gov/doclib/about/offices/opr/pdf/semiannual-dmd.pdf.
11. The ODO and the other details of Obama’s reform
plan are discussed at length in a 2010 joint report by
NIJC, DWN, and the Midwest Coalition for Human
Rights, Year-One Report Card: Human Rights and the
Obama Administration’s Immigration Detention Reforms, (Oct. 6, 2010), http://immigrantjustice.org/sites/
immigrantjustice.org/files/ICE%20report%20card%20
FULL%20FINAL%202010%2010%2006.pdf.
12. Sakamoto, Reginald Dep., Jan. 29, 2014, https://
www.documentcloud.org/documents/2105817-saka-

The Immigration Detention Transparency & Human Rights Project - October 2015 Report

motos-deposition.htmlhttps:/www.documentcloud.org/
documents/2105817-sakamotos-deposition.html.
13. Migration and Refugee Services/United States
Conference of Catholic Bishops & Center for Migration Studies, Unlocking Human Dignity: A Plan to
Transform the U.S. Immigrant Detention System (May
2015), http://www.usccb.org/about/migration-and-refugee-services/upload/unlocking-human-dignity.pdf.
14. U.S. Commission on Civil Rights, With Liberty and
Justice for All: The State of Civil Rights at Immigration
Detention Facilities (Sept. 2015), http://www.usccr.
gov/pubs/Statutory_Enforcement_Report2015.pdf
15. See NIJC’s These Lives Matter blog: http://theselivesmatter.tumblr.com/.
16. See 2012 Northwest Detention Center ERO
Inspection, https://www.documentcloud.org/documents/1813477-northwest-denteion-center-tacoma-wa-2012-ero.html#document/p3/a248252; 2012
Etowah ODO Inspection, https://www.documentcloud.
org/documents/797500-etoway-county-detention-center-gadsden-al-odo.html#document/p7/a248253.
17. U.S. Immigration and Customs Enforcement, 2000
Detention Operations Manual, http://www.ice.gov/detention-standards/2000.
18. U.S. Immigration and Customs Enforcement,
2008 Operations Manual ICE Performance-Based
National Detention Standards, http://www.ice.gov/detention-standards/2008/.
19. U.S. Immigration and Customs Enforcement,
2011 Operations Manual ICE Performance-Based
National Detention Standards, http://www.ice.gov/
detention-standards/2011/ (Note that while this report
does not cover detention facilities inspected to the
ICE Family Residential Standards, NIJC has released
inspection reports based on those standards for Berks
County Family Shelter and Hutto Correctional Center.)
20. See NDS, PBNDS 2008, and PBNDS 2011. “Procedures in italics are specifically required for SPCs
and CDFs. IGSA facilities must conform to these
procedures or adopt, adapt or establish alternatives,
provided they meet or exceed the intent represented
by these procedures.”
21. See Section IV focus report on Stewart Detention
Center, and 2012 Stewart ERO Inspection, https://
www.documentcloud.org/documents/2065390-stewart-detention-center-ga-2012-ero-inspection.html.

22. See example from 2012 Northwest Detention
Center ERO Inspection, at 2, https://www.documentcloud.org/documents/1813477-northwest-denteion-center-tacoma-wa-2012-ero.html.
23. Id.
24. Following the creation of the Department of
Homeland Security in 2002, ICE was created to deal
with immigration enforcement. ERO was then formed
as a subset of ICE to manage and oversee immigration detention.
25. Nakamoto Group, MGT of America, and Creative
Corrections are the primary contractors on the inspections that were reviewed for this report.
26. These include the Joint Integration Case Management System (JICMS) and the ENFORCE Alien
Booking Module (EABM) and Alien Removal Module
(EARM).
27. 2011 Stewart Detention Center ODO Inspection, at 4, https://www.documentcloud.org/
documents/2065395-stewart-detention-center-ga-2011-odo-inspection.html.
28. Sakamoto, Reginald Dep., Jan. 29, 2014, https://
www.documentcloud.org/documents/2105817-sakamotos-deposition.html.
29. House Committee on Appropriations Report
110-181 to accompany H.R. 2638, FY 2008 (June
8, 2007), at 42, 43, available at http://www.gpo.gov/
fdsys/pkg/CRPT-110hrpt181/pdf/CRPT-110hrpt181.
pdf.
30. “Consolidated Security, Disaster Assistance, and
Continuing Appropriations Act, 2009.” 110th Congress, (H.R. 2638), P.L. 110-329, https://www.congress.gov/110/plaws/publ329/PLAW-110publ329.pdf.
31. ICE Director John Morton testimony before the
House Appropriations Subcommittee on Homeland
Security, “The FY11 Budget for U.S. Immigration
and Customs Enforcement,” March18, 2010, http://
www.dhs.gov/news/2010/04/16/assistant-secretary-john-mortons-testimony-us-immigration-and-customs-enforcement.
32. See 2012 Northwest Detention Center ERO
Inspection, https://www.documentcloud.org/documents/1813477-northwest-denteion-center-tacoma-wa-2012-ero.html#document/p3/a248252; 2012
Etowah ODO Inspection, https://www.documentcloud.
org/documents/797500-etoway-county-detention-cen-

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Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse

ter-gadsden-al-odo.html#document/p7/a248253.
33. U.S. Government Accountability Office, Immigration Detention: Additional Actions Needed to Strengthen Management and Oversight of Facility Costs and
Standards (GAO-15-153), Oct. 2014, http://www.gao.
gov/assets/670/666467.pdf.

46. U.S. Immigration and Customs Services, List of
Deaths in ICE Custody October 2003 - July 20, 2015,
http://www.ice.gov/sites/default/files/documents/
Report/2015/detaineedeaths2003-present.pdf. (Accessed Oct. 19, 2015)

34. Id.

47. 2009 Eloy ERO Inspection, https://www.documentcloud.org/documents/1865594-eloy-az-2009-eroinspection.html#document/p8/a244124.

35. ICE, 2000 Detention Operations Manual.

48. Id.

36. INS Detention Standard, Special Management
Unit (Sept. 2000), http://www.ice.gov/doclib/dro/detention-standards/pdf/smu_adm.pdf.

49. Megan Jula & Daniel Gonzalez, “Eloy Detention
Center: Why so many suicides?” The Arizona Republic, Jul. 29, 2015, http://www.azcentral.com/story/
news/arizona/investigations/2015/07/28/eloy-detention-center-immigrant-suicides/30760545.

37. INS Detention Standard, Hunger Strikes (Sept.
2000), http://www.ice.gov/doclib/dro/detention-standards/pdf/hunger.pdf.
38. ICE, 2008 Operations Manual ICE Performance-Based National Detention Standards.
39. ICE, 2011 Operations Manual ICE Performance-Based National Detention Standards.
40. Office of Congressman Raúl Grijalva. Letter to
U.S. Attorney General Loretta Lynch re: Death of José
Jésus Deniz-Sahagún at Eloy Detention Center. Jun.
16, 2015, https://grijalva.house.gov/news-and-pressreleases/grijalva-to-doj-investigate-deaths-at-eloy-detention-center.
41. 2007 Eloy ERO Inspection, https://www.documentcloud.org/documents/1865591-eloy-az-2007-eroinspection.html#document/p2/a244108.
42. 2012 Eloy ERO Inspection, https://www.documentcloud.org/documents/1865593-eloy-az-2012-eroinspection.html#document/p98/a244905.
43. Nina Bernstein, “Officials Hid Truth of Immigrant
Deaths in Jail,” The New York Times (Jan. 9, 2010),
http://www.nytimes.com/2010/01/10/us/10detain.html.
44. U.S. Immigration and Customs Enforcement, List
of Deaths in ICE Custody October 2003 - December
6, 2012, http://immigrantjustice.org/sites/immigrantjustice.org/files/Detainee%20Deaths%20in%20ICE%20
Custody%202003-2012.pdf (Downloaded from ICE
website July 12, 2013)
45. U.S. Immigration and Customs Enforcement, List
of Deaths in ICE Custody October 2003 - December
2, 2013, http://www.ice.gov/doclib/foia/reports/detaineedeaths2003-present.pdf (Accessed Oct. 19, 2015)

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50. ICE/DRO Detention Standard: Medical Care,
(Dec. 2, 2008), https://www.documentcloud.org/documents/2433679-2008-pbnds-medical-care-standard.
html#document/p12/a244862.
51. ICE/DRO Detention Standard: Medical Care
(Dec. 2, 2008), https://www.documentcloud.org/documents/2433679-2008-pbnds-medical-care-standard.
html#document/p13/a244870.
52. 2011 Eloy ODO Inspection, https://www.documentcloud.org/documents/1865603-eloy-az-2011odo-inspection.html#document/p15/a244654.
53. Women’s Refugee Commission, Migrant Women and Children at Risk: In Custody in Arizona, Oct.
2010, https://womensrefugeecommission.org/resources/document/656.
54. Bob Ortega, “Woman Alleges Abuse in Eloy Prison, Suing ICE,” The Arizona Republic, Dec. 8, 2011,
http://www.azcentral.com/news/articles/2011/12/08/
20111208woman-alleges-abuse-eloy-prison.html.
55. 2011 Eloy ERO Inspection, https://www.documentcloud.org/documents/1865592-eloy-az-2011-ero-inspection.html#document/p57/a244482.
56. ACLU, “ACLU of Arizona Files Lawsuit on Behalf
of Transgender Woman Sexually Assaulted by CCA
Guard,” Dec. 5, 2011, https://www.aclu.org/news/
aclu-arizona-files-lawsuit-behalf-transgender-woman-sexually-assaulted-cca-guard.
57. Detention Watch Network, Expose & Close: Baker
County Jail, Florida, Nov. 2012, http://www.detentionwatchnetwork.org/sites/detentionwatchnetwork.org/
files/expose-bakernov12.pdf.

The Immigration Detention Transparency & Human Rights Project - October 2015 Report

58. 2011 Baker ERO Inspection, https://www.documentcloud.org/documents/1692936-baker-county-fl-2011ero-audit.html.

75. 2011 Etowah ERO Inspection, https://www.documentcloud.org/documents/1700692-etowah-county-al2011-ero-inspection.html.

59. Id.

76. Expose & Close: Etowah County Jail, Alabama,
at 6, http://www.detentionwatchnetwork.org/sites/
detentionwatchnetwork.org/files/ExposeClose/Expose-Etowah11-13.pdf.

60. 2011 Baker ODO Follow-Up Inspection, https://
www.documentcloud.org/documents/2451543-bakercounty-fl-2011-odo-follow-up-inspection.html.
61. No 2010 ODO inspection was released for Baker.
62. 2012 Baker ERO Inspection, https://www.documentcloud.org/documents/1692935-baker-county-fl2012-ero-audit.html.
63. Id.
64. In referring to an “outdoor recreation area,” the
inspector means that it is outside of the housing pods.
65. 2012 Baker ERO Inspection.
66. 2011 Baker ERO Inspection, https://www.documentcloud.org/documents/1692936-baker-county-fl-2011ero-audit.html, at 28.
67. Detention Watch Network, Expose & Close:
Etowah County Jail, Alabama, Nov. 2012, at 1, http://
www.detentionwatchnetwork.org/sites/detentionwatchnetwork.org/files/ExposeClose/Expose-Etowah11-13.
pdf.
68. Hannah Rappleye, “When Feds Sought to Shutter Immigration Jail, Politics Intervened,” NBC News,
Aug. 22, 2012, http://investigations.nbcnews.com/_
news/2012/08/22/13398156-when-feds-sought-toshutter-immigration-jail-politics-intervened.
69. 2012 Etowah ERO Inspection, https://www.documentcloud.org/documents/1700693-etowah-county-al2012-ero-inspection.html.
70. 2012 Etowah ODO Inspection, at 3, https://www.
documentcloud.org/documents/797500-etoway-county-detention-center-gadsden-al-odo.html.
71. 2012 Etowah ERO Inspection, at 35.
72. Id.

77. Corrections Corporation of America, “The CCA
Story: Our Company History,” https://www.cca.com/
our-history
78. Detention Watch Network, Expose & Close: Houston Processing Center, Texas (Nov. 2012), at 6, http://
www.detentionwatchnetwork.org/sites/detentionwatchnetwork.org/files/expose-houstonnov12.pdf.
79. See Christy Carnegie Fujio & Mike Corradini,
Buried Alive: Solitary Confinement in the U.S. Detention System, Physicians for Human Rights, Apr. 2013,
http://physiciansforhumanrights.org/library/reports/
buried-alive-solitary-confinement-in-the-us-detention-system.html?referrer=http://www.immigrantjustice.org/end-solitary-confinement-immigration-detention; National Immigrant Justice Center & Physicians
for Human Rights, Invisible in Isolation: The Use of
Segregation and Solitary Confinement in Immigration
Detention, Sept. 2012, http://www.immigrantjustice.
org/publications/report-invisible-isolation-use-segregation-and-solitary-confinement-immigration-detenti; Interim Report of the Special Rapporteur of the Human
Rights Council on Torture and Other Cruel, Inhuman,
or Degrading Treatment or Punishment, Aug. 5, 2011,
http://www.immigrantjustice.org/sites/immigrantjustice.
org/files/2011_08%20United%20Nations%20Report%20on%20Solitary%20Confinement.pdf.
80. Expose & Close: Houston Processing Center,
Texas, at 6.
81. Expose & Close: Houston Processing Center,
Texas, at 4; Authors of the report visited the facility in
July 2012.
82. 2012 Houston CDF ERO Inspection, at 73, https://
www.documentcloud.org/documents/1736877-houston-cdf-cca-tx-2012-ero-inspection.html.

73. Expose & Close: Etowah County Jail, Alabama, at
5.

83. 2011 Houston CDF ERO Inspection, at 69, https://
www.documentcloud.org/documents/1736874-houston-cdf-cca-tx-2011-ero-inspection.html.

74. 2011 Etowah ERO Inspection, https://www.documentcloud.org/documents/1700692-etowah-county-al2011-ero-inspection.html, at 22.

84. Expose & Close: Houston Processing Center,
Texas, at 4.

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85. Expose & Close: Houston Processing Center,
Texas, at 5.
86. 2011 Houston CDF ERO Inspection, https://www.
documentcloud.org/documents/1736874-houston-cdfcca-tx-2011-ero-inspection.html.
87. Id.
88. 2012 Stewart ERO Inspection, https://www.
documentcloud.org/documents/2065390-stewart-detention-center-ga-2012-ero-inspection.html. “IGSAs
must conform to these procedures or adopt, adapt or
establish alternatives, provided they meet or exceed
the intent represented by these procedures” (written
into the 2008 PBNDS in regards to how IGSAs should
conform to standards that apply to CDFs/SPCs).

Justice Center, Expose & Close: Tri-County Detention
Center, Illinois (Nov. 2012), http://www.detentionwatchnetwork.org/sites/detentionwatchnetwork.org/
files/expose-tricountynov12.pdf.
102. 2011 Pulaski ERO Inspection, marked as
“N/A” at 36 (https://www.documentcloud.org/documents/2065596-tri-county-jail-il-2011-ero-inspection.
html#document/p171/a250934) and “Meets Standard”
at 2012FOIA3030.010009 (inspection page number
not legible in document, view at https://www.documentcloud.org/documents/2065596-tri-county-jail-il2011-ero-inspection.html#document/p171/a250934).
103. Id. at 68.
104. Id. at 69.

89. 2011 Stewart ODO Inspection, at 2, https://www.
documentcloud.org/documents/2065395-stewart-detention-center-ga-2011-odo-inspection.html.

105. 2012 Pulaski ERO Inspection, https://www.documentcloud.org/documents/2065597-tri-county-jail-il2012-ero-inspection.html.

90. Id. at 17.

106. Id.

91. Id. at 7.

107. Id. at 88.

92. 2012 Stewart ERO Inspection at 127.

108. Id.

93. 2011 Stewart ODO Inspection, at15, https://www.
documentcloud.org/documents/2065395-stewart-detention-center-ga-2011-odo-inspection.html.

109. Expose & Close: Tri-County Detention Center,
Illinois at 5.

94. Detention Watch Network, Expose & Close: Stewart Detention Center, Georgia (Nov. 2012), at 3, http://
www.detentionwatchnetwork.org/sites/detentionwatchnetwork.org/files/expose-stewartnov12.pdf.
95. ACLU of Georgia, Prisoners of Profit: Immigrants
and Detention in Georgia (May 2012), http://www.
acluga.org/files/2713/3788/2900/Prisoners_of_Profit.
pdf.
96. 2011 Stewart ODO Inspection at 15; 2012 Stewart
ERO Inspection ,at 78.
97. 2012 Stewart ERO Inspection.
98. Id.
99. Expose & Close: Stewart Detention Center,
Georgia (Nov. 2012), at 4, http://www.detentionwatchnetwork.org/sites/detentionwatchnetwork.org/files/
expose-stewartnov12.pdf.
100. There was no ODO inspection.
101. Detention Watch Network & National Immigrant

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110. The 2012 inspectors wrote that “Telephones are
available in numbers that exceed the minimum ratio
required” and continues on that “Any repairs needed
are promptly reported.”
111. 2011 Pulaski ERO Inspection. Information regarding drop box deficiencies is annotated at https://
www.documentcloud.org/documents/2065596-tricounty-jail-il-2011-ero-inspection.html#document/
p170/a250975