ICE Detention Standards Compliance Audit - Berks Family Residential Center, Leesport, PA, ICE, 2008

ICE Detention Standards Compliance Audit - Berks Family Residential Center, Leesport, PA, ICE, 2008

• June 2, 2016 • Locations: United States of America -> Pennsylvania • Topics: Corrections Audits, Immigration

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erks F

.. An

Uy Residenti

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Review Re

Prepared for:

Department of Homeland Security (DHS)
Immigration Customs and Enforcement (ICE)
Office of Detention and Removal (DRO)
Juvenile and Family Residential Management Unit GFRMU)

By:

The Nakamoto

Inc.

Table of Contents

Backgrou nd .................................................................................................. 4-5
Berks Family Residential Facility ................................................................. .4
Compliance Support .................................................................................. 4
Summary of Previous Findings ......................................................................... 5

Overview...................................................................................................................................... 6-7
Bi-Annual Compliance Review ........................................................................................... 6
Compliance Ratings ............................................................................................................. 6
Organization of the Report .................................................................................................. 7

Areas of Best Practice ...................................................................................... 7-8
Recreation .................................................................................................. 8
Religious Practices ..................................................................................... 8

Summary of Findings ..................................................................................... 8-10
Compliant ............................................................................................... 8
Not Compliant ......................................................................................... 9

Recommendations for Improvement ................................................................. 10-19
Section A: Not Compliant Ratings .............................................................. 10-16
Life, Health and Safety .......................................................................................... 10
Admissions and Release ....................................................................... 12
Educational Policy .......................................................................... 13
Emergency Plans ................................................................................ 13
Food Service ................................................................................... 14
Housekeeping and Voluntary Work Program ........................................................ 15
Sexual Abuse and Assault Prevention and Intervention .............................. 15
Suicide Prevention and Intervention .................................................... 16

Page 2 of 19

Table of Contents

Section B: General Compliance Recommendations ........................................ 17-19
Contraband ...................................................................................... .1 7
Discipline and Behavior Management.. ................................................................ .17
Env ironl11ental Health ............................................................................................ 18
Resident Census ..................................................................................................... 18
Staff Hiring and Training ....................................................................................... 18
Transportation ........................................................................................................ 19

Summary ...................................................................................................... 19

Page 3 of 19

BACKGROUND:

Berks Family Residential Facility
U.S. Immigration and Customs Enforcement CICE") established the Berks Family Residential
Facility ("Berks") in March 2001. Designed as a non-secure residential facility to accommodate
the unique needs of undocumented children and their families, Berks became the first of its kind
in the U.S. dedicated to keeping families and children together while undergoing immigration
proceedings.
Located in Leesport, PA, the eighty-five (85) bed facility that was once a nursing home is nestled
in a quiet, small-town community. Berks, along with the 512 bed T. Don Hutto Family
Residential Facility ("Hutto") in Taylor, Texas (established in May 2006), provides non-violent,
non-criminal families with a variety of supportive services throughout their stay. Some of these
services include:
•

Access to on-site, routine medical, dental and mental health care provided by the
Division of Immigration Health Services ("D IHS");

•

Educational courses for school age children 5 days per week;

•

English as a second language (ESL) classes for adults;

•

Age and culturally and linguistically appropriate recreational activities for residents;

•

On-site spiritual support; and

•

On-going access to case management services which ensures each resident has access to
legal services and social supports.

In addition, each facility is staffed with professionals, paraprofessionals, and officers who
undergo training in areas related to the Family Residential Standards ("Standards") to ensure the
provision of safe and humane care to residents.
Compliance Support
Since September 25,2007, the Nakamoto Group has provided contractor and compliance support
services to the Juvenile and Family Residential Management Unit ("JFRMU") of the Office of
Detention and Removal Operations ("DRO"). Created in March 2007, JFRMU serves to
optimize DRO's ability to manage ICE's immigration policy as it pertains to undocumented and
unaccompanied children and their families. To fulfill part of this mission and to ensure the
highest level of care and treatment for residents within ICE custody, the JFRMU contracted the
services of the Nakamoto Group to assist with providing support and consultation in the areas of
family services, education, primary and mental health care, youth and adolescent care and
development, and facility development and compliance.

Page 4 of 19

Presently, the Nakamoto Group continues to provide compliance support services to the JFRMU
which is inclusive of routine facility inspections, annual compliance reviews, consultation
services, and specialized compliance support services. In April 2008, for instance, for eight (8)
weeks, the Nakamoto Group's Juvenile and Corrections Subject Matter Experts ("SMEs")
provided on-site and telecommuting guidance in several areas, to include: policy and procedure
development; fire safety and inspections; resident intake and orientation procedures; and
recruitment and training needs. The SME worked closely with Berks facility administrators and
staff providing recommendations for facility and service enhancement. Most recently, the
JFRMU requested and obtained the assistance of a full-time Compliance Reviewer to provide
additional specialized support services, including monthly inspections of each Family
Residential Facility. In addition to reviewing areas of the facility each month for compliance, a
monthly report of findings is also submitted to the JFRMU to aid facilities in their on-going
efforts to achieve 100% compliance with the Family Residential Standards. Finally, as it is
JFRMU's personal mission to have each facility achieve 100% compliance, a bi-annual
compliance review process was implemented Hence, approximately every six (6) months, the
Nakamoto Group conducts a full review of each Family Residential Facility and provides a
report of findings to the JFRMU. This report follows the second review of the Berks Family
Residential Facility and includes a summary of findings.
Summary of Previous Findings
During the week of July 14th - 17th 2008, six (6) members of the Nakamoto Group's Compliance
Review Team ("Team") completed the first compliance review of the Berks Family Residential
Facility. The Team was impressed with the strides Berks made in incorporating
recommendations from the specialized compliance support services provided in April 2008, as
well as additional enhancements and revisions to the facility. Utilizing an older rating system,
Berks achieved 78% compliance by obtaining a rating of "Exceptional" or "Standard"
(translating as "Compliant" with the cun-ent rating system I) on 29 of the 37 Family Residential
Standards. Eight (8) of those Standards were rated as "Inadequate" (translating as "Not
Compliant" with current rating system) during the baseline review. (Reference Matrix A for an
overview of rated Standards).
Recommendations for enhancements were provided by the Compliance Review Team and both
Berks and ICE administrators worked to incorporate recommendations. Following is an overview
of the second and most recent review of the facility. It is the hope of the Nakamoto Compliance
Review Team that ICEIJFRMU staff and Berks administrators find the information presented in
this report to be beneficial to the ongoing development and compliance attainment of the facility,
as well as the continued care of its residents.

lThe older rating system included a four (4) item compliance scale consisting of "Exceptional", "Standard",
"Minimal", and "Inadequate" ratings. These ratings indicated the facility's level of compliance as compared to the
requirements outlined in the Family Residential Standards ("Standards") established on December 21, 2007.

Page 5 of 19

implement suggestions within 90 days of site visit report. Documentation of implementation
to be received by ICE/ORO within 90 days. Revisit of facility may be warranted.
Further, the revised version of the Monitoring Tool also includes a "Life Health Safety" or
"LHS" component document. Developed as a succinct way to review the most critical
operational areas of the facility, the LHS document is compiled of component items derived
from select ICE/ORO Family Residential Standards (Reference "LHS Components" attached)
and replaces the quantitatively scored "Critical Components" section utilized in previous
versions of the Monitoring Tool. In general, LHS components are considered to be those by
which non-compliance may significantly:
•
•
•

Impair the health and safety of residents and/or staff;
Diminish the basic quality of life afforded to residents; and
Undermine the mission and mandate of JFRMU to appropriately manage ICE's
immigration policy as it pertains to undocumented families with children and protecting
their safety and dignity.

Rating of the LHS document followed the "Compliant" and "Not Compliant" format with a
preponderance of "Not Compliant" ratings resulting in an overall rating of "Not Compliant" for
LHS. Per the JFRMU, such a rating warrants a 15-30 day plan of action response by the facility
following receipt of report.
Organization of the Report
This report provides outcomes and recommendations regarding the Berks review based upon the
assessment of the thirty-seven (37) Family Residential Standards in accordance with the
aforementioned rating scale. Included in this report are (in-order):
1. Areas of Best Practice
2. Summary of findings
3. Recommendations for Improvement

AREAS OF BEST PRACTICE
Review and observation of the facility's operation revealed that Berks administrators, along with
ICE officials, continue to strive to implement recommendations as well as maintain previous
levels of best or standard practices. As found previously, several areas of facility operations were
found to be well above Standard requirements by way of implementation and practice. These
areas are cited as "Best Practices" for a juvenile and family care facility and include the
following:
Page 7 of 19

Recreation
Recreation continues to be a strong program within the facility and a model program for a
children and family residential center. The program is well organized, services are tailored for
specific age groups, and all services are appropriately and thoroughly documented. The program
has also involved the community in previous endeavors and has established plans to continue
encouragement of community involvement.
Religious Practices
The Religious Services program at the Berks facility is one that is of significant importance to
residents. As such, the facility contracted a full-time chaplain to provide services for residents
and to ensure spiritual needs are addressed. Since his beginning with the facility approximate
seven (7) months ago, current residents reference the Chaplain, and the ability to freely engage in
religious practices, as being significant sources of support. Volunteers are also in place to
provide additional spiritual support services (e.g., Mass services); making the Religious Services
program a strong and vital component within the facility.
SUMMARY OF FINDINGS
Overall, Berks continues efforts to incorporate recommendations as well as feedback from
consultants and ICE/DROIJFRMU to enhance facility operation and services. Such
implementation has led to Berks rating as "Compliant" in 30, or 81 %, of the 37 assessed domains
(not including the LHS items; reference Matrix B for performance summary). A complete outline
of findings is as follows (in alphabetical order):

COMPLIANT: The following 30 Standards were rated as "COMPLIANT":
1. Contraband
2. Correspondence and Other Mail
3. Discipline and Behavior Management
4. Environmental Health and Safety
5. Escorted Trips for Non-Medical Emergencies
6. Funds and Personal Property
7. Grievance System
8. Hunger Strikes
9. Key and Lock Control
10. Law Libraries and Legal Materials
11 . Legal Rights Group Presentations
Page 8 of 19

12. Marriage Requests
13. Medical Services
14. News Media Interview and Tours
15. Personal Hygiene
16. Post Orders
17. Recreation
18. Religious Practices
19. Resident Census
20. Resident's Files
21. Searches of Residents
22. Staff Hiring and Training
23. Staff-Resident Communication
24. Telephone Access
25. Terminal Illness and Advanced Directives
26. Tool Control
27. Transfer of Residents
28. Transportation (Land)
29. Use of Physical Force and Restraints
30. Visitation
NOT-COMPLIANT: Thefollowing 8 items were rated as "NOT CaMPLJANT" (7 of the
Standard items plus L!fe, Health and Safety)
1. Admissions and Release
2. Educational Policy
3. Emergency Plans
4. Food Service
5. Housekeeping and Voluntary Work Program
6. Life, Health and Safety (LHS) Critical Components

Page 9 of 19

7. Sexual Abuse and Assault Prevention and Intervention
8. Suicide Prevention and Intervention

RECOMMENDATIONS FOR IMPROVEMENT
The following section provides recommendations to improve facility operations based upon the
Family Residential Standards. Designed to accompany the completed Monitoring Tool
(attached), and therefore not exhaustive of items found to be non-compliant, this section
highlights components that are suggested as priority when developing a corrective plan of action.
Section A provides compliance recommendations for those Standards rated as "Not-Compliant",
to include areas deemed by the Team as critical areas of focus. Section B provides compliance
recommendations for those Standards rated as "Compliant". While not necessarily considered
critical, these recommendations support guidelines as indicated in the Standards and will serve to
enhance facility operations.

SECTION A:
Not Compliant Ratings
Life, Health and Safety (LHS) (CRIT/CALl

Areas of non-compliance:

•

One of the washbasins and showers in the men's restroom was found to have only cold
water. Another shower area found the temperature to be 87 degrees Fahrenheit (below the
required 100-120 degrees Fahrenheit). Although staff indicated they had received
complaints about water being too hot in the facility and adjusted temperatures
accordingly, the work order had not been resolved to allow for corrected water
temperatures and the availability of hot water at the time of the review (Reference:
Personal Hygiene, p. 3; #5).

•

Arriving residents do not receive a handbook that details the facility rules in a language
the resident understands. Although handbooks exist within the facility, they are only
provided in English and residents are not provided with individual copies. Instead, one
copy is provided for each residential wing within the facility. The present handbook is
being translated in Spanish. However, due to the length of time (7 month) that the
handbook has been out for translation, some of the information contained will require
updating. In addition, residents are not provided with a formal orientation of the facility
operations. Although forms are provided for residents to sign, a full overview regarding

Due to the critical nature of the overall LHS components, it is listed first in order of Non-Compliance.

Page 10 of 19

b2 high, b7e

b2 high, b7e
b2 high, b7e

b2 high, b7e

b2 high, b7e
b2 high, b7e

Educational Policy

Areas of non-compliance:
•

CRITICAL: Pre-kindergarten instruction is not provided to eligible four-year-old
children. A resource room is available for children five years of age and for children in
need of English as a Second Language (ESL) services and/or more academic preparation
(Reference: Educational Policy, p. 2; Section Ih).

•

Documentation of educational staff training was not available at time of review.
Documentation is maintained in educator files off site (Reference: Educational Policy, p.
5, Section 6f; p. 7, Section IIa).

•

Special needs educational assessments are not administered to each student upon arrival
(Reference: Educational Policy, p. 2; Section Ig).

•

Library holdings are not sufficient in quantity or language diversity for resident's use
(Reference: Educational Policy, p. 6, Section 8a).

•

A bookmobile is used in lieu of an on-site residential library. The Standards mandate an
on-site library be available and an offsite system is not used as an alternate (Reference:
Educational Policy, p. 6; 8b).

Recommendations:
•

Adapt educational program to provide pre-kindergarten and kindergarten services as
required for eligible children four-year olds and up.

•

Obtain copies of staff training and other relevant documents an maintain on-site in staff
files.

•

Develop a formalized system to conduct special educational needs assessments for all
school-age residents.

•

Collaborate with community resources to enhance diversity and availability of books for
resident's use on-site.

Emergency Plans

Areas of non-compliance:
•

CRITICAL: The facility has developed and emergency plan policy and made contacts
with local responders. However, the policy does not take the place of a well written, well
rehearsed, and well critique emergency plan (Reference: Emergency Plans: Section
V.3.a.2).
Page 13 of 19

•

Documentation of once a month emergency list call-down procedure is not available
(Reference: Emergency Plans: p. 7; Section C).

•

Although a policy has been developed, several specified areas of security and other
planning components are not included (Reference: Emergency Plans: p. p. 5; p. 6; p. 6;
Section V.B; Section V.J., Section V.M.).

Recommendation:
•

The facility has not developed a local emergency plan but has been part of a county wide
emergency system. While this serves to support the facility, it does not provide the level
of preparedness required in the facility as required by the Standards. Priority in the
development of a facility-specific Emergency Plan and training on such plan is
warranted.

Food Service

Areas of non-compliance:
•

CRITICAL: Timelines from the evening meal to breakfast exceed the time lines as
established by the Standard (no more than 14 hours) (Reference: Food Service, p. 6;
Section 4a).

•

CRITICAL: Maintenance of information regarding resident's medical diets does not
meet Standard requirements. For instance, facility staff receive notification from residents
regarding special dietary needs. Food Service staff (who are located in another facility)
obtain resident dietary information from facility staff. Due to lack of effective
communication, food service staff do not maintain updated information regarding
residents' dietary needs. (Reference: Food Service, p. 16; Section 7a)

•

CRITICAL: Menus at the facility are changed without consideration of two hot meals
per day and with no documentation provided to show changes - resulting in meal
selections that are not being appropriately reviewed for nutritional needs/content as
required by the Standards. (Reference: Food Service, p. 17, Section 8b).

•

A kosher meal system is not in place to meet the needs of participating residents
(Reference: Food Service, p. 12; p.15, #2).

•

Residents working in the food service area (sanitation) are not provided with training and
a supervisor is not assigned to the dining area (Reference: Food Service, p. 4, Section c;
p. 7, Section b).

Page 14 of 19

Recommendations:
•

Establish a timeline for meals that minimizes the 14 hour gap between the evening and
breakfast meals. Presently, serving dinner at 4:30 P.M. should be reviewed to consider
later evening feeding.

•

Establish a system of communication and accountability that ensures resident's medial
and religious meal needs are met.

•

Work with licensed nutritionist to develop menu items and ensure a system of
accountability whereby menu changes must be reviewed and signed off on by the Facility
Administrator with notification to ICE as to when and why menu was changed.

•

Provide training to residents working in food service and other areas of the facility and
ensure documentation of training is maintained. In addition, assign a supervisor to
oversee the dining area during meals.

Housekeeping and Voluntary Work Program

Area of non-compliance
•

CRITICAL: Appropriate training is not available for all residents. For instance, the
facility has a limited number of residents that are assigned mainly to the kitchen area
sanitation employees. Resident's files did not include required training, job descriptions,
and agreements required by the Standards. The facility also has a house keeping plan that
requires all adult residents to clean various areas of the facility on a rotating basis,
however, training on chemicals was not provided in areas such as "Right to Know" as
required by OSHA and the State laws (Reference: Housekeeping and Voluntary Work
Program, Section V. 11).

Recommendation:
• In accordance with the Standard, ensure all residents are provided appropriate training in
areas of work. Include documentation of training in residents' files.
Sexual Abuse and Assault Prevention and Intervention

Areas of non-compliance:
•

CRITICAL: The training coordinator has been assigned as the Sexual Abuse
Coordinator. However, the training coordinator is not on-site to ensure ongoing
availability to residents (currently located at Juvenile Facility). Additionally, residents are
not aware of policies or information regarding sexual abuse and sexual harassment.
Documentation is provided on a laminated board near the phone areas in each wing and
documents are signed during intake, however verbal discussion regarding resident rights
and behavioral expectations while at the facility is not provided to residents. (Reference:
Sexual Abuse and Assault Prevention and Intervention, page, 3; paragraph 3; C).
Page 15 of 19

•

The facility follows both its own and DIHS national policy. However, the policies are not
clear regarding the provision of prevention (e.g., discussion of residents' rights) or
discipline/prosecution of assailants. (Reference: Sexual Abuse and Assault Prevention
and Intervention, page, 2; Section B).

•

Facility policy does not include ICE/DRO and JFRMU as contacts in the event of
allegations of sexual misconduct (Reference: Sexual Abuse and Assault Prevention and
Intervention, page, 6; #2).

Recommendations:
•

Officially appoint a coordinator for the Sexual Abuse and Assault Prevention program
who, at a minimum: is on-site and available for residents and staff; has appropriate
background/training/credentials in topic area; is in charge of ensuring resident's
awareness of rights and responsibilities; and who collaborates with staff in the
development and review of site specific policies, orientation programs, and trainings.

•

Facility staff and DIHS collaborate to develop a clear, site specific policy that addresses
requirements indicated in the Standards.

Suicide Prevention and Intervention

Areas of non-compliance:
•

CRITICAL: A suicide/homicide screening is currently conducted at resident intake;
however, this screening is not a standardized screening tool/assessment and is not
conducted by specially trained staff or a licensed health care provider.

•

The date of the last policy revision was 200S.The Standard requires an annual review
(Reference: Suicide Prevention and Intervention, page 1; Section VI).

•

The suicide and prevention training program did not include requisite components such
as guidelines for returning a previously suicidal resident to the general population
(Reference: Suicide and Prevention Intervention, pages 1-2).

Recommendations:
•

Include DIHS staff members in the intake screening process and/or provide specific,
ongoing training for designated intake staff in the area of Suicide Prevention and
Intervention to include, at a minimum: practice, observation, and cultural and linguistic
sensitivity. Additionally, incorporate the use of standardized screening/assessment tools.

•

DIHS and ICEIJFRMU collaborate to develop an institutionally-based Suicide Prevention
and Intervention policy that meets the requirements outlined in the Standard, to include
an annual review.
Page 16 of 19

SECTIONB:
General Compliance Recommendations (in alphabetical order)
Contraband

Area of non-compliance:
•

A review of contraband definition and policies and procedures are not provided to
residents at intake (Reference: Contraband, Section 11.4).

Recommendation:
•

Develop a formalized orientation process to include review of specific topics, such as
contraband, as required by the Standards.

Discipline and Behavior Management

Areas of non-compliance:
•

Current rules established for facility residents do not distinguish between age appropriate
behaviors for children and adults (Reference: Discipline and Behavior Management, p. 3,
paragraph 5).

•

The behavior management program does not include systemic feedback from staff to
each resident as required by the Standard. (Reference: Discipline and Behavior
Management, p. 3, paragraph 4).

•

Although a policy is in place, low level rule infractions are not investigated (Reference:
Discipline and Behavior Management, p. 8, MRC)

Recommendations:
•

Develop rules/codes of conduct that account for and distinguish between age appropriate
behaviors. Ensure rules/codes of conduct are reviewed verbally with staff and residents
and ample opportunities are provided for residents to seek clarification. Also, ensure
rules/codes of conduct are posted conspicuously in languages residents understand.

•

In accordance with the Standards, incorporate a systemic feedback system from staff to
residents as part of the behavior management program.

•

Develop practice that follows policy guidelines with regard to investigation of
infractions. Ensure full documentation of practice in residents' file and develop practice
that ensures residents understand of processes and outcomes.

Page 17 of 19

b2 high, b7e

Recommendation:
•

Utilize community resources (e.g., local cultural diversity groups/programs), facility staff
and resources (e.g., DIHS Mental Health providers), and other sources of support to
strengthen and implement on-going cultural and linguistic competency training for staff.

Transportation

Area of non-compliance:
•

Transportation post order and emergency plan does not include all information as
required by the Standard (Reference: Transportation [Land Transportation], pp. 11-13).

Recommendation:
•

Update post order and emergency plan accordingly.

SUMMARY
The Bi-Annual Compliance Review of the Berks Family Residential Center revealed that facility
administrators and ICE/JFRMU staff continue efforts toward achieving 100% compliance.
ICE/JFRMU's diligence of instituting a full-time compliance reviewer to assist the facility by
having monthly inspections will serve to aid the facility compliance efforts. In addition, the care
and compassion displayed by staff for residents, the ongoing interaction between staff and
residents, and the consistent communication between ICE/JFRMU and Executive facility staff all
contribute to the structural and procedural enhancements that are evident since the first review.
Overall, Berks' greatest asset continues to be it staff. With the addition ofDIHS personnel for
medical and mental health services and the religious staff to address the on-going spiritual needs
of residents, the facility is beginning to branch out in the provision of more comprehensive and
innovative services. Combining this with the implementation of recommendations provided in
the report could aid the facility in achieving its goal of 100% compliance in the future.

Page 19 of 19

MA TRIX B: Performance Matrix Summary of Findings from Bi-Annual Review

Berks Family Residential Facility
Bi-Annual Compliance Review Performance Matrix
Feburary 2009

Standard

MA TRIX A: Summary of Findings from Baseline Review

Berks Family Residential Facility
Baseline Compliance Review Report
Performance Summary Matrix

Standard

The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
ADMISSIONS AND RELEASE
PURPOSE AND SCOPE:

Residents are admitted to or released from a facility in a

secure and orderly fashion.
EXPECTED OUTCOMES:

The expected outcomes of this Residential Standard are as
follows:

1. Each adult resident will be searched upon admission to ensure facility safety, security,
and good order.
2. Each minor resident will be searched upon admission using the least intrusive methods
available.

3. Each resident's personal property and valuables will be checked upon admission for
contraband which, if found, will then be inventoried, receipted, and stored.

4. Each resident's identification documents will be secured in the resident's file.
5. Each resident will be medically screened upon admission to protect the health of the
resident and others in the facility.

6. Each resident will be given an opportunity upon admission to shower and be issued clean
clothing, bedding, towels, and personal hygiene items.

7. Each resident will undergo screening interviews and complete questionnaires and other
forms upon admission.

8. Each newly admitted resident will be kept separated from previously admitted residents
until in processing is completed and housing is assigned.

9. Each newly admitted resident will be oriented to the facility through written material on
facility policies, rules, prohibited acts, and procedures and, in some facilities, by viewing
an orientation video.

10. Residents will be released, removed, or transferred from a facility only when staff have
followed specified procedures and completed required forms.

11. The facility will maintain accurate records and documentation on all residents'
admission, orientation, and release.
12. Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.

13. The standard complies with federal laws and with DHS regulations regarding residents
with special needs.
Admissions and Release
Page 1 of 5
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
REFERENCES: The First National Residential Standards were written using a variety of

methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
Flores vs. Reno
October 15, 2007, Memorandum from DRO Director John Torres, "Change Notice: Admissions
and Release National Detention Standard Strip-Search Policy".
American Correctional Association 4th Edition, Standards for Adults Local Detention Facilities:
4ALDF-2A-08, 2A-17, 2A-19, 2A-20, 2A-21 , 2A-22, 2A-23, 2A-24, 2A-25, 2A-26, 2A-27 , 2A-28,
2A-29, 2A-30, 2A-32 , 2A-33, 2C-03, 2C-04, 2C-05, 3A-01, 4B-02, 4B-06, 4C-29, 5B-18, 6A-05,
7D-11,7D-20.
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3 JDF-5A-02, 5A-04,5A-11, 5A-14-16, 3C-03, 2E-12
To determine this rating the reviewer will:

o Review written Policy and Procedure to verify it is in line with Residential Standards.
o Review current resident handbook.
o Review completed personal property inventory form.
o Review contraband log including destruction documentation.
o Review room assignment to determine appropriateness.
o Review confinement records and place of storage of confinement records.
o Observe admission/orientation process, if possible.
o Observe contraband storage area.
o Observe resident clothing for appropriateness for the season.
o Observe Interview residents regarding orientation process.

o
o
o

Inspect personal hygiene items.
Interview staff regarding release of information.
Interview staff that are responsible for the release of residence to determine their
knowledge of the procedures.
Admissions and Release
Page 2 of 5
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Compliant

Not
Compliant

rzJ

Missing Resident Property
Ref V. 2.f

rzJ

Funds and Valuables
Ref. V.2.g

rzJ

Medical Screening
Ref. V.2.h

rzJ

Housing
RefV.3

rzJ

Admissions Documentation
Ref VA

rzJ

Orientation
RefV.5

rzJ

Resident Handbook
RefV.6

rzJ

Releases
Ref V.7

rzJ

Components

Policies and procedures include:
a. Search of Residents and
personal property
RefV.2.a
b. Showers
Ref V.2.d
c.

Establishment of a Resident
File
RefV.2.i
Clothing and Bedding
V.2

"Pat downs" are not conducted
unless a reasonable and
articulated suspicion can be
documented.
RefV.2.a
Searches are conducted in an area
that affords as much privacy as
possible.
Ref V.2.c

Admissions and Release
Page 3 of 5
The Nakamoto Group, Inc.

Remarks

Facility does not have a resident handbook

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

Procedures are in place for the
inventory and receipt of resident
baggage, personal property, funds
and valuables upon admission
RefV.2.b.2
Staff completes Form 1-387 or
similar form for every lost or
missing property claim.
RefV. f
Residents are issued appropriate
and sufficient clothing and bedding
for the climatic conditions.
RefV.2
Families are evaluated for
appropriate housing assignment
prior to being placed in a living
unit.
Ref V.3
All releases are coordinated with
the ICE office of jurisdiction.
RefV.7

Compliant

Not
Compliant

r8J

Compliant

Not
Compliant

r8J

Compliant

Not
compliant

r8J

Remarks

Facility is providing residents with a staff
request form which is being responded to by
ICE staff but does not document lost property
claims by residents

Staffing and Training
Components

Staff marks resident property
obtained during searches as
contraband or funds/personal
property.
Ref V.2.b

Remarks

Resident Intake & Orientation

Components

10. All residents receive a shower or
bath upon arrival to the facility.
Ref V.d
11. Arriving residents are maintained
separately from general population
until intake/orientation process
complete.
Ref V.1

Admissions and Release
Page 4 of 5
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

CONTRABAND
PURPOSE AND SCOPE: Contraband is identified, detected, controlled and properly
disposed, thereby protecting residents and staff and enhancing facility security and
good order.
EXPECTED OUTCOMES: The expected outcomes of this Standard are as
follows:
1. Contraband will be identified, detected, controlled, and disposed of properly.
2. Resident's personal property that would be considered contraband within the facility will be
mailed to a third party or stored until the resident's release, unless that property is illegal or
a threat to safety and security.
3. Contraband that may be evidence in connection with a violation of a criminal statute will be
preserved, inventoried, controlled, and stored so as to maintain and document the chain of
custody.
4. Where required, residents have regular access to translation services and/or are provided
information in a language that they understand.
5. The standard complies with federal laws and with DHS regulations regarding residents with
special needs.
REFERENCES: The First National Residential Standards were written using a variety of
methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
American Correctional Association

4th

Edition Standards for Adult Local Detention Facilities: 2C-

01, 2C-02, 2C-06.

Contraband
Page 1 of 4
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
To determine this rating the reviewer will:

o Review written policies, procedures and practices for contraband.
o Review the following documents for inclusion of procedure for contraband:
•

Admissions and Release Policy and Post Order

•

Mail Policy and Post Order

•

Resident's handbook

•

Unit Officer's Post Orders

•

Transportation Policy and Post Orders

•

Visitation rules and Post Orders

•

Personal Property Policy

o Review Unit logbooks.
o Interview staff to determine their knowledge of the contraband policy and the
differences between hard and soft contraband.

o Review facility's list of allowed items to be in personal possession.
o

Review destruction of contraband log book and/or documentation

o Interview the director and chaplain to determine handling of religious property.
o

Interview medical authority on receipt of medication through intake or mail.

o Observe and review safe area for storage of contraband.

(Note: only look at

contraband. If you remove items from storage, you will be in the chain of custody and
required to sign chain of custody documents and be subject to subpoena in

Contraband
Page 2 of 4
The Nakamoto Group, Inc.

COUlt.)

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

Compliant

Not
Compliant

!8l

Policies and procedures are in
place for the appropriate handling
of contraband by staff.
RefV.2
Policies and procedures are in
place for the resident dispute of
contraband ownership.
RefV.2.c
Staff forwards an arriving
resident's medicine to the medical
staff.
Ref V.1A
Acceptable Chain of Custody
procedure is followed for illegal
contraband that may lead to
prosecution.
Ref VA
Policies and procedures are in
place for the destruction of
contraband.
Ref V.3
Religious property is not declared
contraband without prior approval
of chaplain and/or facility director.
RefV.2.b

Remarks

!8l

The policy is in place but does not include all
of the documentation required by Standards.

!8l

Compliant

Not
Compliant

Resident Intake & Orientation
Components

Residents receive definitions
and policies regarding
contraband during
intake/orientation process in a
language the resident
understands (or translated
where applicable).
Ref 1104

Remarks

The new resident orientation that was observed
during the review did not include contraband.

!8l

Contraband
Page 3 of 4
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
CORRESPONDANCE AND OTHER MAIL
PURPOSE AND SCOPE: Residents will be able to maintain ties with their families, the
community, legal representatives, and consular officials through correspondence.
EXPECTED OUTCOMES:

The expected outcomes of this Residential Standard are as
follows:

1. Residents will be able to maintain ties with their families, the community, legal
representatives, and consular officials through correspondence.
2. Residents will be notified of the facility's rules on correspondence and other mail through
a resident handbook, or equivalent that is provided to each resident upon admittance in
English, Spanish and other languages most widely spoken among residents. Translation
or interpretation services will be provided to residents who are not proficient in English.
3. The amount and content of correspondence residents send at their own expense will not
be limited except if needed for order and security.
4. Indigent residents will receive a specified postage allowance to maintain community ties
and the necessary postage for privileged correspondence.
5. Residents will have access to publications.
6. Incoming and outgoing mail will be opened to inspect for contraband and to intercept
cash, checks, and money orders.
7. General correspondence will not be read or rejected, except if needed for order and
security, and residents will be notified in writing when correspondence is withheld in part
or in full.
8. Residents will be permitted to send and receive Special Correspondence to persons and
organizations as identified in this standard. Outgoing and incoming correspondence from
persons and organizations as identified in this standard will be opened to inspect for
contraband only in the presence of the resident, unless waived by the resident or unless
contamination of the correspondence is suspected.
9. Incoming and outgoing letters will be held for no more than 24 hours and packages no
more than 48 hours, excluding weekends, holidays, and emergency situations.
10. Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.
Correspondence and Other Mail
Page 1 of 5
The Nakamoto Group, Inc.
Revised: 212712009 10:29:00 AM

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
11. The standard complies with federal laws and with DHS regulations regarding residents
with special needs.
REFERENCES: The First National Residential Standards were written using a variety of
methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
American Correctional Association 4th Edition, Standards for Adult Detention Facilities: 4-ALDF58-05,58-06,58-07,58-08,58-09,58-10, 2A-27, 2A-60, 6A-02, 6A-04, 6A-06, 6A-09.
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3 JDF-5G-01 through 10
To determine this rating the reviewer will:

o Review written Policy and Procedure to verify it is in line with Residential Standards.
o Interview staff responsible for mail policy to determine their knowledge of Standards.
o Review contraband log to verify residents were informed and had an opportunity to
appeal the decision not to allow items.

o Interview Facility Notary of Public and person responsible for Legal Library to determine
system for providing Notary Services for Residence.

Correspondence and Other Mail
Page 2 of 5
The Nakamoto Group, Inc.
Revised: 21271200910:29:00 AM

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

Compliant

Not
Compliant

Remarks

Writing paper, writing implements,
and envelopes are available at no
~
0
cost to residents.
Ref: V.11
The facility has a system in place
to handle contraband coming
~
0
through mail.
RefV.6
Resident correspondence guidelines indicate and/or provide:
a. That a resident may
receive mail
~
0
Ref V.3.a
b.

That a resident may send
mail and the procedure for
sending
Ref V.3.c
General correspondence
will not be read or rejected,
except if needed for order
and security, and residents
will be notified in writing
when correspondence is
withheld in part or in full
Ref V.3.d
The definition of Special
Correspondence, including
instructions on the proper
labeling of mail as "Special
Correspondence"
Ref V.3.E
That Special
Correspondence may only
be opened in the resident's
presence, and may be
inspected for contraband,
but not read
Ref V.3.F
That a package may
neither be sent nor
received without advance
arrangements approved by
the facility administrator, as
well as the mechanism for
obtaining such approval

Correspondence and Other Mail
Page 3 of 5
The Nakamoto Group, Inc.
Revised: 21271200910:29:00 AM

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

A description of the type of
mail that may be rejected
by the facility
RefV.3.H
The procedure for
obtaining writing
instruments, paper, and
envelopes
RefV.3.J
The procedure for
purchasing postage and
the rules for providing
residents free postage.
RefV.3.K

Compliant

Not
Compliant

IZl

Remarks

Staff Training
Components

Remarks

The facility provides a Notary
Public for legal documents
RefV.13

Residential Intake and Orientation
Components

New residents are notified of
policies and procedures relating to
correspondence and other mail
through a resident handbook, or
equivalent, provided to each
resident upon admittance in
English, Spanish and other
languages most widely spoken
among residents. Translation or
interpretation services are provided
to residents who are not proficient
in English.
Ref 11.2

Compliant

Not
Compliant

IZl

Remarks

Correspondence and Other Mail
Page 4 of 5
The Nakamoto GrouP. Inc.
Revised: 21271200910:29:00 AM

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
DISCIPLINE AND BEHAVIOR MANAGEMNT
PURPOSE AND SCOPE: Facility standards of conduct and enforcement of those
standards are expected in order to provide a safe and orderly living environment.
Facility authorities will manage discipline and behavioral problems in a manner that
ensures the safety and welfare of staff, residents, and visitors.

EXPECTED OUTCOMES:

The expected outcomes of this Residential Standard are as
follows:

1. Residents will be informed of facility rules and regulations, prohibited acts, disciplinary
sanctions that may be imposed, and the procedure for appealing disciplinary findings.
2. Each facility will have graduated severity scales of prohibited acts and disciplinary
co nsequences.
3. Where permitted by facility policy, staff will informally settle minor transgressions by mutual
consent, whenever possible.
4. Staff who witness a prohibited act that cannot or should not be resolved informally, or have
reason to suspect one, will prepare a clear, concise, and complete Incident Report.
5. Each Incident Report will be objectively and impartially investigated by a person of
supervisory rank.
6. When appropriate, a serious incident that may constitute a criminal act will be referred to the
proper investigative agency, and the administrative investigation will be suspended, pending
the outcome of that referral.
7. At each step of the disciplinary process, the detainee will be advised of his or her rights.
8. A Management Review Committee (MRC) will further investigate and adjudicate the incident
and may impose minor sanctions or refer the matter to a higher level disciplinary panel.
9. A three-member Executive Review Panel (ERP) will conduct formal hearings on Incident
Reports referred from an MRC and may impose higher level sanctions for "Greatest" and
"High" level prohibited acts.
10. Detainees appearing before the ERP will be afforded a staff representative, upon request, or
automatically if the detainee is illiterate, has limited English language skills, or otherwise
needs special assistance.

Discipline and Behavior Management
Page 1 of 9
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
11. Actions of the ERP will be reviewed by the facility administrator, who may concur with the
findings and conclusions or may modify them.
12. At all steps and levels in the disciplinary process, any sanctions imposed will be
commensurate with the severity of the committed prohibited act and intended to encourage
the detainee to comply with the rules and regulations.
13. All steps of the disciplinary process will be done within the required time limits.
14. At all steps of the disciplinary process, accurate and complete records will be maintained,
and the detainee will receive the copies to which he or she is entitled.
15. If a resident is found not guilty at any stage of the disciplinary process, the incident records
will not be included in the detainee's file (even if they are retained elsewhere for statistical or
historical purposes).
16. Residents will be able to appeal disciplinary decisions through a formal grievance process.
17. Residents do not receive any discipline or punishment that is considered to be harsh, cruel,
unusual, unnecessary, demeaning or humiliating.
18. Residents under age 12 will not be referred for disciplinary review.
19. Where required, residents have regular access to translations seNices and/or are provided
information in a language that they understand.
20. The standard complies with federal laws and with DHS regulations regarding residents with
special needs.

REFERENCES: The First National Residential Standards were written using a variety of
methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
American Correctional Association, 4th Edition, Standards for Adult Local Detention Facilities: 4ALDF-3A-01, 3A-02, 6C-01 through 6C-19.
Pennsylvania Welfare Code Chapter 3800: Child Residential and Day Treatment Facilities.

Discipline and Behavior Management
Page 2 of 9
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Texas Department of Family and Protective Services: Minimum Standards for General
Operations and Residential Treatment Centers.
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3-JDF-3C-01 through 06 JDC 3A-05 and 06
To determine this rating the reviewer will:

o Review written policies and procedures to ensure it is in line with standard.
o Review resident handbook and orientation to determine

if resident are informed of

rules and regulation and behavior management system

o Review Rule violation to determine if they are designated as minor and major rule
violations

o Examine documentation to determine if privileges are provided once they are
earned.

o Interview staff and residents to determine how rules of conduct are used and
penalties for breaking the rules.

o Interview residents to determine their knowledge of the appeal process for rule
violations.

o Interview staff and residents

to determine their knowledge of the behavior

management system and to verify provisions of privileges once they are earned.

o Review written documentation provided staff particularly new staff on unacceptable
sanctions and actions within the facility.

o Review incident reports written by staff to determine their accuracy,
o Discuss the behavior management system with key administrators including:
•

Facility Director

•

Education Supervisor

•

Assistant Director

•

Director or chief of security

•

Medical administrator

o Interview Line staff to determine how consequences for inappropriate behavior are
determined

o Interview staff and residents to determine if residents are provided an opportunity to
learn a better way
Discipline and Behavior Management
Page 3 of 9
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
o Interview staff regarding parent responsibilities and intervention for inappropriate
behavior

o Observe staff, parent and youth interaction when youth displays inappropriate
behavior

o Review major disciplinary rule infraction from action until final decision to make
certain there was due process and a review at the supervisory level. ..

o Review system for reporting inappropriate disciplinary action against resident,
superficially allegations of abuse by youth.

Discipline and Behavior Management
Page 4 of 9
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Compliant

Not
Compliant

L8J

Present rules are generic and don't deal with
education conduct or age appropriate actions

L8J

Facility need more specific education rules of
conduct

Policy indicates corporal
punishment of children is not
allowed.
Ref: p. 4; b1

L8J

The behavioral modification
program includes systemic
feedback from staff to each
resident.
Ref: p. 3; para 4

L8J

Components

The behavioral management
system is implemented uniformly.
Ref: p. 3; para 2

Remarks

Non-restraining procedures (such
as verbal interventions, loss of
privileges and time out) are the first
methods of management for
minors.

Ref: p. 3; para 2
3.

Parental intervention is utilized
whenever possible.

Ref: p. 3; para 3
4.

Rules and discipline are formulated
with consideration of the range of
ages and maturity and are
culturally sensitive to the needs of
residents.

Ref: p. 3; para 5
5.

The behavioral modification
program includes rules, rewards
and consequences, and a list of
minor and major behavioral
infractions with particular attention
to the needs of minors.

Ref: p. 3; para 4

This is not part of the behavior management
plan.

Discipline and Behavior Management
Page 5 of 9
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Not
Compliant

13. Staff are available to represent
residents who speak limited
English, have no means of
collecting evidence, or as
requested.
Ref: p. 9; #4

14. Graduated scales of offenses and
disciplinary consequences are in
place.
Ref: p. 14;; #8

Components

The rules are written in a way that
are easily understandable by
residents and provided in the
language(s) of the majority of the
population.
Ref: p. 3; para 5

Remarks

Residents are able to appeal
disciplinary decisions through a
formal grievance process.
Ref: p. 2; #16

10. If a resident is found not guilty at
any stage of the disciplinary
process, the incident records are
not included in the resident's file.
Ref: p. 12; b
11. Rules are reviewed at least
annually and updated when
necessary, with documentation of
the review (even if no update
occurred).
Ref: p. 3; para 2
12. At all steps of the disciplinary
process, accurate and complete
records are maintained, and the
resident receives copies.
Ref: p. 2; #14

15. An intermediate level of
investigation/adjudication to
adjudicate low or moderate rules
infractions is established.

There is a process but a review of the
resident files did not contain any investigation
for low level rule violations.

Ref: p. 8; MRC

Discipline and Behavior Management
Page 6 of 9
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

Compliant

Not
Compliant

16. Duration of penalties is within
established limits.
Ref: p. 12; #7
17. All incident reports are investigated
within 24 hours of the incident.
Ref: p. 7; #3

18. Care providers written rules that
specify acts prohibited while
residing at the program and
consequences that may be
imposed for various degrees of
violation.

Remarks

Low level offenses were not investigated

Ref: p. 3; para 5
19. Incident reports are formatted such that:
Ref: p. 6; #2
a.

Facts are clear, concise, and
complete.

Officers, residents and
witnesses are identified.

The relevant rule or standard is
cited.

Resident Intake and Orientation
Components

Compliant

Not
Compliant

20. The resident handbook includes information on:
Ref: p. 19; #11
a.

Managing and handling rules
violations

The prohibited acts and
potential sanctions for
prohi bited acts

The procedure for appealing
sanctions or adverse
administrative findings

Discipline and Behavior Management
Page 7 of 9
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Staffing and Training
Components

Remarks

Compliant

21. Staff training includes proactive
versus reactive interactions.
Ref: p. 3; para 3
22. A Management Review Committee
(MRC) conducts administrative
reviews.
Ref: .8; MRC
23. The MCR consists of 3 members,
with at least one manager who
holds the rank of Captain or higher,
one Unit Manager, and one ICE
Supervisory officer.
Ref: .8; MRC
24. Unresolved and serious charge
cases are forwarded to an
Executive Review Panel (ERP).
Ref: p. 8; MRC

25. The ERP does not include the
reporting officer, the investigating
officer, and a member of the
referring MRC, or anyone who
witnessed or was directly involved
in the incident.
Ref: p. 8; MRC

Discipline and Behavior Management
Page 8 of 9
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
EDUCATIONAL POLICY
PURPOSE AND SCOPE: All children residing in an ICE Residential Family Facility who

reach the minimum age required by applicable state law shall be provided with
educational services and programming appropriate to the minor's level of development
and communication skills in a structured classroom setting.
EXPECTED OUTCOMES:

The expected outcomes of this Residential Standard are as
follows:

1. All eligible children will be administered an Initial Educational Assessment within three
days of their arrival to the facility.
2. All eligible children will be provided with a minimum of one-hour daily instruction in
each of the core subjects, Monday through Friday, on a year-round schedule.

3. All teaching staff are qualified to teach in accordance with state licensing
req uirements.

4. All curricula and associated texts and learning materials are based on state
requirements and best practices.
5. Comprehensive education files will be maintained on each student.

6. All children with disabilities and/or in need of special education and related services
are identified, located, evaluated, and referred to an appropriate agency for
intervention.

7. All facilities shall convene an IEP Team, consisting of staff from the following
disciplines: education, medical, mental health, administration, social work, and
physical education.

8. Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.

9. The standard complies with federal laws and with DHS regulations regarding
residents with special needs.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
Individuals with Disabilities Education Improvement Act of 2004.
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3 ,JDF-5C-01- 03, 2E-05, 50- 01-03,06,07 &11-13
To determine this rating the reviewer will:

o Review school calendar and school schedule.
o Review individual student schedules.
o Review IEP for student services.
o Review student transcripts.
o Observe operation of the education program.
o Review school attendance records and compare with admission to the facility dates.
o Interview school staff.
o Interview students.
o Observe whether classrooms are free of auditory and visual obstruction.
o Observe number of students in regular and special education classes to determine if
there are sufficient desks, chairs, unencumbered space for the number of youth in the
room on any given day.

o Interview teachers about class sizes.
o Review personnel files for appropriate certifications.
o Review training records.
o Review school schedule and institutional master schedule to see if they are in line with
each other.

o Review Lesson Plans to determine appropriate curriculum is being taught.
o Observe classes for subject matter relating to lesson plan.
o Review behavior management program within school.

Educational Policy
Page 2 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILYAND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components
Children are provided with
a minimum one hour daily
instruction in science,
social studies, math,
language arts and physical
education.
Ref: p. 2; 1d
2. Pre-Kindergarten
instruction is provided to
eligible four-year-old
children.
Ref: p. 2; 1h
3. Pre-K instruction provides
comprehensive child
development services (i.e.,
educational, health,
nutritional, and social
services).
Ref: 2; 'Ih
4. Educational field trips are
provided.
Ref: p. 2; 1j
5. Students are assigned to
grades according to
educational assessment
outcomes.
Ref: p. 3; 3b
6. Lesson plans and curricula
are based on a state
approved model program
and are available for
review in each classroom.
Ref: p. 4; 4d
7. Progress reports are
distributed to all students
on a regular and consistent
schedule.
Ref: p. 4; 5b
8. Facility policy encourages
the scheduling of parentteacher conferencing to
discuss student
achievement.
Ref: p. 4; 5b

Compliant

Not
Compliant

A resource room is available to children who are
five years of age and for children in need of ESL
and more preparation.

Pre-K children are not excluded from
developmental services that are available to
children at the facility.

Remarks

.9l!

Specific grade level assignment is subsumed in
assignment to multi-age, multi-level rooms.

Educational Policy
Page 3 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

Components

Students completing the
learning requirements for
the maximum learning level
are provided the
opportunity for learning
advancement.
Ref: p. 5; 5c
10. Students approved for
GED testing are
administered the GED pretest.
Ref; p. 5; 5d
11. Memoranda confirming
student's dates of
enrollment are provided to
all students at the time of
their departure.
Ref: p. 5; 5e
12. A public awareness effort
focusing on the early
identification of children
eligible for services is in
place.
Ref: p. 7; 11a
13. Access to students is
permitted to the local
educational agency (LEA)
instructional and
assessment personnel and
ARD committee members.
Ref: p. 8; 11 c
14. Transportation services are
provided to those students
whose special education
needs cannot be met
onsite.
Ref: p. 8; 11e
15. The Code of Conduct is
provided to residents and
staff and posted in
common areas in English
and Spanish.
Ref: p. 2; 1i

Compliant

Not
Compliant

[g]

Remarks

Educational Policy
Page 4 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Staffing & Training
Components

16. The Education Department
administrator is qualified
and trained as an
administrator in the state.
Ref: p. 5; 6d
17. Translation services are
available and provided on
an as-needed basis.
Ref: p. 2; 1i
18. lesson plans and curricula
are developed by teaching
staff.
..... ,x.
. 4; 4d
19. Teaching staff submit
weekly lesson plans to the
administrator.
Ref: p. 4; 4d
20. Teaching staff record
student attendance twice
daily (morning and
afternoon).
Ref: p. 4; 5a
21. Student teacher ratio does
not exceed 20:1.
Ref: p. 5; 6b

Compliant

Not
Compliant

[gJ

Remarks

[gJ

22. Teaching staff is qualified
and certified to teach in the
[gJ
state.
Ref: p 5; 6a
23. Teaching staff are certified
ESl instructors, or enrolled
[gJ
in an ESl certification
program.
Ref: p. 5; 6c
24. There is on file and available for review a Staff Development Plan that includes:
Ref: p. 5; 6e
a. ESl strategies and
[gJ
No SOP available
materials
b.

Instructional best
practices

[gJ

No SOP available

No Child left Behind
(NClB) rules and
regulation

[gJ

No SOP available

Educational Policy
Page 5 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

Components

Lesson Plan
development

Compliant

Not
Compliant

[2J

25. A member of the IEP team
participates in ARO
meetings when LEA
[2J
assistance has been
requested.
Ref: p. 8; 12 para 1
26. Staff coordinate with LEA
to provide for the education
[2J
and related services for
eligible students.
Ref: p. 7; 11
27. Staff attend trainings on
identifying and assessing
children potentially in need
of early intervention or
special education services.
Ref: p. 7; 11a
28. Assessment administrators
are qualified to supervise
[2J
the respective assessment.
Ref: p. 3; 2c
29. Staff is provided with pre-service and ongoing
Ref: p. 5; 6f; and Staffing and Hiring Standard
a. Responding to
emergencies such as
suicide attempts or threats
(refresher training occurs
no less than twice yearly)
b. Observing, preventing,
documenting and
responding to signs and
symptoms of depression
c. PTSO, physical and sexual
abuse, and behavior
management approaches
d. Cultural awareness and
sensitivity
e.

Child development theory
and acculturation training

Remarks

No SOP available

[2J

Attendance documentation not on site (at BCIU)

D
training that includes, but is not limited to,

[2J

Attendance documentation not on site (at BCIU)

[2J

[2J
[2J
[2J

First Aid, CPR, and AEO

[2J
g.

ICE policies and
procedures.

[2J
Educational Policy
Page 6 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

Components

Compliant

Not
Compliant

Remarks

Privacy and confidentiality.

~
i.

Prohibition of giving legal
advice or counsel.

30. Refresher training is
provided at least twice per
year.
Ref: p. 5; Sf

Resident Intake & Assessment
Components

31. Assessments are readministered on a 90-day
rotation to track individual
student progress.
Ref: p. 2; 1f
32. A Special Needs
Assessment is
administered to each
student upon arrival.
Ref: p. 2; 19
33. Assessment interviews
are conducted in the
child's primary language.
Ref: p. 2; 2e
34. Copies of all assessments
are filed in the student's
individual education files.
Ref: 2; 2h
35. Educational assessments
and/or transcripts are
provided upon request to
institutions of leaming on
behalf of student.
Ref: p. 5; 5e
3S. Staff complete the
Educational Services
Eligibility Worksheet form
as requested and deliver
or make available to LEA
within 2 days.
Ref: p. 7; 11a

Compliant

Not
Compliant

Remarks

Report cards issued

LAS and MATH, and API; No ESEW Form

Educational Policy
Page 7 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

Components

37. Facility utilizes
standardized screening
tools as approved by the
respective state and in
use by the LEA.
Ref: p. 7; 11a

... liant

[gJ

Not
Compliant

Remarks

LAS, BASC2

Supplies
Components

38. Classrooms are equipped
with textbooks and
directives for each of the
core subjects (excluding
Physical Education).
Ref: p. 6; 7a
39. All classrooms are
equipped with a desktop
computer with Internet
access, and attendance
and grading software.
Ref: p. 6; 7c
40. Classrooms have
manipulatives readily
available and
developmentally
appropriate to each
classroom.
Ref: p. 6; 7d
41. Each student has the
tools necessary to
complete a particular task
on their own, except
when the curriculum calls
for a group or partnered
activity.
Ref: p. 6; 7d
42. Classrooms are equipped
with writing and other
instruments as needed
and required by curricula
tasks and objectives.
Ref: p. 6; 7e

Compliant

Not
Compliant

Remarks

[gJ

Educational Policy
Page 8 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

Library
Components

43. Library services are
provided and available to
all residents.
Ref: p. 6; 8a
44. The library provides
residents with
appropriate reading
material in languages
other than English for use
during leisure time.
Ref: p. 6; 8a
45. Reading material reflects
racial and ethnic diversity
and interests and is
appropriate for various
levels of competency.
Ref: p. 6; 8a
46. Participation in a local
library system is not used
in lieu of an on-site
residential library.
Ref: p. 6; 8b
47. Each facility utilizes the
U.S. Department of
Education's Blue Ribbon
School Program's best
practices library
benchmark in
determining the number
of items in each library
based on how many
patrons are eligible to
utilize the library.
Ref: p. 6; 8c

Compliant

Not
Compliant

Remarks

cg]
Holdings do not seem of sufficient quantity or
diversity (language)

cg]

Bookmobile still scheduled and seems to function
as a residential library substitute.

cg]
Although the benchmark has not been located, a
review of the shelved materials presented a
minimal holding.

cg]

Compliant

Not
Compliant

cg]

It is unlikely that this facility would meet any
recommended holdings criteria.

Files
Components

48. Student files include:
Ref: p. 4; 4c
a. Copies of all
assessments

Progress Reports

Remarks

Educational Policy
Page 9 of 11
The Nakamoto Group, Inc.
Revised 2/11/09

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

Components

Compliant

Not
Compliant

Report Cards

Copies of all
requests testing and
test results
e. Requests and followups ofal!
conferences, reviews
and meetings
49. Student files are securely
maintained in the
Education Department.
Ref: p. 7; 9a
50. All training sessions are
documented in staff
personnel files.
Ref: p. 6; 6j

Remarks

Depends on timing of arrival of student (quarterly)

As needed

BCIU training records are being transitioned to
Berks

Educational Policy
Page 10 of 11
The Nakamoto Group, Inc.
Revised 2111109

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
EMERGENCY (CONTINGENCY) PLANS
PURPOSE AND SCOPE:
Contingency plans are in place to quickly and effectively respond to any emergency situations
that arise and to minimize their severity; thereby providing a safe environment to residents and
staff. These general emergency plans are in addition to those developed under the facility's
health authority for control of communicable diseases (including avian flu).
EXPECTED OUTCOMES: The expected outcomes of this Residential Standard are as
follows:
1. Each facility will have in place contingency plans to quickly and effectively respond to any
emergency situations that arise and to minimize their severity.
2. Staff will be trained at least annually in emergency preparedness and implementation of
the facility's emergency plans.
3. An evacuation plan will be in place in the event of a fire or other major emergency, and
the plan will be locally approved and updated at least annually.
4. Events, staff responses, and command-related decisions during and immediately after
emergency situations will be accurately recorded and documented.
REFERENCES:

The First National Residential Standards were written using a variety of

Standard

Use of Physical

Force and

Restraints that provides

requirements and guidelines for emergency situations that require use of force.

Emergency (Contingency) Plan
Page 1 of 10
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Memorandum dated 7/14/2006 on Escape Reporting from the ICE/ORO Director, which
specifies requirements for the reporting, tracking, and investigating of the escape of an
ICEIDRO resident.
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3-JDF-38-06 through 08, 38 10 through 13, 4C-26.

Reviewer Guidelines: To determine this rating the reviewer will:

o Review emergency plan manual to determine its completeness.
o Review recent fire marshal reports.
o Review documentation of monthly and quarterly tests and inspections of all
emergency equipment

o Review written agreement(s) for emergency services and other health care services.
o Review documentation of special incident reports and ensure appropriate
documentation.

o Review documentation of first aid and emergency protocols.
o Review records of CPR and first aid training.
o Review evacuation egress plans to determine if they accurately depict exits and
equipment and are prepared according to policy.

o Review fire drill procedures and logs for documentation of fire drills and determine if
conducted with all shifts.

o Review reports of emergency response drills for appropriate triage, timeliness of
response, and completeness of documentation.

o Ensure the contact information inside the emergency plan is current.
o Ensure evacuation plans are posted in English and Spanish, minimally.
o Observe posted plans to determine if conspicuously located.
o Observe smoking procedures and receptacles.
o Interview staff and residents to determine their knowledge of the evacuation plan and
procedures for fire drill practice.

o Interview staff to determine knowledge of location of fire alarm box or outside
telephone and participating in and frequency of unannounced fire drill practice.

o Interview facility administrator about fire prevention and inspection procedures

Emergency (Contingency) Plan
Page 2 of 10
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

Compliant

Contingency plans have been
developed with local, State, and
Federal law enforcement agencies
and formalized agreements with
Memoranda of Understanding
(MOU) are in place.
RefV.E
Annual reviews of the contingency
plan are in effect. Documentation of
each annual review is available
even if the review resulted in no
modifications.
RefV.3.a.2
Finalized or developed contingency
plans include a statement
prohibiting unauthorized disclosure
of the plan.

cgJ

RefV.2.c

A listing is available of who is
designated to have access to the
contingency plans and whether
they are employees of ICE/ORO or
other cooperative entities
RefV.3.c

cgJ

Guidelines of the contingency plans list include:
a.

Where copies of the various
plans are stored
RefV.3.c

cgJ

In what quantity the plans are
to be reproduced
RefV.3.c

cgJ

A master copy of each plan is kept
outside the facility, along with an
itemized list of the number of plans
that have been created, the names
of the persons who are authorized
access to the plans, and where to
find each specific copy of the plans.
RetV.3.c

Remarks

Emergency (Contingency) Plan
Page 3 of 10
The Nakamoto Group, Inc.

Facility has developed and emergency plan
policy and made contacts with local
responders. However, a policy does not take
the place of a well written, well rehearsed,
and well critiques emergency plan.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Not
Compliant

A checkout system that accounts
for all plans at all times, with
safeguards against resident
access, is implemented.
Ref 3.C

[2J

Emergency preparedness plans
include activation of the Command
Post phone lines and other
logistical support systems at least
monthly.
Ref VAA

Information is contained within the policy.

No documentation available at the facility.

Components

Documentation of once a month
emergency list call-down procedure
is available.
RefPg 7 Sec C

10. The contingency plan specifies
procedures for providing immediate
and follow-up medical care to
residents and staff, with alternative
or back-up procedures explained
for a variety of emergency
scenarios.
RefV.k Pg 9
11. The contingency plan specifies
procedures for updating the Food
Service Administrator when
emergency conditions change the
number of people who will be
requiring food service.

[2J

RefV.1
12. The contingency plan provides for
emergency utility control, including
plot plans identifying water and gas
shut-off valves and electricity on-off
switches.
Ref V.1.1
13. The contingency addresses
professional conduct and
responsibility, including what to do
if taken hostage.
RefV.1.2
14. The contingency plan specifies
alternative access routes.
RefV.I.3

Emergency (Contingency) Plan
Page 4 of 10
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

Compliant

Not
Compliant

15. The contingency plan specifies how
and when staff shall notify nearby
residences of the situation,
including the type of emergency,
actions being taken, evacuation
routes, and special precautions.
RefV.I.4

Information is not in policy.

Information is not in policy

16. The process of notifyi ng nearby
residents of the emergency
situation is coordinated with the
ICE Public Affairs Office.

Remarks

RefV.1.4
17. The contingency plan specifies
whether the remote batterycharging units are maintained in
the Control Center or outside the
secure perimeter.
RefV.1.5
Written procedures include:
a.

Resident roll-call
RefV.J

Intensifying security
RefV.J

Emergency Security Measures
RefV.J

Security Key Access
Ref V.J

Evidence Preservation
Ref V.J

Chain of command
Ref V.4 Pg 5

Incident command posUcenter
staff recall
RefV.4 Pg 5
Staff assem bly
RefV.4 pg 5

Emergency response
components
RefV.4 pg 5

Emergency (Contingency) Plan
Page 5 of 10
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Not
Compliant

[ZJ

Information is not in policy

[ZJ

Information is not in policy

Ref VA pg 5

[ZJ

Information is not in policy

Employee conduct and
responsibility

[ZJ

Information is not in policy

[ZJ

Information is not in policy

[ZJ

Information is not in policy

[ZJ

Information is not in policy

[ZJ

Information is not in policy

Preserving evidence
Ref V.m Pg 10

[ZJ

Information is not in policy

Accountability
RefV.m pg 10

[ZJ

Information is not in policy

[ZJ

Information is not in policy·

[ZJ

Information is not in policy

[ZJ

Information is not in policy

[ZJ

Components

Use of force
Ref VA pg 5

Videotaping
Ref VA pg 5

Records and logs
Ref VA pg 5

m. Utility shut-off

Remarks

Ref VA pg 5
o.

Public relations
Ref VA pg 5

Facility Security
Ref VA pg 5

18. The post-emergency plan includes:

a. Segregating the residents
involved in the incident
RefV.m Pg 10
Collecting written reports
Ref V.m Pg 10
<

Damage assessment and
repair of the facility
Ref V.m Pg 10
Documentation of the
nature and extent of any
injuries
RefV.m Pg 10
Coordination legal
actions/ prosec uti on
RefV.mPg10
Debriefing and follow up
RefV.m Pg 10

Emergency (Contingency) Plan
Page 6 of 10
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Components

General review and
critique of the emergency
operations and
management
Ref V.m Pg 10

Not
Compliant

Remarks

Information is not in policy

Structure and Maintenance
Compliant

Components

Not
Compliant

Remarks

19. Primary command posts are established outside the perimeter that are equipped with:
a.

A speakerphone

Do not have a primary control post but would
use an area at Juvenile Facility based on
staff interview.

Ref V.b.1 Pg.5

A second line and a separate
line for internal
communications

Ref V.b.1 Pg.5

Information is not in policy

Videotapes
Ref V.b.1 Pg.5

Information is not in policy

Ref V.b.1 Pg.5

Information is not in policy

Videotape player/television

Information is not in policy

Ref V.b.1 Pg.5
c.

Radio equipment
Ref V.b.1 Pg.5

Computer with internet
Ref V.b.1 Pg.5

Facility plot plan

Escape post kits
Ref V.b.1 Pg.5

Contingency plans
Ref V.b.1 Pg.5

Hostage negotiation equipment

Emergency (Contingency) Plan
Page 7 of 10
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Not
Compliant

Ref V.b.1 Pg.5

C2l

Information is not in policy

Voice activated or conventional
recorder
Ref V.b.1 Pg.5

C2l

Information is not in policy

C2l

Information is not in policy

Components

Remarks

Ref V.b.1 Pg.5
k.

Video camera

m. Assault/breach plans
Ref V.b.1 Pg.5

Emergency (Contingency) Plan
Page 8 of 10
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Staffing and Training
Components

Compliant

20. Appropriate personnel are trained
under the Disturbance Control
Program (DCP).
Ref Pg 7. Sec e
21. A Special Response Team (SRT)
and Hostage Negotiation Team
(HNT) are established and
maintained in accordance with ICE
policies and directives.
Ref pg 13
22. Emergency preparedness is a part
of the initial orientation and training
provided to all new employees.
RefV.1

Not
Compliant

Remarks

Information is not in policy

[2J
Information is not in policy

[2J

Emergency (Contingency) Plan
Page 9 of 10
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
ENVIRONMENTAL HEALTH AND SAFETY
PURPOSE AND SCOPE:

High facility standards of cleanliness and sanitation, safe work

practices, and control of hazardous substances and equipment are employed at the facility,
thereby protecting residents, staff, volunteers, and contractors from injury and illness

EXPECTED OUTCOMES: The expected outcomes of this Residential Standard are as
follows:
1. I\/Iaintenance of facility cleanliness and sanitation.
2. Compliance with all applicable safety and sanitation laws, ensured by documented
internal and external inspections and corrective action when indicated.
3. Compliance with all applicable fire safety codes. Facility furnishings will meet fire safety
performance requirements. Periodic safety drills will be scheduled.
4. Control and safe use of flammable, poisonous, toxic, and caustic materials.
5. Written plans and training will advise staff of required procedures in emergency situations,
including those that require evacuation from the facility.
6. A plan providing for immediate release of residents from locked areas, will be in place and
will include a secondary back-up system.
7. Emergency exits will be clearly marked, clear from obstruction, sufficient in number, and
properly positioned.
8. The need for emergency repairs will be negated and if necessary, replacement parts will
be available to minimize or avoid the creation of life-threatening situations.
9. Disease transfer will be minimized by proper sanitation of barbering equipment and
supplies.
10. Pests and vermin pests will be controlled and eliminated.
11. The facility's potable water source will be safe.
12. Emergency lighting and life-sustaining functions will be maintained and

periodically

tested.
13. Garbage and hazardous waste will. be disposed of safely and in compliance with
applicable government regulations.
14.

Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.

Environmental Health and Safety
Page 1 of 6
The Nakamoto Group

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
15. The standard complies with federal laws and with DHS regulations regarding residents
with special needs

REFERENCES:
The First National Residential Standards were written using a variety of methodologies including
previous and current practices, review and comment from various subject matter experts, review
and comment from various government and non-government organizations, and review of
current state codes in Pennsylvania and Texas. Each standard is written in a manner that
affords each resident admission and continuous housing to a family residential facility in a
dignified and respectful manner. There are no specific codes, certifications, or accreditations
that deal specifically with unique management requirements of families awaiting the outcome of
their immigration proceeding in a non-secure custodial environment.
American Correctional Association 4th Edition Standards for Adult Local Detention Facilities: 4ALDF-1A-01, 1A-02, 1A-03, 1A-07, 1C-01, 1C-02, 1C-03, 1C-04, 1C-05, 1C-07, 1C-OS, 1C-09,
1C-10, 1C-11, 1C-12, 1C-13, 1C-14, 1C-15, 4B-07, 4C-1S.
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3 JDF-5G-01 through 10.

To determine this rating the reviewer will:

Observe storage of all toxic and caustic materials to ensure areas are secured and
inaccessible to youth.

Interview staff to verify practice of use of toxic and caustic materials.

Observe chemical storage area for material safety data sheet (MSDS) forms and
perpetual inventory sheets.

Observe containers for accurate labeling of product in container.

Interview residents to determine if supervision of chemical usage occurs.

Environmental Health and Safety
Page 2 of 6
The Nakamoto Group

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

The MSDSs are readily
accessible to staff and
residents in the work areas.
Ref VA
Hazardous materials are
always issued under proper
supervision
RefV.3
Hazardous material
quantities are limited
RefV.a

Compliant

Not
Compliant

Remarks

D
cg]

cg]

4. All products containing

diluted methyl alcohol are
clearly labeled.
Ref V.9
Products containing diluted
methyl alcohol that are
distributed to residents are
issued in the smallest
workable quantities
RefV.9
The facility conducts fire
and safety inspections
periodically.
Ref Pg.8

cg]

Written procedures
regulate the handling and
[8J
disposal of used needles
and other sharp objects
Ref VIII
Standard cleaning practices include:
a.

Using specified
equipment;
cleansers;
disinfectants and
detergents.
RefV.6.a
An established
schedule of
cleaning and
follow-up
inspections.

Complex has a safety committee that serves the
entire complex. The facility conducts regular safety
inspection.

cg]

Environmental Health and Safety
Page 3 of 6
The Nakamoto Group

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Not
Compliant

Components
RefV.6.a
The pest control program
includes preventive
spraying for indigenous
insects.
Ref IX.3

Remarks

Files
Components

Compliant

10. The manufacturer's
Material Safety Data
Sheet (MSDS) file is upto-date for every
hazardous substance
used.
Ref V.4.a

Not
Compliant

Remarks

rzl

There were chemicals found in the food service area
that did not have MSDS provided for the chemicals
in the food service area.

Not
Compliant

Remarks

rzl

There were chemicals found in the food service area
that did not have MSDS provided for the chemicals
in the food service area.

Inventory and Storage
Components

Compliant

11. The facility has a system
for storing, issuing, and
maintaining inventories of
hazardous materials.
Ref V.3.a
12. Constant Perpetual
inventories are maintained
for all flammable, toxic,
and caustic substances
used/stored in each
section of the facility.
RefV.3.a

rzl

Structure
Components
13. The facility has sufficient
ventilation and provides
and ensures clean air
exchanges throughout all
buildings.
RefV.7
14. Vents, return vents, and
air conditioning ducts are
not blocked or obstructed
in cells or anywhere in the
facility.

Complaint

Not
Compliant

rzl

Environmental Health and Safety
Page 4 of 6
The Nakamoto Group

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components
(TBO)
15. Living units are
maintained at appropriate
temperatures in
accordance with industry
standards.
REO. JFRMU
16. Shower and sink water
temperatures do not
exceed the industry
standard of 120 degrees.
REO. JFRMU

Complaint

Not
Compliant

[8J

Compliant

Not
Compliant

[8J

Remarks

Staff and Training
Components
17. Staff receives training
centered on universal
precautions.
Ref VII 1.2

Remarks

All personnel using flammable, toxic, and/or caustic substances adhere to the following procedures:
a. wear personal
[8J
protective equipment
0
RefV.1
b. report hazards and
spills to the
[8J
0
designated official.
RefV.1
18. Staff receives a list of
products containing
[8J
diluted methyl alcohol
0
(e.g. shoe dye)
RefV.9.b
19. Staff directly supervises
and accounts for products
[8J
0
with methyl alcohol
RefV.9.b
20. Staff always supervise
residents utilizing hazard
[8J
0
waste and materials
21. Ref V.9.b
22. A
Iicensed/Certified/T rai ned
pest-control professional
[8J
inspects for rodents,
0
insects, and vermin at
least monthly.
Ref IX.3

Environmental Health and Safety
Page 5 of 6
The Nakamoto Group

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
ESCORTED TRIPS FOR NON-MEDICAL EMERGENCIES
PURPOSE AND SCOPE: Residents may visit critically ill members of their immediate
family or attend their funerals under certain circumstances through emergency staffescorted trips into the cornmunity.
EXPECTED OUTCOMES: The expected outcomes of this Standard are as
follows:
1. Within the constraints of safety and security and while under constant staff supervision,
selected residents will be able to visit critically-ill members of their immediate family or
attend family member's funerals.
2. Safety and security will be primary considerations in planning, approving, and escorting
a resident from a facility for a non-medical emergency.
3. Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.
4. The standard complies with federal laws and with DHS regulations regarding residents
with special needs.
REFERENCES: The First National Residential Standards were written using a variety of
methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
American Correctional Association 4th Edition Standards for Adult Local Detention Facilities: 4ALDF-18-06.
ICEIDRO Residential Standard on "Searches of Residents"
ICEIDRO Residential Standard on "Land Transportation"
ICE/DRO Residential Standard on "Use of Force"

Escorted Trips for Non-Medical Emergencies
Page 1 of 4
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
To determine this rating the reviewer will:

o Review written policies, procedures and practices.

o Interview the facility director and the office in charge (OIC) to determine
understanding of policy and implementation of appropriate procedures.

o Review handbook, bulletin boards or other information sharing documents (town
meeting) to determine if information is made available to residents.

o Review any documented request non emergency trips.
o Interview residents for their understanding of policy and procedure.
o Review any documentation provided to residents regarding Rules and Expectations
during the trip.

Escorted Trips for Non-Medical Emergencies
Page 2 of 4
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

Compliant

Not
Compliant

Remarks

Not
Compliant

Remarks

1. All trips are accompanied by

no fewer than two escorts, of
which no more than one may
be a probationary staff
member.
RefV.3
Resident's are informed of
expectations during non
medical emergency trips in a
language the resident
understands.
Ref 11.3

[8l

Staffing and Training
Compliant

Components

The facility appoints a staff
member to help residents
prepare requests for non
medical emergency trips.
RefV.1
The district director
establishes criteria for non
medical emergency trips
Ref V.1
All staff receive training on
policies and procedures
RefV.5

[8l

Escorted Trips for Non-Medical Emergencies
Page 3 of 4
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
FOOD SERVICE
PURPOSE AND SCOPE:

Residents are provided a nutritionally balanced diet that is

prepared and presented by a sanitary and hygienic food service operation.
EXPECTED OUTCOMES:

The expected outcomes of this Residential Standard are as
follows:

1. All residents will be provided nutritionally balanced diets that are reviewed at least
quarterly by food service personnel, and at least annually by a certified dietician.

2. Sound safety and sanitation practices will be applied in all aspects of food service and
dining room operations.

3. Dining room facilities and operating procedures will provide sufficient space and time for
residents to eat meals in a relatively relaxed, unregimented atmosphere.
4. Food service facilities and equipment will meet established government health and safety

codes, as documented by an independent, outside source.

5. Any resident assigned to work in food service operations will be screened and cleared
medically in advance.

6. Food service areas will be continuously inspected by food service staff and other
assigned personnel on schedules determined by the food service administrator and in
accordance with applicable policy requirements.

7. Stored food goods will be maintained in accordance with required conditions and
temperatu res.

8. Therapeutic medical diets and supplemental food will be provided as prescribed by
appropriate clinicians.

9. Special diets and special ceremonial meals will be provided for residents whose religious
beliefs require the adherence to religious dietary laws.

10. Where required, residents have regular access to translations services and/or are
provided information in a language that they understand.

11. The standard complies with federal laws and with DHS regulations regarding residents
with special needs.

Food Service
Page 1 of 11
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
REFERENCES: The First National Residential Standards were written using a variety of

methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
American Correctional Association Standards for Adult Local Detention Facilities, 4th Edition: 4ADLF-4A-01 through 4A-18. (Five of those Expected Practices are mandatory for accreditation:
4A-07, 4A-11, 4A-13, 4A-15, and 4A-16.)
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3 JDF-4A-03, 04, 06, 08 through12, 14 & 3A-23.
To determine this rating the reviewer will:

o Review Organizational Chart and Job Descriptions of Food service staff including
any Residents working in Food Service area.
o

Review Current Handbook

o
o
o
o
o
o

Review completed personal property inventory form
Interview Food Service Manager
Observe Meals at various time
Review documentation of menu approval by Registered Dietitian
Review a minimum of three planned menus and compare to what is actually served
Observe food appearance and check temperature of food being served to determine
if hot foods are served at 140 degrees Fahrenheit and cold foods are at 40 degrees
Fahrenheit.

o Taste test the food served to residents for food flavor, texture, and palatability
o Compare quantity of food being served with the menu
o Interview staff and residents about food flavor types of food served and if food is
served at the correct temperature

o Review food service Diet Manual for special diets

Food Service
Page 2 of 11

The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
o Review snack and drink area in living units to determine amount and restocking
systems.

o Interview food service personnel about the handling and documentation of special
diets

o Interview residents and staff about the procedure for setting up a special diet and if
the diet is served

o Review special diet forms for original signature of dentist , physician, nurse
practitioner, or physician's assistant

Interview facility administrator or designee about process for ordering religious diet

o Observe various meals to determine if special diet meals are prepared as ordered.
o Review meal schedule.
o

Count the number of hours between the start of the evening meal being served to the
start of breakfast being served.

o Interview staff and youth regarding meal schedules.
o

Review daily documentation of temperatures of refrigerators, freezers.

o Observe dishwasher in operation to ensure the wash and rinse cycles are the
appropriate temperature.

Observe storage of food in dry storage, refrigerators, coolers, and freezers.

o Review pack out lunches for resident being out of the facility for compliance with
approved dietary requirements.

o Observe area for storage of "hot" food service items such as mace, yeast, sugar to
ensure it is behind lock doors with

a perpetual inventory control system.

o Check current temperature of dry storage food area.

o Observe storage of knives to determine if they are shadowed and secured.
o Review documentation of sharps inventory and check in/out system.
o Observe for cleanliness in the kitchen and dining area.
o Interview food service staff to verity availability and frequency of pest control
services.

o Observe for evidence of pests and vermin to determine adequacy of pest control
services.

o Observe dining area for appropriate furniture and suitable decoration
o Review written housekeeping or cleaning schedule.
Food Service
Page 3 of 11
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
o

Observe that food is ample in refrigerator and check dates (food may be saved in
plastid bags).

Interview food service staff regarding procedure and practice for saving sample trays
of food.

Review documentation of medical clearance for residents working in food service.

Observe for hairneUcap use.

Observe uniforms of food service staff and residents for cleanliness.

Interview food service and residents about hand washing practices.

Food Service
Page 4 of 11
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
General Components
Policy and Procedures
Components

Compliant

Not
Compliant

1. Meals are nutritionally balanced.
Ref: p. 1; purpose and scope
2. Signs are posted instructing staff to
wash hands after using the
restroom.
Ref: p. 19; b1

rEl

Adequate and conveniently located
toilet facilities are provided for all
food service staff and resident
workers.
Ref: p. 25; 0

rEl

Residents are able to volunteer in
the food service program.
Ref: p. 4; 3a

rEl

Documentation is available of
resident volunteers.
Ref: TBD

Before starting work in the
department, residents sign for
receipt of his or her job description.

rEl

Ref: p. 4; 3b

7. A copy of the resident's job
description is on file for as long as
the resident continues to work in
the food service department.
Ref: p. 4; 3b

Residents assigned to the food
service department have a neat
and clean appearance.
Ref: p. 5; f

rEl

Resident uniform consists of the
white, summer-type uniform pants
and short-sleeved shirts; safety
work shoes; a white paper hat or
white "baseball" cap and white
aprons or smocks.
Ref: p. 5; f

rEl

Food Service
Page 5 of 11
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Not
Compliant

10. Table arrangement facilitates free
seating, ease of movement and
accommodates all ages including
infants and toddlers.
Ref: p. 5; 4a

11. Residents are afforded a
reasonable amount of time to
complete their meal while aSSisting
children.
Ref: p. 5; 4a

Components

12. No time limits are established
regarding total time allowed to
complete meals.

Remarks

Ref: p. 5; 4a
13. No more than 14 hours elapse
between the last meal served and
the first meal of the following day.
Ref: p. 5; 4a

14. Sugar, condiments, seasonings,
and dressings available for selfservice are provided in individual
packages, closed dispensers, or
automated condiment-dispensing
systems.
Ref: p. 6; 6

15. Salad dressings served in open
containers include a ladle that
extends beyond the top edge of the
container.
Ref: p. 6; #6

16. The serving line is constructed in a
manner that allows residents to
view and choose from a variety of
selections.
Ref: p. 7; d

17. Self-service beverage-and-ice
stations are sanitary.
Ref: p. 7; f

18. Residents whose religious beliefs
require adherence to particular
dietary laws are referred to the
chaplain through an Authorization
for Common Fare Participation
Form.

Food Service
Page 6 of 11
The Nakamoto Group, Inc.

Timelines from the evening meal to breakfast
exceed the time lines as established by
standards.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

Compliant

Not
Compliant

cg]

Remarks

Ref: p. 12; 6a
19. During Ramadan, residents
participating in the fast receive
approved meals after sundown.
Ref: p. 15; k1
20. During Passover, the facility has
standard Kosher-for-Passover
foods for participating residents.
Ref: p. 15; #2

cg]

21. No-flour meals are served during
Passover.

Common fare program is not in place to meet
the needs of all religions. There is not kosher
meals system in place

Ref: p. 15; #2
22. During Lent, a meatless meal
(lunch or dinner) shall be served
Fridays and on Ash Wednesday.
Ref: p. 16; #3
23. The Common Fare program
accommodates residents
abstaining from particular foods or
fasting for religious purposes at
. prescribed times of year.

cg]

Common fare program is not in place to meet
the needs of all religions. There is not kosher
meals system in place .

Ref: p. 12
24. Residents with certain conditionschronic or temporary- are
prescribed special diets as required
and appropriate.
Ref: p. 16; 7a
25. The food service program
addresses medical diets.
Ref: p. 16; 7a

26. Snacks, fruits, juice and milk are
available via self-service within
each housing unit.

cg]

Food Service
Page 7 of 11
The Nakamoto Group, Inc.

Local staff indicated they rely on resident to
let staff know of any medical diets. Complex
staff indicated they rely on information rec'd
from the facility. Medical staff provides
information to facility staff. Due to lack of
communication the facility food service did
not have any information of diets while the
medical provided information on several
residents that had been place on medical
diets within the week of the review. A more
timely information sharing system needs to
be put in place.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Not
Compliant

28. The infant-toddler menu program
meets recommended government
guidelines for well-baby and wellchild growth and development.
Ref: p. 17; 8b

29. Infant and toddler bottles and
utensils are properly sterilized.
Ref: p. 17; 8b

30. Standard operating procedures
include weekly inspections of all
food service areas, including dining
and food-preparation areas and
equipment.
Ref: p. 28; s

31. Procedures include inspecting all
incoming food shipments for
damage, contamination, and pest
infestation.
Ref: p. 28; 3: 1

32. All knives not in a secure cutting
room are physically secured to the
workstation.
Ref: p. 3; b

33. All flammable, toxic, and caustic
materials are distinctively labeled
and stored in a locked cabinet or
room.
Ref: p. 27; bullets 3&4

Components

Remarks

Ref: p. 17; 8a
27. A food service program is in place
which provides for the minimum
nutritional needs of toddlers and
infants, ranging in age from
newborn to four years old.

Menu is changed without notification of
facility managers.

Ref: p. 17; 8b

This task is not being completed by staff.

Staffing and Training
Components

34. The food service program is
supervised by a Food Service
Administrator (FSA).
Ref: p. 2; #1
35. Staff monitor the condition of
knives and dining utensils.

Compliant

Not
Compliant

Food Service
Page 8 of 11
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Compliant

Not
Compliant

Iz;]

37. Cook SupeNisors (CS) instruct
newly-assigned resident workers in
the rules and procedures of the
food seNice department.
Ref: p.4; c

Iz;]

38. A registered dietitian with
experience in both adult and
pediatric meal seNice conducts a
complete nutritional analysis, at
least annually, of every mastercycle menu planned.
Ref: p. 1; #1

Iz;]

Components

Remarks

Ref: p. 3; b
36. A supeNisor is assigned to the
dining room.
Ref: p. 7; b

39. Food seNice personnel requirements include:
a.

Residents with hair
shoulder-length or longer
wear a hair net or caps

Iz;]

Ref: p. 5; f
Residents with facial hair
wear beard guards
Ref: p. 5; f

Residents working in the
garbage room, dish
machine room, panwashing area, etc., wear
rubber or plastic aprons
and rubber boots

Ref: p. 5; f
e.

Residents working in
refrigerated and freezer
areas are provided with
appropriately insulated
clothing
Ref: p. 5; f

Residents seNing food
wear plastic gloves
Ref: p. 6; 3

Food SeNice
Page 9 of 11
The Nakamoto Group, Inc.

Residents are only assigned to the food
seNice sanitation area but are not provided
with all training required.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Resident Intake and Orientation
Components

Compliant

40. Residents have regular access to
translations services and/or are
provided information in a language
~
that they understand.
Ref: p. 1; #10
41. Orientation and training sessions include:
Ref: p. 4; c
a. explanation and
demonstration of safe work
practices and methods in a
D
language the resident
understands
b.

identification of safety
features of individual
products and equipment
workplace hazard
recognition and deterrence

protective devices and
clothing, and how to report
any malfunctions or other
safety-related problems

Not
Compliant

Remarks

The facilities voluntary work program
provides general information on job
responsibilities but does not provide for a
formal training program, signed off by the
resident and place in facility file.

ADD IN: The facility will maintain a high level of sanitation and cleanliness in all
areas of food service preparation and dining.
Dining area and food service area were clean during the time of the visit. The
facility does not have a formal inspection system of this area. However, persons
assigned to work in food service are showed a lot of enthusiasm for maintaining
a clean work area.

The facility has shown much improvement since last review in the area of food
availability to residents. There is more than fourteen hours between the evening
meal and breakfast meal.
The breakfast meal is. always the same than does not include any hot entrees.

Food Service
Page 10 of 11
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

FUNDS AND PERSONAL PROPERTY
PURPOSE AND SCOPE: Residents' personal property, including funds, valuables, and

baggage, is safeguarded and controlled, and contraband does not enter a residential
facility.
EXPECTED OUTCOMES:

The expected outcomes of this Standard are as
follows:

1. That the security, safety, and good order of each facility will be maintained
through an immediate and thorough search of each newly-admitted resident and
his or her property.
2. That every resident's funds, valuables, baggage, and personal property will be
inventoried, receipted, stored, and safeguarded.
3. That every resident will be informed about what happens to funds and property
that cannot be retained in his or her possession, and the procedures necessary
to report missing or damaged property
4. Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.
5. The standard complies with federal laws and with DHS regulations regarding
residents with special needs.
REFERENCES: The First National Residential Standards were written using a variety of

methodologies including previous and current practices, review and comment from
various subject matter experts, review and comment from various government and nongovernment organizations, and review of current state codes in Pennsylvania and
Texas. Each standard is written in a manner that affords each resident admission and
continuous housing to a family residential facility in a dignified and respectful manner.
There are no specific codes, certifications, or accreditations that deal specifically with
unique management requirements of families awaiting the outcome of their immigration
proceeding in a non-secure custodial environment.

Funds and Personal Property
Page 1 of 6
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
American Correctional Association 4th Edition, Standards for Adult Detention Facilities:
4-ALDF-2A-20, 2A-23, 2A-24, 6A-07(M)
To determine this rating the reviewer will:
o Review written Policy and Procedure to verify it is in line with Residential
Standards.
o Review current resident handbook.
o Review completed personal property inventory form.
o Interview residents regarding personal property.
o Interview business manager to determine understanding of policy and
procedures.
o Interview staff responsible for Admission and Release to determine their
knowledge of Standards.
o Interview

person

responsible

for

mail

and

packages

determine

understanding of policy and procedures.
o Interview person responsible for commissary to determine understanding of
policy and procedures.

Funds and Personal Property
Page 2 of 6
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components
1.

An audit system in place to ensure
accountability.
RefV.10
Procedures are in place to ensure
staff searches of arriving residents
and their personal property for
contraband are within parameters
established by Admission and
Release Standards.
RefV.4
The facility allows residents to
keep religious jewelry.
RefV.f

4. There is a written policy for
5.

returning property to residents.
Ref: p. 2; #5
There is a written policy for
property discrepancies.
Ref V.12.b

Compliant

Not
Compliant

[gJ

Reviewed

[gJ

Reviewed

Remarks

Observed

Inventory and Storage

~Pliant

Components
6.

Resident funds and valuables are
properly separated and stored
away.
Ref 11.2
Resident funds and valuables are
accessible to deSignated
supervisor(s) only.
RefV.b.3
The business office has a system
in place for putting funds in an
account accessible by residence.
The facility utilizes a system to
ensure accountability for
resident's property.
Ref: V1; V9

Not
Compliant

Remarks

[gJ

observed

[gJ

Supervisor walked reviewer thru process of
accessing valuables

[gJ

Observed

[gJ

Funds and Personal Property
Page 3 of6
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

Compliant

Not
Compliant

10. Residents' large valuables are
secured in a location accessible to
designated supervisor(s) or
processing staff only.
Ref, V.b

Funds and Personal Property
Page 4 of 6
The Nakamoto Group, Inc.

Remarks

Inspected

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Staffing and Training
Components

Compliant

Not
Compliant

•

11. A supervisor verifies funds and
valuables.
Ref: p. 5; #8
12. Staff forwards an arriving
resident's medicine to the medical
staff.
Ref. VA

Funds and Personal Property
Page 5 of 6
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
GRIEVANCE SYSTEM

PURPOSE AND SCOPE: Residents are provided a procedure by which they may file
formal grievances and receive timely responses.
EXPECTED OUTCOMES: The expected outcomes of this Standard are as
follows:

1. Residents will be informed about the facility's informal and formal grievance system.
2. Staff and residents will mutually resolve most complaints and grievances orally and
informally in their daily interaction.
3. Residents will be able to file formal grievances, and receive written responses, in a
timely manner.
4. Residents will be able to file emergency grievances that involve an immediate

t~reat

to their safety or welfare.
5. Residents will be able to appeal decisions on grievances to a higher level (Resident
Grievance Committee or designated single Grievance Staff) and, if still not satisfied,
to the facility administrator.

6. Accurate records will be maintained on grievances filed and their resolution.
7. No resident will be harassed, disciplined, punished, or otherwise retaliated against
for filing a complaint or grievance.

8. Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.

9. The standard complies with federal laws and with DHS regulations regarding
residents with special needs.
REFERENCES: The First National Residential Standards were written using a variety of
methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
Grievance System
Page 1 of 5
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
families awaiting the outcome of their immigration proceeding in a non-secure custodial
envi ron ment.
American Correctional Association Standards for Adult Local Residential Facilities, 4th Edition:
4-ALDF-2A-27, 6A-07, 68-01.
To determine this rating the reviewer will:

o Review written policies and procedures.
o Review grievance forms to determine that timeframes and policy are followed.
o Interview staff and residents to determine their level of awareness and understanding
of the grievance process.

o Determine if the process is unimpeded.
o Observe the grievance system in action, if possible.
o Monitor the number of residents that discuss concerns with you during the interview
process to determine if they are receiving resolution from staff (inform staff of any
concerns and follow-up on resolution during facility visit).

Grievance System
Page 2 of 5
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

Procedures are in
place for residents to
orally present the issue
of concern informally to include translation
assistance.
Ref: p. 3; #3a

Compliant

Not
Compliant

[8J

A supply of grievance
forms is available in
common areas and/or
day rooms along with a
locked box where
residents may submit
grievances.
Ref: p. 3; b

Grievance forms and
signage for grievance
boxes is written in
English, Spanish and
other dominant
languages of the
resident population or
translation services are
available).
Ref: TBD
Grievances are
collected on a daily
basis.
Ref: p. 3; b
The grievance system
allows for resolution at
the lowest level (when
applicable)
Ref 11.2
The handbook and
information posted on
unit bulletin boards
explains the process
for reporting incidents
directly to Immigrations
and Customs
Enforcement (ICE)
Offices, in English and
the dominant language
of the residents.
Ref: p2; #2

Grievance System
Page 3 of 5
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

Compliant

Not
Compliant

r8]

7. An appeal process is in
place for the resident
grievance process.
Ref: p. 5; #5
8. A Resident Grievance
Log or other
appropriate method of
recording resident
grievances is in place.
Ref: p. 6; #8

Grievance System
Page 4 of 5
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
HOUSEKEEPING AND VOLUNTARY WORK PROGRAM
PURPOSE AND SCOPE: Residents will be provided with opportunities to work and earn

money while confined, subject to the number of work opportunities available and the
constraints of safety, security, and good order. Residents will be responsible for
personal housekeeping at the facility.
EXPECTED OUTCOMES: The expected outcomes of this Residential Standard are as
follows:
1. Eligible adult residents will have opportunities to work and eam money while in residence,
subject to the number of work opportunities available and the constraints of safety, security
and good order.
2. Residents will be able to volunteer for work assignments, but otherwise not be required to
work, except to do personal housekeeping.
3. Essential operations and services will be enhanced by the work accomplished by residents.
4. The negative impact of confinement will be reduced because of improved morale, and fewer
incidents requiring corrective action.
5. Resident working conditions will comply with all applicable federal, state, and local work
safety laws.
6. There will be no discrimination regarding access to the work program based on race,
religion, national origin, gender, sexual orientation, or disability.
7. Where required, residents have regular access to translation services and/or are provided
information in a language that they understand.
8. The standard complies with federal laws and with DHS regulations regarding residents with
special needs.
REFERENCES: The First National Residential Standards were written using a variety of
methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-govemment
9rganizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
Housekeeping and Voluntary Work Program
Page 1 of 5
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
American Correctional Association 4th Edition, Standards for Adult Residential Facilities.
ALDF-5C-06, 5C 08, 5C - 11 (M), 68-02.

To determine this rating the reviewer will:

o Review written policies, procedures and practices.
o Review handbook for information regarding work opportunities.
o Review work rosters for residents.
o Review resident job descriptions.
o Interview residents regarding job opportunities.
o Interview work area supervisors regarding the following:
•

Resident's selection process

•

Hiring of Physical and Mentally challenge Residents

•
•

Hours of work
Compensation

•

Removal from work detail

•

Job training

o Review medical clearance for residents assigned to food service.
o Observe living areas for sanitation.
o Interview unit officers in reference to house keeping plan.

o Review daily, weekly and monthly sanitation reports.
o

Review facility wide house keeping plan.

o Review post orders in sensitive areas such as mail room, medical, commissary,
control rooms to determine limitation of access by residents.

Housekeeping and Voluntary Work Program
Page 2 of 5
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

No resident under the age
of 18 is authorized to
perform work, other than
general cleaning of their
personal housing area
under the supervision of a
parent.
RefV.1
Residents who are
physically and mentally
able to work are provided
the opportunity to do so.
RefV.1
Rules have been
developed for selecting
work detail volunteers.
RefV.3
Residents receive
monetary gratuity for work
completed ($1.00 per day)
RefV.8
Monetary compensation is
placed into the family units'
commissary account.
RefV.8
The facility has a system in
place that ensures
residents receive the pay
owed to them prior to being
transferred or released.
RefV.8
Procedures are in place for
informing resident
volunteers about job
responsibilities and
reporting procedures.
RefV.10
Appropriate training is
available for all resident
workers.
RefV.11
Procedures are in place for
immediately and
appropriately responding to
on-the-job injuries,
including immediate
notification to ICEIDRO.
RefV.12

Compliant

Not
Compliant

l8l

Remarks

l8l

There is a system that is not formal are written but
general understanding by the residents that they
can volunteer to work in the food service area
"washing dishes".

l8l

There is no training program in place for residents.

Housekeeping and Voluntary Work Program
Page 3 of 5
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
Components

10. The facility has a
housekeeping plan for
residents - to include
residents' care of personal
living areas.
Ref: p. 2; #2
11. The facility conducts and
documents inspection of
living and common areas
on daily sanitation reports
Ref: TBD

Compliant

Not
Compliant

l2l

Housekeeping and Voluntary Work Program
Page 4 of 5
The Nakamoto Group, Inc.

Remarks

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
HUNGER STRIKES
PURPOSE AND SCOPE: The health and well-being of adult residents is protected by
monitoring, counseling, and, when appropriate, treatment of any adult resident on a
hunger strike.
(Nothing in this Residential Standard is·intended to limit or override the exercise of
sound medical judgment by the medical authority responsible for a resident's medical
care. Each case must be evaluated on its own merits and specific circumstances, and
treatment shall be given in accordance with accepted medical practice.)

EXPECTED OUTCOMES:

The expected outcomes of this Standard are as
follows:

1. Any resident who does not eat for 72 hours will be referred to the medical
department for evaluation and possible treatment.
2. When medically advisable, a resident on a hunger strike will be placed under
close supervision for observation and monitoring.
3. The Chief, JFRMU and ICE/ORO Field Office Director will be notified when a
resident is on a hunger strike.
4. The resident's health will be carefully monitored and documented, along with the
resident's intake of food and liquids.
5. A resident on a hunger strike will be counseled and advised of the medical risks,
and will be encouraged to end the hunger strike or to accept medical treatment.
6. Medical treatment will be administered against a resident's will only with the
medical, psychiatric, and legal safeguards specified herein
7. Where required, residents have regular access to translation services and/or are
provided information in a language that they understand.
S.

The standard complies with federal laws and with DHS regulations regarding
residents with special needs.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
American Correctional Association 4th Edition, Standards for Adult Detention Facilities: 4-ALDF2A-52,4D-15.

To determine this rating the reviewer will:

o Review written policies, procedures and practices or medical protocols
maintained in the health services unit to determine review dates and sign off.

o Review staff training plans for training on recognition of hunger strikes.
o Review medical files if resident has gone on hunger strike.
o Review emergency drill or table top discussions if no hunger strike has
occurred.

o Randomly interview medical staff for awareness of hunger strike plan.

Hunger Strikes
Page 2 of 4
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS

PERFORMANCE STANDARDS
Policy and Procedures
Components

Compliant

1. Initial medical evaluation of resident includes:
Ref: p. 2; #3a
a. Record of height and weight.
~
b.

Not
Compliant

Remarks

Vital Sign

Urinalysis

Psychol og ical/psych iatric
evaluation

General physical condition

Radiographs/laboratory
studies as warranted.

Residents requiring forced
medical treatment are
transferred to an alternate ICE
facility or other facility, as
appropriate for intervention.
Ref: p. 4; #5
3. All staff are trained annually to
recognize the signs of a Hunger
Strike and the treatment and
referral process.
Ref: p. 2; #2

Hunger Strikes
Page 3 of 4
The Nakamoto Group, Inc.

Appropriate documentation is noted
within training folders.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
KEY AND LOCK CONTROL
PURPOSE AND SCOPE: Keys and locks are properly controlled and maintained, enhancing
safety and security at the facility.
EXPECTED OUTCOMES: The expected outcomes of this Residential Standard are as
follows:
1. All staff will be trained in the proper care and handling of keys and locks.
2. Keys will be controlled and accounted for.
3. Locks and locking devices will be continually inspected, maintained, and inventoried.
4. Firearms will be stored in secure gun lockers before their carriers enter the facility.
5. Where required, residents have regular access to translations services and/or are
provided information in a language that they understand.
6. The standard complies with federal laws and with DHS regulations regarding residents
with special needs.
REFERENCES: The First National Residential Standards were written using a variety of
methodologies including previous and current practices, review and comment from various
subject matter experts, review and comment from various government and non-government
organizations, and review of current state codes in Pennsylvania and Texas. Each standard is
written in a manner that affords each resident admission and continuous housing to a family
residential facility in a dignified and respectful manner. There are no specific codes,
certifications, or accreditations that deal specifically with unique management requirements of
families awaiting the outcome of their immigration proceeding in a non-secure custodial
environment.
Individuals with Disabilities Education Improvement Act of 2004.
American Correctional Association 3rd Edition, Standards for Juvenile Detention Facilities: ACA
3 JDF-5C-01- 03, 2E-05, 50- 01-03,06,07 &11-13
To determine this rating the reviewer will:
o

Review written Policy and Procedure to verify it is written in line with accepted Practices
and Residential Standards.

Interview staff responsible for key control to determine understanding of policy and key
control system.

Observe the issuance of keys during shift change.
Key and Lock Control
Page 1 of 7
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
o

Randomly review key rings to determine compliance with policy.

Review monthly inspections of emergency key log.

Review incident reports for broken keys.

Observe and compare the back up key box to ensure enough back up keys are present
in light of the reports of broken keys.

Review training record if lock smith is on staff or cooperative agreement of lock smith if
contracted for services.

Interview random staff about knowledge of key control system including reporting of lost
or broken key.

Have key control officer access an isolated area of the facility through the use of the
emergency key ring for that Zone or area.

Review logbooks for quarterly audit of all keys.

Key and Lock Control
Page 2 of 7
The Nakamoto Group, Inc.

OFFICE OF DETENTION AND REMOVAL

FAMILY AND RESIDENTIAL STANDARDS
PEFORMANCE STANDARDS
Policy and Procedures
Components

Procedures are
documented for identifying
all key rings, including
individual keys and
preventing keys from
being removed once
issued
Ref V.4.d
Written policy is available
regarding procedures to
ensure key accountability
Ref Sec 0 pg 8

Padlocks and/or chains
are not used on residents'
room doors
RefV.d.7

Compliant

Not
Compliant

[gJ

A preventive maintenance program is in place and includes:
a adjusting and
servicing vehiclegates for changing
(hoUcold) weather
[gJ
D
conditions twice a
year, in the spring
and early fall
Ref V.e.1
b adjusting and
servicing frontentrance and
[gJ
other gate
D
operations at least
once a year
Ref V.e.2
c lubricating all
other locks
[gJ
D
quarterly
Ref V.e.3

Key and Lock Control
Page 3 of 7
The Nakamoto Group, Inc.

Remarks

b2 high, b7e

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