U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
Chicago Field Office
Boone County Jail
Burlington, Kentucky

June 17–19, 2014

COMPLIANCE INSPECTION
BOONE COUNTY JAIL
CHICAGO FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................2
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................6
ICE 2000 NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................7
Access to Legal Material .....................................................................................................8
Detainee Classification System............................................................................................9
Detainee Grievance Procedures .........................................................................................10
Environmental Health and Safety ......................................................................................12
Funds and Personal Property .............................................................................................14
Medical Care ......................................................................................................................15
Recreation ..........................................................................................................................18
Staff-Detainee Communication .........................................................................................19
Suicide Prevention and Intervention ..................................................................................20
Telephone Access ..............................................................................................................22

INSPECTION PROCESS
The U.S. Immigration and Customs Enforcement (ICE), Office of Professional
Responsibility (OPR), Office of Detention Oversight (ODO) conducts broad-based compliance
inspections to determine a detention facility’s overall compliance with the applicable ICE
National Detention Standards (NDS) or Performance-Based National Detention
Standards (PBNDS), and ICE policies. ODO bases its compliance inspections around specific
detention standards, also referred to as core standards, which directly affect detainee health,
safety, and well-being. Inspections may also be based on allegations or issues of high priority or
interest to ICE executive management.
Prior to an inspection, ODO reviews information from various sources, including the Joint Intake
Center (JIC), Enforcement and Removal Operations (ERO), detention facility management, and
other program offices within the U.S. Department of Homeland Security (DHS). Immediately
following an inspection, ODO hosts a closeout briefing at which all identified deficiencies are
discussed in person with both facility and ERO field office management. Within days, ODO
provides ERO a preliminary findings report, and later, a final report, to assist in developing
corrective actions to resolve identified deficiencies.

REPORT ORGANIZATION
ODO’s compliance inspection reports provide executive ICE and ERO leadership with an
independent assessment of the overall state of ICE detention facilities. They assist leadership in
ensuring and enhancing the safety, health, and well-being of detainees and allow ICE to make
decisions on the most appropriate actions for individual detention facilities nationwide.
ODO defines a deficiency as a violation of written policy that can be specifically linked to ICE
detention standards, ICE policies, or operational procedures. Deficiencies in this report are
highlighted in bold and coded using unique identifiers. Recommendations for corrective actions
are made where appropriate. The report also highlights ICE’s priority components, when
applicable. Priority components have been identified for the 2008 and 2011 PBNDS; priority
components have not yet been identified for the NDS. Priority components, which replaced the
system of mandatory components, are designed to better reflect detention standards that ICE
considers of critical importance. These components have been selected from across a range of
detention standards based on their importance to factors such as health and safety, facility
security, detainee rights, and quality of life in detention. Deficient priority components will be
footnoted, when applicable. Comments and questions regarding this report should be forwarded
to the Deputy Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

(b)(6), (b)(7)c

Inspections and Compliance Specialist (Team Lead)
Inspections and Compliance Specialist
Inspections and Compliance Specialist
Contractor
Contractor
Contractor

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ODO
ODO
ODO
Creative Corrections
Creative Corrections
Creative Corrections
Boone County Jail
ERO Chicago

EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Boone County Jail (BCJ) in Burlington,
Kentucky, from June 17 to 19, 2014. BCJ, which opened in 2005, is owned and operated by
Boone County Fiscal Court. ERO began housing detainees at BCJ in 2005 under an
intergovernmental service agreement (IGSA) between the County of Boone and the U.S.
Marshals Service. Male and female detainees of all security classification levels (Levels I
through III) are detained at the facility for periods in excess of 72 hours. The inspection
evaluated BCJ’s compliance with
the 2000 NDS.
Capacity and Population Statistics
Quantity
The ERO Field Office
Director (FOD), in Chicago,
Illinois, is responsible for ensuring
facility compliance with the 2000
NDS and ICE policies. No ICE
employees are located at BCJ. An
ERO Detention Service Manager
(DSM) assigned to BCJ.

Total Bed Capacity

424

ICE Detainee Bed Capacity

150

Average Daily Population

415

Average ICE Detainee Population

145

Average ICE Length of Stay (Days)

30

Male Detainee Population (as of 06/17/14)

152

Female Detainee Population (as of 06/17/14)

5

A Jailer at BCJ is responsible for oversight of daily facility operations and is supported by(b)(7)e
personnel. The County of Boone provides food services and Southern Health Partners provides
medical services. BCJ holds no accreditations.
In August 2011, ODO conducted a quality assurance review of BCJ under the 2000 NDS. ODO
reviewed 25 standards and found BCJ compliant with 12 standards. ODO found a total of
28 deficiencies in the remaining 13 standards.
During this inspection, ODO inspected 16 standards and found BCJ compliant with six
standards. ODO found a total of 20 deficiencies in the remaining ten standards: Access to Legal
Material (2 deficiencies), Detainee Classification System (1), Detainee Grievance Procedures
(2), Environmental Health and Safety (2), Funds and Personal Property (3), Medical Care (4),
Recreation (1), Suicide Prevention and Intervention (3), Staff-Detainee Communication (1), and
Telephone Access (1). ODO cited one best practice in this report. 1
This report details all deficiencies and refers to the specific, relevant sections of the 2000 NDS.
ERO will be provided a copy of this report to assist in developing corrective actions to resolve
all identified deficiencies. ODO discussed preliminary findings with BCJ and ERO staff during
the inspection and at a closeout briefing conducted on June 19, 2014.
ERO staff at the Louisville, Kentucky sub-office conducts initial processing of detainees prior to
arrival at BCJ. All incoming detainees are searched, screened, fingerprinted, and photographed
upon arrival at BCJ. Strip searches are not performed unless reasonable suspicion is established
in accordance with facility and ICE policy.

1

Best practices are annotated in this report as “BP.”

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Classification and reclassification of detainees is conducted by BCJ classification staff. BCJ
uses a classification system that takes into account both the criminal and mental health history of
detainees. BCJ also uses information received from ERO; however ERO does not always
provide the information necessary to complete the classification.
All detainees are issued an ICE National Detainee Handbook and facility handbook in either
English or Spanish during intake. Thirty active and 15 inactive detention files confirmed
detainees routinely receive both. A BCJ committee reviews the facility handbook annually to
ensure it is current and makes revisions when necessary; the handbook was last reviewed in
March 2014.
Detainee funds and personal property are tracked and stored at BCJ. Valuables are placed in a
property bags; however, those bags cannot be locked. They are kept within the property room,
accessible by all officers. BCJ does not use a safe or locker. Further, BCJ does not have policy
or procedures to address detainee property reported missing or damaged. Also, BCJ’s handbook
does not include notice procedures for claiming property upon release, transfer, or removal or for
filing a claim for lost or damaged property.
Detainees are afforded a minimum of five hours of library access, seven days per week. BCJ’s
handbook does not inform detainees of the procedure for requesting additional time beyond the
five hours per week minimum. BCJ does not post policies and procedure governing access to
legal materials in the law library.
Six formal grievances were filed by detainees in the 12 months preceding the inspection and all
were addressed within a reasonable time. The facility does not have procedures for identifying
and handling emergency grievances. BCJ’s handbook does not provide notice of the right to
have the grievance referred to higher levels, the procedure for contacting ICE to appeal a
decision, or the information about the opportunity to file a complaint about officer misconduct.
Sanitation levels during the inspection were very good. Monthly fire drills are conducted on
each shift; however a review of documentation found emergency keys were not drawn and tested
during fire drills. Only one exit diagram was posted in the lobby area and none were found in
the secure portion of the facility, including detainee housing units. 2
Food preparation and storage areas, the cooler, freezer, and restrooms were clean and well
organized during the inspection. All food service staff and inmate workers received preemployment health screenings and documentation reflects workers are visually checked by staff
members as they arrive for their shifts. The main menu is on a 28-day cycle and certified
annually by a registered dietician. BCJ has a satellite system of meal service and food
temperatures tested during the inspection were in compliance with the NDS. Procedures are in
place for approving and issuing medical and religious diets.
Medical services are provided by Southern Health Partners (SHP), a private contractor. The
clinic is open seven days a week, 24 hours a day, with administrative oversight provided by the

2

This is a repeat deficiency from ODO’s August 2011 inspection.

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Medical Team Administrator (MTA). 3 The MTA is an LPN under the supervision of the
Kentucky Region Administrator (KRA). The medical director, a physician, is the designated
clinical medical authority. Medical and mental intake screenings are completed by trained
security staff. Detainees receive hands-on physical examinations and dental screenings by
Registered Nurses (RN). All health appraisals reviewed by ODO were signed by a physician.
The examination/treatment room at BCJ does not afford medical providers and detainees
privacy; it is located in an open area frequently accessed my medical staff. Further, an officer is
present during patient encounters, as required by both facility and SHP policy.
Detainees access healthcare services by completing written medical requests available in English
and Spanish. The forms are turned into the housing unit officer, who then enters the request
verbatim into the facility’s Jail Management System for retrieval electronically by medical staff.
The involvement of the officers in the process violates patient confidentiality. 4
ODO verified detainees are screened for suicide risk during the intake process. A review of
incident reports found two detainees were placed on suicide watch in the 12 months preceding
the inspection. Although the reports indicate detainees were referred to the mental health
counselor for follow up, there was no documentation of suicide risk assessment to validate or
discontinue the suicide watch. In one case, suicide watch was discontinued by the physician, and
in the second case, the detainee was transferred from BCJ prior to removal from suicide watch
by the physician.
ODO evaluated BCJ’s sexual abuse and assault prevention and intervention program. Although
BCJ was not required to comply with the 2011 Sexual Abuse and Assault Prevention and
Intervention (SAAPI) standard at the time of the inspection, ODO noted any efforts by the
facility to comply with the standard’s requirements. Detainees are informed of the Prison Rape
Elimination Act (PREA) and SAAPI standard by way of the facility handbook. There is a
program coordinator in place. According to BCJ staff and query results from the JIC, no
allegations of sexual abuse and sexual assault involving detainees were reported during the 12
months preceding this inspection.
BCJ’s Special Management Unit (SMU) has 16 single-occupancy capacity cells for male
detainees and four for females. The SMU is used for both administrative and disciplinary
segregation. Two detainees were assigned to administrative segregation and two to disciplinary
segregation during the 12 months preceding the inspection. ODO confirmed segregation orders
were issued, and the detainees received the services, privileges and access to activities required
by the standard.
Indoor and outdoor recreation is available to detainees at BCJ. Although detainees have access
to outdoor recreation it is not always provided at a reasonable time. BCJ’s recreation schedule is
organized by housing unit and shift schedule, which causes detainees on the schedule for third
shift to receive recreation between the hours of 11 p.m. and 7 a.m.

3

The Medical Team Administrator functions as the medical health authority, commonly referred to as a Health
Services Administrator.
4
This is a repeat deficiency from ODO’s August 2011 inspection.

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Detainees have opportunities to interact informally with both ERO and BCJ staff. ERO staff
visits the housing units every Wednesday to address detainee questions and concerns. Detainee
requests are generally responded to within 72 hours; however copies are not placed in detention
files.
Detainees have access to telephones daily from 7 a.m. to 12 a.m. The telephone availability ratio
is roughly ten detainees per phone. Call rates range from $0.20 per minute for local, toll, and
long distance calls, and $1 per minute for international calls. Notification that calls are subject to
monitoring are posted near each telephone and in the facility handbook; however, the procedures
for obtaining an unmonitored call are not posted or included in the handbook.
BCJ has written policy governing the use of force. Four immediate use-of-force incidents
involving detainees occurred during the 12 months preceding the inspection. ODO’s review of
written documentation and video taken by way of cameras worn by the shift supervisor
confirmed compliance with the standard. Training records for(b)(7)erandomly-selected officers
confirmed current training in use of force and oleo capsicum (OC) spray deployment.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 20 randomly-selected detainees (15 males and five females) to assess the
conditions of detention at BCJ. All detainees interviewed had been housed at the facility from
one day to six and one-half months. Interview participation was voluntary and none of the
detainees made allegations of abuse, discrimination or mistreatment.
Facility Handbook: Eight detainees stated they did not receive the facility handbook at
admission. ODO reviewed a total of 30 active detention files, including those who reported not
receiving the handbook, and verified all files contained signed handbook receipt
acknowledgements. ODO further reviewed 15 inactive detention files and found all contained
signed handbook receipts.
Recreation: Ten detainees stated recreation was inconsistent and reported often only having
outdoor recreation between 1 a.m. and 3 a.m. ODO reviewed the recreation standard and found
BCJ staff does not always offer outdoor recreation at a reasonable time. ODO found recreation
for some detainees is offered at unusual hours.
Medical Care: One male detainee alleged he did not receive adequate care for a toothache, and
ultimately removed his own molar on an unknown date. ODO and BCJ medical staff
interviewed the detainee and reviewed his medical file. The detainee later recanted his statement
about removing his own molar. BCJ medical staff concluded the detainee’s allegations were
unfounded. However, as a precaution, the detainee was scheduled for a dental appointment by
medical staff.
Other services: None of the detainees interviewed by ODO expressed concerns regarding access
to mail, telephones, the grievance system, religious services, or visitation. Food service and
medical care were generally described as satisfactory.

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 NDS and found BCJ fully compliant with the following
six standards:
1.
2.
3.
4.
5.
6.

Admission and Release
Detainee Handbook 5
Food Service
Special Management Unit-Administrative Segregation
Special Management Unit-Disciplinary Segregation
Use of Force

As the standards above were compliant at the time of the inspection, a synopsis for these
standards is not included in this report.
ODO found 20 deficiencies in the following ten standards.
1. Access to Legal Material
2. Detainee Classification System
3. Detainee Grievance Procedures
4. Environmental Health and Safety
5. Funds and Personal Property
6. Medical Care
7. Suicide Prevention and Intervention
8. Staff-Detainee Communication
9. Telephone Access
10. Recreation
Findings for these standards are presented in the remainder of this report.

5

The Detainee Handbook standard was found compliant during the inspection; however, deficiencies related to the
Detainee Handbook are located under Deficiencies ALM-1, DGP-2, F&PP-3 and TA-1.

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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at BCJ to determine if detainees have
access to a law library, legal materials, and supplies and equipment to facilitate the preparation
of legal documents, in accordance with the ICE NDS. ODO inspected the areas designated for
law library use, reviewed policies, procedures, and the facility handbook, and interviewed staff
and detainees.
The law library is located in a designated room near the housing units. The designated room is
well-lit, contains sufficient furnishings, and is equipped to support legal research and case
preparation. The law library includes a desktop computer, a printer and supplies to support legal
research and case preparation by detainees. ODO verified the computer contained a current
version of LexisNexis and word processing software. Detainees have access to paper, writing
utensils, and envelopes. Legal documents can be printed and copies are made with the assistance
of a staff member.
Detainees request use of the law library by submitting a request form. Detainees are afforded a
minimum of five hours seven days a week, with exception of meal and visitation periods.
Additional time is available upon request. BCJ policy affords the same law library privileges to
detainees in special management units.
BCJ staff informed ODO that illiterate and limited English proficient detainees are provided
assistance with their legal paperwork, as needed. Detainees with appropriate language, reading,
and writing abilities are allowed to provide assistance. The law library custodian provides
indigent detainees with free envelopes, stamps, notary services, and certified mail for legal
matters.
BCJ’s handbook does not inform detainees of the procedure for requesting additional time in the
law library beyond the five hours per week minimum (Deficiency ALM-1). Also, BCJ does not
post library policies and procedures in the designated room (Deficiency ALM-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE NDS, Access to Legal Material, section (III)(Q)(4), the FOD must
ensure “the detainee handbook or equivalent, shall provide detainees with the rules and
procedures governing access to legal materials, including the following information:
4. the procedure for requesting additional time in the law library (beyond the 5 hours per
week minimum).”
DEFICIENCY ALM-2
In accordance with the ICE NDS, Access to Legal Material, section (III)(Q), the FOD must
ensure the policies and procedures governing access to legal materials “shall also be posted in
the law library.”

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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System standard at BCJ to determine if there is a
formal classification process for managing and separating detainees based on verifiable and
documented data, in accordance with the ICE NDS. ODO toured the booking area and
classification department, interviewed staff, and reviewed classification documentation and local
policy.
BCJ’s classification system takes into account both the criminal and mental health history of
detainees. BCJ classification staff classifies new detainees using information provided by ERO.
Classification staff stated ERO staff does not routinely provide the information and forms
necessary to complete the classification process on detainees at the time of admittance
(Deficiency DCS-1). On June 16, 2014, ODO observed six detainees arrive at the facility
without any classification paperwork from ERO. Whenever this situation arises, BCJ staff
usually notifies ERO staff and ERO staff usually provides the necessary documentation within
one to three days. Availability of information supporting the assigned classification level is
important for validation and reclassification.
ODO reviewed 15 detention files and all contained an I-203 form, Order to Detain or Release,
and the Risk Classification Assessment form. Detention files also showed supervisors are
reviewing and approving the classification level assigned to detainees.
BCJ’s classification system allows new arrivals to appeal their classification levels. Detainees
may appeal by filing a grievance. Once submitted, the grievance will initiate a reclassification
assessment by one of the classification officers. A review of a detainee’s classification may
occur every 90 days, or if there is an institutional incident. For detainees in segregation, a review
occurs no less than once monthly and whenever there is a change in the detainee’s status.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE NDS, Detainee Classification System section (III)(A)(1), the FOD
must ensure, “All detainees are classified upon arrival, before being admitted into the general
population. ICE will provide CDF’s and IGSA facilities with the data they need from each
detainee’s file to complete the classification process.”

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedure standard at BCJ to determine if a process to
submit formal or emergency grievances exists, and responses are provided in a timely manner,
without fear of reprisal. In addition, the review was conducted to determine if detainees have an
opportunity to appeal responses, and if accurate records are maintained, in accordance with the
ICE NDS.
The grievance system at BCJ allows detainees to file informal and formal grievances; however,
the facility does not have procedures for identifying and handling an emergency grievance
(Deficiency DGP-1). 6 Grievance forms are available in the housing units and detainees may
obtain assistance from another detainee or facility staff in preparing a grievance. BCJ staff
forward to ERO any grievances alleging staff misconduct and has established a grievance
committee to address detainee appeals.
BCJ maintains a grievance log to document and track detainee grievances. Six formal
grievances were filed by detainees in the 12 months preceding the inspection and all were
addressed within a reasonable time. Responses are provided to detainees in writing and a copy is
placed in the detention file. The six grievances involved the following issues/topics:
•
•
•
•

Lights being left on in the housing unit (2)
Incorrect request forms (2)
Problems making a telephone call (1)
Request for a court date (1)

No patterns or trends were observed.
The facility’s handbook provides notice to detainees of the opportunity to file a formal and
informal grievance, the procedure for filing a grievance and appeal, and the policy prohibiting
staff from retaliating against any detainee for filing a grievance. BCJ’s handbook does not
provide notice of the right to have the grievance referred to higher levels, the procedure for
contacting ICE to appeal a decision of the Officer In Charge (OIC), and the information about
the opportunity to file a complaint about officer misconduct (Deficiency DGP-2). 7

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(B), the FOD
must ensure “Each facility shall implement procedures for identifying and handling an
emergency grievance.”

6
7

The facility initiated corrective action during the inspection.
The facility initiated corrective action during the inspection.

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DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G), the FOD
must ensure, “The grievance section of the detainee handbook will provide notice of the
following:
3. The procedures for resolving a grievance or appeal, including the right to have the
grievance referred to higher levels if the detainee is not satisfied that the grievance has
been adequately resolved. The level above the CDF-OIC is the ICE-OIC.
4. The procedures for contacting ICE to appeal the decision of the OIC of a CDF or an
IGSA facility.
6. The opportunity to file a complaint about officer misconduct directly with the Justice
Department by calling 1-800-869-4499 or by writing to:”
In accordance with the Change Notice National Detentions Standards Staff-Detainee
Communication Standard, dated June 15, 2007, the FOD must ensure, until the detainee
handbooks can be revised during the annual update, ICE staff shall ensure that each detainee
in ICE custody is informed in writing the OIG contact information: DHS OIG Hotline
Write to:
245 Murray Drive, S.E., Building 410
Washington, D.C. 20538
Email to:
DHSOIGHOTLINE@DHS.GOV
OR Telephone
1-800-323-8603

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at BCJ to determine if the facility
maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility,
interviewed staff, and reviewed policies and documentation of inspections, hazardous chemical
management, and fire drills.
Sanitation throughout the facility was very good. Hazardous substances are listed in a master
index which includes Material Safety Data Sheets (MSDS), emergency contact information, and
documentation of periodic review for accuracy. MSDS binders are also present in areas where
substances are stored and used. Running inventories of chemicals were accurate. During
interviews, BCJ staff verbalized good understanding of proper storage and handling of all
chemicals.
ODO reviewed documentation of weekly and monthly fire and safety inspections conducted by a
BCJ officer trained to perform this function. Monthly inspections by BCJ’s designated safety
officer affirm the weekly inspection findings, allowing identification and correction of potential
problems before they become life-safety issues. ODO observed only one exit diagram was
posted (Deficiency EH&S-1). 8 The diagram was in the lobby area, and no diagrams were found
in the secure portion of the facility, including detainee housing units. Both the NDS and facility
policy require posting of exit diagrams in all areas.
Fire drills are conducted monthly in all areas on all shifts. Documentation shows emergency
keys were not drawn and tested during the fire drills (Deficiency EH&S-2). The safety officer
informed ODO he tests the emergency keys weekly as part of his safety inspections. Use of
emergency keys during fire drills supports staff familiarity with their use.
Reports maintained by the safety officer reflect the emergency electrical generator is tested
weekly for a 30-minute period. According to the safety officer, manufacturer guidelines call for
testing for 30 minutes, only. The generator is tested and serviced annually by an external
company.
Inspection of the medical department found documentation of sharps inventories are conducted
at the beginning and end of each shift. ODO inventoried the sharps with the Medical Team
Administrator (MTA) and confirmed the equipment was accurately counted and documented.
The facility is inspected twice a year by the Kentucky Department of Corrections, Division of
Local Facilities. ODO was informed the local health department and fire marshal do not inspect
BCJ. Compliance with health and fire regulations is audited by state inspectors during the
Kentucky Department of Corrections semi-annual inspections.

8

This is a repeat deficiency from ODO’s August 2011 inspection.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(h), the
FOD must ensure, “Every institution will develop a fire prevention, control, and evacuation plan
to include, among other things, the following: conspicuously posted exit diagrams
conspicuously posted for and in each area.”
DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the
FOD must ensure, “Monthly fire drills will be conducted and documented separately in each
department. Emergency key drills will be included in each fire drill, and timed. Emergency keys
will be drawn and used by the appropriate staff to unlock one set of emergency exit doors not in
daily use. NFPA recommends a limit of four and one-half minutes for drawing keys and
unlocking emergency doors.”

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at BCJ to determine if controls are in
place to inventory, document, store, and safeguard detainees’ personal property, in accordance
with the ICE 2000 NDS. ODO toured the facility, reviewed local policies, the facility handbook,
and detention files, interviewed staff, and inspected areas where detainee property and valuables
are stored.
All detainee personal property is tracked and stored. U.S. currency is deposited into a kiosk,
which provides the detainee commissary funds. Four kiosks are located in the booking area and
one in the lobby area. If currency cannot be read by the kiosk, the funds are dropped into a
locked cash safe in the booking area. The cash safe is only accessible by the Jailer,(b)(7)e
lieutenants, and the executive assistant. Foreign currency is treated as a valuable. All valuables
are placed in a smaller bag within the larger property bag. Both the small and large bags do not
have zipper locks and the facility does not have a safe or locker for valuables (Deficiency
F&PP-1). The property room is accessible by all officers, and is monitored by two cameras.
Any excess baggage, or forgotten or abandoned property, is forwarded to ERO. Based on a
review of 30 active and 15 inactive detention files, detainee property is properly documented.
The facility does not have a written policy and procedure for detainee property reported missing
or damaged (Deficiency F&PP-2). 9
The BCJ handbook did not include notice of the procedure for claiming property upon release,
transfer, or removal nor did it provide the procedures for filing a claim for lost or damaged
property (Deficiency F&PP-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE NDS, Funds and Personal Property, section (III)(A), the FOD must
ensure, “Both the safe and the large-valuables locker should be kept in the shift supervisor’s
office.”
DEFICIENCY F&PP-2
In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must
ensure, “Each facility shall have a written policy and procedures for detainee property reported
missing or damaged.”
DEFICIENCY F&PP-3
In accordance with the ICE NDS, Funds and Personal Property, section (III)(J ), the FOD must
ensure, “The detainee handbook or equivalent shall notify the detainees of facility policies and
procedures concerning personal property, including:
4. The procedure for claiming property upon release, transfer, or removal;
5. The procedures for filing a claim for lost or damaged property.”
9

The facility initiated corrective action during the inspection.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at BCJ to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE NDS. ODO toured the clinic, observed a health appraisal, reviewed policies, procedures
and staff training records, verified medical staff credentials, and interviewed staff. In addition,
ODO examined 20 medical records of detainees in the following categories: chronic care,
females, detainee complaints (addressed in another section of this report), five emergency room
visits, and suicide watch.
BCJ holds no accreditations. Medical services are provided by SHP, a private contractor. The
clinic is open seven days a week, 24 hours a day, with administrative oversight provided by the
MTA. The MTA is an LPN under the supervision of the Kentucky Region Administrator
(KRA). The medical director, a physician, is the designated clinical medical authority. He is on
site, one day a week for as long as necessary, and is on call 24 hours a day, seven days a week.
Additional staff includes a full-time registered nurse, (b)(7)e part-time licensed practical nurses,
and a medical clerk. A contract dentist visits BCJ every six months to provide routine treatment.
Detainees in need of urgent dental care are referred to community providers.
ODO reviewed documentation reflecting there were 27 off-site dental appointments for detainees
in the past four months. Mental health services are provided by a mental health clinician who
works three days a week. According to the MTA and KRA, there were no vacancies at the time
of the review. All professional licenses were present and primary source verified with the
issuing state boards for authentication purposes. ODO verified all medical and(b)(7)erandomlyselected correctional staff had current certification in cardiopulmonary resuscitation and first aid.
The clinic is small with a waiting area, one examination/treatment room containing emergency
response equipment, a medication room, and an administrative office for four persons. BCJ staff
installed a telephone line in the examination/treatment room for the express purpose of accessing
a language translation service. The examination/treatment room is located in an open area
accessible by nursing and medical administrative staff. Further, ODO observed an officer
present during patient encounters which compromises patient privacy (Deficiency MC-1).
Officer presence is required by facility and SHP policy. For medical and mental health services
beyond the scope of care provided by BCJ, detainees are transferred to St. Elizabeth Medical
Center in Cincinnati, Ohio. The Urgent Care Facility in Florence, Kentucky, just six minutes
away, is used for emergency care. BCJ has no cells with negative air flow for tuberculosis (TB)
isolation. In the event a detainee requires respiratory isolation, he or she would be taken to the
hospital until transfer is arranged.
Specially trained security staff conducts the intake screening. Any positive response to
significant medical, mental health or medication issues triggers an immediate referral to medical
staff for follow-up screening. ODO confirmed comprehensive intake screening was completed,
and all 20 detainees whose records were reviewed were screened for symptoms of TB and
received a chest X-ray on admission. Officer training in conducting intake screening was
confirmed by review of(b)(7)erandomly-selected training records. A review of the training
curriculum for intake screening found it complete.
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Signed, general consent for treatment statements were present in all 20 records reviewed.
However, ODO identified two detainees who were receiving psychotropic medications did not
sign specific consent (Deficiency MC-2).
The medical record review confirmed all 20 detainees received health appraisals which included
a hands-on physical examination and dental screening within no more than five days of arrival,
exceeding the standard. The health appraisals are conducted by the RN, whose training in the
function was confirmed by ODO. The medical director co-signed all health appraisals.
ODO found detainees with chronic conditions were seen by the medical director, and essential
medications were ordered and administered as required.
Detainees in general population and the special management units access health care services by
completing written medical requests available in English and Spanish. Request forms were
present in all housing units during the inspection. The forms are turned into the housing unit
officer, who then enters the request verbatim into the facility’s Jail Management System for
retrieval electronically by medical staff up to four times daily. This allows nursing staff to
expeditiously triage and address health care requests; however, the involvement of the officers in
the process violates patient confidentiality of health care information (Deficiency MC-3). 10 Sick
call is conducted in the clinic four times daily using SHP nursing protocols. ODO verified the
protocols were reviewed and signed by the BCJ medical director. Because of the short length of
stay at the facility, the medical record review identified only six sick call requests. In all six
cases, the requests were promptly triaged and addressed in accordance with the applicable
protocol.
During a review of suicide prevention protocols, ODO found one detainee transferred from BCJ
on August 26, 2013, while on active suicide watch. Though the detainee was determined at risk,
a written medical/psychiatric alert notifying the OIC was not generated (Deficiency MC-4). The
Medical Record of Federal Prisoner in Transit Form documented the MTA cleared the detainee
for transfer, but made no reference to the fact the detainee was on suicide watch. While this is
not a deficiency under the Medical Care standard, the Detainee Transfers standard, section
(III)(D)(6)(3)(b), requires transfer summaries to document “Current mental and physical health
status, including all significant health issues.” Absent this information on the transfer form,
there is no assurance that the transporting officers were aware the detainee was at risk for
suicide, or the institution assuming custody was aware of the active suicide watch.
ODO cites the bar code feature of BCJ’s electronic Jail Management System as a best practice
(BP-1). The system uses bar codes to document tasks completed by correctional and medical
staff. This provides an easy system for documenting and auditing certain critical activities such
as medication administration and meals eaten or refused.

10

This is a repeat deficiency from ODO’s August 2011 inspection.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE NDS, Medical Care, section (III)(B), the FOD must ensure, “Adequate
space and equipment will be furnished in all facilities so that all detainees may be provided basic
health examinations and treatment in private.”
DEFICIENCY MC-2
In accordance with ICE NDS, Medical Care, section (III)(L), the FOD must ensure, “The facility
health care provider will obtain signed and dated consent forms from all detainees before any
medical examination or treatment, except in emergency circumstances.”
DEFICIENCY MC-3
In accordance with ICE NDS, Medical Care, section (III)(M), the FOD must ensure, “All
medical providers shall protect the privacy of detainee’s medical information to the extent
possible while permitting the exchange of health information required to fulfill program
responsibilities and to provide for the well-being of detainees.”
DEFICIENCY MC-4
In accordance with the ICE NDS, Medical Care, section (III)(N), Medical/Psychiatric Alert, the
FOD must ensure, “When the medical staff determines that a detainee’s medical or psychiatric
condition requires either clearance by the medical staff prior to release or transfer or requires
medical escort during deportation or transfer, the OIC will be so notified in writing.”

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RECREATION (R)
ODO reviewed the Recreation standard at BCJ to determine if detainees are provided access to
recreational programs and activities within the constraints of a safe and secure environment, in
accordance with the ICE NDS.
Indoor and outdoor recreation is available for detainees at BCJ. Although detainees have access
to outdoor recreation for at least one hour daily, five days a week, it is not always provided at a
reasonable time (Deficiency R-1). BCJ’s recreation schedule is organized by housing unit and
shift schedule. Detainees scheduled for recreation on first shift will be allowed out during the
hours of 7a.m. to 3p.m.; those scheduled for second shift are allowed recreation between 3p.m.
and 11p.m.; and those scheduled for third shift are allowed recreation between 11p.m. and 7a.m.
BCJ tries to alternate the schedule so that detainees are not always scheduled for recreation
during the third shift; however, detainees are scheduled for outdoor recreation during the third
shift anywhere from one to three days weekly.
The facility does not require detainees to forgo law library privileges for recreation privileges.
BCJ has assigned an individual with the responsibility for the oversight of the recreation
program. Dayrooms in the general-population housing units offer board games, televisions and
other sedentary activities. Recreation areas are under continuous supervision by staff.
All detainees participating in outdoor recreation have access to drinking water and toilet
facilities. Detainees housed in SMU are offered recreation apart from the general population.
The facility notifies ERO if a detainee is denied recreation privileges in excess of 15 days.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY R-1
In accordance with the ICE NDS, Recreation, section (III)(B)(1), the FOD must ensure “If
outdoor recreation is available at the facility, each detainee shall have access for at least one hour
daily, at a reasonable time of the day, five days a week, weather permitting.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at BCJ to determine if procedures
are in place to allow formal and informal contact between detainees and key ICE and facility
staff; and if ICE detainees are able to submit written requests to ICE staff and receive responses
in a timely manner, in accordance with the ICE NDS. ODO reviewed policies, documentation,
and interviewed detainees and staff.
An Assistant Field Office Director is assigned to the facility and is responsible for oversight of
ICE-related activities. BCJ staff revealed supervisory ERO staff performs frequent unannounced
and scheduled visits to the facility’s living, activity areas, and housing units. These visits are
logged in at the front entrance in the facility visitor’s log book, and in the ERO Liaison Daily
Logbook.
ERO has no permanent presence at the facility. Deportation Officers (DO) and Immigration
Enforcement Agents (IEA) from the Louisville, Kentucky sub-office are assigned to manage the
detainee caseload at the facility. DOs make scheduled visits on Wednesdays to address ICE
detainee requests and concerns. Visitation schedules were posted in each housing unit and
reflected availability consistent with ERO’s practice during the inspection. Visits by ERO nonsupervisory staff are documented by Facility Liaison Checklists and in BCJ housing unit logs.
All detainees at the BCJ have the opportunity to submit written requests to both ICE staff and
BCJ staff members. Although the facility employs an indirect supervision model, detainees are
able to submit their requests to the BCJ housing unit officer. If the detainees wish to direct their
requests to ICE, BCJ staff sends the requests electronically, to ERO and without delay. The
facility handbook states detainees have the opportunity to submit written questions, requests, or
concerns to ICE and facility staff, and the procedures for doing so.
Both BCJ and ERO staff respond to requests within72 hours of receipt. BCJ staff sends ERO
copies of any requests they address separately. ODO reviewed 933 detainee requests, from June
2013 through June 2014. The majority of requests reviewed by ODO related to removal or
immigration status, telephone calls, commissary funds, visitation, and other facility-related
matters. All requests are logged with the following information: the date the detainee request
was received; detainee’s name; Alien number, nationality; officer’s name; the date the request;
and staff’s response and action.
Detainee requests are not placed in detention files, as the facility maintains all requests
electronically. ODO reviewed 15 detention files and verified completed requests are not
included (Deficiency SDC-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE NDS, Staff Detainee Communication section (III)(B)(2), the FOD
must ensure “All completed Detainee Requests will be filed in the detainee’s detention file and
will remain in the detainee’s detention file for at least three years.”

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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at BCJ to determine if the
health and well-being of detainees are protected by training staff in effective methods of suicide
prevention, in accordance with the ICE NDS. ODO inspected the suicide watch cells,
interviewed medical, administrative, and training staff, and reviewed suicide prevention policies,
the training curriculum, staff training records and medical records.
Incoming detainees are screened for suicide risk during the intake process. Detainees on suicide
watch are housed in a designated cell in the medical observation area. BCJ has eight available
suicide watch cells. ODO found them free from protrusions and objects that could assist in a
suicide attempt. The cells are monitored by correctional staff via closed-circuit surveillance
cameras in booking and central control. Fifteen-minute checks are electronically documented
using the facility’s Jail Management System. Detainees on suicide watch may also be assigned
to constant one-to-one direct observation status, in which an officer is physically present to
observe the detainee at all times. All detainees wear a quilted suicide smock, and are given a
quilted blanket, if needed.
Incident reports show two detainees were placed on suicide watch in the 12 months preceding
the inspection. The documentation reflects in both cases, the captain directed placement on
suicide watch status until “cleared by the jail mental health counselor.” Although the incident
reports reflect the detainees were referred to the mental health counselor for follow up, the
medical records document only that the counselor monitored the detainees while on suicide
watch. There was no documentation of suicide risk assessment to validate or discontinue the
suicide watch status (Deficiency SP&I-1). In one case, suicide watch was discontinued by the
physician; in the second, the detainee was transferred from BCJ prior to removal from suicide
watch by the physician (Deficiency SP&I-2). The Medical Record of Federal Prisoner in
Transit Form documented transfer clearance by the Medical Team Administrator, which in
effect, discontinued the suicide watch. The transfer form made no reference to the suicide watch
in place at the time of transfer. The Detainee Transfers standard, section (III)(D)(6)(3)(b),
requires transfer summaries to document “Current mental and physical health status, including
all significant health issues.” Absent this information on the transfer form, it cannot be assured
the transporting officers were aware the detainee was at risk for suicide, or the institution
assuming custody was aware of the active suicide watch (Deficiency SP&I-3).
Training records for all medical and(b)(7)e andomly-selected correctional staff confirmed
completion of initial and annual suicide prevention and intervention training. A curriculum
developed by the Boone County Sheriff’s Department is presented by the mental health
counselor and covers the elements required by the NDS.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(B), the FOD
must ensure, “Detainees identified as ‘at risk’ for suicide will be promptly referred to medical
staff for evaluation.”
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DEFICIENCY SP&I-2
In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD
must ensure, “A detainee formerly under a suicide watch may be returned to general population,
upon written authorization from the CD.”
DEFICIENCY SP&I-3
In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(B), the FOD
must ensure, “Upon change of custody, the staff with custody will inform the staff assuming
custody about indications of suicide risk.”

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at BCJ to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and
others in the community, in accordance with the ICE NDS. ODO interviewed facility staff and
detainees; reviewed policy, procedures, and the facility handbook; and conducted functionality
tests on the telephones located in detainee housing units.
Detainees have reasonable and equitable access to telephones at BCJ. The telephone availability
ratio for each housing unit is approximately ten detainees per telephone. Telephones are on
every day from 7 a.m. to 12 a.m. The facility provides a TTY when needed. All calls are
restricted to 20 minutes in duration.
Combined Public Communications is the telephone service provider. If paying with direct pay,
PIN debit, or calling card, the charge is $0.20 per minute for local, toll, and long distance calls,
and $1 per minute for international calls, varying by country. For traditional collect calls to
local, toll, and long distance numbers, the charge is $2.50 per minute for the first ten minutes,
followed by $0.25 per minute for minutes 11 through 20.
BCJ and ERO staff inspect phones regularly and report out-of-order telephones for repair. ODO
verified serviceability checks by reviewing weekly serviceability worksheets. ODO conducted
operation checks of telephones in detainee housing units and found them to be in good working
order. Pro bono numbers were updated and working.
The listings for pro bono services, DHS Office of Inspector General, consulates, and embassies,
as well as telephone operating instructions, are cycled through televisions in each housing unit.
Notifications that calls are subject to monitoring are posted near each telephone, and included in
the facility handbook. An attorney room is available for detainees to make private and
unmonitored legal calls. However, the procedures for obtaining an unmonitored call to a court, a
legal representative, or for the purposes of obtaining legal representation were not included in the
facility handbook or posted by the telephones in each housing unit at the time of the inspection
(Deficiency TA-1). 11 The facility initiated corrective action during the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE NDS, Telephone Access, section (III)(K)(2), the FOD must ensure,
“The facility shall have a written policy on the monitoring of detainee telephone calls. If
telephone calls are monitored, the facility shall notify detainees in the detainee handbook or
equivalent provided upon admission. It shall also place a notice at each monitored telephone
stating:
2. the procedure for obtaining an unmonitored call to a court, legal representative, or for
the purposes of obtaining legal representation.”
11

The facility initiated corrective action during the inspection.

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