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
ERO St. Paul
Carver County Jail
Chaska, Minnesota

April 15–17, 2014

COMPLIANCE INSPECTION
CARVER COUNTY JAIL
ERO ST. PAUL FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................2
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................8
ICE 2000 NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................9
Access to Legal Material ...................................................................................................10
Admission and Release ......................................................................................................11
Detainee Classification System..........................................................................................12
Detainee Grievance Procedures .........................................................................................13
Environmental Health and Safety ......................................................................................16
Funds and Personal Property .............................................................................................18
Medical Care ......................................................................................................................19
Special Management Unit – Disciplinary Segregation ......................................................24
Staff-Detainee Communication .........................................................................................25
Telephone Access ..............................................................................................................27
Terminal Illness, Advanced Directives and Death ............................................................30
Use of Force .......................................................................................................................31
Visitation ............................................................................................................................33

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.

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INSPECTION TEAM MEMBERS

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

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Management Program Analyst (Team Lead) ODO
ODO
Inspections & Compliance Specialist
Special Agent
ODO
Special Agent
ODO
Contractor
Creative Corrections
Contractor
Creative Corrections
Contractor
Creative Corrections

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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Carver County Jail (CCJ) in Chaska, Minnesota,
from April 15 to 17, 2014. CCJ, which opened in 1995, is owned and operated by the County of
Carver, Minnesota. ERO began housing detainees at CCJ in 1993 under an Intergovernmental
Service Agreement. 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. This inspection
evaluated CCJ’s compliance with the
2000 NDS.
Capacity and Population Statistics

The ERO Field Office
Director (FOD), in Saint Paul,
Minnesota, is responsible for
ensuring facility compliance with the
2000 NDS and ICE policies. (b)(7)e
ERO staff is assigned to oversee
detention functions at CCJ. There is
no ERO Detention Service Manager
(DSM) assigned to CCJ.

Quantity

Total Bed Capacity

99

ICE Detainee Bed Capacity

30

Average Daily Population

80

Average ICE Detainee Population

26

Average Length of Stay (Days)

17

Male Detainee Population (as of 04/15/14)

26

Female Detainee Population (as of 04/15/14)

5

The Jail Administrator and Assistant Jail Administrator are responsible for oversight of daily
facility operations and are supported by(b)(7)estaff. Aramark provides food services and the
County of Carver provides medical services. The facility holds no accreditations.
This inspection represented ODO’s first visit to CCJ. During this inspection, ODO reviewed 18
standards and found CCJ compliant with five. ODO found a total of 26 deficiencies, in the
following 13 standards: Access to Legal Material (1 deficiency), Admission and Release (2),
Detainee Classification System (1), Detainee Grievance Procedures (5), Environmental Health
and Safety (1), Funds and Personal Property (1), Medical Care (4), Special Management Unit –
Disciplinary Segregation (1), Staff-Detainee Communication (2), Telephone Access (4),
Terminal Illness, Advanced Directives and Death (1), Use of Force (2) and Visitation (1). ODO
made five recommendations 1 regarding facility policy and procedures.
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 these deficiencies with CCJ and ICE staff during the
inspection and at a closeout briefing conducted on April 17, 2014.
Detainees entering CCJ are initially processed and classified through the ERO Saint Paul Field
Office. ERO issues detainees the ICE National Detainee Handbook. Upon arrival to CCJ, CCJ
staff conducts a second classification assessment and issues clothing, towels, bedding and some
hygiene items to the detainees. Detailed medical, mental health and sexual abuse screenings are
performed during the intake process. A facility handbook and video orientation are provided in
both English and Spanish languages. ODO found CCJ does not replenish hygiene items for all
detainees and ERO does not consistently provide risk classification assessments to assist CCJ
1

Recommendations will be annotated in the report as “R.”

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management. Further all detainees are strip searched upon entrance, and again each time they
depart from and return to the facility.
The facility handbook, last revised April 15, 2012, describes the facility rules, regulations,
services and programs available to detainees. English and Spanish versions of the facility
handbook are provided to all newly arriving detainees. Detainee property is logged and
documented on a personal property form and stored in a secure area. Funds are secured in a lock
box until they are deposited into the detainee’s commissary account. CCJ conducts quarterly
inventory audits of all detainee property. CCJ’s facility handbook lacks policies and procedures
concerning the retention, storage, and claiming of personal property.
Detainees are provided access to legal material via a computer on a mobile cart. The computer
contained a current version of LexisNexis and word-processing software at the time of the
inspection. Detainees, including those in special management units (SMU), are afforded a
minimum of five hours of law library time weekly. The facility handbook lacks required notices,
such as the hours of access and the procedures for requesting access, additional time, reference
materials, and how to notify staff of missing or damaged material.
The grievance system at CCJ allows detainees to file informal, formal and emergency
grievances; however, the following issues were identified with regard to grievances:1) CCJ does
not maintain a grievance log; 2) detainees are required to first resolve grievances with the
detention officer on duty; 3) ERO is not notified of staff misconduct allegations; 4) grievances
are not maintained in detention files; 5) detainees are not informed of the procedure for filing
grievances or appeals; 6) detainees are not informed of how to contact ICE to appeal decisions;
7) detainees are not notified of the prohibition on retaliation for filing a grievance; and 8)
detainees are not informed they are allowed to file complaints involving officer misconduct.
ODO recommends ERO carefully monitor all detainee requests and grievances at CCJ for an
appropriate amount of time to ensure CCJ staff are providing appropriate responses.
Facility sanitation was very good at the time of the inspection. Chemicals used in the facility
were listed in Material Safety Data Sheets and a listing of emergency phone numbers was readily
available. Documentation of receipt by the local fire department was on file. ODO confirmed
running inventories of hazardous substances were accurate. Medical sharps are inventoried each
shift. ODO inspected the inventories and found them accurate. CCJ does not have a dedicated
room for barbering; instead, barbering is conducted in the waiting area of the receiving section
when not in use for intake processing.
Local policy requires the notification of ICE in the case of any detainee hunger strike or refusal
of care for hunger striking detainees. The policy addresses routine medical procedures for
hunger strikes including medical and management evaluations.
CCJ does not have a clinical director. The Assistant Jail Administrator provides administrative
supervision of non-clinical functions. (b)(7)e registered nurse (RN) staffs the medical department
from 8 a.m. to 4:30 p.m., Monday through Friday. An additional RN, who was recently hired,
was receiving orientation and training during the course of this inspection. The facility
contracted with a community physician to provide “off-site” consultation services. Mental

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health services are provided at the First Street Center or the Carver County Crisis Center. The
facility transports any detainee needing dental care to a local dentist’s office.
Detainees receive intake screenings by trained deputies within 12 hours of arrival. An RN
performs health appraisals, to include hands-on physical examinations and dental screenings.
Health appraisals are not reviewed and signed by the physician. Sick call forms are not sealed or
deposited in locked boxes and CCJ requires detainees to sign a release at intake authorizing the
release of medical information to all jail employees.
ODO recommends CCJ notify the Jail Administrator if a special needs detainee arrives at the
facility; notify its medical staff of the impending release or transfer of a detainee as soon as
possible to facilitate the preparation of medical transfer summaries and medications; and address
the issue of untrained correctional staff delivering medical treatment in lieu of licensed medical
professionals after hours and on weekends.
Written procedures govern placement of detainees in administrative or disciplinary segregation.
No detainees were in administrative or disciplinary segregation during the inspection. Thirteen
detainees received disciplinary segregation during the 12 months preceding the inspection.
CCJ’s SMU consists of eight single-capacity cells within a double-tiered housing unit. Cells
contain a bunk, a toilet/sink combination unit, and a desk and stool fixture, and were found to be
well ventilated, adequately lit, appropriately heated and in good sanitary condition. CCJ’s SMU
housing log includes all events and activities that occur on the post. Entries are inconsistent and
unspecific. To improve record-keeping and support compliance with the NDS in the event of
future assignments to disciplinary or administrative segregation, ODO recommends CCJ
implement separate SMU housing records patterned after ICE Form I-888.
ODO reviewed the facility’s policy on suicide prevention and intervention. ODO confirmed
facility policy addresses requirements of the NDS. CCJ confirmed there have been no suicide
attempts or suicide watches during the 12 months preceding this inspection. Detainees are
screened for suicide risk during intake screening, and procedures are in place for referral to
medical staff for evaluation. Inspection of the cells used for suicide watch found them free of
any elements which could facilitate a suicide attempt. The cells are monitored by camera.
According to policy, officers are required to make and document monitoring checks every 15
minutes.
ODO evaluated CCJ’s sexual abuse and assault prevention and intervention program. CCJ was
not contractually required to comply with the 2011 Sexual Abuse and Assault Prevention and
Intervention (SAAPI) standard at the time of the inspection; however, ODO documented any
efforts by the facility to comply with the standard’s requirements. The Assistant Jail
Administrator has been assigned the responsibility to implement a program that will comply with
the Prison Rape Elimination Act (PREA). ODO confirmed that new staff, contractors and
volunteers receive PREA training during orientation. Detainees are provided information by
way of the facility handbook regarding sexual misconduct and how to report it. ODO observed
postings in the housing unit and booking areas regarding the facility’s zero tolerance for sexual
assault and abuse, and how to report it. Detainees are asked about any history of sexual abuse
during the intake process. According to CCJ leadership, no incidents or allegations of sexual
abuse occurred during the 12 months preceding this inspection.
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ERO staff conducts weekly scheduled and monthly unscheduled visits to CCJ. Detainees have
the opportunity to submit written questions, requests or concerns to ERO using a CCJ request
form available in English and Spanish. No locked boxes specifically for ICE requests exist in
any of the housing units. CCJ does not have written procedures to route detainee requests to the
appropriate ICE official, and does not provide envelopes to prevent requests from being read,
altered or delayed. Completed detainee request forms are not maintained in detention files.
Telephones were continuously turned off throughout the day during the inspection. CCJ staff
does not maintain any documentation demonstrating telephones are routinely checked and kept
in proper working order. The facility handbook states calls to attorneys are limited to 15
minutes, which is fewer than the 20 minutes required by the NDS. The procedure for making an
unmonitored call was not posted in the housing units or in the SMU.
CCJ does not accept detainees who are known to be terminally ill with a life expectancy of less
than six months, or who have a known advanced directive. The nursing protocol states the
facility does not honor “Do Not Resuscitate” orders and will apply full life-saving measures in
emergency medical situations. However, there is no corresponding reference in facility policy or
other documentation reflecting review and approval by the Jail Administrator.
CCJ policy on use-of-force does not distinguish between immediate and calculated use-of-force
situations. The policy does not address confrontation avoidance, the use-of-force continuum,
forced cell moves, application of restraints, and after-action reviews. CCJ does not have
handheld audio video recording equipment for calculated use-of-force incidents, instead relying
on stationary security cameras located throughout the facility. According to facility staff, no
calculated use-of-force incidents involving ICE detainees occurred in the 12 months preceding
the inspection. A search of the Joint Integrity Case Management System shows no calculated
use-of-force incidents were reported for the same period.
Detainees have general visiting privileges three days weekly for two hours. The facility offers
non-contact visits for general visitors and contact visits for attorneys. Detainees are notified of
visitation rules and hours by way of the facility handbook and postings in the housing units. CCJ
does not maintain a log of all general visitors and a separate log for legal visits.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 30 randomly-selected detainees (12 Level I males, 13 Level II males, and 5
Level II females) regarding conditions of detention at CCJ. Interview participation was
voluntary and none of the detainees expressed allegations of abuse, discrimination or
mistreatment. Each detainee confirmed receipt of the ICE National Detainee Handbook and the
facility handbook, which are available in English and Spanish.
All detainees stated they received personal hygiene items when they arrived at admission. ODO
confirmed personal hygiene supplies are replenished only for indigent detainees. All detainees
expressed satisfaction with the medical care and food service provided. One male detainee
complained of a toothache and alleged that he had not received any medication. ODO reviewed
the detainee’s medical file and found he was seen and treated by a medical provider.
All detainees stated they have access to the grievance system, recreation, religious services and
visitation by family members and ERO.

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 NDS and found CCJ fully compliant with the following
five standards:
1.
2.
3.
4.
5.

Detainee Handbook
Food Service
Hunger Strikes
Special Management Unit – Administrative Segregation
Suicide Prevention and Intervention

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 26 deficiencies in the following 13 standards.
1. Access to Legal Material
2. Admission and Release
3. Detainee Classification System
4. Detainee Grievance Procedures
5. Environmental Health and Safety
6. Funds and Personal Property
7. Medical Care
8. Special Management Unit – Disciplinary Segregation
9. Staff-Detainee Communication
10. Telephone Access
11. Terminal Illness, Advanced Directives, and Death
12. Use of Force
13. Visitation
Findings for these standards are presented in the remainder of this report.

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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at CCJ 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.
The detainee housing units have dedicated rooms for the law library. Each room is well-lit, has
sufficient furnishings, and is equipped with adequate equipment and supplies to support legal
research and case preparation. The facility has one computer, located on a mobile cart, which is
moved from one of the dedicated law library spaces to another when requested to be used by a
detainee. The mobile cart also includes a printer and various supplies for case preparation.
During the inspection, the computer contained a current version of LexisNexis and wordprocessing 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 completed form. The law library cart is
moved to the corresponding housing unit as requests are submitted. Detainees are afforded a
minimum of five hours per week during designated library hours every day between 7:30a.m.and
10:30 p.m. Additional time is available upon request. CCJ policy affords the same law library
privileges to detainees in special management units.
Illiterate and limited English proficient detainees may receive assistance with their legal
paperwork from detainees with appropriate language, reading and writing abilities, as needed.
Indigent detainees are provided with free envelopes, stamps, notary services and certified mail
services for legal matters.
The facility handbook informs detainees the law library is available for use, but does not include
the following: scheduled hours of access; the procedure for requesting access; the procedure for
requesting additional time; the procedure for requesting legal reference materials not maintained
in the law library; and the procedure for notifying a designated employee that library material is
missing or damaged (Deficiency ALM-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE 2000 NDS, Access to Legal Material, section (III)(Q)(2)(3)(4)(5)(6)
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:
2. the scheduled hours of access to the law library;
3. the procedure for requesting access to the law library;
4. the procedure for requesting additional time in the law library (beyond the 5 hours per
week minimum);
5. the procedure for requesting legal reference materials not maintained in the law library;
and
6. the procedure for notifying a designated employee that library material is missing or
damaged.”
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ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at CCJ to determine if procedures are in
place to protect the health, safety, security and welfare of each person during the admission and
release process, in accordance with the ICE NDS. ODO reviewed policies, procedures, and the
detainee handbook, inspected detention files, interviewed staff and detainees, and observed the
intake process and viewed the orientation video.
Upon arrival to CCJ, detainees undergo screenings and receive a personal property receipt,
hygiene items, clothing, towels and bedding. CCJ staff complete an observation questionnaire
and medical staff complete required follow-up evaluations depending on questionnaire
responses. The facility handbook is available in English and Spanish. Facility staff provides
new detainees a 30-minute orientation on the rules and regulations, and on programs and
activities available. Afterwards, detainees are afforded an opportunity to ask questions. An
orientation video in English and Spanish is broadcast in the housing units each morning.
All detainees are strip searched upon entrance, and again each time they depart from and return
to the facility. None of the 30 detention files reviewed by ODO contained documentation
supporting a strip search based on reasonable suspicion (Deficiency AR-1).
The facility handbook states detainees will only be provided an initial issuance of hygiene items,
which includes one deodorant, soap, toothpaste, toothbrush and shampoo, a comb and razor upon
request. ODO confirmed through staff and detainee interviews that personal hygiene supplies
are only replenished for indigent detainees (Deficiency AR-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
Change Notice Admission and Release-National Detention Standard Strip Search Policy, dated
October 15, 2007, states, “Facilities are reminded that strip searches, cavity searches, monitored
changes of clothing, monitored showering, and other required exposure of the private parts of a
detainee’s body for the purpose of searching for contraband are prohibited, absent reasonable
suspicion of contraband possession. Facilities may use less intrusive means to detect contraband,
such as clothed pat searches, intake questioning, X-rays, and metal detectors. If information
developed during admissions processing supports reasonable suspicion for a full search, the
information supporting that suspicion should be documented in detail on Form G-1025, Record
of Search.”
DEFICIENCY AR-2
In accordance with the ICE 2000 NDS, Admission and Release, section (III)(G), the FOD must
ensure, “Staff shall provide male and female detainees with the items of personal hygiene
appropriate for, respectively, men and women. They will replenish supplies as needed.”

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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System standard at CCJ to determine if there is a
requirement for a formal classification process for managing and separating detainees based on
verifiable and documented data, in accordance with the ICE NDS. ODO interviewed staff, and
reviewed policy, housing unit rosters, and detainee files.
ERO does not consistently provide risk classification assessments to assist CCJ management
with classification of detainees. A review of 30 detention files confirmed only nine contained
the required documentation from ERO (Deficiency DCS-1). The facility initiated corrective
action during the inspection.
CCJ management classifies detainees as minimum, medium or maximum. A classification
officer runs criminal history checks using a state criminal history database to determine the
appropriate classification level for each detainee. Security classifications are reviewed by a
supervisor for accuracy and completeness. CCJ maintains a daily detainee behavior log, which is
reviewed daily by a classification officer. The facility handbook contains information regarding
appeals of security classifications by submitting a formal grievance.
ODO did not identify any misclassified detainees. No Level III detainees were housed at CCJ at
time of inspection. ODO observed ERO provide CCJ management with a Record of
Deportable/Inadmissible Alien, Form I-213, for each detainee currently housed at the facility.
ODO confirmed all detainees had been appropriately classified.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE 2000 NDS, Detainee Classification System, section (III)(D), the
FOD must ensure, “INS [ICE] offices shall provide non-INS [ICE] facilities with the necessary
information for the facility to classify INS [ICE] detainees.”

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DETAINEE GRIEVANCE PROCEDURE (DGP)
ODO reviewed the Detainee Grievance Procedure standard at CCJ to determine if a process to
submit formal or emergency grievances exists, and to determine if 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 CCJ allows detainees to file informal, formal and emergency
grievances; however, CCJ requires detainees to first attempt to resolve all grievances with the
detention officer on duty before proceeding to the formal process (Deficiency DGP-1).
Grievance forms are available upon request from a staff officer in the housing units and
detainees may obtain assistance from another detainee or facility staff in preparing a grievance.
The facility has a policy for identifying and handling emergency grievances and has established a
grievance committee
Twenty-seven grievances and requests were filed by detainees in the 12 months preceding the
inspection. ODO reviewed all 27 grievances and requests, and identified a number of
deficiencies and concerns. First, two grievances alleging officer misconduct were not forwarded
to ICE (Deficiency DGP-2). ODO informed ERO of these two grievances during the course of
the inspection. Second, the responses provided by CCJ staff to several grievances and requests
were inappropriate based on the facts provided. Below are five examples:
Subject of grievance or request
1. Two separate detainees alleged
misconduct by one female officer.
2. Detainee requested to speak with
his/her Deportation Officer.
3. Detainee requested information for
his/her upcoming court hearing.
4. Detainee requested to be moved to
another cell due to alleged harassment
and threats by a cellmate.
5. Detainee requested the telephone
number to a human rights organization.

Response by CCJ staff
The facility solicited a response from the
officer of “I am not harassing you” and
showed the response to the detainees.
CCJ denied the request. No further
explanation was provided on the form.
The request was never forwarded to ERO.
CCJ responded “no internet lookup for
offenders.” No other explanation was
provided on the form.
CCJ denied the request. No further
explanation was provided on the form.
CCJ denied the request because the call or
party was not considered legal in nature.

ODO recommends ERO carefully monitor all detainee requests and grievances at CCJ for an
appropriate amount of time to ensure CCJ staff are providing appropriate responses (R-1).
Responses should not discourage attorney-client communication, discourage communication
with ERO staff, create a contentious environment between detainees and staff, nor should they
create a potentially litigious situation for ICE.

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CCJ does not maintain a grievance log to document and track grievances filed by detainees
(Deficiency DGP-3). CCJ does not place a copy of its written responses to grievances in
detainee detention files (Deficiency DGP-4).
The facility handbook fails to provide detainees notice of the following requirements in the NDS:
1) procedure for filing a grievance and appeal; 2) the right to have the grievance referred to
higher levels; 3) the procedure for contacting ICE to appeal a decision of the OIC; 4) the policy
prohibiting staff from retaliating against any detainee for filing a grievance; and 5) the
opportunity to file a complaint about officer misconduct (Deficiency DGP-5).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(A)(2), the
FOD must ensure, “The OIC must allow the detainee to submit a formal , written grievance to
the facility’s grievance committee. The detainee may take this step because he/she is unsatisfied
with the outcome of the informal process, or because he/she decides to forgo the informal
procedures.”
DEFICIENCY DGP-2
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(F), the FOD
must ensure, “Staff must forward all detainee grievances containing allegations of officer
misconduct to a supervisor or higher-level official in the chain of command. CDF’s and IGSA
facilities must forward detainee grievances alleging officer misconduct to INS [ICE]. INS [ICE]
will investigate every allegation of officer misconduct.”
DEFICIENCY DGP-3
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(E), the
FOD must ensure, “Each facility will devise a method for documenting detainee grievances. At
a minimum, the facility will maintain a Detainee Grievance Log.”
DEFICIENCY DGP-4
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(E), the
FOD must ensure, “A copy of the grievance will remain in the detainee’s detention file for at
least three years. The facility will maintain that record for a minimum of three years and
subsequently, until the detainee leaves INS [ICE] custody.”
DEFICIENCY DGP-5
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(G), the
FOD must ensure, “The facility shall provide each detainee, upon admittance, a copy of the
detainee handbook or equivalent. The grievance section of the detainee handbook will provide
notice of the following:
1. The opportunity to file a grievance, both informal and formal.
2. The procedures for filing a grievance and appeal, including the availability of assistance
in preparing a grievance.

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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 INS [ICE]-OIC.
4. The procedures for contacting the INS [ICE] to appeal the decision of the OIC of a CDF
or an IGSA facility.
5. The policy prohibiting staff from harassing, disciplining, punishing or otherwise
retaliating against any detainee for filing a grievance.
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:
Department of Justice
P.O. Box 27606
Washington, DC 20038-7606”

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at CCJ 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, chemical
management, and fire drills.
During the tour, ODO found a high level of sanitation was maintained throughout the facility.
Chemicals used in the facility were listed in a master index, which includes Material Safety Data
Sheets (MSDS), emergency contact information, and documentation of periodic review for
accuracy. MSDS binders were also present in areas where substances are stored and used. ODO
confirmed running inventories of chemicals were accurate. During interviews, staff verbalized a
good understanding of proper storage and handling of all chemicals. No flammable or
combustible materials are stored in the facility.
CCJ has an extensive fire control plan which has been approved by the City of Chaska. ODO
reviewed documentation and confirmed monthly fire drills are conducted in each area of the
facility. The fire department conducts annual fire inspections. The most recent inspection
occurred on October 16, 2013, and no violations were recorded. In addition, inspection of the
fire suppression system by Ahern Fire Protection on September 23, 2013, certified its proper
functioning.
CCJ is on the city water and sewer system. Documentation reflects the water supply was
certified by the Minnesota Department of Public Health in June 2013. Emergency generators are
tested every other week for an hour, and Interstate Power Systems performs quarterly generator
inspections and maintenance. ODO verified CCJ contracts with Guardian Pest Solutions Inc., for
monthly and as-needed pest control inspections and eradication. There was no visible evidence
of rodent or pest infestation at the facility.
A review of documentation confirmed medical sharps and syringes are inventoried on each shift.
ODO’s inspection verified the inventories were accurate. Bio hazardous medical waste is
removed by Stericycle, a licensed transporter. Bloodborne pathogens protection and cleanup kits
were observed positioned in various locations in the facility and readily available for spills.
Due to space constraints, barbering is conducted in the waiting area of the receiving section
when not in use for intake processing (Deficiency EH&S-1). ODO found proper barbering
sanitation requirements were posted and observed in accordance with the standard, and running
water was accessible.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with ICE 2000 NDS, Environmental Health and Safety, section (III)(P)(1), the
FOD must ensure, “Sanitation of barber operations is of the utmost concern because of the
possible transfer of diseases through direct contact or by towels, combs, and clippers. Towels
must not be reused after use on one person. Instruments such as combs and clippers will not be
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used successively on detainees without proper cleaning and disinfecting. The following
standards will be adhered to:
1. The operation will be located in a separate room not used for any other purpose. The
floor will be smooth, nonabsorbent and easily cleaned. Walls and ceiling will be in good
repair and painted a light color. Artificial lighting of at least 50-foot candles will be
provided. Mechanical ventilation of 5 air changes per hour will be provided if there are
no operable windows to provide fresh air. At least one lavatory will be provided. Both
hot and cold water will be available, and the hot water will be capable of maintaining a
constant flow of water between 105 degrees and 120 degrees.”

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at CCJ to determine if controls are in
place to inventory, document, store, and safeguard detainees’ personal property, in accordance
with the ICE NDS. ODO toured the facility; reviewed local policies, the detainee handbook, and
detention files; interviewed staff; and inspected areas where detainee property and valuables are
stored.
Observation of the intake area and facility’s computer system confirmed personal property is
inventoried and entered electronically onto inventory forms. Forms are given to the detainee,
attached to the property bag, placed in the detention file and scanned into the electronic record.
Property bags are sealed, assigned a control number and secured in the property room, which is
under the direct supervision of the jail supervisor. Small valuables, such as jewelry, are
inventoried separately, placed in a plastic bag, and secured in a caged area inside a separate
locked section within the property room.
During intake, all funds are counted and verified in the presence of the detainee by two staff
members, noting the amount of funds on the intake form. U.S. currency is deposited into an
account for the detainee and is available for commissary purchases. Foreign currency is
inventoried and stored in locked cabinets in a designated locked room within the control center.
This area is under constant video monitoring and with limited access by facility staff. Any
balance for U.S. currency is returned by check to the detainee upon release, unless otherwise
requested by ERO. Review of 20 inactive detention files showed detainees signed for their funds
and property upon release.
CCJ’s facility handbook lacks policies and procedures concerning the retention, storage, and
claiming of personal property (Deficiency F&PP 1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE 2000 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:
1. Which items they may retain in their possession;
2. That, upon request, they will be provided an INS [ICE]-certified copy of any identity
document (passport, birth certificate, etc.) placed in their A-files:
3. The rules for storing or mailing property not allowed in their possession
4. The procedure for claiming property upon release, transfer, or removal;
5. The procedures for filing a claim for lost or damaged property.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at CCJ 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 areas where medical services are provided, reviewed the policies
and procedures, and examined detainee medical records. Interviews were conducted with
nursing staff, the administrative sergeant, the Assistant Jail Administrator, and a housing unit
deputy.
CCJ did not hold any accreditations or have a clinical director at the time of the inspection. The
medical department was staffed with(b)(7)e RNs employed by the County of Carver. The (b)(7)eRN
provides coverage from 8 a.m. to 4:30 p.m., Monday through Friday. The (b)(7)e RN, who was
newly hired, was being trained in clinic operations during the inspection. The RNs at CCJ
maintain equal status and neither is designated as the administrative health authority. They did
not provide on-call coverage after hours or on weekends at the time of the inspection. Their
nursing licenses were current and documentation of primary source verification with the
Minnesota Board of Nursing was present. The Assistant Jail Administrator provides
administrative supervision of non-clinical functions.
A community physician was contracted by CCJ to provide “off-site” consultation services. The
physician’s December 11, 2012 contract states he is responsible for, “providing consultation
assistance and supervision of delegated medical functions to the jail medical unit staff, to ensure
appropriate medical advice for health services.” Designation as the clinical medical authority is
not specified in the contract. A copy of the physician’s license was not maintained at CCJ at the
time of the inspection. ODO received a copy via fax and confirmed current. The physician’s
Drug Enforcement Administration registration was also provided and confirmed current.
According to the RN, the physician may request detainees be brought to his office for in-person
evaluation.
Mental health services are provided at the First Street Center or the Carver County Crisis Center,
the latter of which conducts tele-psychology visits with detainees requiring mental health
evaluation and follow up.
Detainees needing dental care are transported off-site to the dentist’s office. Medical care
beyond the scope of services available at CCJ is provided at the Ridgeview Medical Center,
Two-Twelve Medical Building, or St. Francis Regional Medical Center.
According to the RN, the Ridgeview Medical Center ambulance service responds to medical
emergencies in less than five minutes.
The (b)(7)e RN reported medication ordering and renewals are generally conducted by faxing the
medication request with medical information such as history, blood pressure readings and vital
signs, to the doctor’s office for review and signature.
For pharmaceuticals, CCJ uses McKesson and a local pharmacy, Center Drug, which delivers
medications to the facility upon receipt of faxed prescriptions. ODO observed medications were
in blister packs with patient and drug information labeling.
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No chronic care conditions were documented in the medical records of the current detainee
population. Although ODO’s medical record review did not identify any detainees with special
needs, such as HIV or conditions requiring medical isolation, there is no procedure in place for
notification of the Jail Administrator. To support compliance with the NDS in any future special
needs cases, ODO recommends development of a policy requiring notification of the Jail
Administrator (R-2).
CCJ has standing orders and nursing protocols on file, signed by the consultant physician in
November 2013. When asked for the protocols, the RN voiced uncertainty as to whether they
existed, but they were subsequently located. ODO’s medical record review confirmed that
documented nursing practice complied with the protocols and was within the scope of the RN’s
license. Throughout the inspection, the RN demonstrated a strong command of policies and
procedures.
The CCJ clinic consists of a nurses’ work area, which is encircled by an examination room, the
administrative sergeant’s office, and a locked storage area for medications and medical records.
Medical records are maintained in files stored in a rolling cart with detainee and inmate files
separated. Records of transferred and released detainees are stored in a locked cabinet in the
nurses’ work area. ODO’s inspection of the examination room found it is of adequate size to
perform basic examinations and provides for privacy of patient encounters. Two chairs located
outside the examination room for patient waiting. According to the (b)(7)e RN, a deputy remains
with detainees in the waiting area at all times. CCJ does not have a room with negative airflow
for respiratory isolation; therefore, detainees with possible infectious disease would be
transferred to the hospital.
Review of medical records for 23 current detainees confirmed intake screenings for all 23 were
completed within 12 hours of arrival. Intake screenings are conducted by deputies trained by the
RN. The screening form addresses medical history, medications, suicide risk, mental disabilities,
history and symptoms of tuberculosis (TB), substance abuse, and need for interpretation services.
Completed forms are reviewed by the RN when on duty or the next business day.
TB screening is conducted by way of chest X-rays performed by Professional Portable X-ray
Company, with reports provided by fax the same or next day. The medical record review
confirmed TB screening in accordance with the NDS.
Health appraisals, which include hands-on physical examinations and dental screenings, are
conducted by the RN. ODO confirmed RN training in performing health appraisals was
conducted by the physician in his office. In the review of the 23 medical records, ODO observed
documented health appraisals were conducted within seven days or less in five cases and within
eight to 14 days in 16 cases. The remaining two cases were new arrivals. None of the health
appraisals was reviewed and signed by the physician (Deficiency MC-1).
Based on interviews of staff, medical record documentation, and a review of policies and CCJ’s
sick call request system, ODO determined there is a considerable level of involvement in
detainee health care by correctional staff. As allowed by the NDS, officers distribute
medications when there is no nursing coverage. The system described to ODO by a deputy
involves identifying detainees by photo comparison, administering the medication, and recording
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the administration or refusal on the medication administration record (MAR). A review of 20
MARs verified accurate completion and noted the detainee’s signature of receipt for each dose.
ODO confirmed deputies are trained in medication distribution by the RN.
In addition to bearing responsibility for after-hours and weekend administration of medication,
responsibility for assessing detainees’ medical complaints falls to correctional staff when nurses
are not on site. According to the administrative sergeant and RN, the on-duty sergeant contacts
the physician when necessary, and then verbally relays the complaint and clinical information
such as blood sugar test results and blood pressure readings.
Both the sergeant and RN reported telephone orders are accepted from the physician, to include
orders for prescription medication. The administrative sergeant contacted the physician and
carried out orders many times over the past five years, including some for prescription
medication. He stated he carefully records the orders and reads them back to ensure accuracy.
ODO reviewed email messages in two detainee medical records documenting after-hours
assessment of detainee complaints by a sergeant. In one case, a sergeant tested the blood sugar
of a diabetic detainee who complained of not feeling well. Finding it low, the sergeant contacted
the physician. The physician gave the sergeant instructions to give the detainee two glucose
tablets, and the sergeant followed those instructions. But the sergeant deferred acting on the
physician’s suggestion to change the standing insulin order, because the nurse would be back on
duty in the morning. In the second case, a sergeant took the blood pressure and vital signs of a
detainee having a pacemaker, but opted not to call the physician, instead referring the detainee
for evaluation by the nurse the next day. In an email to the nurse, the sergeant documented that
in making the determination, she reviewed the detainee’s medical record. ODO recommends
CCJ address the issue of untrained correctional staff delivering medical treatment in lieu of
licensed medical professionals after hours and on weekends (R-3).
Upon further inquiry, ODO learned all sergeants have access to detainees’ medical records. The
CCJ sick call process also allows correctional staff to access detainees’ medical information.
Sick call request forms, available in English and Spanish, are provided by the housing unit
deputy upon request. Detainees return completed forms to the officer, who forwards them to the
RN. The sick call forms are not sealed or deposited in locked boxes, and, according to the unit
deputy, he has full access to them (Deficiency MC-2).
Detainees sign a statement at intake authorizing the release of medical information to all facility
staff. Requiring detainees to sign these statements and allowing non-medical staff to access
medical records and sick call requests does not safeguard the privacy of detainees’ medical
information (previously cited as Deficiency MC-2).
Officer involvement in healthcare is codified in policy and nursing protocols. Per CCJ Work
Rule 6619, Prescription Medication, in the absence of a nurse, deputies are responsible for
verifying prescription medication brought in with detainees, by calling the prescribing pharmacy
or physician, or using internet sites Drugs.com or webMD.com. The related nursing protocol
states that after-hours correctional staff is responsible for ensuring prescriptions brought into the
facility are verified and administered in a timely manner.

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The nursing protocol addressing treatment of 20 non-acute medical conditions states the nurse
may delegate related nursing functions to correctional staff. Included in the conditions listed in
the protocol are gastrointestinal discomfort, scabies, crabs, hemorrhoid discomfort, vaginal yeast
infection, and sore throat. However, the only delegated functions found documented during the
inspection were blood pressure monitoring and blood glucose testing.
Although policies and nursing protocols repeatedly refer to “health-trained” deputies, ODO’s
review of training records found no documentation of specialized medical training for CCJ
correctional staff, except in intake screening and medication distribution, as previously noted.
According to the sergeant, (b)(7)ecorrectional staff member did have previous training as an
Emergency Medical Technician. Based on the extent to which health care responsibilities are
provided by non-medical staff in practice and per policy and protocol, ODO found the current
medical staffing plan insufficient (Deficiency MC-3).
According to the Jail Administrator, Language Line Solutions is used for language interpretation,
and the intake screening form includes a question concerning the need for language assistance.
However, in the previously referenced case, where a sergeant assessed the complaint of a
detainee with a pacemaker, she documented interpretation assistance was provided by an inmate.
No documentation was presented to confirm the inmate’s proficiency and reliability were
assessed or that the detainee consented to the use of an inmate as an interpreter (Deficiency MC4).
During review of the 23 medical files, ODO found they all contained signed consent statements
specific to each medical procedure and examination performed, including a chest X-ray and a
14-day health appraisal. Though the facility’s policy requires obtaining blanket consent for
treatment at the time of intake, the Assistant Jail Administrator stated procedures for obtaining
blanket consent have not been implemented. The nursing protocol, which is inconsistent with
the policy, maintains instruction for obtaining individual consent for each procedure and
examination.
Automated external defibrillators (AED) and emergency first aid bags were located in the
housing units, booking area, and medical department, with monthly checks documented by a
sergeant. Review of the training logs of(b)(7)eofficers and the RN confirmed all were current in
cardiopulmonary resuscitation, AED, and first-aid training.
During the review of procedures for release or transfer of detainees, ODO verified medical
transfer summaries for six detainees scheduled for departure were prepared, placed in sealed
envelopes, and labeled as required by the NDS. The RN reported she is sometimes provided late
notification of scheduled discharges, challenging her ability to prepare medical transfer
summaries and medication. She always manages to complete them, though doing so has, on
occasion, delayed performance of other nursing functions. ODO identified no records of prior
detainees that did not contain transfer summaries; however, ODO recommends CCJ ensure
earliest possible notification of detainee release or transfer (R-4).

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE 2000 NDS, Medical Care, section (III)(D), the FOD must ensure,
“Health appraisals will be performed according to NCCHC [National Commission on
Correctional Health Care] and JCAHO [Joint Commission] standards.” In accordance with
National Commission on Correctional Health Care standard J-E-04, section (2)(d)(ii), “The
hands-on portion of the health assessment may be performed by an RN only when the nurse
completes appropriate that is approved or provided by the responsible physician. (All findings
are reviewed by a physician when the RN completes the physical.”
DEFICIENCY MC-2
In accordance with ICE 2000 NDS, Medical Care, section (III)(M), the FOD must ensure, “All
medical providers protect the privacy of detainees’ medical information to the extent possible
while permitting the exchange of health information required to fulfill program responsibilities
and to provide for the wellbeing of detainees.”
DEFICIENCY MC-3
In accordance with ICE 2000 NDS, Medical Care, section (III)(A), the FOD must ensure, “All
facilities will employ, at a minimum, a medical staff large enough to perform basic exams and
treatments for all detainees.”
DEFICIENCY MC-4
In accordance with ICE 2000 NDS, Medical Care, section (III)(D), the FOD must ensure, “If
language difficulties prevent the health care provider/officer from sufficiently communicating
with the detainee for purposes of completing the medical screening, the officer shall obtain
translation assistance. Such assistance may be provided by another officer or by a professional
service, such as a telephone translation service. In some cases, other detainees may be used for
translation assistance if they are proficient and reliable and the detainee being medically
screened consents.”

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SPECIAL MANAGEMENT UNIT (SMU) - DISCIPLINARY
SEGREGATION
ODO reviewed the Special Management Unit (SMU) – Disciplinary Segregation standard at CCJ
to determine if the facility has procedures in place to temporarily segregate detainees for
disciplinary reasons, in accordance with the ICE NDS. ODO toured the facility, interviewed
staff, and reviewed policies and available documentation.
CCJ’s SMU consists of eight single-capacity cells within a double-tiered housing unit. Four of
the cells are on the upper tier, and four cells and a dayroom are on the lower tier. Cells contain a
bunk, a toilet/sink combination unit, and a desk and stool fixture. The cells were well ventilated,
adequately lit, appropriately heated and in good sanitary condition at the time of the inspection.
The SMU is supervised by a deputy, who is also responsible for supervising the adjacent generalpopulation housing unit.
ODO verified disciplinary segregation placement may only occur through the disciplinary
system. Facility policy addresses segregation orders, status reviews, and the basic living
conditions required by the standard, including medical rounds, and access to legal materials,
telephones, visiting, recreation, commissary, mail, religious services, clothing and bedding
exchange, and hygiene items.
No detainees were in disciplinary segregation at the time of the inspection. Thirteen detainees
received disciplinary segregation sanctions in the 12 months preceding the inspection, seven of
whom served 30 days. Disciplinary segregation orders were issued and status reviews were
conducted; however, ODO could not verify the detainees received the services, privileges and
access to activities required by the NDS. Though the written policy specifies segregation
conditions consistent with the standard, CCJ does not maintain individual housing records
documenting fulfillment of these requirements. Instead of detainee-specific SMU housing
records, all events and activities that occur on the post are recorded on the post-activity log by
the deputy. Activity log entries were unspecific, free-form, inconsistent and in sequential order
as events occur. For example, an officer documented the number of meals served in segregation
and that one meal was declined; however, the officer failed to record which detainees accepted or
refused the meal. Likewise, inconsistent entries existed for acceptance or refusal of showers and
recreation. The permanent post activity log did not adequately record all activities for the
detainees assigned to disciplinary segregation (Deficiency SMU DS-1). To improve recordkeeping and support compliance with the NDS, ODO recommends the facility implement
separate SMU housing records patterned after ICE Form I-888 (R-5).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU DS-1
In accordance with the ICE 2000 NDS, Special Management Unit – Disciplinary Segregation,
section (III)(E)(1), the FOD must ensure, “A permanent log will be maintained in the SMU. The
log will note all activities concerning the SMU detainees, e.g., meals served, recreation, visitors,
etc.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at CCJ 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 interviewed staff and detainees,
toured and observed housing units, and reviewed ERO logbooks and the Facility Liaison Visit
Checklists.
ERO St. Paul Field Office has a local policy and procedure in place to ensure visitation to the
facility by supervisory and non-supervisory ERO staff. ODO verified regular unannounced
visits are conducted and documented by interviews with CCJ staff and review of logbooks. (b)(7)e
ERO staff is assigned to the facility to conduct weekly scheduled visits and to address detainee
concerns. ODO confirmed through staff and detainee interviews that an Supervisory Detention
and Deportation Officer conducts regular, monthly unscheduled visits to monitor detention
conditions, and to address inquiries and requests from detainees. ERO visitation schedules are
conspicuously posted in English and Spanish languages in each housing unit, including the
special management units. ODO visited three housing units and the special management units,
and confirmed each housing unit had a logbook to document ICE visits.
Scheduled visits by ERO occur on Thursdays and Fridays, and notices are posted in the detainee
living areas and other areas with detainee access. These visits are documented on Facility
Liaison Visit Checklists maintained at the ERO St. Paul Field Office, and in the facility visitation
logbook.
Detainees have opportunities to communicate with ERO and CCJ staff regularly. Detainees have
direct access to request forms in each housing unit. Request forms are available in English and
Spanish. The CCJ Inmate Request Form is used by ICE detainees to submit questions, requests,
and concerns to ICE or facility staff. CCJ does not have lockboxes specifically for ICE requests
in any of the housing units; therefore, any ICE requests are submitted directly to a housing unit
officer. The housing unit officers read all written requests regardless of subject matter, which
does not comply with the NDS. CCJ does not have written procedures to route detainee requests
to ICE staff (Deficiency SDC-1).
ODO reviewed 60 detainee request forms from November 2013 through April 2014. Fifty forms
involved immigration proceedings; ten involved visitation. ODO found completed copies of the
forms are not maintained in detention files (Deficiency SDC-2). All detainee request forms to
CCJ staff were addressed immediately upon receipt, logged, and responded to within 72 hours.
Maintaining a record of the requests allows CCJ management to accurately monitor the request
process.
ODO verified ICE staff are conducting, documenting, and maintaining the weekly telephone
serviceability worksheets. The DHS OIG hotline posters are posted in all units housing ICE
detainees.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE 2000 NDS, Staff-Detainee Communication, section (III)(B), the
FOD must ensure, “All detainees shall have the opportunity to submit written questions,
requests, or concerns to ICE staff using the attached detainees request form, local IGSA form or
a sheet of paper. The OIC must ensure that adequate supplies of detainee requests and writing
implements are available. All facilities that house ICE detainees must have written procedures to
route detainee requests to the appropriate ICE official.”
DEFICIENCY SDC-2
In accordance with the ICE 2000 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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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at CCJ 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, conducted functionality tests of telephones in housing units, and reviewed policy,
procedures, and the detainee handbook.
Upon admission, detainees are provided a pin number enabling them to access the telephones
daily from 7 a.m. to 10 p.m. There is a minimum of one telephone for every 13 detainees, which
complies with the standard. Detainees are given emergency messages and allowed to return
emergency telephone calls without delay. The facility handbook contains telephone rules, and
detainees are required to sign for receipt of the handbook upon admission to the facility. The
telephone rules are posted in each housing unit where detainees can easily see them.
CCJ staff does not maintain any documentation demonstrating telephones are routinely checked
and kept in proper working order (Deficiency TA-1). ERO staff checks all telephones weekly.
ODO reviewed ERO Telephone Serviceability Worksheets for January 2014 through April 2014,
and found all were complete.
ODO reviewed five telephone maintenance/repair orders submitted during the 12 months
preceding the inspection, indicating past problems with the telephones. ODO tested the
operability of telephones during the inspection and identified a number of operability issues.
First, the DHS OIG number did not work upon testing. Second, the DHS Detainee Deportation
Duty Officer number was inoperable, resulting in detainees being unable to make direct calls to
local immigration courts, the Board of Immigration Appeals, Federal and State courts, legal
service providers, and government offices. Third, the instructions associated with the preprogrammed numbers to foreign consulates were incorrect (Deficiency TA-2). ERO and facility
staff attempted to address the issues during the inspection, but upon retest, the numbers still did
not work.
Facility policy permits detainees to make personal calls in the event of a family emergency, or
when the detainee can otherwise demonstrate a compelling need when they have been approved
and programmed into the telephone system. However, the facility handbook states attorney calls
are limited to a strict 15-minute time limit, which is fewer than the 20 minutes required by the
NDS (Deficiency TA-3).
All telephone calls made from the housing units are automatically recorded. Detainees may
obtain an unmonitored telephone call to an attorney or legal representative by submitting a
request. When and if approved, the number is programmed into the telephone system enabling
detainees to have an unmonitored call. The procedure for obtaining an unmonitored call to a
court, legal representative, or for the purpose of obtaining legal representation, is not posted on
or near any of the telephones in any of the housing units (Deficiency TA-4).

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE 2000 NDS, Telephone Access, section (III)(D), the FOD must
ensure, “The facility shall maintain detainee telephones in proper working order. Appropriate
facility staff shall inspect the telephones regularly, promptly report out-of-order telephones to the
repair service, and ensure that required repairs are completed quickly.
DEFICIENCY TA-2
In accordance with the ICE 2000 NDS, Telephone Access, section (III)(E), the FOD must
ensure, “Even if telephone service is generally limited to collect calls, the facility shall permit the
detainee to make direct calls:
1.
2.
3.
4.

To the local immigration court and the Board of Immigration Appeals;
To Federal and State courts where the detainee is or may become involved in a legal
proceeding;
To consular officials;
To legal service providers, in pursuit of legal representation or to engage in consolation
concerning his/her expedited removal case;
To a government office, to obtain documents relevant to his/her immigration case; and
In a personal or family emergency, or when the detainee can otherwise demonstrate a
compelling need (to be interpreted liberally).

5.
6.

If the limitations of its existing phone system will initially preclude the facility from meeting
these requirements, the OIC must report this to ICE. ICE will respond by providing some means
of access, e.g., cell phones into which facility staff can pre-program authorized numbers (in the
above categories) with all other numbers blocked. These phones will be maintained by on-site
ICE liaison officers or local officials, and must be provided in an environment that meets privacy
standards.
DEFICIENCY TA-3
In accordance with the ICE 2000 NDS, Telephone Access, section (III)(F), the FOD must ensure,
“The facility shall not restrict the number of calls a detainee places to his/her legal
representatives, nor limit the duration of such calls by rule or automatic cut-off, unless necessary
for security purposes or to maintain orderly and fair access to telephones. If time limits are
necessary for such calls, they shall be no shorter than 20 minutes, and the detainee shall be
allowed to continue the call if desired, at the first available opportunity.”
DEFICIENCY TA-4
In accordance with the ICE 2000 NDS, Telephone Access, section (III)(K), 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 the
equivalent provided upon admission. It shall also place a notice at each monitored telephone
stating:
1. that detainee calls are subject to monitoring; and

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2. the procedure for obtaining an unmonitored call to a court, legal representative, or for the
purposes of obtaining legal representation.”

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TERMINAL ILLNESS, ADVANCED DIRECTIVES, AND DEATH (TIADD)
ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not
Resuscitate orders and organ donations, at CCJ to determine if the facility’s policies and
practices are in accordance with the ICE NDS. ODO interviewed medical staff and reviewed
policies and procedures.
According to the nurse and nursing protocols signed by the consultant physician in November
2013, the facility does not accept detainees who are known to be terminally ill with a life
expectancy of less than six months, or who have a known advanced directive. The nursing
protocol also states the facility does not honor Do Not Resuscitate orders and will apply full
codes in emergency medical situations. Although Do Not Resuscitate orders were addressed in
the nursing protocol, there is no corresponding reference in facility policy, or documentation
reflecting review and approval by the Jail Administrator (Deficiency TIADD-1). Policies are in
place addressing other requirements of the NDS.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TIADD-1
In accordance with ICE 2000 NDS, Terminal Illness, Advance Directives, and Death, section
(III)(C), the FOD must ensure, “The facility establish and implement through written procedure,
policy governing DNR orders. The director and other members of the DIHS governing body
shall review and approve all policies before implementation.”

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USE OF FORCE (UOF)
ODO reviewed the Use of Force standard at CCJ to determine if necessary use of force is utilized
only after all reasonable efforts have been exhausted to gain control of a subject, while protecting
and ensuring the safety of detainees, staff and others, preventing serious property damage, and
ensuring the security and orderly operation of the facility, in accordance with the ICE NDS.
ODO toured the facility, inspected equipment, interviewed staff, and reviewed local policy and
training records.
According to CCJ staff, no calculated use-of-force incidents involving ICE detainees occurred in
the 12 months preceding the inspection. The facility’s use-of-force policy does not distinguish
between immediate and calculated use-of-force situations, the former requiring spontaneous
force to prevent a detainee from harming self or others; the latter allowing assessment and
possible resolution without resorting to force because no immediate threat is posed. In addition,
the policy does not address confrontation avoidance prior to using force, the procedures for
calculated force in the form of a cell extraction, and audiovisual recording of incidents. In fact,
CCJ does not have handheld audio/video recording equipment for use in calculated use-of-force
incidents, instead relying on stationary security cameras located throughout the facility.
Stationary cameras do not record audio and may not be properly positioned to capture all actions
taken during an incident, especially those occurring in cells. Deficiency is not cited for these
policy omissions because there were no use-of-force incidents wherein the requirements applied
(Deficiency UOF-1).
Their policy did not include a requirement for after-action review of use-of-force incidents
(previously cited as Deficiency UOF-1). Per the NDS, there must be written procedures
governing after-action reviews to assess the reasonableness of the actions taken. During an
interview with a sergeant and the Assistant Jail Administrator, ODO was informed allegations of
excessive or improper use of force are forwarded to the jail administration for investigation, but
after-action reviews of every use-of-force incident are not conducted.
Review of(b)(7)erandomly-selected staff training records confirmed current training in the use of
force. However, a review of the curriculum found it did not include the subject of confrontation
avoidance (Deficiency UOF-2). The NDS lists confrontation avoidance among the topics to be
covered in annual training.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF-1
In accordance with the ICE 2000 NDS, Use of Force, section (III)(K), the FOD must ensure,
“Written procedures shall govern the use-of-force incident review, whether calculated or
immediate, and the application of restraints. The review is to assess the reasonableness of the
actions taken (force proportional to the detainee's actions), etc. IGSA will pattern their incident
review process after INS [ICE]. INS [ICE] shall review and approve all After Action Review
procedures.”

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DEFICIENCY UOF-2
In accordance with the ICE 2000 NDS, Use of Force, section (III)(O), the FOD must ensure, “To
control a situation involving an aggressive detainee, all staff must be made aware of their
responsibilities through ongoing training. All detention personnel shall also be trained in
approved methods of self-defense, confrontation avoidance techniques, and the use of force to
control detainees. Staff will be made aware of prohibited use-of-force acts and techniques.
Specialized training shall be required for certain non-lethal equipment e.g. OC spray/electronic
devices. Staff members will receive annual training in confrontation-avoidance procedures and
forced cell-move techniques. Each staff member participating in a calculated use of force cell
move must have documentation of annual training in these areas.
Training should also cover use of force in special situations. Each officer must have be [sic]
specifically certified to use a given device.
Among other things, training shall include:
1.
2.
3.
4.
5.
6.

Communication techniques;
Cultural diversity;
Dealing with the mentally ill;
Confrontation-avoidance procedures;
Application of restraints (progressive and hard); and
Reporting procedures.”

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VISITATION (V)
ODO reviewed the Visitation standard at the CCJ to determine if authorized persons, including
legal and media representatives, are able to visit detainees within security and operational
constraints, in accordance with the ICE NDS.
Visiting procedures and hours are posted in the lobby main entrance area. Detainees are notified
of visitation rules and hours by way of the facility handbook and postings in the housing units.
Visitors are required to complete a non-contact visit form and present photo identification at the
main desk. After verification of identity, visitors pass through metal detectors before proceeding
to the visiting areas. CCJ has 12 visitation rooms and two are designated for legal visits. CCJ
does not maintain a log of all general visitors and a separate log for legal visits (Deficiency V-1).
The facility offers non-contact visits for general visitors and contact visits for attorneys.
Detainees have general visitation privileges Wednesdays, Saturdays and Sundays between 1 and
3 p.m., 3:30 and 4:30 p.m., in addition to Wednesday evenings between 6:30 p.m. and 9 p.m.
Legal visits are permitted seven days per week. Form G-28, Notice of Appearance, is available
in the front lobby.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY V-1
In accordance with the ICE 2000 NDS, Visitation, section (III)(C), the FOD must ensure, “The
facility shall maintain a log of all general visitors, and a separate log of legal visitors as described
below.”

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