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
Clay County Jail
Brazil, Indiana

February 3–5, 2015

COMPLIANCE INSPECTION
CLAY COUNTY JAIL
CHICAGO FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................2
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................8
ICE 2008 PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed……………………………………………………………9
Admission and Release ......................................................................................................10
Classification System .........................................................................................................11
Detainee Handbook ............................................................................................................13
Disciplinary System ...........................................................................................................14
Environmental Health and Safety ......................................................................................18
Food Service ......................................................................................................................21
Funds and Personal Property .............................................................................................23
Grievance System ..............................................................................................................25
Medical Care ......................................................................................................................26
Religious Practice ..............................................................................................................29
Sexual Abuse and Assault Prevention and Intervention ....................................................30
Special Management Units – Administrative/Disciplinary Segregation ...........................32
Staff-Detainee Communication .........................................................................................35
Staff Training .....................................................................................................................36
Telephone Access ..............................................................................................................38
Use of Force .......................................................................................................................40

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)
Inspections & Compliance Specialist
Inspections & Compliance Specialist
Inspections & Compliance Specialist
Contractor
Contractor
Contractor
Contractor
Contractor
Contractor

2

ODO
ODO
ODO
ODO
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections

Clay County Jail
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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Clay County Jail (CCJ) in Brazil, Indiana, from
February 3 to 5, 2015. CCJ, which opened in 2006, is owned by Clay County and operated by
the Clay County Sheriff’s Office. ERO began housing detainees at CCJ in August 2013 under an
Intergovernmental Service Agreement contract with 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 CCJ’s compliance with the 2008
PBNDS.
Capacity and Population Statistics

Quantity

Total Bed Capacity
176
The ERO Field Office
ICE Detainee Bed Capacity
65
Director (FOD), in Chicago, Illinois,
is responsible for ensuring facility
Average Daily Population
115
compliance with the 2008 PBNDS
Average ICE Detainee Population
49
and ICE policies. An Assistant Field
Average Length of Stay (Days)
21
Office Director (AFOD), a
Male Detainee Population Count (February 3, 2015)
50
Supervisory Detention and
Female Detainee Population Count
0
Deportation Officer (SDDO), and a
Deportation Officer/Detention
Standards Compliance Officer oversee daily ICE operations at CCJ. There is no ERO Detention
Service Manager assigned to the CCJ. CCJ had not signed a contract modification to comply
with the 2011 Sexual Abuse and Assault Prevention and Intervention (SAAPI) standard.

A Jail Commander is responsible for oversight of daily facility operations and is supported by (b)(7)e
sheriff deputies,
dispatch and(b)(7)eupport personnel. Clay County provides food services and
Quality Correctional Care provides medical services. CCJ holds no accreditations.
This inspection represented ODO’s first visit to CCJ. During this inspection ODO reviewed 18
PBNDS and found CCJ compliant with two standards. ODO found a total of 50 deficiencies,
nine of which relate to priority components,1 in the remaining 16 standards: Admission and
Release (2 deficiencies), Classification System (2), Detainee Handbook (2), Disciplinary
System (7), Environmental Health and Safety (7), Food Service (2), Funds and Personal
Property (1), Grievance System (1), Medical Care (5), Religious Practices (1), Sexual Abuse and
Assault Prevention and Intervention (1), Special Management Units (9), Staff-Detainee
Communication (1), Staff Training (2), Telephone Access (5), and Use of Force (2). ODO made
two recommendations2 regarding facility policy and procedures, cited one best practice3 in the
Medical Care standard and identified five opportunities where the facility initiated corrective
action4 during the course of the inspection.
This report details all deficiencies and refers to the specific, relevant sections of the 2008
PBNDS. ERO will be provided a copy of this report to assist in developing corrective actions to
1

Deficient priority components were found in the following five standards: Classification System (1), Detainee
Handbook (1), Disciplinary System (2), Medical Care (3), and Special Management Units (2).
2
Recommendations will be annotated in the report as “R.”
3
Best practices are annotated in this report as “BP.”
4
Corrective actions initiated by the facility are annoted in the report as “C”.

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resolve all identified deficiencies. ODO discussed preliminary findings with CCJ and ERO
management during the inspection and at a closeout briefing conducted on February 5, 2015.
Upon admission into CCJ, detainees are issued facility clothing, linens and personal hygiene
items. The facility handbook, which is available in English and Spanish, was not issued to all
detainees during admission. Changes to the handbook are made on an as-needed basis by the
facility, and CCJ does not have an appointed committee established to conduct annual reviews of
the handbook.
Classification of detainees at CCJ is conducted by ERO using the ICE Risk Classification
Assessment System. ODO identified four detainees assigned to disciplinary segregation had not
been reassessed before leaving segregation. ODO confirmed the detainee handbook contains
detailed explanations for each classification level and procedures for appealing classification
decisions. A review of the facility grievance log for the past year found no grievances were filed
regarding classification decisions.
Detainees arrive at CCJ with sealed plastic bags containing property inventoried by ERO field
office staff. The clothing worn by the detainee during admission is inventoried on a CCJ form
and secured in the detainee’s locker. Detainees sign the form, receive a copy and a copy is
placed in their file. Currency is processed by the facility ICE Coordinator. Foreign currency is
sealed in an envelope with the amount recorded on the front, then placed in a safe. Domestic
currency is placed in the detainee’s commissary account and a copy of the transaction is given to
the detainee. CCJ does not obtain a forwarding address from detainees for use in the event
forwarding of property or funds becomes necessary. The facility’s detainee handbook provides
procedures for filing a claim of lost or damaged property.
CCJ has a designated law library that is well-lit and adequately equipped. Detainees have access
to the law library a minimum of five hours per week, and can request additional time by
submitting a request to the library coordinator. Detainees housed in special management units
are afforded the same access to law library privileges as general population detainees. Writing
implements, paper and envelopes are provided by the facility to support a detainee’s legal
research and case preparation. All computers contained a current version of LexisNexis and
word-processing software.
The grievance system allows detainees to file informal, formal and emergency grievances. The
facility maintains a grievance log to track grievances filed by detainees. ODO reviewed the
grievance log and noted that, at the time of inspection, no grievances were filed within the last
six months. The detainee handbook provides a notice of the right to file medical grievances and
the opportunity to file a complaint directly to DHS/OIG in writing. CCJ’s policy does not
establish a procedure to file an emergency grievance.
ODO toured the facility and found sanitation in the facility was acceptable overall. ODO
determined CCJ does not have a facility-wide system in place for control of hazardous
substances. Except for the food service area, there were no current inventories, or material safety
data sheet (MSDS) files with locations and diagrams. The facility did not have a master index of
hazardous substances. ODO observed ice remover pellets being stored in an improperly marked
container. Weekly and monthly fire and safety inspections are completed. ODO’s review of the
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fire plan found it does not meet all requirements of the standard. The posted exit diagrams were
only in English and only identified the primary route of evacuation. The facility could not
produce documentation of quarterly fire drills for all areas.
The facility’s food service vendor does not require its employees to undergo a pre-employment
medical exam to test for communicable diseases. CCJ did not provide special menus for holiday
meals or evaluation by the registered dietitian for nutritional adequacy. ODO observed CCJ’s
satellite system. Prepared food items are placed on insulated trays then placed on carts for
delivery to housing units by inmate workers under officer supervision. Records for health
department inspections, pest control treatment, and storage and inventory of chemicals were
current. Sanitation of the kitchen, storage areas, and all equipment was excellent.
The health clinic is staffed 14 hours a day, Monday through Friday, by (b)(7)e egistered nurses.
Administrative oversight is provided by a company named Quality Correctional Care (QCC).
The designated clinical medical authority is an advanced practice registered nurse practitioner
who is on site once a week for four hours or more as needed. The nurse provides services under
the license of a physician. The physician is available for consultation and provides on call
services 24 hours a day, seven days a week. Mental health services are provided by a licensed
psychologist who visits CCJ on a bi-weekly basis and as needed. CCJ has a one-room clinic
which is adjacent to the booking area. There is a large window in the clinic door that is not
tinted or screened, which fails to provide detainees privacy during examinations. Review by the
clinical medical authority to assess priority for treatment was not documented in any of the
screening forms. Information on how to access medical care is addressed in the detainee
handbook. The sick call request form was available only in English. The medical records did
not document treatment plans addressing patient involvement and education, and scheduled
monitoring. ODO’s review of the medical records revealed no documented informed consent for
detainees on psychotropic medications. A photograph of each detainee is attached to the
medication administration records to facilitate detainee identification and reduce medication
errors. ODO cites this as a best practice. A total of 21 Medication Administration Records
(MARs) were reviewed, and all included clear documentation of medication distribution.
CCJ has a comprehensive written policy that provides for the prevention, reporting, and
investigation of sexual assaults. CCJ has a Lieutenant in charge of the SAAPI program. CCJ
employees, volunteers, and contractors participated in the annual SAAPI training, as required.
The intake process includes screening detainees for sexual abuse victimization history and
history of predatory behavior to identify potential sexual aggressors. Detainees are shown a
SAAPI orientation video at the time of admission into the facility. Detainees also are provided
with information on the SAAPI program through the facility handbook and postings located in
housing units. At the time of inspection, the facility reported no cases of sexual assault or abuse
within the last year. The facility does not have a tracking system in place to follow any SAAPI
incidents that may occur.
ODO reviewed the facility policy and training records, inspected the room used for housing
detainees on suicide watch, and interviewed medical and detention staff. ODO verified
screening for suicide risk occurs as part of intake screening by detention and medical staff.
Detainees determined to be at risk for suicide are housed and monitored in accordance with the

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standard. Monitoring is continuous and only a physician can discontinue a detainee on suicide
watch.
The facility operates a Special Management Unit (SMU) consisting of two tiers with four double
occupancy cells on each tier. The tiers may house detainees assigned to administrative
segregation or disciplinary segregation. ODO found the SMUs to be well ventilated, adequately
lit and maintained in a sanitary condition. The walls in all eight cells had graffiti. Some of the
graffiti was associated with known hate groups. Officers make rounds within the unit and the
officer rounds are electronically recorded by pushing sensors located at each end of the upper
and lower tiers. Rounds are made every hour instead of every 30 minutes as required by the
standard. There were no detainees in administrative or disciplinary segregation at the time of
inspection.
Five detainees were placed in administrative segregation during the year preceding the
inspection. Two of the five detainees were placed in administrative segregation for protective
custody. CCJ did not have justification documented for placing the detainees in protective
custody. Four detainees were placed in disciplinary segregation during the year preceding the
inspection. One of the four detainees placed in disciplinary segregation did not plead guilty and
did not waive his right to a hearing. The disciplinary segregation term was imposed by the
officer who witnessed the alleged rule violation and was approved by a supervisor. The detainee
was not afforded the rights and protections of the formal disciplinary process.
CCJ documents actions related to a detainee’s assignment to segregation, but detainees are not
provided a copy. ODO found incomplete or incorrect documentation of release information for
six detainees assigned to segregation in the year preceding the inspection. ODO’s review found
gaps in recorded information on the Special Management Unit Housing Record form. The forms
did not document daily visits by medical staff for two of the detainees assigned to disciplinary
segregation.
ICE staff makes weekly scheduled and unscheduled visits. Scheduled visit times and days are
posted in housing units. Visits are documented in the facility’s front entrance log books. Visits
by ERO non-supervisory staff are documented by facility liaison checklists, CCJ front entrance
log books and in the detainee housing unit log. ERO was unable to provide documentation for
detainee requests from December 2013 to January 2014. OIG informational posters are located
on a bulletin board in the detainee housing units and the SMU. ERO tests telephones weekly and
documents the results on a telephone serviceability worksheet.
The facility staff training coordinator for facility staff maintains electronic and hard copy
training files. The staff training coordinator did not have a documented facility training program.
Staff members authorized to use firearms and chemical agents were trained by certified
instructors. The staff training coordinator for healthcare is a licensed practical nurse in the state
of Indiana with an active license. The healthcare training coordinator did not have
documentation that training was administered to current staff members.
CCJ has a comprehensive use of force policy addressing confrontation avoidance, using force
only as a last resort, and reporting requirements when force is used. ODO reviewed staff training
records and found that jail staff are trained in the use of force and are certified in the use of
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oleoresin capsicum (OC) spray during pre-service and annual training. There are no records that
the OC spray canisters have been inspected. A review of facility’s post orders found
responsibility for inspection of chemical agents and related security equipment is not addressed.
CCJ does not have procedures in place addressing after action review of all use of force
incidents. There were no incidents involving use of force in the 12 months preceding the
inspection or grievances filed by detainees alleging use of force.
Detainees have regular access to telephones and can make calls for up to 20 minutes at a time.
There is no restriction on the number of calls made. Detainees housed in segregation have the
same telephone privileges as detainees in general population. The telephone availability ratio is
approximately four detainees per telephone. The telephones are not inspected daily by facility
staff. The facility’s phone system does not have a recorded message that advises detainees that
calls are subject to monitoring. The facility has one operational TTY device located in booking
and receiving, but does not offer privacy for the detainee. The facility did not have
accommodations for detainees with speech disabilities. ODO checked telephones in housing
units and reviewed ERO telephone serviceability worksheets to confirm that telephones are
operable and in good working order.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 25 randomly-selected male detainees (seven Level I; nine Level II; and nine
Level III) to assess the conditions of confinement at CCJ. There were no female detainees in
custody during the inspection. Interview participation was voluntary and none of the detainees
expressed allegations of abuse, discrimination or mistreatment. The majority of the detainees
reported being satisfied with the facility services, with the exception of one complaint regarding
a lack of access to medical care/medication. One detainee also alleged that the entire cell block
had been strip searched recently.
ODO reviewed facility logs and identified that the entire cell-block had been recently “patsearched” but that no detainee had ever been strip searched.
One of the detainees stated that medical care was not provided after communicating that he was
in pain. The detainee alleged he was not receiving needed medication for his gastritis.
An examination of the detainee’s medical treatment records revealed the facility was in the
process of seeking further information regarding the detainee’s alleged gastritis before providing
him with medication.
All of the detainees stated they know how to communicate or submit request forms to ICE
officials, and facility staff. ODO reviewed the sign-in logs at the front entrance of the facility
and verified that ERO visits the facility weekly.

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ICE 2008 PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 PBNDS and found CCJ fully compliant with the following two
standards:
1. Law Libraries and Legal Materials
2. 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 50 deficiencies in the following 16 standards.
1. Admission and Release
2. Classification System
3. Detainee Handbook
4. Disciplinary System
5. Environmental Health and Safety
6. Food Service
7. Funds and Personal Property
8. Grievance System
9. Medical Care
10. Religious Practices
11. Sexual Abuse and Assault Prevention and Intervention
12. Special Management Units
13. Staff Detainee Communication
14. Staff Training
15. Telephone Access
16. Use of Force and Restraints
Findings for these standards are presented in the remainder of this report.

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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 2008 PBNDS. ODO reviewed policies, procedures
and the detainee handbook, inspected detention files, interviewed staff, and toured the intake and
property area.
No detainees were admitted or released during the inspection. The facility has written policies
addressing admission and release procedures, including detainee searches and the inventory and
receipt of funds and property. According to policy, property and funds are processed by the CCJ
staff person designated as the ICE Coordinator. The facility ICE Coordinator issues clothing,
bedding, towels, and hygiene items, interviews the detainee, and applies the classification
determined by ERO prior to detainee arrival. Detainees are pat-searched, photographed and
fingerprinted by facility officers, and medical screening is completed. ODO verified facility
policy prohibits strip searches without reasonable suspicion that a detainee is secreting
contraband. Detainees are not allowed to shower during the intake process (Deficiency AR-1).
During interviews, detainees stated they were not issued the ICE National Detainee Handbook or
the facility’s handbook. ODO’s review of 25 randomly selected detainee files found none
contained signed statements acknowledging receipt of the handbooks (Deficiency AR-2). Staff
stated handbooks are issued during the intake process, but detainees are not required to sign
receipts. During the inspection, procedures were implemented requiring detainees to sign
receipts when handbooks are issued. ODO verified detainees view a PowerPoint orientation
presentation with audio in English and Spanish prior to transfer to their assigned housing unit.
With the exception of handbook receipts, ODO’s review of 25 current detainee files and ten files
of detainees who had been released, confirmed all contained required documentation.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
In accordance with the ICE 2008 PBNDS, Admission and Release, section (V)(B)(2), the FOD
must ensure, “Staff shall permit the detainee to change clothing and shower in a private room
without being visually observed by staff, unless there is reasonable suspicion to search the
detainee in accordance with the section on Strip Searches and the Detention Standard on
Searches of Detainees.”
DEFICIENCY AR-2
In accordance with the ICE 2008 PBNDS, Admission and Release, section (V)(G)(1), the FOD
must ensure, “In accordance with the Detention Standard on Detainee Handbook, every facility
shall issue to each newly admitted detainee a copy of the ICE National Detainee Handbook and
local supplement that fully describes all policies, procedures, and rules in effect at the facility.”

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CLASSIFICATION SYSTEM (CS)
ODO reviewed the Classification System standard at CCJ 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 2008 PBNDS. ODO toured the facility, interviewed staff, and
reviewed policy, the detainee handbook, housing roster, and detainee files.
Detainees arriving at CCJ were classified by ERO using the ICE Risk Classification Assessment
system (RCA). The RCA is an electronic system, which determines classification levels of low,
medium-low, medium-high, or high custody based on objective, detainee-specific data, including
criminal history. A review of the housing roster for February 3, 2015 found four detainees were
classified as low, 12 were medium-low, 22 were medium-high, and 12 were classified as high.
The roster showed low custody detainees were housed in J unit with medium-low and mediumhigh detainees. ODO’s review of the detention files of the medium-high detainees confirmed
they did not have a history of assaultive or combative behavior which would have prohibited
them from being commingled with low custody detainees.
ODO’s review of the housing roster also found high custody detainees were housed with
medium-high and medium-low detainees. ODO reviewed 25 randomly selected detention files.
The review revealed one detainee designated as medium-low on the roster was classified as low
on his RCA form. The detainee was housed in E unit with high classification detainees
(Deficiency CS-1).5 His rating was corrected and he was transferred to appropriate housing
when the error was brought to the attention of CCJ staff (C-1). ODO identified three other
detainees whose classifications on the roster did not match the classifications on their RCA
forms. The errors did not result in prohibited commingling. Upon further review, ODO learned
CCJ applies the classification level recorded on the Order to Detain or Release, Form I-203,
which is sent to the facility by ERO in advance of detainees’ arrival. The forms listing the four
detainees identified erroneous classification levels applied by CCJ. ERO staff explained the
discrepancy between the RCA forms and the Forms I-203 as a technical problem with the
system. ODO recommends that CCJ apply the classification level appearing on the RCA forms,
and that ERO correct the technical problem with its forms to avoid confusion (R-1).
According to the standard, detainees are to undergo classification reassessment within 24 hours
before leaving disciplinary segregation. ODO identified four detainees who were in disciplinary
segregation during the year preceding the inspection, none of whom were reassessed (Deficiency
CS-2). The facility does not comply with their internal policy on disciplinary actions. The
policy requires that classification staff receives notification of disciplinary actions; further, that
they receive, “final disposition from the disciplinary board for classification action.” ODO
found no documentation supporting compliance with the policy in the four detainee disciplinary
actions reviewed.
ODO confirmed the detainee handbook contains detailed explanations for each classification
level and procedures for appealing classification decisions. A review of the facility grievance
log for the past year found no grievances were filed regarding classification decisions.
5

Priority Component

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY CS-1
In accordance with the ICE PBNDS, Classification System, section (V)(F)(1), the FOD must
ensure, “All facilities shall ensure that detainees are housed according to their classification
level.
1. Level 1 Classification
 May not be co-mingled with Level 3 detainees.”
DEFICIENCY CS-2
In accordance with the ICE PBNDS, Classification System, section (V)(B), the FOD must
ensure, “A special reassessment must be completed within 24 hours before a detainee leaves
disciplinary segregation.”

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DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at CCJ to determine if the facility provides each
detainee with a handbook, written in English and any other languages spoken by a significant
number of detainees housed at the facility, describing the facility’s rules and sanctions,
disciplinary system, mail and visiting procedures, grievance system, services, programs, and
medical care, in accordance with the ICE 2008 PBNDS. ODO reviewed the facility handbook,
staff training records, detention files, and interviewed staff and detainees.
During detainee interviews it became apparent that every detainee was not being issued an ICE
National Detainee Handbook or the facility’s handbook upon intake (Deficiency DH-1).6 ODO
reviewed 25 detention files for receipt of the facility handbook after several detainees claimed to
have not received a copy during detainee interviews. ODO found that the facility does not
require detainees to sign for facility handbooks (Deficiency DH-2). ODO did note the majority
of detainee files examined contained a blank sheet requesting the detainee’s signature for
acknowledgement of receipt of the handbook. The facility does not require detainees to sign an
acknowledgement form, or equivalent, for receipt of the handbook on a routine and mandatory
basis. As a result, it cannot be verified that detainees received the handbook. The facility
initiated corrective action during the course of the inspection, by ensuring handbooks were
issued and each detainee signed the acknowledgement form (C-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE 2008 PBNDS, Detainee Handbook, section (V)(4), “Upon admission
to the facility, as part of the orientation program, each detainee shall be provided a copy of the
ICE National Detainee Handbook and the facility’s local supplement to the handbook.”
DEFICIENCY DH-2
In accordance with the ICE 2008 PBNDS, Detainee Handbook, Section (V)(5), “Staff shall
require each detainee to verify, by signature, receipt of the handbook and maintain that
acknowledgement in the detainee’s detention file”.

6

Priority Component

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DISCIPLINARY SYSTEM (DS)
ODO reviewed the Disciplinary System standard at CCJ to determine if sanctions imposed on
detainees who violate facility rules are appropriate, and if the discipline process includes due
process requirements, in accordance with the ICE 2008 PBNDS. ODO interviewed staff and
reviewed disciplinary reports, the detainee handbook, and policy.
No disciplinary hearings were conducted during the inspection. CCJ classifies prohibited acts as
major and minor. Graduated severity scales of prohibited acts and disciplinary sanctions are in
place, and informal resolution for minor infractions is encouraged. Prohibited acts and sanctions,
the disciplinary process, detainee rights, and appeal procedures are addressed in the detainee
handbook.
The facility’s policy states that when an officer witnesses a prohibited act, he or she is required
to prepare and issue an incident report. There is no requirement for the report to be investigated
by supervisory staff, and investigations are not completed in practice (Deficiency DS-1).7
CCJ does not have a unit disciplinary committee (UDC) (Deficiency DS-2).8 Instead, the officer
who issued the report is authorized to dispose of low/moderate level infractions classified as
minor by CCJ (Deficiency DS-3). For disciplinary actions imposed by officers, detainees are not
afforded due process rights required for UDC level proceedings, including the right to attend a
hearing, the right to present statements and evidence, and the right to appeal any finding
(Deficiency DS-4). ODO notes the sanctions officers may impose, without due process, include
loss of one or more privileges for up to three days, and/or cell restriction for 23 hours a day for
up to three days.
ODO’s review of documentation found four detainees were subjected to disciplinary action in
the year preceding the inspection. Three of the detainees received sanctions of five days in
disciplinary segregation imposed by the officer who wrote the incident reports, all with
supervisory approval of the sanctions. It is noted two of the three detainees sanctioned with five
days disciplinary segregation pled guilty and agreed to the sanctions without a hearing before the
disciplinary panel. The third detainee did not admit guilt, waive his right to a hearing, or agree
to the sanctions. The disciplinary segregation sanction recommended by the officer was imposed
upon approval of the supervisor without hearing before the disciplinary panel (Deficiency DS-5).
Documentation reflects the fourth detainee who was subject to disciplinary action was properly
served with a notice of his rights, including the right to staff representation, the right to request
witnesses, the right to a fair hearing before impartial decision makers, and the right to a written
copy of the findings. The detainee pled not guilty, and a hearing was held within 24 hours. He
was found guilty of the offense and received a sanction of 15 days disciplinary segregation.
ODO’s review of hearing documentation found the detainee’s comments, the reason for the
decision, and the reason for the sanction imposed were not recorded (Deficiency DS-6). In
addition, the signature lines for the names of the members and the chair of the disciplinary board
7
8

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were blank. Staff stated that while a copy of the decision is placed in the detainee file, the
detainee is not provided with a copy of the written decision (Deficiency DS-7).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DS-1
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(E), the FOD must
ensure, “IGSAs shall have procedures in place that ensure that all incident reports are
investigated within 24 hours of the incident.
The investigating officer shall have supervisory rank or higher (unless prevented by personnel
shortages) and shall have had no prior involvement in the incident, either as witness or officer at
the scene.”
DEFICIENCY DS-2
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(F), the FOD must
ensure, “all facilities shall establish an intermediate level of investigation/adjudication process to
adjudicate low or moderate infractions. They shall also ensure that the detainee is afforded all
the UDC rights listed below.”
DEFICIENCY DS-3
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(F), the FOD must
ensure, “the UDC shall not include the reporting officer, the investigating officer, or an officer
who witnessed or was directly involved in the incident. Only in the unlikely event that
practically every available officer witnessed or was directly involved in the incident may an
exception occur.’
DEFICIENCY DS-4
In accordance with the ICE PBNDS, Disciplinary System, section (V)(F), the FOD must ensure,
“The detainee in UDC proceedings shall have the right to:
1. Remain silent at any stage of the disciplinary process.
2. Due process, which includes:
 Attending the entire hearing (excluding committee deliberations);
 Waiving the right to appear; or
 Having a UDC hearing within 24 hours after the conclusion of the investigation.
If security considerations prevent detainee attendance, the committee must document the
security considerations and, to the extent possible, facilitate the detainee’s participation
in the process via telephonic testimony, the submission of documents, written
statements, or questions to be asked of witnesses.
3. Present statements and evidence, including witness testimony on his or her own behalf.
4. Appeal the committee's determination through the detainee grievance process.”

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DEFICIENCY DS-5
In accordance with the ICE PBNDS, Disciplinary System, section (V)(H), the FOD must ensure,
“all facilities that house ICE/DRO detainees shall have a disciplinary panel to adjudicate
detainee Incident Reports. Only the disciplinary panel may place a detainee in disciplinary
segregation.
The term “Institution Disciplinary Panel” or “IDP” refers either to a three-person panel
appointed by the facility administrator, or a one-person disciplinary hearing officer, depending
on the practice at the facility. The panel may not include the reporting officer, the investigating
officer, any member of the referring UDC, or anyone who witnessed or was directly involved in
the incident. Exceptions may occur only if the number of officers required for the panel cannot
be filled due their direct involvement in the incident. The IDP shall have the authority to:
1. Conduct hearings on all charges and allegations referred by the UDC.
2. Call witnesses to testify.
3. Consider written reports, statements, physical evidence, and oral testimony.
4. Hear pleadings by detainee and staff representative.
5. Make findings that the detainee did or did not commit the rule violation(s) or prohibited
act(s) as charged, based on the preponderance of evidence.
6. Impose sanctions as listed and authorized in each category.
The detainee in IDP proceedings shall have the right to:
1. Remain silent at any stage of the disciplinary process.
2. Due process, which includes:
 Attending the entire hearing (excluding committee deliberations);
 Waiving the right to appear; or
 Having an IDP hearing within 24 hours after the conclusion of the investigation.
If security considerations prevent the detainee’s attendance, the committee must document
the security considerations and, to the extent possible, facilitate the detainee’s participation in
the process by telephonic testimony, the submission of documents, written statements or
questions to be asked of witnesses.
3. Present statements and evidence, including witness testimony, on his or her behalf.
4. Appeal the committee’s determination through the detainee grievance process.”
DEFICIENCY DS-6
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(H)(5), the FOD must
ensure, “the IDP shall prepare a written record of any hearing. This record must show that the
detainee was advised of his or her rights. It must also document the evidence considered by the
Panel and subsequent findings and the decision and sanctions imposed along with a brief
explanation.”
DEFICIENCY DS-7
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(H)(7), the FOD must
ensure, “the IDP shall:

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7. Serve the detainee with written notification of the decision, which must contain the
reason for the decision.”

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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 2008 PBNDS. ODO toured the
facility, interviewed staff, and reviewed procedures and documentation of inspections, hazardous
chemical management, and fire drills.
ODO found sanitation in the facility was acceptable overall. However, shower areas in the
housing areas were not maintained in a sanitary fashion and a substantial amount of graffiti was
observed in the general population housing units and SMU.
The facility’s fire-safety officer was not available during the inspection due to illness. Based on
observation, review of documentation and interviews with other staff, ODO determined CCJ
does not have a facility-wide system in place for control of hazardous substances. Except for the
food service area, there were no current inventories (Deficiency EH&S-1), and every department
or other area of the facility using hazardous substances did not maintain a file of Material Safety
Data Sheets (MSDSs) that includes a list of the locations where hazardous substances are stored,
along with a diagram and legend of these locations (Deficiency EH&S-2). In addition, there
was no master index of hazardous substances or master file of MSDS and emergency numbers
(Deficiency EH&S-3). Steps were taken toward correction of these deficiencies during the
inspection, by implementation of inventory procedures and creation of MSDS binders for areas
where hazardous substances are stored.
When arriving at the facility, ODO observed ice remover pellets at the entrance in a container
marked “Chicken Gravy Granules” (Deficiency EH&S-4).
Weekly and monthly fire inspection reports were available. Inspection of invoices found the fire
suppression system is maintained and tested under private contract, and documentation of
weekly fire extinguishers testing was available. Documentation reflects CCJ’s fire plan is
reviewed annually by the Brazil fire department chief. The last approval was received in
October, 2014. ODO’s review of the fire plan found it does not meet all requirements of the
standard. The fire plan does not address control of ignition sources or control of combustible
and flammable fuel load sources, and does not mandate posting of required evacuation and exit
diagrams (Deficiency EH&S-5). While touring the facility, ODO noted exit diagrams were not
posted in the administration and visiting area. Exit diagrams posted elsewhere in the facility
were in English and provided a general layout of the facility with arrows indicating only the
primary route of evacuation (Deficiency EH&S-6). The facility could not produce
documentation of fire drills conducted at least quarterly in all areas of the facility (Deficiency
EH&S-7). The reports documented there were only eight fire drills in various areas during
2014, but in no quarter were all areas covered.
ODO reviewed invoices confirming pest control services are provided under contract with an
external vendor. A certificate from the city of Brazil documented current water testing. The
emergency power generator is serviced semi-annually by an outside service company in
accordance with the manufacturer’s recommendation.
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ODO reviewed procedures, interviewed medical staff, and inspected areas where needles and
sharp objects are used and stored. Inventories of needles and sharps were accurate and the
facility staff reports that an arrangement exists with the local hospital to dispose of their
hazardous waste.
The barbering operation takes place in the recreation area during the evening shift. The staff
reported disinfecting the tools after each use, though ODO could not confirm compliance and
noted hair care sanitation regulations were not posted or available.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with ICE 2008 PBNDS, Environmental Health and Safety, section (VI)(C), the
FOD must ensure, “every area shall maintain a current inventory of the hazardous substances
(flammable, toxic, or caustic) used and stored there. Inventory records shall be maintained
separately for each substance. Entries for each shall be logged on a separate card filed
alphabetically by substance. The entries shall contain relevant data, including purchase dates
and quantities, use dates and quantities on hand.”
DEFICIENCY EH&S-2
In accordance with ICE 2008 PBNDS, Environmental Health and Safety, section (VI)(D), the
FOD must ensure, “every department or other area of the facility using hazardous substances
shall maintain a file of Material Safety Data Sheets (MSDSs) that includes a list of the locations
where hazardous substances are stored, along with a diagram and legend of these locations.”
DEFICIENCY EH&S-3
In accordance with ICE 2008 PBNDS, Environmental Health and Safety, section (VI)(E), FOD
shall compile:




a master index of all hazardous substances in the facility and their locations,
a master file of MSDSs;
a comprehensive, up-to-date list of emergency numbers (fire department, poison control,
etc.).
The designee maintains this information in the safety office and ensures a copy is sent to the
local fire department.”
DEFICIENCY EH&S-4
In accordance with ICE 2008 PBNDS, Environmental Health and Safety, section (VI)(K), the
FOD shall individually assign the following responsibilities associated with the labeling
procedure:


Requiring use of properly labeled containers for hazardous materials, including any and
all miscellaneous containers into which employees might transfer the material.
DEFICIENCY EH&S-5

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In accordance with ICE 2008 PBNDS, Environmental Health and Safety, section (VII)(C)(1), (2)
and (7), the FOD shall “develop a fire prevention, control, and evacuation plan that includes the
following:
1. Control of ignition sources;
2. Control of combustible and flammable fuel load sources;
7. Accessible, current floor plans (buildings and rooms); prominently posted evacuation
maps/plans; exits signs and directional arrows for traffic flow; with a copy of each
revision filed with the local fire department.”
DEFICIENCY EH&S-6
In accordance with ICE 2008 PBNDS, Environmental Health and Safety, section (VII)(E), the
FOD must ensure that “in addition to a general area diagram, the following information must be
provided on the signs:




Instructions in English, Spanish and the next prevalent language at the facility;
You are Here” markers on the exit maps; and
Emergency equipment locations.

Areas of Safe Refuge’ shall be identified and explained on diagrams.”
DEFICIENCY EH&S-7
In accordance with ICE 2008 PBNDS, Environmental Health and Safety, section (VII)(D), the
FOD must ensure, “fire drills shall be conducted and documented at least quarterly in all facility
locations including administrative areas.”

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at CCJ to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE 2008 PBNDS.
ODO reviewed policy and procedures, inspected all areas of the food service operation, observed
meals being prepared and served, and interviewed staff and detainees.
The food service staff at CCJ is employed by the Clay County Sheriff’s Department and consists
of (b)(7)efull-time food service supervisor and (b)(7)epart-time assistants, all of whom have ServSafe
certification. There are(b)(7)ecounty inmates and no detainees assigned to work in the kitchen.
Documentation was produced reflecting the inmate workers were trained in kitchen sanitation
and proper equipment usage, and all received medical clearance. However, none of the staff had
pre-employment medical examinations clearing them to work in a food service operation
(Deficiency FS-1). ODO observed inmate workers were visually inspected prior to shift for
signs of hygiene and health concerns.
Certification of the facility’s general cycle and medical diet menus by a registered dietician was
available. A printed common fare menu was provided, however, it did not provide special
menus for holiday meals or evaluation by the registered dietitian for nutritional adequacy
(Deficiency FS-2).
CCJ has a satellite system of meal service. ODO observed a lunch time meal service; prepared
food items are placed on insulated trays which are then placed on carts for delivery to the
housing units by inmate workers under the supervision of officers. Special diet meals are placed
on trays of a different color than trays used for general meals. ODO used a digital thermometer
to verify all food items met the requirements of the standard when placed on trays. As trays are
issued, detainees are required to show their identification wristband to the officer, who checks
their names against the housing roster.
Records for health department inspections, pest control treatment, and storage and inventory of
chemicals were current. Sanitation of the kitchen, storage areas, and all equipment was
excellent. Knives and all kitchen utensils are kept in a locked storage cabinet on a shadow board
in the food service supervisor’s office. Knives are secured to the workstation when used by
inmate workers. Documentation of sanitation inspections was available and complete.
A cleaning/sanitation schedule was prominently displayed in the kitchen. Staff and inmate
worker restrooms were clean and equipped with filled hand soap dispensers, paper towels, and
hand-washing reminder signs.
Storage areas were neat, organized, and items were all dated to ensure stock rotation. A
minimum 15 day supply of food is on hand at all times.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE 2008 PBNDS, Food Service, section (V)(J)(3), the FOD must ensure,
a. “All food service personnel, including staff and detainees, shall receive a preemployment medical examination noting the importance of identifying those
communicable diseases more likely to be found in the immigrant population.”

DEFICIENCY FS-2
In accordance with ICE 2008 PBNDS, Food Service, section (V)(G)(2), the FOD must ensure,
“Common Fare menu is based on a 14-day cycle, with special menus for the 10 Federal holidays.
The menus must be certified as exceeding minimum daily nutritional requirements and meeting
daily allowances (RDAs).”

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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, receipt, store, and safeguard detainees’ personal property, in accordance with
the ICE 2008 PBNDS. ODO reviewed policies, interviewed staff, inspected property storage
areas, and reviewed detainee files.
There were no detainees admitted to CCJ during the inspection. According to the facility’s ICE
Coordinator, detainees arrive at CCJ with sealed plastic bags containing property inventoried by
ERO field office staff. Bags received with detainees contain the signed inventories prepared by
ERO, and are not opened upon arrival at CCJ. The in-tact bags are secured in a locker marked
with each detainee’s name, photograph, and A-number in CCJ’s designated storage room.
Inspection of the storage room found it is secure and under video camera surveillance, with
access restricted to the coordinator and shift supervisors. The clothing worn by a detainee upon
admission is inventoried on a CCJ form and added to the detainee’s locker. Detainees sign the
CCJ inventory form and receive a copy, with a copy of the inventory form included in the
detention file. ODO notes a copy of the property inventory generated by ERO is not available
for inclusion in the detention file.
Domestic and foreign currency arriving with a detainee is processed by the coordinator. Foreign
currency is recorded in denominations on an envelope which is then sealed and placed in a safe
in the coordinator’s office. Domestic currency is counted by the coordinator, who establishes the
detainee’s commissary account and issues a copy of the transaction to the detainee. The funds
are turned over to the facility’s accountant for verification of the recorded amount. ODO’s
review of the detention files of 20 randomly selected detainees confirmed a copy of funds
receipts were included.
CCJ does not obtain a forwarding address from detainees for use in the event forwarding of
property or funds becomes necessary (Deficiency F&PP-1). Inspection of the detention files for
ten randomly selected detainees released from CCJ found they signed for their property,
including the bags originating at ERO, clothing worn upon admittance, and foreign currency.
Per facility policy and procedure, monies remaining in a detainee’s commissary account are to be
returned by way of a debit card; however, ODO found seven debit cards ranging in value
between $3.00 to $150.00 in the safe in the coordinator’s office. The coordinator stated the debit
cards were placed in the safe prior to his assignment to the position and could not explain why
the detainees did not receive them. He stated the facility reported the cards to ERO and was
informed the detainees could not be located.
ODO’s review confirmed the CCJ handbook delineates what property a detainee can and cannot
have in their possession, how their property is stored, and instructions for whom to contact in the
event of lost or damaged property. Obtaining personal identity documents is also addressed in
the handbook.

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STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with ICE 2008 PBNDS, Funds and Personal Property, section (V)(D), the FOD
must ensure, “standard operating procedure shall include obtaining a forwarding address from
every detainee for use in the event that personal property is lost or forgotten in the facility after
the detainee’s release, transfer, or removal.”

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at CCJ 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 2008
PBNDS.
A review of the facility’s policy and detainee handbook confirmed both address CCJ’s informal
and formal grievance process, appeals, and guarantee against reprisal for detainees who file a
grievance. The handbook also provides a notice of the right to file medical grievances and the
opportunity to file a complaint directly to DHS/OIG in writing. However, CCJ’s policy does not
establish a procedure to file an emergency grievance (Deficiency GS-1(V)(B).
CCJ does provide detainees with envelopes in which to seal grievances and identify them as
sensitive or medically sensitive. These grievances are delivered directly to medical personnel
within the same day, as medical staff members are available and on site 24 hours per day. A
review of the grievance log found there were no grievances filed since CCJ started accepting
detainees. ODO found CCJ does have procedures in place to allow for appeal of grievance
decisions and ensure that detainees receive written decisions about their appeals.
Interviews with the grievance coordinator and staff confirmed that CCJ has a system in place to
forward all copies of grievances alleging any staff misconduct to ICE/ERO.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE PBNDS, Grievance Systems, section (V)(B), the FOD shall provide
each detainee, upon admittance, a copy of the Detainee Handbook/local supplement, in which the
grievance section provides notice of:
 “The process for filing emergency grievances.”

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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 2008 PBNDS. ODO toured the clinic, reviewed policies and procedures, verified
medical staff credentials, and interviewed detainees and medical and detention staff. In addition,
ODO interviewed (b)(7)e epresentatives from the medical contractor’s corporate office. The
medical records of 32 detainees were reviewed, including detainees with chronic conditions and
women previously detained. There were no women housed in the facility at the time of the
inspection.
CCJ has no national accreditations. Medical care is provided by Quality Correctional Care
(QCC), an Indiana based health care provider holding contracts with numerous jails in the state.
ODO was provided with training documentation indicating QCC health care staff received
training in the 2008 PBNDS. The clinic is staffed 14 hours a day, Monday through Friday, by
(b)(7)e registered nurses, (b)(7)eof whom serves as the health service administrator, and a licensed
practical nurse. The designated clinical medical authority is an advanced practice registered
nurse practitioner who is on site once a week for four hours or more as needed. She provides
services under the license of a physician who is available for consultation and provides on call
services 24 hours a day, seven days a week.
Mental health services are provided by a licensed psychologist who visits CCJ on a bi-weekly
basis. The number of hours the psychologist is available on a bi-weekly basis is not specified in
the psychologist’s contract. Facility staff stated the psychologist is there for the hours needed
during that bi-weekly visit.
ODO confirmed the licenses of all health care staff were on site, primary source verified, and
current with no identified restrictions. Dental services are provided in the community.
The facility’s emergency services plan is comprehensive and addresses consultation with a
provider and procedures for emergency transportation to the local hospital. ODO’s review of all
medical and ten randomly selected detention officers’ training records confirmed current training
in first aid, cardio pulmonary resuscitation, and automated external defibrillator use.
CCJ has a one-room clinic which is adjacent to the booking area. There is no waiting area;
therefore, detainees are escorted to the clinic one at a time for health care encounters. There is a
large window in the clinic door that is not tinted or screened which does not assure privacy
during examinations (Deficiency MC-1). 9 ODO observed several inmate workers repeatedly
walk past this door enroute to their work site while detainees were being examined. Medical
records are secured in locking cabinets within the clinic and are accessible only by medical staff.
Medications are stored in a locking cart maintained in the clinic. CCJ has a room equipped with
negative air flow for respiratory isolation. The room is in the booking area and documentation
was produced reflecting inspection and certification by an engineer on a quarterly basis.

9

Priority Component

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Prior to admittance to CCJ, detainees receive clearance for tuberculosis by way of chest x-ray at
Saint Vincent’s Hospital. Tuberculosis clearance by the hospital was documented in all 32
medical records reviewed.
Detainees receive initial medical and mental health screening upon arrival at CCJ. The screening
is performed by nurses when on duty, using ICE Health Services Corp (IHSC) form 795-A. In
the event a detainee is admitted when nurses are not on duty, officers perform and document
intake screening on an equivalent CCJ form, which is reviewed by nursing staff upon return to
duty. Documentation of training in conducting intake screening was present in(b)(7)erandomly
selected officers’ training records. The 32 detainees whose records were reviewed by ODO
documented intake screening conducted by nursing staff upon arrival. Review by the clinical
medical authority to assess priority for treatment was not documented in any of the records
(Deficiency MC-2). According to staff, no routine review of intake screenings by the provider
occurs; although the nurse practitioner or physician is contacted by telephone to obtain orders for
detainees received with medications. In addition, detainees with identified chronic conditions
are scheduled for examination by the nurse practitioner.
All 32 medical records contained documentation of initial health appraisals completed within 14
days of detainee arrival. The health appraisals included hands on physical examinations
documented on IHSC form 795-B. Clinical medical authority review of health appraisals
conducted by registered nurses was documented within the required timeframe. A review of the
registered nurses’ training files confirmed they received training in performance of the function
by the physician. Dental screenings completed during all 32 health appraisals were documented
on a dental progress note with a chart of teeth. ODO confirmed training in performing dental
screenings was provided by a community dentist.
Information on how to access medical care is addressed in the detainee handbook. Detainees
request care by completing sick call requests and depositing them in secure mailboxes accessible
only by medical staff. The sick call request form was available only in English (Deficiency MC3). Prior to completion of the inspection, a Spanish translation of the form was made available
(C-3). A review of medical files found detainees health requests are triaged within 48 hours, and
detainees were seen for sick call within one to three days following the date of request. ODO
confirmed routine sick call is conducted by registered nurses following physician-approved
protocols.
ODO’s medical record review included three female detainees previously held at CCJ, all of
whom were tested for pregnancy with negative results. In addition, the records of detainees with
chronic conditions were reviewed, including three detainees with diabetes, one with a seizure
disorder, one with hypertension, and two receiving psychotropic medication. Although the
records documented medications and provider-ordered diets where appropriate, there were no
documented treatment plans addressing patient involvement and education, and scheduled
monitoring (Deficiency MC-4).10 In addition, ODO’s review of the medical records for the
detainees on psychotropic medications found they had not signed specific consent for the
medications (Deficiency MC-5).11 ODO notes the facility uses IHSC medical consent form 793,
10

11

Priority Component
Priority Component

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which gives consent for mental health treatment but is not specific to the drug prescribed. Staff
stated they believe this to be sufficient.
Medication rounds are made twice a day by nurses when on duty. On weekends, medications are
distributed by trained detention officers. ODO’s review of the training plan confirmed it is
adequate, and inspection of ten randomly selected officers’ training records confirmed current
training. Medications provided to detainees are recorded on medication administration records
(MAR). Staff initial when a medication is given to a detainee, and the detainee initials the
Medication Administration Record (MAR) to indicate the medication was received. A
photograph of each detainee is attached to the MAR to facilitate detainee identification and
reduce medication errors. ODO cites this as a best practice (BP). A total of 21 MARs were
reviewed, and all included clear documentation of medication distribution.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(E)(1), the FOD must ensure,
“Adequate space and equipment shall be furnished so that all detainees may be provided basic
health examinations and treatment in private while ensuring safety.”
DEFICIENCY MC-2
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(I)(1), the FOD must ensure,
“The clinical medical authority shall be responsible for review of all health screening forms
within 24 hours or the next business day to assess the priority for treatment.”
DEFICIENCY MC-3
In accordance with ICE 2008 PBNDS, Medical Care, section (V)(N), the FOD must ensure, “If
the procedure uses a written request slip, they shall be provided in English and the most common
languages spoken by the detainee population of that facility. Non- English speaking detainees
and detainees who are deaf or hard of hearing will be provided interpretation/translation services
as needed or other assistance as needed to complete a request slip.”
DEFICIENCY MC-4
In accordance with the ICE 2008 PBNDS. Medical Care, section (V)(R), the FOD must ensure,
“When a detainee requires close medical supervision, including chronic and convalescent care, a
written treatment plan that includes access to health care and other personnel regarding care and
supervision, shall be developed and approved by the appropriate physician, dentist or mental
health practitioner, in consultation with the patient with periodic review. The written treatment
plan will conform to NCCHC and TJC requirements.”
DEFICIENCY MC-5
In accordance with the ICE 2008 PBNDS. Medical Care, section (V)(T), the FOD must ensure,
“As a rule, medical treatment shall not be administered against a detainee's will.
 For any additional procedure, a separate documented informed consent will be obtained.”

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RELIGIOUS PRACTICES (RP)
ODO reviewed the Religious Practices at CCJ to determine if detainees of different religious
beliefs are provided reasonable and equitable opportunities to participate in the practices of their
respective faiths, in accordance with the ICE 2008 PBNDS. The facility does not have a
chaplain but instead has the assistant facility administrator act as the designated staff member
who supervises all aspects of the religious program. The staff member is an ordained elder in a
local church and has access to all areas of the facility to minister to detainees and staff. ODO
toured the facility, interviewed staff and detainees and reviewed policies and detainee files.
Detainee participation in religious activities is voluntary, without discrimination, and open to the
entire detainee population, including detainees in the SMU. Religious texts are available to
detainees in both English and Spanish. The facility has recently implemented written procedures
regarding the observance of holy days. Detainees are permitted religious headgear or prayer rugs
though ODO was informed that to date CCJ had not received a request for such. Prayer beads
are permitted by detainees throughout the facility though the facility does not provide them
(detainees bring their own). Religious services are offered to detainees through a variety of local
churches. At the time of inspection, all religious services were offered in English though the
facility administrator indicated he would look into providing religious services in Spanish.
The facility does not have detainees designate “any” or “no religious preference” on intake, nor
does it note this information in the detainee’s file (Deficiency RP-1). Upon being informed of
this and the need for detainees to be able to change their religious preference designation at any
time, the facility initiated corrective action during the course of the inspection by creating a form
that can be signed by detainees upon intake, indicating their religious preference (or lack thereof)
(C-4).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY RP-1
In accordance with the ICE 2008 PBNDS, Detainee Handbook, section (V)(B), the FOD must
ensure, “each detainee shall designate any or no religious preference during in-processing.”

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SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION
(SAAPI)
ODO reviewed the Sexual Abuse and Assault Prevention and Intervention (SAAPI) standard at
CCJ to determine if the facility acts to prevent sexual abuse and assaults on detainees, provides
prompt and effective intervention and treatment for victims of sexual abuse and assault, and
controls, disciplines, and prosecutes the perpetrators, in accordance with ICE 2008.
At the time of inspection, CCJ had not signed a contract modification obligating them to comply
with ICE’s 2011 SAAPI standard. However, ODO notes the facility has established a
comprehensive zero-tolerance written policy and procedures addressing the Prison Rape
Elimination Act (PREA). CCJ has a Lieutenant in charge of the SAAPI program.
While undergoing the admission process, detainees receive a PREA risk screening, and are
shown an orientation video that addresses the facility’s PREA program. The screening tool
identifies detainees who have a prior history of sexual abuse, or those that may be susceptible to
abuse. The contents of the orientation video included: a reiteration of the facility’s zero
tolerance policy on sexual abuse and harassment; definitions of types of sexual abuse (i.e. Inmate
on Inmate, Staff on Inmate and harassment); victim reporting procedures for sexual abuse
incidents; services offered by the facility in response to sexual abuse incidents; methods to avoid
potential sexual abuse and harassment; confidentiality of victims reporting sexual abuse; and
freedom of reprisal.
CCJ staff is required to take annual training regarding SAAPI/PREA. Staff must actively
participate in the class. ODO reviewed the staff training roster to confirm required training is
completed. The training curriculum provides an overview of PREA; defines types of sexual
abuse; describes preventative measures, to include the inmate risk assessment; lists factors to
consider for female and lesbian gay bi-sexual transgender inter-sex (LGBTI) detainees; and
defines the necessary steps for officers to take in response to a sexual abuse incident.
There were no incidents of sexual abuse or assault at CCJ in the last year. When asked how the
facility would respond if an alleged case of sexual abuse was reported by a detainee, the PREA
coordinator stated the facility would immediately notify ERO of the incident via telephone and
email. Once all necessary information is gathered, the facility would complete an incident report
and forward the report to internal investigators within the Clay County Sheriff’s Office, where
they would conduct a formal investigation. If the incident involved staff on detainee abuse, the
staff member involved may be placed on administrative leave pending results of the
investigation.
During a review of CCJ’s record keeping system, it was determined the facility does not have a
tracking system in place to follow any SAAPI incidents that may occur (Deficiency SAAPI-1).

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SAAPI-1
In accordance with the ICE 2008 PBNDS, Sexual Abuse and Assault Prevention and
Intervention, section (V)(M), the FOD must ensure, “Monitoring and evaluation are essential
for assessment of the rate of occurrence of sexual assault and agency effectiveness in
reducing sexually abusive behavior. Accordingly, the facility administrator must maintain
two types of files.


General files include:
o The victim(s) and assailant(s) of a sexual assault,
o Crime characteristics,
o Detailed reporting timeline, including the name of the staff member receiving
the report of sexual assault, date and time the report was received, and steps
taken to communicate the report up the chain of command, and
o Formal and or informal action taken.



Investigative files include:
o All reports,
o Medical forms,
o Supporting memos and videotapes, if any, and
o Any other evidentiary materials pertaining to the allegation.”

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SPECIAL MANAGEMENT UNITS (SMU)
ODO reviewed the Special Management Units standard at CCJ to determine if the facility has
procedures in place to temporarily segregate detainees for disciplinary and administrative
reasons, in accordance with the ICE 2008 PBNDS. ODO inspected the SMU, reviewed facility
policies and SMU logs, inspected detention files, and interviewed staff and detainees.
The facility’s G unit is the designated SMU. The G unit has two tiers with four double
occupancy cells on each tier. According to staff, both tiers may house detainees on either
administrative segregation or disciplinary segregation, with separation afforded by cell
assignment. Each cell is equipped with a shower, sink and toilet, a steel-framed bunk bed
attached to the wall and floor, and a desk and stool attached to the wall. Each cell is also
equipped with an intercom system to communicate with staff. ODO’s inspection found the cells
appropriately heated and adequately ventilated and lit. However, the walls in all eight cells had a
significant amount of graffiti, including graffiti associated with white supremacy groups such as
the Klu Klux Klan and the Aryan Brotherhood (Deficiency SMU-1). The dayroom of the unit
contains two video visitation terminals, two telephones, a television mounted on the wall, and
four steel tables with affixed stools. There were no detainees in SMU at the time of our
inspection.
The SMU is monitored by an officer assigned to the tower post, which is an enclosed work
station elevated above the unit. The tower officer maintains surveillance of the SMU through
direct observation and security monitors. In addition, officers make rounds within the unit. The
officer rounds are electronically recorded by pushing sensors located at each end of the upper
and lower tiers. Rounds are made every hour instead of every 30 minutes as required by the
standard (Deficiency SMU-2).12
According to documentation and staff reports, nine detainees were housed in the SMU during the
year preceding the inspection, five on administrative segregation status and four on disciplinary
segregation. Three of the five detainees on administrative segregation status were placed there
by order of medical staff and were returned to general population within two days. Available
documentation for the other two detainees indicated they were placed in segregation for
protective custody; however, no further information on the justification for the assignment was
documented, including whether protective custody was requested by the detainees or determined
necessary by facility staff (Deficiency SMU-3). One detainee was released from administrative
segregation after two days and the second was assigned to the status during the inspection,
pending a review.
Of the four detainees placed on disciplinary segregation, one was sanctioned with 15 days but
was returned to general population after serving five days. The other three were sanctioned with
five days, two of whom pled guilty, waived their right to a hearing, and accepted the sanctions.
The third did not plead guilty and did not waive his right to a hearing. The disciplinary
segregation term was imposed by the officer who witnessed the alleged rule violation and was

12

Priority Component

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approved by a supervisor. The detainee was not afforded the rights and protections of the formal
disciplinary process (Deficiency SMU-4).
CCJ documents all actions related to a detainee’s assignment to segregation on a form titled,
“Special Management Unit Housing Record.” The form includes sections to record the reason
for the placement, the date and time of admission and release from the SMU, and staff person
authorizing the placement. A copy of this form is not provided to the detainee (Deficiency
SMU-5). In addition, ODO found incomplete or incorrect documentation of release information
for six of the detainees assigned to segregation in the year preceding the inspection; specifically,
dates were missing or incorrect (Deficiency SMU-6).
The Special Management Unit Housing Record form is posted outside the cell of each detainee,
and is used to record such activities as meals delivered, showers, visits, recreation and rounds by
medical and supervisory staff. ODO’s review found gaps in recorded information (Deficiency
SMU-7). For example, the log for a detainee who served five days in disciplinary segregation
documented he was only served two meals over the five day period, although staff stated he was
served all meals. In addition, the logs did not document daily visits by medical staff for two of
the detainees assigned to disciplinary segregation (Deficiency SMU-8)13; neither shift
supervisors nor an administrator documented daily contact with two detainees while on
disciplinary segregation (Deficiency SMU-9).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU-1
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(B)(4), the
FOD must ensure, “Cells and rooms used for purposes of segregation must be well ventilated,
adequately lit, appropriately heated and maintained in a sanitary condition at all times.”
DEFICIENCY SMU-2
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(B)(7), the
FOD must ensure, “Detainees in SMU are personally observed at least every 30 minutes on an
irregular basis.”
DEFICIENCY SMU-3
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(C)(2)(a) and
(h) the FOD must ensure,
a. “The facility administrator or designee shall complete the Administrative Segregation
Order (Form I-885 or equivalent), detailing the reasons for placing a detainee in
Administrative Segregation, before his or her actual placement.
h. If the segregation is ordered for protective custody purposes, the order shall state whether
the detainee requested the segregation, and whether the detainee requests a hearing
concerning the segregation.”

13

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DEFICIENCY SMU-4
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(A), the FOD
must ensure, “A detainee may be placed in Disciplinary Segregation only after being found
guilty, through a formal disciplinary process, of a facility rule violation.”
DEFICIENCY SMU-5
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(C)(2)(e), the
FOD must ensure, “a copy of the completed Administrative Segregation order be given to the
detainee within 24 hours of placement in Administrative Segregation, unless delivery would
jeopardize the safe, secure, or orderly operation of the facility.”
DEFICIENCY SMU-6
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(C)(2)(g), the
FOD must ensure, “when a detainee is released from the SMU, the releasing officer shall
indicate date and time of release on the Administrative Segregation Order. The completed order
is then forwarded to the chief of security for inclusion into the detainee’s detention file”
DEFICIENCY SMU-7
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(E)(1), the
FOD must ensure, “a permanent log be maintained in the SMU to record all activities concerning
the SMU detainees, such as meals served, recreational time, and visitors.”
DEFICIENCY SMU-8
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(B)(9), the
FOD must ensure, “a health care provider visits every detainee in an SMU at least once daily.”
DEFICIENCY SMU-9
In accordance with the ICE 2008 PBNDS, Special Management Units, section (V)(B)(8)(a)(b),
the FOD must ensure, “in addition to the direct supervision performed by unit staff:
a. The shift supervisor shall see each segregated detainee daily, including weekends and
holidays.
b. The facility administrator (or designee) shall visit each SMU daily.”

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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 2008 PBNDS. ODO interviewed staff and
detainees, toured and observed housing units, and reviewed ERO visitation records and Facility
Liaison Visit Checklists.
The Chicago Field Office and the CCJ have policies and procedures on staff detainee
communication and adhere to the 2008 PBNDS. An SDDO, DOs and IEAs have frequent,
formal and informal access to and interaction with detainees.
An SDDO conducts weekly unannounced, unscheduled visits to the CCJ. These visits are
documented in the facility’s front entrance log books. Through interviews, detainees confirmed
interacting with the SDDO during those visits. DOs and IEAs from the Indiana Sub-Office visit
the facility on a weekly basis, usually on Wednesdays. Visitation schedules are posted in the
detainee housing units. A majority of detainees interviewed stated the ERO visits are consistent
with the posted schedule. Visits by ERO non-supervisory staff are documented by facility
liaison checklists, CCJ front entrance log books and in the detainee housing unit log.
Detainees may submit written requests or concerns to ICE ERO staff using an ICE-specific form
available from the housing unit officer’s desk. All completed requests are placed in an ICE
secure drop box or given to the housing unit officer, who then forwards all ICE related requests
to the Chicago Field Office for processing. Upon completion, the requests are emailed back to
the facility and given to the detainee by CCJ staff.
Facility staff stated if a detainee’s request pertains to the CCJ it may be resolved by the housing
unit officer or passed on to a shift supervisor for resolution. A copy of the facility related
requests are faxed or emailed to ERO staff at the Chicago Field Office.
ERO staff stated they maintain an electronic log of all requests. ODO requested copies of all
detainee requests from December 2013 through January 2014. ERO could not provide any
requests logs for that period to ODO (Deficiency SDC-1). ERO stated the previous staff
member passed away and the requests or logs could not found.
OIG informational posters were located on a bulletin board in the detainee housing units and the
SMU. ERO tests telephones weekly and documents the results on a telephone serviceability
worksheet. The DHS Office of Inspector General Hotline posters were observed in the housing
units and in appropriate common areas.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with ICE 2008 PBNDS, Staff-Detainee Communication, section (V)(B)(2), the
FOD must ensure, “all requests shall be recorded in a logbook (or electronic logbook)
specifically designed for that purpose.”
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STAFF TRAINING (ST)
ODO reviewed the Staff Training standard at CCJ to determine if facility staff, contractors, and
volunteers are receiving initial, annual and ongoing training, in accordance with the ICE
PBNDS.
ODO verified the coordinators for the staff development and training programs met minimum
training qualifications to facilitate the training programs.
The staff training coordinator for jail staff maintains electronic and hard copy training files. The
files consist of the date of training, final test scores and certificates of completion. The staff
training coordinator did not have a documented facility training program (Deficiency ST-1).
ODO verified that CCJ staff members assigned to situation response teams met the training
requirements outlined in the standard. Personnel authorized to use firearms and chemical agents
were trained by certified instructors. CCJ uses the Indiana Law Enforcement Academy standard
qualification course of fire for staff members authorized to use firearms. Staff members
authorized to use chemical agents are trained in the composition of the chemical agent, the
affects and treatment after exposure.
The staff training coordinator for healthcare is a licensed practical nurse in the state of Indiana
with an active license. ODO reviewed the training agenda for healthcare personnel. The
healthcare training coordinator did not have documentation that training was administered to
current staff members (Deficiency ST-2). The facility initiated corrective action during the
course of the inspection by providing documentation that current staff members received
required training (C-5).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ST-1
In accordance with the ICE PBNDS, Staff Training, section (V)(A), the FOD shall ensure the
facility “develop and document a facility training plan that is reviewed and approved annually by
the facility administrator.”
DEFICIENCY ST-2
In accordance with the ICE PBNDS, Staff Training, section (V)(C)(3), the FOD shall ensure,
“full-time health care employees and contractors: In addition to the training areas above, the
health-care employee orientation program includes instruction in the following:
 ICE/DRO National Detention Standards update
 The purpose, goals, policies, and procedures for the facility sand parents agency security
and contraband regulations
 Key and lock control; appropriate conduct with detainees
 Medical grievance procedures and protocols
 Emergency medical procedures
 Requirements of special-needs detainees
 Code of ethics
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








Drug-free workplace
Responsibilities and rights of employees
Standard precautions
Occupational exposure
Personal protective equipment
Bio-hazardous waste disposal
Overview of the detention operations
Hostage situations and staff conduct if take hostage”

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at the 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 ICE 2008 PBNDS. ODO interviewed facility staff
and detainees, reviewed policy, procedures, and the detainee handbook, and conducted
functionality tests on the telephones located in detainee housing units.
ODO verified detainees have reasonable and equitable access to telephones at CCJ. CCJ
requires detainees to participate in the telephone voice enrollment system to establish a phone
personal identification number (pin). The pin enables detainees the ability to make collect calls
for domestic locations, but must purchase calling cards for international calls. Telephone
service, maintenance and rates are managed by Global Tel*Link Corporation. The system
allows for collect or debit calls. Debit call rates are a flat fee of $3.95 for local calls and $0.89 a
minute for interstate calls with a surcharge of $3.95. The telephone availability ratio is
approximately four detainees per phone.
The telephones are not inspected daily by facility staff, but the ICE SDDO and DO conduct
weekly inspections of the telephones and maintain record of the inspections (Deficiency TA-1).
ODO conducted operation checks of telephones in detainee housing units and random pro bono
numbers, and all were found to be in good working order. The facility’s phone system does not
have a recorded message that advises detainees calls are subject to monitoring, but written
notification is located in English and Spanish on the wall in the housing unit (Deficiency TA-2).
Phone calls are limited to 20 minutes, but telephones are accessible from approximately 6:00 am
to 11:00 pm. The phones are turned off for lockdown, maintenance work, shakedown and meal
periods. CCJ delivers emergency phone call messages to the detainees and allow detainees to
return the phone calls in a timely manner.
The telephone access rules were observed in the immediate vicinity of each designated telephone
location and explained in the detainee handbook. The detainee handbook was not issued to some
detainees upon admission (Deficiency TA-3). ODO confirmed listings for pro-bono services,
the OIG, consulates and embassies were accessible in each housing unit in English and Spanish.
CCJ has procedures for obtaining an unmonitored call to court, legal representatives, OIG, Civil
Rights and Civil Liberties, and pro bono calls outlined in the detainee handbook.
The facility has one operational TTY device located in booking and receiving, but does not offer
privacy for the detainee who may use the device (Deficiency TA-4). The facility did not have
accommodations for detainees with speech disabilities (Deficiency TA-5).

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE PBNDS, Telephone Access, section (V)(A)(3), the FOD shall
maintain detainee telephones in proper working order and designated facility staff shall inspect
the telephones daily, promptly report out-of-order telephones to the repair service and ensure that
required repairs are completed quickly. This information will be logged.
DEFICIENCY TA-2
In accordance with the ICE PBNDS, Telephone Access, section (V)(B), the FOD “shall have a
written policy on the monitoring of detainee telephone calls. If telephone calls are monitored,
the facility shall:
 Include a recorded message on its phone system stating that all telephone calls are subject
to monitoring.”
DEFICIENCY TA-3
In accordance with the ICE PBNDS, Telephone Access, section (V)(B), the FOD “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.”
DEFICIENCY TA-4
In accordance with the ICE PBNDS, Telephone Access, section (V)(G), the FOD must ensure
that consistent with the order and safety of the facility, “the facility shall ensure that the privacy
of telephone calls by detainees using Accessible Telephones or TTY is the same as other
detainees using telephones.”
DEFICIENCY TA-5
In accordance with the ICE PBNDS, Telephone Access, section (V)(G), the FOD must ensure
that “accommodations shall also be made for detainees with speech disabilities.”

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USE OF FORCE AND RESTRAINTS (UOF)
ODO reviewed the Use of Force and Restraints 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 2008 PBNDS. ODO toured the facility, inspected equipment, interviewed staff,
and reviewed policy and training records.
Based on review of documentation and according to the jail commander and assistant jail
commander, there have been no use of force incidents involving detainees since CCJ began
housing detainees in August 2013. ODO’s review of(b)(7)erandomly selected staff training records
confirmed completion of the 40-hour jail training course which includes training in confrontation
avoidance and the use of force, and completion of annual refresher training. CCJ has an
emergency response team (ERT) on all shifts in the event calculated use of force is necessary.
The training records of five ERT members confirmed current training.
The jail commander, assistant jail commander and (b)(7)e shift supervisors are trained and
authorized to carry the (b)(7)e within the facility. CCJ’s policy expressly prohibits use of
tasers on detainees, and interviews of the staff authorized to carry them confirmed their
understanding of the policy. Supervisory staff have been trained and are authorized to carry
oleoresin capsicum (OC) spray; however, there are no records documenting the OC canisters
have ever been checked for condition or expiration date. A review of facility’s post orders found
responsibility for inspection of chemical agents and related security equipment is not addressed
(Deficiency UOF&R-1). CCJ has a restraint chair, but staff reported it has never been used for
restraining a detainee. ODO confirmed there are handheld video cameras available for use in the
event of a calculated use of force incident, and numerous fixed security cameras were observed
throughout the facility.
CCJ does not have procedures in place addressing after-action review of all use-of-force
incidents (Deficiency UOF&R-2). In addition, ODO’s review of the facility’s use-of-force
policy found it does not address several procedures required by the standard, including use of
force in special circumstances for pregnant detainees, detainees with wounds or cuts and
detainees with special medical or mental health needs. Further, the policy does not address
protective clothing for handling spilled blood and body fluids; participation in a calculated useof-force incident by staff members with a skin disease or skin injury; inspection of areas by a
supervisor following a use-of-force incident that resulted in a blood or body fluid spillage; and
sanitizing of the area, equipment, and articles of clothing. No deficiencies are cited for these
policy omissions because there was no use-of-force incidents allowing assessment of whether the
requirements were met in practice. However, to support compliance in the event of future useof-force incidents, ODO recommends revision of the facility’s policy to address all procedural
requirements of the standard (R-2).

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF&R-1
In accordance with the ICE 2008 PBNDS, Use of Force and Restraints, section (V)(G)(2), the
FOD must ensure, “staff will maintain a written record of routine and emergency distribution of
security equipment and shall specifically designate and incorporate, in one or more post orders,
responsibility for staff to inventory chemical agents and related security equipment at least
monthly to determine their condition and expiration dates.”
DEFICIENCY UOF&R-2
In accordance with the ICE 2008 PBNDS, Use of Force and Restraints, section (V)(P)(1), the
FOD will ensure, “the facility has ICE/DRO-approved written procedures for the After-Action
Review of use-of-force incidents (immediate or calculated) and applications of restraints. The
primary purpose of an After-Action Review is to assess the reasonableness of the actions taken
and determine whether the force used was proportional to the detainee’s actions.”

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