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
Philadelphia Field Office
Clinton County Correctional Facility
McElhatten, Pennsylvania

July 29–31, 2014

COMPLIANCE INSPECTION
CLINTON COUNTY CORRECTIONAL FACILITY
PHILADELPHIA FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................2
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................7
ICE 2000 NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................8
Access to Legal Materials ....................................................................................................9
Detainee Grievance Procedures .........................................................................................10
Food Service ......................................................................................................................12
Medical Care ......................................................................................................................13
Staff-Detainee Communication .........................................................................................17
Suicide Prevention and Intervention ..................................................................................19
Use of Force .......................................................................................................................20

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

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

INSPECTION TEAM MEMBERS

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

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

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ODO
ODO
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections

Clinton County Correctional Facility
ERO Philadelphia

EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Clinton County Correctional Facility (CCCF) in
McElhattan, Pennsylvania, from July 29 to July 31, 2014. CCCF, which opened in 1991, is
owned and operated by the County of Clinton. ERO began housing detainees at CCCF in
January 2004 under a United States Marshall Service contract. Male and female detainees of
security classification levels I through III are detained at the facility for periods in excess of 72
hours. The inspection evaluated
CCCF’s compliance with the 2000
Capacity and Population Statistics
Quantity
NDS.
The ERO Field Office
Director (FOD), in Philadelphia,
Pennsylvania, is responsible for
ensuring facility compliance with the
2000 NDS and ICE policies. No ICE
employees are located at CCCF.
There is no ERO Detention Service
Manager (DSM) assigned to CCCF.

Total Bed Capacity

320

ICE Detainee Bed Capacity

100

Average Daily Population

263

Average ICE Detainee Population

13

Average Length of Stay (Days)

7

Male Detainee Population (as of 07/29/14)

6

Female Detainee Population (as of 07/29/14)

0

A Warden is responsible for oversight of daily facility operations and is supported by(b)(7)e
personnel. CCCF provides food services and PrimeCare Medical provides medical services.
The facility holds no accreditations.
In June 2012, ODO conducted an inspection of CCCF under the 2000 NDS. ODO reviewed
18 standards and found CCCF compliant with six standards. ODO found a total of
28 deficiencies in the remaining 12 standards.
During this inspection, ODO reviewed 15 standards and found CCCF compliant with eight
standards. ODO found a total of 13 deficiencies in the remaining seven standards: Access to
Legal Material (1 deficiency), Detainee Grievance Procedures (3 ), Food Service (1), Medical
Care (3), Staff-Detainee Communication (3), Suicide Prevention and Intervention (1), and Use of
Force (1). ODO made four recommendations 1 regarding facility policy and procedures
(deficiencies) and cited one best practice.
This report details all deficiencies and refers to the specific, relevant sections of the 2000 NDS.
ERO will be provided a copy of this report to assist in developing corrective actions to resolve
all identified deficiencies. ODO discussed preliminary deficiencies with CCCF and ERO
management during the inspection and at a closeout briefing conducted on July 31, 2014.
ODO observed the admissions process of two detainees during the inspection. The detainees
were escorted into the intake area by ERO transport staff with accompanying documentation and
property. The detainees were allowed to make phone calls and were provided the ICE National
Detainee Handbook and facility handbook. Three orientation videos were shown: “CCCF
Orientation,” “Know Your Rights,” and “Prison Rape Elimination Act - What You Need to
1

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

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Know.” Following inventory of funds and property, the detainees were escorted to a private area
and pat searched. The detainees changed into uniforms and were subsequently photographed and
issued facility identification cards. The admission process ended with the detainees being
escorted to the medical unit where they were screened by medical staff prior to being assigned a
housing unit based on their classification.
Detainees are classified by ERO staff prior to arrival at CCCF. ODO’s review of six detainee
files confirmed they included a Risk Classification Assessment and supporting information, and
proper approvals prior to housing unit assignment. ODO verified level I and III detainees are not
housed together, and procedures are in place to prevent commingling outside of the housing
units.
Detainee A-files are maintained by ERO. CCCF has pre-numbered files containing all forms
that must be completed during the admission process. When processing a new detainee, CCCF
intake officers use the next pre-numbered file in sequence. This system is cited as a best practice
because it greatly reduces the time spent assembling detainee files at intake and ensures all
required forms are completed.
All funds, property and valuables are inventoried in the presence of detainees at CCCF.
Detainees sign and receive a copy of the inventory sheet. Completed sheets are placed in the
detention files. Cash and checks are deposited directly into a secure safe accessible only to
CCCF accounting staff. ODO was informed foreign currency is inventoried and stored in the
detainees’ property bags. Valuables are stored in the shift commander’s office, which is
accessible only by supervisory staff. The deputy warden audits detainee property on a monthly
basis. ODO verified the facility’s policy addresses return of funds and property upon release or
transfer.
Detainees are issued the ICE National Detainee Handbook and the facility handbook during the
admissions process. CCCF’s handbook is reviewed annually and the last review was conducted
in May 2014. The handbook covers all the topics required by the standard. ODO reviewed 15
detention files and confirmed all 15 detainees received the facility handbook.
The grievance system at CCCF allows detainees to file informal, formal, and emergency
grievances. However, policy and the facility handbook state there must be attempts to resolve
grievances informally prior to submitting a formal grievance. Nine formal grievances were filed
by detainees in the 12 months preceding the inspection; however, only three were present in
detention files. According to CCCF staff, none involved staff misconduct. The facility
handbook does not provide notice of the right to have the grievance referred to higher levels, the
procedure for contacting ICE to appeal a decision of the Officer In Charge (OIC), and the
information about the opportunity to file a direct complaint about officer misconduct. The
facility initiated corrective action during the course of the inspection.
ODO observed a high level of sanitation throughout the facility. The CCCF shift commander is
the designated fire safety officer. Procedures are in place for handling hazardous materials. The
hazardous materials master index is maintained by maintenance staff and included Material
Safety Data Sheets (MSDS). During the inspection, all flammable and combustible materials
were stored in an approved storage cabinet. Additional MSDS were present in locations where
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hazardous substances were used. Inventories were reviewed and confirmed accurate. ODO’s
inspection confirmed uniform procedures exist within the health service department to ensure the
safe handling, disposal and accountability for all medical sharps. A review of hazardous
materials and medical sharps inventories confirmed their accuracy. Monthly fire drills were
conducted on each shift and documentation was maintained by the shift commander. Fire
prevention, control, and evacuations plans were reviewed and approved by the assistant chief of
the Wayne Township Fire Department on June 13, 2014, who also inspected the facility on this
date. Reports documenting monthly pest control services and water and generator testing were
available in the maintenance shop.
The food service operation at CCCF is managed by facility employees. Staff consists of the food
service manager, (b)(7)e cook foremen, and a crew of(b)(7)einmate workers. No detainees work in
food service. ODO verified all staff and inmate workers are medically cleared to work in a food
service operation, and received Serv-Safe certification. ODO also verified the menus are
certified by a registered dietitian, and religious and medically prescribed meals were provided
and documented. CCCF has a satellite feeding operation. While ODO found the meal carts are
not secured to prevent food tampering, ODO did observe officers supervising the delivery of the
meal carts to the housing units.
The law library is located in a room near the housing units. The law library includes a desktop
computer, a printer and supplies to support legal research and case preparation by detainees.
ODO verified the computer contained a current version of LexisNexis and word-processing
software. Detainees have access to paper, writing utensils, and envelopes. Legal documents can
be printed and copies are made with the assistance of a staff member. The law library policies
and procedures are not posted in the law library. 2 The facility initiated corrective action during
the course of the inspection.
Medical services are provided by Prime Care Medical, Inc., a private contractor. The clinic is
open seven days a week, 16 hours a day and is managed by the Health Services Administrator
(HSA) who is a registered nurse.
ODO observed a detainee undergo intake screening in the clinic while another medical staff
member was making medical record entries. The room is so small there is insufficient space for
a privacy screen, and information on the computer screen can be easily seen by detainees being
examined. There are no negative air flow cells for respiratory isolation at CCCF. The HSA
stated that in the event respiratory isolation is required, the detainee would be transferred to a
local hospital or another facility.
ODO reviewed 23 medical records during the inspection. In three out of 23 records reviewed,
ODO found medical transfer summaries documented TB clearance by means of a chest X-ray in
2009, 2011, and 2012. All three detainees were negative for signs and symptoms of TB, and two
of the detainees received timely chest X-rays at CCCF, which were negative for the presence of
TB. However, the third detainee was transferred from CCCF prior to completion of the chest Xray. The detainee arrived on February 14, 2014, but was not scheduled for a chest X-ray until
February 18, 2014, the date on which the mobile X-ray service was next scheduled to visit the
2

This is a repeat deficiency from ODO’s June 2012 inspection.

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facility. Because he was transferred prior to this date, screening for TB was never completed by
PPD or chest X-ray at CCCF. CCCF’s electronic medical record system triggers an automatic
alert for detainees whose mental health needs require special consideration with respect to
housing, transfer, or transportation. However, the system does not trigger alerts for medical
conditions requiring special consideration, and no alternative, non-electronic mechanism was in
place. As a consequence, no alert was generated for the detainee who did not have TB clearance
prior to transfer.
According to the Warden, there were no detainee suicide attempts or suicide watches since
ODO’s last compliance inspection. ODO verified detainees are screened for suicide during
intake. Although there were no suicide watch records to review, examination of CCCF and
Prime Care suicide prevention and intervention policies confirmed they meet and exceed the
requirements of the NDS. ODO’s review of training files for all medical staff confirmed initial
and annual suicide prevention training was completed. However, documentation of current
training was not present in the training files of (b)(7)e randomly-selected detention staff.
ODO evaluated CCCF’s sexual abuse and assault prevention and intervention program.
Although CCCF was not required to comply with the 2011 PBNDS Sexual Abuse and Assault
Prevention and Intervention (SAAPI) standard at the time of the inspection, ODO noted any
efforts by the facility to comply with the standard’s requirements. The Warden is designated as
the Prison Rape Elimination Act (PREA) coordinator for the facility. CCCF has a policy
addressing sexual abuse and assault, including a clear zero tolerance statement. Staff interviews
supported they are knowledgeable with respect to the PREA program and how to handle any
reports or observations concerning possible sexual abuse or assault. Detainees are informed of
the PREA/SAAPI program, including reporting procedures, by way of the CCCF Guide on
Sexual Abuse and Assault, issued at booking, as well as by means of dormitory postings. CCCF
telephones contain a main menu prompt for reporting PREA incidents to a free, Pennsylvania
state-run PREA hotline, as well instructions for free, anonymous calls to report incidents to the
ICE detainee Helpline. Detainees watch a PREA video, a facility orientation video, and the
American Bar Association “Know Your Rights” video during the orientation and booking
processes. CCCF maintains cooperation with community services. Victims are transported to
the Lock Haven Hospital. The hospital has a Sexual Assault Response Team (SART) complete
with counselors and a Sexual Assault Nurse Examiner (SANE). The Clinton County Women’s
Center is notified to send a rape counselor to respond to the hospital to assist the victim. The
PREA Coordinator stated there have been no reported incidents of sexual abuse or assault at
CCCF to date, and ODO found no cases in the OPR Joint Integrity Case Management System.
CCCF’s Special Management Unit (SMU) for administrative and disciplinary segregation has
two single occupancy cells and 14 double occupancy cells. Separation is afforded by cell
assignment. The cells share a dayroom area in the center of the unit, with access to telephones
and indoor recreational activities. Outdoor recreation is available adjacent to the unit. The SMU
has two showers. ODO’s inspection found the cells were well-lit, adequately ventilated, and
maintained in a sanitary condition. No detainees were on administrative segregation at the time
of the compliance inspection. During the 12 months preceding the inspection, four detainees
were assigned to administrative segregation status, all pending disciplinary hearings. The
hearings were held within 48 hours of the detainees’ placement on administrative segregation
and none were sanctioned with disciplinary segregation. ODO’s review of documentation
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confirmed segregation orders were issued, status reviews were conducted, and the detainees
received privileges and services required by the NDS.
No detainees were on disciplinary segregation at the time of the compliance inspection, and
according to facility staff and ERO, no detainees received disciplinary segregation sanctions
during the 12 months preceding the inspection. ODO’s review of the facility’s policy confirmed
it requires detainees to receive privileges and services consistent with the NDS.
Detainees have opportunities to communicate with ERO and CCCF staff regularly. The ICE
request log included all required information with the exception of the detainee’s nationality and
the date of the request, with staff response and action. All detainee requests reviewed by ODO
were responded to within 72 hours; however, copies of the response were not placed in the
detention files. 3 The detainee handbook does not state that the detainee has the opportunity to
submit written questions, requests or concerns to ICE staff nor does it include the procedure for
doing so, including the availability of assistance. The facility initiated corrective action during
the inspection.
CCCF provides detainees two telephones in each of the 32-bed housing units. Detainees are
notified that telephone calls are subject to monitoring by way of a recording prior to connection
of the call, and by way of a posting in English and Spanish on each phone. Access and usage
rules are addressed in the facility’s handbook and are posted at telephone locations in both
English and Spanish. Speed dial listings for the Department of Homeland Security Office of
Inspector General, various consulates and embassies, and pro-bono services, were present in
each housing unit. Detainees may request to make an unmonitored call by submitting a request
slip to the shift supervisor. The Warden or deputy warden approves and makes arrangements for
the unmonitored call. ODO’s operability check of all phones in the detainee housing areas
confirmed they were in good working order. ERO staff completed weekly inspections of the
phones for the 12 months preceding the inspection.
According to CCCF and ERO staff, no use-of-force incidents involving detainees occurred in the
12 months preceding the inspection. The facility’s policy and training curriculum confirmed
both emphasize confrontation avoidance prior to use of physical force. The policy addresses
video-recording of calculated force incidents, post-incident medical examination, notification of
ERO, and other procedural requirements of the NDS. Only one exception was noted: the policy
does not address after action reviews. The facility initiated corrective action during the
inspection.

3

This is a repeat deficiency from ODO’s June 2012 inspection.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed all six detainees at CCCF to assess the conditions of confinement. Interview
participation was voluntary and none of the detainees expressed allegations of abuse,
discrimination or mistreatment. The majority of detainees reported being satisfied with facility
services, including receipt of the detainee handbook and the ICE National Detainee Handbook;
receipt and replenishment of hygiene kits; access to telephones; visitation procedures; medical
care; and access to recreation, religious services and the law library. All detainees reported
seeing ERO staff in the facility at least twice weekly.
The only complaint shared with ODO during the inspection involved food portions. Several
detainees said the portions are too small. ODO found the menu well-balanced and the caloric
count adequate.

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 15 NDS and found CCCF fully compliant with the following
eight standards:
1.
2.
3.
4.
5.
6.
7.
8.

Admission and Release
Detainee Classification System
Detainee Handbook 4
Environmental Health and Safety
Funds and Personal Property
Special Management Unit-Administrative Segregation
Special Management Unit-Disciplinary Segregation
Telephone Access

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 13 deficiencies in the following seven standards.
1.
2.
3.
4.
5.
6.
7.

Access to Legal Materials
Detainee Grievance Procedures
Food Service
Medical Care
Staff-Detainee Communication
Suicide Prevention and Intervention
Use of Force

Findings for these standards are presented in the remainder of this report.

4

The Detainee Handbook standard was found compliant during the inspection; however, deficiencies related to the
Detainee Handbook are located under Deficiencies DGP-3 and SDC-3.

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ACCESS TO LEGAL MATERIALS (ALM)
ODO reviewed the Access to Legal Material standard at CCCF to determine if detainees have
access to a law library, legal materials, and supplies and equipment to facilitate the preparation
of legal documents, in accordance with the ICE 2000 NDS. ODO toured the law library,
interviewed staff, and reviewed the detainee handbook.
The law library is located in a designated room near the housing units. The law library is welllit, contains sufficient furnishings, and is equipped with adequate equipment, such as a desktop
computer, a printer and supplies, to support legal research and case preparation. ODO verified
the computer contained a current version of LexisNexis and word-processing software.
Detainees have access to paper, writing utensils, and envelopes. Legal documents can be printed
and copies are made with the assistance of a staff member.
Detainees request use of the law library by submitting a request form. Detainees are afforded a
minimum of five hours per week during designated library hours every day between 8 a.m. and 9
p.m. Additional time is available upon request. CCCF policy affords the same law library
privileges to detainees in special management units.
Facility staff informed ODO that illiterate and limited English proficient detainees are provided
assistance with their legal paperwork, as needed. Detainees with appropriate language, reading,
and writing abilities are also allowed to provide assistance. The law library custodian provides
indigent detainees with free envelopes, stamps, notary services, and certified mail for legal
matters.
The facility’s handbook informs detainees that the law library is available for use, the scheduled
hours of access, the procedure for requesting access, the procedure for requesting additional
time, the procedure for requesting legal reference materials not maintained in the law library and
the procedure for notifying a designated employee that library material is missing or damaged.
These policies and procedures are not posted in the law library (Deficiency ALM-1). 5 The
facility initiated corrective action during the course of the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE 2000 NDS, Access to Legal Material, section (III)(Q), the FOD must
ensure the policies and procedures governing access to legal materials, “Shall also be posted in
the law library.”

5

This is a repeat deficiency from ODO’s June 2012 inspection.

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedure standard at CCCF 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 2000 NDS. ODO reviewed detention files, logbooks, policies, and the facility handbook,
and interviewed staff.
The grievance system at CCCF allows detainees to file informal, formal, and emergency
grievances. However, policy and the facility handbook state that an attempt must be made to
resolve the grievance informally prior to submitting a formal grievance (Deficiency DGP-1).
As required by the standard, the detainee must be free to bypass or terminate the informal
grievance process and proceed directly to the formal grievance stage.
Grievance forms are available by submitting a request form, and detainees may obtain assistance
from another detainee or facility staff in preparing a grievance. The facility will forward any
grievances alleging staff misconduct to ERO and has established an appeals process for formal
grievances.
CCCF maintains a written grievance log to document and track grievances filed by detainees.
Nine formal grievances were filed by detainees in the 12 months preceding the inspection, none
of which involved staff misconduct. ODO reviewed the detention files for each of these nine
grievances, but found only three present in the files (Deficiency DGP-2). One involved a
request for a special diet; one a request for a work authorization; and one a lost razor. No
patterns or trends were observed. The standard states a copy of each grievance must remain in
the detainee’s detention file for at least three years.
The facility’s handbook provides notice to detainees of the opportunity to file a formal and
informal grievance, the procedures for filing a grievance and appeal, and the policy prohibiting
staff from retaliating against any detainee for filing a grievance. CCCF’s handbook does not
provide notice of the right to have the grievance referred to higher levels, the procedure for
contacting ICE to appeal a decision of the OIC, and the information about the opportunity to file
a direct complaint about officer misconduct (Deficiency DGP-3). The facility initiated
corrective action during the course of this inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(A)(1), the
FOD must ensure, “The detainee is free to bypass or terminate the informal grievance process,
and proceed directly to the formal grievance stage.”

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DEFICIENCY DGP-2
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(E), the
FOD must ensure, “A copy of the grievance will remain in the detainee’s detention file for at
least three years.”
DEFICIENCY DGP-3
In accordance with the ICE 2000 NDS, Detainee Grievance Procedures, section (III)(G), the
FOD must ensure, “The grievance section of the detainee handbook will provide notice of the
following:
3. The procedures for resolving a grievance or appeal, including the right to have the
grievance referred to higher levels if the detainee is not satisfied that the grievance has
been adequately resolved. The level above the CDF-OIC is the ICE-OIC.
4. The procedures for contacting ICE to appeal the decision of the OIC of a CDF or an
IGSA facility.
6. The opportunity to file a complaint about officer misconduct directly with the Justice
Department by calling 1-800-869-4499 or by writing to:”
In accordance with the Change Notice National Detentions Standards Staff-Detainee
Communication Standard, dated June 15, 2007, the FOD must ensure, until the detainee
handbooks can be revised during the annual update, ICE staff shall ensure that each detainee in
ICE custody is informed in writing the OIG contact information:
DHS OIG Hotline
Write to:
245 Murray Drive, S.E., Building 410
Washington, D.C. 20538
Email to:
DHSOIGHOTLINE@DHS.GOV
OR Telephone
1-800-323-8603

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at CCCF to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE 2000 NDS. ODO
inspected food storage and preparation areas, observed meal preparation and service, reviewed
relevant documentation, and interviewed staff.
The food service operation at CCCF is managed by facility employees. The staff consists of the
food service manager, (b)(7)e cook foremen, and a crew of(b)(7)einmate workers. No detainees work
in food service. ODO reviewed documentation confirming all staff and inmate workers were
medically cleared to work in a food service operation, and staff received Serv-Safe certification.
ODO verified all menus were certified by a registered dietitian, and religious and medically
prescribed meals were provided and documented. ODO observed the preparation and service of
the noon meal on July 30, 2014. Staff and inmate workers wore clean uniforms, gloves, hair nets
and beard guards for facial hair. Staff was seen testing food temperatures using a food
thermometer and actively supervised the work crew. Clean-as-you-go procedures were followed
throughout the course of meal preparation. The meal was sampled and found appetizing, and the
portions were consistent with the menu. Once prepared, food items were placed on thermal trays
and loaded onto carts for transport to the housing units by inmate workers. While the carts were
not secured to prevent food tampering (Deficiency FS-1), ODO observed officers supervising
their delivery to the housing units and service of the trays to detainees.
ODO’s inspection found the kitchen was clean, equipment was in good working order; and the
vent hoods, cooler, freezer, and dry storage area were clean and well organized. Logs for the
walk-in freezer and cooler and for dishwasher water temperatures were reviewed and confirmed
current and in compliance with the standard. Documentation reflects daily and weekly
inspections are conducted by food service staff, and monthly inspections are conducted by the
registered nurse. The food service operation was last inspected by the Clinton County Health
Department in 2013 with no violations of code noted. At that time, the inspector informed
CCCF the health department would no longer conduct inspections of the food service department
because CCCF does not serve food to the public. ODO recommends CCCF request written
notification of that information, and consult ERO as to seeking an alternative external inspection
source (R-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE 2000 NDS, Food Service, section (III)(C)(2)(g), the FOD must ensure,
“Food will be delivered from one place to another in covered containers. These may be
individual containers, such as pots with lids, or larger conveyances that can move objects in bulk,
such as enclosed, satellite-feeding carts. Food carts must have locking devices.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at CCCF to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE 2000 NDS. ODO inspected the area used as the clinic, observed an intake screening,
reviewed policies, procedures and staff training records, verified medical staff credentials, and
interviewed the HSA, junior vice president of operations for Prime Care Medical, Inc., the ICE
Health Service Corps (IHSC) Field Medical Coordinator, on site ERO personnel, and CCCF
administrative and supervisory detention staff. In addition, ODO examined 23 medical records,
including the records of the six detainees housed at CCCF at the time of the inspection, and 17
detainees previously held at the facility.
Medical services are provided by Prime Care Medical, Inc., a private contractor. The clinic is
open seven days a week, 16 hours a day and is administered by the HSA who is a registered
nurse. She is on site eight hours a day, Monday through Friday, and on call during non-business
hours. Clinical oversight is provided by the medical director, a physician, who is on site up to
two hours one day a week and on call 24 hours a day, seven days a week. Additional staff
includes a physician assistant who is on site up to four hours per week and shares on call
coverage with other corporate physician assistants; and (b)(7)e full-time and (b)(7)e as needed,
licensed practical nurses.
Detainees in need of dental care are referred to community providers. Mental health services are
provided by a Prime Care psychiatrist who is on site up to two hours per week, and a clinical
social worker employed by the county who is on site three times weekly for up to 15 hours. All
professional licenses were present and primary source verified with the issuing state boards for
authentication purposes. Based on the current staffing plan, there were no vacancies at the time
of the inspection.
During the hours healthcare staff is not on duty (11 p.m. to 7 a.m.), shift commanders are
responsible for assessing any medical issues which may arise, and for calling the HSA and on
call providers as necessary. Prime Care has a detailed lesson plan, “Health Care Liaison
Training,” which corporate staff stated is presented to the shift commanders annually. However,
inspection of their training files found the training was not documented. During interviews, the
shift commanders stated they did not recall being trained, although they satisfactorily articulated
understanding of general medical issues and when medical staff should be contacted. ODO
recommends providing refresher training to the shift commanders and that the training is
documented in staff training records (R-2). ODO’s review of all medical and(b)(7)erandomlyselected detention officers confirmed all were current in cardiopulmonary resuscitation and first
aid.
In the event a detainee should need medical services beyond the scope of care provided by
CCCF, he or she would be transferred to Lock Haven Hospital or Jersey Shore Hospital, both
about ten minutes away. Detainees requiring mental health care are sent to Divine Providence
Hospital in Williamsport, also about ten minutes away.
Healthcare is provided in a small room used for examinations and treatment, and medication and
supply storage. The room also has a desk with a computer used for making entries to the
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electronic medical record system. There is additional office space for the HSA in a storage room
down the hall from the clinic area. ODO observed a detainee undergo intake screening in the
clinic, while another medical staff member was making medical record entries. The room is so
small there is insufficient space for a privacy screen, and information on the computer screen can
be easily seen by detainees being examined (Deficiency MC-1). CCCF installed a telephone
line in the examination/treatment room for use accessing interpretation services when a language
barrier exists.
Correctional staff conducts initial medical and mental health screenings. ODO’s review of the
intake screening lesson plan confirmed it is adequate, and inspection of(b)(7)erandomly-selected
detention officers’ training records confirmed current training. Consistent with Prime Care
policy, detainees receive subsequent screening by nursing staff within four hours of admission.
All 23 records reviewed documented completion of intake screening by officers and nurses.
There are no negative air flow cells for respiratory isolation at CCCF. The HSA stated that in
the event respiratory isolation is required, the detainee would be transferred to a local hospital or
another facility. The screening, which is completed by officers and nurses, addresses signs and
symptoms of tuberculosis (TB). Testing by way of purified protein derivative (PPD) skin test is
completed by nursing staff, and chest X-rays are completed via mobile X-ray service when
required. In three out of 23 records reviewed, ODO found medical transfer summaries
documented TB clearance by means of chest X-ray in 2009, 2011, and 2012. All three detainees
were negative for signs and symptoms of TB, and two of the detainees received timely chest Xrays at CCCF which were negative for the presence of TB. However, the third detainee was
transferred from CCCF prior to completion of the chest X-ray. The detainee arrived on February
14, 2014, but was not scheduled for a chest X-ray until February 18, 2014, the date on which the
mobile X-ray service was next scheduled to visit the facility. Because he was transferred prior to
this date, screening for TB was never completed by PPD or chest X-ray at CCCF
(Deficiency MC-2).
Of the 23 detainees whose records were reviewed by ODO, 16 were transferred within 13 days
of admission. ODO verified the remaining seven detainees received health appraisals conducted
by the HSA, between five and 12 days following their arrival. Health appraisals included handson physical examinations and examination of the oral cavity for dental caries or other oral cavity
abnormalities. Review by the medical director was documented in all seven cases. The HSA’s
training records included documentation of training in conducting health appraisals.
Detainees access health care services by completing written medical request forms. ODO was
informed the medical request forms are available in the housing units, though during the tour,
ODO noted one housing unit had no request forms. This was corrected immediately by the HSA
during the inspection. ODO recommends that medical staff routinely verify medical request
forms are available in the housing units, replenishing them as necessary (R-3). Detainees deposit
requests in a locked, wall-mounted box for pick-up by medical staff on the evening shift.
According to the HSA, requests are triaged upon receipt for urgency. Because of the short length
of stay at CCCF, the record review identified only six sick call requests. All were triaged and the
detainees were promptly seen. Sick call is conducted daily in the clinic area using Prime Care
nursing protocols signed by the medical director. Of the 23 medical records reviewed, only six
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of the detainees had chronic conditions. Their records documented early enrollment in CCCF’s
chronic care program and monitoring by a provider for the term of detention.
Licensed practical nurses distribute medications and document administration in the electronic
medication administration record (MAR). The system is user friendly and has many useful
features, including automatic calculation of the medication compliance ratio for each medication.
In reviewing MARs, ODO identified a detainee who was prescribed an anti-seizure medication
upon admission. The MAR documented that following the prescription, he did not take three of
six doses of the medication. Nurses recorded a question mark for one of the missed doses,
signifying the reason was unknown; and for the other two, “absent” was recorded, signifying the
detainee did not report to the medication cart.
ODO identified another detainee whose compliance with morning diabetic medications was
marginal in the months of June and July 2014. “Absent” was recorded for the missed
medications. According to the HSA, CCCF does not consider absence the same as refusal of
medication; therefore, no refusal form was signed by the detainees, the provider was not notified,
and the detainees were not counseled on the serious risk of non-compliance. In the first
referenced case, the detainee was taken to the emergency room after having a seizure, and was
transferred from CCCF the day after he returned. The facility’s policy on medication refusal
requires completion of refusal forms, provider notification, and patient counseling. During the
inspection, the HSA changed the procedure to require that nurses individually call for detainees
who do not initially report to the medication cart. Refusals of medication at that point will be
treated as required by facility policy. Adherence to this new procedure will ensure appropriate
follow up to missed medications.
CCCF’s electronic medical record system triggers an automatic alert for detainees whose mental
health needs require special consideration with respect to housing, transfer, or transportation.
This alert is directed to security personnel and the IHSC Field Medical Coordinator. However,
the system does not trigger alerts for medical conditions requiring special consideration, and no
alternative, non-electronic mechanism was in place. As a consequence, no alert was generated
for the detainee who did not have TB clearance prior to transfer (Deficiency MC-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE 2000 NDS, Medical Care, section (III)(M), the FOD must ensure, “All
medical providers shall protect the privacy of detainees' medical information to the extent
possible while permitting the exchange of health information required to fulfill program
responsibilities and to provide for the well being of detainees.
DEFICIENCY MC-2
In accordance with ICE 2000 NDS, Medical Care, section (III)(D), the FOD must ensure, “All
new arrivals shall receive TB screening by PPD (mantoux method) or chest x-ray. The PPD
shall be the primary screening method unless this diagnostic test is contraindicated; then a chest
x-ray is obtained.”

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DEFICIENCY MC-3
In accordance with ICE 2000 NDS, Medical Care, section (III)(N), the FOD must ensure, “When
the medical staff determines that a detainee’s medical or psychiatric condition requires either
clearance by the medical staff prior to release or transfer, or requires medical escort during
deportation or transfer, the OIC will be so notified in writing.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at CCCF 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 2000 NDS. ODO interviewed staff and detainees
and reviewed the Facility Liaison Visit Checklists.
ERO staff conducts weekly scheduled and unscheduled visits to CCCF. ODO reviewed a sign-in
log and interviewed both ERO and CCCF staff to confirm visits are conducted and documented.
ODO reviewed the Facility Liaison Visit Checklists for the 12 months preceding the inspection,
and noted that an Immigration Enforcement Agent (IEA) and a Deportation Officer (DO) are
assigned to the facility to conduct weekly scheduled and unscheduled visits to monitor detention
conditions, and to address inquiries and requests from detainees. A posting of scheduled ERO
visits appeared in all housing units during the inspection.
Detainees have opportunities to communicate with ERO and CCCF staff regularly. Detainee
request forms are available in all housing units. Detainees give all request forms regarding
facility concerns to the housing unit officer. When detainees have requests for ERO, housing
unit officers provide envelopes to detainees so that requests can be sealed and placed in a
separate box for ERO. Detainee requests are collected and logged by ERO staff. The logs
contained all required information except for the detainee’s nationality, the date of the request,
staff’s response and action, and the date of the response (Deficiency SDC-1).
Detainees submitted 31 total requests in the 12 months preceding the inspection. Twelve related
to case status or release date; eight to telephone calls; four regarding property; two for medical
care and five related to miscellaneous issues. ODO verified all detainee requests are responded
to within 72 hours; however, copies of the response are not placed in the detention files
(Deficiency SDC-2). 6
ERO staff documents and completes serviceability tests and the Facility Liaison Visit Checklist
weekly. Department of Homeland Security Office of Inspector General (OIG) hotline posters are
posted in every housing unit. The detainee handbook does not state that detainees have the
opportunity to submit written questions, requests or concerns to ERO staff and the procedure for
doing so, including the availability of assistance (Deficiency SDC-3). The facility initiated
corrective action during the course of the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE 2000 NDS, Staff-Detainee Communication, section (III)(B)(2)(d)(f),
the FOD must ensure “the log, at a minimum, shall contain:
d. Nationality;
f. The date that the request, with staff response and action, is returned to the detainee.
6

This is a repeat deficiency from ODO’s June 2012 inspection.

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In IGSA’s, the date the request was forwarded to ICE and the date it was returned shall
also be recorded.”
DEFICIENCY SDC-2
In accordance with the ICE 2000 NDS, Staff-Detainee Communication, section (III)(B)(2), the
FOD must ensure, “All completed Detainee Requests will be filed in the detainee’s detention file
and will remain in the detainee’s detention file for at least three years.”
DEFICIENCY SDC-3
In accordance with the ICE 2000 NDS, Staff-Detainee Communication, section (III)(B)(3), the
FOD must ensure, “The handbook shall state that the detainee has the opportunity to submit
written questions, requests, or concerns to ICE staff and the procedure for doing so, including the
availability of assistance in preparing the request.”

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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at CCCF to determine if the
health and well-being of detainees are protected by training staff in effective methods of suicide
prevention, in accordance with the ICE 2000 NDS. ODO inspected the suicide watch cells,
interviewed medical, administrative, and training staff, and reviewed suicide prevention policies,
the training curriculum, and staff training records.
According to the Warden, no detainee suicide attempts or suicide watches occurred since ODO’s
June 2012 inspection. The two cells used for suicide watch are monitored by closed circuit
camera. In addition, the facility’s policy states an officer must be stationed directly outside the
cell to maintain constant monitoring during a suicide watch, because the cells have an open bar
grill. The cells were otherwise free from any other protrusions or objects that could assist in a
suicide attempt. A quilted suicide smock and quilted suicide blanket are issued.
ODO verified detainees are screened for suicide risk during intake. Medical staff complete a
screening form based on the New York Risk Assessment Model which uses a point system to
score screening elements. A score of eight or higher results in assignment to suicide watch.
Although there were no suicide watch records to review, examination of CCCF and Prime Care
suicide prevention and intervention policies confirmed they meet and exceed the requirements of
the NDS.
All staff is required to receive initial and ongoing suicide prevention training which addresses
identification of suicide risk factors, recognizing the signs of suicidal thinking and behavior,
referral procedures, suicide prevention techniques, and responding to an in-progress suicide
attempt. According to the deputy warden, CCCF uses a curriculum developed by a psychologist
for the Lycoming-Clinton Mental Health/Intellectual Disabilities Program which is presented by
a psychologist via a video. ODO’s review of training files for all medical staff confirmed initial
and annual suicide prevention training was completed. However, documentation of current
training was not present in (b)(7)e randomly-selected training files (Deficiency SP&I-1). The
deputy warden assured ODO all detention staff are trained annually, though completion of
training is sometimes documented on cards instead of the training files. The cards were not
produced to verify the remaining(b)(7)e officers had current training. ODO recommends CCCF
consolidate training documentation (R-4).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with ICE 2000 NDS, Suicide Prevention and Intervention, section (III)(A), the
FOD must ensure, “All staff will receive training, during orientation and periodically, in the
following: recognizing signs of suicidal thinking, including suspect behavior; facility referral
procedures; suicide- prevention techniques; and responding to an in-progress suicide attempt. All
training will include the identification of suicide risk factors and the psychological profile of a
suicidal detainee.”

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USE OF FORCE (UOF)
ODO reviewed the Use of Force standard at CCCF to determine if necessary use of force is used
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 2000 NDS.
ODO toured the facility, interviewed facility and ERO staff, and reviewed the use of force policy
and staff training records.
According to CCCF and ERO staff, no use-of-force incidents involving detainees occurred in the
12 months preceding the inspection. An ERO Supervisory Detention and Deportation Officer
(SDDO) could not recall when the last use-of-force incident involving a detainee occurred. The
facility’s policy and training curriculum both emphasize confrontation avoidance prior to use of
physical force. The policy addresses video recording of calculated force incidents, post-incident
medical examination, notification of ERO, and other procedural requirements of the NDS. Only
one exception was noted: the policy does not address after action reviews (Deficiency UOF-1).
During the course of the inspection, the policy was amended to include procedures for afteraction reviews and the SDDO documented review and approval of the procedures.
CCCF has Tasers, an electro-muscular disruption device, but policy forbids their use on
detainees. Oleo capsicum (OC) spray is secured and its use must be authorized by a shift
supervisor. ODO’s review of training files for(b)(7)erandomly-selected officers confirmed OC
spray certification and current training in the use-of-force team technique. Inspection confirmed
protective gear and video cameras were available and checked routinely to ensure proper
functioning.

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

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