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
Focus Compliance Inspection

Enforcement and Removal Operations
Houston Field Office
Joe Corley Detention Facility
Conroe, Texas

June 3–5, 2014

FOCUS COMPLIANCE INSPECTION
JOE CORLEY DETENTION FACILITY
ERO HOUSTON FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................2
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................6
ICE 2011 PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................7
Disciplinary System .............................................................................................................8
Food Service ......................................................................................................................10
Grievance System ..............................................................................................................12
Medical Care ......................................................................................................................14
Special Management Units ................................................................................................18
Staff-Detainee Communication .........................................................................................20
Use of Force and Restraints ...............................................................................................22
Visitation ............................................................................................................................24

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

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

INSPECTION TEAM MEMBERS

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

Inspections and Compliance Specialist (Team Lead) ODO
Inspections and Compliance Specialist
ODO
Contractor
Creative Corrections
Contractor
Creative Corrections
Contractor
Creative Corrections

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EXECUTIVE SUMMARY
ODO conducted a focus compliance inspection of the Joe Corley Detention Facility (JCDF) in
Conroe, Texas, from June 3 to 5, 2014. 1 JCDF, which opened in July 2008, is owned by
Montgomery County and operated by GEO Group, Incorporated (GEO). ERO began housing
detainees at JCDF in October 2008 under an intergovernmental service agreement (IGSA)
contract. Male detainees of all security classification levels (Levels I through III) are detained at
the facility for periods in excess of 72 hours. No female detainees are held at JCDF. In addition
to ICE detainees, JCDF also accommodates United States Marshals Service inmates. The
inspection evaluated JCDF’s
Capacity and Population Statistics
Quantity
compliance with the 2011 PBNDS.
The ICE ERO Field Office Director
(FOD) in Houston, Texas, is
responsible for ensuring facility
compliance with the 2011 PBNDS
and ICE policies. (b)(7)e ERO staff
and a Detention Service Manager
work onsite at the facility.

Total Bed Capacity

1,517

ICE Detainee Bed Capacity

1,100

Average Daily Population

1,366

Average ICE Detainee Population

1,059

Average Length of Stay (Days)

28

Male Detainee Population (as of 6/04/14)

898

Female Detainee Population (as of 6/04/14)

N/A

A Warden at JCDF and is responsible for oversight of daily facility operations and is supported
by (b)(7)epersonnel. GEO provides both food and medical services. The facility holds
accreditation from the American Corrections Association (ACA).
In April 2013, ODO conducted a compliance inspection of JCDF under the 2008 PBNDS. ODO
reviewed 16 standards and found JCDF compliant with 14 standards. Two deficiencies were
found in the remaining two standards.
During this inspection, ODO reviewed 11 2011 PBNDS and found JCDF compliant with three
standards. ODO found a total of 19 deficiencies, eight of which relate to priority components, 2
in the remaining eight standards: Disciplinary System (3 deficiencies), Food Service (4),
Grievance System (1), Medical Care (3), Special Management Units (2), Staff-Detainee
Communication (2), Use of Force and Restraints (2), and Visitation (2).
This report details all deficiencies and refers to the specific, relevant sections of the 2011
PBNDS. ERO will be provided a copy of this report to assist in developing corrective actions to
resolve all identified deficiencies. ODO discussed preliminary findings with JCDF and ERO
staff during the inspection and at a closeout briefing conducted on June 5, 2014.

1

On April 18, 2014, ODO received a request from the Houston FOD to inspect JCDF as a result of detainees that
were on a hunger strike from March 17, 2014 to March 28, 2014. Standards selected were based on results of
agency and open-source intelligence gathering from various sources, such as non-governmental organization
concerns reported in the media, allegations reported in the Joint Integrity Case Management System, and the
interrelation among some standards, i.e. Hunger Strike, Medical Care, Food Service and Grievances.
2
Deficient priority components were found in the following six standards: Disciplinary System, Food Service,
Grievance System, Medical Care, Staff-Detainee Communication, and Use of Force and Restraints.

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Upon admission into JCDF, detainees receive a local facility handbook. Although the handbook
notifies detainees of the rules of conduct, prohibited acts and sanctions, and disciplinary and
appeal procedures, the facility does not have written disciplinary policy and procedures clearly
defining detainee rights and responsibilities. In addition, ODO found JCDF’s disciplinary
hearing process for detainees charged with high severity offenses is not always conducted by the
institution disciplinary panel (IDP) as required. Further, the facility’s unit disciplinary
committee (UDC) sometimes adjudicates high-level charges instead of forwarding them to the
IDP.
JCDF has a satellite feeding operation, whereby food trays are delivered to detainees in
individual housing units instead of using a traditional cafeteria setting. Detainee workers are
medically cleared to work in the kitchen, and are paid $3 daily. The master menu is on a 42-day
cycle, and is certified by a registered dietician. ODO discovered issues with the water
temperatures and storage areas in the kitchen. JDCF staff initiated corrective action for these
deficiencies during the inspection.
JCDF maintains a grievance log for tracking informal and formal grievances filed by detainees
and inmates. Forty-five grievances (31 informal grievances, 11 medical grievances and three
formal grievances) were filed within the 12 months preceding the inspection. Of the three formal
grievances filed, two involved allegations of staff misconduct. Staff misconduct grievances were
forwarded to ERO; however, JCDF staff failed to properly notify ICE OPR, as required by the
standard.
On March 17, 2014, 183 detainees declared a hunger strike due to dissatisfaction with food
service and overall treatment at JCDF, specifically dealing with the nutritional value of food and
access to telephones. During the first 72 hours, 160 of the detainees were observed consuming
milk and/or juice. The remaining 23 detainees underwent a clinical assessment, including mental
health and physical evaluations, and were determined to have fasted. Twenty of the 23 detainees
were observed eating the next meal and were monitored for the following two days to ensure that
negative health effects did not result from the fasting event. The remaining three detainees were
placed in isolated housing cells within the medical unit for close observation and supervision by
staff. Of the three detainees, one discontinued his hunger strike on March 25, 2014, and the
other two discontinued their strikes on March 28, 2014. The hunger strike incident was managed
in full accordance with the 2011 PBNDS, and proper notifications were made to ERO. JCDF
staff receives initial and annual hunger strike training.
JCDF is accredited by ACA and is scheduled for a National Commission on Correctional Health
Care (NCCHC) review in September 2014. Healthcare services are provided 24 hours a day,
seven days a week at JCDF under contract with GEO. The Health Services Administrator
(HSA), who is a licensed professional counselor, oversees the clinic, and a full-time physician is
the designated clinical medical authority. The clinic also has mental health and dental services
available onsite. Detainees are screened by certified medical assistants upon arriving at the
facility. Medical intake screening forms do not inquire about a detainee’s gender selfidentification. Hands-on physical examinations are performed by registered nurses (RN) with
documented training. Physical examinations are cosigned by the physician. A dentist completes
screenings within 14 days. Detainees access health care services at JCDF by completing sick
call request forms printed in English and Spanish. Although sick call requests are generally
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responded to appropriately, ODO found that two sick call requests submitted by two transgender
detainees requesting hormone treatment were not properly triaged, and they were not seen, nor
were their requests, evaluated by the physician.
The facility has a comprehensive written policy providing for the prevention, reporting, and
investigation of sexual assaults. There were no reported cases of sexual assault or abuse at the
facility within the past year. The facility compliance administrator is the designated Sexual
Abuse and Assault Prevention and Intervention (SAAPI) program coordinator. JCDF has a
coordinated, multi-disciplinary approach to responding to sexual abuse. The team is made up of
the Warden, compliance administrator, medical staff and designated investigators. The intake
process includes screening detainees for sexual abuse victimization history and risk and for
predatory history to identify potential sexual aggressors. Detainees are also shown a SAAPI
orientation video at the time of admission. Each detainee signs an acknowledgment form to
verify they viewed the video. Detainees are provided information on the SAAPI program via the
facility handbook and through postings located in housing units.
One detainee was in administrative segregation at the time of the inspection, pending a
disciplinary hearing for a rule violation. Sixty-four detainees were housed in the SMU at JCDF
during the 12 months preceding the inspection: 54 on administrative segregation status and ten
on disciplinary segregation status. Although ERO was notified of the detainees placed in
administrative segregation, the administrative segregation orders were not provided to ERO at
the time of notice. Further, ODO found in three disciplinary segregation cases, sanctions were
imposed and the segregation order was issued by the UDC rather than by the IDP.
ERO staff makes weekly scheduled and unscheduled visits. Scheduled visit times and days are
posted in housing units. Visits are documented by ERO on the ICE Facility Liaison Visit
Checklist and in housing unit logbooks. ERO maintains an electronic spreadsheet to track
detainee requests; however, the electronic log does not contain all the required information.
Detainees fill out ICE request forms and submit them to JCDF correctional officers to place in
secure drop boxes. The location of drop boxes for ICE detainees to communicate with ICE
management is not conducive for detainees to communicate directly with ICE.
JCDF has a comprehensive use-of-force policy, which supports confrontation avoidance. The
policy distinguishes immediate and calculated use-of-force protocol. Three use-of-force
incidents (one calculated and two immediate uses of force) occurred within the 12 months
preceding the inspection. After-action reviews were conducted by the facility, and use-of-force
reports were forwarded to ERO. A video recording captured the calculated incident; however, it
did not document close-up images during the medical exam that would have focused on any
absence/presence of injury to the detainee that may have been caused during the incident.
JCDF is a non-contact visitation facility. Detainees are permitted general visitation once weekly.
Legal visits are permitted without restriction. Detainees in segregation are afforded the same
privileges as detainees in general population. Legal representatives are not required to complete
and submit Form G-28 and the form is unavailable in the visitation reception area. Additionally,
the facility’s written policy regarding legal visitation does not address requirements for legal

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assistants working under the supervision of an attorney, the dress code, or the use and procedures
for Form G-28s.
Detainees have the opportunity to participate in the voluntary work program. Detainees
classified at Levels I and II are afforded the opportunity to work and earn money; detainees
classified as Level III are unable to work due to potential security risks. Work assignments are
completely voluntary; however, all detainees must participate in personal housekeeping duties.
Medical clearance forms and work agreements were completed as required by the 2011 PBNDS.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 50 randomly-selected ICE detainees and all six detainees housed in the
Transgender Housing Unit to assess the conditions of confinement at JCDF. Most of the
detainees stated that food service was adequate, and that they received recreation, telephone,
mail and visitation privileges regularly.
Medical Care: Six detainees complained about receiving medical treatment several days after
requesting to be seen. ODO reviewed medical records of these detainees and found, except for
two transgender detainees, sick call requests were either responded to within a reasonable
timeframe (i.e. one to two days), or detainees refused the recommended treatment plans offered
by providers.
Two of the six transgender detainees interviewed stated that they each submitted one sick call
request to receive hormone treatments. ODO reviewed those sick call requests and found that
medical staff denied treatment, stating that hormone treatment therapy was either not available at
the facility, or that it would be the detainee’s burden to pay for the treatments. Further, neither
of the transgender detainees was assessed by a qualified health provider after submitting the sick
call requests. ODO addressed this with ERO leadership while onsite, and was told that ERO
would make arrangements for the two transgender detainees to be immediately seen by
appropriate medical staff.
Facility Handbook: The vast majority of detainees stated they received JCDF’s local handbook.
However, 27 detainees stated they did not receive the ICE National Detainee Handbook. ODO
reviewed a random sample of detention files and found the majority contained signed
acknowledgement forms for the ICE National Detainee Handbook. ODO did not identify any
deficiencies with issuance of any of the handbooks.
Staff-Detainee Communication: Most of the detainees stated they knew how to communicate or
submit request forms to ICE. However, 35 detainees stated they had not interacted with, nor
seen ICE officials in the facility speaking with other detainees. ICE request forms were offered
in the English and Spanish languages, and ODO found that the “Name of Detainee” section of
the Spanish form was improperly translated to read “Nombre de delincuente,” which translates to
“Name of Delinquent.” ODO reviewed the Staff-Detainee Communication standard and found
ERO staff regularly conducts scheduled visits to housing units at least once weekly to address
detainee questions and concerns.

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ICE 2011 PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 11 2011PBNDS and found JCDF fully compliant with the following
standards:
1.
2.
3.

Hunger Strikes
Sexual Abuse and Assault Prevention and Intervention
Voluntary Work Program

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 19 deficiencies in the following eight standards.
1.
2.
3.
4.
5.
6.
7.
8.

Disciplinary System
Food Service
Grievance System
Medical Care
Special Management Units
Staff-Detainee Communication
Use of Force and Restraints
Visitation

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

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DISCIPLINARY SYSTEM (DS)
ODO reviewed the Disciplinary System standard at JCDF 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 2011 PBNDS. ODO toured the facility,
conducted interviews, and reviewed policy, disciplinary records, and the facility handbook.
The facility handbook notifies detainees of the rules of conduct, prohibited acts and sanctions,
disciplinary and appeal procedures, and detainee rights. In addition, ODO observed the rules and
prohibited acts were posted in each housing unit. The facility’s disciplinary policy covers all
elements required with one exception: it does not clearly define detainee rights and
responsibilities (Deficiency DS-1). 3
The facility maintains a tracking log for documenting disciplinary incidents and outcomes.
Sixty-nine disciplinary actions involving detainees occurred in the 12 months preceding the
inspection. In nine cases, the detainees were released from JCDF prior to adjudication, and in an
additional nine cases, the reports were resolved informally. Ten of the remaining 51 cases
resulted in disciplinary segregation sanctions, none of which exceeded 30 days. ODO’s review
of documentation in five cases confirmed investigations were completed within 24 hours, and
hearings were conducted within the required time frame. In three of the five cases, ODO found
the hearings were conducted by the UDC instead of the IDP, though the detainees were charged
with high severity offenses (Deficiency DS-2). 4 According to the standard, the UDC may only
adjudicate high-moderate or low-moderate charges. In addition, the UDC imposed disciplinary
segregation sanctions in these three cases, exceeding its authority (Deficiency DS-3). The
standard states only the IDP may impose disciplinary segregation terms.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DS-1
In accordance with the ICE 2011 PBNDS, Disciplinary System, section (V)(A)(2), the FOD must
ensure, “Each facility holding ICE/ERO detainees in custody shall have a detainee disciplinary
system with progressive levels of reviews, appeals, procedures and documentation procedures.
Written disciplinary policy and procedures shall clearly define detainee rights and
responsibilities. The policy, procedures and rules shall be reviewed annually at a minimum.
DEFICIENCY DS-2
In accordance with the ICE 2011 PBNDS, Disciplinary System, section (V)(F)(1), the FOD must
ensure, “Unresolved cases and cases involving serious charges are forwarded to the institution
disciplinary panel.”
The UDC shall have authority to:
1. Conduct hearings and resolve incidents involving high moderate or low moderate
charges.”
3
4

Priority Component
Priority Component

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DEFICIENCY DS-3
In accordance with the ICE 2011 PBNDS, Disciplinary System, section (V)(H), the FOD must
ensure, “All facilities that house ICE/ERO detainees shall have a disciplinary panel to adjudicate
detainee Incident Reports. Only the disciplinary panel may place a detainee in disciplinary
segregation.”

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at JCDF to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE 2011 PBNDS.
ODO reviewed policy and procedures, inspected the food service area, observed meals being
prepared and served, and interviewed staff and detainees.
GEO operates JDCF’s food service department. Staff includes a food service manager, a
production supervisor,(b)(7)ecook supervisors, a clerk, and a maintenance worker. Additionally, a
work crew of(b)(7)edetainees supports the food service operation on three shifts. The detainee
workers are paid $3 daily. ODO’s review of files for all staff and(b)(7)erandomly-selected detainee
workers confirmed all were medically cleared to work in the food service department. Detainee
workers complete an orientation and training program prior to assignment of designated jobs.
Documentation reflects the facility’s religious, medical, and main menus are certified by a
registered dietician. The master menu is on a 42-day cycle, exceeding the standard. At the time
of the inspection, 64 detainees were on medical diets and none were on religious diets. Special
diet meals are prepared on a separate serving line, and are placed in color-coded trays to make
them easily distinguishable from regular meal trays. Detainees receiving medical diets are
required to sign for their meals. Interviews with officers confirmed they were knowledgeable as
to procedures for reporting refusal of a meal.
The food service manager produced documentation reflecting he conducts quarterly surveys to
seek detainees’ feedback on food quality and to invite suggestions for items to be added or
removed from the menu. ODO’s review of the noon meals served on June 4 and 5, 2014,
confirmed the items served were the same as those listed on the menu, and in the prescribed
portions.
JCDF has a satellite system of meal service. Food service staff were observed taking
temperatures of food in the kitchen and when served in the housing units.
The sack meals issued for detainee transports did not include a fruit item (Deficiency FS-1).
Staff visually inspects detainee workers for visible signs of health or hygiene concerns at the
beginning of each shift. On three occasions in the 90 days preceding the inspection, detainees
were sent back to their housing units to address observed hygiene issues. Detainee workers,
staff, and visitors to the kitchen are all required to wear hairnets and beard nets for facial hair.
ODO observed gloves were worn by all personnel handling food.
The overall sanitation of the kitchen and storage areas during the inspection was good.
Documentation confirmed the food service manager conducts weekly inspections of the food
service area, and a team of staff members headed by the HSA conducts monthly inspections.
Montgomery County Environmental Health Services inspects the JCDF food service operation
annually, and the last inspection was completed on April 17, 2014. No violation or deficiency
was noted in the report. Signs reminding staff and detainees to wash their hands were posted in
the restrooms and at the hand washing locations throughout the kitchen. However, ODO
discovered hot water temperatures at the hand washing sinks in the food preparation area and in
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the employee and detainee restrooms were only lukewarm (Deficiency FS-2). 5 JCDF staff
initiated corrective action during the inspection by adjusting the water temperatures. ODO
retested the water on June 5, 2014, and found them within acceptable ranges. Temperatures for
the coolers, freezers, and dishwashing machines are checked and recorded on each shift, as
confirmed by ODO’s review of logs.
ODO identified two deficiencies during inspection of storage areas. First, in the chemical
storage area, boxes were stacked nearly to the ceiling and were inside the minimum 18 inch
clearance space beneath the sprinkler deflectors required by the standard (Deficiency FS-3).
Stacking boxes too close to sprinklers constitutes a fire hazard, because the coverage range and
effectiveness of the sprinkler system is compromised. While inspecting the dry storage area,
ODO found trash and food items underneath the pallets, and observed open packages of food
items (Deficiency FS-4). JCDF staff initiated corrective action during the inspection. ODO reinspected the chemical and dry storage areas prior to completion of the inspection and found the
deficiencies were corrected.
Pest control services are provided by a local contractor on a monthly and as-needed basis. ODO
observed no signs of vermin or rodent infestation in the food service area.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE 2011 PBNDS, Food Service, section (V)(I)(6)(c)(1), the FOD must
ensure, “Each sack shall include: one piece of fresh fruit, or properly packaged canned fruit (or
paper cup with lid), complete with a plastic spoon.”
DEFICIENCY FS-2
In accordance with ICE 2011 PBNDS, Food Service, section (V)(J)(5)(i), the FOD must ensure,
“Facilities must possess a ready supply of hot water (105-120 F degrees).”
DEFICIENCY FS-3
In accordance with ICE 2011 PBNDS, Food Service, section (V)(J)(5)(e), the FOD must ensure,
“The area underneath sprinkler deflectors must have at least an 18 inch clearance.”
DEFICIENCY FS-4
In accordance with ICE 2011 PBNDS, Food Service, section (V)(K)(7)(c), the FOD must ensure,
“Vigilant housekeeping to keep the room clean and free from rodents and vermin (a drain for
flushing is desirable).”

5

Priority Component

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at JCDF 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 2011 PBNDS. ODO interviewed the grievance officer and ICE personnel assigned to the
facility, and reviewed grievances and grievance logs.
The facility has a comprehensive policy addressing grievance procedures. According to the
grievance officer and policy, staff is encouraged to settle grievances informally, if possible.
ODO’s review confirmed detailed information on the grievance process and appeal procedures
are included in the facility handbook. Prohibition against reprisal for filing a grievance is clearly
stated in both the policy and handbook. The procedures for handling emergency grievances
include the requirement they be brought to the immediate attention of the Warden.
While touring the facility, ODO noted grievance forms are readily available to detainees in the
housing units; however, the mail boxes for submitting grievances are located in the adjacent
hallways. Facility administration informed ODO that plans are underway for relocating
grievance boxes inside the housing units.
JCDF’s grievance officer is responsible for processing all non-medical related grievances and for
submitting weekly reports to ERO on any grievances received. The Director of Nursing
processes medical grievances. Detainees filed 31 informal grievances, 11 medical grievances
and three formal grievances in the 12 months preceding the inspection. Of the three formal
grievances, two alleged staff misconduct and one involved an officer’s behavior. Below are
details on the outcome of each grievance:
Grievance 1: The detainee alleged staff misconduct, stating he was struck by a food tray,
which an officer kicked at him. An internal investigation was initiated. Security camera
video footage did not support the allegation and there were no corroborating witnesses.
Grievance 2: The detainee alleged staff misconduct, stating an officer called him a thief
in the presence of another officer and detainees. The officer resigned when questioned.
Grievance 3: The detainee alleged an officer exhibited unprofessional behavior towards
him. Unfortunately, there are no specifics regarding the actual context of the allegation
since the officer resigned when questioned by the facility.
These grievances alleging staff misconduct were forwarded to ERO; however, JCDF staff did not
forward copies to the ICE Office of Professional Responsibility (Deficiency GS-1). 6 ODO’s
review of documentation reflected all formal and medical grievances were responded to within
the required timeframe.

6

Priority Component

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDING
DEFICIENCY GS-1
In accordance with ICE 2011 PBNDS, Grievance System, section (V)(F), the FOD must ensure,
“Upon receipt, facility staff must forward all detainee grievances containing allegations of staff
misconduct to a supervisor or higher level official in the chain of command. While such
grievances are to be processed through the facility’s established grievance system, CDFs and
IGSA facilities must also forward a copy of any grievances alleging staff misconduct to
ICE/ERO in a timely manner with a copy going to ICE’s Office of Professional Responsibility
(OPR) Joint Intake Center and/or local OPR office for appropriate action.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at JCDF to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE 2011 PBNDS. ODO toured the facility and medical clinic, observed intake screening,
interviewed staff, verified all healthcare staff credentials, and reviewed the medical policies,
procedures, and detainee medical records.
JCDF is accredited by ACA and is scheduled for an NCCHC review in September 2014. JCDF’s
healthcare policies reference adherence to ACA, NCCHC and State of Texas Detention
Standards. Healthcare is provided 24 hours a day, seven days a week under contract with GEO.
Staffing includes the HSA, who is a licensed professional counselor; a full-time physician, who
is the designated clinical medical authority; the Director of Nursing, who is a registered nurse;
(b)(7)e additional registered nurses;(b)(7)elicensed vocational nurses (LVN);(b)(7)ecertified medical
assistants; and(b)(7)e medical records technicians. In addition, a full-time mental health
professional provides onsite mental health services, and tele-psychiatric services are provided by
a contract psychiatrist. Dental services are provided by a full-time dentist and dental assistant,
and radiology services are provided by contract X-ray technicians and a radiologist on an on-call
basis. ODO verified all licenses of GEO healthcare and contract staff were current and primary
source verified. Documentation of current cardiopulmonary resuscitation certification, first aid
and automated external defibrillator (AED) training was present for all health care staff and(b)(7)e
randomly-selected correctional staff.
JCDF’s health services unit (HSU) has a 15-person waiting room with benches and an accessible
restroom. There are six cells equipped with negative air pressure, three of which have security
cameras for monitoring purposes, a mental health counseling room, an infection control office, a
one-chair dental operatory with lab, and a trauma/physician examination room. Due to limited
space in the trauma room, response bags, an AED and the transport stretcher are positioned in the
hall near the negative pressure cells and the HSU rear exit. HSU’s six cells were clean and
equipped with sinks, showers and toilets. Located in an adjacent wing are the medication room,
phlebotomy room, medical records, nurses’ desks and an officer’s station. The HSU areas were
secured throughout the inspection. Mounted needle-disposal boxes and biohazard trash cans
were available in all areas. Stericycle, a private contractor, provides biohazard trash removal on
a weekly basis. Emergency services and care beyond the scope of care available at JCDF are
provided by Conroe Regional Medical Center located ten minutes from the facility.
Montgomery County Emergency Medical Services provides emergency ambulance transport
with a response time of five to ten minutes.
New detainees are screened by nursing staff in a dedicated medical room, which has four desks
and a small dental examination area, each separated by a privacy screen. A telephone is
available in one of the screening areas for telephonic interpretation services, as needed. ODO’s
review of screening forms confirmed they document past and present medical problems, mental
illness, infectious disease, substance abuse and withdrawal, history of physical or sexual
victimization, and dental needs. However, they did not include a screening element for detainees
who self-identify as transgender (Deficiency MC-1). 7 In all 30 detainee medical records
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reviewed, documentation of intake screening within 12 hours of arrival was present, with review
and signature of the physician occurring within 24 hours. Procedures are in place for prompt
physician evaluation of detainees who have a chronic health condition, and for detainees who
arrive with medication.
Detainees are screened for tuberculosis (TB) upon intake by way of chest X-ray. A mobile
digital X-ray machine is on site, made available through a contract with Corridor Mobile
Medical Services. X-rays are completed by contract X-ray technicians and read by a contract
radiologist, with results reported within hours. The medical record review confirmed completion
of TB screening in all 30 cases. The written infection control plan addresses all subject matter
mandated by the 2011 PBNDS, and review of logs and reports confirmed routine reporting to the
Texas State Health Department. JCDF, through GEO, participates in an international TB control
program to support continuity of treatment and follow-up care. English and Spanish versions of
educational pamphlets on communicable diseases were available in the HSU waiting room.
Health appraisals, which include dental screenings and hands-on physical examinations, are
conducted by registered nurses who have documented training in performing these functions.
ODO verified the health appraisals were conducted and reviewed by the physician within the
required 14-day timeframe. In addition to the dental screening conducted by the nurses, the
dentist conducts a baseline dental examination on all detainees.
ODO’s medical record review included 20 detainees with chronic health conditions, including
stabilized hypertension and diabetes. Treatment plans were present in the records and included
documented diagnostic testing and monitoring, with follow-up clinic scheduling through the
GEO Track System.
The full-time mental health professional is responsible for reviewing intake mental health
screenings, conducting suicide risk assessments, and conducting mental health evaluations upon
referral. The medical record review identified two cases in which detainees were referred for
mental health evaluation, and in both cases, the evaluations were completed within 72 hours as
required by the standard. The mental health professional acts in concert with the contract
psychiatrist, who is available via tele-psychiatry every Thursday, to provide consultation and see
patients. In addition, the psychiatrist is available 24 hours a day, seven days a week for
consultation and patient encounters in urgent situations. Prior to any tele-psychiatry session, the
mental health professional faxes pertinent documentation, including case notes, laboratory
reports, and medication administration records. Upon completion of the session, the psychiatrist
immediately faxes a progress note back to the mental health professional for review and filing, as
well as any medication orders. ODO’s medical record review identified two detainees who were
receiving psychotropic medications. In both cases, the detainees signed consent statements
specific to the medications ordered.
According to the HSA, nurses conduct rounds in the general population housing units and in the
SMU twice daily, during which sick call requests are gathered. The same day, a registered nurse
date-stamps the requests and determines if the need is urgent, routine, or for written response
only. Tracking numbers are assigned to each sick call request for referencing all subsequent
assessments, treatment, and follow-up for each specific problem. ODO’s review of 30 medical
records confirmed appropriate triage the same day of the request. However, as a result of
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detainee interviews, ODO also reviewed the sick call requests of two transgender detainees who
alleged they each submitted one sick call request to medical for hormone therapy treatments.
ODO found that the sick call requests were not properly triaged, as neither detainee was given an
assessment by appropriate medical personnel (Deficiency MC-2). 8 As a result, the requests for
hormone treatments were arbitrarily denied by medical staff (Deficiency MC-3). JCDF medical
staff formally stated that it was either not available at the facility, or that treatments would be
offered at the detainee’s expense. ODO addressed this with ERO leadership while onsite, and
was told that ERO would make arrangements for the two transgender detainees to be seen
immediately by appropriate medical staff. For non-urgent medical issues beyond the nurses’
knowledge or scope of practice, appointments with the physician are scheduled using the GEO
Track System. Physician assessments were typically completed and provided the same or next
day. For routine healthcare needs, physician-approved nursing protocols are utilized to
administer over-the-counter medications. Instructions and patient information were consistently
documented.
ODO’s review of JCDF’s emergency plan found it was complete. Emergency contacts were
posted and documentation reflected the emergency go-bag was recently inventoried and sealed.
Orientation and annual training of medical staff in the use of emergency equipment were
verified. Two emergency response drills were conducted during the 12 months preceding the
inspection.
Pharmacy services are provided through GEO’s contract with Correct Rx, a private correctional
pharmacy company which fills patient-specific prescriptions using the blister-pack system.
Medication orders are sent via fax before 4 p.m. and the prescription arrives the next morning.
Emergency medication orders are filled by a local community pharmacy. In addition to
providing medications, a Correct Rx pharmacist visits JCDF quarterly to review inventories,
medication administration records (MAR), error reports and prescription practices. In addition,
the pharmacist facilitates a quarterly meeting with healthcare administrative staff to discuss
findings. Medications are distributed by(b)(7)ecertified medical assistants using secure medication
carts. The carts are taken to the housing units and SMU twice daily, at 8 a.m. and 4 p.m., with
provisions made for more frequent administration of medications, if ordered. ODO observed
medication distribution by the certified medication assistants and found the process was efficient
and professional, and officers assisted by controlling the queue and checking to ensure detainees
swallowed their medications. ODO’s review of 48 MARs found entries were legible and
complete.
Administrative meetings are held quarterly, at which time healthcare statistics, infectious disease
control, and performance improvement activities are reviewed. Signed attendance rosters
documented participation by ten or more representatives of various JCDF departments, including
the health services administrator, mental health professional, assistant warden, the major,
compliance administrator, and managers for the training safety, and food service departments.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE 2011 PBNDS, Medical Care, section (V)(J)(15), the FOD must ensure,
“The [intake] screening shall inquire into the following:
15. A transgender detainee’s gender self-identification and history of transition-related care,
when a detainee self-identifies as transgender.”
DEFICIENCY MC-2
In accordance with ICE 2011 PBNDS, Medical Care, section (V)(Q)(4), the FOD must ensure,
“Each facility shall have a sick call procedure that allows detainees the unrestricted opportunity
to freely request health care services (including mental and dental services) provided by a
physician or other qualified medical staff in a clinical setting. This procedure shall include:
4. An established procedure shall be in place at all facilities to ensure that all sick call
requests are received and triaged by appropriate medical personnel within 24 hours after
a detainee submits the request. “
DEFICIENCY MC-3
In accordance with ICE 2011 PBNDS, Medical Care, section (V)(U), the FOD must ensure, “All
transgender detainees shall have access to mental health care, and other transgender-related
health care and medication based on medical need. Treatment shall follow accepted guidelines
regarding medically necessary transition-related care.”

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SPECIAL MANAGEMENT UNIT (SMU)
ODO reviewed the Special Management Unit (SMU) standard at JCDF to determine if the
facility has procedures in place to temporarily segregate detainees for disciplinary and
administrative reasons, in accordance with the ICE 2011 PBNDS. ODO toured the SMU,
interviewed staff, and reviewed policies, log books and available SMU documentation.
JCDF’s F unit is designated as the SMU for detainees assigned to administrative and disciplinary
segregation, with separation afforded by cell assignment. The unit is on one level with five
single-occupancy cells. The beds, toilet, sink, desk, and stool are affixed to the cell walls. There
is a day room and a shower for detainee use. There are seven outdoor recreation enclosures.
ODO’s inspection verified the unit is well lit, maintained in good sanitary condition and properly
ventilated.
Per the policy and in accordance with the 2011 PBNDS, disciplinary segregation is a sanction
imposed through the disciplinary process, and administrative segregation is a non-punitive form
of separation from the general population when the presence of the detainee poses a serious
threat to self, other detainees, staff, property, or the security and orderly operation of the facility.
Detainees in segregation have access to the telephone and legal materials by request. The
telephone is on a portable cart brought to the cells, and a portable computer equipped with LexisNexis is available. Detainees are provided with books for leisure reading via a mobile library
cart. JCDF policy allows visiting privileges for detainees housed in SMU, consistent with the
general population. Detainees are offered recreation and showers daily.
No detainees were housed in disciplinary segregation during the inspection, and one detainee
was on administrative segregation pending a disciplinary hearing for refusing a housing
assignment. During an ODO interview, the detainee stated he wanted to remain in segregation,
and refused to return to the general population.
ODO reviewed documentation and conducted interviews with staff and learned 64 detainees
were housed in the SMU during the 12 months preceding the inspection, 54 in administrative
segregation and ten in disciplinary segregation. ODO reviewed documentation for 15 detainees
assigned to administrative segregation and confirmed segregation orders were completed and
provided to the detainees. ERO was notified the detainees were placed on administrative
segregation; however, administrative segregation orders were not forwarded (Deficiency SMU1). The detainees were placed in administrative segregation, because they were either awaiting a
disciplinary hearing, or because they requested to be placed in protective custody. Of the 15 files
reviewed, the longest duration of administrative segregation was seven days.
ODO’s review of documentation for five of the ten detainees placed in disciplinary segregation
found that in three cases, the sanctions were imposed and the segregation order was issued by the
UDC rather than by the IDP (Deficiency SMU-2). Documentation reflects 72-hour and seven
day reviews were conducted in the administrative and disciplinary segregation cases and
detainees received privileges and services required by the standard and facility policy.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU-1
In accordance with the ICE 2011 PBNDS, Special Management Units, section (V)(A)(2)(g), the
FOD must ensure, “A copy of the administrative segregation order shall also be immediately
provided to the Field Office Director or his designee.”
DEFICIENCY SMU-2
In accordance with the ICE 2011 PBNDS, Special Management Units, section (V)(B)(2)(a), the
FOD must ensure, “A written order shall be completed and signed by the chair of the IDP (or
disciplinary hearing officer) before a detainee is placed into disciplinary segregation.
a. Prior to a detainee’s actual placement in disciplinary segregation, the IDP chairman shall
complete the disciplinary segregation order (Form I-883 or equivalent), detailing the reasons
for placing a detainee in disciplinary segregation. All relevant documentation must be
attached to the order.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at JCDF 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 2011 PBNDS. ODO reviewed policies,
procedures, request forms, and logs; and interviewed detainees and staff.
Detainees complete ICE request forms and submit them to JCDF correctional officers. Officers
collect the forms and drop them in secure drop boxes located outside of housing units. Although
the facility provides drop boxes for detainees to communicate with ICE management, the
location of these boxes is not conducive for detainees to communicate “directly” with ICE
(Deficiency SDC-1). 9 Detainee requests were responded to within three business days of
receipt. ODO verified copies of responses to the requests were placed in detention files. The
facility handbook lists procedures for detainees to submit written questions, requests or concerns
to ERO. JCDF and ICE staff tests all telephones weekly. ERO staff documents and completes
weekly telephone serviceability tests. The DHS Office of Inspector General Hotline posters
were observed in every housing unit and in appropriate common areas.
ICE ERO staff makes one scheduled and one unscheduled visit weekly to the detainee housing
units. The AFOD and SDDO make at least monthly visits to the facility to ensure compliance
with the 2011 PBNDS. The days and times for scheduled visits are posted in the housing units.
During these visits, ICE ERO staff checks on the conditions of the facility and responds to
detainee requests. Visits are documented by ICE ERO on the ICE Facility Liaison Visit
Checklist and in housing unit logbooks. Responses to detainee requests are logged
electronically.
The electronic log captures the date of receipt; detainee’s name, A-number and nationality; the
name of the staff member who logged the request; the date the request was returned to the
detainee; and other pertinent information. However, ODO found the electronic log does not
contain a data field that addresses urgent requests and reasons why a faster response time is
required (Deficiency SDC-2). Through interviews with ICE staff, ODO learned JCDF staff tries
to respond to all requests within one day. Staff stated they have never experienced an urgent
request requiring a faster response time.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE 2011 PBNDS, Staff-Detainee Communication, section (V)(B), the
FOD must ensure, “The facility shall provide a secure-drop box for ICE detainees to correspond
directly with ICE management. Only ICE personnel shall have access to the drop-box.”

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DEFICIENCY SDC-2
In accordance with the ICE 2011 PBNDS, Staff-Detainee Communication, section (V)(B)(2)(h),
the FOD must ensure, “All requests shall be recorded in a logbook (or electronic logbook)
specifically designed for that purpose. At a minimum the log shall record:
h. specific reasons why the detainee’s request is urgent and requires a faster response.”

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USE OF FORCE AND RESTRAINTS (UOF&R)
ODO reviewed the Use of Force and Restraints standard at JCDF 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 2011 PBNDS. ODO toured the facility, inspected security equipment, interviewed
staff, and reviewed the local policies, training records, and use of force documentation.
JCDF has a comprehensive use-of-force policy addressing all requirements of the 2011 PBNDS,
including confrontation avoidance and using force only as a last resort. A review of(b)(7)e
randomly-selected staff training records confirmed staff is trained on the use of force and
restraints in accordance with the standard; however, ODO found the training curriculum does not
address procedures governing forced medication (Deficiency UOF&R-1). The facility training
officer initiated corrective action during the inspection by developing a lesson plan addressing
the forced medication component.
ODO verified trained staff is available on all shifts in the event the need arises to assemble a
calculated use of force team. The facility also has a Certified Emergency Response Team
(CERT). ODO found protective equipment is readily accessible to team members and is stored
in a secure room with staff-only access. Video cameras are available in the control center and
are tested for operability each shift.
The JCDF use-of-force policy has provisions for use of four/five-point restraints when
ambulatory restraints are insufficient to protect and control a detainee. Oleoresin Capsicum
(OC) spray is authorized in accordance with facility policy, and ODO’s review of training
records confirmed current certification for staff authorized to deploy OC spray. Electromuscular disruption devices are not used at JCDF.
According to staff interviews and based on review of documentation, ODO determined there was
one calculated and two immediate use-of-force incidents in the 12 months preceding the
inspection. Review of written documentation and video recordings for the calculated use of
force incident found the detainee was in a single cell in the medical unit and causing harm to
himself by banging his head on the door. After unsuccessful attempts at avoiding physical
intervention, OC was used, and the five person team entered the cell and escorted the detainee to
a medical examination area. The video recording did not include close-ups of the detainee’s
body during the medical exam, focusing on the presence/absence of injuries (Deficiency
UOF&R-2). 10 Facility staff identified the deficiency during the after-action review of the
incident. In the two immediate incidents, force was used to gain control of detainees who were
assaulting staff. ODO confirmed after-action reviews were conducted, and ERO was notified in
all three use-of-force cases.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF&R-1
In accordance with the ICE 2011 PBNDS, Use of Force and Restraints, section (V)(D)(1)(l), the
FOD must ensure, “All new officers shall be sufficiently trained during their first year of
employment. Through ongoing training (to occur annually at a minimum), all detention facility
staff must be made aware of their responsibilities to effectively handle situations involving
aggressive detainees.
At a minimum, training shall include:
l. forced medication procedures.”
DEFICIENCY UOF&R-2
In accordance with the ICE 2011 PBNDS, Use of Force and Restraints, section (V)(I)(2)(e), the
FOD must ensure, “While ICE/ERO requires that all use-of-force incidents be documented and
forwarded to ICE/ERO for review, for calculated use of force, it is required that the entire
incident be audio visually recorded. The facility administrator or designee is responsible for
ensuring that use of force incidents are audio visually recorded. Staff shall be trained in the
operation of audiovisual recording equipment. There shall be a sufficient number of cameras
appropriately located and maintained in the facility. The audiovisual record and accompanying
documentation shall be included in the investigation package for the after-action review
described below.
Calculated use-of-force incidents shall be audio visually-recorded in the following:
e. Take close-ups of the detainee’s body during a medical exam, focusing on the
presence/absence of injuries. Staff injuries, if any, are to be described but not shown.”

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VISITATION (V)
ODO reviewed the Visitation standard at JCDF to determine if authorized persons, including
legal and media representatives, are able to visit detainees within security and operational
constraints, in accordance with the ICE 2011 PBNDS. ODO reviewed policies, the facility
handbook, and postings, and interviewed staff and detainees.
Visiting rules and hours are written in the facility handbook, posted in the housing units, and
accessible to the public via ERO’s website, by telephone, and in the visitor waiting area in both
English and Spanish. Each detainee is permitted one visit from family or friends weekly, not to
exceed one hour in duration. General visitation hours are available Thursday, Friday, Saturday,
Sunday, and federal holidays. Legal visits have no limit in frequency or duration, and are
available 24 hours per day, seven days per week. Detainees in administrative or disciplinary
segregation have the same visiting privileges as the general population. JCDF is a non-contact
visitation facility.
JCDF maintains a paper log for legal visits and a separate electronic record of all general
visitors. Incoming property for detainees is accepted by mail only, with the exception of legal
documents and materials. Visitors may deposit money into a detainee’s commissary account
through a kiosk in the main entrance lobby. JCDF maintains a dress code for visitors, which is
made available to the public by way of waiting room postings, telephone operator, and facility
handbook.
Consular officials and community service organization representatives are permitted to visit
detainees. Visiting legal representatives do not complete and submit a Form G-28, and the Form
G-28 is not available in the visitation reception area (Deficiency V-1). The facility initiated
corrective action during the inspection. JCDF maintains a written legal visitation policy which
specifies visitation hours, procedures and standards. However, the policy does not address dress
code, legal assistants working under the supervision of an attorney, and Form G-28 requirements
(Deficiency V-2). The facility initiated corrective action during the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY V-1
In accordance with the ICE 2011 PBNDS, Visitation, section (V)(J)(8), the FOD must ensure,
“Once an attorney-client relationship has been established, or if an attorney-client relationship
already exists, the legal representative shall complete and submit a Form G-28, available in the
legal visitation reception area. Staff shall collect completed forms and forward them to
ICE/ERO.”
DEFICIENCY V-2
In accordance with the ICE 2011 PBNDS, Visitation, section (V)(J)(15), the FOD must ensure,
“The facility’s written legal visitation policy shall be available upon request. The site-specific
policy shall specify visitation hours, procedures and standards and address, at a minimum, the
following:

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b. dress code
c. legal assistants working under the supervision of an attorney
e. Form G-28 requirements”

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