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
San Antonio Field Office
LaSalle County Regional
Detention Center
Encinal, Texas

March 5 – 7, 2013

COMPLIANCE INSPECTION
LASALLE COUNTY REGIONAL DETENTION CENTER
SAN ANTONIO FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...............................................................................................1
INSPECTION PROCESS
Report Organization .................................................................................................6
Inspection Team Members .......................................................................................6
OPERATIONAL ENVIRONMENT
Internal Relations .....................................................................................................7
Detainee Relations ...................................................................................................7
ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ................................................................................8
Environmental Health and Safety ............................................................................9
Food Service ..........................................................................................................10
Funds and Personal Property .................................................................................12
Medical Care ..........................................................................................................13

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the LaSalle County Regional Detention
Center (LCRDC) in Encinal, Texas, from March 5 to 7, 2013. LCRDC, which opened in 2004,
is owned by La Salle County and operated by Emerald Correctional Management (ECM). The
U.S. Immigration and Customs Enforcement (ICE), Office of Enforcement and Removal
Operations (ERO) began housing detainees at LCRDC in December 2004 under an
Intergovernmental Service Agreement with ECM and the US Marshals Service. Male and
female detainees of all security classification levels (Level I - lowest threat; Level II - medium
threat; Level III - highest threat) are detained at the facility for periods in excess of 72 hours.
LCRDC allocates a total of 200 beds for ICE detainees. At the time of this CI, LCRDC housed
91 ICE detainees (82 male; 9 female). The average daily detainee population at LCRDC is 79.
The average length of stay for an ICE detainee at LCRDC is 11 days. ECM provides food
service and medical care. LCRDC holds accreditation from the American Correction
Association.
The ERO Field Office Director (FOD) in San Antonio, Texas (ERO San Antonio) is responsible
for ensuring facility compliance with ICE policies and the ICE National Detention
Standards (NDS). The Assistant Field Office Director (AFOD) assigned to the Laredo Detention
Center in Laredo, Texas, maintains oversight of LCRDC. There is no ICE staff stationed at
LCRDC. (b)(7)e Deportation Officers (DO) and (b)(7)eImmigration Enforcement Agent assigned to
the Laredo Detention Center monitor compliance with the ICE NDS, and interact with LCRDC
staff and detainees. ICE personnel conduct multiple scheduled and unscheduled visits each
week. There is no Detention Service Manager assigned to LCRDC.
The Warden is the highest-ranking official at LCRDC, and is responsible for oversight of daily
operations. In addition to the Warden, LCRDC supervisory staff consists of an Assistant
Warden (b)(7)eLieutenants, and(b)(7)eSergeant. There are(b)(7)enon-supervisory LCRDC staff
members.
In July 2011, ERO Detention Standards Compliance Unit contractor, MGT of America,
conducted an annual review of the NDS at LCRDC. LCRDC received a recommended rating of
“Acceptable” and was found compliant with 34 of 35 standards reviewed. LCRDC was found
non-compliant with the Key and Lock Control NDS.
This is the first ODO inspection of LCRDC. During this CI, ODO reviewed 18 NDS and found
LCRDC compliant with 14 standards. ODO found seven deficiencies in the following four
standards: Environmental Health and Safety (1 deficiency), Food Service (2), Funds and
Personal Property (1), and Medical Care (3).
This report details all deficiencies and refers to the specific, relevant sections of the NDS. ERO
will be provided a copy of this report to assist in developing corrective actions to resolve all
identified deficiencies. These deficiencies were discussed with LCRDC and ICE personnel
during the inspection, as well as during the closeout briefing conducted on March 7, 2013.

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Overall, ODO found LCRDC to be orderly and well managed. ODO attributes the high level of
compliance to the presence of an LCRDC Compliance Manager. The LCRDC Compliance
Manager monitors compliance with the ICE NDS; revises the facility handbook annually;
maintains records, logs, policies, and procedures; and addresses issues affecting the health and
welfare of ICE detainees. The LCRDC Compliance Manager meets with ICE staff on a weekly
basis to discuss detention oversight issues.
Sanitation throughout the facility, including the food service area, the medical clinic, and the
admission and release area was good overall; however, ODO observed two showers in housing
unit N with a buildup of soap scum, and one shower in housing unit P with trash on the floor and
mildew. Facility management was briefed on these conditions during the inspection.
During the admissions process, detainees are medically screened, attend a facility orientation,
and receive an LCRDC facility handbook and an ICE National Detainee Handbook. Both
handbooks are available in English and Spanish. An ICE orientation video and an LCRDC
orientation video are shown to detainees during the admissions process. Detainee property is
inventoried and logged during the intake process, and documented on a personal property form
attached to an individual property bag. Valuables and personal property are appropriately stored
in a secure area. Upon release, detainees sign a receipt for valuables and personal property, are
fingerprinted, and surrender facility-issued clothing and bedding.
LCRDC has a dedicated law library in a quiet area, containing adequate office furnishings. The
law library has five computers equipped with the most recent version of LexisNexis, two
typewriters, and a copier. Law library hours are conspicuously posted in the library and in the
detainee housing units. The facility handbook also provides guidance on use of the law library.
Additional legal materials are available in hardcopy format in the law library. An LCRDC staff
member assigned to the law library is available to assist detainees upon request.
ODO confirmed ERO classifies detainees using the ICE Detainee Classification System, and
LCRDC adheres to the classification levels assigned by ERO. ODO reviewed 24 detention files
and confirmed each file contained verification of supervisory review and approval. The facility
handbook addresses classification, reclassification, and appeal procedures.
LCRDC has a detainee grievance system that allows detainees to file informal, formal, and
emergency grievances, and to appeal grievance decisions. ODO verified grievance forms,
printed in English and Spanish, are available in all housing units. The detainee handbook
contains comprehensive information regarding grievance procedures, and all detainees
interviewed were aware of the grievance process and the opportunity to file grievances. There is
a secure grievance box in every housing area where detainees can deposit grievance forms.
There are procedures to assist illiterate, disabled, and non-English speaking detainees who wish
to file a grievance. A detainee can also request assistance directly from LCRDC staff. Facility
management seeks to resolve informal grievances at the lowest possible level; however,
detainees can initiate the formal grievance process at any time by submitting a grievance form.
There were no grievances filed between January 2012 and the date of the ODO inspection. ODO
attributes the lack of grievances to frequent interaction by ICE staff with detainees on an ongoing
basis.

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Disciplinary policy at LCRDC addresses all NDS requirements. Prohibited acts, sanctions, the
disciplinary process, detainee rights, and appeal procedures are addressed in the facility
handbook, and are reviewed with detainees during orientation. Postings in housing units list
prohibited acts and sanctions. ODO confirmed there were no detainee disciplinary incidents
between January 2012 and this ODO inspection. A review of 20 randomly selected detainee files
found no history of disciplinary incidents.
ODO verified LCRDC maintains a master index of hazardous substances and Material Safety
Data Sheets (MSDS). MSDS were present in locations where substances are stored and used;
however, the master index and MSDS are not reviewed semi-annually or on any scheduled basis.
Weekly and monthly fire and safety inspections are properly documented. Evacuation diagrams
in English and Spanish are prominently posted throughout the facility. The diagrams include the
location of emergency equipment and directional arrows for traffic flow. Fire drills are
conducted monthly, and include testing of emergency keys.
All work associated with the preparation and service of meals is performed by contractor ECM.
No ICE detainees or inmates work in the food service department. Review of employee records
confirmed all staff members are medically cleared to work in food service, and are certified for
food safety via the Texas AgriLife Extension Service Food Handler Program. A review of the
master cycle menu confirmed it is reviewed annually by the Food Service Director and certified
by a registered dietician. The dietician provides nutritional analysis for both the regular and
special diet menus. ODO confirmed the menu includes a minimum of two hot meals per day. At
the time of the review, five detainees were on medically-ordered diets. LCRDC policy includes
provisions for religious diets, and the facility handbook contains instructions for requesting
religious diets.
The facility has a satellite system of meal service involving preparation of meals in the food
service kitchen and delivery to the detainee housing units. At the time of the inspection,
detainees were not required to turn in plastic drinking cups and plastic eating utensils after
meals; detainees retained and re-used them on an on-going basis. This practice did not ensure
the items were properly sanitized to prevent illness caused by bacteria. In response to this
finding, the Quality Control Manager directed that all cups and utensils be returned with food
trays upon completion of meals, and amended LCRDC policy and procedure to require issuance
of sanitized cups and utensils for every meal. Inspection confirmed food preparation equipment
was clean, properly installed, and equipped with emergency gas shut-off valves; however, the
meat slicer was not equipped with an anti-restart device. Equipment powered by electricity stops
working when electrical power is interrupted. Once power is restored, the equipment restarts
automatically, which creates a significant safety hazard. Prior to completion of the review, the
Assistant Warden contacted the company from which the machine was purchased to assess and
rectify the issue.
Detainee property is inventoried quarterly, and valuables are inventoried weekly; however,
procedures were not in place to audit detainee funds. Facility management revised LCRDC
policy to require a weekly audit of detainee funds to correct this deficiency going forward.
Routine audits ensure an accurate accounting of funds.

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Medical services are managed by contractor ECM, with on-site administrative oversight by the
Health Services Administrator (HSA). The designated Clinical Medical Authority (CMA) is a
physician. The CMA provides on-site medical and psychiatric services one day each week, and
is on-call 24 hours a day. (b)(7)eemergency medical technicians and (b)(7)elicensed vocational nurses
work 12-hour shifts and provide 24 hour clinical coverage. (b)(7)epart-time registered nurse (RN)
is responsible for conducting a physical examination (PE) within the 14-day NDS requirement.
A (b)(7)e RN is available on an as-needed basis to assist when volume is high. A family nurse
practitioner provides female health care and referral examinations one day each week. A dentist
is on-site two days each month to provide routine dental services. The Clinical Director provides
routine mental health evaluations and treatment, with supplementary mental health services
provided under contract by a community agency. There have been no detainee deaths at
LCRDC.
Initial health screenings are completed by nurses in a designated area of the intake processing
department. A review of 30 medical records confirmed completion of chest x-rays to screen for
tuberculosis within 24 hours of admission, and a follow-up purified protein derivative skin test at
the time of the PE. Each PE is completed by a trained RN and reviewed by the physician. ODO
notes documentation of PE training is present in the credential files for all nurses. ODO found in
four of the 30 cases reviewed, an RN completed an examination from one to three weeks beyond
the 14 days required by the NDS. In two other cases, the physician failed to review the PE
within the required 14 days. The PE process is not complete until finalized by a physician. A
review of PE documentation confirmed it is hands-on; however, the dental examination section
of the form does not document an actual oral examination. As dental health has proven to be
related to many physical illnesses (heart disease; diabetes; HIV), a thorough assessment is
necessary for early detection and treatment planning. The Director of Health Services for ECM
stated training of nurses in this procedure by the dentist will be scheduled. Prior to completion
of the CI, a supplemental dental form was implemented for documentation of specific baseline
tooth and oral tissue findings.
Both English and Spanish sick call request forms are available in the housing units and the
Special Management Unit (SMU). ODO investigated five detainee complaints regarding access
to care and found all five complaints were unsubstantiated. Medical records confirmed adequate
care was provided in a timely manner in each circumstance.
A substantial number of LCRDC staff is fluent in Spanish and capable of providing direct
translation services. Consent forms for medical, mental health, and dental treatment, as well as
authorizations for release of information were found in each of the 30 records reviewed;
however, the medical file of a detainee in the mental health clinic did not contain a consent form
for psychotropic medication. It is important for a detainee to fully understand and consent to
psychotropic treatment prior to receiving medication, because of the potential for adverse side
effects.
LCRDC has zero tolerance for sexual abuse and assault. LCRDC has policies and procedures in
place to address Sexual Abuse and Assault Prevention and Intervention (SAAPI). Facility policy
requires all employees, volunteers, and contractors to receive SAAPI training. All personnel are
trained during entrance training to properly address sexual abuse and sexual assault, and each
staff member completes annual refresher training thereafter. Conspicuous postings regarding
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prevention of sexual abuse and assault are present in each detainee housing unit. There were no
incidents of alleged sexual abuse or sexual assault at LCRDC during the 12 months preceding
the CI.
The LCRDC SMU consists of two wings with ten single cells on each, as well as four separate
cells outside the wings for housing females. The SMU is used for both administrative and
disciplinary segregation, with separation afforded by wing and cell assignment. Each cell is
equipped with a shower, a stainless steel toilet with a sink, one bunk secured to the floor, and a
table with an attached chair, both of which are also secured to the floor. The units are clean,
ventilated, well-lit, and maintained at an appropriate temperature. ODO verified written
procedures are in place governing the placement of detainees in administrative and disciplinary
segregation. Review of the procedures confirmed they address all requirements of the standard.
There were no detainees housed in administrative or disciplinary segregation during the review.
The Assistant Warden stated no detainees have been placed in administrative or disciplinary
segregation during the 12 months preceding the CI. Review of 20 randomly-selected detainee
files and corresponding disciplinary records confirmed none of the detainees had been placed in
administrative or disciplinary segregation.
The AFOD formally visits LCRDC on a monthly basis to meet with facility management and
observe conditions of confinement. ICE staff makes three scheduled visits and multiple
unscheduled visits each week. ODO confirmed the visits by the AFOD and ICE staff via review
of ICE Facility Liaison Visit Checklists, logbooks located throughout the facility, and interviews
with staff. ICE visitation schedules identifying each DO by name are conspicuously posted in
each of the housing units. Detainee request forms, printed in English and Spanish, are readily
available in all detainee housing units. ODO reviewed the electronic detainee request log from
September 2012 through February 2013, and confirmed all detainee requests were logged and
responded to within 72 hours of receipt.
LCRDC has two designated suicide watch cells connected to the health services department.
The cells were clean, and there were no fixtures which could facilitate a suicide attempt. The
cells are monitored in accordance with the NDS. A review of the training curriculum confirmed
it addresses all aspects of suicide risk identification, management of suicide gestures and
attempts, procedures for mental health referrals, and suicide watch management. A review of(b)(7)e
custody and all medical staff training records confirmed completion of suicide prevention
training at orientation and annually. Detainees are screened for suicide risk during the intake
process. There have been no suicides at LCRDC.
Detainees have reasonable and equitable access to telephones at LCRDC. The number of
telephones in the general housing areas and the SMU meets NDS requirements. ICE staff
conducts weekly telephone serviceability tests to determine operability of telephones in the
housing units. During the CI, ODO tested a sampling of telephones, and all were in working
order. Rules of telephone access, and contact information for consulates and the US Department
of Homeland Security, Office of Inspector General (OIG) hotline are posted in all areas where
telephones are located. A recorded message alerts detainees that telephone calls are subject to
monitoring. Detainees complete a form to request an unmonitored call to a legal representative.
An unmonitored telephone in a private room is provided for this purpose.

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ICE NDS requirements are highlighted in blue in LCRDC written policies and procedures to help
support familiarity and adherence to the ICE NDS among staff members. ODO cites this as a
best practice.

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INSPECTION PROCESS
ODO inspections evaluate the welfare, safety, and living conditions of detainees. ODO primarily
focuses on areas of noncompliance with the ICE NDS or the ICE Performance-Based National
Detention Standards, as applicable. The NDS apply to LCRDC. In addition, ODO may focus its
inspection based on detention management information provided by ERO Headquarters and
ERO field offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at LCRDC to determine compliance with current policies
and detention standards. Prior to the inspection, ODO collected and analyzed relevant
allegations and detainee information from multiple ICE databases including the Joint Integrity
Case Management System, the ENFORCE Alien Booking Module, and the ENFORCE Alien
Removal Module. ODO also gathered facility facts and inspection-related information from
ERO Headquarters staff to prepare for the site visit at LCRDC.

REPORT ORGANIZATION
This report documents inspection results, serves as an official record, and is intended to provide
ICE and detention facility management with a comprehensive evaluation of compliance with
policies and detention standards. It summarizes those NDS that ODO found deficient in at least
one aspect of the standard. ODO reports convey information to best enable prompt corrective
actions and to assist in the on-going process of incorporating best practices in nationwide
detention facility operations.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
NDS, ICE policy, or operational procedure. When possible, the report includes contextual and
quantitative information relevant to the cited standard. Deficiencies are highlighted in bold
throughout the report and are encoded sequentially according to a detention standard designator.
Comments and questions regarding the report findings should be forwarded to the Deputy
Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

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

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Special Agent (Team Leader)
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

7

ODO, Houston
ODO, Houston
ODO, Houston
Creative Corrections
Creative Corrections
Creative Corrections

LaSalle County Regional Detention Center
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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the AFOD, the Warden, and the Assistant Warden. All stated the working
relationship between LCRDC and ICE personnel is excellent, morale is high, and working
conditions are adequate to accomplish all required duties. The Warden stated there are
(b)(7)evacancies at LCRDC, but those vacancies do not affect continuity of operations or the ability
to properly care for ICE detainees. The Warden stated he regularly observes ICE staff visiting
detainees in the housing units throughout the week, communicating with detainees and
addressing detainee concerns.
The AFOD stated resources are sufficient to carry out all assigned duties and responsibilities.

DETAINEE RELATIONS
ODO interviewed 12 randomly-selected ICE detainees (ten male; two female) to assess detention
conditions at LCRDC. No complaints were received regarding issuance of hygiene supplies,
access to religious services, food service, telephones, visitation, or the law library. Detainees can
send and receive mail. Three detainees could not identify a DO by name. ICE visitation
schedules listing the names of each assigned DO are posted in every housing unit. All detainees
are able to contact ICE staff via ICE request forms, or through interaction with ICE staff during
ICE weekly visits.
Five detainees stated recreation time often overlaps with other scheduled facility activities. ODO
brought this to the attention of LCRDC management, and the recreation schedule was amended
prior to completion of the CI to avoid interference with meals and other programs.
ODO investigated five detainee complaints regarding access to care, and all five complaints were
unsubstantiated. Medical records confirmed adequate care was provided in a timely manner in
each circumstance.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 NDS and found LCRDC fully compliant with the following
14 standards:
Access to Legal Material
Admission and Release
Correspondence and Other Mail
Detainee Classification System
Detainee Grievance Procedures
Detainee Handbook
Detainee Transfers
Disciplinary Policy
Special Management Unit (Administrative Segregation)
Special Management Unit (Disciplinary Segregation)
Staff Detainee Communication
Suicide Prevention and Intervention
Telephone Access
Use of Force
As these 14 standards were compliant at the time of the review, a synopsis for these standards is
not prepared for this report.
ODO found deficiencies in the following four standards:
Environmental Health and Safety
Food Service
Funds and Personal Property
Medical Care
Findings for each of these standards are presented in the remainder of this report.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at LCRDC to determine if the
facility maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility,
interviewed staff, and reviewed documentation of inspections, hazardous chemical management,
and fire prevention procedures.
ODO verified LCRDC management maintains a master index of hazardous substances and
MSDS. An MSDS is present in each location where the substances are stored and used; however,
the master index and MSDS are not reviewed semi-annually, or on any scheduled basis
(Deficiency EH&S-1). Periodic review bolsters accountability and confirms the accuracy of
MSDS for all hazardous substances. During the review, the LCRDC Safety Officer implemented
procedures requiring quarterly reviews to correct this deficiency going forward. ODO confirmed
on-going inventories of hazardous substances are accurate.
The LCRDC Safety Officer provided documentation of weekly and monthly fire and safety
inspections. ODO observed evacuation diagrams prominently posted throughout the facility in
English and Spanish, which included locations of emergency equipment and directional arrows
for traffic flow. Fire drills are conducted monthly, and include testing of emergency keys.
Detainees, including females, have access to hair care services five days a week. There is a room
at LCRDC dedicated to hair care that has a sink with hot and cold running water. Sanitation
regulations, printed in both English and Spanish, are conspicuously posted on the wall of the
barbershop.
Sanitation of the facility is good overall; however, ODO observed two showers in housing unit N
with a buildup of soap scum, and a shower in housing unit P with trash on the floor and mildew.
Facility management was briefed on these conditions during the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDING
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section, (III)(C), the FOD
must ensure the Maintenance Supervisor or designate will compile a master index of all
hazardous substances in the facility, including locations, along with a master file of MSDSs.
He/she will maintain this information in the safety office (or equivalent), with a copy to the local
fire department. Documentation of the semi-annual reviews will be maintained in the MSDS
master file.
The master index will also include a comprehensive, up-to-date list of emergency phone numbers
(fire department, poison control center, etc.).

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at LCRDC to determine if detainees are provided with
a nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO
reviewed policy and documentation, interviewed staff, observed meal service and delivery, and
inspected food storage and preparation areas.
All work associated with the preparation and service of meals is performed by contractor ECM.
The food service staff consists of the Food Service Manager (b)(7)e Cook Supervisors, and (b)(7)e
Cook Specialists. No ICE detainees or inmates work in the food service department. Review of
employee records confirmed all staff members are medically cleared to work in food service, and
are certified for food safety via the Texas AgriLife Extension Service Food Handler Program.
A review of the master cycle menu confirmed the menu is reviewed annually by the Food
Service Director and certified by a registered dietician. The dietician provides nutritional
analysis for both the regular and special diet menus. ODO confirmed the menu includes a
minimum of two hot meals per day. At the time of the review, five detainees were on medicallyordered diets. LCRDC policy includes procedures for religious diets, and the facility handbook
includes instructions for requesting religious diets.
The facility has a satellite system of meal service involving preparation of meals in the food
service kitchen and delivery to the detainee housing units. During preparation of a lunch meal
during the review, ODO observed staff wearing hair restraints and gloves, calibrating
thermometers, and recording food temperature readings. ODO tested food temperatures
delivered to detainees in housing units to confirm requirements were met. Food was taste tested
and found palatable. At the time of the review, detainees were not required to turn in plastic
drinking cups and plastic eating utensils after meals. Detainees were allowed to keep and re-use
the items on an on-going basis. This practice did not ensure the items were properly sanitized to
prevent illness caused by bacteria (Deficiency FS-1). During the review, the Quality Control
Manager directed that all cups and utensils be returned with food trays upon completion of
meals, and amended policy and procedure to require issuance of sanitized cups and utensils for
every meal.
The food service storage areas consist of one spacious dry storage room, two walk-in freezers,
and two walk-in coolers. Items are properly stored, and ODO confirmed temperatures in the
freezers and coolers are maintained at the required level.
ODO observed sanitation throughout the food service area is maintained at a high level.
Documentation confirmed daily and weekly sanitation inspections are conducted by food service
staff. Cleaning schedules are posted in all food service areas, and staff was observed following
“clean as you go” procedures. Annual inspection by the South Texas Restaurant Services Food
Establishment Field Inspection Division on March 27, 2012, found LCRDC in compliance with
State of Texas food service regulations. Pest control inspections and treatment are conducted
monthly under contract with ORKIN Pest Control.
Inspection confirmed food preparation equipment is clean, properly installed, and equipped with
emergency gas shut-off valves; however, the meat slicer is not equipped with an anti-restart
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device (Deficiency FS-2). Equipment powered by electricity stops working when electrical
power is interrupted. Once power is restored, the equipment restarts automatically, which
creates a significant safety hazard. Prior to completion of the review, the Assistant Warden
contacted the company from which the machine was purchased to assess and rectify the issue.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE NDS, Food Service, section (III)(H)(5)(h), the FOD must ensure, to
prevent cross-contamination, kitchenware and food-contact surfaces should be washed, rinsed,
and sanitized after each use and after any interruption of operations during which contamination
would occur.
DEFICIENCY FS-2
In accordance with the ICE NDS, Food Service, section (III)(H)(12)(c)(4), the FOD must ensure
meat saws, slicers, and grinders shall be equipped with anti-restart devices.

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at LCRDC to determine if controls are
in place to inventory, receipt, store, and safeguard detainees’ personal property, in accordance
with ICE NDS. ODO reviewed local policies, interviewed staff, inspected property storage
areas, and reviewed detainee files.
A review of the detainee handbook confirmed it includes all required information concerning
funds and personal property policies and procedures at LCRDC. Property is inventoried during
intake, and a copy of the inventory is signed by the detainee and placed in the individual
detention file. Any funds transferred with a detainee are placed into an individual commissary
account. The detainee signs a receipt acknowledging placement of the funds; one copy of the
receipt is provided to the detainee and a second copy is placed in the detention file. Personal
property is stored in a sealed plastic bag bearing the name of the detainee, the alien file number,
and a copy of the inventory. Each bag is clearly marked as ICE detainee property, and stored on
shelves in the property room designated for ICE detainee property. Valuables are stored in
sealed plastic bags in a separate container. A review of ten files of detainees released from
LCRDC confirmed each detention file contained a signed statement acknowledging receipt of all
funds and property.
Detainee property is inventoried quarterly and valuables are inventoried weekly; however,
procedures were not in place for auditing detainee funds (Deficiency F&PP-1). A revision of
the facility policy to require a weekly audit of detainee funds was approved by facility
management during the CI to correct this deficiency going forward. Routine audits ensure an
accurate accounting of funds.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE NDS, Funds and Personal Property, section (III)(F), the FOD must
ensure each facility shall have a written procedure for inventory and audit of detainee funds,
valuables, and personal property.

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Initial health screening is completed by nurses in a designated area of the intake processing
department. Completed initial assessment forms address past and present suicide risk status and
clinical signs suggestive of acute substance abuse or withdrawal. The HSA stated drug and
alcohol detoxification is managed at the Laredo Medical Center. A review of 30 medical records
confirmed completion of chest x-rays to screen for tuberculosis within 24 hours of admission,
and follow-up purified protein derivative skin tests at the time of the PE. A PE is a completed by
a trained RN and reviewed by a physician. ODO notes documentation of PE training was
present in all nurse credential files. ODO found in four of the 30 cases reviewed that an RN
completed an examination from one to three weeks beyond the 14 days required by the NDS. In
two other cases, the physician failed to review the physical examinations within the required
14 days (Deficiency MC-1). A review of PE documentation confirmed they are hands-on;
however, the dental examination section of the form does not document an actual oral
examination (Deficiency MC-2). As dental health has proven to be related to many physical
illnesses (heart disease; diabetes; HIV), a thorough assessment is necessary for early detection
and treatment planning. The Director of Health Services for ECM stated training of nurses in
this procedure by the dentist will be scheduled. Prior to completion of the CI, a supplemental
dental form was implemented for documentation of specific baseline tooth and oral tissue
findings.
Sick call request forms in English and Spanish are available in the housing units and the SMU.
Nurses retrieve completed forms from secure drop boxes twice daily. Nurses triage and address
detainee complaints within 48 hours using problem-specific, physician-approved treatment
protocols for over-the-counter medications, non-pharmaceutical treatment instructions, and
patient education. ODO confirmed annual review and approval of these protocols by the CMA.
Documentation confirmed referrals to a physician when medical issues were beyond the
knowledge or scope of practice of a nurse. ODO investigated five detainee complaints regarding
access to care, and all five complaints were unsubstantiated. Medical records confirmed
adequate care was provided in a timely manner in each circumstance.
A substantial number of LCRDC staff is fluent in Spanish and capable of providing direct
translation services. Consent forms for medical, mental health, and dental treatment, as well as
authorizations for release of information were contained in each of the 30 records reviewed;
however, the medical file of a detainee in the mental health clinic did not contain a consent form
for psychotropic medication (Deficiency MC-3). It is important for a detainee to fully
understand and consent to psychotropic treatment prior to receiving medication, because of the
potential for adverse side effects.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure the health
care provider of each facility will conduct a health appraisal and physical examination on each
detainee within 14 days of arrival at the facility.
DEFICIENCY MC-2
In accordance with the ICE NDS Medical Care, section (III)(E), the FOD must ensure an initial
dental screening exam should be performed within 14 days of the detainee’s arrival. If no on-site
Office of Detention Oversight
March 2013
OPR 201304590

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LaSalle County Regional Detention Center
ERO San Antonio

dentist is available, the initial dental screening may be performed by a physician, physician’s
assistant or nurse practitioner.
DEFICIENCY MC-3
In accordance with the ICE NDS Medical Care, section (III)(L), the FOD must ensure the facility
health care provider will obtain signed and dated consent forms from all detainees before any
medical examination or treatment, except in emergency circumstances.

Office of Detention Oversight
March 2013
OPR 201304590

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LaSalle County Regional Detention Center
ERO San Antonio