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
Saint Paul Field Office
Ramsey County Adult Detention Center
Saint Paul, Minnesota

March 11-13, 2014

COMPLIANCE INSPECTION
RAMSEY COUNTY ADULT DETENTION CENTER
SAINT PAUL FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization ............................................................................................................ 1
Inspection Team Members .................................................................................................. 1
EXECUTIVE SUMMARY ........................................................................................................... 2
OPERATIONAL ENVIRONMENT
Detainee Relations ............................................................................................................... 6
ICE 2000 NATIONAL DETENTION STANDARDS
Deficient Detention Standards ............................................................................................. 7
Access to Legal Material ..................................................................................................... 8
Admission and Release ...................................................................................................... 10
Contraband ........................................................................................................................ 12
Correspondence and Other Mail ........................................................................................ 13
Detainee Classification System ......................................................................................... 15
Detainee Grievance Procedures ......................................................................................... 17
Detainee Handbook ........................................................................................................... 18
Environmental Health and Safety ...................................................................................... 19
Food Service ...................................................................................................................... 21
Funds and Personal Property ............................................................................................. 23
Medical Care...................................................................................................................... 24
Staff-Detainee Communication ........................................................................................ 26
Telephone Access .............................................................................................................. 29

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 replace 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
Team members on this inspection included: (b)(6), (b)(7)c Special Agent (Team Lead), ODO;
Special Agent, ODO; (b)(6), (b)(7)c Inspections and Compliance Specialist, ODO;
(b)(6), (b)(7)c
Inspections and Compliance Specialist, ODO; (b)(6), (b)(7)c Contract Inspector,
Creative Corrections; and
Contract Inspector, Creative Corrections; and(b)(6), (b)(7)c
(b)(6), (b)(7)c
(b)(6), (b)(7)cContract Inspector, Creative Corrections.

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Ramsey County Adult Detention Center
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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Ramsey County Adult Detention Center
(RCADC) in Saint Paul, Minnesota, from March 11 to 13, 2014. RCADC, which opened in
December 2003, is owned by the County of Ramsey and operated by the Ramsey County
Sheriff’s Office (RCSO). ERO began housing detainees at RCADC in February 2004 under an
intergovernmental service agreement between ICE and the County of Ramsey. Male and female
detainees of all security classification
Capacity and Population Statistics
Quantity
levels (Levels I-III) are detained at the
Total Bed Capacity/Emergency Capacity
500/600
facility for periods in excess of 72
hours. The inspection evaluated
ICE Bed Capacity/Emergency Capacity
20/60
RCADC’s compliance with the 2000
Average ICE Detainee Daily Population
17
NDS.
Average ICE Detainee Length of Stay (Days)

28

ICE Male/Female Count (on March 11, 2014)
17/2
The ERO Field Office Director (FOD)
in Saint Paul, Minnesota, is responsible
for ensuring facility compliance with the ICE NDS and ICE policies. There are no ICE
employees physically located at RCADC. An Assistant Field Office Director (AFOD), a
Supervisory Detention and Deportation Officer (SDDO) and Deportation Officers (DO) oversee
ICE operations at RCADC. There is no Detention Service Manager (DSM) assigned to this
facility.

The Undersheriff is the highest-ranking official at RCADC and is responsible for oversight of
daily operations. (b)(7)e RCADC supervisory staff and (b)(7)enon-supervisory staff support the
Undersheriff. There were no vacancies at RCADC at the time of the inspection. The County of
Ramsey provides medical care, and A’viands Food and Services Management (AFSM) provide
food service. The facility holds no accreditations.
In June 2012, ODO conducted an inspection of RCADC under the 2000 NDS. Among the 19
standards reviewed, six were in full compliance with the NDS. ODO cited 23 deficiencies in the
remaining 13 standards.
During this inspection, ODO reviewed 18 standards, five of which were fully compliant. 1 Fortyfour deficiencies were identified in the following 13 standards: Access to Legal Material (3),
Admission and Release (6), Contraband (1), Correspondence and Other Mail (3), Detainee
Classification System (4), Detainee Grievance Procedures (2), Detainee Handbook (1),
Environmental Health and Safety (3), Food Service (5), Funds and Personal Property (2), Medical
Care (2), Staff-Detainee Communication (8), and Telephone Access (4). ODO did not make any
recommendations regarding facility policy and procedures or cite any best practices.

1

The following standards were compliant at the time of the inspection; therefore, synopses for these standards are not
included in this report: Special Management Unit – Administrative Segregation, Special Management Unit –
Disciplinary Segregation, Suicide Prevention and Intervention, Terminal Illness, Advanced Directives, and Death, and
Use of Force.
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This report details all deficiencies and refers to the specific, relevant sections of the NDS. ERO will
be provided with a copy of this report to assist in developing corrective actions to resolve all
identified deficiencies. These deficiencies were discussed with ERO and RCADC staff during the
on-site inspection and at a subsequent closeout briefing conducted on March 13, 2014.
Upon admission to RCADC, detainees receive clothing, towels, bedding, personal hygiene items,
and medical, mental health, suicide and sexual abuse and assault screenings. Medical staff performs
follow-up evaluations depending on screening results. Detainees are expected to purchase
replenishment hygiene items from the commissary; the facility only replenishes soap.
Detainee property is inventoried during the admission and stored in a dedicated room, which is
locked and accessible only to authorized staff. RCADC does not have a dedicated safe or
secured locker accessible to only designated supervisors to store valuables. Further, the facility
handbook does not include a procedure for requesting certified copies of identity documents
such as passports and birth certificates.
Per RCADC policy, all inmates and detainees with gross misdemeanor offenses are strip searched as
they enter the facility and each time they re-enter the facility from outside the secure perimeter. All
19 detainees interviewed by ODO stated they had been strip searched at some point during their
detention at RCADC. ODO reviewed the detention files of all 19 detainees present at the time of
the inspection and found no documentation supporting strip searches based on reasonable suspicion.
Further, ODO found ERO does not consistently provide documentation to assist RCADC
management with classification. During the inspection, two detainees (Levels I and III) were
improperly classified.2
ERO provides detainees an ICE National Detainee Handbook prior to arrival at RCADC; however,
RCADC staff does not issue detainees a facility handbook or show an orientation video. Facility
handbooks are maintained inside a drawer in the housing units accessible only to staff. RCADC has
established policy and procedures for the handling and destruction of contraband. There has not
been a seizure of contraband at RCADC during the 12 months preceding this inspection. The
facility handbook addresses the safeguarding of detainee property, but it does not notify detainees of
rules and procedures governing contraband.
Detainees may access computers with the current version of LexisNexis for a minimum of five
hours per week. The facility handbook does not include scheduled hours of access to the law
library, the procedures for requesting additional library time, legal reference material not
maintained in the law library, or the procedure for notifying a designated employee that library
material is missing or damaged. RCADC staff does not provide detainees photocopies of legal
materials.
Detainees at RCADC are permitted to receive mail; however, the facility handbook lacks required
notifications, including: the definition of special correspondence; instructions on the proper labeling for
special correspondence; and the responsibility to inform senders of the labeling requirements for
2

These are all repeat deficiencies from the last ODO inspection in June 2012.

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special correspondence. Further, RCADC management does not have a written record of items
removed from detainee mail, notify detainees that packages cannot be sent or received without prior
approval, or have a procedure for obtaining prior approval.
RCADC allows detainees to file informal, formal and emergency grievances. There is an
established grievance committee and RCADC staff maintains a grievance log. Six formal
grievances were filed by detainees during the 12 months preceding this inspection and each received
a timely response. No grievances alleged staff misconduct. Responses are provided to detainees in
writing, but a copy is not placed in the detention file. The facility handbook does not provide
instructions on how to file complaints about officer misconduct.
Facility sanitation of RCADC was excellent at the time of the inspection. Hazardous materials are
properly stored and inventories maintained. Fire drills are conducted quarterly instead of monthly
as required by the NDS. In addition, the quarterly drills were not conducted in all areas of the
facility and were not performed by all shifts. Exit diagrams are printed in English and Spanish and
show the locations of emergency equipment; however, they do not identify areas of safe refuge. 3
The facility’s emergency power generator is tested monthly for a period of four hours, rather than
bi-weekly for one hour, as required by the NDS. In addition, testing by an external generator
service company is completed every six months instead of quarterly.
The entire food service operation at RCADC is performed by the contractor AFSM. ODO observed
a high level of sanitation throughout the food service area. The facility has a satellite feeding
system. A registered dietician certifies the master menu, which is a 28-day cycle menu with a
variety of foods. All food temperatures tested by ODO during the inspection complied with the
NDS. Deficiencies identified include: no differentiation between medical diets for detainees versus
inmates; RCADC’s policy not requiring development of a ceremonial meal schedule; no common
fare meal program for religious dietary needs; food service personnel not receiving pre-employment
medical examinations;4 the facility failing to provide meatless lunch and dinner meals on Fridays or
Ash Wednesday; and food service inspections not occurring on a weekly basis.5
Health care at RCADC is provided by Ramsey County 24 hours per day, seven days per week.
Seriously or terminally ill detainees are not accepted at RCADC. Correctional officers conduct
medical and mental health screenings at intake; however, they do not receive training on how to
perform these screenings. A nurse practitioner performs health appraisals within 14 days, which
includes a hands-on physical examination and dental screening. Detainees access health care
services by completing sick call forms and handing them to officers, 6 or placing them in an
unsecured box in the housing unit.
RCADC conducts sexual abuse and assault screenings of detainees upon arrival to detect
victimization and predatory risk. According to facility staff and a query of records from the Joint
Integrity Case Management System (JICMS), there were no reported incidents or allegations of
sexual abuse or assault at RCADC during the 12 months preceding this inspection.

3

This is a repeat deficiency from the last ODO inspection in June 2012.
This is a repeat deficiency from the last ODO inspection in June 2012.
5
This is a repeat deficiency (food service inspections) from the last ODO inspection in June 2012.
6
This is a repeat deficiency from the last ODO inspection in June 2012.
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ICE staff conducts scheduled weekly and unscheduled monthly visits at RCADC. All visits are
documented on a log maintained by RCADC management; however, there is no documentation
indicating which areas are visited.7 ERO’s visitation schedule was not posted in all housing units.
Further, Facility Liaison Visit Checklists and Telephone Serviceability Worksheets were missing for
specific periods. The facility initiated corrective action during the inspection by posting schedules
in the housing units.
RCADC does not have written procedures for routing detainee requests through the appropriate ICE
officials. Detainees can submit sealed, written requests to ICE by labeling it “immigration.” ODO
reviewed all detainee requests from October 2013 through March 2014 and confirmed that all
requests received a response within 72 hours. RCADC does not maintain a log to track requests.
RCADC staff initiated corrective action during the inspection by creating a log. The facility
handbook lacks required notifications on how to submit written questions and concerns to ICE staff,
the procedures for doing so, the availability of assistance in preparing the request and the Office of
Inspector General’s (OIG) contact information.
The Special Management Unit (SMU) at RCADC is comprised of two, single-occupancy cells used
for administrative and disciplinary segregation for males and females. Each cell contains a single
bed with a mattress, a toilet, a sink and a writing surface. The cells and shower areas were
adequately lit, well ventilated, temperature-appropriate, and maintained in a sanitary condition. No
ICE detainees were assigned to administrative and disciplinary segregation at the time of the
inspection and none had been placed on administrative segregation during the 12 months preceding
this inspection. Four detainees had been sanctioned with disciplinary segregation since March 2013.
RCADC’s policy on suicide prevention and intervention covers training, identification, intervention,
housing and hospitalization of at-risk detainees. Detainees identified as at-risk are immediately
referred to the medical unit for further evaluation and housed and monitored in accordance with the
standard. Only a physician or mental health professional is authorized to remove a detainee from
suicide watch. RCADC staff reported no detainees were placed on suicide watch during the
12 months preceding this inspection. The cell designated for suicide watch is free of objects or
structures that could facilitate a suicide attempt. Medical staff and detention staff receive suicide
prevention and intervention training.
Detainees have equitable access to telephones at RCADC. Telephones are inspected daily by
facility staff. ODO tested all telephones and found none allowed detainees free access to
embassies, consulates, pro-bono entities, or other governmental agencies. Calls are limited to 15
minutes in length before automatic cut-off. RCADC does not provide detainees with written
telephone access rules, and the procedure for obtaining an unmonitored call.
No uses of force involving ICE detainees occurred at RCADC during the 12 months preceding this
inspection, according to facility staff and the JICMS. Detention personnel at RCADC use a restraint
chair when needed and RCADC supervisors carry Tasers. Tasers have not been used on ICE
detainees to date. Training records confirmed staff received current training in the application of
force.
7

This is a repeat finding from the last ODO inspection in June 2012.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed all detainees in custody (17 males and two females) to assess conditions of
detention at RCADC. None of the detainees expressed concerns RCADC or treatment by RCADC
staff. Detainees denied witnessing or experiencing abuse or discrimination from RCADC officers.
All 19 detainees alleged they were strip searched at some point during their detention at RCADC.
Further, they all stated they did not receive a facility handbook or watch an orientation video upon
admission. A majority of the detainees could not name their DO or knew how to contact him/her;
however, all stated ERO visits the housing units weekly. Detainees complained about having to
purchase hygiene items from the commissary. ODO confirmed that other than soap, the facility
does not provide detainee replacements after issuance of the initial kit.

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 NDS and found 44 deficiencies in the following 13
standards:
1. Access to Legal Material
2. Admission and Release
3. Contraband
4. Correspondence and Other Mail
5. Detainee Classification System
6. Detainee Grievance Procedures
7. Detainee Handbook
8. Environmental Health and Safety
9. Food Service
10. Funds and Personal Property
11. Medical Care
12. Staff-Detainee Communication
13. Telephone Access
Findings for these standards are presented in the remainder of this report.

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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at the RCADC to determine if detainees have
access to a law library, legal materials, courts, counsel and document copying equipment to
facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO interviewed
detainees and staff, reviewed policies, procedures, and the detainee handbook, and inspected the
area designated for law library use.
The facility maintains two computers and two printers for use by ICE detainees to access legal
materials and prepare legal documents. Both are equipped with the most-recent version of
LexisNexis. A computer is kept in each of the two housing units that house ICE detainees. Each
computer is mobile and may be moved to an adjacent interview room to afford privacy. The
interview room is well-lit, isolated from noise and contains a chair and table. The facility employs
an ICE liaison who is responsible for checking the computers on a weekly basis to ensure they are in
good working order. The facility handbook directs that ICE detainees may request access to the
computer via a Law Library Request Form available in the housing units.
The law library is available for use from 7:30 a.m. to 10 p.m. There is no time limitation unless
multiple detainees request use of legal materials at the same time.
Since the facility is near the county courthouse law library, RCADC officials routinely use that
library to obtain legal materials that are not available in the RCADC law library. Detainees can
request materials in writing by specifying a particular statute, decision, or other legal document
(motions, briefs, etc.), and RCADC officials retrieve those documents from the courthouse law
library. This procedure is reflected in written policy at RCADC.
RCADC does not have procedures in place to prevent detainees from damaging, destroying or
removing equipment, materials or supplies from the library (Deficiency ALM-1).
According to RCADC policy and procedures, detainees are not allowed to obtain photocopies of
legal material. The NDS requires that facilities ensure that detainees are able to obtain photocopies
of legal materials necessary for legal proceedings involving the detainee (Deficiency ALM-2).
The facility handbook does not include the scheduled hours of access to the law library, the
procedure for requesting additional time in the law library beyond the five hours per week
minimum, the procedure for requesting legal reference materials not maintained in the law library,
or the procedure for notifying a designated employee that library material is missing or damaged.
During the inspection, ODO observed the rules associated with the use of the law library are not
posted in the housing units, or in the Special Management Unit (Deficiency ALM 3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE NDS, Access to Legal Materials, section (III)(H), the FOD must
ensure, “The facility shall develop procedures that effectively prevent detainees from damaging,
destroying or removing equipment, materials or supplies from the law library.
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Facilities are encouraged to monitor detainees’ use of legal materials to prevent vandalism.”
DEFICIENCY ALM-2
In accordance with the ICE NDS, Access to Legal Materials, section (III)(J)(1)(2)(3)(4), the FOD
must ensure “The facility shall ensure that detainees can obtain photocopies of legal material, when
such copies are reasonable and necessary for a legal proceeding involving the detainee. This may be
accomplished by providing detainees with access to a copier or by making copies upon request.
The number of copies of documents to be filed with a particular court, combined with the number
required for INS records and at least one copy for the detainee’s personal use will determine the
number of photocopies required. Requests for photocopies of legal material shall be denied only if:
1.
2.
3.
4.

the document(s) might pose a risk to the security and orderly operation of the detention
facility;
there are other legitimate security reasons;
copying would constitute a violation of any law or regulation; or
the request is clearly abusive or excessive.

Facility staff shall inspect documents offered for photocopying to ensure that they comply with these
rules. However, staff may not read a document that on its face is clearly related to a legal
proceeding involving the detainee.”
DEFICIENCY ALM-3
In accordance with the ICE NDS, Access to Legal Materials, section (III)(Q)(2)(4)(5)(6), the FOD
must ensure, “The detainee handbook or equivalent, shall provide detainees with the rules and
procedures governing access to legal materials, including the following information:
2.
4.
5.
6.

the scheduled hours of access to the law library;
the procedure for requesting additional time in the law library (beyond the 5 hours per week
minimum);
the procedure for requesting legal reference materials not maintained in the law library; and
the procedure for notifying a designated employee that library material is missing or
damaged.

These policies and procedures shall also be posted in the law library along with a list of the law
library's holdings.”

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ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at the RCADC to determine if procedures are in
place to protect the health, safety, security, and welfare of each person during the admission and
release process, in accordance with the ICE NDS. ODO reviewed policies, procedures, and the
detainee handbook. ODO also inspected detention files, interviewed staff and detainees, and viewed
the orientation video.
Upon admission to RCADC, detainees receive clothing, towels, bedding, personal hygiene items,
and medical, mental health, suicide and sexual abuse and assault screenings. Medical staff
completes required follow-up evaluations depending on the detainee’s answers to the intakescreenings. Property bags are kept in a property room and receipts provided to detainees and placed
in each property bag. All funds (U.S. currency) for each detainee are transferred to an individual
vending card account, which can be accessed by the detainee while housed at RCADC.
RCADC has an orientation video that covers facility rules and regulations, but it is not shown to
detainees at admission (Deficiency AR-1). The detainee handbook states that detainees receive one
free personal hygiene kit. The hygiene kit includes deodorant, soap, toothpaste, a toothbrush and
shampoo. Through detainee and staff interviews, ODO confirmed only soap is replenished at no
cost to the detainee (Deficiency AR-2).
Among the 19 detention files reviewed by ODO, only two contained an Order to Detain or Release
Alien (Form I-203) (Deficiency AR-3). Furthermore, ERO is not providing any documentation for
classification purposes (Deficiency AR-4).
Detainees are not provided a copy of the facility handbook at admission (Deficiency AR-5).
Handbooks are retained in the housing units; however, detainees are not told they are available, and
the handbook is not issued as detainees arrive in the housing units. Facility staff stated the
handbooks are kept in a drawer to prevent damage and detainees can request to read the handbook at
any time. However, none of the detainees interviewed by ODO were aware a facility handbook was
available that contained pertinent information regarding RCADC policies and procedures.
Upon admission, all detainees with a gross misdemeanor charge are automatically strip-searched as
he/she enters the facility. Detainees are also strip searched each time they re-enter the facility from
outside the secure perimeter. RCADC written policy states that all detainees with a misdemeanor
charge will be strip searched during intake. Not one of the 19 detention files reviewed by ODO
contained documentation to support a strip search based on reasonable suspicion
(Deficiency AR-6). This is a repeat deficiency from the last ODO inspection in June 2012.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
In accordance with the ICE NDS, Admission and Release, section (III)(A)(1), the FOD must ensure,
“The orientation process supported by a video (INS) and handbook shall inform new arrivals about
facility operations, programs, and services.”

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DEFICIENCY AR-2
In accordance with the ICE NDS, Admission and Release, section (III)(G), the FOD must ensure,
“Staff shall provide male and female detainees with the items of personal hygiene appropriate for,
respectively, men and women. They will replenish supplies as needed.”
DEFICIENCY AR-3
In accordance with the ICE NDS, Admission and Release, section (III)(H), the FOD must ensure,
“An order to detain or release (Form I-203 or I-203a) bearing the appropriate official signature shall
accompany the newly arriving detainee.”
DEFICIENCY AR-4
In accordance with the ICE NDS, Admission and Release, section (III)(B) , the FOD must ensure,
“Admission staff will use the documentation accompanying each new arrival for identification and
classification purposes. If the classification officers are not ICE employees, ICE will provide only
the information needed for classification-processing.”
DEFICIENCY AR-5
In accordance with the ICE NDS, Admission and Release, section (III)(K), the FOD must ensure,
“Upon admission every detainee will receive a detainee handbook.”
DEFICIENCY AR-6
In accordance with the Change Notice: Strip Search Guidelines for Admissions to Detention
Facility, dated April 14, 2003, the FOD must ensure, “Immigration detainees shall not be strip
searched upon admission to a facility unless there is a reasonable suspicion that an individual may
be concealing a weapon or other contraband.”

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CONTRABAND (C)
ODO reviewed the Contraband standard at RCADC to determine if procedures are in place to
protect detainees and staff, enhance security, and identify, detect, control and properly dispose of
contraband, in accordance with the ICE NDS.
RCADC has established policy and procedures for the handling and destruction of contraband.
When contraband is discovered, an incident report is completed by the officer that describes the
details of the contraband, and where it was found. The contraband is inventoried on a report form
and placed in a secure storage area until it is destroyed. There has not been a seizure of contraband
at RCADC during the 12 months preceding this inspection.
The facility handbook addresses the safeguarding of detainee property, but it does not notify
detainees of rules and procedures governing contraband at RCADC (Deficiency C-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY C-1
In accordance with the ICE NDS, Contraband, section (III)(D)(1), the FOD must ensure, “The
detainee handbook, or equivalent, shall notify detainees of the following:
1. The facility’s rules and procedures governing contraband.”

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CORRESPONDENCE AND OTHER MAIL (C&OM)
ODO reviewed the Correspondence and Other Mail standard at the RCADC to determine if the
facility provides detainees the opportunity to send and receive correspondence, in a timely manner,
subject to limitations required for the safe and orderly operation of the facility, in accordance with
the ICE NDS.
RCADC has no restrictions on the amount of mail detainees can send or receive. Procedures are in
place at RCADC to ensure the confidentiality of legal correspondence. The facility handbook fails to
notify detainees of specific requirements (Deficiency C&OM-1), including:







General correspondence and other mail addressed to them shall be opened and inspected only
in their presence, unless there are security concerns;
Special correspondence will be opened only in their presence to inspect for contraband, but not
read by RCADC staff;
Definition of special correspondence;
RCADC management provides no written notification to detainees about packages that may
not be sent or received without advance arrangements, and there is no procedure at RCADC
for obtaining prior approval;
Description of rejected mail, or mail detainees are not permitted to keep; and
Notification that detainees are not allowed to keep identity documents in their possession, but
will be provided with copies of identity documents certified by an ICE officer to be true and
correct copies.

Further, RCADC does not provide a written record documenting items removed from detainee mail
(Deficiency C&OM-2).
The facility does not have a procedure in place that requires an officer to make a written record
documenting the detainee’s name and A-number, the name of the sender and recipient, a description
of the mail in question, a description of the action taken, the reason for the action (including
significant dates), disposition of the item, the date of disposition, and the signature of the officer in
the event an item is removed from a detainee’s mail (Deficiency C&OM-3).

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY C&OM-1
In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(B)(3)(4)(5)(6)(7),
the FOD must ensure, “The facility shall notify detainees of its policy on correspondence and other
mail through the detainee handbook or equivalent provided to each detainee upon admittance.
At a minimum, the notification shall specify:
3. That general correspondence and other mail addressed to detainees shall be opened and
inspected in the detainee’s presence, unless the OIC authorizes inspection without the
detainee’s presence for security reasons

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4. That special correspondence may only be opened in the detainee’s presence, and may be
inspected for contraband, but not read;
5. The definition of special correspondence, including instructions on the proper labeling for special
correspondence, without which it will not be treated as special mail. The notification shall
clearly state that it is the detainee's responsibility to inform senders of special mail of the
labeling requirement;
7. A description of mail which may be rejected by the facility and which the detainee will not be
permitted to keep in his/her possession (for additional information refer to Section III.G.,
below). The notification will state that identity documents, such as passports, birth
certificates, etc., are contraband and may be used by the INS as evidence or as otherwise
appropriate. The notification will state that if detainees are not allowed to keep an identity
document in their possession, they will be provided with a copy of the document, certified by
an INS officer to be a true and correct copy.”
DEFICIENCY C&OM-2
In accordance with the ICE NDS, Correspondence and Other Mail, section (III)(G), the FOD must
ensure, “All facilities shall implement policies and procedures addressing the issue of acceptable
and non-acceptable mail. Procedures shall cover the rejection of incoming and outgoing mail
rejected for reasons of facility order and security. Incoming and outgoing general correspondence
and other mail may be rejected by the OIC to protect the security, good order, or discipline of the
institution; to protect the public; or to deter criminal activity.
The affected detainees shall be notified when incoming or outgoing mail is confiscated or withheld
(in whole or in part). The detainee shall receive a receipt for the confiscated or withheld item(s).”
DEFICIENCY C&OM-3
In accordance with the ICE NDS, Correspondence and Other Mail, section
(III)(H)(1)(2)(3)(4)(5)(6), the FOD must ensure, “When an officer finds an item that must be removed
from a detainee’s mail, he/she shall make a written record. This shall include:
1.
2.
3.
4.
5.
6.

The detainee’s name and A-number;
The name of the sender and recipient;
A description of the mail in question;
A description of the action taken and the reason for it (including significant dates);
The disposition of the item and the date of disposition; and
The signature of the officer.”

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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System standard at the RCADC to determine if there is a
formal classification process for managing and separating detainees based on verifiable and
documented data, in accordance with the ICE NDS. ODO interviewed staff, and reviewed policy,
housing unit rosters, and detainee files.
RCADC management classifies detainees as minimum, medium and maximum. Officers run
criminal history checks using NCIC to determine the highest level conviction for each detainee.
ODO confirmed that classification of detainees is not reviewed for accuracy and completeness by a
supervisor (Deficiency DCS-1).
ERO does not consistently provide risk classification assessments to assist RCADC management
with classification of detainees upon admission to the facility. A review of 19 detention files
confirmed only two contained documentation from ERO regarding detainee classification
(Deficiency DCS-2). This is a repeat deficiency from the last ODO inspection in June 2012.
RCADC has ten housing units, two of which are used for male and female ICE detainees. Each ICE
housing unit has two tiers. Level I and II detainees are housed on one tier of the housing unit, and
Level III detainees are housed on the remaining tier. RCADC release one tier out at a time to
prevent commingling. ODO confirmed two detainees were improperly classified, which resulted in
the commingling of Level I and III detainees (Deficiency DCS-3). This is a repeat deficiency from
the last ODO inspection in June 2012.
ODO reviewed written policies and procedures at RCADC. According to RCADC policy, detainee
classification is reviewed on a monthly basis. ODO found that detainees are not re-classified and a
detainee’s classification level is solely dependent on the highest criminal conviction contained in the
criminal history (Deficiency DCS-4). The facility handbook contains information regarding appeals
of security classifications via a formal grievance.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE NDS, Detainee Classification System, section (III)(C), the FOD must
ensure, “In all detention facilities, a supervisor will review the intake/processing officer’s
classification files for accuracy and completeness. Among other things, the reviewing officer shall
ensure that each detainee has been assigned to the appropriate housing unit.”
DEFICIENCY DCS-2
In accordance with the ICE NDS, Detainee Classification System, section (III)(D), the FOD must
ensure, “ICE offices shall provide non-ICE facilities with the necessary information for the facility
to classify ICE detainees.”

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DEFICIENCY DCS-3
In accordance with the ICE NDS, Detainee Classification System, section (III)(E)(1)(a), the FOD
must ensure that, “Level 1 classification,
a. May not be housed with Level 3 Detainees.”
DEFICIENCY DCS-4
In accordance with the ICE NDS, Detainee Classification System, section (III)(G), the FOD must
ensure, “All facility classification systems shall ensure that a detainee may be reclassified any time
and the classification level re-determined.”

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedures standard at RCADC 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
NDS. ODO interviewed staff and detainees, and reviewed facility policy, the detainee handbook,
and grievance documentation.
ODO found the grievance system at RCADC allows detainees to file informal, formal and
emergency grievances. Grievance forms are available in the housing units, and detainees may
obtain assistance from another detainee or a facility staff member in preparing a grievance. RCADC
policy identifies procedures for handling emergency grievances, and there is an established
grievance committee.
RCADC maintains a grievance log to document and track grievances filed by detainees. A review
of the log confirmed there were six formal grievances filed by detainees during the 12 months
preceding this inspection, and each received a timely response. ODO confirmed responses are
provided to detainees in writing, but a copy is not placed in the individual detention file
(Deficiency DGP-1). All six grievances involved miscellaneous issues, and no pattern or trend was
observed regarding grievance subject matter. No grievances alleged staff misconduct.
The facility handbook provides notice to detainees of the opportunity to file formal and informal
grievances, the procedure for filing a grievance and an appeal, the right to have a grievance referred
to a higher level of review, the procedure for contacting ICE to appeal a decision of the OIC, and the
policy prohibiting staff from retaliating against a detainee for filing a grievance. The facility
handbook does not provide instructions on how to file officer misconduct complaints directly with
the U.S. Department of Justice (Deficiency DGP-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must
ensure, “A copy of the grievance will remain in the detainee’s detention file for at least three years.”
DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(6), the FOD must
ensure, “The grievance section of the detainee handbook will provide notice of the following:
6. The opportunity to file a complaint about officer misconduct directly with the Justice
Department by calling 1-800-869-4499 or by writing to:
Department of Justice
P.O. Box 27606
Washington, DC 20038-7606.”

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DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at RCADC to determine if the facility provides
each detainee with a handbook written in English and any other languages spoken by a significant
number of detainees housed at the facility, describing the facility’s rules and sanctions, disciplinary
system, mail and visiting procedures, grievance system, services, programs, and medical care, in
accordance with the ICE NDS. ODO reviewed facility policy and the handbook, and interviewed
staff and detainees.
The facility handbook is available in English, Spanish and Hmong. The ICE National Detainee
Handbook is issued to detainees at the ERO Field Office in Bloomington, Minnesota, prior to arrival
at RCADC. A committee consisting of two program officers and four lieutenants reviews and
updates the facility handbook annually. After revisions and updates are made to the facility
handbook, the administrative lieutenant approves the final revised version before it is printed. The
facility handbook was last revised on October 29, 2012.
A review of 19 active detention files and interviews of 19 detainees confirmed the facility does not
provide detainees a facility handbook upon admission (Deficiency DH-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with ICE NDS, Detainee Handbook, section (I), the FOD must ensure, “Every OIC
will develop a site-specific detainee handbook to serve as an overview of, and guide to, the detention
policies, rules, and procedures in effect at the facility. The handbook will also describe the services,
programs, and opportunities available through various sources, including the facility, ICE, private
organizations, etc. Every detainee will receive a copy of this handbook upon admission to the
facility.
Detainees are expected to behave in accordance with the rules set down in the handbook, and will be
held accountable for violations. Therefore, the facility staff will advise every detainee to become
familiar with the material in the handbook.”

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at RCADC 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, reviewed policy and procedures, documents and logs, documentation of hazardous chemical
management, and fire prevention and control policies and procedures.
ODO found the sanitation at RCADC to be excellent. Hazardous substances are stored in a fire
resistant storage cabinet in the building services area, which is located outside the facility’s secure
perimeter. ODO confirmed RCADC has a system for storing, issuing, and maintaining inventories
of hazardous materials. Inspection of storage sites confirmed hazardous substances are properly
stored and a review confirmed inventories are accurate. ODO confirmed the master index of
chemicals includes their locations and documentation of semi-annual review. MSDS are present for
all chemicals.
A review of documentation confirmed fire drills are conducted quarterly instead of monthly as
required by the NDS. The quarterly drills are not conducted in all areas of the facility and are not
performed by all shifts (Deficiency EH&S-1). Monthly fire drills in all areas of the facility and on
all shifts ensure the entire staff is knowledgeable of actions to take in the event of a fire, including
evacuation procedures and routes. Exit diagrams were replaced following the last ODO inspection
in June 2012, and the diagrams, printed in English and Spanish, are posted in common areas
throughout the facility. The diagrams show the locations of emergency equipment; however, areas
of safe refuge are not identified (Deficiency EH&S-2). Facility administrators believe including
this information on exit diagrams is a security risk. Designation of areas of safe refuge serves an
important life-safety function in the event of fire or other emergency requiring individuals to shelter
in place. This is a repeat deficiency from the last ODO inspection in June 2012.
ODO reviewed documentation confirming pest and rodent control services are provided on a
monthly basis by Plunkett’s Pest Control, Inc. ODO also reviewed documentation of drinking and
waste water testing by the City of St. Paul Municipal Water Plant.
The emergency power generator is run monthly for four hours and not biweekly for one hour, as
required by the NDS. Testing by an external generator service company is completed every six
months and not quarterly, as required by the NDS (Deficiency EH&S-3). ODO reviewed
documentation that reflects the frequency and duration of generator tests is consistent with
guidelines set by the manufacturer, but those guidelines do not comply with the NDS.
Barbering services are provided by a contractor on a monthly basis. Detainees are charged $25 for a
haircut. ODO confirmed RCADC management does not mandate hair length. Barbering is
conducted in a dedicated room. Inspection of the room confirmed it is in excellent condition, and
sanitation regulations are posted.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4), the FOD
must ensure, “Monthly fire drills will be conducted and documented separately in each department.”
DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a)(b)(c), the
FOD must ensure, “In addition to a general diagram, the following information must be provided on
existing signs:
a. English and Spanish instructions;
b. “You Are Here” markers;
c. Emergency equipment locations.
New signs and sign replacements will also identify and explain ‘Areas of Safe Refuge.’”
DEFICIENCY EH&S-3
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(O), the FOD must
ensure, “Power generators will be tested at least every two weeks. Other emergency equipment and
systems will undergo quarterly testing, with follow-up repairs or replacement as necessary.
The biweekly test of the emergency electrical generator will last one hour. During that time, the oil,
water, hoses and belts will be inspected for mechanical readiness to perform in an emergency
situation. The emergency generator will also receive quarterly testing and servicing from an
external generator-service company. Among other things, the technicians will check starting battery
voltage, generator voltage and amperage output.”

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at RCADC to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO reviewed
documentation, interviewed staff, inspected the food service area, and observed meal preparation
and service.
All work associated with preparing meals is performed by the contractor AFSM. No detainees or
county inmates are assigned to work in the food service area, which is located outside the secure
perimeter of RCADC. The contractor employs a total of(b)(7)efood service staff, including the FSD,
an assistant FSD, (b)(7)e full-time cooks, and(b)(7)epart-time cooks. ODO verified that RCADC
reviews the master cycle menu annually and a registered dietician certifies the menu based on a
complete nutritional analysis. Review confirmed the master menu is a 28-day cycle and offers a
variety of food items.
The FSD provided documentation that 30 medical diets were approved at the time of the inspection;
however, documentation did not differentiate detainees from inmates. The medical staff approves
all medical diets. The facility does not offer a common fare program to accommodate detainees
whose religious dietary needs cannot be met by the regular menu (Deficiency FS-1). Per facility
policy, approval of a detainee request for a religious diet is granted in consultation with contract
religious leaders, and arrangements are made to provide the approved diet. ODO confirmed
RCADC policy does not require development of a ceremonial meal schedule (Deficiency FS-2).
The FSD stated that during Lent, the facility does not provide a meatless lunch and dinner on
Fridays, or on Ash Wednesday (Deficiency FS-3).
The FSD stated pre-employment medical examinations are not completed for food service staff,
because medical examinations are not required by AFSM policy (Deficiency FS-4). Medical
clearance serves the critical purpose of ensuring food service workers do not have a communicable
disease in any transmissible stage or condition. This is a repeat deficiency from the last ODO
inspection in June 2012.
RCADC employs a satellite system of meal service involving preparation of meals in the kitchen
and delivery to housing units on insulated trays. ODO observed the food service staff preparing
meals and loading carts for delivery to the housing units. ODO sampled the Wednesday evening
meal and confirmed it was of good quality and taste. All items served were on the approved menu
and in the prescribed portion size. Appropriate condiments were provided. Temperatures of the
items served were verified in compliance with the NDS using a food service thermometer. ODO
observed the cook supervisor checking temperatures as the trays were loaded at the serving line.
Hot items were observed at 180 degrees Fahrenheit as trays were prepared and 140 degrees
Fahrenheit upon service. Trays were served to detainees within 30 minutes of preparation. ODO
observed the service of the meal in the housing units, and there were no complaints from detainees
regarding food service. Inspection of sack meals provided to detainees confirmed the contents met
NDS requirements.
During the inspection, ODO observed a high level of sanitation in the food service area. The most
recent annual inspection by the Saint Paul-Ramsey County Public Health, Environmental Health
Section was conducted on November 14, 2013. The report documents three minor violations, none
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of which affected compliance with the NDS. The food service director stated daily and weekly
inspections are completed; however, a review of documentation found the most-recent weekly
inspection was documented in November 2013 (Deficiency FS-5). Frequent, documented
inspections ensure sanitary conditions on an ongoing basis. This is a repeat deficiency from the last
ODO inspection in June 2012.
The food service storage areas consist of a dry storage room, a walk-in freezer, and a walk-in cooler.
ODO confirmed temperatures in the walk-in freezer and cooler unit are maintained at the required
levels. The facility stocks a 15-day minimum supply of food and has a first-in/first-out stock
rotation system. ODO observed RCADC has appropriate tool accountability in the food service
area.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE NDS, Food Service, section (III)(E)(2), the FOD must ensure, “Common
fare is intended to accommodate detainees whose religious dietary needs cannot be met on the main
line. The common-fare menu is based on a 14-day cycle, with special menus for the ten Federal
holidays. The menus must be certified as exceeding minimum daily nutritional requirements.”
DEFICIENCY FS-2
In accordance with ICE NDS, Food Service, section (III)(E)(10), the FOD must ensure, “The
Chaplain, in consultation with the local religious leaders, if necessary, shall develop the ceremonialmeal schedule for the next calendar year, providing it to the OIC. This schedule shall include the
date, religious group, estimated number of participants, and special foods required. Ceremonial and
commemorative meals shall be served in the food service facility unless otherwise approved by the
[Officer in Charge].”
DEFICIENCY FS-3
In accordance with ICE NDS, Food Service, section (III)(E)(11)(c), the FOD must ensure, “During
the Christian season of Lent, a meatless meal (lunch or dinner) shall be served on the main line on
Fridays and on Ash Wednesday.”
DEFICIENCY FS-4
In accordance with ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure, “All food
service personnel (both staff and detainee) shall receive a pre-employment medical examination.”
DEFICIENCY FS-5
In accordance with ICE NDS, Food Service, section (III)(H)(13)(a), the FOD must ensure, “The
facility shall implement written procedures for the administrative, medical, and/or dietary personnel
conducting the weekly inspections of all food service areas, including dining, storage, equipment,
and food-preparation areas. All components of the food service department, (ranges, ovens,
refrigerators, mixers, dishwashers, garbage disposal, etc.) require frequent inspection to ensure their
sanitary and operable condition. Staff shall check refrigerator and water temperatures daily,
recording the results.
The FSA or CS of food service shall inspect food service areas weekly.”
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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at RCADC to determine if controls are in
place to inventory, receipt, store, and safeguard detainees’ personal property, in accordance with the
ICE NDS. ODO toured the facility, reviewed local policies, the detainee handbook, and detention
files, interviewed staff, and inspected areas where detainee property and valuables are stored.
Property is inventoried during the intake process. ODO reviewed property bags for each of the 19
detainees at RCADC and confirmed inventory forms are signed by intake officers and detainees.
Personal property is placed in hanging garment bags and stored in a locked property room. The
property room is secure and only accessible to authorized staff. Documentation confirmed personal
property is inventoried on a bi-weekly basis by the property room supervisor.
Upon admission, detainee cash is deposited in an electronic funds receiver, which creates an account
for the detainee that is accessible via a vending card issued at admission. Valuable property items
are placed in a sealed clear envelope, which is placed inside of the hanging garment bag. RCADC
does not have a dedicated safe or secured locker accessible to only designated supervisors to store
valuables (Deficiency F&PP-1).
The facility handbook provides notice to detainees of which items may be retained in their
possession, the rules for storing or mailing property not allowed in their possession, the procedure
for claiming property upon release, and the procedure for filing a claim for lost or damaged
property. The facility handbook does not provide the procedure for requesting a certified copy of
identity documents such as passports and birth certificates (Deficiency F&PP-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE NDS, Funds and Personal Property, section (III)(A)(2)(3)(4), the FOD
must ensure “each facility will have the following:
2.
3.
4.

Valuable-property envelopes, accessible to designated supervisor(s) only;
A dedicated safe for the cash box and property envelopes;
A secured locker for holding large valuables, accessible to designated supervisor(s) only.”

DEFICIENCY F&PP-2
In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2), the FOD must
ensure “the detainee handbook or equivalent shall notify the detainees of facility policies and
procedures concerning personal property, including:
2. That, upon request, they will be provided an INS-certified copy of any identity document
(passport, birth certificate, etc.) placed in their A-files.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at RCADC to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with the
ICE NDS. ODO toured the clinic, reviewed policies and procedures, observed medication
distribution and sick call, and verified medical staff credentials. ODO examined the medical records
of each of the 19 detainees held at RCADC, one of whom had a chronic health condition.
Interviews were conducted with detainees, health care personnel, and administrative staff.
Health care at RCADC is provided by Ramsey County 24 hours per day, seven days per week by 14
registered nurses (RNs) and (b)(7)emedical assistants. (b)(7)e RN is a nurse clinician and serves as the
administrative health authority. The clinical medical authority is a physician who is on site four
hours weekly. Additional services are provided by a nurse practitioner eight hours per week, a
psychiatrist on site six hours per week, and a dentist and dental assistant on site four hours per week.
In-patient and out-patient services are provided by Regions Hospital, St. Paul, Minnesota. Health
Partners Specialty Group, a group of physicians affiliated with Regions Hospital, provide medical
specialty services. RCADC also has contracts with the Ramsey County Mental Health Crisis Team
and with DaVita Dialysis for in-house dialysis three days weekly, as necessary. Bilingual staff and
a telephone interpretation service are used as needed. ODO determined current staffing is sufficient
to perform basic examinations and provide treatment to the detainee population at RCADC.
The clinic has two examination rooms, a medication room, a dental suite/dialysis room, a medical
records room, three short-term observation rooms, a nursing station, and the nurse clinician’s office.
There is a waiting room with a drinking fountain and restroom facilities.
Correctional officers conduct intake medical screening, which addresses medical, mental health, and
suicide risk factors. If the correctional officer identifies a medical or mental health issue, suicidal
ideation, or confirms that a detainee is taking medication, the screening form is sent electronically to
the nursing station in the medical unit, where it is printed. This system ensures nursing staff is
notified immediately of any health care needs requiring follow-up. Based on interviews with
facility staff assigned to the intake area, correctional officers do not receive training to perform
intake screenings (Deficiency MC-1). Specialized training is critical to ensure officers possess the
skill set necessary to conduct thorough intake screenings and to identify and document issues
requiring attention.
A chest X-ray is performed in-house within 24 hours of admission to rule out tuberculosis (TB).
ODO reviewed the medical records for each of the 19 detainees housed at RCADC and confirmed
chest X-rays were performed within 24 hours of admission in all cases. RCADC does not have a
negative pressure room; therefore, detainees with an abnormal chest X-ray or symptoms of TB are
transported to the local hospital for continued observation and treatment.
A nurse practitioner performs health appraisals, which include a hands-on physical examination and
dental screening. A review confirmed the appraisal form used at RCADC meets NDS requirements.
ODO confirmed health appraisals were completed within 14 days of arrival at the facility in each of
the 19 cases reviewed.

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Detainees access health care by completing sick call request forms available in English and Spanish.
The sick call request forms are obtained from a housing unit correctional officer. Completed sick
call request forms are given to a correctional officer or directly to nursing staff during medication
administration. ODO observed nursing staff picking up completed sick call request forms from an
unsecured box in the officer’s station within the housing unit. During interviews, detainees stated
they turn in sick call request forms to a housing unit officer (Deficiency MC-2). Involvement of
officers in this process violates patient confidentiality, because medical information is documented
on the forms. Access to health care may be impeded if detainees are reluctant to request services
through correctional staff. This is a repeat deficiency from the most-recent ODO inspection in June
2012.
ODO verified sick call requests are triaged upon receipt by nursing staff, and detainees are evaluated
at sick call in a timely manner. Nursing staff conducts sick call five days per week using
standardized nursing protocols. Consent for Treatment is included on each sick call request form.
The nurse clinician stated that seriously or terminally ill detainees are not accepted at RCADC. If a
detainee becomes seriously ill or injured, a transfer is arranged through ERO. ODO verified facility
policy addresses required components of the NDS.
Omni Care provides mail order pharmacy services under contract. Nurses are responsible for
administering medication within the housing units, and they complete rounds using medication
carts. ODO reviewed medication administration records and confirmed entries were complete.
ODO confirmed medication carts are inventoried three times per day at shift change.
RCADC has an emergency plan that includes emergency contact phone numbers. ODO observed an
emergency response cart, including an automated external defibrillator (AED) located in the medical
unit. There is an AED and a first aid kit at each correctional officer station. A review of training
records for all medical staff and(b)(7)erandomly-selected correctional officers confirmed all received
initial and periodic training in first aid, including the requirement to respond to medical
emergencies within a four-minute response time. Training records also confirmed current
certification in cardio-pulmonary resuscitation (CPR) and the use of an AED.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE NDS, Medical Care, section (III)(D), the FOD must ensure, “All new
arrivals receive initial medical and mental health screening immediately upon their arrival by a
health care provider or an officer trained to perform this function.”
DEFICIENCY MC-2
In accordance with ICE NDS, Medical Care, section (III)(M), the FOD must ensure, “All medical
providers shall protect the privacy of detainees’ medical information to the extent possible while
permitting the exchange of health information required to fulfill program responsibilities and to
provide for the well-being of detainees.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at the RCADC to determine if
procedures are in place to allow formal and informal contact between detainees and key ICE and
facility staff, and if ICE detainees are able to submit written requests to ICE staff and receive
responses in a timely manner, in accordance with the ICE NDS. ODO interviewed staff and ICE
detainees, and reviewed logbooks, policies, and procedures.
Unannounced visits are conducted by an SDDO on a monthly basis, but there is no documentation
of which areas are visited (Deficiency SDC-1). The facility staff member designated as the ICE
liaison stated the SDDO only visits the housing units. A DO conducts weekly scheduled visits to
the housing units on Fridays. While touring the housing units, ODO found weekly visitation
schedules were not posted in all of the housing units (Deficiency SDC-2). The facility initiated
corrective action during the inspection by posting schedules in the housing units. This is a repeat
finding from the July 2012 ODO inspection.
RCADC does not have written procedures for routing detainee requests through the appropriate ICE
officials (Deficiency SDC-3). Detainees can submit written requests to ICE staff by filling out a
request form and labeling it “Immigration.” Envelopes are available in the housing units if the
detainee wishes to seal the request. A facility staff member scans and emails each request to ERO.
ODO reviewed all detainee requests from October 2013 through March 2014 and confirmed all
requests received a response within 72 hours. There is no log to track detainee requests
(Deficiency SDC-4). Facility staff initiated corrective action during the inspection by creating a
log.
The facility handbook does not inform detainees they can submit written questions and concerns to
ICE staff, or the procedures for doing so, including the availability of assistance in preparing a
request (Deficiency SDC-5). The facility handbook does not contain OIG Hotline information
(Deficiency SDC-6).
ODO verified that ICE staff documents and completes the Telephone Serviceability Worksheet and
the Facility Liaison Visit Checklist; however, records were missing from each for two and threeweek periods (Deficiencies SDC-7 and 8).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(1)(a)(b)(c)(d), the
FOD must ensure, “Policy and procedures shall be in place to ensure and document that the ICE
Officer in Charge (OIC), the Assistant Officer in Charge (AOIC) and designated department heads
conduct regular unannounced (not scheduled) visits to the facility’s living and activity areas to
encourage informal communication between staff and detainees and informally observing living and
working conditions. These unannounced visits shall include but not be limited to:
a. Housing Units;
b. Food Service preferably during the lunch meal;
c. Recreation Area;

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d. Special Management Units (Administrative and Disciplinary Segregation); and Infirmary
room.”
DEFICIENCY SDC-2
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(A)(2)(b), the FOD
must ensure, “written schedules shall be developed and posted in the detainee living areas and other
areas with detainee access.”
DEFICIENCY SDC-3
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B), the FOD must
ensure, “all facilities that house ICE detainees must have written procedures to route detainee
requests to the appropriate ICE official.”
DEFICIENCY SDC-4
In accordance with the ICE NDS, Staff-Detainee Communication, section
(III)(B)(2)(a)(b)(c)(d)(e)(f)(g), the FOD must ensure, “All requests shall be recorded in a logbook
specifically designed for that purpose. The log, at a minimum, shall contain:
a.
b.
c.
d.
e.
f.
g.

The date the detainee request was received;
Detainee’s name;
A-number;
Nationality;
Officer logging the request;
The date that the request, with staff response and action, is returned to the detainee; and
Any other site-specific pertinent information.

In IGSAs, the date the request was forwarded to ICE and the date it was returned shall also be
recorded.”
DEFICIENCY SDC-5
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(3), the FOD must
ensure, “The handbook shall state that the detainee has the opportunity to submit written questions,
requests, or concerns to ICE staff and the procedures for doing so, including the availability of
assistance in preparing the request.”
DEFICIENCY SDC-6
In accordance with the Change Notice National Detention Standards Staff-Detainee Communication
Standard, dated June 15, 2007, the FOD must ensure, “The OIG Hotline information is to be
included in the detainee handbook in each of the aforementioned locations.”
DEFICIENCY SDC-7
In accordance with the Change Notice, National Detention Standards Staff/Detainee
Communication Model Protocol, dated June 15, 2007, the FOD must ensure, “For InterGovernmental Service Agreements (IGSAs) facilities housing ICE detainees the model protocol
should be completed weekly for regularly used facilities and each visit for facilities, which are used
intermittently.”

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DEFICIENCY SDC-8
In accordance with the Detainee Telephone Services memorandum, dated April 6, 2007, the FOD
must ensure, “Effective immediately, concurrent with staff/detainee communications visits, ICE
staff will verify serviceability of all telephones in detainee housing units by conducting random calls
to pre-programmed numbers posted on the pro bono/consulate list. ICE staff will also interview a
sampling of detainees and review written detainee complaints regarding detainee telephone access.
The Field Office Director (FOD) shall ensure that all phones in all applicable facilities are tested on
a weekly basis.
Each serviceability test shall be documented using the attached form [Telephone Serviceability
Worksheet].”

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at RCADC to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and others
in the community, in accordance with the ICE NDS. ODO interviewed staff, reviewed local policies
concerning telephone access, and tested randomly-selected telephones in the housing units to
determine operability.
ODO verified detainees have reasonable and equitable access to telephones at RCADC. The
telephone availability ratio is one detainee per telephone. The facility also provides a teletype
(TTY) device, if needed. Notification that calls are subject to monitoring is posted in English and
Spanish at each telephone station.
ODO verified both facility and ICE logbooks and serviceability worksheets which indicated the
telephones were inspected daily by facility staff and at least weekly by ICE staff. During the
inspection, ODO tested all the telephones in the detainee housing units and confirmed that none of
the telephones in the male, female, and SMU housing units allowed detainees telephone access to
embassies and consulates, pro-bono entities, DHS OIG, or other governmental agencies
(Deficiency TA-1).
RCADC policy limits detainee telephone calls to 15 minutes before the call is automatically cut-off
(Deficiency TA-2). RCADC explains the telephone access rules in the detainee handbook, but
detainees are unaware of the telephone access rules because they are not receiving the detainee
handbook upon admission (Deficiency TA-3). The access rules for telephone use did not identify
procedures for obtaining an unmonitored call to a court, a legal representative, or for the purposes of
obtaining legal representation, and a notice of the procedures was not posted at each telephone
location (Deficiency TA-4).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE NDS, Telephone Access, section (III)(E)(1)(2)(3)(4)(5), the FOD must
ensure, “Even if telephone service is generally limited to collect calls, the facility shall permit the
detainee to make direct calls:
1.
2.
3.
4.
5.

to the local immigration court and the Board of Immigration Appeals;
to Federal and State courts where the detainee is or may become involved in a
legal proceeding;
to consular officials;
to legal service providers, in pursuit of legal representation or to engage in
consultation concerning his/her expedited removal case;
to a government office, to obtain documents relevant to his/her immigration case;

If the limitations of its existing phone system will initially preclude the facility from meeting these
requirements, the OIC must report this to INS. INS will respond by providing some means of
access, e.g., cell phones into which facility staff can pre- program authorized numbers (in the above
categories) with all other numbers blocked. These phones will be maintained by on-site INS liaison
officers or local officials, and must be provided in an environment that meets privacy standards.”
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DEFICIENCY TA-2
In accordance with the ICE NDS, Telephone Access, section (III)(F), the FOD must ensure, “The
facility shall not restrict the number of calls a detainee places to his/her legal representatives, nor
limit the duration of such calls by rule or automatic cut-off, unless necessary for security purposes or
to maintain orderly and fair access to telephones. If time limits are necessary for such calls, they
shall be no shorter than 20 minutes, and the detainee shall be allowed to continue the call if desired, at
the first available opportunity.
The facility may place reasonable restrictions on the hours, frequency and duration of the other direct
and/or free calls listed above, but these must not unduly limit a detainee attempting to obtain legal
representation.”
DEFICIENCY TA-3
In accordance with the ICE NDS, Telephone Access, section (III)(B), the FOD must ensure, “As
described in the “General Provisions” standard, the facility shall provide telephone access rules in
writing to each detainee upon admittance, and also shall post these rules where detainees may easily
see them.”
DEFICIENCY TA-4
In accordance with the ICE NDS, Telephone Access, section (III)(K)(2), the FOD must ensure,
“The facility shall have a written policy on the monitoring of detainee telephone calls. If telephone
calls are monitored, the facility shall notify detainees in the detainee handbook or equivalent provided
upon admission. It shall also place a notice at each monitored telephone stating:
2.

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

A detainee’s call to a court, a legal representative, or for the purposes of obtaining legal
representation will not be aurally monitored absent a court order. The OIC retains the discretion to
have other calls monitored for security purposes.”

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