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
ERO Boston
Suffolk County House of Correction
Boston, Massachusetts

May 6–8, 2014

COMPLIANCE INSPECTION
SUFFOLK COUNTY HOUSE OF CORRECTION
ERO BOSTON
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................2
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................7
ICE 2000 NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................9
Access to Legal Materials ..................................................................................................10
Admission and Release ......................................................................................................12
Detainee Grievance Procedures .........................................................................................14
Detainee Handbook ............................................................................................................16
Environmental Health and Safety ......................................................................................17
Food Service ......................................................................................................................19
Funds and Personal Property .............................................................................................21
Medical Care ......................................................................................................................23
Special Management Unit-Administrative Segregation ....................................................26
Special Management Unit-Disciplinary Segregation.........................................................27
Staff-Detainee Communication .........................................................................................28
Suicide Prevention and Intervention ..................................................................................30
Telephone Access ..............................................................................................................31
Use of Force .......................................................................................................................33

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

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

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INSPECTION TEAM MEMBERS

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

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Section Chief, Inspections (Team Lead)
Management and Program Analyst
Inspections and Compliance Specialist
Inspections and Compliance Specialist
Contractor
Contractor
Contractor

2

ODO
ODO
ODO
ODO
Creative Corrections
Creative Corrections
Creative Corrections

Suffolk County House of Correction
ERO Boston

EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Suffolk County House of Correction (SCHC) in
Boston, Massachusetts, from May 6 to 8, 2014. SCHC, which opened in 1991, is owned by the
State of Massachusetts and operated by the Suffolk County Sheriff’s Department. ERO began
housing detainees at SCHC in November 2003 under an intergovernmental service agreement
(IGSA) contract. Male and female detainees of all security classification levels (levels I through
III) are detained at the facility for periods in excess of 72 hours. The inspection evaluated
SCHC’s compliance with the 2000 NDS.
The ERO Field Office
Director (FOD), in Boston, MA, is
responsible for ensuring facility
compliance with the 2000 NDS and
ICE policies. A minimum of (b)(7)e
ERO staff and (b)(7)eDetention Service
Manager (DSM) is assigned to the
facility.

Capacity and Population Statistics
Total Bed Capacity

Quantity
2,052

ICE Detainee Bed Capacity
Average Daily Population

250
1,050

Average ICE Detainee Population

204

Average Length of Stay (Days)

34

Male Detainee Population (as of 5/6/14)

182

A Superintendent is responsible for
Female Detainee Population (as of 5/6/14)
oversight of daily facility operations
and is supported by(b)(7)epersonnel. Trinity Services Group provides food services and
NaphCare, Inc. provides medical services. The facility is accredited by the National
Commission on Correctional Health Care (NCCHC).

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In September 2009, ODO conducted a quality assurance review of SCHC under the 2000 NDS.
ODO reviewed 22 standards and found SCHC compliant with 14 standards. ODO found a total
of 16 deficiencies in the remaining eight standards.
During this inspection, ODO inspected 15 standards and found SCHC compliant with one
standard. ODO found a total of 27 deficiencies in the remaining 14 standards: Access to Legal
Material (3 deficiencies), Admission and Release (3), Detainee Grievance Procedures (3),
Detainee Handbook (1), Environmental Health and Safety (1), Food Service (2), Funds and
Personal Property (4), Medical Care (2), Special Management Unit-Administrative Segregation
(1), Special Management Unit-Disciplinary Segregation (1), Staff-Detainee Communication (2),
Suicide Prevention and Intervention (1), Telephone Access (2), and Use of Force (1). ODO
made seven recommendations1 regarding facility policy and procedures (deficiencies) and cited
one best practice.
This report details all deficiencies and refers to the specific, relevant sections of the 2000 NDS.
ERO will be provided a copy of this report to assist in developing corrective actions to resolve
all identified deficiencies. ODO discussed these deficiencies with SCHC and ICE personnel
during the inspection and at a closeout briefing conducted on May 8, 2014.

1

Recommendations are annotated in this report with a “R.”

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Classification and reclassification of detainees at SCHC is conducted solely by ERO. ERO uses
the Risk Classification Assessment for initial classification. Upon arrival at SCHC, detainees
receive screenings, personal hygiene items, clothing, towels and bedding. Hygiene starter kits
are provided at admission for all detainees; however, SCHC expects all detainees, including
indigent detainees, to purchase replacement supplies through the canteen.
Orientation is conducted in male housing units twice weekly and in female housing units twice
monthly. Orientation includes an explanation of facility rules, detainee rights and the Prison
Rape Elimination Act. Male detainees receive a facility handbook upon admission; however,
female detainees are not provided a facility handbook until one of the bi-monthly orientation
sessions.
SCHC’s written policies and procedures on funds and personal property do not completely meet
the requirements in the NDS. SCHC does not have procedures for the loss of or damage to
property, procedures for investigating and reporting property loss of or damage, or policies
stating supervisory staff will conduct the investigation. Further, the written policy fails to state
the facility will not arbitrarily impose a ceiling on the amount to be reimbursed and that a senior
contact will immediately notify the designated ICE officer of all claims and outcomes.
Additional deficiencies for funds and personal property are detailed in the body of this report.
Each housing unit at SCHC contains a designated room for detainees to access legal material.
Detainees are afforded a minimum of five hours weekly during designated library hours. All
computers contained a current version of LexisNexis and word-processing software. SCHC
policy does not allow detainees in special management units (SMU) direct access to the law
library. Further, the facility does not allow detainees to assist others in researching and
preparing legal documents.
The grievance system at SCHC allows detainees to file informal, formal and emergency
grievances; however, detainees are unable to bypass or terminate the informal grievance process
and proceed directly to the formal grievance process. ODO reviewed all 82 formal grievances
filed by detainees in the 12 months preceding the inspection. All were addressed within a
reasonable time. Six of the 82 grievances filed alleged staff misconduct and were not forwarded
to ERO.2 Five of those six grievances alleged misconduct by one particular SCHC officer. ODO
notified ERO of the staff misconduct grievances during the inspection.
Sanitation throughout the facility was very good at the time of the inspection. SCHC policy
addresses control of hazardous substances and provides guidelines supporting safety and proper
control. All flammable, caustic and toxic substances were accurately inventoried and stored and
a master index of hazardous substances is maintained.
SCHC has a satellite feeding operation. ODO observed the preparation and delivery of the lunch
meal on Tuesday, May 7, 2014. ODO found lunch meals delivered to housing unit 8-4 are

2

The 82 grievance topics were as follows: medical care (14), food service (9), funds and personal property (8), staff
misconduct (6), mail (5), legal issues (2), and miscellaneous issues (38). Miscellaneous issues included but were not
limited to complaints about television, the canteen and housing unit conditions.

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routinely delayed due to a 12 p.m. count, affecting food temperatures. Further, sack lunches for
detainees did not contain all the items required by the NDS.
ODO found barbering is conducted in multi-purpose rooms within the housing units. These
rooms are typically used for religious services, professional visits and other unit activities. The
rooms lacked lavatories and appropriate cabinets or covered metal containers for waste. Hair
care sanitation regulations were not posted in any of the rooms. Barbering supplies, which are
maintained in a large bag and locked in the staff office, had not been properly cleaned and
sanitized at the time of the inspection. Hair and other dirt and debris were visible on all the
equipment.
A Health Services Administrator (HSA) administers the medical clinic at SCHC, which is staffed
24 hours a day, seven days a week. Clinical oversight is provided by the medical director, a fulltime physician. On-call coverage is shared with the medical director,(b)(7)epart-time physician
and (b)(7)e full-time mid-level providers. Nurses conduct detainee medical and mental health
intake screenings. Detainees receive hands-on physical examinations by a physician or midlevel provider within 24 hours of admission. Detainees with positive responses to mental health
questions are automatically referred for a mental health evaluation. ODO cited this as a best
practice, because it ensures efficient identification and prompt follow up of mental health
concerns.
ODO identified one detainee who was not screened for tuberculosis (TB) in a timely manner,
placing other detainees and staff at risk. ODO also discovered signed, consent forms were not
obtained for four detainees receiving psychotropic medication.
During a medical record review, ODO found two detainees identified as “at-risk” for suicide and
two who had attempted suicide. All four detainees were placed in a suicide watch cell,
immediately referred to mental health staff, and evaluated within 24 hours. The two detainees
who attempted suicide were placed on constant watch and the other two on 15-minute checks
with camera surveillance. The detainees were released from suicide watch following an
assessment by a mental health professional; however, the medical director did not document
written authorization for their return to general population as required by the local policy and
NDS.
ODO evaluated SCHC’s sexual abuse and assault prevention and intervention program.
Although SCHC was not required to comply with the 2011 PBNDS Sexual Abuse and Assault
Prevention and Intervention (SAAPI) standard at the time of the inspection, ODO noted any
efforts by the facility to comply with the standard’s requirements. Detainees are shown a Prison
Rape Elimination Act (PREA) video upon intake, and detainees are screened to identify those
likely to be sexual aggressors or victims. The Superintendent serves as the PREA Coordinator.
SCHC has a PREA Review Committee, which is responsible for conducting assessments of the
facility’s response to sexual abuse and harassment allegations.
According to SCHC staff, one detainee reported being sexually harassed by other detainees in
the last 12 months preceding the inspection. Documentation reflects that on September 2, 2012,
a detainee reported the harassment to a housing unit officer, who immediately reported it to a
supervisor. The detainee was examined by health care staff and transferred to another general
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population housing unit, with “keep separate” orders initiated to prohibit contact with the alleged
perpetrators. The allegation was referred to and investigated by the sheriff’s office, which later
closed the case. ERO was not notified about the allegation by SCHC staff.3
SCHC’s Special Management Unit (SMU) has 16 single-capacity cells for male detainees and 16
single-capacity cells for female detainees. The SMU is used for both administrative and
disciplinary segregation. One detainee was assigned to administrative segregation and another to
disciplinary segregation during the inspection. The SMU log confirmed detainees had access to
services and most privileges required by the standard, including recreation and legal materials.
Per SCHC policy, detainees on administrative and disciplinary segregation status are not
permitted to have social visits.
The ERO Boston Field Office has a staff-detainee communication policy in place.4 Detainees
have opportunities to interact informally with both ERO and SCHC staff. Non-supervisory ERO
staff visits the housing units daily. Visits by supervisory ERO staff do not occur as frequently as
required by policy. ODO found the facility handbook lacks procedures on how to submit
requests or the availability of assistance in preparing requests. ODO made two recommendations
regarding patient confidentiality with medical care requests and SCHC maintaining accurate
housing unit logs.
Detainees have up to six hours daily to access telephones at SCHC. Call rates range from $0.10
to $0.25 per minute, not including a minimum $2.50 surcharge. ERO tests telephones weekly,
but not in a unit where detainees are routinely housed. The procedures for obtaining an
unmonitored call are missing from the facility handbook and in some locations throughout the
facility. Also, the OIG speed-dial number is not printed on the OIG hotline poster. ODO
recommends ERO staff test all telephones weekly and update the OIG hotline poster to include
the speed-dial number.
SCHC has a comprehensive written policy governing the use of force. Training records for 18
randomly-selected officers confirmed current training in use of force and oleo capsicum (OC)
deployment. There were eight immediate and two calculated use-of- force incidents involving
detainees during the 15 months preceding the inspection. Both calculated use-of-force incidents
were recorded using a hand-held video camera; however, the video recordings did not identify
the camera operator during introduction of the team by the leader.

3

Prior to verbally notifying the housing unit officer of the alleged sexual harassment, the detainee wrote an August
31, 2012 letter to DHS OIG. The OIG declined to open an investigation and referred the matter to the ICE Office of
Professional Responsibility (OPR). On January 10, 2013, a case was opened in the OPR Joint Intake Center
Management System and on January 29, 2013, it was assigned to OPR in Portsmouth, New Hampshire, for
investigation. The case was closed on March 6, 2013.
4
According to a March 1, 2012 policy memo issued by the Boston Field Office Director, Boston ERO staff is
expected to follow the ERO requirements contained in the 2008 PBNDS on Staff-Detainee Communication. The
ERO requirements in the 2008 PBNDS correspond with the requirements contained in the June 2007 Change Notice
and Model Protocol on Staff-Detainee Communication. ODO evaluated ERO’s compliance with the 2008 PBNDS
and SCHC’s compliance with the NDS.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 48 randomly-selected detainees (38 males and ten females) of all classification
levels. Interview participation was voluntary and none of the detainees expressed egregious
allegations of abuse, discrimination or mistreatment. The majority of detainees reported being
satisfied with facility services, with the exception of isolated complaints about medical care,
classification, facility handbook, personal hygiene, food service and language access.
Medical Care: Two detainees complained about being unable to see and in need of eyeglasses.
ODO reviewed the medical files for these detainees and found eyeglasses were ordered for both.
Medical staff had assured the detainees their prescriptions would arrive soon.
Classification: ODO discovered most detainees were unaware of their classification levels and
therefore, unable to appeal their level. ERO stated classification appeals are available to
detainees, but acknowledged no detainee at SCHC has ever appealed his or her classification
level.
Facility Handbook: Several detainees claimed they did not receive a facility handbook. ODO
found male detainees receive the handbook upon admission and are provided orientation twice
weekly. Female detainees, on the other hand, are only provided a handbook during their
orientation, which occurs twice monthly. ODO found the delayed orientation left female
detainees unaware of facility rules and unable to navigate services.
Personal Hygiene: Detainees are required to purchase hygiene items if they have money in their
accounts, which conflicts with ICE policies. Even for indigent detainees, case workers stated
that it is very hard to obtain replenishment of hygiene items. ODO found the facility has a very
convoluted request procedure for requesting hygiene items. Procedures for replacing hygiene
items are not included in the facility handbook.
Food Service: ODO received numerous complaints about food service. Detainees stated food
service at the facility was poor and contained small portions. ODO found the menu was wellbalanced and the caloric intake adequate.
Language access: SCHC has a large limited English proficient population, yet only one ERO
staff and few SCHC staff spoke a language other than English. The telephonic interpretation line
did not appear to be a commonly used resource among SCHC staff. The majority of detainees
interviewed by ODO complained about the inability of ERO and SCHC staff to communicate
with them in a language they understand. Several English-speaking detainees verified the
language difficulties between staff and detainees. As a result of the language difficulties,
detainees stated they were unaware of how to replenish hygiene items, request undergarments
and submit grievances and requests.
ODO met a female detainee for whom SCHC staff had not completed orientation due to a
language barrier. The detainee entered the facility on April 19, 2014. SCHC staff stated they
used the telephonic language line and reached out to the Vietnamese consulate for assistance in
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communicating with the detainee. As of the time of the inspection, her orientation was still
incomplete. ODO recommends ERO and SCHC proactively work together to identify those
detainees requiring language assistance, particularly for interactions during admission,
classification, medical encounters, grievances and disciplinary hearings (R-1).

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 15 NDS and found SCHC fully compliant with one standard:
1.

Detainee Classification System

As the standards above were compliant at the time of the inspection, a synopsis for each of these
standards is not included in this report.
ODO found 27 deficiencies in the following 14 standards.
1. Access to Legal Material
2. Admission and Release
3. Detainee Grievance Procedures
4. Detainee Handbook
5. Environmental Health and Safety
6. Food Service
7. Funds and Personal Property
8. Medical Care
9. Special Management Unit-Administrative Segregation
10. Special Management Unit-Disciplinary Segregation
11. Staff-Detainee Communication (2008 PBNDS and NDS)
12. Suicide Prevention and Intervention
13. Telephone Access
14. Use of Force
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 SCHC to determine if detainees have
access to a law library, legal materials, and supplies and equipment to facilitate the preparation
of legal documents, in accordance with the ICE NDS.
The law library is located in a designated room in each housing unit containing detainees.
Detainees submit request forms to SCHC officers in order to access the law library. Detainees
are afforded a minimum of five hours per week during designated library hours and can request
additional time if needed. Policies and procedures are posted in the law library along with a list
of the library’s holdings.
The law library is well-lit, equipped with adequate furnishings, and includes two computers in
each of the three male housing units and one in the female housing unit equipped with
LexisNexis. Printers and supplies to support legal research and case preparation by detainees are
also available in each unit. Computers contained a current version of LexisNexis and wordprocessing software. Detainees have access to paper, writing utensils, and envelopes. Legal
documents can be printed or saved on a thumb-drive with the assistance of a staff member.
SCHC has a legal services department that detainees in special management units can use to
request legal materials; however, SCHC policy does not allow these detainees law library
privileges (Deficiency ALM-1).
The facility does not allow detainees to assist other detainees in researching and preparing legal
documents (Deficiency ALM-2). The law library custodian provides indigent detainees with
free envelopes, stamps, notary services and certified mail for legal matters.
The facility handbook does not include the procedure for requesting additional time in the law
library beyond the five hour per week minimum or the procedure for notifying a designated
employee that library material is missing or damaged (Deficiency ALM-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE NDS, Access to Legal Material, section (III)(M), the FOD must
ensure, “Detainees housed in Administrative Segregation or Disciplinary Segregation units shall
have the same law library access as the general population, unless compelling security concerns
require limitations.”
DEFICIENCY ALM-2
In accordance with the ICE NDS, Access to Legal Material, section (III)(K), the FOD must
ensure, “The facility shall permit detainees to assist other detainees in researching and preparing
legal documents upon request, except when such assistance poses a security risk.”
DEFICIENCY ALM-3
In accordance with the ICE NDS, Access to Legal Material, section (III)(Q)(4)(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:
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4.
6.

the procedure for requesting additional time in the law library (beyond the 5 hours per
week minimum);
the procedure for notifying a designated employee that library material is missing or
damaged.”

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ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at SCHC 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 interviewed staff and detainees
concerning the intake and out-processing procedures at the facility, and reviewed detention files.
The ERO Burlington Sub-Office processes detainees prior to their transfer to SCHC including
classifying detainees and documenting and storing their personal property. SCHC uses ERO’s
classification and reclassification determinations. SCHC does not classify or reclassify
detainees. Upon arrival to SCHC, detainees receive a medical screening, hygiene items, clothing,
towels and bedding. All detainees sign forms acknowledging receipt of the facility handbook
and orientation. Orientation covers facility rules, visitation procedures, telephone access and the
Prison Rape Elimination Act.
Male detainees are provided a facility handbook upon admission and their orientation is
delivered in the housing units twice weekly via an oral presentation by supervisory correctional
staff. However, female detainees are not provided a handbook during admission; instead, they
receive a handbook during orientation, which occurs in their housing unit only twice monthly
(Deficiency AR-1). SCHC staff interviewed by ODO stated facility caseworkers meet with
female detainees within 72 hours of their admission to determine if those females have any
questions regarding their detention and to explain the visitation process. Orientation topics are
not discussed in detail during these meetings unless the detainee specifically asks for information
(Deficiency AR-2).
Thirteen of 14 randomly-selected male detention files did not contain a signed form
acknowledging receipt of orientation. Interviews with facility staff and male detainees indicate
male detainees are receiving orientation within four days of arrival. Signed acknowledgement
forms are sent to SCHC’s records department; however, the forms are not being appropriately
placed in detainee files.
Review of active female detention files showed that up to 14 days passed before some female
detainees received the facility handbook or orientation. ODO found SCHC staff had not
completed orientation for one female detainee who entered the facility on April 19, 2014,
because of a language barrier. SCHC staff stated they used the telephonic language line and
reached out to the Vietnamese consulate for assistance in communicating with the detainee. As
of the time of the inspection, her orientation was still incomplete.
A starter hygiene kit containing small containers of soap, toothpaste, and a toothbrush are
provided to all detainees upon admission to SCHC. When detainees need to replace hygienic
supplies, they must purchase replacement items through SCHC’s canteen (Deficiency AR-3). If
a detainee is indigent, he or she must submit a written request for replacement items through a
facility caseworker. Caseworkers interviewed by ODO stated that after verifying a detainee’s
indigence, replacement hygienic supplies are ordered for that detainee. The replacement supplies
are provided by the SCHC canteen, which comes to each housing unit once per week. If a
detainee needs hygienic supplies in the interim, the caseworker will attempt to provide them with
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any needed items from the supplies used for the starter hygiene kits. Caseworkers stated that
these items are often difficult to obtain, and not always available to a detainee upon request.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
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-2
In accordance with the ICE NDS, Admission and Release, section (III)(A), the FOD must ensure,
“Every new arrival shall undergo screening interviews, complete questionnaires and other forms,
attend the facility’s site-specific orientation program, and comply with other admission
procedures (issuance of clothing, bedding, towels, bedclothes, etc.).”
DEFICIENCY AR-3
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.”

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DETAINEE GRIEVANCE PROCEDURE (DGP)
ODO reviewed the Detainee Grievance Procedure standard at SCHC 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 found the grievance system at SCHC allows detainees to file informal, formal and
emergency grievances; however, detainees are unable to bypass or terminate the informal
grievance process and proceed directly to the formal grievance process (Deficiency DGP-1).
Grievance forms are available in the housing units and detainees may obtain assistance from
another detainee or facility staff in preparing a grievance. The facility has a policy for
identifying and handling emergency grievances and has established a grievance committee.
SCHC maintains a grievance log to document and track grievances filed by detainees. Both the
log and grievance forms confirmed 82 formal grievances filed by detainees in the 12 months
preceding the inspection and all were addressed within a reasonable time. ODO confirmed
responses are provided to detainees in writing and a copy is placed in the detention file. The 82
grievances involved the following topics:
Grievance categories

Quantity

Medical care

14

Food service

9

Funds and personal property

8

Staff misconduct

6

Mail

5

Legal issues

2

Miscellaneous issues (i.e., television,
canteen and housing unit conditions.

38

The six staff misconduct grievances were not forwarded to ERO by SCHC (Deficiency DGP-2).
Five of the six staff misconduct grievances involved the same SCHC officer. ODO notified ERO
during the inspection of the grievances alleging staff misconduct.
The facility’s handbook provides notice to detainees of the opportunity to file both a formal and
informal grievance, the procedure for filing a grievance and appeal, the right to have the
grievance referred to higher levels, the procedure for contacting ICE to appeal a decision of the
OIC, the policy prohibiting staff from retaliating against any detainee for filing a grievance, and
information about the opportunity to file a complaint about officer misconduct directly with the
Justice Department. Although SCHC’s handbook provides notice of both the informal and
formal grievance procedure, it states detainees must first attempt to resolve issues informally
before filing a written grievance (Deficiency DGP-3).
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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(1), the FOD
must ensure, “The detainee is free to bypass or terminate the informal grievance process, and
proceed directly to the formal grievance stage.”
DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(F), the FOD must
ensure that facility staff, “Forward detainee grievances alleging officer misconduct to ICE.”
DEFICIENCY DGP-3
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(1), the FOD
must ensure, “The grievance section of the detainee handbook will provide notice of the
following:
1.

The opportunity to file a grievance, both informal and formal.”

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DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at SCHC 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 the facility
handbook, detention files, and interviewed staff and detainees.
All detainees at SCHC receive a detainee/facility handbook and an orientation that covers facility
rules, visitation procedures, telephone access and the Prison Rape Elimination Act. However,
provision of the detainee/facility handbook and orientation differ between male and female
detainees.
Male detainees are provided a detainee/facility handbook upon admission and their orientation is
delivered in the housing units twice weekly via an oral presentation by supervisory correctional
staff. However, female detainees are not provided a handbook during admission; instead, they
receive a handbook during orientation, which occurs in their housing unit only twice monthly.
Detainees complained they were unaware of facility rules and services as a result of the delayed
orientation.
ODO reviewed the facility handbook for all of the required components and found the handbook
compliant with this standard. However, other deficiencies related to information missing from
the Detainee Handbook are reported as Deficiencies ALM-3, AR-2, DGP-3, and F&PP-4.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE NDS, Detainee Handbook section (I), the FOD must ensure, “Every
detainee will receive a copy of this [facility] handbook upon admission the facility.”

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at SCHC 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 procedures, inventories, the fire plan, and documentation of
inspections.
Sanitation throughout the facility was very good. Monthly sanitation and maintenance
inspections are conducted by the facility safety officer, with the results reported to the
Superintendent. Detainees are responsible for keeping their housing units clean and housing unit
officers inspect the units on a daily basis. Documentation reflects weekly pest control
inspections and preventative and eradication services are provided by a licensed pest control
company. ODO’s review of SCHC’s electronic system for tracking maintenance work orders
found maintenance concerns are reported and resolved in a timely manner.
SCHC policy addresses control of hazardous substances and provides guidelines supporting
safety and proper control. ODO’s review of documentation confirmed all flammable, caustic
and toxic substances were accurately inventoried and stored. A master index of hazardous
substances is maintained and Material Safety Data Sheets (MSDS) were available in all
locations.
All staff must complete annual fire safety training and are tested to demonstrate their
competency in the subject. Inspection of training files of (b)(7)eofficers and (b)(7)esupervisor
confirmed all completed and passed the training in the past year. The facility’s safety officer
holds certification as a fire safety officer. There are 400 fire extinguishers located throughout the
nearby jail and SCHC. The SCHC has an electronic system that monitors the presence, pressure
and any blockage on all extinguishers. This system was demonstrated to ODO by removing a
fire extinguisher from the base, which triggered an email to the safety officer within minutes so
that the extinguisher could be inspected. Facility staff participates in weekly fire drills on all
three shifts which include the evacuation of detainees. Exit diagrams posted throughout the
facility include instructions in Spanish, “You Are Here” markers, and emergency equipment
locations.
The water at SCHC is supplied by the Massachusetts Water Resources Authority (MWRA). The
most-recent report, dated 2012, stated the water was found to meet or surpass all United States
Environmental Protection Agency and State of Massachusetts Department of Environmental
Protection water quality standards.
ODO’s review of documentation confirmed the generators at the SCHC are load tested weekly.
The most recent inspection by an external generator service company was conducted on April
29, 2014, and all generators passed inspection.
Barbering is conducted in multi-purpose rooms within the housing units. In addition to
barbering, the rooms are used for religious services, professional visits, and other unit activities.
The rooms do not have a lavatory, although hot and cold water are available immediately outside
the rooms; there are no appropriate cabinets or covered metal containers for waste; and hair care
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sanitation regulations are not posted. In addition, ODO’s inspection of barbering supplies, which
are maintained in a large bag and locked in the staff office, found the combs and other
instruments had not been properly cleaned and sanitized. Specifically, hair and other dirt and
debris were visible on all the equipment (Deficiency EH&S-1).
Inspection of the medical unit found used sharps and infectious waste are placed in a locked
room clearly marked, “Bio-Hazard” and are removed by a contractor on a bi-weekly basis.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with ICE NDS, Environmental Health and Safety, section (III)(P)(1)(2)(3)(4), the
FOD must ensure, “Sanitation of barber operations is of the utmost concern because of the
possible transfer of diseases through direct contact or by towels, combs and clippers. Towels
must not be reused after use on one person. Instruments such as combs and clippers will not be
used successively on detainees without proper cleaning and disinfecting. The following
standards will be adhered to:
1.

2.

3.

4.

The operation will be located in a separate room not used for any other purpose. The
floor will be smooth, nonabsorbent and easily cleaned. Walls and ceiling will be in good
repair and painted a light color. Artificial lighting of at least 50-foot candles will be
provided. Mechanical ventilation of 5 air changes per hour will be provided if there are
no operable windows to provide fresh air. At least one lavatory will be provided. Both
hot and cold water will be available, and the hot water will be capable of maintaining a
constant flow of water between 105 degrees and 120 degrees.
Each barbershop will be provided with all equipment and facilities necessary for
maintaining sanitary procedures of hair care. Each shop will be provided with
appropriate cabinets, covered metal containers for waste, disinfectants, dispensable
headrest covers, laundered towels and haircloths.
Between detainees, all hair care tools coming in contact with the detainees will be
cleaned and effectively disinfected. Hair care tools come into intimate contact with the
detainee’s scalp and skin, and when reused without disinfection, provide excellent means
for transfer of ringworm or other skin and scalp diseases. Clippers may be treated for
pathogenic organisms and fungi by an approved bactericidal and fungicidal process.
Ultraviolet lights may only be used for maintaining tools after sterilization.
Each barber area will have detailed hair care sanitation regulations posted in a
conspicuous location for the use of all hair care personnel and detainees.”

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at SCHC to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO
interviewed staff and detainees, reviewed documentation, inspected food preparation and storage
areas, observed food service operations, and sampled a meal.
The food service operation at SCHC is managed by Trinity Services Group, a private contractor.
Staff consists of a food service administrator and(b)(7)ecooks, supported by a work crew of(b)(7)e
inmates on each shift. No detainees work in the food service area. A correctional lieutenant
oversees security within the kitchen on a full-time basis. Documentation of medical clearances
was present for all staff and(b)(7)erandomly selected inmate workers. ODO confirmed staff
visually inspects workers at the start of every shift to identify any hygiene concerns or signs of
illness. All workers wore clean uniforms, gloves, hairnets and beard guards for facial hair.
Sanitation in the food service area was good. The department was last inspected by the
Massachusetts Department of Public Health on March 27 and 28, 2014. Minor deficiencies in
sanitation and maintenance were reported and corrected. Documentation of weekly pest control
inspections and treatment was produced. Inspection of lavatories found they were properly
equipped with soap, hot water and paper towels.
No knives are used at the facility. ODO verified other sharp tools such as dough cutters and canopeners were stored in a locked cabinet in a staff office and were inventoried daily. SCHC does
not use yeast or other items such as alcohol-based flavorings, which would require special
handling. Chemicals were properly stored and inventoried.
A sink with three labeled compartments is used for manual washing, rinsing and sanitizing
utensils and equipment. Walk-in freezers and coolers were maintained at proper temperatures.
Water temperatures were checked and found to meet requirements. A review of documentation
confirmed temperatures were taken and logged by staff once per shift.
ODO verified menus were certified by a registered dietitian based on a complete nutritional
analysis. Detainees are served at least two hot meals daily and no more than 14 hours elapses
between the evening meal and breakfast. Detainees are advised of a no-pork menu through the
facility handbook. SCHC provides religious and medical diets in accordance with the standard.
Medical diets are approved by the medical department and religious diets are approved by the
chaplain. Special diets are issued on color-coded trays and clearly labeled. Food service staff
notifies officers when a special diet tray is en route to the unit.
SCHC has a satellite feeding operation, which involves preparation of meals in the kitchen and
delivery to the housing units on thermal trays. The trays are assembled, placed on carts covered
by a thermal blanket, and escorted to the housing units by a correctional officer. Twenty-eight
total carts are prepared for each meal. Meals to SMU are served on thermal, flexible trays,
which prevent them from being used as a weapon.
ODO observed the preparation and delivery of the lunch meal to housing unit 8-4 on Tuesday,
May 6, 2014. The lunch consisted of a hamburger patty, bun, cheese, corn, corn chips, cookies
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and fruit juice. The hot food items were maintained in a heated serving line in the kitchen and
tested at appropriate temperatures. However, the temperatures of these items dropped
significantly during delivery to unit 8-4. Due to a daily population count at 12 p.m., at which
time all movement stops, the cart for unit 8-4 is routinely delayed. During the inspection, ODO
observed an approximate 25-minute delay (Deficiency FS-1). ODO discussed the issue with the
assistant superintendent and the food service administrator, and was informed delays in delivery
occur only during the lunch meal due to the 12 p.m. count. They indicated the delays would be
addressed either by adjusting the count or lunch meal time.
Sack lunches for detainees being transported outside the facility contained two sandwiches, a
piece of fruit and a container of milk. However, a dessert item or extra items such as fresh
vegetables, crackers or potato chips were not included (Deficiency FS-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE NDS, Food Service, section (III)(G)(1), the FOD must ensure,
“Foods shall be kept hot enough or cold enough to destroy or arrest the growth of infectious
organisms. The FSA shall ensure that staff understand the special handling required by
potentially hazardous foods, e.g., meat, cream, or egg dishes. Staff must understand the critical
importance of time and temperature in delivering safe food….Foods in the potentially hazardous
category should remain under refrigeration until cooking time and, after cooking, maintained at
or above 140 degrees F.”
DEFICIENCY FS-2
In accordance with the ICE NDS, Food Service, section (III)(G)(6)(c)(2)(3), the FOD must
ensure, “In addition, each sack shall include:
2.

3.

One ration of a dessert item, e.g., cookies, doughnuts, fruit bars. Extremely perishable
items, e.g., fruit pie, cream pie, other items made with milk, cream, or other dairy
ingredients shall be excluded; and
Such extras as properly packaged fresh vegetables, e.g., celery sticks, carrot sticks, and
commercially packaged “snack foods,” e.g., peanut butter crackers, cheese crackers,
individual bags of potato chips. These items enhance the overall acceptance of the
lunches.”

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at SCHC to determine if controls are in
place to inventory, document, store, and safeguard detainees’ personal property, in accordance
with the ICE 2000 NDS. ODO toured the facility; reviewed local policies, the detainee/facility
handbook, and detention files; interviewed staff; and inspected areas where detainee property
and valuables are stored.
Male detainees are processed in Building 8 and female detainees are processed in Building 1
along with county inmates. At each location, detainees are given facility-issued clothing and
personal property is inventoried and receipted. Funds are placed into the detainee’s canteen
account. The facility does not accept any cash. All valuables are kept or sent to the ICE field
office. Personal property bags are kept in rooms on each floor of Building 8. Female property is
kept in a property room in Building 1. Male detainees do not sign an outgoing property receipt,
but female detainees do. ODO recommends the facility have detainees sign property receipts
when leaving the facility, in order to document the chain of custody in the event property is
claimed to be missing or damaged (R-2).
ODO reviewed the facility’s written policies and procedures on detainee property and funds, and
found policies missing on audit procedures for valuables and personal property (Deficiency
F&PP-1). In addition, no procedures were found for detainee property reported missing or
damaged (Deficiency F&PP-2).
SCHC does not have or follow procedures for: 1) the reporting and investigation of lost or
damaged property; 2) the requirement of supervisory staff to conduct the investigation; and 3)
the requirement of a senior facility contract officer to process all detainee claims. Procedures are
also missing for the following requirements: 1) the official deciding the claim be at least one
level higher in the chain of command than the official investigating the claim; 2) the facility
reimbursing the detainee for any validated property losses caused by facility negligence; 3) the
facility not arbitrarily imposing a ceiling on the amount to be reimbursed for a validated claim;
and 4) a senior contract officer immediately notifying the designated ICE officer of all claims
and outcomes (Deficiency F&PP-3).
ODO reviewed the facility handbook, which identifies how much cash/personal property a
detainee may retain in his/her possession, and the rules for storing or mailing property not
allowed. The facility handbook was missing the notice that detainees will be provided a copy of
any identity document placed in their A-files upon request; the procedures for claiming property
upon release, transfer or removal; and the procedures for filing claims for lost or damaged
property (Deficiency F&PP-4). The facility initiated corrective action during the course of the
inspection for this deficiency.

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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DEFICIENCY F&PP-2
In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must
ensure, “Each facility shall have a written policy and procedures for detainee property reported
missing or damaged.”
DEFICIENCY F&PP-3
In accordance with the ICE NDS, Funds and Personal Property, section (III)(H), the FOD must
ensure, “All CDFs and IGSA facilities will have and follow a policy for loss of or damage to
properly receipted detainee property, as follows:
1.
2.
3.
4.
5.
6.
7.

All procedures for investigating and reporting property loss or damage will be
implemented as specified in this standard;
Supervisory staff will conduct the investigation
The senior facility contract officer will process all detainee claims for lost or damaged
property promptly;
The official deciding the claim will be at least one level higher in the chain of command
than the official investigating the claim
The [facility] will promptly reimburse detainees for all validated property losses caused
by facility negligence;
The [facility] will not arbitrarily impose a ceiling on the amount to be reimbursed for a
validated claim; and
The senior contract officer will immediately notify the designated ICE officer of all
claims and outcomes.”

DEFICIENCY F&PP-4
In accordance with the ICE NDS, Funds and Personal Property, section (III)(J)(2)(4)(5), the FOD
must ensure, “The detainee handbook or equivalent shall notify the detainees of facility policies
and procedures concerning personal property, including:
2.
4.
5.

That, upon request, they will be provided an INS-certified copy of any identity document
(passport, birth certificate, etc.) placed in their A-files;
The procedure for claiming property upon release, transfer, or removal;
The procedures for filing a claim for lost or damaged property.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at SCHC 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, verified medical staff
credentials, and interviewed the Health Services Administrator (HSA), Assistant Deputy
Superintendent, director of nursing, and clinical nursing supervisor. In addition, ODO examined
20 detainee medical records.
SCHC is accredited by the National Commission on Correctional Health Care. Medical services
are provided by NaphCare, Inc., a private contractor. The clinic is administered by the HSA and
staffed 24 hours a day, seven days a week. Clinical oversight is provided by the medical
director, who is a full-time physician. The medical director shares on-call coverage with (b)(7)e
part-time physician and (b)(7)e full-time mid-level providers. Additional staff includes the
director of nursing, assistant director of nursing, clinical nurse manager,(b)(7)emedical discharge
planner, and(b)(7)e administrative staff. On-site dental services are provided by(b)(7)epart-time and
(b)(7)efull-time dentist and(b)(7)edental assistant. Mental health services are provided by a mental
health director who is on call 24 hours a day, seven days a week, (b)(7)e part-time psychiatrists,
(b)(7)efull-time and (b)(7)e part-time mental health clinicians, and(b)(7)emental health discharge
planners. These positions are augmented by a complement of (b)(7)e full-time and(b)(7)epart-time
registered nurses,(b)(7)efull-time and(b)(7)epart-time licensed practical nurses,(b)(7)ecertified medical
assistants (b)(7)e phlebotomist,(b)(7)ephysical therapy assistant, and(b)(7)epart-time optometrist.
According to the HSA, there are(b)(7)evacant positions: a mental health clinician and a psychiatric
nurse practitioner. Dialysis services are provided three times weekly by a contract nephrology
consultant group. All professional licenses were present and primary source verified with the
issuing state boards for authentication purposes. ODO found staffing sufficient to provide basic
medical services to the detainee population.
For medical services beyond the scope of care available at SCHC, detainees are transferred to
Lemuel Shattuck Hospital in Boston. Emergency care is provided at Boston Medical Center,
minutes away from the facility. Off-site mental health services are provided at Worcester
Recovery Center and Hospital or Soloman Carter Fuller Mental Health Center.
The clinic contained a spacious waiting area, six offices, an officers’ station, nursing station,
medication room, X-ray room, laboratory, storage room, utility room, a one chair dental suite,
and a two chair dialysis unit. In addition, the clinic contained three examination/treatment rooms
containing emergency response equipment, supplemented by satellite examination rooms in the
housing unit. SCHC also has an infirmary with 47 beds, two negative air flow cells for TB
isolation, five suicide watch cells, an officer/nurses’ station, kitchen, dayroom, multi-purpose
room and four storage rooms. A correctional officer is always present for supervision when
detainees are in the clinic or infirmary, though ODO’s observation confirmed medical encounters
are provided in privacy.
According to the HSA, if a language barrier exists between medical staff and a detainee,
interpretation assistance is provided by a bilingual staff member or an interpretation service.
However, during medical record review, ODO found interpretation assistance is not documented.
TechCare, SCHC’s electronic medical record system, includes a header indicating the detainee’s
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language; however, ODO found it was consistently left blank. The director of nursing informed
ODO this header is electronically transferred to the EMR from intake information documented
by correctional staff. ODO recommends that this information be consistently documented (R-3).
Detainees are screened for symptoms of TB on admission and receive a purified protein
derivative (PPD) skin test or a chest X-ray. ODO identified one detainee for whom this process
was not completed in a timely manner following his admission on November 8, 2013.
According to the clinical nursing supervisor, it was thought the PPD was planted during the
intake process; however, because the medical department was transitioning to an upgrade in its
EMR system, documentation of the PPD was improperly entered. Consequently, the skin test
was not read when due. The PPD was replanted upon discovery of the error on November 14,
2013, and was read as positive on November 16, 2013. A chest X-ray was not performed until
November 25, 2013 (Deficiency MC-1). Though the chest X-ray was negative for the presence
of TB, the delay in testing and ruling out of TB placed other detainees and staff at risk of
exposure.
Nursing staff conduct medical and mental health intake screening in a private examination room,
entering the screening directly into the EMR. Positive responses to mental health questions are
automatically highlighted and a referral for mental health evaluation is triggered. ODO cited this
as a best practice, because it ensures efficient identification and prompt follow up of mental
health concerns. ODO determined the evaluations were completed within 24 hours in all 14
cases where referrals were made. ODO’s review of 20 detainee medical records confirmed
completion of intake screening within 12 hours of detainee arrival, and though not required by
the NDS, a provider documented review of all screening forms to assess priority for treatment.
All detainees received a hands-on physical examination by a physician or mid-level provider
within 24 hours of admission, well within the 14 days required by the standard. The medical
record review confirmed essential medications were ordered and administered pursuant to the
physical examination findings. Treatment plans and routine follow up were documented in the
records of detainees with chronic conditions. Documentation of oversight and review by the
medical director was present in the medical records of chronic care patients. Though general
consent for treatment was documented in all 20 records reviewed, four detainees receiving
psychotropic medication did not sign a specific consent form (Deficiency MC-2).
Detainees access health care services by completing written medical request forms available in
English and Spanish. These forms are available in the housing units or may be obtained from
nursing staff. The forms are deposited into a locked box accessed only by nursing staff and
picked up during medication distribution. Sick call is conducted in the clinic on a daily basis
using physician approved NaphCare nursing protocols. Nursing staff conduct a preliminary
triage of the requests on the housing unit, so that any urgent needs may be immediately
addressed. ODO’s review of 37 sick call requests found same or next-day triage, and in many
cases, same-day follow up.
Review of training records for the(b)(7)emedical and(b)(7)erandomly-selected correctional staff
confirmed current certification in cardiopulmonary resuscitation (CPR) and first aid.

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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 shall receive TB screening by PPD (mantoux method), or chest x-ray.”
DEFICIENCY MC-2
In accordance with ICE NDS, Medical Care, section (III)(L), the FOD must ensure, “As a rule,
medical treatment will not be administered against the detainee’s will. 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.”

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SPECIAL MANAGEMENT UNIT– ADMINISTRATIVE SEGREGATION
(SMU-AS)
ODO reviewed the Special Management Unit – Administrative Segregation standard at SCHC to
determine if the facility has procedures in place to temporarily segregate detainees for
administrative reasons, in accordance with the ICE NDS. ODO toured the SMU, interviewed
facility and ERO staff, and reviewed policies, detainee files, and the SMU log.
SCHC’s SMU for administrative segregation has 16 single-capacity cells for male detainees and
16 single-capacity cells for female detainees. There is sight and sound separation between the
male and female areas. The SMU was well-lit, in good sanitary condition, adequately ventilated
and temperature controlled. Each cell has one bed affixed to the wall, a sink and toilet affixed to
the wall and floor, and a shower. A recreation area is adjacent to the unit. Detainees on
administrative segregation are locked in their cells 23 hours a day.
During the inspection, one detainee was assigned to administrative segregation. He was placed
on this status two days earlier for possession of a weapon, and was pending a disciplinary
hearing. A review of documentation found 31 detainees were assigned to segregation during the
past 18 months. In all but four cases, the detainees were pending disciplinary hearings for rule
violations. Among the remaining four, two were assigned to administrative segregation due to
gang membership and two were on protective custody. All four were transferred within 30 days
and administrative segregation orders were issued and status reviews were conducted in
accordance with the NDS.
ODO’s review of detention files of 15 of the detainees assigned to administrative segregation
pending a disciplinary hearing found they were charged with offenses such as fighting,
threatening another detainee or staff, and destroying institutional property. They were on
administrative segregation for one to four days prior to their hearings, and all received
disciplinary segregation sanctions.
ODO’s review of entries on the SMU log confirmed detainees had access to services and most
privileges required by the standard, including recreation and legal materials. Per SCHC policy,
detainees on administrative segregation are not permitted to have social visits
(Deficiency SMU AS-1). ODO confirmed legal visits are permitted.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU AS-1
In accordance with the ICE NDS, Special Management Unit - Administrative Segregation,
section (III)(D)(13) , the FOD must ensure, “The facility shall follows the ‘Visitation’ standard
in setting rules for detainees in administrative segregation. Ordinarily, a detainee retains
visitation privileges while in administrative segregation.” In accordance with the ICE NDS,
Visitation, section (III)(H)(5), the FOD must ensure, “A detainee shall ordinarily retain visiting
privileges while in administrative or disciplinary segregation status.”

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SPECIAL MANAGEMENT UNIT - DISCIPLINARY SEGREGATION
(SMU-DS)
ODO reviewed the Special Management Unit – Disciplinary Segregation standard at SCHC to
determine if the facility has procedures in place to temporarily segregate detainees for
disciplinary reasons, in accordance with the ICE NDS. ODO toured the SMU, interviewed
facility and ERO staff, and reviewed policies, detainee files, and the SMU log.
SCHC’s SMU for disciplinary segregation has 16 single-capacity cells for male detainees and 16
single-capacity cells for female detainees. There is sight and sound separation between the areas.
The SMU was well-lit, in good sanitary condition, adequately ventilated and temperature
controlled. Each cell has one bed affixed to the wall, a sink and toilet affixed to the wall and
floor, and a shower. A recreation area is adjacent to the unit. Detainees on disciplinary
segregation are locked in their cells 23 hours a day.
During the inspection, one detainee was in disciplinary segregation. The detainee had been
sanctioned with 14 days through the disciplinary process for insolence toward staff and
destroying institutional property. A review of documentation found 63 detainees received
disciplinary segregation sanctions during the past 18 months. ODO reviewed 46 of the 63
detainees’ files and found they were sanctioned for offenses such as fighting, threatening other
detainees, destroying institutional property, and disruptive behavior. Two of the detainees
served 30-day terms. Disciplinary segregation orders were issued and the required status reviews
were conducted for the detainee currently on disciplinary segregation and the 46 detainees
assigned to this status in the past. Entries on the SMU log documented medical rounds were
conducted and with one exception, the detainees had access to services and privileges required
by the standard, including recreation, telephones and legal materials. Per SCHC policy,
detainees on disciplinary segregation are not permitted to have social visits
(Deficiency SMU DS-1). ODO confirmed legal visits are permitted.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU DS-1
In accordance with the ICE NDS, Special Management Unit - Disciplinary Segregation, section
(III)(D)(17) , the FOD must ensure, “The facility shall follow the ‘Visitation’ standard in setting
rules for detainees in disciplinary segregation. As a rule, a detainee retains visiting privileges
while in disciplinary segregation. The determining factor if the reason for which the detainee is
being disciplined. In accordance with the ICE NDS, Visitation, section (III)(H)(5), the FOD
must ensure, “A detainee shall ordinarily retain visiting privileges while in administrative or
disciplinary segregation status.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at the SCHC 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.
No deficiencies were identified in this standard during ODO’s 2007 and 2009 inspections. ODO
identified two deficiencies during this inspection.
When asked for a copy of the current field office policy on staff-detainee communication, ERO
staff provided ODO a March 1, 2012 policy memo advising ERO Boston staff to follow the 2008
PBNDS with regard to staff-detainee communication. ODO evaluated ERO’s compliance with
this standard under the 2008 PBNDS.5 SCHC’s compliance was evaluated under the NDS.
ERO requirements: The 2008 PBNDS requires ERO staff to have frequent, informal access to
and interaction with detainees. The Boston Field Office’s policy requires staff to interact with
detainees at least three times weekly at facilities with populations of 50 detainees or greater.
Non-supervisory ERO staff 6 currently exceeds this policy requirement by visiting the housing
units daily Monday through Friday. Detainees corroborated ERO’s frequent visitation.
Visitation schedules are posted in each housing unit and reflect availability consistent with
ERO’s current practice. Visits by non-supervisory ERO staff are documented by Facility Liaison
Checklists and in SCHC housing unit logs.
Supervisory ERO staff7 reported making unannounced visits to housing units once weekly,
occasionally on weekends. However, neither the Facility Liaison Checklists nor the SCHC
housing unit logs reflected this frequency (Deficiency SDC-1).
Detainees may submit written requests or concerns directly to ICE ERO staff using an ICEspecific form available at the housing unit officer’s desk in the day room. A secure drop box is
available inside each housing unit for ICE requests, including SMU. Only ERO staff has access
to the box. ERO staff maintains a written log book containing the minimum information
required by the NDS. ODO reviewed 49 requests submitted in March 2014 and 188 requests in
April 2014. All were addressed by ERO within the 72-hour timeframe. Approximately 99% of
the requests related to removal or immigration case status.
On occasion, ERO staff receives requests relating to medical and mental health care. According
to ERO staff, these requests are given priority over other issues. ERO staff stated they provide
the detainee’s name and/or alien number to medical staff for follow up. Unfortunately, patient
confidentiality is inadvertently compromised the moment ERO reviews these requests. ODO
recommends ERO and SCHC address this issue together by clarifying for detainees the various
request systems (R-4).
5

The June 15, 2007 memos issued by former Director John P. Torres, titled “Change Notice National Detention
Standards Staff-Detainee Communication” and “Change Notice National Detention Standards Staff-Detainee
Communication Model Protocol,” contain the same ERO requirements found in the 2008 PBNDS.
6
Detention Officers and Immigration Enforcement Agents
7
Supervisory Detention and Deportation Officers

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OIG informational posters were found posted in all detainee housing units either near the
telephones or on a community board.8 The monitoring of detainee telephone services is covered
under the Telephone Access section of this report.
Facility requirements: Detainees have opportunities to interact informally with SCHC staff. The
facility handbook encourages inmates and detainees to “utilize the proper chain of command” in
addressing needs and issues, but allows for contact with leadership as needed. While the
handbook provides a mailing address to direct ICE correspondence, there are no procedures on
how to submit requests or the availability of assistance in preparing requests
(Deficiency SDC-2).
When asked how the request system at SCHC works, SCHC staff was unable to provide ODO a
clear description of the system. ODO learned through detainee interviews that request forms are
provided in the day room. Caseworkers are responsible for addressing requests relating to
conditions of detention, hygiene products, clothing, shoes, bedding, food, etc. Both caseworkers
and ERO staff are available to assist detainees in completing requests; however, as described in
the Detainee Relations section of this report, language barriers between staff and detainees
hinder effective communication. ODO provided ERO staff a DHS “I Speak” Language
Identification Guide to assist ERO staff in identifying qualified language interpreters as needed.
The standard requires each facility to develop a method to document unannounced visits by
ERO. SCHC’s practice is to document ICE movement in the housing unit logs. ODO reviewed
the housing logs of several units and found SCHC staff routinely failed to document ERO’s entry
and exists from the housing units. ODO recommends ERO reiterate to SCHC management the
importance of maintaining an accurate log for accountability (R-5).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with ICE 2008 PBNDS, Staff-Detainee Communication, section (V)(A)(1), the
FOD must ensure, “Each field office shall have policy and procedures to ensure and document
that the ICE/DRO assigned supervisory staff conduct frequent unannounced, unscheduled visits
to the SPC, CDF, and IGSA facility’s living and activity areas to informally observe living and
working conditions and encourage informal communication among staff and detainees. These
unannounced visits shall be conducted at least weekly. Each facility shall develop a method to
document the unannounced visits and ICE/DRO staff shall document their visits to IGSAs.”
DEFICIENCY SDC-2
In accordance with 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.”

8

ODO made a recommendation under the Telephone Access section of this report regarding the OIG informational
posters.

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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at SCHC to determine if the
health and well-being of detainees are protected by training staff in effective methods of suicide
prevention, in accordance with the ICE NDS. ODO inspected the suicide watch cells,
interviewed medical and training staff, and reviewed detainee medical records, the suicide
prevention policies, training curriculum, and staff training records.
All staff receives initial and ongoing suicide prevention training, which includes the
identification of suicide risk factors, recognizing the signs of suicidal thinking and behavior,
referral procedures, suicide prevention techniques, and responding to an in-progress suicide
attempt. SCHC uses a curriculum developed by the Suffolk County Sheriff’s Department in
collaboration with NaphCare mental health clinicians. A review of training files for(b)(7)e
randomly-selected detention officers and(b)(7)emedical staff confirmed current training.
ODO verified detainees are screened for suicide risk during the intake process. ODO was
informed there have been a total of 31 detainees on mental health watch since NaphCare took
over the healthcare contract in March 2012. Detainees on suicide watch are housed in one of
five designated cells in the infirmary. All cells are monitored by correctional staff via a closed
circuit surveillance camera with 15-minute documented checks. Detainees may also be assigned
constant, one-to-one direct observation status in which a correctional officer is physically present
outside the cell. In either case, detainees are issued a suicide-resistant quilted smock and
blanket.
The medical record review found two detainees who had been identified at risk for suicide and
two detainees who had attempted suicide. All four detainees were placed in a suicide watch cell,
immediately referred to mental health staff, and evaluated within 24 hours. The two detainees
who had attempted suicide were placed on constant watch and the other two on 15-minute
checks with camera surveillance. Suicide watch management was consistent with the standard;
however, the facility does not comply with a requirement in its policy that exceeds the standard.
Specifically, per local policy, detainees on suicide watch are to be reassessed daily by a qualified
mental health professional. In the cases reviewed by ODO, a reassessment did not take place on
weekends because mental health staff is not present on Saturdays and Sundays. ODO found the
detainees were released from suicide watch following assessment by a mental health
professional; however, the medical director did not document written authorization for their
return to general population as required by the local policy and NDS (Deficiency SP&I-1). The
HSA stated the medical director makes daily rounds in the infirmary but does not document
clearance for detainees on suicide watch to return to general population. On the last day of the
inspection, procedures were developed and communicated to staff to ensure the clearance for
general population is documented in writing.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD
must ensure, “A detainee formerly under a suicide watch may be returned to general population,
upon written authorization from the [Clinical Director].”
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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at SCHC 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.
Deficiencies were identified in telephone access during ODO’s 2007 and 2009 inspections. In
2007, SCHC was cited deficient for not having privacy panels between telephones. In 2009,
ERO was cited for not conducting weekly telephone serviceability checks. During this
inspection, ODO found ERO is not properly conducting telephone serviceability checks and
SCHC is not properly notifying all detainees of how to place an unmonitored call.
SCHC has a telephone policy in place with the purpose of providing detainees reasonable and
equitable telephone access. Telephone service, maintenance and rates are managed by vendor
Securus Technology, Inc. The system allows for collect or debit calls only. Call rates range
from $0.10 to $0.25 per minute, not including a minimum $2.50 surcharge. Detainees have
opportunities to make free and inter-facility calls upon request.
Upon admission to SCHC, detainees are issued a personal identification number, which enables
them to complete calls. Telephones are located in the day rooms of each unit. Detainees in
general population can access telephones at various times throughout the day for up to six hours
daily, seven days a week. Calls are limited to 20 minutes each by automatic disconnection and
cannot exceed 60 minutes daily. Detainees in special management units are afforded up to 60
minutes daily for telephone use during recreation. The first ten unique numbers dialed by
detainees automatically becomes their preferred caller list on file and the list resets monthly.
Speed-dial numbers are posted on a wall near the telephones for each housing unit. The
telephone-detainee ratio met the requirement of the standard. One TTY is available for detainee
use and is stored in Securus Technology’s onsite office.
ODO performed operability checks on two telephones in each housing unit. Each phone was in
good working order and the automated prompts matched the posted instructions. Both Securus
Technology, Inc. and ERO staff routinely and independently inspect telephones for operability.
Securus Technologies staff test telephones in each housing unit every three weeks. ERO tests
telephones weekly and documents the results on Telephone Serviceability Worksheets; however,
the tests are performed in a unit in which detainees are not routinely housed (Deficiency TA-1).
ODO recommends ERO test the telephones in all housing units, particularly those units where
detainees are routinely housed (R-6).
Telephones in the male housing units are located in the dayroom, approximately 20 feet from the
housing officer’s desk. The location offers reasonable privacy for legal calls without being
overheard by officers, but not from other detainees using the telephones. Telephones in the
female housing unit are located next to the entrance to the unit, approximately ten feet away
from the housing officer’s desk. None of the telephones in the male and female housing units
offer privacy panels; however, detainees may request from ERO a private room to make a legal
or emergency call as needed.

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SCHC’s telephone system policy describes the monitoring of “privileged communication” and
outlines the procedures for obtaining an unmonitored call. However, these procedures are
missing from the facility handbook and in some housing units (Deficiency TA-2).
As referenced in past ODO reports, the DHS OIG informational posters contain an 800 number
that is not cross-referenced with the DHS OIG speed-dial code. One male detainee at SCHC
stated he had tried to call the OIG following a use-of-force incident, but was unable to reach OIG
using the number on the poster. The detainee was unaware OIG could be reached via one of the
speed-dial numbers. ODO recommends ERO update the posters in order to eliminate the
confusion over how to reach the OIG hotline (R-7).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the April 4, 2007 memo on Detainee Telephone Services issued by former
Assistant Director for Management Gary E. Mead, the FOD must ensure: “Effective
immediately, concurrent with staff/detainee communication visits, ICE staff will verity [sic]
serviceability of all telephones in detainee housing units by conducting random calls to preprogrammed 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.”
DEFICIENCY TA-2
In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure,
“The facility shall have a written policy on the monitoring of detainee calls… 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:
1. that detainee calls are subject to monitoring; and
2. the procedure for obtaining an unmonitored call to a court, legal representative, or for the
purposes of obtaining legal representation.”

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USE OF FORCE (UOF)
ODO reviewed the Use of Force standard at SCHC to determine if necessary use of force is
utilized only after all reasonable efforts have been exhausted to gain control of a subject, while
protecting and ensuring the safety of detainees, staff and others, preventing serious property
damage, and ensuring the security and orderly operation of the facility, in accordance with the
ICE NDS. ODO toured the facility, reviewed policies, training records, and use of force
documentation, viewed video recordings, and interviewed staff.
SCHC has a comprehensive written policy governing the use of force. Confrontation avoidance
is emphasized in policy as well as in the training curriculum. ODO’s review of the training
records for(b)(7)erandomly-selected officers confirmed current training in use of force and oleo
capsicum (OC) deployment. In addition, documentation reflects use of force is addressed
regularly at roll call trainings throughout the year. ODO verified a handheld video camera is
available in the Special Emergency Response Team (SERT) lieutenant’s office for recording
calculated use-of-force incidents.
There were eight immediate and two calculated use-of-force incidents involving detainees during
the last 15 months. ODO confirmed both calculated use-of-force incidents were recorded using a
hand-held video camera; however, the video recordings did not identify the camera operator
during introduction of the team by the SERT leader (Deficiency UOF-1). The video recordings
met all other NDS requirements. OC was deployed in both cases, and documentation reflects
decontamination procedures were followed for all affected detainees, including allowing the
detainees to shower and providing them with fresh clothing. In all ten use-of-force incidents,
ODO confirmed detailed incident reports from staff involved were available, medical
examinations and after action reviews were completed, and ERO was notified. The written
documentation for the eight immediate use-of-force incidents was supported by surveillance
video from fixed security cameras, review of which further confirmed compliance with the
standard.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF-1
In accordance with the ICE NDS, Use of Force, section (III)(A)(4)(g)(1), the FOD must ensure,
“Calculated use-of-force videotape will be edited as follows:
1.

Introduction by Team leader, stating facility name, location, time, date, etc.; describing
the incident that led to the calculated use of force; and naming the video-camera operator
and any other staff present.”

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