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
Dallas
Tulsa County Jail
Tulsa, Oklahoma

June 10–12, 2014

COMPLIANCE INSPECTION
TULSA COUNTY JAIL
ERO DALLAS FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................2
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................7
Detainee Relations ...............................................................................................................7
ICE 2000 NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................8
Detainee Classification System…………………………………………………………...9
Detainee Grievance Procedures……………………………………………………….....10
Detainee Handbook…………..…………………………………………………………..11
Disciplinary Policy…………..…...………………………………………………………12
Environmental Health and Safety...……………………………………………………...13
Food Service ......................................................................................................................14
Funds and Personal Property .............................................................................................17
Medical Care ......................................................................................................................18
Special Management Unit-Administrative Segregation ....................................................20
Staff-Detainee Communication .........................................................................................22

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

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

INSPECTION TEAM MEMBERS

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

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

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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of Tulsa County Jail (TCJ) in Tulsa, Oklahoma, from
June 10 to 12, 2014. TCJ, which opened in 1999, is owned by Tulsa County and operated by the
Tulsa County Sheriff’s Office. ERO began housing detainees at TCJ in September 2007 under
an intergovernmental service agreement (IGSA) contract. Male and female detainees of all
security classification levels (Level I through III) are detained at the facility for periods in excess
of 72 hours. The inspection evaluated TCJ’s compliance with the 2000 NDS and the 2011
PBNDS Sexual Abuse and Assault Prevention and Intervention (SAAPI) standard. 1
The ICE ERO Field Office Director
Capacity and Population Statistics
(FOD) in Dallas, Texas, is
Total Bed Capacity
responsible for ensuring facility
ICE Detainee Bed Capacity
compliance with the 2000 NDS and
Average Daily Population
2011 SAAPI standard, and ICE
policies. An Assistant Field Office
Average ICE Detainee Population
Director (AFOD) in Tulsa,
Average Length of Stay (Days)
Oklahoma, has primary oversight
Male Detainee Population Count (as of 6/10/14)
responsibility at TCJ. (b)(7)e ICE
Female Detainee Population Count (as of 6/10/14)
personnel are stationed onsite at the
facility. There is no ERO Detention Service Manager assigned to TCJ.

Quantity
1,770
190
1,740
135
19.4
139
13

The Jail Administrator is responsible for oversight of daily facility operations and is supported
by (b)(7)epersonnel. Aramark provides food services, and Armor Correctional Health Services,
Inc. provides medical services. The facility holds accreditations from the American Correctional
Association (ACA), the National Commission on Correctional Health Care (NCCHC), and the
Commission on Accreditation for Law Enforcement Agencies.
In September 2012, ODO conducted a compliance inspection of TCJ under the 2000 NDS. ODO
reviewed 16 standards and found TCJ compliant with six standards. A total of 19 deficiencies
were found in the remaining ten standards.
During this inspection, ODO reviewed 16 NDS and one 2011 PBNDS and found TCJ compliant
with seven standards. 2 ODO found a total of 19 deficiencies, in the remaining ten standards:
Detainee Classification System (1 deficiency), Detainee Grievance Procedures (1), Detainee
Handbook (2), Disciplinary Policy (2), Environmental Health and Safety (1), Food Service (3),
Funds and Personal Property (1), Medical Care (1), Special Management Unit- Administrative
(3), and Staff-Detainee Communication (4). ODO made four recommendations regarding
facility policy and procedures. 3

1

The facility signed a contract modification to incorporate the 2011 SAAPI standard on October 19, 2012.
The Disciplinary Policy standard was not within the original scope of this inspection. However, two deficiencies
in the Disciplinary Policy standard were noted by ODO in the course of inspecting the Special Management UnitDisciplinary Segregation standard. Therefore, deficiencies noted under the Disciplinary Policy standard are
inclusive of the total number of deficiencies found during this inspection.
3
Recommendations are annotated in this report as “R”, followed by a number.
2

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This report details all deficiencies and refers to the specific, relevant sections of the 2000 NDS.
ERO will be provided a copy of this report to assist in developing corrective actions to resolve
all identified deficiencies. ODO discussed preliminary findings with TCJ and ERO management
during the inspection and at a closeout briefing conducted on June 12, 2014.
Upon admission into TCJ, detainees are issued facility clothing, linens, personal hygiene items
and a facility handbook which is available in both English and Spanish. The handbook does not
include information stating that detainees exhibiting literacy or language problems have access to
translation assistance. Changes to the handbook are made on an as-needed basis by the facility,
and TCJ does not have an appointed committee established to conduct annual reviews of the
handbook.
Classification and reclassification of detainees at TCJ is conducted solely by ERO. ERO uses a
standardized risk assessment form for initial classification. ERO also reclassifies detainees
following disciplinary actions, or when new information is learned and is relevant to a detainee’s
classification level. Newly arriving detainees are not routinely informed about their
classification levels and are, therefore, unable to appeal their classification level. Following
classification, detainees view an orientation video advising them of facility rules, detainee rights
and the Prison Rape Elimination Act.
During intake, detainee funds and personal property are inspected for contraband and
inventoried. Personal property is placed in hanging garment bags and stored in a secured
property room that is only accessible by authorized TCJ staff. Detainees receive a signed and
dated receipt for personal property. Funds are deposited directly into the detainee’s account,
which is accessible through an electronic kiosk system located in the housing units. TCJ’s
detainee handbook does not provide a procedure for filing a claim of lost or damaged property.
TCJ has a designated law library that is well-lit and adequately equipped as required by the
standard. Detainees have access to the law library a minimum of five hours per week, and can
request additional time by submitting a request through the facility’s electronic kiosk system.
Detainees housed in special management units are afforded the same access to law library
privileges as general population detainees. Writing implements, paper and envelopes are
provided by the facility to support a detainee’s legal research and case preparation. All
computers contained a current version of LexisNexis and word-processing software.
The grievance system at TCJ allows detainees to file informal, formal and emergency
grievances. The facility maintains an electronic grievance log to track grievances filed by
detainees. ODO reviewed the grievance log and noted that, at the time of inspection, a total of
47 grievances were filed within the last six months. ODO found that TCJ did not respond to 13
of the 47 grievances in a timely manner, which is identified as 72 hours in the facility’s written
grievance procedure. No trends or patterns were noted among the grievances reported.
ODO toured the facility and found the building was well maintained and sanitary. Hazardous
substances are listed in a master index which includes locations, Material Safety Data Sheets
(MSDS), emergency contact information, and documentation of semi-annual reviews. Weekly
and monthly fire and safety inspections are completed, and evacuation diagrams are posted
throughout the facility in English and Spanish. Although fire drills are conducted monthly in
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each area of the facility, emergency keys are not consistently drawn and tested. This represents a
repeat deficiency from ODO’s September 2012 inspection.
The facility’s food service vendor does not require its employees to undergo a pre-employment
medical exam to confirm they do not have a communicable disease. ODO observed the
preparation and delivery of the lunch meal on Wednesday, June 11, 2014. ODO found hot food
items to be within the necessary temperature ranges required by the NDS. However, the
temperature for cold food items fell above the acceptable limit of 41 degrees. Additionally, sack
lunches for detainees did not contain a snack food item. Although the sanitation of the food
service area was found to be in relatively good condition, ODO observed two restrooms
designated for use by workers to be disorderly, missing trash receptacles, soap dispensers and
signs reminding workers to wash their hands before returning to work.
Medical services are provided 24 hours a day seven days a week, with administrative oversight
provided by the Health Services Administrator (HSA). The HSA has an extensive background in
the mental health profession as a social worker. Clinical oversight is provided by the physician.
On-call weekend coverage is provided by a part-time physician’s assistant. A dentist and dental
assistant are onsite three days per week. Nurses, which include(b)(7)eregistered nurses and (b)(7)e
licensed practical nurses conduct detainee medical and mental health intake screenings. Health
appraisals, which include hands-on physical examinations and dental screenings, are performed
by trained registered nurses and cosigned by the clinical director. Detainees may submit written
or electronic sick call requests. Electronic requests are routed directly to medical where they are
triaged by nursing staff upon receipt. Detainees place written sick call requests in locked boxes
located in the housing units, and the request slips are picked up, sorted and forwarded to medical
by mail room staff. This process does not protect patient confidentiality.
There were no attempted suicides reported by TCJ in the past year, nor were there any detainees
on suicide watch at the time of inspection. ODO verified detainees are screened at the time of
intake by nursing staff to determine any potential risk for suicide. If detainees are found to be at
risk during the screening, nursing staff makes an immediate referral for the detainee to be
evaluated by a mental health professional. Additionally, housing and monitoring protocols are
followed as required by the standard. 4 ODO noted that facility policy did not stipulate that the
clinical director must authorize release from suicide watch. A deficiency was not cited because
there was no documentation that detainees discontinued suicide watch by order of unauthorized
personnel. However, ODO recommends that the HSA revise the policy to align with the
standard (R-1).
TCJ has a comprehensive written policy that provides for the prevention, reporting, and
investigation of sexual assaults. One of the facility’s internal investigators is the designated
4

Although housing protocols are monitored as required by the standard, ODO noted the following as an area of
concern. This concern was addressed by ODO in the closeout briefing with ERO and TCJ leadership on
June 12, 2014. There are four cells in the infirmary designated for ICE detainees on suicide watch. Each cell is
equipped with cameras to provide constant monitoring; however, in the event of overflow, ICE detainees may be
placed in other cells without cameras. Additionally, cells are covered with heavy opaque shades to provide privacy
for ICE detainees (males, females and juveniles). Although there were no ICE detainees on suicide watch at the
time of inspection, ODO found the shades invite the potential for suicide attempts in between the time officers and
medical staff conduct required rounds.

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SAAPI program coordinator. TCJ employees, volunteers, and contractors are required to take
pre-service and annual training about SAAPI. Staff interviews and a review of training records
confirmed staff is knowledgeable about the SAAPI program. The intake process includes
screening detainees for sexual abuse victimization history and history of predatory behavior to
identify potential sexual aggressors. Detainees are shown a SAAPI orientation video at the time
of admission into the facility. Detainees also are provided with information on the SAAPI
program through the facility handbook and postings located in housing units.
At the time of inspection, the facility reported one case of sexual assault or abuse within the last
year. The incident was reported on December 3, 2013, and involved officers removing a pair of
undershorts deemed as contraband from a detainee who refused to remove the shorts. The case
was reported to ERO and the Joint Intake Center, and has since been investigated, found
unsubstantiated, and the case was closed.
The facility operates two separate Special Management Units (SMU) – one for male detainees
and the other for female detainees. Each of the SMUs is used for administrative and disciplinary
segregation. ODO found the SMUs to be well ventilated, adequately lit and maintained in a
sanitary condition. There were no detainees in administrative or disciplinary segregation at the
time of inspection.
Eight detainees were placed in administrative segregation in 2014. ODO reviewed each of the
detainees’ detention files and found that in one of the eight cases, there was no documentation
showing that a TCJ supervisor reviewed and approved the detainee’s placement into
administrative segregation. Further, the forms that were used were outdated, and not in line with
the current form attached to TCJ’s segregation policy. There was no record of seven-day status
reviews being conducted on detainees housed in administrative segregation for seven days or
more. Permanent logs capturing daily activities specific to detainees in administrative
segregation were also improperly filled out and inconsistently maintained in detention files.
ODO noted two deficiencies in the Disciplinary Policy standard in the course of inspecting the
Special Management Unit- Disciplinary Segregation standard. ODO found that detainees are
placed on 72-hour lockdowns for punishment without undergoing a formal disciplinary process,
and that TCJ staff does not document all events relevant to a disciplinary incident in accordance
with its own procedures.
ICE staff makes weekly scheduled and unscheduled visits. Scheduled visit times and days are
posted in housing units. Visits are documented in the facility’s electronic logbook, ICE Facility
Liaison Visit Checklists, and telephone serviceability worksheets. The facility does not have
standard operating procedures established for detainees who need assistance in preparing request
forms. Additionally, ERO’s electronic log did not have all of the required data fields to
document the status and nature of detainee requests. However, ODO reviewed the logs and
found that detainee requests are responded to within 72 hours as required by the standard.
Although the facility handbook lists written procedures specifying how detainees can route
requests to ICE officials, the handbook does not include instruction for detainees that need
assistance in preparing an ICE request.

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TCJ has a comprehensive use of force policy addressing confrontation avoidance, using force
only as a last resort, and reporting requirements when force is used. ODO reviewed staff training
records and found that detention officers are trained in the use of force and are certified in the
use of oleoresin capsicum (OC) spray during pre-service and annual training. There were no
incidents involving use of force in the 12 months preceding the inspection, nor were there any
grievances filed by detainees alleging use of force.
Detainees have regular access to telephones and can make calls for up to 20 minutes at a time.
There is no restriction on the number of calls made. Detainees housed in segregation have the
same telephone privileges as detainees in general population. The telephone availability ratio is
approximately ten detainees per telephone. ODO checked telephones in housing units and
reviewed ERO telephone serviceability worksheets to confirm that telephones are operable and
in good working order.

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
Due to(b)(7)edetention officer vacancies, TCJ management instituted housing unit lockdowns on
four separate occasions since April 2014, each lockdown lasting no longer than eight hours. As a
result, some detainees have had to forego visitation, religious practices, telephone access and
recreation during those brief periods. Management stated these lockdowns were necessary in
order to maintain safety, security and order at the facility. Since April 2014, the detention officer
workforce has been placed on “mandatory call-back” status, requiring them to work an additional
24 hours per month. TCJ graduated an academy class in July 2014, filling(b)(7)eof its(b)(7)edetention
officer vacancies..

DETAINEE RELATIONS
ODO interviewed 35 randomly-selected detainees (22 males and 13 females) to assess the
conditions of confinement at TCJ. The vast majority of the detainees stated that food service
quality was adequate and none of the detainees complained about medical care.
Detainee Handbook: Fourteen detainees reported they did not receive the ICE National Detainee
Handbook and 12 detainees reported that they did not receive the facility handbook. ODO
reviewed 15 randomly selected detention files and found that each of the files contained
acknowledgement forms documenting the detainee’s receipt of both the ICE National Detainee
Handbook and facility handbook. The vast majority of detainees stated they received the facility
handbook. Additionally, the facility maintains copies of the ICE National Detainee Handbook
and facility handbook in the electronic kiosks which are located in each of the facility’s housing
units.
Detainee Privileges: Although detainees have regular access to telephone, recreation and
visitation privileges, several detainees complained about not receiving those privileges when the
facility is on lockdown. ODO reviewed TCJ’s shift logs and determined that the facility has
been on lockdown four times since April 2012. Lockdowns mainly occurred during second shift
and lasted no longer than eight hours at a time. ODO interviewed TCJ’s Jail Administrator and
learned that lockdowns occur infrequently to maintain security and order within the confines of
the facility, and are due to staffing shortages.
Staff-Detainee Communication: Most of the detainees stated they saw ERO staff speaking with
other detainees at least once a week and knew how to communicate or submit request forms if
they wanted to speak with an ICE officer. However, 19 detainees stated that they did not know
who their deportation officer was. ODO found that five of the 19 detainees were recent arrivals
at TCJ and had only been at the facility for one week prior to interviews taking place. Further,
ODO reviewed the Staff-Detainee Communication standard and found that ICE staff regularly
conducts scheduled visits to housing units at least once a week to address detainee questions and
concerns.

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 NDS and one 2011 PBNDS and found TCJ fully compliant with the
following standards:
1.
2.
3.
4.
5.
6.
7.

Access to Legal Materials
Admission and Release
Sexual Abuse and Assault Prevention and Intervention (2011 PBNDS)
Special Management Unit- Disciplinary
Suicide Prevention and Intervention
Telephone Access
Use of Force

As the standards above were compliant at the time of the inspection, a synopsis for these
standards is not included in this report.
ODO found 19 deficiencies in the following ten standards:
1. Detainee Classification System
2. Detainee Grievance Procedures
3. Detainee Handbook
4. Disciplinary Policy
5. Environmental Health & Safety
6. Food Service
7. Funds and Personal Property
8. Medical Care
9. Special Management Unit- Administrative
10. Staff-Detainee Communication
Findings for these standards are presented in the remainder of this report.

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DETAINEE CLASSICATION SYSTEM (DCS)
ODO reviewed the Classification System standard at TCJ 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 2000 NDS. ODO toured the facility, reviewed local policies
and procedures, interviewed staff, and inspected detainee files, the detainee handbook and
related documentation.
TCJ has written policies and procedures addressing the classification of detainees. ODO verified
the facility handbook provides information on the classification process, including appeal
procedures. The facility policy section K, “Classification Appeals” states, “Any inmate may
appeal a classification decision using the grievance procedure. The Detention Division Chief
will make the final determination of an inmate’s classification.” However, staff at TCJ
acknowledged that detainees are not routinely informed (Deficiency DCS-1).
During the intake process, ERO is solely responsible for the classification and reclassification of
detainees. In addition, ERO also addresses reclassification of detainees following disciplinary
actions, or in the event new information is learned which is relevant to the detainee’s
classification level. Detainees were found to be properly housed given their classification levels.
A review of 15 active and 15 archived detention files confirmed all contained documentation of
initial classification and reclassification processes, and appropriate information supporting
classification decisions.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE 2000 NDS, Detainee Classification System section (III) (H), The
FOD must ensure, “All facility classification systems shall include procedures by which new
arrivals can appeal their classification levels.”

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedure standard at TCJ to determine if a process to
submit formal or emergency grievances exists, and responses are provided in a timely manner,
without fear of reprisal. In addition, the review was conducted to determine if detainees have an
opportunity to appeal responses, and if accurate records are maintained, in accordance with the
ICE 2000 NDS. ODO interviewed staff and detainees, and reviewed facility policy, the facility
handbook, and grievance documentation.
TCJ policies and the facility handbook both address informal and formal grievance processes,
emergency grievances, the availability of assistance in filing a grievance, procedures for appeal,
and the opportunity to file a complaint involving officer misconduct. Detainees can file a
grievance by submitting a grievance form to the housing unit officers or by filling out an
electronic grievance on TCJ’s kiosk system, which is located in each housing unit. Detainees
can appeal a grievance to the grievance committee, which consists of the facility administrator,
one facility major, and one facility sergeant. If the detainee is dissatisfied with the outcome, he
or she may appeal the grievance directly to ICE.
The facility maintains an electronic grievance log. Grievances and responses to grievances are
filed in the detainee’s detention file. ODO reviewed the grievance log and found that 47
grievances were filed in the past six months. In reviewing each grievance, ODO found that
facility staff did not address 13 grievances in a timely manner (Deficiency DGP-1). The facility
handbook identifies 72 hours a reasonable response time to detainee grievances. Grievances
included ICE-specific questions, issues with food service, and telephone access. ODO did not
identify any recurring issues or trends in the grievances reported.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with ICE 2000 NDS, Detainee Grievance Procedures, section (III)(A)(1), the FOD
must ensure, “The facility shall make every effort to resolve the detainee's complaint or
grievance at the lowest level possible, in an orderly and timely manner.”

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DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at TCJ 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 2000 NDS. ODO reviewed the facility handbook,
detention files, and interviewed staff and detainees.
Detainees are issued the facility handbook at the time of admission into TCJ. The handbook is
also available through an electronic kiosk. The handbook is available in both English and
Spanish. Detainees sign an acknowledgement form stating that they received the facility’s
handbook. ODO reviewed 15 randomly-selected detention files to ensure that detainees receive
the handbook. Acknowledgment forms were also present in detention files indicating that
detainees received the ICE National Detainee Handbook as well.
ODO reviewed the facility handbook and found that it covers the following areas as required by
the standard: 1) overview of programs and services, 2) detainee rights and responsibilities, 3)
disciplinary procedures and sanctions, 4) contraband, 5) grievance and appeals procedures, and
5) prohibited acts and behaviors. Aside from the above noted inclusions, the handbook also
includes sections that inform detainees about the facility’s zero tolerance sexual abuse,
harassment and retaliation policy, housing assignments, commissary, personal property,
telephone and library privileges, mail and telephone usage, and recreation and visitation rules.
The handbook does not include information stating that detainees exhibiting literacy or language
problems have access to translation assistance (Deficiency DH-1). However, ODO verified the
facility does have a contract with the LanguageLine Solutions to provide such services.
The facility makes revisions and updates to the detainee handbook as the need arises. TCJ does
not have an appointed committee to conduct annual reviews of the handbook (Deficiency DH-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE 2000 NDS, Detainee Handbook section (III)(E), the FOD must
ensure that, “The OIC will provide translation assistance to detainees exhibiting literacy or
language problems and those who request it. This may involve translators from the private
sector or from the detainee population.”
DEFICIENCY DH-2
In accordance with the ICE 2000 NDS, Detainee Handbook section (III)(I), the FOD must ensure
“An appointed committee will conduct annual reviews of the handbook, after the annual reviews
and revisions by facility department heads and the OIC.”

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DISCIPLINARY POLICY (DP)
ODO did not review the Disciplinary Policy standard in its entirety during the
inspection 5; however, in the course of inspecting the SMU-Disciplinary Segregation standard,
ODO became aware of Disciplinary Policy deficiencies.
By TCJ policy, officers are authorized to sanction detainees they believe have violated housing
unit and other minor rules by restricting them to their cells for one to 72 hours. This restriction
occurs absent supervisory review, outside the disciplinary process, and without due
process. ODO finds this practice does not safeguard against capricious or retaliatory actions
(Deficiency DP-1).
In addition, ODO discovered that for matters handled through the formal disciplinary process,
not all documentation relating to the disciplinary action is maintained. During a review of eight
detainee files, ODO noted only the initial charging document was present. The disposition as
determined at a disciplinary hearing is entered in the computer system, but no additional
information is recorded in the file or computer system, including any witness testimony, the
detainee’s statements, or the basis for the finding of guilt and imposed sanctions (Deficiency
DP-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DP-1
In accordance with ICE 2000 NDS, Disciplinary Policy section (III)(A)(2) , the FOD shall
ensure, “Disciplinary action may not be capricious or retaliatory.”
DEFICIENCY DP-2
In accordance with ICE 2000 NDS, Disciplinary Policy section (III)(J), the FOD shall ensure,
“All documents relevant to the incident, subsequent investigation, hearing(s), etc., will be
completed in accordance with facility procedures.”

5

The Disciplinary Policy standard was not initially considered for inclusion prior to conducting this compliance
inspection.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at TCJ 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 ICE 2000 NDS. ODO toured the
facility, interviewed staff, and reviewed procedures and documentation of inspections, hazardous
chemical management, and fire drill documentation.
ODO observed the sanitation of the facility was good and the building was well maintained.
Hazardous substances are listed in a master index which includes locations, MSDS sheets,
emergency contact information, and documentation of semi-annual reviews for accuracy. A
copy of the index is on file with the local fire department. MSDS sheets were also present in
areas where substances are stored and used. Inventories of hazardous substances and chemicals
used in the facility were current and accurate. Hazardous substances are stored outside the
secure perimeter in two separate storage areas.
ODO’s review of documentation provided by the fire safety officer confirmed required weekly
and monthly fire and safety inspections are completed. ODO observed exit/evacuation diagrams
in both English and Spanish are present in the housing units and throughout the facility, and they
meet the requirements of the NDS. TCJ is inspected annually by the Oklahoma Department of
Health, Jail Inspection Division, and the last inspection was completed on April 28, 2014. In
addition, the state fire marshal conducted the most recent annual fire inspection on May 29,
2014.
Fire drills are conducted monthly in each area of the facility and are well documented; however,
emergency keys were only drawn and tested in four drills during the past year
(Deficiency EH&S-1). 6 ODO reviewed a random sample of(b)(7)eemployee training records and
verified staff received training in fire, safety, and use and storage of chemicals.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENCT FINDING
DEFICIENCY EH&S-1
In accordance with ICE 2000 NDS Environmental Health and Safety, section (III)(L)(4)(c), the
FOD must ensure, “Emergency key drill will be included in each fire drill, and timed.
Emergency keys will be drawn and used by the appropriate staff to unlock one set of emergency
exit doors not in daily use. NFPA recommends a limit of four and one-half minutes for drawing
keys and unlocking emergency doors.”

6

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

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at TCJ to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with ICE 2000 NDS. ODO
interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed
policy and relevant documentation.
The food service operation at TCJ is managed by contractor Aramark Correctional Services. The
staff consists of the food service director, assistant food service director, and(b)(7)ecook
supervisors, supported by a crew of(b)(7)ecounty inmate workers assigned to three shifts. No ICE
detainees work in food service. Security in the kitchen is supervised by(b)(7)ecorrectional
officers. ODO reviewed documentation indicating inmate workers are medically cleared prior to
assignment to the kitchen; however, Aramark employees do not undergo a pre-employment
medical examination to confirm they do not have a communicable disease (Deficiency FS-1).
Aramark management informed ODO that medical examinations are not performed, because
they are not required by the local health department.
ODO verified a registered dietician certified the facility’s menus based on a complete nutritional
analysis. Religious and medical diets are approved and provided in accordance with the NDS.
At the time of the inspection, six detainees were on medical diets and five detainees were on
religious diets.
TCJ has a satellite feeding operation. ODO observed the preparation of the noon meal on
Wednesday during the inspection, and noted food service staff taking temperatures of food with
a digital food thermometer as the trays were being prepared. The temperature of the hot item,
baked beans, was 177 degrees and cold items, coleslaw and salami, were 38 degrees and 41
degrees, respectively. Other items, a bun and cake, were room temperature. ODO observed the
trays were placed on a cart, which was locked by an officer, after which the cart was delivered to
the housing unit, where it was unlocked by another officer. ODO sampled the meal and found it
acceptable.
Inspection of the sack meals provided to detainees who are being transported found they
contained two non-pork meat sandwiches, a fruit item, and a dessert item. These meals did not
include any extra item such as packaged fresh vegetables or commercially packaged snack foods
(Deficiency FS-2). The food service manager stated adding the extra item would increase the
cost of the meals and would have to be approved by the jail administration.
The Food Protection Services division of the Tulsa Health Department inspects TCJ’s food
service operation every quarter. The last inspection was conducted on May 23, 2014, with no
violations cited. Documentation reflects the food service director conducts inspections of the
kitchen area on a weekly basis. ODO observed the sanitation of the food service operation was
good overall; however, inspection of the two restrooms designated for inmate workers found
unsanitary conditions. Trash was observed on the floors, and there were no soap dispensers or
soap, hand towels, trash containers, or signs reminding workers to wash their hands before
returning to work (Deficiency FS-3). The staff restroom was clean and appropriately equipped.
ODO notes the food service director’s weekly inspections did not include the inmate workers’
restrooms. Upon re-inspection, ODO found the workers’ restrooms rooms had been cleaned and
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dispensers for paper towels and liquid soap had been installed; however, there were no soap,
paper towels, signs, or trash cans. To ensure sanitary conditions are maintained, ODO
recommends that the food service director’s weekly inspections of the food service area include
the workers’ restrooms (R-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE 2000 NDS, Food Service, section (III)(H)(3)(a)(b), the FOD must
ensure,
a. “All food service personnel (both staff and detainee) shall receive a pre-employment
medical examination. The purpose of this examination is to exclude those who have a
communicable disease in any transmissible stage or condition. Detainees who have been
absent from work for any length of time for reasons of communicable illness (including
diarrhea) shall be referred to Health Services for a determination as to fitness for duty
prior to resuming work.
b. The food service workers' examination shall be conducted in sufficient detail to
determine absence of:
1.
2.
3.
4.

Acute or chronic inflammatory condition of the respiratory system.
Acute or chronic infectious skin disease.
Communicable disease.
Acute or chronic intestinal infection.”

DEFICIENCY FS-2
In accordance with ICE 2000 NDS, Food Service, section (III)(G)(6)(c)(3), the FOD must ensure
“Each sack shall contain at least two sandwiches per meal, of which at least one will be meat
(non-pork). Commercial bread or rolls may be preferable because they include preservatives.
To ensure freshness, fresh, facility-made bread may be used only if made on the day of lunch
preparation. Sandwiches should be individually wrapped or bagged in a secure fashion, to
prevent the food from deteriorating. Meats, cheeses, etc., should be freshly sliced the day of
sandwich preparation. Leftover cooked meats shall not be used after 24 hours.
In addition, each sack shall include:
3. 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.”
DEFICIENCY FS-3
In accordance with ICE 2000 NDS, Food Service, section (III)(H)(9)(a)(b)(c), the FOD must
ensure:

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a. “Adequate and conveniently located toilet facilities shall be provided for all food service
staff and detainee workers. Toilet fixtures shall be of sanitary design and readily
cleanable. Toilet facilities, including rooms and fixtures, shall be kept clean and in good
repair. Signs shall be prominently displayed directing all personnel to wash hands after
using the toilet.
b. Lavatories shall have readily available hot and cold water.
c. Soap or detergent and paper towels or a hand-drying device providing heated air shall be
available at all times in each lavatory. Waste receptacles shall be conveniently placed
near the hand washing facilities.”

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at TCJ to determine if controls are in
place to inventory, receipt, store, and safeguard detainees’ personal property, in accordance with
the ICE 2000 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 the detainees
at TCJ 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 by the property room supervisor.
Upon admission, the detainee deposits cash in an electronic funds receiver, which creates an
account for the detainee that is accessible through a kiosk system located in each housing unit.
Valuable property items are placed in a sealed clear envelope, which is placed inside a secure
property room apart from hanging garment bags.
The facility handbook provides notice to detainees about items that may be retained in their
possession, the rules for storing or mailing property not allowed in their possession, and the
procedure for claiming property upon release, transfer, or removal. The facility handbook does
not provide the procedure for filing a claim for lost or damaged property (Deficiency F&PP-1).
This deficiency was communicated on-site to TCJ administrative staff, and ODO recommended
updating the handbook on the kiosk system, adding an addendum to the facility handbook, and/
or posting the revision on bulletin boards located in each housing unit (R-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE 2000 NDS, Funds and Personal Property, section (III)(J)(5), the FOD
must ensure, “The detainee handbook or equivalent shall notify the detainees of facility policies
and procedures concerning personal property, including:
5.

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 TCJ to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE 2000 NDS. ODO toured the clinic, reviewed the department’s policies and procedures,
observed administration of medication and sick call, verified medical staff credentials, and
examined the medical files of 25 detainees, ten of whom had a chronic health condition.
Interviews were conducted with detainees, health care staff, and administrative staff.
Armor Correctional Health Services, Inc., has held TCJ’s health services contract since
November 2013. The facility is accredited by the ACA and by the NCCHC. Medical services
are provided 24 hours a day, seven days a week, with administrative oversight provided by the
HSA who has an extensive background in the mental health profession as a social worker.
Clinical oversight is provided by the physician. In addition to the HSA and physician, full-time
staff includes a psychiatrist, an advanced practice registered nurse practitioner, a director of
nursing,(b)(7)eregistered nurses,(b)(7)elicensed practical nurses, (b)(7)e certified medical assistants,
(b)(7)e icensed mental health counselors, an infection control registered nurse, a utilization
review/discharge planning registered nurse, and (b)(7)e administrative support staff. A part-time
physician’s assistant provides weekend coverage, and a dentist and dental assistant are on-site
three days a week. Coverage for annual leave and training is provided by (b)(7)eas-needed medical
staff per diem positions. At the time of the review, the per diem positions were vacant, including
a physician, (b)(7)eregistered nurse,(b)(7)elicensed practical nurses, and (b)(7)ecertified medical
assistant. In-patient and out-patient services are provided by Oklahoma State University
Hospital, located in Tulsa, Oklahoma. All professional licenses were present and primary source
verified.
The clinic is spacious, well equipped, and includes a 28-bed infirmary. There are two
examination rooms, a treatment room, pharmacy, dental suite/dialysis room, radiology room, and
a large nursing station and several offices. Sick call is conducted five days a week in
examination rooms located in each of the housing units. A contract is in place to provide inhouse dialysis three days a week when needed. The infirmary area includes eight negative
pressure cells and four suicide watch cells. Bilingual staff or a translation service is used when a
language barrier is encountered. The detainee waiting area is adequate and has a drinking
fountain and restroom facilities.
Medical and mental health screening is completed by nursing staff at intake. General consent for
treatment is obtained during the intake process. Detainees are screened for tuberculosis (TB)
using the purified protein derivative skin test (PPD). ODO verified documentation of screening,
TB testing, and consent for treatment was present in all 25 medical records reviewed.
Detainees symptomatic of TB or those who have a positive PPD with an abnormal chest x-ray
are housed in a negative pressure room.
Health appraisals, which include hands-on physical examinations and dental screenings, are
performed by trained registered nurses and cosigned by the clinical director. Review of the
nurses’ training files confirmed they were trained by the physician in conducting the health
appraisal. The appraisal form currently being used meets the NDS and NCCHC requirements.
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ODO’s medical record review confirmed health appraisals for all 25 detainees were completed
within 14 days of arrival at the facility.
Detainees have two options for accessing health care: they may submit a written sick call
request or submit an electronic request using the facility’s kiosk system. Both the electronic and
written requests are available in English and Spanish. The kiosk system is available in each of
the housing units and directly routes requests to health services where they are triaged by nurses
upon receipt. Written requests are placed in a locked box in the housing unit and picked up by
mailroom staff. Mailroom staff sorts the requests by department and the medical requests are
picked up by nursing staff on a daily basis. Involvement of non-medical staff in this process
violates patient confidentiality, as medical information is documented on the forms
(Deficiency MC-1). ODO verified sick call requests were triaged upon receipt by nursing staff,
and detainees were evaluated at sick call within 24 to 36 hours.
ODO’s review confirmed the facility’s emergency plan includes emergency contact phone
numbers. An emergency response cart, including an automated external defibrillator (AED), is
located in the medical clinic. AEDs and first aid kits are also located in the booking area and
master control. ODO’s review of training records for medical staff and(b)(7)edetention officers
confirmed all received initial and annual training in first aid, including the requirement to
respond to medical emergencies within four minutes. Training records also confirmed they had
current certification in cardio-pulmonary resuscitation (CPR) and the use of an AED.
TCJ contracts with Maxor National Pharmacy Services Corp., for mail order pharmacy services.
Nursing staff are responsible for administering medication to the detainees in the housing units.
ODO observed psychotropic medication and controlled substances are crushed prior to
administration. Specific consent for psychotropic medications was present in detainee medical
records. Ten medication administration records were reviewed, and the entries were found to be
complete. Documentation verifies the medication carts are inventoried twice per day at shift
change.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE 2000 NDS, Medical Care, section (III)(M), the FOD must ensure,
“Medical providers shall protect detainee’s 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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SPECIAL MANAGEMENT UNIT (SMU) - ADMINISTRATIVE
SEGREGATION
ODO reviewed the Special Management Unit (SMU) - Administrative Segregation standard at
TCJ to determine if the facility has procedures in place to temporarily segregate detainees for
administrative reasons in accordance with the ICE 2000 NDS. ODO toured the SMU, reviewed
policies, interviewed staff, and inspected detainee files.
TCJ operates two separate SMUs, one for male detainees, the second for female detainees. The
SMU for male detainees has three units with a total of 48 single-occupancy cells. One unit has
12 cells, the second has 14 cells, and the third has 22 cells. Each of the three units has its own
shower and dayroom area. An outdoor recreation area is adjacent to the unit control center. The
female SMU consists of 16 single occupancy cells with a shower, dayroom, and accessible
outdoor recreation area. ODO’s inspection found the SMUs well ventilated, adequately lit, and
maintained in a sanitary condition.
Since January 2014, a total of eight detainees were either placed in administrative segregation for
pre-disciplinary hearing detention (three detainees), or protective custody (five detainees). There
were no detainees housed in administrative segregation during the time of the inspection.
ODO’s review of the detainees’ files found all were cleared by medical staff prior to their
placement. In addition, the Supervisory Detention and Deportation Officer stated he was
notified of all eight SMU placements and that the facility notifies him when a detainee is
assigned to segregation. Written segregation orders were completed for the eight detainees;
however, in one case, there was no documentation a supervisor reviewed and approved the
detainee’s placement in administrative segregation (Deficiency SMU AS-1). ODO also notes
that in all eight cases, an outdated form was used for the segregation orders. The form used is
dated July 2005, though the current version attached to the segregation policy is dated October
23, 2012, and includes sections for recording different information. Though both versions of the
form meet the requirements of the standard, ODO recommends that the facility take necessary
action to ensure the current version is used (R-4).
Of the eight detainees placed in administrative segregation over the past year, only three
remained on the status after seven days. There was no documentation reflecting completion of
seven day status reviews in any of the three cases, though required by facility policy as well as
the NDS (Deficiency SMU AS-2). One detainee was in segregation for seven days, one for eight
days, and one for 23 days.
Detainees on administrative segregation receive privileges and services required by the standard,
including indoor and outdoor recreation, showers, personal and legal visits, meals, medical
rounds, telephone access, and access to legal materials. A permanent log documenting these
activities is maintained and incorporated in the detainee’s file; however, in one case, activity logs
are missing for a four-day period, and in a second case, there were no dates recorded for security
rounds (Deficiency SMU AS-3). It is also noted that in a third case, the detainee’s activity logs
were present and complete, but ODO found logs for an inmate were included in the file as well.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU AS-1
In accordance with the ICE 2000 NDS, Special Management Unit-Administrative Segregation,
section (III)(B), the FOD must ensure, “A written order shall be completed and approved by a
supervisory officer before a detainee is placed in administrative segregation, except when
exigent circumstances make this impossible.
DEFICIENCY SMU AS-2
In accordance with the ICE 2000 NDS, Special Management Unit-Administrative Segregation,
section (III)(C), the FOD must ensure, “All facilities shall implement written procedures for the
regular review of all administrative detention cases, consistent with the procedures specified
below. A supervisory officer shall conduct the same type of review after the detainee has spent
seven days in administrative segregation, and every week thereafter for the first month and at
least every 30 days thereafter. The review shall include an interview with the detainee. A
written record shall be made of the decision and the justification.”
DEFICIENCY SMU AS-3
In accordance with the ICE 2000 NDS, Special Management Unit –Administrative Segregation,
section (III)(E), the FOD must ensure, “A permanent log will be maintained in the SMU. The
log will record all activities concerning the SMU detainees, e.g., meals served, recreation,
visitors, etc.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at TCJ to determine if procedures
are in place to allow formal and informal contact between detainees and key ICE and facility
staff, and if ICE detainees are able to submit written requests to ICE staff and receive responses
in a timely manner, in accordance with the ICE 2000 NDS. ODO interviewed staff and
detainees, visually inspected housing units, and reviewed records.
ERO staff conducts weekly scheduled and unscheduled visits at TCJ. The days and times for
scheduled visits are posted in housing units. During visits, ICE officials check on the overall
condition of the facility and respond to detainee requests. Visits are documented in the facility’s
electronic logbook. ODO reviewed Facility Liaison Checklists and telephone serviceability
worksheets to verify weekly checks are completed and that records are maintained.
The facility handbook lists written procedures specifying how detainees can route requests to
ICE officials. However, the facility does not have established standard operating procedures
covering detainees with special requirements who may need assistance from another detainee,
housing unit officer, or other facility staff member in preparing a request form
(Deficiency SDC-1). Furthermore, these procedures are not listed in the facility handbook.
Detainees can submit written or electronic ERO request forms if they would like to speak with
ERO officials. The facility uses an electronic kiosk system that routes detainee requests directly
to ERO officials; written requests are dropped in a designated box accessible only by ERO
personnel. ERO officials maintain an electronic log to document detainee requests. Although
the electronic log captures the date of receipt; the detainee’s name and nationality; A-number;
name of the staff member who logged the request; the date the request was returned to the
detainee; and other pertinent information, the log does not include the date the request was
forwarded to ICE (Deficiency SDC-2). This is especially important for detainee requests that
are submitted in written form. ODO reviewed the logs and found that staff responds to detainee
requests within 72 hours.
The facility does not include instruction for detainees that need assistance in preparing an ERO
request (Deficiency SDC-3). In accordance with the ICE “Change Notice National Detention
Standards,” dated June 15, 2007, DHS Office of Inspector General Hotline posters were not
observed in every housing unit and in appropriate common areas (Deficiency SDC-4). ODO
spoke with ICE officials and corrective action was initiated during the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE 2000 NDS, Staff-Detainee Communication, section (III)(B), the
FOD must ensure that, “The OIC shall ensure that the standard operating procedures cover
detainees with special requirements, including those who are disables, illiterate, or know little or
no English. Each facility will accommodate the special assistance needs of such detainees in
making a request.”

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DEFICIENCY SDC-2
In accordance with the ICE 2000 NDS, Staff-Detainee Communication, section (III)(B)(2), the
FOD must ensure that the detainee request logbook includes “the date the request was forwarded
to ICE.”
DEFICIENCY SDC-3
In accordance with the ICE 2000 NDS, Staff-Detainee Communication, section (III)(B)(3), the
FOD must ensure the handbook states 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-4
In accordance with the ICE “Change Notice National Detention Standards, Staff-Detainee
Communication,” dated June 15, 2007, the FOD must ensure, “the attached document regarding
the OIG Hotline (see Attachment A) is conspicuously posted in all units housing ICE detainees.”

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Attachment A:

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