U.S. Department of Homeland Security

Immigration and Customs Enforcement
Office of Professional Responsibility
Inspections and Detention Oversight Division
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
ERO Salt Lake City Field Office
Utah County Jail
Spanish Fork, Utah

May 18–21, 2015

COMPLIANCE INSPECTION
for the
UTAH COUNTY JAIL
SPANISH FORK, UTAH
TABLE OF CONTENTS
EXECUTIVE SUMMARY
Overall Findings...................................................................................................................2
Findings by National Detention Standards (NDS) 2000 Major Categories .........................3
INSPECTION PROCESS .............................................................................................................4
DETAINEE RELATIONS ............................................................................................................5
INSPECTION FINDINGS
DETAINEE SERVICES
Admission and Release ........................................................................................................6
Detainee Classification System............................................................................................6
Food Service ........................................................................................................................6
Funds and Personal Property ...............................................................................................6
Staff-Detainee Communication ...........................................................................................7
Telephone Access ................................................................................................................7
SECURITY AND CONTROL
Environmental Health and Safety ........................................................................................7
HEALTH SERVICES
Medical Care ........................................................................................................................8
Suicide Prevention and Intervention ....................................................................................9

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INSPECTION TEAM MEMBERS

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

Office of Detention Oversight
May 2015
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Lead Inspections and Compliance Specialist
ODO
Inspections and Compliance Specialist
ODO
Inspections and Compliance Specialist
ODO
Contractor
Creative Corrections
Contractor
Creative Corrections
Contractor
Creative Corrections
Contractor
Creative Corrections

1

Utah County Jail
ERO Salt Lake City

EXECUTIVE SUMMARY
The Office of Detention Oversight (ODO) conducted a compliance inspection of the Utah
County Jail (UCJ) in Spanish Fork, Utah, from May 18 to 21, 2015. 1 UCJ opened in 1997 and is
owned and operated by the Utah County Sheriff’s Office. Enforcement and Removal Operations
(ERO) began housing detainees at UCJ in 1997 pursuant to an Intergovernmental Service
Agreement (IGSA), under the oversight of ERO’s Field Office Director (FOD) in Salt Lake City,
Utah.
ERO staff members are not assigned
Capacity and Population Statistics
Quantity
to the facility, and a Detention
Services Manager is not assigned to ICE Detainee Bed Capacity 2
250
the facility. A Chief Deputy is Average ICE Detainee Population 3
157
responsible for oversight of daily Male Detainee Population (as of 05/19/2015)
172
facility operations and is supported
Female Detainee Population (as of 05/19/15)
3
by (b)(7)e personnel. Utah County
Sheriff’s Office provides food services and the County of Utah provides medical services. The
facility holds an accreditation with the National Commission on Correctional Health Care.

OVERALL FINDINGS
In May 2012, ODO conducted an
inspection of UCJ under the
National
Detention
Standards
(NDS) 2000, reviewing the
facility’s compliance with 18
standards and finding the facility
compliant with 14 standards. There
were a total of 11 deficiencies in the
remaining four standards.

Inspection Results
Compared

FY 2012
(NDS 2000)

FY2015
(NDS 2000/
SAAPI)

Standards Reviewed

18

16

Deficient Standards
Overall Number of
Deficiencies

4

9

11

17

0

1

N/A

N/A

Corrective Action
Deficient Priority
Components

In FY2015, ODO evaluated UCJ’s compliance with 15 standards under the NDS 2000, in
addition to the Performance-Based National Detention Standards 2011, Sexual Abuse and
Assault Prevention and Intervention (SAAPI) 4 standard, and found the facility compliant with
seven standards. ODO found 17 deficiencies, one of which was a repeat deficiency, under the
remaining nine standards. 5 Finally, ODO identified one opportunity where the facility initiated
corrective action during the course of the inspection. 6
1

Male and female detainees of security classification levels “Low,” “Medium,” and “High” are detained at the
facility for periods in excess of 72 hours.
2
Data Source: ERO Facility List Report as of May 18, 2015.
3
Ibid.
4
The UCJ is contractually required to comply with the PBNDS 2011 Sexual Abuse and Assault Prevention
Intervention (SAAPI) standard, as of November 1, 2012.
5
ODO identified a repeat deficiency in the Environmental Health and Safety standard.
6
Corrective actions, where immediately implemented, best practices and ODO recommendations, as applicable,
have been identified in the Inspection Findings section and annotated with a “C”, “BP” or “R”, respectively.

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Utah County Jail
ERO Salt Lake City

FINDINGS BY NDS 2000 MAJOR CATEGORIES
NDS 2000 STANDARDS INSPECTED 7

DEFICIENCIES

Part 1 – Detainee Services
1. - Access to Legal Material
2. - Admission and Release
4. - Detainee Classification System
5. - Detainee Grievance Procedures
6. - Detainee Handbook
7. - Food Service
8. - Funds and Personal Property
15. - Staff-Detainee Communication
16. - Telephone Access
Sub-Total

0
1
2
0
0
1
2
2
1
9

Part 2 – Security and Control
7. - Environmental Health and Safety
13 - Special Management Unit (Administrative)
14. - Special Management Unit (Disciplinary)
17. - Use of Force
Sub-Total

2
0
0
0
2

Part 3 – Health Services
2. - Medical Care
3. - Suicide Prevention and Intervention
Sub-Total
PBNDS 2011 STANDARD INSPECTED

4
2
6
DEFICIENCIES

Part 4 – Safety
2.11 - Sexual Abuse and Assault Prevention and Intervention
Sub-Total
Total Deficiencies

7

0
0
17

For greater detail on ODO’s findings, see the Inspection Findings section of this report.

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Utah County Jail
ERO Salt Lake City

INSPECTION PROCESS
Every fiscal year, the Office of Detention Oversight (ODO), a unit within U.S. Immigration and
Customs Enforcement’s (ICE) Office of Professional Responsibility (OPR), conducts
compliance inspections at detention facilities in which detainees are accommodated for periods
in excess of 72 hours and with an average daily population greater than ten to determine
compliance with the applicable ICE National Detention Standards (NDS) 2000, the PerformanceBased National Detention Standards (PBNDS) 2008 or 2011.
During the compliance inspection, ODO reviews each facility’s compliance with those detention
standards that directly affect detainee health, safety, and/or well-being. 8 Any violation of written
policy specifically linked to ICE detention standards, other policies, or operational procedures
that ODO identifies is noted as a deficiency. ODO will highlight any deficiencies found
involving those standards that ICE has designated with either the PBNDS 2008 or 2011 to be
“priority components.” 9 ICE considers those components to be of critical importance, given
their impact on facility security and/or the health and safety, legal rights, and quality of life of
detainees in ICE custody.
Immediately following an inspection, ODO hosts a closeout briefing in person with both facility
and ERO field office management to discuss their preliminary findings, which are summarized
and provided to ERO in a preliminary findings report. Thereafter, ODO provides ERO with a
final compliance inspection report to: (i) assist ERO in working with the facility to develop a
corrective action plan to resolve identified deficiencies; and (ii) provide senior ICE and ERO
leadership with an independent assessment of the overall state of ICE detention facilities. The
reports enable senior agency leadership to make decisions on the most appropriate actions for
individual detention facilities nationwide.

8
9

ODO reviews the facility’s compliance with selected standards in their entirety.
Priority components have not been identified for the NDS 2000.

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Utah County Jail
ERO Salt Lake City

DETAINEE RELATIONS
ODO interviewed 26 detainees, who volunteered to participate. None of the detainees made
allegations of mistreatment, abuse, or discrimination. The majority of detainees reported being
satisfied with facility services, with the exception of the complaints below:
•

Medical Care: One detainee alleged he needed eyeglasses, knee surgery, dental work and
medical treatment for his eye. One detainee alleged he was supposed to receive surgery
three weeks prior to the inspection to remove a lump on his body.
Action Taken: ODO consulted with medical staff about the aforementioned
allegations. Medical services notified ODO that the detainee, with allegations of
needing dental and other medical services, visited the dentist three months earlier
and made no further requests for additional dental work. The detainee had a
previous appointment for his eyes, which did not need medical treatment. At the
time of the inspection, glasses were ordered for the detainee. A review of the
medical request log revealed there were no documented requests for the detainee
to have his knee examined; consequently, the detainee was referred to the medical
department for further review. Medical services notified ODO that the detainee,
with allegations of needing surgery for a lump on his body, received medical care
for the lump, which was determined not to be life-threatening. Rather, the lump
was determined to be infected, and the detainee was prescribed pain medication
and an antibiotic to treat the infection. The detainee was referred to the medical
department for further review; however, since receiving medical care, the detainee
has not submitted a request for the removal of the lump.

•

Strip Searches: Two detainees alleged they were strip-searched at the facility. One
detainee alleged he was strip-searched during the admission process. Another detainee
alleged he was strip-searched while in the Special Management Unit.
Action Taken: ODO reviewed security footage of the intake process for the
detainee alleging he was strip-searched during admission. The detainee was
observed receiving a pat down search during admission. The detainee went to the
restroom alone and returned to complete the admission process. The detainee was
not observed being striped searched during any point of the admission process.
The detainee, alleging he was strip-searched in the special management unit, was
strip-searched in accordance with the facility’s policy, due to suspicion of
concealing weapons and contraband.

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Utah County Jail
ERO Salt Lake City

INSPECTION FINDINGS
DETAINEE SERVICES
ADMISSION AND RELEASE (AR)
The orientation video provides the required information on facility operations, programs and
services; however, the Supervisory Detention and Deportation Officer and UCJ lieutenant in
charge of policies stated they are unaware of any written or oral approval of the orientation video
received from the field office (Deficiency AR-1 10).
DETAINEE CLASSIFICATION SYSTEM (DCS)
An ODO review of 25 classification records and interview with facility classification staff
revealed all detainees are classified as level II regardless of criminal history, which does not
meet ICE requirements (Deficiency DCS-1 11).
An ODO review of 25 classification records and interview with facility classification staff
revealed a supervisory officer does not conduct a review of each classification in accordance
with the standard (Deficiency DCS-2 12).
FOOD SERVICE (FS)
An interview with the food service manager and review of available inspection reports and logs
revealed, water temperatures in the dishwashing machines are not checked and recorded at least
daily, and there is no documentation the food service manager walks through the food service
area once a week (Deficiency FS-1 13).
FUNDS AND PERSONAL PROPERTY (F&PP)
An interview with intake staff and a review of 25 detainee files revealed the facility does not
obtain a forwarding address from detainees who have property (Deficiency F&PP-1 14). Staff
notified ODO that instances of abandoned or forgotten property are reported to ERO. Corrective
10
“In IGSAs the INS office of jurisdiction shall approve all orientation procedures.” See ICE NDS 2000, Standard,
Admissions and Release, Section (III)(J).
11
“The facility shall abide by INS policy, rules and guidelines as set forth in this Standard and implemented in the
attached Detainee Classification system for classifying detainees. CDFs and IGSA facilities may continue using the
systems established locally, if the classification criteria are objective and all procedures meet INS requirements.”
See ICE NDS 2000, Standard, Detainee Classification System, Section (III)(A).
12
“The first-line supervisor will review and approve each detainee's classification.” See ICE NDS 2000, Standard,
Detainee Classification System, Section (III)(A)(3).
13
“All components of the food service department, (ranges, ovens, refrigerators, mixers, dishwashers, garbage
disposal, etc.) require frequent inspection to ensure their sanitary and operable condition. Staff shall check
refrigerator and water temperatures daily, recording the results. The FSA or CS of food service shall inspect food
service areas weekly.” See ICE NDS 2000, Standard, Food Service, Section (III)(H)(13)(a).
14
“Standard operating procedure will include obtaining a forwarding address from every detainee who has personal
property that could be lost or forgotten in the facility after the detainee’s release, transfer, or removal.” See ICE
NDS 2000, Standard, Funds and Personal Property, Section (III)(C).

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Utah County Jail
ERO Salt Lake City

action was not initiated prior to the completion of the inspection, but the Supervisory Detention
and Deportation notified ODO a forwarding address will be collected from all detainees in the
future.
The facility conducted inventories and audits of detainee funds, valuables and personal property
as required by NDS 2000 but do not have a written policy addressing the inventories and audits
(Deficiency F&PP 2 15).
STAFF-DETAINEE COMMUNICATION (SDC)
A review of the facility’s standard operating procedure for Inmate Request Forms revealed it
does not cover 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 16).
ICE officials retain copies of detainee ICE requests, but do not record detainee ICE requests in a
logbook specifically designed for that purpose (Deficiency SDC-2 17).
TELEPHONE ACCESS (TA)
A review of the facility handbook and postings in the housing units, revealed the facility does not
inform detainees to contact an officer if they have difficulty making a confidential call relating to
a legal proceeding (Deficiency TA-1 18).

SECURITY AND CONTROL
ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
A copy of the Material Safety Data Sheets are maintained in the safety office and medical
department; however, an interview with staff revealed, the index has not been provided to the
local fire department (Deficiency EH&S-1 19).
Inventories of hazardous materials were available; however, the inventories of two substances
stored in a flammables cabinet were inaccurate. The quantities on hand of the aerosol “Open and
15

“Each facility shall have a written procedure for inventory and audit of detainee funds, valuables, and personal
property.” See ICE NDS 2000, Standard, Funds and Personal Property, Section (III)(F).
16
“The OIC shall ensure that the standard operating procedures cover detainees with special requirements, including
those who are disabled, illiterate, or know little or no English. Each facility will accommodate the special assistance
needs of such detainees in making a request.” See ICE NDS 2000, Standard, Staff-Detainee Communication,
Section (III)(B).
17
“All requests shall be recorded in a logbook specifically designed for that purpose.” See ICE NDS 2000,
Standard, Staff-Detainee Communication, Section (III)(B)(2).
18
“The facility shall inform detainees to contact an officer if they have difficulty making a confidential call relating
to a legal proceeding.” See ICE NDS 2000, Standard, Telephone Access, Section (III)(J).
19
“The Maintenance Supervisor or designate will compile a master index of all hazardous substances in the facility,
including locations, along with a master file of MSDSs. He/she will maintain this information in the safety office
(or equivalent), with a copy to the local fire department.” See ICE NDS 2000, Standard, Environmental Health and
Safety, Section (III)(C). This is a repeat deficiency.

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Utah County Jail
ERO Salt Lake City

Shut,” a lubricating oil, and “LPA 1,” a protective agent, were less than the amounts documented
on the inventories (Deficiency EH&S-2 20).

HEALTH SERVICES
MEDICAL CARE (MC)
All professional licenses were present and current but have not been primary source verified with
the issuing state boards for authentication purposes (Deficiency MC-1 21).
Corrective Action: The facility initiated corrective action during the inspection by
completing primary source verification (C-1).
Consent for medical treatment statements were included on the intake forms and signed by the
detainees in 24 of 25 medical records reviewed by ODO, and six of the consent forms were not
dated (Deficiency MC-2 22).
ODO’s medical record review found two of 25 health appraisals were not reviewed by the
physician; furthermore, in 13 cases the physician’s review was completed outside the required 14
days. In one of the 13 cases, the physician’s review was documented nine months later
(Deficiency MC-3 23).
UCJ has an on-site dentist, but the dentist does not conduct initial dental screenings. Instead,
dental screenings are performed by a registered nurse when conducting the health appraisal
(Deficiency MC-4 24).

20

“Accountability: Inventory records for a hazardous substance must be kept current before, during, and after each
use.” See ICE NDS 2000, Standard, Environmental Health and Safety, Section (III)(E)(4).
21
“The health care staff will have a valid professional licensure and or certification. The USPHS, Division of
Immigration Health Services, will be consulted to determine the appropriate credentials requirements for health care
providers.” See ICE NDS 2000, Standard, Medical Care, Section (III)(C).
22
“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.” See ICE NDS 2000, Standard, Medical
Care, Section (III)(L).
23
“Health appraisals will be performed according to NCCHC and JCAHO standards.” See ICE NDS 2000, Standard,
Medical Care, Section (III)(D).
24
“An initial dental screening exam should be performed within 14 days of the detainee’s arrival. If no on-site
dentist is available, the initial dental screening may be performed by a physician, physician’s assistant or nurse
practitioner.” See ICE NDS 2000, Standard, Medical Care, Section (III)(E).

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Utah County Jail
ERO Salt Lake City

SUICIDE PREVENTION AND INTERVENTION (SP&I)
The facility training for suicide prevention and intervention does not cover making referrals,
response to suicide attempts, observation procedures, or follow-up reporting and documentation
(Deficiency SP&I-1 25).
The facility has six designated suicide watch cells located in different areas of the facility.
Inspection found five of the cells were free of objects or structural elements that could facilitate a
suicide; however, the sixth (Brighton 4, Dorm 4) has a metal privacy partition affixed to the wall
supported by a metal floor-to-ceiling rod (Deficiency SP&I-2 26).

25

“All staff will receive training during orientation and periodically, in the following: recognizing signs of suicidal
thinking, including suspect behavior; facility referral procedures; suicide-prevention techniques; and responding to
an in-progress suicide attempt. All training will include the identification of suicide risk factors and the
psychological profile of a suicidal detainee.” See ICE NDS 2000, Standard, Suicide Prevention and Intervention,
Section, (III)(A).
26
“The isolation room will be free of objects or structural elements that could facilitate a suicide attempt. If
necessary, the detainee may be placed in the Special Management Unit, provided space has been approved for this
purpose by the medical staff.” See ICE NDS 2000, Standard, Suicide Prevention and Intervention, Section, (III)(C).

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ERO Salt Lake City