6415 Calder, Suite B • Beaumont, Texas 77706
409.866.9920 • www.correctionalexperts.com
Making a Difference!

November 30, 2007
MEMORANDUM FOR:

FROM:

John P. Torres, Director
Office of Detention and Removal
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~

Reviewer-In-Charie
Creative Corrections

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West Texas Detention Facility
Annual Detention Review

SUBJECT:

Creative Corrections conducted the Annual Detention Review (ADR) of the West Texas
Detention Facility on November 26-28,2007. The United States Marshals Service (USMS) has
a contract with Hudspeth County operated by Emerald Companies. It is an over 72 hours facility
and primarily houses USMS prisoners, involved in criminal proceedings. There is also an
agreement with Immigration and Customs Enforcement (ICE) to house detainees involved in
immigration proceedings. As noted on the attached documents, the team of Subject Matter
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Experts (SME) included;
SME for Security;
SME for Health
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SME for Safety;
SME for Food Services; and
,
Services; b6,b7c
Senior Project Manager.
Type of Review:
This review is a scheduled Detention Standard Review to determine general compliance with
established ICE National Detention Standards.
Review Summary:
The facility began operation in 2004 and received accreditation by the American Correctional
Association (ACA) in August of2007. The facility is not accredited by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) or the National Commission on
Correctional Health Care (NCCHC).
Standards Compliance:
The following information summarizes the standards reviewed and the overall compliance for
this review as well as the previous review.
October 26 2 2006 2 Review
Compliant
36
0
Deficient
At Risk
0
Non Applicable
2

November 26-28 2 20072 Review
Compliant
34
Deficient
2
At Risk
0
Non Applicable
2

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

Food Service - Deficient

•

Every facility will provide detainees in its care with nutritious and appetizing meals, prepared in
accordance with the highest sanitary standards.
•

The Food Service Program is not under the direct supervision of a professionally trained
and Certified Food Service Administrator.

•

The Food Service Manager (FSM) does not provide Food Service employees with
training that specifically addresses detainee-related issues (e.g. ICE Food Service
standard).

•

The FSM is not conducting annual reviews of the detainee-volunteer job descriptions to
ensure they are accurate and up-to-date. Currently, the FSM does not issue any job
descriptions to detainees assigned to Food Service.

•

There is no documentation available for review to ensure the Cook Foremen are
providing orientation and training sessions on safe work practices and methods, safety
features of individual products/pieces of equipment, and training covering the safe
handling of hazardous materials.

•

The Cook Foremen are not documenting or providing any training to the assigned
detainees. Staff is not placing completed training forms in the individual detainee files in
Food Service.

•

The Registered Dietitian has not completed a nutriti0nal analysis of every Master-Cycle
Menu as required.

•

The FSM has not established procedures to ensure that items on the Master-Cycle Menu
are prepared and presented according to approved recipes. There were no recipe cards
available for staff or detainees to utilize.

•

The Cook Foremen are not documenting each menu substitution and providing a written
justification to the FSM.

•

There are no written procedures for food preparation, in place and available for staff
and/or detainee to provide written guidance for meal production.

•

The Food Service Department does not have a Common Fare Program.

•

The Satellite-Feeding Program is not following proper sanitation guidelines.

•

The Food Service staff is not providing appropriate training to detainee volunteer workers
on the proper sanitation requirements, and the care and maintenance of equipment.

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

2

•

Staff/detainees workers in the Food Service Department are not complying with Food
Safety and Sanitation Requirements.

•

The weekly sanitation inspections of all Food Service areas and equipment are not being
conducted and/or documented.

•

The Food Service area and equipment has not been inspected in over a year, by an
independent authority (i.e. Health Department), to ensure compliance with Health and
Safety Codes and Regulations as required.

•

The Food Service Department does not have a cleaning schedule posted for each work
area within the department.

Recommendations
•

Recommend that the Food Service Manager receive Serv-Safe training to enhance his
professional skills in the Food Service field.

•

Require the Food Service Manager to provide Food Service employees with training that
specifically addresses detainee related issues.

•

The Food Service Manager should develop and issue detainee job descriptions. These
descriptions should be reviewed annually for content.

•

The Cook Foremen should provide and document detainee worker orientation and
training sessions on safe work practices and methods, safety features of individual
products/pieces of equipment, and the safe handling of hazardous materials.

•

The Cook Foremen should document all training sessions and place in the individual
detainee workers files in the Food Service Department.

•

The Registered Dietitian should conduct and complete a nutritional analysis of every
Master-Cycle Menu on an annual basis.

•

The Food Service Manager should establish procedures to ensure that items on the
Master-Cycle Menu are prepared and presented according to approved recipes. He
should also have recipe cards available for staff and detainee workers.

•

The Cook Foreman should document each substitution on the Master-Cycle Menu and
provide written justification to the Food Service Manager.

•

The Food Service Manager should develop and implement the Common Fare Program as
required.

•

The Food Service staff should enforce and follow proper sanitation guidelines.

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•

The Food Service staff should instruct detainee volunteers on the proper sanitation
procedures, and the care and maintenance of all equipment.

• . The Food Service Manager should conduct formal weekly sanitation inspections of all
Food Service areas and equipment.
•

The Food Service Department should ensure the department and all equipment are
inspected on an annual basis from an independent authority (i.e. Health Department).
This will ensure compliance with Health and Safety Codes and Regulations as required.

•

The Food Service Manager should develop and post a cleaning schedule for each work
area within the department.

Environmental Health and Safety - Deficient
Every facility will control flammable, toxic, and caustic materials through a hazardous materials
program. The program will include, among other things, the identification and labeling of
hazardous materials in accordance with applicable standards (e.g., National Fire Protection
Association (NFP A); identification of incompatible materials, and safe-handling procedures.
•

The facility does not have a comprehensive system for storing, issuing, and maintaining
inventories of hazardous materials.

•

Constant inventories are not maintained for all flammable, toxic, and caustic substances
used/stored in each section of the facility.

•

The manufacturer's Material Safety Data Sheet (MSDS) file is not up-to-date for every
hazardous substance used.

•

All toxic and caustic materials are not stored in their original containers in a secure area.

•

Employees and detainees using flammable, toxic, or caustic materials do not receive
.
advance training in their use, storage, and disposal.

•

The facility does not fully comply with the most current edition of applicable codes,
standards, and regulations of the NFP A and the Occupational Safety and Health
Administration (OSHA).

•

The officer who conducts the fire and safety inspections is not technically qualified.

•

The facility does not have an approved Fire Prevention, Control, and Evacuation Plan.

•

Fire drills are not conducted and documented monthly in all areas of the facility.

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

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•

The sanitation standards are not conspicuously posted in the barbershop.

Recommendations
•

Develop a system for storing, issuing, and maintaining inventories of hazardous
chemicals for all hazardous chemicals that are used and stored in the facility.

•

Develop a system to maintain constant inventories for all flammable, toxic, and caustic
substances used/stored in each section of the facility.

•

Ensure the MSDS file is up-to-date for every hazardous chemical used.

•

Store all toxic and caustic materials in a secure area.

•

Provide advance training to employees and detainees who use flammable, toxic, or
caustic materials. The training must include use, storage and disposal of said materials.

•

Ensure that the facility fully complies with the most current edition of applicable codes,
standards, and regulations of the NFPA and OSHA.

•

Provide Fire and Environmental Health/Safety Training for the officer who conducts the
Fire and Safety Inspections.

•

Obtain approval from the local authority having jurisdiction for the Fire Prevention,
Control, and Evacuation Plan.

•

Conduct and document monthly fire drills in all areas of the facility.

•

Post the sanitation standards in a conspicuous area in the barbershop.

RIC Issues and Concerns
Admission and Release
•

All detainees are routinely strip searched without the reasonable suspicion requirement
being taken into consideration.

Detainee Handbook
•

The Detainee Handbook does not explain how to file a complaint about officer
misconduct to the Department of Homeland Security.

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Detainee Grievance Procedures
•

The Detainee Handbook does not describe how to file a grievance about officer
misconduct with the Department of Homeland Security.

Issuance and Exchange of Clothing, Bedding. and Towels
•

Detainees do not receive a daily issuance of clean socks and undergarments.

Visitation
•

The detainee families do not have the ability to leave money or property with the
detainee during a social visit.

Access to Medical Care
•

Reviewers observed the staff physician did not complete physical examinations unless
the detainee was referred to the physician by the nursing staff. Recently, the West Texas
Detention Facility (WTDF) became aware of standard requirements regarding physical
examinations. Two weeks prior to this audit a Corrective Action Plan to address physical
examinations standards was implemented. The facility now plans to have the Clinical
Director perform the physical examinations on the detainees. At the time of this review,
twenty three physical examinations were completed. There are plans to continue having
the physical examinations done weekly. IIJ. addition to the Clinical Director, a Physician
Assistant-Certified (PAC) is scheduled to start coming in on a weekly basis to perform
the physical examinations as required by this standard. The facility must continue this
practice to remain compliant in the future.

•

The WTDF performed urine dipstick and urine pregnancy testing without the appropriate
Clinical Laboratory Improvement Amendment (CLlA) identification and waiver
certificate. The Health Services Administrator, who oversees Emerald Health Care
Systems, was made aware of the CLIA public law. She contacted CLIA for application
of the appropriate CLIA identification and waiver certification at the time of this review.
No further action is required.

Emergency Plans
•

The WTDF has no plans in place to identify the location of shut-off valves and switches
for the utilities. The facility should develop written plans to identify the exact locations
of the shut-off valves and switches for water, gas and electric.

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Key and Lock Control
•

The Security Officer has been in his current position for approximatetly two weeks. It is
recommended that he attend an approved Locksmith Training Program.

•

The Maintenance Supervisor performs maintenance work when staff submit a work
order. There was no documentation available to support that the preventive maintinance
requested was being completed. The facilty staff should develop a "Preventive
Maintenance Program".

Post Orders
•

The WTDF has no Post Orders that specifically provide instructions to staff in the event
of an escape or an incident that would require the use of deadly force. It is recommended
that Post Orders be developed for all armed posts, which include shoot-no-shoot
considerations.

Tool Control
•

Reviewers observed a five pound sledge hammer stored in the non-restricted tool storage
area and a plastic case of security screw bits, secured in a locked wooden drawer. It is
recommend that the sledge hammer classification be reviewed and the security screw bits
be secured in the hazardous tool cage.

•

A review of the broken tool list indicated a kitchen knife had been disposed of
appropriately; however, the documentation did not list the tool marking and the date of
disposal. It is recommended that the tool identification marking and the date of disposal
be documented when broken tools are removed from inventory.

Use of Force
•

There is no documentation available to support a system is in place to ensure
management's review of Use of Force incidents. Recommend that a system be developed
to review and document the incidents.

StafflDetainee Communications
•

Deportation Officer (DO) assignments are not posted in the living units but visits are
made on a random basis.

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Recommended Rating and Justification
It is the Reviewer-in-Charge (RIC) recommendation that the facility receive a rating of
"Acceptable." It is also recommended by the RIC that a Plan of Action be required for this
facility identifying necessary corrective actions.

RIC Assurance Statement:
All findings of this review have been documented on Form CC-324A and are supported by the
.
written documentation contained in the review file.

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

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Creative corrections

Detention Facility Inspection Form

A. Type of Facility Reviewed
ICE Service Processing Center
ICE Contract Detention Facility
ICE
Intergovernmental Service Agreement
~

Basic Rates per Man-Day
$60.00
Other Charges: (If None, Indicate N/A)
,
N/A
,
,
Estimated Man-days Per Year
127,750

o
o

B. Current Inspection
Type of Inspection
Field Office ~ HQ Inspection
Date[s] of Facility Review
November 26-28

o

G. Accreditation Certificates
List all State or National Accreditation[s] received:
American Correctional Association, August 13,2007
Check box if facility has no accreditation[s]

o

C. PreviouslMost Recent Facility Review .
Date[s] of Last Facility Review
October 24, 2006
Previous Rating
Superior 0 Good ~ Acceptable 0 Deficient 0 At-Risk

H. Problems / Complaints (Copies must be attached)
The Facility is under Court Order or Class Action Finding
Court Order
0 Class Action Order
The Facility has Significant Litigation Pending
Major Litigation
Life/Safety Issues
~ Check if None.

o
o

o

.

D Namean dL oca f Ion 0 fF aCITt
Ity
Name
West Texas Detention Facility
Address (Street and Name)
401 S. Vaquero Avenue, P.O. Box 430
City, State and Zip Code
Sierra Blanca, Texas 79851
County
Hudspeth County
Name and Title of Chief Executive Officer
(Warden/O IC/Superintendent)

I

F aCITt
Ity H'IS t ory
Date Built
August 2004
Date Last Remodeled or Upgraded
N/A
Date New Construction / Bedspace Added
N/A
Future Construction Planned
~ Yes 0 No Date: Jan 2008
Current Bed space
Future Bedspace (# New Beds only)
500
Number: 500 Date: Jan 15,2008

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Telephone # (Include Area Code)
915- b6,b7c
Field Office / Sub-Office (Office w/oversight responsibilities)
El Paso, Texas
Distance from Field Office
90 Miles

J. Total Facility Population
Total Facility Intake for previous 12 months
3,042
Total ICE Mandays for Previous 12 months
9540 (Approximately five months)

.

E ICE Information
Name ofInspector (Last Name, Title and Duty Station)
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RIC / Reviewer-in-Charge
eam Member / Title / Duty Location
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/ SPM / Senior Proiect Man~er
Name of Team Member / Title / Duty Location
/ SME / Food Service
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Name of Team Member / Title / Duty Location
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/ SME / Health Services
Name of Team Member / Title / Duty Location
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/ SME / Security
Team Member / Title / Duty Location
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/ SME / Environmental Health and Safety

o

K. Classification Level (ICE SPCs and CDFs Only)
L-l

I AdultMale
I Adult Female

L-2

F
aCllty
T Ca :>aclty
Rated
Operational
Emergency
Adult Male
470
452
492
Adult Female
48
48
50
Facility holds Juveniles Offenders 16 and older as Adults
L

o

M Average Dal'1y Popu Ia f IOn
ICE
72
0
Facility Staffing Level

USMS
396
45

I Adult Male
I Adult Female
Contract Number
80-05-0005

Date of Contract or IGSA
04-01-07

L-3

I

N.

Other

port:
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Form CC-324A SIS

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

Detention Facility Inspection Form

Creative corrections

Significant Incident Summary Worksheet
For Creative Corrections to complete its review of your facility, the following information must be completed prior to the scheduled
review dates. The information on this form should contain data for the past twelve months in the boxes provided. The information on
this form is used in conjunction with the ICE Detention Standards in assessing your Detention Operations against the needs of the ICE
and its detained population. This form should be filled out by the facility prior to the start of any inspection. Failure to complete this
section will result in a delay in processing this report and the possible reduction or removal of ICE' detainees at your facility.

5
Assault:
Offenders on
Offenders!

Assault: ,
Detainee on
Staff

Number of Forced Moves,
inc!. Forced Cell moves 3

# Times Four/Five Point
Restraints applied/used
Offender / Detainee Medical
Referrals as a result of
sustained.

0

0

o

o

5

9

6

2

0

2

0

0

0

2

0

3

o

o

0

0

o

o

0

0

0

0

o

o

0

0

o

o

0

0

o

o

3

0

2

o

0

0

o

o

0

0

o

o

7

31

21

8

2

o

0

0

o

o

0

0

o

o

10

21

32

16

0

0

o

o

Escapes

Grievances:
Received
# Resolved in favor of
OffenderlDetainee
Reason (V=Violent, I=Illness,
S=Suicide, A=Attempted

Deaths

Psychiatric / Medical
Referrals

# Medical Cases referred for
Outside Care
# Psychiatric Cases referred for
Outside Care

o
o

o
o

o

Any attempted physical contact or physical contact that involves two or more offenders
Oral, anal or vaginal penetration or attempted penetration involving at least 2 parties, whether it is consenting or non-consenting
Routine transportation of detainees/offenders is not considered "forced"
Any incident that involves four or more detainees/offenders, includes gang fights, organized multiple hunger strikes, work stoppages, hostage situations,
major fires, or other large scale incidents.

Form CC-324A SIS

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Admission and Release
Classification System
Correspondence and Other Mail
Detainee Handbook
Food Service
Funds and Personal Property
Detainee Grievance Procedures
Issuance and Exchange of Clothing, Bedding, and Towels
Marriage Requests
Non-Medical Emergency Escorted Trip
Recreation
Religious Practices
V
Work ...rrlor"rYI

Health
18.
Hunger Strikes
19.
Medical Care
20.
Suicide Prevention and Intervention
21.
Terminal
Advanced Directives and Death
......·•.-ii", and Control
22.
Contraband
23.
Detention Files
24.
Disciplinary Policy
25.
Emergency Plans
26.
Environmental Health and Safety
27.
Hold Rooms in Detention Facilities
28.
Key and Lock Control
29.
Population Counts
30.
Post Orders
31.
Security Inspections
32.
Special Management Units (Administrative Segregation)
33.
Special Management Units (Disciplinary Segregation)
34.
Tool Control
35.
Transportation (Land management)
Use of Force
36.
37.
Staff / Detainee Communication (Added August 2003)
38.
Detainee Transfer (Added September 2004)

findings (Deficient and At-Risk) require written comment describing the finding and what is necessary to meet compliance.

Form CC-324A SIS

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

RIC Review Assurance Statement

By signing below, the Reviewer-In-Charge (RIC) certifies that all findings of noncompliance with policy or inadequate controls
contained in the Inspection Report are supported by evidence that is sufficient and reliable. Furthermore, findings of noteworthy
accomplishments are supported by sufficient and reliable evidence. Within the scope of the review, the facility is operating in
accordance with applicable law and policy, and property and resources are efficiently used and adequately safeguarded, except for the
deficiencies noted in the report.

Reviewer-In-Charge: (Print Name)

Signature

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Title & Duty Location

RIC,Creative Corrections

November 30,2007

Team Members

..

Print Name, Title, & Duty Location
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Print Name, Title, & Duty Location

SME Food Service

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Print Name, Title, & Duty Location
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SME Security

Recommended Rating:

SME Health Services

Print Name, Title, & Duty Location
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SME Environmental Health and Safety

D Superior
DGood
I:XI Acceptable
D Deficient
D At-Risk

Comments:
West Texas Detention Facility Warden and staff were very professional and extremely helpful during the ICE audit. Their positive
attitudes and work ethic exemplified their desire to run an efficient and effective facility. The ICE Review Team appreciated their
efforts and assistance during this review.

Form CC-324A SIS

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)