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
Atlanta Field Office
York County Detention Center
York, South Carolina

March 12 – 14, 2013

COMPLIANCE INSPECTION
YORK COUNTY DETENTION CENTER
ATLANTA FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................4
Inspection Team Members ...................................................................................................4
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................5
Detainee Relations ...............................................................................................................5
ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................6
Access to Legal Material .....................................................................................................7
Detainee Grievance Procedures ...........................................................................................8
Environmental Health and Safety ......................................................................................10
Key and Lock Control ........................................................................................................13
Medical Care .....................................................................................................................14
Recreation ..........................................................................................................................18
Security Inspections ...........................................................................................................19
Special Management Unit-Administrative Segregation ....................................................20
Special Management Unit-Disciplinary Segregation.........................................................21
Suicide Prevention and Intervention ..................................................................................22
Terminal Illness, Advanced Directives, and Death ..........................................................23
Visitation ............................................................................................................................24

YCDC’s inmate handbook does not notify detainees of the scheduled hours of access to the law
library, the procedure for requesting additional time, the procedure for requesting legal reference
materials not maintained in the law library, or the procedure for notifying a designated employee
that library material is missing or damaged.
The grievance system at YCDC allows detainees to file informal, formal, and emergency
grievances, and to appeal grievance decisions. YCDC staff encourages detainees to resolve their
grievances at the lowest level possible. YCDC’s Grievance Coordinator, who maintains a
grievance logbook, reported there were no informal or formal grievances filed in the last two
years. ODO found the inmate handbook does not contain information concerning ICE detainees
being able to appeal a grievance decision or file a complaint about officer misconduct directly
with the Department of Homeland Security, Office of Inspector General.
Inventories were not maintained for substances stored in two flammables cabinets in the
maintenance area. Gallon cans of paint and small propane cylinders were found on open shelves
and on the floor of the maintenance area. The master index of hazardous substances did not
include the locations where the substances are stored, or the required listing of emergency
telephone numbers. Emergency exit diagrams were not posted in a number of areas, including
the detainee housing area, corridors outside the housing area, the booking area, the laundry area,
and the library. The diagrams that were posted in the facility were only printed in English, and
did not include “You Are Here” markings. Barbering is conducted in an open area of the
housing unit or in the booking area, and the required hair care sanitation regulations are not
posted in these areas.
ODO found the Assistant Chief is responsible for all the administrative duties related to key and
lock control, but those duties are not documented in the position description. Through interviews
and documentation review, ODO found the Assistant Chief does not maintain records concerning
locks or locking devices, and locks throughout the facility were not included on any inventory.
Interviews with the Assistant Chief and county maintenance staff revealed there is no preventive
maintenance program for the key and lock control program.
ODO found two cases where health appraisals were not conducted within 14 days of arrival.
During a review of records for documentation of required tuberculosis (TB) testing, ODO found
two cases where detainees did not undergo screening by way of purified protein derivative (PPD)
or chest x-ray (CXR) upon admission. ODO found an instance where a detainee was admitted
into the general population before his positive PPD results were properly addressed. In another
two cases, ODO found detainees did not receive follow-up CXRs for 96 hours and 15 days,
respectively, following positive PPDs. ODO found completed sick call requests are given
directly to correctional staff for entry into the electronic Jail Management System, exposing the
detainee’s medical information. ODO found the Medication Administration Log (MAL) is not
the same as the Medication Administration Record, and the MAL does not adequately document
distribution of medications in accordance with provider orders. ODO reviewed training records
for all healthcare and(b)(7) randomly-selected correctional staff, and found(b)(7)emedical and (b)(7)e
correctional staff member did not have current certifications in cardiopulmonary resuscitation,
first aid, and use of an automated external defibrillator.

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ODO found YCDC does not have a designated individual responsible for recreation. According
to YCDC staff, the housing unit officers coordinate and oversee the daily recreational activities
of detainees. Designating overall responsibility for recreational activities ensures opportunities
are offered and documented consistently.
YCDC has a comprehensive security inspection system, which includes all areas of the facility.
The facility’s front entrance has a sally port with electronic interlocking doors to prevent
unauthorized entry or exit. Procedures have been established for issuing visitor passes to all
visitors. ODO found YCDC’s policy does not include procedures for documenting vehicles
entering the facility. According to the policy and observations, the control center officer
monitors vehicular traffic; however, documentation of vehicles entering or leaving the facility is
not maintained. Documenting vehicular traffic provides a permanent record of access to the
secure perimeter, supporting facility security.
ODO found healthcare professionals only visit the Special Management Units (SMU) when a
detainee makes a request or to administer medication, which is not compliant with the NDS.
ODO inquired with YCDC management about their sexual assault and abuse policies and
procedures. ODO observed YCDC management conducting Prison Rape Elimination
Act (PREA) training for(b)(7)estaff members. ODO observed PREA posters inside all inmate and
detainee housing units. All YCDC staff is required to fully cooperate in any investigation
regarding an allegation of sexual misconduct or abuse of inmates or detainees. Any staff who
witnesses prohibited conduct is required to report the conduct immediately, and a written report
detailing the incident must be filed as soon as possible. YCDC staff stated there have been no
reported incidents of sexual assaults or misconduct at YCDC. Presently, YCDC management
uses existing misconduct policies as a guide to address any reports of sexual assault or abuse
involving staff, detainees, or inmates.
ODO was informed there have been no detainee suicides at YCDC. There was one suicide
watch in the past year, but no suicide attempts. Review of the medical record confirmed suicide
watch management is consistent with NDS requirements with one exception: the detainee was
released from suicide watch status by a registered nurse (RN) without written authorization from
the physician.
ODO was informed there have been no terminally ill detainees or detainee deaths at YCDC.
ODO interviewed medical staff and reviewed policies and procedures. ODO found YCDC’s
policies do not include written procedures for making autopsy arrangements.
The facility uses a non-contact visitation system. Detainees may receive a one-hour visit each
week on a designated day. Written visiting procedures, including a schedule and hours of
visitation, are posted in the lobby main entrance area. Detainees are notified of visitation rules
and hours by way of the inmate handbook, and postings in the housing units. Legal visits are
permitted seven days per week and take place in the same non-contact booths used for visiting.
ODO found YCDC has one logbook for both general visitors and legal representatives to sign in
and out, which is not compliant with the NDS.

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INSPECTION PROCESS
ODO inspections evaluate the welfare, safety, and living conditions of detainees. ODO primarily
focuses on areas of noncompliance with the ICE NDS or the ICE Performance-Based National
Detention Standards, as applicable. The NDS apply to YCDC. In addition, ODO may focus its
inspection based on detention management information provided by ERO Headquarters and
ERO field offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at YCDC to determine compliance with current policies
and detention standards. Prior to the inspection, ODO collected and analyzed relevant
allegations and detainee information from multiple ICE databases, including the Joint Integrity
Case Management System, the ENFORCE Alien Booking Module, and the ENFORCE Alien
Removal Module. ODO also gathered facility facts and inspection-related information from
ERO Headquarters staff to prepare for the site visit at YCDC.

REPORT ORGANIZATION
This report documents inspection results, serves as an official record, and is intended to provide
ICE and detention facility management with a comprehensive evaluation of compliance with
policies and detention standards. It summarizes those NDS that ODO found deficient in at least
one aspect of the standard. ODO reports convey information to best enable prompt corrective
actions and to assist in the on-going process of incorporating best practices in nationwide
detention facility operations.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
NDS, ICE policy, or operational procedure. When possible, the report includes contextual and
quantitative information relevant to the cited standard. Deficiencies are highlighted in bold
throughout the report and are encoded sequentially according to a detention standard designator.
Comments and questions regarding the report findings should be forwarded to the Deputy
Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

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

Management & Program Analyst (Team Leader)
Management and Program Analyst
Contract Inspector
Contract Inspector
Contract Inspector
Contract Inspector

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ODO, Headquarters
ODO, Headquarters
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections

York County Detention Center
ERO Atlanta

OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed YCDC’s Chief Administrator, the ERO Assistant Field Office Director, a
Supervisory Detention and Deportation Officer, an IEA, a Deportation Officer, and various
correctional officers. All YCDC and ERO personnel described their working relationships and
morale as excellent. YCDC correctional officers stated they consistently observe ICE personnel
visiting the detainee housing units at least three times weekly, and communicating with
detainees.
The Supervisory Detention and Deportation Officer, the Deportation Officer, and the IEA all
stated ERO is adequately staffed to manage and handle the current detainee population at YCDC.
ODO was also informed the 287(g) personnel provide assistance with any matter, voluntarily.
According to the Assistant Field Office Director, although the facility is classified as an over
72-hour facility, it functions as an under 72-hour facility, due to the short detainee stays. During
this CI, only two detainees remained at the facility for more than 72 hours.

DETAINEE RELATIONS
ODO interviewed two Level III male detainees at YCDC. During the CI, ERO transferred
39 detainees to another facility in Georgia. The two detainees interviewed by ODO arrived at
YCDC two days prior to the CI. Due to their short stays, the detainees were unable to answer
many questions presented by ODO. The detainees confirmed they received personal hygiene
items, an inmate handbook, and the ICE National Detainee Handbook upon admission. The
detainees did not express any other concerns during their interviews.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 24 NDS and found YCDC fully compliant with the following
12 standards:
Admission and Release
Contraband
Detainee Classification System
Detainee Handbook1
Disciplinary Policy
Food Service
Hunger Strikes
Religious Practices
Staff-Detainee Communication
Telephone Access
Tool Control
Use of Force
As these standards were compliant at the time of the review, a synopsis for these areas was not
prepared for this report.
ODO found deficiencies in the following 12 standards:
Access to Legal Material
Detainee Grievance Procedures
Environmental Health and Safety
Key and Lock Control
Medical Care
Recreation
Security Inspections
Special Management Unit – Administrative Segregation
Special Management Unit – Disciplinary Segregation
Suicide Prevention and Intervention
Terminal Illness, Advanced Directives, and Death
Visitation
Findings for each of these standards are presented in the remainder of this report.

1

Deficiencies relating to omissions from the detainee handbook are noted under the relevant NDS that requires the
information. See Access to Legal Material (Deficiency ALM-1), and Detainee Grievance Procedures (Deficiency
DGP-1).
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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at YCDC to determine if detainees have
access to a law library, legal materials, courts, counsel, and document copying equipment to
facilitate the preparation of legal documents, in accordance with the ICE NDS. ODO reviewed
policies, procedures, and the detainee handbook, inspected the areas designated for law library
use, tested computer operations, and interviewed facility staff.
YCDC has a designated law library, which contains computers equipped with the most-recent
version of Lexis-Nexis. The law library area contains sufficient tables and chairs to facilitate
legal research and writing for detainees. Office supplies and materials are sufficiently stocked
and provided to detainees upon request. According to YCDC staff, detainees are allowed access
to the law library a minimum of five hours a week, upon request. Detainees in administrative
and disciplinary segregation have the same law library access as the general population.
The facility’s detainee handbook does not notify detainees of the scheduled hours of access to
the law library, the procedure for requesting additional time in the law library, the procedure for
requesting legal reference materials not maintained in the law library, or the procedure for
notifying a designated employee that library material is missing or damaged
(Deficiency ALM-1). Having these procedures listed in the detainee handbook facilitates and
promotes efficient use of the law library and its resources.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE NDS, Access to Legal Material, section (III)(Q)(2-6), the FOD must
ensure the detainee handbook or equivalent, shall provide detainees with the rules and
procedures governing access to legal materials, including the following information:
2. the scheduled hours of access to the law library;
3. the procedure for requesting access to the law library;
4. the procedure for requesting additional time in the law library (beyond the 5 hours per week
minimum);
5. the procedure for requesting legal reference materials not maintained in the law library; and
6. the procedure for notifying a designated employee that library material is missing or
damaged.
These policies and procedure shall also be posted in the law library along with a list of the law
library’s holdings.

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedures standard at YCDC to determine if a process
to submit formal or emergency grievances exists, and responses are provided in a timely manner,
without fear of reprisal. In addition, the review was conducted to determine if detainees have an
opportunity to appeal responses, and if accurate records are maintained, in accordance with the
ICE NDS. ODO visited housing areas, interviewed staff, and reviewed policies and procedures,
the detainee handbook, detention files, and the grievance log.
YCDC has a grievance system allowing detainees to file informal, formal, and emergency
grievances, as well as appeal grievance decisions. Grievance forms are available within the
housing units. The YCDC Unit Manager serves as the Grievance Coordinator.
A review of 15 detention files indicates YCDC staff provides each detainee with the ICE
National Detainee Handbook and a comprehensive local supplement advising detainees of the
grievance process. YCDC maintains a paper grievance logbook. An electronic version of the
grievance logbook is being planned for September 2013. The Grievance Coordinator stated there
have been no grievances filed by detainees in the past two years, due to the short duration of stay
for detainees, so ODO was unable to verify whether detainee grievances are accurately recorded
or maintained in individual detention files. The average length of stay for ICE detainees is
3.6 days.
The detainee handbook does not provide instructions for detainees to contact ICE to appeal a
grievance decision made by YCDC’s Officer in Charge, or to file a complaint about officer
misconduct directly with the Department of Homeland Security, Office of Inspector General
(Deficiency DGP-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(4)(6), the
FOD must ensure the grievance section of the detainee handbook will provide notice of the
following:
4. The procedures for contacting the INS to appeal the decision of the OIC of a CDF or an
IGSA facility.
6. The opportunity to file a complaint about officer misconduct directly with the Justice
Department.
In accordance with Change Notice National Detention Standards Staff-Detainee Communication
Standard, dated June 15, 2007, the FOD must ensure, until the detainee handbooks can be
revised during the annual update, ICE staff shall ensure that each detainee in ICE custody is
informed in writing the OIG contact information:
DHS OIG HOTLINE
Write to:
245 Murray Drive, S.E., Building 410,
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Washington, D.C. 20538
Email to:
DHSOIGHOTLINE@DHS.GOV
OR Telephone:
1-800-323-8603

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at YCDC to determine if the
facility maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility,
interviewed staff, and reviewed procedures and documentation of inspections, hazardous
chemical management, and fire prevention protocols.
ICE detainees are housed in Echo Unit, a two-level open dormitory-style housing unit with
32 beds. There are three showers on the upper level and three showers on the lower level.
Located next to the showers on each level are four commodes and four lavatories. Sanitation in
the housing unit and throughout the facility was very good.
The Training Lieutenant serves as the facility’s Safety Officer. Hazardous substances are stored
in the laundry area, food service, and maintenance area. Inspection confirmed substances in the
laundry and food service areas were inventoried and stored in accordance with the standard;
however, ODO found inventories in the maintenance area were not maintained for substances
stored in two flammables cabinets (Deficiency EH&S-1). Maintaining inventories ensures
hazardous substances are controlled and accounted for. In addition, ODO found gallon cans of
paint and small propane cylinders on open shelves and sitting on the floor
(Deficiency EH&S-2). Proper storage of flammable and combustible materials is critical to
preventing injury to staff or detainees, particularly in the event of a fire.
ODO confirmed a master index was available listing all hazardous substances in the facility;
however, it did not include locations where the substances were stored, or the required listing of
emergency telephone numbers (Deficiency EH&S-3). Identifying the locations of hazardous
substances within the master index supports accountability and efficient emergency response,
and the ready availability of emergency contact information facilitates immediate contact with
responders. ODO confirmed a master file of Material Safety Data Sheets (MSDS) was present in
the index, and MSDS were present at each location where chemicals were used and stored.
Copies of the master index and MSDS file were also available in central control.
The Safety Officer provided documentation of extensive weekly fire and safety inspections, as
well as the required monthly inspections. Documentation supports fire drills were conducted
monthly, and included drawing and testing of emergency keys. During the tour, ODO noted exit
diagrams were not present in the detainee housing area, the corridors outside the housing area,
the booking area, the laundry area, or the library (Deficiency EH&S-4). Diagrams posted
elsewhere in the facility included locations of emergency equipment and directional arrows for
traffic flow; however, they were in English, only, and did not include “You Are Here” markings
(Deficiency EH&S-5). Availability of exit diagrams in all areas of the facility, providing all
required information in English and Spanish, supports expeditious egress in the event of an
emergency.
ODO’s review of invoices confirmed completion of monthly and as-needed treatment by a local
pest control company. ODO verified the accuracy of the sharps inventory in the medical unit,
and confirmed bio-hazardous waste is removed from the facility under contract. Documentation

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of the testing and servicing of the facility’s emergency power generator was reviewed, and found
in compliance with the standard.
Detainees have access to barber services on a weekly basis. ODO was informed, because of the
lack of suitable space, barbering is conducted in an open area of the housing unit or in the
booking area (Deficiency EH&S-6). Required hair care sanitation regulations for barber
operations were not posted not in these areas (Deficiency EH&S-7). ODO observed necessary
equipment was available to ensure sanitary barber operations.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(A), the FOD
must ensure every area will maintain a running inventory of the hazardous (flammable, toxic, or
caustic) substances used and stored in that area. Inventory records will be maintained separately
for each substance, with entries for each logged on a separate card (or equivalent). That is, the
account keeping will not be chronological, but filed alphabetically, by substance (dates,
quantities, etc.).
DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(F)(4)(a)(c), the
FOD must ensure every storage cabinet will [among other things]: be constructed according to
code and securely locked at all times; and be conspicuously labeled: “Flammable-Keep Fire
Away.”
DEFICIENCY EH&S-3
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(C), the FOD
must ensure 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. Documentation of the semi-annual reviews will be maintained in the MSDS
master file. The master index will also include a comprehensive, up-to-date list of emergency
phone numbers (fire department, poison control center, etc.).
DEFICIENCY EH&S-4
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(h), the
FOD must ensure every institution will develop a fire prevention, control, and evacuation plan to
include, among other thing, the following: Conspicuously posted exit diagram conspicuously
posted for and in each area.
DEFICIENCY EH&S-5
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(5)(a-b), the
FOD must ensure, in addition to a general area diagram, the following information must be
provided on existing signs: English and Spanish instructions; and "You Are Here" markers.

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DEFICIENCY EH&S-6
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD
must ensure the [barber] operation will be located in a separate room not used for any other
purpose. The floor will be smooth, nonabsorbent and easily cleaned. Walls and ceiling will be
in good repair and painted a light color. Artificial lighting of at least 50-foot candles will be
provided. Mechanical ventilation of 5 air changes per hour will be provided if there are no
operable windows to provide fresh air. At least one lavatory will be provided. Both hot and cold
water will be available, and the hot water will be capable of maintaining a constant flow of water
between 105 degrees and 120 degrees.
DEFICIENCY EH&S-7
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(4), the FOD
must ensure each barbershop will have detailed hair care sanitation regulations posted in a
conspicuous location for the use of all hair care personnel and detainees.

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KEY AND LOCK CONTROL (K&LC)
ODO reviewed the Key and Lock Control standard at YCDC to determine if facility safety and
security is maintained by requiring keys and locks to be controlled and maintained, in
accordance with the ICE NDS. ODO observed use, accountability, and maintenance of keys;
interviewed the Assistant Chief, maintenance supervisor, and other staff; inspected emergency
keys; and reviewed policy and documentation.
The Assistant Chief is the designated staff member responsible for all the administrative duties
related to key and lock control. The written position description for the Assistant Chief does not
include the duties of key and lock control (Deficiency K&LC-1). County maintenance staff has
been certified and trained by Southern Folger Detention Equipment Company, and are
responsible for general maintenance of locks and locking devices. ODO reviewed inventories of
all keys, to include daily issue and emergency keys in the central control room, and verified they
are complete and current. ODO’s observation and review of documentation confirmed keys are
logged each time they are issued and returned by staff. ODO interviewed staff and verified they
are knowledgeable of key control procedures and the location of emergency keys. Facility key
accountability and procedures are in place for the issuance of restricted keys.
ODO conducted interviews and reviewed available documentation, and found the Assistant Chief
does not maintain records concerning locks or locking devices, and locks throughout the facility
were not included on any inventories (Deficiency K&LC-2). Maintaining inventories and
records of keys, locks, and locking devices ensures proper control and accountability. In
addition, interviews with the Assistant Chief and county maintenance staff found there is no
preventive maintenance program for the key and lock control program (Deficiency K&LC-3).
Preventive maintenance of locks in a correctional environment is essential to supporting safety
and security.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY K&LC-1
In accordance with the ICE NDS, Key and Lock Control, section (III)(A)(1), the FOD must
ensure each facility should establish the position of Security Officer. If this is impracticable, the
OIC shall assign a staff member the collateral duties of Security Officer. The Security Officer
shall have a written position description that includes duties, responsibilities, and chain of
command.
DEFICIENCY K&LC-2
In accordance with the ICE NDS, Key and Lock Control, section (III)(B)(1), the FOD must
ensure the Security Officer shall maintain inventories of all keys, locks and locking devices in
the Lock Shop.
DEFICIENCY K&LC-3
In accordance with the ICE NDS, Key and Lock Control, section (III)(B)(5), the FOD must
ensure the Security Officer shall implement a preventive maintenance program.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at YCDC to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE NDS. ODO toured the clinic, reviewed policies and procedures, verified medical staff
credentials, observed medication administration and sick call, and interviewed the Medical
Service Coordinator (MSC) and ICE staff. In addition, ODO examined 13 medical records of
detainees falling into the following categories: chronic care, detainee sick call, suspect TB, and
one suicide watch. All records were reviewed for sick call timeliness and applicable transfer
documentation. There have been no detainee deaths at YCDC.
YCDC currently holds no accreditations. Medical services at YCDC are provided by employees
of the York County Sheriff’s Office. The clinic is open from 7 am to 6 pm, five days a week.
An on-call RN reports to the facility on weekends and holidays to review intake screens and
perform TB screening. The clinic is administered on a full-time basis by the MSC, who is an
RN. Medical oversight is provided by the contract physician on-site for two hours per day on
Mondays and Thursdays, and is on-call 24 hours a day, seven days a week. Mental health
services are provided by (b)(7)e icensed master’s level social workers who alternate every other
week. These positions are augmented by (b)(7)e RNs, (b)(7)elicensed practical nurse,(b)(7)estate
certified pharmacy technician, and (b)(7)e ecords clerk. At the time of the review, one full-time
licensed practical nurse position was vacant. Dental services are provided by a local dentist onsite once monthly. ODO finds staffing sufficient to provide basic medical services to the
detainee population. ODO verified the staffing plan is reviewed annually. All professional
licenses were present and primary source verified with the issuing state boards for authentication
purposes.
In the event medical services beyond the scope of care provided by YCDC are required,
detainees are transferred to the Piedmont Medical Center in Rock Hill, approximately 10 miles
away. In cases of an emergency, the emergency response ambulance responds from the York
County rescue squad or the local fire department, both located in York.
The clinic contains two examination/treatment rooms, a one-chair dental suite, a break room, a
three-cubicle nurses’ station, a pharmacy, a supply room, a medical records clerk office, one
holding cell, one staff restroom, and two administrative offices. In addition, there are eight
medical observation rooms, two of which have negative airflow for TB isolation. Correctional
supervision is provided by detention officers who escort detainees to the clinic. There are also
designated examination rooms offering adequate privacy in the housing units. According to the
MSC, bilingual staff or a telephone interpretation service is used for language translation when
necessary.
YCDC officers in the booking area conduct the medical intake screening. The officers, who are
members of the Sheriff’s Department staff and part of the ICE 287(g) program, are permanently
assigned to the intake area. ODO verified the officers receive specialized training conducted by
the Security Commander, which includes completion of the intake medical and mental health
screenings. During interviews of the booking officers on duty during the review, ODO found
they possessed a strong command of the principles for effective screening, and awareness of
answers and behaviors necessitating immediate referral to medical staff. Review of 13 screening
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forms found all were thoroughly completed, and information and observations were well
documented. Nursing staff review all intake screen questionnaires upon completion or, if
detainees are admitted after normal clinic hours, the next day. Documentation of review and
appropriate follow-up was noted.
Health appraisals at YCDC are conducted by the physician. Of the 13 medical records reviewed,
ODO found only two where the detainees remained at YCDC for 14 days or more. ODO
verified the health appraisals included hands-on physical examinations and dental screenings;
however, in one case the health appraisal was conducted 18 days following the detainee’s arrival,
and in the second, no health appraisal was performed during the detainee’s 19-day stay at YCDC
(Deficiency MC-1).
During review of records for documentation of required TB testing, ODO found two of
13 detainees did not undergo screening by way of PPD or CXR upon admission
(Deficiency MC-2). Both were transferred to YCDC from other facilities, and transfer
documentation indicated one had a previous CXR in 2008 and the other in 2011, both negative.
The detainees were transferred from YCDC after five days, without TB clearance. The MSC
stated TB screening was not conducted at YCDC because it was thought the previous CXRs
remained valid. ODO notes this stands in conflict with the facility’s policy, which states
rescreening is required if the last results were over a year old. Medical transfer information
prepared by YCDC upon the detainees’ release documented the dates of the previous negative
CXRs.
Transfer documentation on a detainee admitted to YCDC on March 5, 2013, indicated he had a
positive PPD at the sending facility on February 27, 2013, six days earlier. There was no
documentation a CXR was completed by the sending facility. Upon arrival at YCDC, screening
found the detainee was exhibiting no symptoms of TB, resulting in clearance for general
population housing despite the positive PPD (Deficiency MC-3). A positive PPD is a symptom
requiring isolation pending TB clearance, in accordance with the standard. He remained in
general population overnight, and then was transferred to a single cell in the facility’s
classification unit on March 6, 2013. The same day, ICE notified the facility the detainee was to
be transferred on March 7, 2013. According to the MSC, though ICE was informed the detainee
had not yet been cleared for TB; YCDC was advised the transfer would be completed. Transfer
information prepared by YCDC documented the positive PPD and necessity to complete a CXR.
ODO notes the detainee was transferred to and from YCDC in a vehicle with other detainees and
staff without a surgical mask, as called for under Center for Disease Control guidelines.
In another two cases, the detainees did not receive follow-up CXRs for 96 hours and 15 days,
respectively, following positive PPDs (Deficiency MC-4). ODO notes these detainees had no
symptoms of TB upon admission, and were housed in single cells until cleared; however, the
time awaiting clearance was protracted in violation of the requirement for prompt evaluation.
ODO further notes Center for Disease Control guidelines call for CXRs within 72 hours
following positive PPD tests.
During discussion of the deficiencies related to TB testing, the MSC stated the facility is
challenged to complete CXRs before detainees are transferred. YCDC does not have a mobile
x-ray service, so detainees are transported to an off-site facility. According to the MSC,
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correctional officer availability may delay transport, and the vendor used until recently did not
report CXR results for up to a week. The MSC stated it is anticipated the new vendor will report
results more quickly. ODO recommends the facility and ERO take necessary actions to ensure
detainees receive prompt TB clearances prior to transfer.
Detainees request healthcare services by completing written medical requests forms printed in
English and Spanish. ODO was informed these forms are available in the housing units;
however, during the tour, ODO found no sick call request slips were on-hand in one unit. The
MSC promptly remedied the situation by supplying request forms to the housing area. ODO
learned completed sick call requests are given to correctional staff for entry in the electronic Jail
Management System and transmission to nursing staff (Deficiency MC-5). The same
procedures are followed in the SMUs. Involvement of correctional officers in this process
violates patient confidentiality, because medical information is documented on the forms.
Further, access to medical care may be impeded if detainees are reluctant to request services
through correctional staff. Medical staff retrieves and triages the electronic requests once daily,
five days a week, to determine priority of care. ODO was informed, in addition to the written
sick call request process, nursing staff on medication rounds will frequently entertain “walk-up”
requests and address the detainee’s complaint. A sick call request is completed to document the
encounter.
YCDC has an electronic medical record system. According to the MSC, a facility administrator
has unrestricted access to the electronic medical record. ODO cites this as a second violation of
patient confidentiality (Previous Deficiency MC-5). Access by non-medical staff should be on
a need-to-know basis, for purposes related to oversight of delivery of healthcare services in
specific cases.
YCDC staff stated detainees are not charged co-payments or fees, yet the detainee handbook
states otherwise. To ensure this information does not deter detainees from seeking healthcare,
ODO recommends YCDC management modify the detainee handbook to specify that detainees
are not charged for medical services.
Medications are distributed by nursing staff and documented on Medication Administration
Records during hours the facility has nursing coverage. Correctional staff distributes
medications when medical staff is not on duty, documenting distribution on a MAL. Review
found the MAL is not the same as the Medication Administration Records, and does not
adequately document distribution of medications in accordance with provider orders
(Deficiency MC-6). The MAL documents the date and time the detainee was given all
prescribed medications, the detainee signature, and the officer’s signature; however, it does not
itemize the medications or document dosage. ODO was advised a revised MAL is being
developed to itemize medications. ODO further notes the lesson plan used for training of
officers, conducted by the certified pharmacy technician, states the officer may allow detainees
to take less of the medication, but never more. ODO notes, should a detainee be allowed to take
less of a prescribed medication, distribution would not be in accordance with provider orders.
Because the current MAL does not provide medication-specific information, ODO was unable to
determine if there were instances in which a detainee was given less of a medication than
ordered.

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Facility healthcare and correctional staff are required to maintain current certification in
cardiopulmonary resuscitation, first aid, and use of an automated external defibrillator. ODO’s
review of training records for all healthcare and(b)(7)erandomly-selected correctional staff found
(b)(7)emedical and(b)(7)e correctional staff member did not have current certifications
(Deficiency MC-7). The MSC and training manager stated arrangements have been made for
the(b)(7)e staff members to complete training.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure the health
care provider of each facility will conduct a health appraisal and physical examination on each
detainee within 14 days of arrival at the facility.
DEFICIENCY MC-2
In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure all new
arrivals shall receive TB screening by PPD (mantoux method) or chest x-ray.
DEFICIENCY MC-3
In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure detainees
with symptoms suggestive of TB will be placed in an isolation room and promptly evaluated for
TB disease.
DEFICIENCY MC-4
In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure detainees
with symptoms suggestive of TB will be placed in an isolation room and promptly evaluated for
TB disease.
DEFICIENCY MC-5
In accordance with the ICE NDS, Medical Care, section (III)(M), the FOD must ensure all
medical providers shall protect the privacy of detainees' medical information to the extent
possible while permitting the exchange of health information required to fulfill program
responsibilities and to provide for the wellbeing of detainees.
DEFICIENCY MC-6
In accordance with the ICE NDS, Medical Care, section (III)(I), the FOD must ensure
distribution of medication will be according to the specific instructions and procedures
established by the health care provider. Officers will keep written records of all medication
given to detainees.
DEFICIENCY MC-7
In accordance with the ICE NDS, Medical Care, section (III)(H)(2), the FOD must ensure
detention staff will be trained to respond to health-related emergencies within a 4-minute
response time. This training will be provided by a responsible medical authority in cooperation
with the OIC and will include the following [among other things]: The administration of first aid
and cardiopulmonary resuscitation (CPR).

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RECREATION (R)
ODO reviewed the Recreation standard at YCDC to determine if detainees are provided access to
recreational programs and activities within the constraints of a safe and secure environment in
accordance with the ICE NDS. ODO inspected the recreation areas, reviewed policies, and
interviewed staff and detainees.
A recreation yard is directly adjacent to the detainee housing unit. Detainees have outdoor
recreation privileges a minimum of one hour a day, seven days a week. ODO was informed, and
observed, access to the yard is generally allowed during dayroom hours. The housing unit
dayroom has various board games and a stationary exercise station for pull-ups, chin-ups, and
sit-ups. Recreation privileges are addressed in the detainee handbook. Detainees in the SMU
receive a minimum of one hour a day of recreation, seven days a week, in a yard adjacent to the
SMU.
The facility does not have a designated individual responsible for recreation (Deficiency R-1).
According to staff, the housing unit correctional officers coordinate and oversee the daily
recreational activities of detainees housed in general population and the SMU. Designating
overall responsibility for recreational activities ensures opportunities are offered and documented
consistently.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY R-1
In accordance with the ICE NDS, Recreation, section (III)(F), the FOD must ensure all facilities
shall have an individual responsible for the development and oversight of the recreation program.

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SECURITY INSPECTIONS (SI)
ODO reviewed the Security Inspection standard at YCDC to determine if facility security is
maintained, and events posing a risk of harm are prevented, in accordance with the ICE NDS.
ODO reviewed logbooks, policies, and post orders; observed vehicle sally port operations,
perimeter security, and entrance procedures; and interviewed staff.
YCDC has a comprehensive security inspection system, which includes all areas of the facility.
The facility’s front entrance has a sally port with electronic interlocking doors to prevent
unauthorized entry or exit. Procedures have been established for issuing visitor passes to all
visitors.
YCDC policy does not include procedures for documenting vehicles entering the facility.
According to policy and as observed by ODO, the control center officer monitors vehicular
traffic; however, documentation of vehicles entering or leaving the facility is not maintained
(Deficiency SI-1). Documenting vehicular traffic provides a permanent record of access to the
secure perimeter, supporting facility security.
The facility’s SMU has a sally port entrance with doors controlled electronically by the master
control center officer. Documentation supports regular searches of the facility are conducted.
All housing units are inspected daily. The perimeter fence is checked at least once on each shift.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SI-1
In accordance with the ICE NDS, Security Inspections, section (III)(D)(3)(1)(a), the FOD must
ensure facilities shall have policies and procedures to control and document all vehicular traffic
entering the facility.

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SPECIAL MANAGEMENT UNIT (SMU)
Administrative Segregation
ODO reviewed the Special Management Unit – Administrative Segregation standard at YCDC to
determine if the facility has procedures in place to temporarily segregate detainees for
administrative reasons, in accordance with the ICE NDS. ODO toured the SMU, interviewed
staff, and reviewed policies and the electronic log system.
YCDC’s SMU for administrative segregation consists of 16 single cells, each with a bed, toilet,
and sink attached to the wall. There is a separate SMU with the same configuration for
disciplinary segregation. ODO’s inspection found the units were well ventilated, adequately lit,
maintained at an appropriate temperature, and appearing clean and sanitary. There were no ICE
detainees assigned to administrative segregation at the time of the review. According to staff, a
detainee was most recently placed in administrative segregation on February 4, 2013, pending a
disciplinary hearing. ODO confirmed an administrative segregation order was issued, and a
medical assessment was completed prior to placement in the SMU. The detainee received a
disciplinary hearing within 24 hours, and was transferred to disciplinary segregation. A review
of the facility’s electronic log found no other detainees were placed in administrative segregation
in the last six months.
The facility maintains an electronic log to record placements in the SMU and document
provision of services. ODO’s review of the log and facility policy confirmed they address all
requirements of the NDS with respect to living conditions and privileges, including meals, law
library, recreation, and visitation. However, healthcare professionals only visit the SMU when a
detainee makes a request or to administer medication (Deficiency SMU AS-1). Regular visits by
a medical professional at least three times a week ensures medical and mental health concerns
are identified and addressed.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU AS-1
In accordance with the ICE NDS, Special Management Unit (Administrative Segregation),
section (III)(D)(12), the FOD must ensure a medical professional shall visit every detainee in
administrative segregation at least three times a week. In addition to the direct supervision
afforded by the unit officer, the shift supervisor shall see each segregated detainee daily,
including weekends and holidays.

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SPECIAL MANAGEMENT UNIT (SMU)
Disciplinary Segregation
ODO reviewed the Special Management Unit – Disciplinary Segregation standard at YCDC to
determine if the facility has procedures in place to temporarily segregate detainees for
disciplinary reasons, in accordance with the ICE NDS. ODO toured the SMU, interviewed staff,
and reviewed policies and the electronic log system.
YCDC’s SMU for disciplinary segregation has 16 single cells, each with a bed, toilet, and sink
attached to the wall. There is a separate SMU with the same configuration for administrative
segregation. ODO’s inspection found the units were well ventilated, adequately lit, maintained
at an appropriate temperature, and appeared clean and sanitary. There were no ICE detainees
assigned to disciplinary segregation at the time of the review. According to staff, a detainee was
most recently sanctioned with disciplinary segregation for a term of seven days on
February 5, 2013. He was transferred to another facility on February 7, 2013. A review of
documentation confirmed a disciplinary segregation order was issued. A review of the facility’s
electronic log found no other detainees were placed in disciplinary segregation in the last six
months.
The facility maintains an electronic log to record placements in the SMU and document
provision of services. ODO’s review of the log and facility policy confirmed they address all
requirements of the NDS with respect to living conditions and privileges, including meals, law
library, and visitation. However, healthcare professionals only visit the SMU when a detainee
makes a request or to administer medication (Deficiency SMU DS-1). Regular visits by a
medical professional at least three times a week ensures medical and mental health concerns are
identified and addressed.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU DS-1
In accordance with the ICE NDS, Special Management Unit (Disciplinary Segregation),
section (III)(D)(16), the FOD must ensure a medical professional shall visit every detainee in
administrative[sic] segregation at least three times a week. In addition to the direct supervision
afforded by the unit officer, the shift supervisor shall see each segregation detainee daily,
including weekends and holidays.

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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at YCDC to determine if the
health and well-being of detainees are protected by training staff in effective methods of suicide
prevention, in accordance with the ICE NDS. ODO inspected the suicide watch cells,
interviewed medical and training staff, and reviewed suicide prevention policies, the training
curriculum, and staff training records.
Facility policy requires all staff to receive initial and ongoing suicide prevention training, which
includes the identification of suicide risk factors, recognizing the signs of suicidal thinking and
behavior, referral procedures, suicide prevention techniques, and responding to an in-progress
suicide attempt. YCDC uses a curriculum covering these elements and includes a video
produced by “Lock-up USA,” presented by the training manager. Review of all medical and
b)(7)erandomly-selected detention staff training files confirmed completion of initial and ongoing
suicide prevention training.
ODO verified detainees are screened for suicide risk during the intake process. Detainees on
close-observation suicide watch are housed in an observation cell located in the clinic.
Inspection confirmed the cells are free from protrusions or objects that could assist in a suicide
attempt. Each has a camera, which is monitored in three places: central control, at the
observation area desk, and in the booking area.
ODO was advised there have been no detainee suicides at YCDC. There have been no suicide
attempts and one suicide watch in the past year. Review of the medical record confirmed suicide
watch management is consistent with NDS requirements, with one exception: the detainee was
released from suicide watch status by an RN, without written authorization from the physician
(Deficiency SP&I-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with the ICE NDS, Suicide Prevention and Intervention, section (III)(C), the FOD
must ensure a detainee formerly under a suicide watch may be returned to general population,
upon written authorization from the CD.

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TERMINAL ILLNESS, ADVANCE DIRECTIVES, AND DEATH (TIADD)
ODO reviewed the Terminal Illness, Advance Directives, and Death standard, to include Do Not
Resuscitate orders, and organ donations, at YCDC to determine if the facility’s policies and
practices are in accordance with the ICE NDS. ODO interviewed medical staff, and reviewed
policies and procedures.
ODO was informed there have been no terminally ill detainees or detainee deaths at YCDC. A
review of policies confirmed they address the requirements of the NDS, with one exception: they
do not include written procedures for making autopsy arrangements (Deficiency TIADD-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TIAAD-1
In accordance with the ICE NDS, Terminal Illness, Advance Directives, and Death,
section (III)(J), the FOD must ensure, with the Chaplain’s assistance, the OIC shall develop and
implement written procedures for making autopsy arrangements.

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VISITATION (V)
ODO reviewed the Visitation standard at YCDC to determine if authorized persons, including
legal and media representatives, are able to visit detainees within security and operational
constraints, in accordance with the ICE NDS. ODO reviewed local policy and the detainee
handbook, inspected the visiting area, and interviewed staff and detainees.
The facility uses a non-contact visitation system. Visitors are required to present photo
identification at the main entrance desk. After verification of identity and clearing a metal
detector, visitors proceed through a corridor to the visiting area, which adjoins the housing units.
Detainees, when notified of a visit, proceed to one of four booths on the housing unit side of the
visiting area. There is secure separation between the visitor and detainee booths. Written
visiting procedures, including a schedule and hours of visitation, are posted in the lobby’s main
entrance area. Detainees are notified of visitation rules and hours by way of the detainee
handbook and postings in the housing unit.
Detainees may receive a one-hour visit each week on a designated day. Special visits may be
approved by the Jail Administrator in consultation with the IEA. ODO was advised, there have
been no requests for special visits due to the short length of stay at YCDC. Legal visits are
permitted seven days per week, and take place in the same non-contact booths used for visiting.
General visitors and legal representatives sign in and out of the same logbook (Deficiency V-1).
Maintaining separate logs facilitates easy retrieval of documentation of legal visits.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDING
DEFICIENCY V-1
In accordance with the ICE NDS, Visitation, section (III)(C), the FOD must ensure the facility
shall maintain a log of all general visitors, and a separate log of legal visitors.

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