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
Philadelphia Field Office
York County Prison
York, Pennsylvania

April 17 – 19, 2012

FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law
enforcement, management, and employee information. It has been written for the express use of the
Department of Homeland Security to identify and correct management and operational deficiencies. In
reference to ICE Policy 17006.1, issued 09/22/05; any disclosure, dissemination, or reproduction of this
document, or any segments thereof, is prohibited without the approval of the Assistant Director, Office of
Professional Responsibility.

COMPLIANCE INSPECTION
YORK COUNTY PRISON
PHILADELPHIA FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................5
Inspection Team Members ...................................................................................................5
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................6
Detainee Relations ...............................................................................................................6
ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................8
Detainee Handbook ..............................................................................................................9
Environmental Health and Safety ......................................................................................10
Facility Security and Control .............................................................................................13
Food Service ......................................................................................................................15
Funds and Personal Property .............................................................................................17
Grievance System ..............................................................................................................19
Key and Lock Control........................................................................................................22
Law Libraries and Legal Material......................................................................................23
Medical Care ......................................................................................................................24
Personal Hygiene ...............................................................................................................26
Sexual Abuse and Assault Prevention and Intervention ....................................................28
Staff-Detainee Communication .........................................................................................29
Suicide Prevention and Intervention ..................................................................................31

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the York County Prison (YCP) in York,
Pennsylvania, from April 17 - 19, 2012. YCP, which opened in 1979, is owned and operated by
the County of York. U.S. Immigration and Customs Enforcement (ICE), Office of Enforcement
and Removal Operations (ERO) began housing detainees at YCP in 1998. In September 2011,
YCP signed a new Intergovernmental Service Agreement (IGSA) with ICE to perform under the
2008 Performance Based National Detention Standards (PBNDS). Male and female detainees of
all security classification levels (Level I - lowest threat; Level II - medium threat; Level III highest threat) are detained at the facility for periods in excess of 72 hours. The 650,000 square
foot facility has a total capacity of 2,522, with no specified number dedicated to ICE detainees.
Of the 2,522 beds, 2,235 are designated for males, and 287 are allocated for females. The
facility can house as many ICE detainees as the number of available unassigned beds. At the
time of the CI, YCP housed 788 male ICE detainees (464 Level I; 243 Level II; 81 Level III),
and 34 female ICE detainees (23 Level I; 6 Level II; and 5 Level III). The average length of stay
for detainees is 59 days. The average daily detainee population is 800. Additional bed space at
YCP is utilized for male and female prisoners who have committed criminal offenses in York
County. Food service is operated and supervised by York County employees. Medical care is
provided by contractor PrimeCare Medical, Inc. and the ICE Health Service Corps (IHSC). YCP
holds accreditation from the National Commission on Correctional Healthcare (NCCHC).
In 1999, YCP added two Immigration Courtrooms, office space for Immigration Court
administration, administrative space for detention and litigation personnel, and space dedicated
for secure storage of property. In 2006, additional office space and beds were added to support
the Philadelphia Air Transport Hub (PATH) initiative, which began in 2008 to facilitate and
expedite detainee removal by providing a centralized transportation hub. In 2010, a third
Courtroom was added to the facility for ICE. YCP also provides support for the Executive
Office for Immigration Review, repatriation flights coordinated by ICE Air Operations, and
video teleconferencing, which provides access to Immigration Judges in remote locations.
The ICE, Office of Enforcement and Removal Operations (ERO), Field Office Director,
Philadelphia, Pennsylvania (FOD/Philadelphia), is responsible for ensuring facility compliance
with ICE policies and the PBNDS. There are(b)(7)eAssistant Field Office Directors (AFOD)
located onsite at YCP. One AFOD is responsible for oversight of detention, transportation, and
compliance inspections; the other AFOD is responsible for oversight of case management and
travel. Additional onsite supervisory ERO staff is comprised of(b)(7)e Supervisory Detention and
Deportation Officers (SDDO), and (b)(7)e Supervisory Immigration Enforcement Agents (SIEA).
Non-supervisory ICE staff is comprised of(b)(7)eDeportation Officers (DO),(b)(7)eImmigration
Enforcement Agents (IEA), and(b)(7)eEnforcement and Removal Assistants (ERA). Currently,
there is no ERO Detention Services Manager (DSM) assigned to YCP. The DSM position is
vacant, and a job announcement is planned. In the interim, a Supervisory DSM is covering YCP
until the vacancy is filled.
The total number of non-ICE staff employed at YCP is (b)(7)e The Warden is the highest ranking
county official and is responsible for oversight of daily operations. Supervisory staff includes
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Deputy Wardens(b)(7)eCaptains, and(b)(7)eLieutenants. Non-supervisory staff is composed of
(b)(7)e male and(b)(7)efemale Corrections Officers (CO). Kitchen cooks, maintenance workers, and
records clerks account for the remaining non-supervisory, non-corrections facility staff.
(b)(7)e

The medical clinic is open 24 hours a day, seven days a week and is managed by a Health
Services Administrator (HSA). Medical oversight is provided by the Medical Director. A
physician,(b)(7)efull-time Physician Assistants (PA), and (b)(7)epart-time PA, share on-call
coverage. Additional staff includes an Assistant HSA, a Director of Nursing (DON), an
Assistant DON, an Infection Control Nurse, a pharmacy technician, and(b)(7)e administrative staff.
(b)(7)e part-time dentists, a dental assistant, and an oral surgeon deliver onsite dental care. Mental
health services are provided by a psychiatrist, a psychologist,(b)(7)emental health counselors, and
(b)(7)e Licensed Practical Nurses (LPN). These positions are augmented by a complement of(b)(7)e
registered nurses (RN),(b)(7)eLPNs (b)(7)e emergency medical technician, and(b)(7)eertified medical
assistants. ODO finds medical staffing at YCP sufficient to meet the basic healthcare needs of
all detainees.
In March 2009, the OPR Detention Facilities Inspection Group (DFIG), predecessor to ODO,
conducted a Quality Assurance Review (QAR) of YCP and reviewed a total of 26 ICE National
Detention Standards (NDS). During the QAR, the DFIG identified 60 deficiencies in 17
standards. The remaining nine standards reviewed were found to be fully compliant.
In April 2010, ODO conducted a Follow-up Inspection of YCP to ascertain whether the facility
had addressed the deficiencies noted in the 2009 QAR. Reviewers documented 13 (22 %)
repeated deficiencies in eight of the NDS reviewed.
In October 2011, the ERO Detention Standards Compliance Unit (DSCU) contractors, MGT of
America, Inc., conducted a Compliance Review of the ICE NDS at YCP. The facility received
an overall rating of “Acceptable.”
During this CI, ODO reviewed a total of 18 PBNDS. Five standards were found to be fully
compliant; 36 deficiencies were found in the remaining 13 standards: Detainee Handbook (1
deficiency), Environmental Health and Safety (7), Facility and Security Control (4), Food
Service (6), Funds and Personal Property (2), Grievance System (5), Key and Lock Control (1),
Law Libraries and Legal Materials (1), Medical Care (2), Personal Hygiene (3), Sexual Abuse
and Assault Prevention and Intervention (1), Staff-Detainee Communication (2), and Suicide
Prevention and Intervention (1).
This report details all deficiencies and refers to specific, relevant sections of the ICE PBNDS.
OPR will provide ERO a copy of the report to assist in developing corrective actions to resolve
the 36 identified deficiencies. On April 19, 2012, ODO conducted a closeout briefing with YCP
and ERO management at the conclusion of the inspection to discuss deficiencies requiring
immediate attention. Overall, ODO found a majority of the 36 deficiencies identified were
minor, with minimal impact regarding life-safety issues and operational readiness.
In the area of Environmental Health and Safety, “You Are Here” markers on exit diagrams are
inaccurate and incorrectly labeled, potentially preventing the safe and expeditious exit of staff
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and detainees during an emergency. Under Facility Security and Control, vehicles departing the
facility are not searched prior to exiting the facility, which potentially facilitates the escape of
detainees. ODO also noted the facility serves a food loaf to detainees placed in disciplinary
segregation instead of a regular meal. Food Loaf refers to a single food item that replaces the
normal menu. It is nutritionally adequate, but is intended to serve behavior modification
purposes for detainees who pose disciplinary problems. According to the PBNDS, food rations
shall not be reduced or changed as a disciplinary tool.
Not all detainees received a physical examination within 14 days of admission to the facility.
Medical grievances are not delivered directly to medical staff for processing, and medical
personnel do not act within five working days of receipt to provide detainees with written
responses to medical grievances.
The initial issuance of basic hygiene items is free of charge to all detainees, but detainees are
required to purchase toothpaste, shampoo, and deodorant using personal funds to replenish these
basic hygiene items. Detainees determined by YCP management to be indigent receive
replenishment of these basic hygiene items free of charge. YCP management defines an indigent
detainee as one having an account balance of less than $15.00 for three consecutive weeks.
ODO cited this as a deficiency under the Personal Hygiene NDS. Additionally, a memorandum
written by Kevin Rooney, Acting Commissioner, Immigration and Naturalization Service (INS),
to all INS Regional Directors and Administrative Center Directors, dated May 18, 2001, states
that detainees may not be charged for basic hygiene items, such as soap, shampoo, toothpaste,
and shaving cream. This precludes charging detainees for replenishment of basic hygiene
products.
Staff-detainee communication documents demonstrate that ERO officers consistently visit
detainees in their housing units each week; however, ODO found that the majority of Facility
Liaison Visit Checklists documenting these visits were incomplete with required fields on the
form left blank.
Since transitioning from the NDS to the PBNDS in October 2011, YCP has processed a total of
567 detainee grievances. Of the 567 grievances, 108 (19%) were medical grievances, 99 (17%)
pertained to the facility mail room, 11 (2%) were related to food service, and four (1%) pertained
to use of force. The remaining 345 (61%) grievances were classified as “general” grievances.
General grievances relate to issues such as access to law libraries and legal materials, detainee
funds and personal property, religious services, classification system, personal hygiene,
recreation, and visitation.
Detainees can appeal grievance decisions to ERO. Detainees also have the option to appeal
grievance decisions to the York County Board of Commissioners for review by the County
Solicitor. If a detainee is dissatisfied with the decision of the County Solicitor, the grievance
may be further appealed to the York County Prison Board. ODO recognizes this system of
appeals to be a best practice, because it provides detainees a clear, impartial appeals process.
During this inspection, there were 14 male detainees in disciplinary segregation. No detainees
were in administrative segregation, and one detainee was in protective custody. No female
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detainees were in segregation at the time of the inspection. ODO interviewed five randomly
selected male detainees in disciplinary segregation; all stated that access to the law library, legal
visitation, and telephones is granted subsequent to submission of a written request, and
recreation occurs five times a week with no request required. Detainees in protective custody are
not required to submit written requests.
A state of the art electronic medical record (EMR) system tracks medical information from the
point of intake. This ensures continuity of care for chronic patients. When a detainee is
admitted, the EMR automatically creates an initial chronic care appointment in addition to
regularly scheduled follow-up appointments. ODO cites this as a best practice.
To assure continuity of care, the PBNDS require a medical/psychiatric alert for any detainee
whose condition requires clearance by medical staff prior to release or transfer. Designated staff
created a spreadsheet listing all detainees for whom an alert is required for medical reasons, and
copies are provided to ICE, IHSC, and YCP personnel. ODO cites this as a best practice,
because it assures all interested parties are aware of detainees with chronic medical conditions.
ODO reviewed 30 detainee medical records and verified that all detainees had undergone
screening for suicide risk during intake processing. The form is comprehensive and utilizes a
point system to apply values to indicators of suicide risk, requiring assignment to suicide watch
for a score of eight or higher. There were 20 documented suicide watches between February
2012 and the inspection, a high number explained by the effectiveness of the screening form in
identifying detainees at risk for suicide. The HSA stated that detainees are placed on suicide
watch if they do not answer questions on the screening form. The HSA explained that an
accurate assessment of suicide risk cannot be made if questions are not answered; therefore, YCP
exercises caution and places detainees on suicide watch until the screening process can be
completed in its entirety, and eligible detainees are cleared for placement in the general
population. ODO considers the use of the Intake Suicide Screening form to be a best practice,
because it allows the facility to detect or diagnose potential suicide risks at an early stage of
detention.
Members of the YCP emergency response team (ERT) wear helmets equipped with video
cameras during calculated use of force (UOF) incidents. This practice provides superior video
recording of UOF incidents since it captures what participating team members see from different
angles rather than from a single vantage point using one camera. Recorded audio is clear and
easy to understand. ODO considers the use of the helmet cameras to be a best practice, because
it enhances the ability of After-Action Review Teams to accurately determine whether ERT
members complied with applicable UOF policies.

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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 PBNDS, as applicable. The
PBNDS apply to YCP. In addition, ODO may focus its inspection based on detention
management information provided by the ERO Headquarters (HQ) and ERO field offices, and on
issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at YCP 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 (JICMS), the ENFORCE Alien Booking Module (EABM), and the
ENFORCE Alien Removal Module (EARM). ODO also gathered facility facts and inspectionrelated information from ERO HQ staff to prepare for the site visit at YCP.

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 PBNDS 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 classifies program issues into one of two categories: deficiencies and areas of concern.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
PBNDS, ICE policy, or operational procedure. OPR defines an area of concern as something
that may lead to or risk a violation of the PBNDS, 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

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Special Agent (Team Leader)
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

5

ODO, San Diego
ODO, Phoenix
ODO, Phoenix
Creative Corrections
Creative Corrections
Creative Corrections

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the Warden, the Deputy Warden of Operations, the Deputy Warden of
Treatment, the AFOD of Detention, and the SDDO of Detention Standards and Inspection.
During the interviews, all personnel from YCP and ERO stated that the working relationship
between YCP and ERO officers is excellent and morale among YCP and ERO staff is high.
The AFOD and the SDDO stated that ERO is understaffed to manage and handle the current
detainee population at YCP. The AFOD stated there are vacancies at YCP for (b)(7)eSIEA
positions,(b)(7)eDO positions, and (b)(7)e IEA positions. The SDDO stated that the addition of (b)(7)e
DO positions, (b)(7)e IEA positions, and (b)(7)eERA position at YCP are required to manage the
current detainee population at the facility. The AFOD and the SDDO stated that more IDENT
machines and computers (laptops and desktops) are needed to assist ERO staff at YCP. The
Warden and both Deputy Wardens stated that YCP is adequately staffed to manage and handle
the current detainee population at the facility.

DETAINEE RELATIONS
ODO interviewed 37 randomly selected male ICE detainees and two randomly selected female
ICE detainees to assess the overall living and detention conditions at YCP. ODO received no
complaints concerning access to the law library and legal materials, recreation, telephones, or
religious services.
All male and female detainees complained that personal hygiene items such as toothpaste,
toothbrushes, deodorant, and shampoo, are not replenished by the facility once these items run
out. YCP staff confirmed detainees are required to purchase these items from their accounts to
replenish them. An exception is made for detainees determined by YCP management to be
indigent. YCP management defines an indigent detainee as one having an account balance of
less than $15.00 for three consecutive weeks. ODO cited this as a deficiency under the Personal
Hygiene PBNDS. Additionally, a memorandum written by Kevin Rooney, Acting
Commissioner, Immigration and Naturalization Service (INS), to all INS Regional Directors and
Administrative Center Directors, dated May 18, 2001, states that detainees may not be charged
for basic hygiene items, such as soap, shampoo, toothpaste, and shaving cream.
Twenty-four (65%) of 37 male detainees and both female detainees complained that medical
staff takes too long to respond to sick call requests, but only four (11%) of the male detainees
provided details to support their claims. Follow-up on the complaints of these four detainees,
determined that three of the four detainees provided information that was not supported by
clinical records. The fourth detainee had requested assistance with a hearing impairment. A
Treatment Authorization Request was approved for this detainee. Medical staff at YCP stated
that audiologists are scarce in the area, and scheduling is difficult. An appointment with an
audiologist is scheduled for August 2012. This was the first available appointment. ODO
confirmed that this medical request was processed and responded to in a timely manner under
the current circumstances at YCP.
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No detainees complained about the quality of the food service, but nine (24%) out of 37 male
detainees stated that food portions are too small. On April 11, 2012, a registered dietician
completed a comprehensive inspection of the food service at YCP and concluded that the menus
meet or exceed the caloric level required by the Reference Dietary Intake. YCP serves nine
different menus in order to accommodate medical and religious needs.
Thirteen (35%) male detainees stated they were familiar with the grievance process and felt
grievances were handled fairly and expeditiously; however, four (11%) male detainees claimed
they did not know how to obtain grievance forms. ODO verified that grievance forms are readily
accessible in all housing areas.

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ICE PERFORMANCE BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 PBNDS and found YCP fully compliant with the following five
standards:
Classification System
Hold Rooms in Detention Facilities
Special Management Units
Telephone Access
Use of Force and Restraints
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 13 standards:
Detainee Handbook
Environmental Health and Safety
Facility and Security Control
Food Service
Funds and Personal Property
Grievance System
Key and Lock Control
Law Libraries and Legal Material
Medical Care
Personal Hygiene
Sexual Abuse and Assault Prevention and Intervention
Staff-Detainee Communication
Suicide Prevention and Intervention
Findings for each of these standards are presented in the remainder of this report.

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DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at YCP to determine if the facility provides
each detainee with a handbook, written in English and any other languages spoken by a
significant number of detainees housed at the facility, describing the facility’s rules and
sanctions, disciplinary system, mail and visiting procedures, grievance system, services,
programs, and medical care, in accordance with the ICE PBNDS. ODO interviewed staff and
detainees and reviewed the YCP detainee handbook.
Upon admission to YCP, all detainees are issued a copy of the ICE National Detainee Handbook
and the YCP detainee handbook. Receipt of the handbooks is acknowledged in writing by
signing and dating the Orientation and Intake Acknowledgement Form. The signed Orientation
and Intake Acknowledgement Form is maintained in the detainee detention file. Both the ICE
National Detainee Handbook and the YCP detainee handbook are available in English and
Spanish. A committee consisting of all (b)(7)e Deputy Wardens, the Grievance Coordinator, the
Grievance Supervisor, and the Treatment Supervisor reviews the YCP detainee handbook
multiple times each year to ensure it is current and up-to-date. According to the Deputy Warden
of Treatment, the YCP detainee handbook was last revised by the committee on August 15,
2011.
The YCP detainee handbook does not notify detainees of the procedures for requesting
interpretive services for essential communication (Deficiency DH-1).
NOTE: Additional handbook omissions are reported as Deficiencies F&PP-1 and GS-2.

STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE PBNDS, Detainee Handbook, section (V)(2), the FOD must ensure
while all applicable topics from the ICE National Detainee Handbook must be addressed, it is
particularly important that each local supplement notify each detainee of:


Procedures for requesting interpretive services for essential communication.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at YCP 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 PBNDS. ODO toured the
facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous
chemical management, generator testing, and fire drills.
ODO verified YCP maintains a master index of hazardous substances and Material Safety Data
Sheets. Procedures for handling caustic and toxic substances are in place. Hazardous substances
are controlled, and when necessary, personal safety equipment is worn. ODO inspected all areas
of the facility and found chemicals in secondary containers (spray bottles) were appropriately
labeled, accounted for, and controlled. The facility was observed to be clean and orderly. All
areas inspected maintained an appropriate level of sanitation.
ODO confirmed that annual tests of drinking and wastewater had not been conducted
(Deficiency EH&S-1).
YCP has four emergency generators. The combined capacity of the generators can allow the
facility to operate for four weeks on generator power, if necessary. YCP inspects and tests the
generators on a weekly basis for 15 minutes and contracts with an external generator company to
conduct bi-annual load testing and maintenance inspections (Deficiency EH&S-2). ODO
reviewed documentation and confirmed internal and external testing is conducted; however, the
duration of the generator tests does not meet the time requirement in the PBNDS. The PBNDS
requires bi-weekly testing for a minimum of one hour. Load testing must be conducted on a
quarterly basis. Regular testing for one hour ensures there is sufficient time for a generator to
reach operating temperature, verifies the ability of the engine to provide the required power over
the full 60-minute testing period, and identifies any fuel or oil leaks. Emergency generators
perform vital functions that provide for the safety of staff and detainees in the event of a power
outage. Prescribed testing and preventive maintenance are essential.
In the maintenance shop, ODO observed welding equipment that could cause eye injuries. Eye
hazard warning signs were not posted (Deficiency EH&S-3), but protective eye and face
equipment were present. Eye hazard warning signs alert anyone in the area to wear protective
eye and face equipment.
YCP is currently using a converted food service cooler for storage of hazardous materials;
however, the cooler is not constructed of fire-resistant material and does not meet other
requirements of the PBNDS for a hazardous chemical storage room (Deficiency EH&S-4). The
Maintenance Supervisor stated that consideration would be given to moving the hazardous
chemicals out of the facility and placing them in a storage area that meets specifications.
ODO confirmed that fire and safety inspections are conducted on a monthly basis, rather than
weekly, as required by the PBNDS (Deficiency EH&S-5). Review of documentation confirmed
completion of monthly inspections and verified that corrective action is taken when security or
maintenance concerns are identified. It is important that weekly inspections are conducted in
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order for the facility to identify and immediately correct potential problems to ensure the safety
of detainees, visitors, and staff.
Exit diagrams in English and in Spanish are posted throughout the facility. Inspection of the
diagrams determined the “You Are Here” markers were inaccurate. Each diagram was found to
contain multiple “You Are Here” markers, which did not accurately identify the actual location
to facilitate safe and expeditious exit during an emergency (Deficiency EH&S-6). The
Maintenance Supervisor stated that the diagrams would be revised to ensure the markers are
accurately placed on the diagrams.
YCP contracts with a mobile barbering service to provide professional haircutting services for
detainees. The facility has a room dedicated for barbering services; however, the room does not
have hot and cold running water (Deficiency EH&S-7). ODO observed barbering operations
and verified that hair care sanitation safeguards are in place and adhered to.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE PBNDS, Environmental Health and Safety, section (V)(E), the FOD
must ensure at least annually, a state laboratory shall test samples of drinking and wastewater to
ensure compliance with applicable standards. A copy of the testing and safety certification shall
be maintained on-site.
DEFICIENCY EH&S-2
In accordance with the ICE PBNDS, Environmental Health and Safety, section (V)(F), the FOD
must ensure at least every two weeks, emergency power generators shall be tested for one hour,
and the oil, water, hoses and belts of these generators shall be inspected for mechanical readiness
to perform in an emergency situation.
Power generators are inspected weekly and load tested quarterly at a minimum, or in accordance
with manufacturer’s recommendations and instruction manual. Among other things, the
technicians shall check starting battery voltage, generator voltage and amperage output.
Other emergency equipment and systems shall be tested quarterly, and needed follow-up repairs
or replacement shall be accomplished as soon as feasible.
DEFICIENCY EH&S-3
In accordance with the ICE PBNDS, Environmental Health and Safety, section (VI)(B), the FOD
must ensure protective eye and face equipment is required where there is a reasonable probability
of injury that can be prevented by such equipment. Areas of the facility where such injuries can
occur shall be conspicuously marked with eye hazard warning signs.

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DEFICIENCY EH&S-4
In accordance with ICE PBNDS, Environmental Health and Safety, section (VI)(G)(3), the FOD
must ensure every hazardous material storage room shall:





Be of fire-resistant construction and properly secured;
Have self-closing fire doors at each opening;
Be constructed with either a four-inch sill or a four-inch depressed floor; and
Have a ventilation system (mechanical or gravity flow) within 12 inches of the floor,
which provides at least six air changes per hour.

DEFICIENCY EH&S-5
In accordance with the ICE PBNDS, Environmental Health and Safety, section (VII)(B), the
FOD must ensure a qualified departmental staff member shall conduct weekly fire and safety
Inspections.
Facility maintenance (safety) staff shall conduct monthly inspections.
Written reports of the inspections shall be forwarded to the facility administrator for review and,
if necessary, corrective action determinations. The Maintenance Supervisor shall maintain
inspection reports and records of corrective action in the safety office. Fire safety deficiencies
shall be promptly addressed.
DEFICIENCY EH&S-6
In accordance with the ICE PBNDS, Environmental Health and Safety, section (VII)(E), the
FOD must ensure in addition to a general area diagram, the following information must be
provided on signs:




Instructions in English, Spanish and the next most prevalent language at the facility;
"You Are Here" markers on exit maps; and
Emergency equipment locations.

"Areas of Safe Refuge" shall be identified and explained on diagrams. Diagram posting will be
in accordance with applicable fire safety regulations of the jurisdiction.
DEFICIENCY EH&S-7
In accordance with the ICE PBNDS, Environmental Health and Safety, section (IX)(1), the FOD
must ensure for sanitation reasons, it is preferable that barbering operations be located in a room
that is not used for any other purpose. The floors, walls, and ceilings should be smooth,
nonabsorbent and easily cleaned. There should be sufficient light, and the room shall be
supplied with hot and cold running water.

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FACILITY SECURITY AND CONTROL (FS&C)
ODO reviewed the Facility Security and Control standard at YCP to determine if facility security
is maintained, and events posing a risk of harm are prevented, in accordance with the ICE
PBNDS. ODO reviewed logbooks, policies, and post orders, interviewed staff, inspected
documentation, and observed vehicle sally port operations, perimeter security, and entrance
procedures.
The front entrance to the facility has a sally port with electronic interlocking doors to prevent
unauthorized entry or exit. Procedures are in place for issuing passes to all visitors. YCP does
not have a perimeter detection system, but the perimeter fence is checked twice during each shift.
Housing unit searches are conducted on every shift, and other areas are searched as scheduled by
the Security Captain.
YCP policy does not include procedures for documenting vehicles entering the facility. Vehicles
enter the facility by pulling up to an intercom connected to central control. The driver verbally
self-identifies, and the control officer opens the gate. A camera captures the vehicle’s entry, exit,
and activity while within the secure perimeter; however, the driver’s license is not requested,
checked, or held while the driver is in the facility (Deficiency FS&C-1). Information such as tag
numbers, driver names, firms represented, vehicle contents, current date, time in, time out, and
the facility employee responsible for the vehicle while it is on-site, are not recorded in a log
(Deficiency FS&C-2). Vehicles are not searched before being allowed to exit the facility
(Deficiency FS&C-3), which poses an escape risk. Control and documentation of vehicular
access within the secure perimeter is critical to facility security.
YCP does not have a written policy or procedures to address securing the Special Management
Unit (SMU) from contraband, and officers assigned to the SMU do not inventory tools entering
or departing the unit (Deficiency FS&C-4). Since an SMU is among the most secure areas in a
detention facility, special security and control measures are required to ensure the safety of
detainees, visitors, and staff.

STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS&C-1
In accordance with the ICE PBNDS, Facility Security and Control, section (V)(C)(2)(a), the
FOD must ensure the main-gate front-entrance officer shall control all vehicular traffic entering
and leaving the facility. The officer shall check the driver's license of every person driving into
the facility, regardless of purpose (visit, delivery, etc.) and may require proof of insurance,
especially for vehicles being driven on the grounds. Only if the license (and insurance) is valid
may the officer admit the vehicle. While the driver is within the facility's secure perimeter, the
officer shall hold the driver's license, as specified under Visitor Passes.
DEFICIENCY FS&C-2
In accordance with the ICE PBNDS, Facility Security and Control, section (V)(C)(2)(b), the
FOD must ensure the post officer shall log the following information on every vehicle: tag

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number, driver's name, firm represented, vehicle contents, date, time in, time out, and facility
employee responsible for the vehicle on-site.
DEFICIENCY FS&C-3
In accordance with the ICE PBNDS, Facility Security and Control, section (V)(C)(2)(c)(4), the
FOD must ensure before the exit gate, the driver shall stop at the spot designated. The gate
operator shall not allow the vehicle to depart until satisfied that neither the driver nor the
escorting officer is under duress. With that established, officers shall again search the vehicle. If
a thorough search is impossible, the vehicle shall be unloaded or held pending completion of the
next official count. If the vehicle or vehicular equipment must remain inside the compound
overnight, staff shall render it inoperable.
DEFICIENCY FS&C-4
In accordance with the ICE PBNDS, Facility Security and Control, section (V)(E)(1), the FOD
must ensure every facility administrator shall establish written policy and procedures to secure
the SMU from contraband.
Items allowed to enter these SMUs shall be kept to an absolute minimum. Any item is allowed
into the unit shall be thoroughly inspected and searched to prevent the introduction of
contraband, including laundry, commissary, food carts, and personal property.
When it becomes necessary to introduce tools into the unit, special care shall be taken. All tools
shall be inventoried by the special housing officer prior to entering. Tools shall be identified and
checked against the inventory upon departing to ensure no tools, hazardous objects, or materials
are left in the unit.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at YCP to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE PBNDS. ODO
interviewed food service staff, reviewed documentation, inspected food and chemical storage
areas, and observed preparation of trays and meal service to detainees.
All work associated with food service and kitchen sanitation is performed by YCP staff, with
support from inmate and detainee workers. All food service staff have completed the ServSafe
course in food handling and preparation and received certification from the National Restaurant
Association. ODO verified all food service staff and workers had received medical clearance.
The facility has a satellite system of meal service, which refers to food that is prepared in one
location for consumption elsewhere. Knives are tethered to tables when in use and are securely
stored at other times. Utensils are stored on shadow boards.
Review of temperature logs and required safety and sanitation inspections confirmed the facility
is compliant with the PBNDS. The food service department prepares menus for nine different
types of diets, including common fare, medical, religious, and vegetarian. The Food Service
Administrator (FSA) stated that consideration is given to the ethnic diversity of the detainee
population when developing menu cycles. Documentation provided by the contract dietician
indicates the nutritional analysis meets or exceeds the U.S. National Academy of Science
Reference Dietary Intake. A standard menu cycle of 28 days is followed.
After food is plated and placed on trays, it is taken to housing units on unsecured carts by inmate
and detainee workers. Delivery of the trays is not supervised by staff, which creates the potential
for tampering (Deficiency FS-1). The FSA stated that due to the size of the facility, 35 food
carts are necessary to deliver the trays to the housing areas, and sufficient staff is not available to
provide escort during the delivery of the meals.
The YCP detainee handbook states that “Inmates/detainees on disciplinary status may be given
FOOD LOAF for specific rule violations.” Food Loaf refers to a single food item that replaces
the normal menu; it is nutritionally adequate but unappetizing enough to serve behavior
modification purposes for detainees who pose disciplinary problems (Deficiency FS-2).
The food service department utilizes a three compartment sink for manual cleaning, rinsing, and
sanitizing of utensils and equipment. ODO observed the compartments were not labeled
(Deficiency FS-3). It is important that each compartment in the sink is labeled to prevent cross
contamination of utensils and equipment during manual cleaning, rising, and sanitizing. The
FSA took immediate action and labeled each compartment to correct the deficiency.
While inspecting the food service area, ODO observed 14 aerosol cans clearly marked
flammable that were placed on a filing cabinet in the office of the FSA (Deficiency FS-4).
Flammable items require storage in cabinet or room that is locked and labeled. The FSA
removed these cans from the facility and replaced them with the same product in a non-aerosol,
pump-spray delivery system.

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ODO verified the FSA conducts stock rotation in the dry goods area, freezers and coolers. No
outdated food items were identified during the inspection; however, the FSA does not maintain a
written stock rotation schedule (Deficiency FS-5). A written schedule provides consistency in
the application of stock rotation procedures.
ODO observed all coolers and freezers in the food service department were unlocked when not
in use (Deficiency FS-6). The FSA explained that due to the size of the inmate and detainee
population at YCP, these units must be constantly accessed in order to maintain food service
operations. The FSA stated that locking the units would hamper the efficiency of the food
service program.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE PBNDS, Food Service, section (V)(D)(1), the FOD must ensure
meals shall always be prepared, delivered, and served under staff (or contractor) supervision.
DEFICIENCY FS-2
In accordance with the ICE PBNDS, Food Service, section (V)(I)(4), the FOD must ensure food
items in excess of the normal prescribed ration shall not be given to detainees in segregation
units as a reward for good behavior, nor shall food rations be reduced or changed or otherwise
used as a disciplinary tool.
DEFICIENCY FS-3
In accordance with the ICE PBNDS, Food Service, section (V)(J)(7)(f)(1), the FOD must ensure
a sink with at least three labeled compartments is required for manually washing, rinsing, and
sanitizing utensils and equipment. Each compartment shall have the capacity to accommodate
the items to be cleaned. Each shall be supplied with hot and cold water.
DEFICIENCY FS-4
In accordance with the ICE PBNDS, Food Service, section (V)(J)(11), the FOD must ensure all
toxic, flammable, and caustic materials shall be segregated from food products and stored in a
locked and labeled cabinet or room.
DEFICIENCY FS-5
In accordance with the ICE PBNDS, Food Service, section (V)(K)(5), the FOD must ensure each
facility shall establish a written stock rotation schedule.
DEFICIENCY FS-6
In accordance with the ICE PBNDS, Food Service, section (V)(K)(8), the FOD must ensure
refrigeration units shall be kept under lock and key when not in use. Walk-in boxes shall be
equipped with safety locks that require no more than 15 pounds of pressure to open easily from
the inside. If latches and locks are incorporated in the door's design and operation, the interior
release mechanism must open the door with the same amount of pressure even when locks or
bars are in place.

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at YCP to determine if controls are in
place to inventory, receipt, store, and safeguard detainees’ personal property, in accordance with
the ICE PBNDS. ODO reviewed policies, procedures, and the local detainee handbook,
interviewed staff, observed processing of detainees, and inspected areas where property is
secured.
The property storage area at YCP is clean and organized. It is located in a basement behind two
locked doors and is only accessible to Receiving and Discharge staff and the Chief of Security.
The area is monitored 24 hours a day from the control room. ODO found all detainee property
bags are clearly marked with a large tag documenting the name and Alien Number of each
detainee. Property is stored and organized using a numerical system.
The YCP detainee handbook does not provide information concerning facility policies and
procedures for filing a claim for lost or damaged property (Deficiency F&PP-1). Including
these procedures in the detainee handbook ensures detainees are aware of local policies related to
detainee property and know what to do in the event personal property is lost or damaged.
In addition, YCP does not have a policy for handling lost or damaged detainee property
(Deficiency F&PP-2). Instituting a policy will ensure the facility investigates claims of lost or
damaged detainee property, provide a procedure for reimbursement for loss or damage due to
negligence, and ensure that ERO is notified of the of the outcome of resulting claims.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must
ensure the detainee handbook or equivalent shall notify the detainees of facility policies and
procedures concerning personal property, including:


Which items (and cash) they may retain in their possession;



That, upon request, they shall be provided a ICE/DRO-certified copy of any identity
document (passport, birth certificate, etc.) placed in their A-files;



The rules for storing or mailing property not allowed in their possession;



The procedure for claiming property upon release, transfer, or removal;



The procedures for filing a claim for lost or damaged property;



Access to detainee personal funds to pay for legal services.

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DEFICIENCY F&PP-2
In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(L)(3), the FOD
must ensure all CDFs and IGSA facilities shall have and follow a policy for loss of or damage to
properly receipted detainee property, as follows:
 All procedures for investigating and reporting property loss or damage shall be
implemented as specified in this Standard;
 Supervisory staff shall conduct the investigation;
 The senior facility contract officer shall process all detainee claims for lost or damaged
property promptly;
 The official deciding the claim shall be at least one level higher in the chain of command
than the official investigating the claim;
 The facility shall promptly reimburse detainees for all validated property losses caused by
facility negligence;
 The facility may not arbitrarily impose a ceiling on the amount to be reimbursed for a
validated claim; and
 The senior contract officer shall immediately notify the designated ICE/DRO officer of
all claims and outcomes.

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at YCP 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 PBNDS.
ODO interviewed staff and reviewed policies, grievance logs, detention files, and the detainee
handbook.
Detainees at YCP are encouraged to resolve grievances informally. However, detainees may file
formal written grievances for any issues by submitting a completed YCP Form 801 (Inmate
Grievance). A supervisor signs and dates the form indicating receipt of the grievance. The
supervisor immediately reviews the issue and determines whether it will be forwarded to the
facility grievance coordinator or routed to the designated medical personnel should the grievance
pertain to a medical issue. The grievance coordinator assigns a grievance number and maintains
an electronic database that tracks each grievance and records its progress through the process.
Detainees can appeal any grievance decision to the Deputy Warden by submitting a completed
YCP Form 804. The decision of the Deputy Warden may be further appealed by submitting a
completed YCP Form 806 to the York County Board of Commissioners for review by the
County Solicitor. The appeal response from the County Solicitor is documented and recorded in
a manner similar to legal documents encountered in criminal and civil legal proceedings. If the
detainee still is not satisfied with the grievance resolution, the decision of the County Solicitor
may be appealed to the York County Prison Board. The YCP appeals process involving the
York County Board of Commissioners and the York County Prison Board is in addition to any
appeals submitted to ERO.
YCP has been in the process of amending its grievance policy and procedures to reflect the
changes required for compliance with the PBNDS. Changes or amendments to YCP policies and
procedures require the approval of the County Solicitor. At the time of the inspection, ODO
confirmed that YCP did not have a procedure ensuring all medical grievances are received by the
administrative health authority within 24 hours or the next business day. There was also no
procedure ensuring that information, advice, or direction are provided to detainees in a language
or manner they can understand, or that interpretation and translation services are utilized
(Deficiency GS-1).
Upon review of the detainee handbook and the local supplement, ODO verified that the
grievance section in the local supplement does not provide notice of the process for filing
emergency grievances, nor does it provide notice of the procedures for contacting ERO to appeal
YCP grievance decisions (Deficiency GS-2).
Although officials make every effort to resolve detainee complaints or grievances at the lowest
level possible in an orderly and timely manner, YCP currently has no written procedures for
detainees to orally present issues of concern informally (Deficiency GS-3).

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To ensure confidentiality, medical grievances may be submitted in a sealed envelope. Grievance
forms concerning medical care that are not sealed in an envelope are first reviewed by the YCP
on-duty grievance supervisor before being routed to medical staff designated to receive and
respond to medical grievances (Deficiency GS-4). Medical personnel do not act within five
working days of receipt to provide detainees with written responses regarding decisions and
rationales. Supervisory medical personnel do not act on unresolved medical grievance referrals
within five working days of receipt to provide a written response regarding the decision and the
rationale (Deficiency GS-5).
The facility is in the process of correcting these deficiencies. Policies and procedures have been
edited and updated to be in compliance with the PBNDS and are waiting for approval by the
York County Solicitor.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE PBNDS, Grievance System, section (V)(A), the FOD must ensure
each facility shall have written policy and procedures for a detainee grievance system that:


Ensures a procedure in which all medical grievances are received by the administrative
health authority within 24 hours or the next business day;



Ensures information, advice, and directions are provided to detainees in a language or
manner they can understand, or that interpretation/translation services are utilized.

DEFICIENCY GS-2
In accordance with the ICE PBNDS, Grievance System, section (V)(B), the FOD must ensure
the facility shall provide each detainee, upon admittance, a copy of the Detainee Handbook /
local supplement, in which the grievance section provides notice of:


The process for filing emergency grievances.



The procedures for contacting ICE/DRO to appeal a decision in a CDF or IGSA facility.

DEFICIENCY GS-3
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(1), the FOD must ensure
the facility administrator, or designee, shall establish written procedures for detainees to orally
present the issue of concern informally (as addressed in the Staff-Detainee Communication
Detention Standard). Illiterate, disabled, or non-English speaking detainees shall be provided
additional assistance, upon request.
DEFICIENCY GS-4
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(3), the FOD must ensure
formal written grievances regarding medical care shall be submitted directly to medical
personnel designated to receive and respond to medical grievances at the facility.

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DEFICIENCY GS-5
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(3)(2)(c)(e)(f), the FOD
must ensure grievance forms concerning medical care shall be delivered directly to medical staff
designated to receive and respond to medical grievances at the facility. Designated medical staff
shall act on the grievance within five working days of receipt and provide the detainee a written
response of the decision and the rationale. This record should be maintained per Section E
“Record-Keeping and File Maintenance.”
If the grievance cannot be resolved to the satisfaction of the detainee, the supervisor shall so
annotate in detail the reasons on the grievance form and refer the written grievance to the next
level of supervision in his or her chain of command or to the appropriate department head within
five working days of receipt.
That person shall act on the grievance within five working days of receipt. The responsible
department head shall provide the detainee a written response of the decision and the rationale.
When the detainee is illiterate, disabled or non-English speaking, the decision shall be read to
him or her in a language that he or she understands, or translation/interpretation shall be provided
as needed.

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KEY AND LOCK CONTROL (K&LC)
ODO reviewed the Key and Lock Control standard at YCP to determine if facility safety and
security is maintained by requiring keys and locks to be controlled and maintained, in
accordance with the ICE PBNDS. ODO interviewed the Security Officer and staff, observed key
and lock issuance, and reviewed facility policies, inventories, and storage records.
YCP has a comprehensive written policy governing key and lock control. Responsibility for the
key control program is assigned to the YCP Maintenance Supervisor and the Captain, both of
whom are designated as Security Officers. The Captain is responsible for key control. The
Maintenance Supervisor is responsible for all facility locks and has completed a locksmith
training program. The entire facility staff is trained and accountable for key control. Keys are
issued from the control center using a metal chit system. Emergency keys are kept in central
control and are readily available when needed for immediate response.
ODO observed slide bolt locks in use at four different locations within the facility. Three of the
four slide bolts were secured with a padlock. All areas where the slide bolt locks were in use are
accessible to detainees (Deficiency K&LC-1). Slide bolt locks are not designed to withstand
force or pressure from the opposite side of the door. Most are made of low strength metal and
continuous pressure on the door can easily spring the bolt from the slide housing.

STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
DEFICIENCY K&LC-1
In accordance with the ICE PBNDS, Key and Lock Control, section (V)(C)(4), the FOD must
ensure either deadbolts or deadlocks shall be used in detainee-accessible areas. Locks not
authorized for use in detainee-accessible areas include, but are not limited to: snap-, key-in-knob,
thumb-turn, push-button, rim-latch, barrel or slide bolt, and removable-core-type locks
(including padlocks). Any such locks in current use shall be phased out and replaced with
mortise lock sets and standard cylinders.

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LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)
ODO reviewed the Law Libraries and Legal Material standard at YCP 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 to the ICE PBNDS. ODO visited the
law library, interviewed staff, and reviewed law library policies and rules in the local detainee
handbook governing detainee use of the law library.
ICE detainees are housed in three main housing units at YCP. Two are for male detainees, and
one is for female detainees. Each housing unit has its own law library, which detainees can
access on a daily basis. The Lexis-Nexis legal resource software on the computers in the law
libraries was last updated on April 17, 2012. All computers are in well-lit rooms and are
reasonably isolated from noisy areas. Additional legal material not available in Lexis-Nexis is
stored on a mobile cart and is provided for detainee use.
Unpublished materials located in the law libraries have no cover page identifying the preparer of
the material, or a statement notifying detainees that ICE/ERO did not prepare the material and is
not responsible for the contents, or the date of preparation (Deficiency LL&LM-1). The cover
page or statement is important because it alerts detainees about the accuracy or reliability of the
information contained in the unpublished material.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY LL&LM-1
In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(F)(2), the
FOD must ensure the facility administrator shall forward as soon as possible any unpublished
immigration-related material received to the Field Office Director for review and approval.
Unpublished material must have a cover page that:
1. Identifies the submitter and the preparer of the material;
2. Clearly states clearly that ICE/DRO did not prepare and is not responsible for the
contents, and
3. Provides the date of preparation.
ICE/DRO shall expeditiously make its decision whether to approve the material, ordinarily
within 45 days. ICE/DRO may object in whole or in part to materials that may pose a likely
threat to the security or good order of the facility, or that misstate immigration law, policy or
procedures. The Field Office Director shall consult with the respective ICE Chief Counsel and
other appropriate ICE/DRO and facility staff to determine whether to approve the materials:
If approved, the ICE/DRO shall notify the facility administrator and the submitter.
If not approved, the ICE/DRO shall inform the submitter in writing of the reasons.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at YCP to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE PBNDS. ODO toured the clinic, reviewed policies, procedures, and medical staff
credentials, and interviewed health care and administrative staff.
The clinic is spacious with a nursing station and six examination rooms within the unit. There
are additional satellite examination rooms in the PATH area and female housing unit. There are
a total of 36 medical observation cells, including six negative air flow cells for tuberculosis (TB)
isolation. If a language barrier exists, bi-lingual staff or a translation service is used. Detainees
requiring a higher level of medical care are sent to York Hospital or Memorial Hospital. YCP
has a large mental health staff and 36 observation beds, so there are few detainees transferred for
psychiatric reasons. When necessary, York Hospital is utilized for psychiatric cases.
A state of the art electronic medical record (EMR) system tracks medical information from the
point of intake. This ensures continuity of care for chronic patients. When a detainee is
admitted, the EMR automatically creates an initial chronic care appointment in addition to
regularly scheduled follow-up appointments. ODO cites this as a best practice.
To assure continuity of care, the PBNDS require a medical/psychiatric alert for any detainee
whose condition requires clearance by medical staff prior to release or transfer. Designated staff
created a spreadsheet listing all detainees for whom an alert is required for medical reasons, and
copies are provided to ICE, IHSC, and YCP personnel. ODO cites this as a best practice,
because it assures all interested parties are aware of detainees with chronic medical conditions.
Copies of all professional licenses were present and maintained on file, but the facility had not
conducted primary source verification for authenticity of the licenses with the issuing agency
(Deficiency MC-1).
ODO examined 30 detainee medical records. All records were spot-checked for sick call
timeliness and reviewed for transfer documentation. Overall, systems and processes are in place
to adequately serve a total population exceeding 2,500.
Detainees are processed into YCP in one of two ways: using the PATH program, or outside of
the PATH program. The PATH program was created by ICE in 2008 to facilitate and expedite
detainee removal by creating a centralized processing and transportation hub. Detainees
processed via the PATH are medically screened by onsite IHSC staff using IHSC screening form
I-795, which is routed to the YCP clinic for review by the shift charge nurse. IHSC staff also
perform chest x-rays (CXR) upon arrival to verify or rule out the presence of TB. Detainees who
are not processed through the PATH program are screened by PrimeCare nursing staff using a
thorough and complete in-house form to identify chronic care issues and medication needs. TB
screening is completed by way of a Protein Derivative (PPD) skin test, and detainees are housed
in an admission dormitory pending clearance. If a CXR is required, a contract radiology
company is used. In all reviewed cases, detainees underwent intake screening within 12 hours of
admission, were screened for TB, and received necessary medications and follow-ups. Detainees
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processed under both regimes at YCP receive medical care at intake that is in compliance with
the PBNDS.
A physical examination (PE) is conducted by an RN trained to perform this function; however,
ODO confirmed that ten (33%) of 30 detainees did not receive a PE within 14 days of admission
to the facility. Specifically, seven (23%) PEs were completed on day 15, and three (10%) were
completed on day 16 (Deficiency MC-2). ODO verified each completed PE was hands-on and
met IHSC Performance Improvement criteria.
Detainees access health care services by completing and submitting sick call request slips
available in English and Spanish. ODO verified requests are triaged within 48 hours to
determine priority for care, and detainees are seen for sick call in a timely manner. Nursing staff
conduct sick call on a daily basis using NCCHC medical protocols. Follow-up appointments and
referrals are completed as indicated.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE PBNDS, Medical Care, section (II)(29), the FOD must ensure health
care services will be provided by a sufficient number of appropriately trained and qualified
personnel, whose duties are governed by thorough and detailed job descriptions and who are
verifiable licensed, certified, credentialed, and/or registered in compliance with applicable state
and federal requirements.
DEFICIENCY MC-2
In accordance with the ICE PBNDS, Medical Care, section (V)(J), the FOD must ensure each
facility’s health care provider shall conduct a health appraisal including physical examination on
each detainee within 14 days of the detainee’s arrival unless more immediate attention is
required due to an acute or identifiable chronic condition, in accordance with the most recent
ACA Adult Local Detention Facility standards for Health Appraisals. If there is documentation
of one within the previous 90 days, the facility health care provider upon review may determine
that a new appraisal is not required.

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PERSONAL HYGIENE (PH)
ODO reviewed the Personal Hygiene standard at YCP to determine if the facility provides clean
clothing, bedding, linens and towels to every detainee upon arrival, and to ascertain if the facility
provides ICE detainees with regular exchanges of items for as long as they remain in detention,
in accordance with the ICE PBNDS. ODO interviewed staff and detainees and reviewed policies
and laundry exchange schedules.
Upon admission into YCP, detainees are issued two jumpsuits, two sheets, one blanket, one
towel, one washcloth, one pillowcase, and one laundry bag. In addition, detainees also receive
two pairs of socks, two sets of underwear, and two T-shirts. For general hygiene, detainees are
initially provided one toothbrush, one tube of toothpaste, one deodorant, and one shampoo.
Detainees must purchase toothpaste, shampoo, and deodorant in order to replenish these items.
There is an exception for indigent detainees. The facility defines an indigent detainee as one
who has an account balance of less than $15.00 for three consecutive weeks. A memorandum
written by Kevin Rooney, Acting Commissioner, Immigration and Naturalization Service (INS),
to all INS Regional Directors and Administrative Center Directors, dated May 18, 2001, states
that detainees may not be charged for basic hygiene items, such as soap, shampoo, toothpaste,
and shaving cream. This precludes charging detainees for replenishment of basic hygiene
products. Male and female detainees are provided three disposable razors each week, and female
detainees can purchase cosmetics such as lipstick, mascara, and eyeliner (Deficiency PH-1). Per
the PBNDS, razors must be issued daily, and cosmetics are prohibited.
The lower level of F block has a maximum capacity of 102 male detainees or inmates. This
block has seven showers. The ratio of detainees or inmates per shower in this housing unit is
14.5 male detainees or inmates to one shower. B block and C block have a maximum capacity of
32 female detainees or inmates. Each of these blocks has two showers. Thus, the ratio of
detainees or inmates per shower in each of these housing units is 16 female detainees or inmates
to one shower (Deficiency PH-2). The PBNDS requires a minimum ratio of one shower for
every 12 detainees.
The Deputy Warden of Treatment stated that socks and underwear are exchanged for washing
twice a week. The facility issues two pairs of socks and two sets of underwear. Detainees are
not able to obtain clean socks and underwear on a daily basis, because these items are exchanged
for washing only twice weekly (Deficiency PH-3). The PBNDS requires that socks and
undergarments be exchanged daily.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY PH-1
In accordance with the ICE PBNDS, Personal Hygiene, section (V)(D), the FOD must ensure
staff shall provide male and female detainees personal hygiene items appropriate for their gender
and shall replenish supplies as needed. The distribution of hygiene items shall not be used as
reward or punishment.

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Razors must be strictly controlled. Disposable razors will be provided to detainees on a daily
basis. Razors will be issued and collected daily by staff. Detainees will not be permitted to share
razors. The facility administrator may modify this list as needed. For example, a modification
can be made to accommodate the use of bulk liquid soap and shampoo dispensers.
Female detainees shall be issued and may retain feminine hygiene items as needed and may be
permitted unbreakable brushes with soft, synthetic bristles to replace combs. Cosmetics are
prohibited, as are electric rollers, curling irons, hair dryers, and similar appliances. Male
detainees shall be issued and may retain necessary hygiene items consistent with this Standard
and facility security.
DEFICIENCY PH-2
In accordance with the ICE PBNDS, Personal Hygiene, section (V)(E), the FOD must ensure
detainees shall be provided operable showers that are thermostatically controlled to temperatures
between 100 and 120 degrees Fahrenheit, to ensure safety and promote hygienic practices.
ACA Expected Practice 4-ALDF-4B-09 requires a minimum ratio of one shower for every 12
detainees.
It is good practice for inspections of housing units to periodically measure and document water
temperature.
DEFICIENCY PH-3
In accordance with the ICE PBNDS, Personal Hygiene, section (V)(H), the FOD must ensure
detainees shall be provided with clean clothing, linen and towels on the following basis:


A daily change of socks and undergarments. An additional exchange of undergarments
shall be made available to detainees if necessary for health or sanitation reasons.

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SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION
(SAAPI)
ODO reviewed the Sexual Abuse and Assault Prevention and Intervention standard at YCP to
determine if the facility acts to prevent sexual abuse and assaults on detainees, provides prompt
and effective intervention and treatment for victims of sexual abuse and assault, and controls,
disciplines, and prosecutes the perpetrators, in accordance with the ICE PBNDS. ODO reviewed
documentation, policies, procedures, training records, and information posted in housing areas,
interviewed staff and detainees, and observed intake processing.
YCP has a zero tolerance policy for sexual abuse, assault, or harassment. The facility has a
designated SAAPI Coordinator. Information concerning the SAAPI program is contained in the
local detainee handbook and is posted in all housing units and other locations throughout the
facility. The postings are in both English and Spanish and provide toll-free telephone numbers
for reporting incidents of sexual abuse and assault by staff or inmates. Detainees are screened
during the intake process for sexual abuse victimization risk and to identify potential sexual
aggressors.
Staff receives SAAPI training during the entrance training academy; however, annual training or
refresher courses on SAAPI are not provided (Deficiency SAAPI-1). During interviews, staff
confirmed their knowledge of the SAAPI program and their awareness of what action to take in
the event of a reported incident.
There were three incidents of reported sexual abuse and assault in 2011. ODO reviewed the case
files and verified documentation notifying ICE and local law enforcement was present in each
file. One of the three incidents was not investigated, because the detainee was released on bond
prior to being interviewed by the investigator. The two remaining incidents were investigated by
the Pennsylvania State Police, and documentation confirmed that ICE was kept apprised of the
status of the investigations. One of the two incidents was determined to be unsubstantiated,
while the other resulted in criminal charges that were subsequently Nolle Prosequi (not
prosecuted). Facility policy and the PBNDS were followed in all three reported incidents.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SAAPI-1
In accordance with the ICE PBNDS, Sexual Abuse and Assault Prevention and Intervention,
section (V)(F), the FOD must ensure training on the facility’s Sexual Abuse and Assault
Prevention and Intervention Program shall be included in training for employees, volunteers, and
contract personnel and shall also be included in annual refresher training thereafter.

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at YCP to determine if procedures
are in place to allow formal and informal contact between detainees and key ICE and facility
staff, and if ICE detainees are able to submit written requests to ICE staff and receive responses
in a timely manner, in accordance with the ICE PBNDS. ODO interviewed staff and detainees,
toured and observed housing units, and reviewed ERO visitation records, Facility Liaison Visit
Checklists, and Telephone Serviceability Worksheets.
Detainees can submit written questions, requests, or concerns to YCP and ERO staff. Request
forms are available in each housing unit, and the facility provides secure drop boxes specifically
designated for ICE detainees throughout the facility. However, detainee requests submitted to
the facility are not recorded by YCP in a single dedicated logbook or electronic database
(Deficiency SDC-1). Specifically, YCP processes each detainee request by forwarding it to the
appropriate department for handling. Once the request has been routed, the department handling
the request records it in a log designated for that department only. The existence of a single
dedicated log or electronic database would enable YCP or ICE to more easily track the
timeliness of responses to requests.
ODO observed that Department of Homeland Security, Office of the Inspector General (OIG),
Hotline Information Posters are conspicuously posted throughout the facility.
ODO reviewed a sample of randomly selected Facility Liaison Visit Checklists from November
2011 to the present and noted that ERO officers are using three different versions of this form to
document visitation. ODO observed that many forms were incomplete with multiple fields left
blank. As a result, ODO could not determine which housing units, or other areas in the facility,
had been visited by ERO officers. Two forms indicated that ERO officers had visited an SMU;
however, officer observations regarding the SMU were not documented on the form. Several
forms did not record officer arrival and departure times, total detainees in the SMU or in the
infirmary, and there was no identification of the housing units visited by the officer. Many ERO
officers had stated on their forms that interviews of ICE detainees had been conducted during
their visits; however, the names and Alien Numbers of interviewed detainees were not listed or
documented. None of the forms addressed recreation at YCP (Deficiency SDC-2). Accuracy of
the Facility Liaison Visit Checklists is essential for ERO to assess the general treatment of
detainees housed at the facility. Incomplete officer observations and missing information
potentially hinders the accurate assessment of the living conditions at YCP.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(B)(2), the FOD
must ensure all requests shall be recorded in a logbook (or electronic logbook) specifically
designed for that purpose. At a minimum, the log shall record:



Date of receipt;
Detainee’s name;

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





Detainee’s A-number;
Detainee’s nationality;
Name of the staff member who logged the request;
Date the request, with staff response and action, was returned to the detainee; and
Any other pertinent site-specific information.

In IGSAs, the date the request was forwarded to ICE/DRO and the date it was returned shall also
be recorded.
DEFICIENCY SDC-2
In accordance with the ICE PBNDS, Staff-Detainee Communication, section (V)(E) the FOD
must ensure a Model Protocol for DRO Officer Facility Liaison Visits, along with associated
documentation forms, are accessible via the website of the Headquarters Detention Standards
Compliance Unit. The Model Protocol is designed to standardize an approach to conducting and
documenting facility liaison visits, observing [sic] living and working conditions, and engaging
in staff-detainee communications.
In accordance with the required frequency of liaison visits described above in the section on
Scheduled Contact with Detainees, Model Program forms shall be:


Completed weekly for SPCs, CDFs, and regularly used IGSA facilities, and for each visit
to intermittently used IGSA facilities.



Submitted annually with the required Annual Detention Reviews.

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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at YCP 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 PBNDS. ODO reviewed local suicide prevention
policies, the suicide prevention training curriculum, and ten staff training records, inspected the
suicide watch cells in the Medical Observation Unit, reviewed documentation on five detainee
suicide watches, and interviewed medical staff and the training manager.
ODO reviewed the medical records of five detainees placed on suicide watch and determined
that YCP practice is consistent with ICE policies, and timeframes for mental health referrals and
nursing rounds are in compliance. However, in one case, re-evaluation of suicide watch status
on a daily basis by trained and qualified medical staff was not completed. Specifically, there was
no documentation showing that suicide watch status had not been re-evaluated on any weekend
days (Deficiency SP&I-1). The detainee was placed on suicide watch for a total of 14 days,
which included two weekends.
All staff receives initial and ongoing suicide prevention training, which includes the
identification of suicide risk factors, recognizing the signs of suicidal thinking and behavior,
referral procedures, suicide prevention techniques, and responding to an in-progress suicide
attempt. The training is presented by YCP certified training instructors.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with the ICE PBNDS, Suicide Prevention and Intervention, section (V)(D), the
FOD must ensure detainees who are placed on suicide watch are to be re-evaluated by
appropriately trained and qualified medical staff on a daily basis and this re-evaluation is
documented in the detainee’s medical record.

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