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

March 18 – 20, 2014

COMPLIANCE INSPECTION
YORK COUNTY PRISON
PHILADELPHIA FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................8
ICE 2008 PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................9
Classification System .........................................................................................................10
Correspondence and Other Mail ........................................................................................11
Detainee Handbook ............................................................................................................12
Disciplinary System ...........................................................................................................13
Environmental Health and Safety ......................................................................................15
Food Service ......................................................................................................................17
Funds and Personal Property .............................................................................................19
Grievance System ..............................................................................................................21
Hunger Strikes ...................................................................................................................23
Law Libraries and Legal Materials ....................................................................................24
Medical Care ......................................................................................................................25
Sexual Abuse and Assault Prevention and Intervention (2011 PBNDS) ..........................28
Special Management Units ................................................................................................30
Telephone Access ..............................................................................................................32
Use of Force and Restraints ...............................................................................................33

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

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

INSPECTION TEAM MEMBERS

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

Management Program Analyst (Team Lead) ODO, Headquarters
Inspections and Compliance Specialist
ODO, Headquarters
Inspections and Compliance Specialist
ODO, Headquarters
Inspections and Compliance Specialist
ODO, Headquarters
ODO, Headquarters
Inspections and Compliance Specialist
Inspections and Compliance Specialist
ODO, Headquarters

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

Contract Inspector
Contract Inspector
Contract Inspector

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Creative Corrections
Creative Corrections
Creative Corrections

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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the York County Prison (YCP) in
York, Pennsylvania, from March 18 to 20, 2014. YCP, which opened in 1979, is owned and
operated by the County of York. ERO began housing detainees at YCP in 1992 under an
intergovernmental service agreement with York County Prison. The facility recognizes three
security classification levels (Level I – lowest threat, Level II - medium-low and medium-high
threat, and Level III - highest threat), and houses male and female detainees for periods in excess
of 72 hours. The inspection
Capacity and Population Statistics
Quantity
evaluated YCP’s compliance with
Total Bed Capacity
2679
the 2008 PBNDS and the
2011 PBNDS Sexual Abuse and
Detainee Bed Capacity
900
Assault Prevention and
Average Daily ICE Population
756
Intervention (SAAPI) standard.
Average Length of Stay (Days)

53

Male Population Count (as of March 18, 2014)
522
The ERO Field Office
Director (FOD) in Philadelphia,
Female Population Count (as of March 18, 2014)
112
Pennsylvania, is responsible for
ensuring facility compliance with the ICE PBNDS and ICE policies. There are (b)(7)eAssistant
Field Office Directors located onsite at YCP. Additional onsite ERO staff includes(b)(7)e
Supervisory Detention and Deportation Officers (SDDOs) and (b)(7)e Supervisory Immigration
Enforcement Agents (SIEAs). The Detention Service Manager position at YCP is vacant at the
moment; a Supervisory Detention Service Manager is covering until the vacancy is filled.

The Warden is the highest-ranking official at YCP and is responsible for oversight of daily
(b)(7)e
operations.
county and contract staff members supported YCP
management at the time of the inspection. Food service is operated and supervised by York
County employees and IHSC and PrimeCare Medical provide medical care at the facility. YCP
holds accreditation from the National Commission on Correctional Healthcare (NCCHC).
In April 2012, ODO conducted an inspection of YCP under the 2008 PBNDS. ODO reviewed
18 PBNDS and found a total of 36 deficiencies. YCP was compliant with five standards.
During this inspection, ODO reviewed 18 PBNDS and the 2011 PBNDS SAAPI standard, and
found YCP compliant with four standards. 1 ODO found a total of 30 deficiencies (7 of which
were deficient priority components) in the remaining 15 standards: 2 Classification
System (1 deficiency), Correspondence and Other Mail (2), Detainee Handbook (2),
Disciplinary System (2), Environmental Health and Safety (2), Food Service (1), Funds and
Personal Property (3), Grievance System (4), Hunger Strikes (2), Law Libraries and Legal
Materials (2), Medical Care (2), Sexual Abuse and Assault Prevention and Intervention (3),
Special Management Units (2), Telephone Access (1), and Use of Force and Restraints (1).
1

The following standards were compliant at the time of the inspection; therefore, a synopsis for these standards is
not included in this report: Admission and Release, Personal Hygiene, Staff-Detainee Communication, and Suicide
Prevention and Intervention.

2

Deficient priority components were found in the following five standards: Correspondence and Other Mail,
Disciplinary System, Grievance System, Medical Care and Sexual Abuse and Assault Prevention and Intervention.

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ODO made four recommendations regarding facility policy and procedures and identified one
best practice in this report.
This report details all deficiencies and refers to the specific relevant sections of the
2008 PBNDS. ERO will be provided a copy of this report to assist in developing corrective
actions to resolve all identified deficiencies. ODO discussed these deficiencies with YCP and
ERO personnel during the inspection and at a closeout briefing conducted on March 20, 2014.
Detainees entering YCP are initially processed through the ERO Philadelphia Field Office. YCP
completes the admissions process by performing screening interviews; completing
questionnaires; and issuing detainees personal hygiene items, clothing, towels, and bedding.
Detailed medical, dental, mental health and sexual abuse history screenings are performed at the
intake area. English and Spanish versions of the YCP facility handbook are provided to all
newly arriving detainees. Although detainees do not receive a copy of the ICE National
Detainee Handbook from YCP, they do receive the handbook from ERO upon entering into ICE
custody.
YCP has a formal classification system for managing and separating detainees based on
verifiable and documented data. Staff enters the assigned classification level on a YCP
classification form and assigns the detainee to an appropriate housing unit. Procedures are in
place for review of a detainee’s classification level every 60 days. Reclassification procedures
are in place to be reviewed every 60 days. Detainees are notified of the disciplinary process
during orientation and by way of the detainee handbook.
YCP does not have a Unit Disciplinary Committee (UDC) or other intermediate level of
adjudication for infractions of low and moderate severity. Additionally, infractions of all
severity levels result in placement in disciplinary segregation prior to adjudication by the
Institutional Disciplinary Panel (IDP), if not informally resolved by the captain. According to
the PBNDS, only the IDP may place a detainee in disciplinary segregation.
YCP’s policy states incoming mail shall be delivered to detainees within 48 hours. However,
interviews with mailroom staff revealed that while it is the facility’s intent to deliver mail within
24 hours that is not always possible. YCP’s policy does not address procedures regarding
detainee packages.
Detainees are issued both the ICE National Detainee Handbook and a facility handbook upon
admission. ODO found the facility handbook does not notify detainees of the procedure for filing
medical grievances under the Grievance System. Further, there is no policy, procedure, or
practice in place for the issuance and distribution of the ICE National Detainee Handbook to
every staff member who has contact with detainees.
YCP conducts weekly and monthly fire and safety inspections; however, ODO inspected several
housing units and observed brown paper bags being used as trash receptacles in dayrooms and
individual cells, creating a significant fire hazard. ODO also confirmed fire drills are conducted
monthly at YCP, but a review of documentation confirmed that emergency keys are not pulled
during each drill.

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All work associated with the food service operation is performed by YCP employees. The staff
is supported by a crew of(b)(7)einmates and (b)(7)e detainees. Food preparation equipment was
found clean and in working order; however, an inspection of the dry storage area revealed it was
unsecured on two consecutive days during the inspection.
YCP has policies and procedures covering the inventory, storage, and safeguarding of detainees’
personal property and funds. Funds and Personal Property Standard Operating Procedures do not
include obtaining a forwarding address from every detainee for use in the event that personal
property is lost or forgotten in the facility after the detainee is released, transferred, or removed.
Also, YCP policy does not state that the senior facility contract officer shall process all detainee
claims for lost or damaged property promptly, and the official deciding the claim shall be at least
one level higher in the chain of command than the official investigating the claim. YCP’s
detainee handbook does not notify detainees of the rules for storing or mailing property not
allowed in their possession, the procedure for claiming property upon release, transfer, or
removal, or access to detainee personal funds to pay for legal services.
The grievance system at YCP allows detainees to file informal, formal, and emergency
grievances. YCP’s handbook does not provide notice about the procedure for filing a medical
grievance. Although YCP’s handbook includes guarantees against reprisal for detainees who file
a grievance, it also includes language stating that nuisance filers may be placed on a grievance
filing restriction. YCP provides detainees with envelopes in which to seal grievances, identifying
them as sensitive or medically sensitive; however, they are opened and recorded in the grievance
log by the grievance coordinator before they are routed to medical staff. Copies of grievance
dispositions are provided to detainees; however, copies are not placed in detention files.
Local policy requires the notification of ICE in the case of any detainee hunger strike or refusal
of care for hunger striking detainees. The policy addresses routine medical procedures for
hunger strikes including medical and management evaluations. A review of the YCP training
program and detention staff training records found no hunger strike training is provided. ODO’s
review of the medical record of the one hunger striker confirmed management was consistent
with policy and the ICE PBNDS with one exception: a urinalysis was not performed as part of
an initial assessment by nursing staff. Facility policy requires this in one section; however, in
another, it stipulates urinalysis is ordered at the discretion of the physician. ODO recommends
revision of the policy to comport with the standard.
YCP has three libraries where detainees can access legal materials for a minimum of five hours
per week, Monday through Friday. Detainees are not provided with a means of saving any legal
work in a secure and private electronic format so that they may return at a later date to access
previously saved legal work product. The facility’s detainee handbook does not include the
procedure for detainees to request legal reference materials not maintained in the law library.
Health care at YCP is provided by IHSC and PrimeCare Medical Inc. Although local policy
states a physician, certified psychiatric nurse practitioner, or other qualified healthcare
professional may order restraints, the PBNDS Medical Care standard stipulates, “Restraints for
medical or mental health purposes may be authorized only by the facility’s clinical medical
authority.” While documentation clearly documents the order from the psychiatrist, ODO could
find no documentation the medical director co-signed authorization of the restraints.
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Although detainees sign general consent forms for healthcare services, consent forms for specific
treatment, such as the administration for psychotropic medication, was inconsistent in ODO’s
review of medical records. Sick call request forms are available to detainees in English and
Spanish, and triage is administered within 48 hours to determine priority for care. ODO
reviewed the handling of grievances by the medical department and confirmed medical
grievances are forwarded to the Health Services Administrator and responded to within five
days. However, grievances are not placed in detainee medical records. This was identified as a
deficiency under the Grievance System standard.
YCP signed a contract modification with ICE on September 19, 2012, agreeing to implement the
2011SAAPI standard. Staff training did not include prevention, recognition, or appropriate
responses to allegations or suspicions of sexual assault involving detainees with mental or
physical disabilities. Detainees are informed of the SAAPI program through the detainee
handbook and through a PREA pamphlet issued during intake. The pamphlet is available in both
English and Spanish. The handbook states that a detainee can report an allegation of sexual
assault. ODO found in one case the facility waited 24 hours before reporting the one particular
allegation to ERO.
YCP has written policies addressing removal of detainees from the general population and
multiple segregation designations. During the inspection, there were eight detainees housed in
SMUs: four by order of health care staff for medical and psychiatric reasons, three for
disciplinary reasons, and one for protective custody. YCP segregates detainees for
administrative and disciplinary reasons as described in the PBNDS; however, they do not refer to
detainee segregation status as “administrative” or “disciplinary.” ODO’s review of the three
disciplinary segregation cases found all three detainees were originally placed on this status prior
to hearing and adjudication by the IDP. Facility policy allows placement on disciplinary
segregation status prior to adjudication by the IDP, if infractions cannot be informally resolved
by the captain who investigates the incident. While awaiting hearing before the IDP, the
detainees were subject to a greater level or restriction of privileges than allowed for a nonpunitive segregation status.
YCP has a policy and procedure regarding communication between detainees and staff.
Detainees have the opportunity to submit written questions, requests, or concerns to ERO
personnel and facility staff via a request form, printed in English and Spanish. ODO reviewed a
visitation log and interviewed YCP staff to confirm visits are conducted and documented. ODO
also reviewed a separate ERO logbook and interviewed ERO staff, confirming visits to the
housing unit for the past year. ODO reviewed the facility’s policy on suicide prevention and
intervention. The policy covers training, identification, intervention, housing, and
hospitalization of at-risk detainees.
ODO verified detainees have reasonable and equitable access to telephones at YCP. The
telephone availability ratio for each housing unit is approximately three detainees per telephone.
The facility provides six TTY devices if needed. The procedure for obtaining an unmonitored
call to a court, legal representative, or for the purpose of obtaining legal representation, is not
included in the detainee handbook or posted near any of the telephones in the housing units or
the SMU.
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YCP has policies and procedures addressing immediate use of force, calculated use of force, and
use-of-force principles and techniques, including confrontation avoidance, the use-of-force
continuum, forced cell moves, and application of restraints. According to facility staff, there
were no calculated and 20 immediate uses of force involving detainees in the past year. YCP
policy does not address after-action reviews. Documentation confirmed use-of -force reports
were written and forwarded to ERO; however, after-action reviews were not conducted in any of
the 20 cases.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO randomly-selected and interviewed 39 detainees (20 Level I males, 10 Level II males, and
9 Level I females) regarding conditions of detention at YCP. Six detainees were interviewed
using interpreters via the Language Line.
Nearly half of all male detainees interviewed did not know their deportation officers, although
most reported observing an ICE officer in the facility weekly. All nine females interviewed
knew their deportation officers. Sixteen of 30 male detainees reported not receiving the ICE
National Detainee Handbook, and three of nine female detainees reported not receiving it. All
reported receiving the YCP handbook.
Overall, most were satisfied with access to legal materials, recreation, religious services,
visitation, and mail. Food service was reported to be acceptable. Two detainees complained
about being housed with the general inmate population. One detainee complained of not having
hot water to cook his food; however, ODO’s found this complaint had no merit. All detainees
reported receiving hygiene items upon arrival, and the ability to replenish them.
The vast majority of detainees were satisfied with medical treatment; however, one male
reported unsatisfactory care regarding his chronic migraines. He alleged submitting multiple
medical grievances for care and never being seen by a doctor. ODO reviewed the detainee’s
medical file and found he was seen and treated by a medical provider.
No detainees reported having ever witnessed or experienced any mistreatment, discrimination, or
abuse (physical, verbal, or sexual) while at YCP.

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ICE 2008 PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 19 PBNDS and found 30 deficiencies in the following 15 standards:
1. Classification System
2. Correspondence and Other Mail
3. Detainee Handbook
4. Disciplinary System
5. Environmental Health and Safety
6. Food Service
7. Funds and Personal Property
8. Grievance System
9. Hunger Strikes
10. Law Libraries and Legal Materials
11. Medical Care
12. Sexual Abuse and Assault Prevention and Intervention (2011 PBNDS)
13. Special Management Units
14. Telephone Access
15. Use of Force and Restraints
Findings for these standards are presented in the remainder of this report. Five of the 15
standards contained deficiencies involving priority components.

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CLASSICATION SYSTEM (CS)
ODO reviewed the Classification System standard at YCP to determine if there is a formal
classification process for managing and separating detainees based on verifiable and documented
data, in accordance with the ICE 2008 PBNDS. ODO toured the facility, reviewed local policies
and procedures, interviewed staff, and inspected detainee files, the detainee handbook and
related documentation.
YCP has written policies and procedures addressing the classification of detainees. ODO
verified the detainee handbook provides information on the classification process, including
appeal procedures.
The ERO field office classifies detainees prior to admission to YCP, and provides the facility
with criminal history records, Form I-203A, Order to Detain/Release Aliens, Form I-213, Record
of Deportable/Inadmissible Alien, and the initial assessment worksheets noting the classification
levels of detainees arriving at YCP. Procedures are in place for review of a detainee’s
classification level every 60 days. In addition, procedures address reclassification of detainees
following a disciplinary action, or in the event new information relevant to the detainee’s
classification becomes known. A review of 30 detention files confirmed all contained
documentation of initial and reclassification, and appropriate information supporting
classification decisions. Detainees’ classification levels are readily identifiable by way of
different colored identification armband for each classification level (Levels, I, II, and III).
During the inspection, ODO confirmed through interviews the commingling of Level I (lowest
threat) and Level III (highest threat) detainees in the infirmary waiting rooms. ODO also
observed that Level III detainees are not being escorted throughout the facility. YCP staff stated
that all detainees, unless in disciplinary or administrative segregation, are allowed to walk the
facility unescorted (Deficiency CS-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY CS-1
In accordance with the ICE 2008 PBNDS, Classification System, section (V)(F)(1)(3), the FOD
must ensure:
1. “ Level 1 Classification
•

May not be co-mingled with Level 3 Detainees.”

3. “ Level 3 Classification
•
•

Level 3 detainee may not be co-mingled with Level 1 detainees
Level 3 detainees are required to be escorted and monitored.”

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CORRESPONDENCE AND OTHER MAIL (C&OM)
ODO reviewed the Correspondence and Other Mail standard at YCP to determine if the facility
provides detainees the opportunity to send and receive correspondence, in a timely manner,
subject to limitations required for the safe and orderly operation of the facility, in accordance
with the ICE 2008 PBNDS. ODO observed the mail receiving and distribution process,
interviewed staff, and reviewed policies, as well as the detainee handbook.
There are no restrictions on the amount of mail detainees can send or receive. The detainee
handbook provides a comprehensive overview about the rules and procedures associated with
correspondence and other mail. More specifically, ODO found that the handbook adequately
addressed labeling instructions for outgoing mail, the definition and mailing privileges specific
to indigent individuals and the rules associated legal correspondence.
The facility has policy and procedures in place regarding detainee mail and other
correspondence. However, YCP’s policy states that incoming mail shall be delivered to
detainees within 48 hours (Deficiency C&OM-1). 3 Interviews with mailroom staff revealed
that it is the facility’s intent to deliver mail within 24 hours; however, that is not always
attainable.
Although rules are outlined in the detainee handbook, YCP’s policy does not address procedures
regarding detainee packages (Deficiency C&OM-2). YCP staff reported the policy was being
revised.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY C&OM-1
In accordance with the ICE 2008 PBNDS, Correspondence and Other Mail, section (V)(D), the
FOD must ensure “incoming correspondence shall be distributed to detainees within 24 hours
(one business day) of receipt by the facility.”
DEFICIENCY C&OM-2
In accordance with the ICE NDS, Correspondence and Other Mail, section (V)(E), the FOD
must ensure “each facility shall implement policies and procedures concerning detainee
packages.”

3

Priority Component

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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 2008 PBNDS. ODO interviewed staff
and detainees and reviewed the YCP detainee handbook.
Upon admission to YCP, all detainees are issued the YCP facility handbook. Receipt of the
facility handbook is acknowledged by signing and dating the Orientation and Intake
Acknowledgement Form. These forms are maintained in the detainee detention file and held by
YCP counselors. ERO issues detainees the ICE National Detainee Handbook at the time of
arrest, and it is treated as the detainee’s property from that time forward. Receipt of the ICE
National Detainee Handbook is acknowledged by signing and dating the Detainee Handbook
Receipt Form, which is maintained in the detainee’s Alien file. Both the ICE National Detainee
Handbook and the YCP detainee handbook are available in English and Spanish.
A committee consisting of the deputy wardens, the treatment supervisor(s), and counselors
review the YCP detainee handbook annually to ensure it is current and to make revisions where
necessary. The YCP detainee handbook was last revised by the committee on July 22, 2013.
ODO found the YCP detainee handbook does not notify detainees of the procedure for filing
medical grievances under the Grievance System section (Deficiency DH-1). This deficiency
was also reported under the Grievance System standard (GS)(V)(B).
There is no policy, procedure, or practice in place for the issuance and distribution of the ICE
National Detainee Handbook to every staff member who has contact with detainees
(Deficiency DH-2).
Deficiencies related to the detainee handbook are also provided in Deficiencies F&PP-1, GS-1,
and LL&LM-2.

STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE 2008 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:
•

The detainee Grievance System, including medical grievances”

DEFICIENCY DH-2
In accordance with the ICE 2008 PBNDS, Detainee Handbook, section (V)(7), the FOD must
ensure, “the facility administrator shall provide a copy of the ICE National Detainee Handbook
and the local supplement to every staff member who has contact with detainees and cover its
contents in initial and annual staff training.”
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DISCIPLINARY SYSTEM (DS)
ODO reviewed the Disciplinary System standard at YCP to determine if sanctions imposed on
detainees who violate facility rules are appropriate, and if the discipline process includes due
process requirements, in accordance with the ICE 2008 PBNDS. ODO interviewed staff and
reviewed policy, disciplinary records, and the YCP detainee handbook.
ODO confirmed YCP’s disciplinary system is described in facility policy. Prohibited acts are
classified as Class I and II levels, with Class I being the most serious. The detainee handbook
describes the disciplinary process and lists the sanctions for each level of infraction. The
handbook also addresses detainee rights, including the right to appeal.
The YCP policy encourages informal resolution of minor infractions. The discipline process
starts with preparation of a report by the staff member observing the incident. The incident
report is forwarded to the captain for review, investigation and determination of whether
informal resolution is appropriate. Based on interviews with staff and review of documentation,
ODO found if the captain does not informally resolve the incident, the detainee is then scheduled
for a hearing before the IDP. YCP does not have a Unit Disciplinary Committee (UDC) or other
intermediate level of adjudication for infractions of low and moderate severity
(Deficiency DS-1). 4 Additionally, infractions of all severity levels result in placement in
disciplinary segregation prior to adjudication by the IDP, if not informally resolved by the
captain (Deficiency DS-2). According to the PBNDS, only the IDP may place a detainee in
disciplinary segregation.
According to the disciplinary hearing log provided to ODO, 258 incident reports were
adjudicated by the IDP. ODO reviewed 25 randomly selected disciplinary reports and confirmed
each was investigated within 24 hours, and the IDP hearing was conducted within the seven day
timeframe established in YCP policy. The sanctions ranged from two to 60 days per infraction,
with credit given for time spent in disciplinary segregation prior to adjudication. No logs
documenting infractions informally resolved were available for review.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY DS-1
In accordance with the ICE PBNDS 2008, Disciplinary System, section (V)(F), the FOD must
ensure, “All facilities shall establish an intermediate level of investigation/adjudication process
to adjudicate low or moderate infractions. They shall also ensure that the detainee is afforded all
the UDC rights listed below.
The UDC administering unit discipline shall be comprised of one to three members, at least one
of whom is a supervisor.
The UDC shall not include the reporting officer, the investigating officer, or an officer who
witnessed or was directly involved in the incident. Only in the unlikely event that practically

4

Priority Component

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every available officer witnessed or was directly involved in the incident may an exception
occur.
The UDC shall conduct hearings and, to the best extent possible, informally resolve cases
involving High Moderate or Low Moderate charges in accordance with the list of charges and
related sanctions noted as Attachment A of this Standard. Unresolved cases and cases involving
serious charges are forwarded to the Institution Disciplinary Panel.”
DEFICIENCY DS-2
In accordance with the ICE 2008 PBNDS, Disciplinary System, section (V)(H), the FOD must
ensure, “All facilities that house ICE/DRO detainees shall have a disciplinary panel to adjudicate
detainee Incident Reports. Only the disciplinary panel may place a detainee in disciplinary
segregation.”

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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 a high level of cleanliness and sanitation, safe work practices and control of hazardous
materials and substances, in accordance with the ICE 2008 PBNDS. ODO toured the facility,
interviewed staff, and reviewed procedures and documentation of inspections, hazardous
chemical management, and the fire plan.
ODO observed the facility sanitation was acceptable overall. A review of(b)(7)eemployee training
records verified staff is trained in fire and safety procedures during initial and annual training.
The facility’s designated fire/safety officer maintains a master index of hazardous substances
with storage locations. The index includes a listing of emergency phone numbers and
documentation of receipt by the local fire department. The master file of Material Safety Data
Sheets was found current, and Material Safety Data Sheets are located in each area where
chemicals are used. ODO confirmed running inventories of hazardous substances were accurate.
Documentation was produced reflecting the facility’s emergency power generator is tested biweekly for one hour and serviced and tested by an external generator service company in
accordance with manufacturer’s recommendations. Pest control services are provided by a local
contractor on a monthly and on call basis, and certification of the water supply by the City of
York was available. Sharp instruments in the medical clinic are inventoried on each shift, and a
spot check confirmed their accuracy. The medical department has a comprehensive policy
addressing accidental needle sticks and safety precautions for staff.
The fire/safety officer provided documentation of weekly and monthly fire and safety
inspections. While inspecting the housing units, ODO observed brown paper bags were being
used as trash receptacles in dayrooms and individual cells, constituting a significant fire hazard
(Deficiency EH&S-1). Evacuation diagrams in English and Spanish were posted throughout the
facility. The diagrams depicted locations of emergency equipment and included directional
arrows for traffic flow. Fire drills are conducted monthly and include evacuation of detainees.
A review of documentation confirmed drills are conducted in all areas and on all shifts; however,
drawing of emergency keys and the unlocking of emergency exits during fire drills was
documented only once in the past year, in violation of both facility policy and the PBNDS
(Deficiency EH&S-2). Use of emergency keys in drills supports staff familiarity with their use
and assures locks are functioning properly.
Hair care services are provided by a contractor who provides all his own equipment and
disinfectant supplies. Barbering is conducted in a vacant holding room, which is not equipped
with hot and cold running water. The facility produced a document issued by the “Unit Chief,
ERO Detention Standards Compliance Unit on November 13, 2012,” waiving the requirement to
comply with the ICE 2008 PBNDS, Environmental Health and Safety, section (IX) stating
barbering operations be conducted in a room not used for any other purpose, with floors, walls,
and ceiling of a smooth surface, sufficient light, and equipped with hot and cold running water.
The waiver states, “York County Prison does not have any large room with running water that
can be re-purposed for barbering; therefore this is a physical structure issue which cannot be
resolved by adding running water. The facility contracts with a mobile barbering service. The
service brings in the necessary equipment to sanitize their tools before every use. There is
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lavatory with hot and cold running water across the hall from the barbering room. Due to the
above factors the facility is able to ensure barbering services are completed in a safe and sanitary
environment without the presence of running water.”
YCP’s fire/safety program is subject to inspection by the Pennsylvania Department of Correction
on an annual basis, with a provision for biennial inspections if no deficiencies are found. YCP
was last inspected in December 2012 and having had no deficiencies, will next be inspected in
2014.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE 2008 PBNDS, Environmental Health and Safety, section (VII)(C)(2)
and (3), the FOD must ensure, “Every facility shall develop a fire prevention, control, and
evacuation plan that includes the following:
2. Control of combustible and flammable fuel load sources.
3. Provisions for occupant protection from fire and smoke.”
DEFICIENCY EH&S-2
In accordance with the ICE 2008 PBNDS, Environmental Health and Safety, section (VII)(D)(3),
the FOD must ensure, “Emergency key drills shall be included in each fire drill, and timed.
Emergency keys shall be drawn and used by the appropriate staff to unlock one set of emergency
exit doors not in daily use. NFPA recommends a limit of four and one-half minutes for drawing
keys and unlocking emergency doors. However, when conducting fire drills, emphasis will be
placed on safe and orderly evacuation rather than speed.”

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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 2008 PBNDS.
ODO reviewed documentation, interviewed staff, inspected the food service area, and observed
meal preparation and service.
The food service operation is managed by YCP employees. The staff consists of the food service
administrator, (b)(7)e full-time cooks, and (b)(7)ecorrectional officers, who are responsible for
overseeing security in the area. The staff is supported by a crew of(b)(7)einmates and (b)(7)e
detainees who are paid $20 weekly. ODO’s review of documentation confirmed staff and
members of the work crew were medically cleared to work in a food service operation. Kitchen
workers were inspected by food service management or detention staff assigned to food service
prior to starting their shift in the kitchen, for any signs of illness or personal hygiene concerns.
All staff and detainees were observed wearing hair nets, aprons, gloves, and beard nets where
necessary, and white kitchen uniforms were worn by the work crew.
ODO verified all menus were certified by a registered dietitian, and religious and medically
prescribed meals were provided and documented. During the inspection, 72 detainees were
receiving medical diets and 19 detainees were receiving religious diets.
YCP has a satellite system of meal service involving preparation of meals in the kitchen and
delivery to housing units on trays. ODO observed housing officers check off detainees’ names
on a meal roster as trays are issued. Special diet meals are in color-coded trays and are issued
once detainee identity is confirmed by comparing the name on the identification bracelet against
the special diet list.
Food service staff was observed taking temperatures of food as prepared in the kitchen and upon
service in the housing units. Using a digital food thermometer, temperatures of items served for
the noon meal on Wednesday during the inspection were checked and confirmed within the
required range. All items served were on the approved menu, in the portion size prescribed on
the menu and properly seasoned.
ODO verified measures are in place to assure accountability and the safe use of knives and
kitchen utensils. Knives and utensils are kept on shadow boards in a locked cabinet and are
signed out and in by the correctional officer. When in use, knives are tethered to the table.
Sanitation of the kitchen area was very good at the time of the inspection. Equipment was in
good working order and food preparation areas, vent hoods, the cooler, freezer, and dry storage
area were clean and well organized. Temperature logs for the walk-in freezer, cooler, and
dishwasher water were current. During the inspection, the dry storage area was found unsecured
on two consecutive days. (Deficiency FS-1). Securing storage areas assures work crew members
cannot gain unauthorized entry and pilfer food items.
Documentation reflects the food service director conducts an inspection of the kitchen each
week. In addition, the dietician conducts a comprehensive inspection of the food service
operation annually when completing the required review of menus and nutritional analysis. The
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food service operation was last inspected by the Pennsylvania Department of Corrections, on
December 28, 2012 with no violations found. ODO notes no detainees voiced concerns or
complaints concerning the meals provided by YCP.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDING
DEFICIENCY FS-1
In accordance with the ICE PBNDS, Food Service, section (V)(K)(7), the FOD must ensure,
“Proper care and control of the dry storeroom involves:
•

Securing it under lock and key to prevent pilferage. The FSA is responsible for key
distribution.”

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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 2008 PBNDS. ODO reviewed policies, procedures, the local detainee handbook,
interviewed staff, and inspected areas where property and valuables are secured.
The property storage room at YCP was a very clean, organized and secure room, only accessible
by the property room officer and supervisors. Any oversized or excess property which cannot fit
in one property bag is stored in a designated excess baggage room. The ICE excess baggage
room is also very clean, organized, and secure. During intake, funds and valuables are
inventoried and dropped in a secure drop-box, accessible only by the supervisor. All U.S. funds
are deposited into the detainee’s commissary account. Small valuables, including foreign
currency, are inventoried and secured in locked cabinets. These cabinets are secured in a
designated locked room within the control center, under constant video monitoring and with
limited access by personnel. YCP uses the chit key system for security and control. Property and
valuables audits occur monthly.
The YCP detainee handbook does not clearly notify detainees of the rules for storing or mailing
property not allowed in their possession, the procedure for claiming property upon release,
transfer, or removal, or access to detainee personal funds to pay for legal services
(Deficiency F&PP-1).
YCP standard operating procedures do not include obtaining a forwarding address from every
detainee for use in the event that personal property is lost or forgotten in the facility after the
detainee is released, transferred, or removed (Deficiency F&PP-2). Interviews substantiated that
a forwarding address is not routinely solicited at the time of admission.
YCP policy for lost and damaged property is lacking two procedures specified and mandated in
the standard. Existing policy does not state that the senior facility contract officer shall process
all detainee claims for lost or damaged property promptly, and that the official deciding the claim
shall be at least one level higher in the chain of command than the official investigating the claim
(Deficiency F&PP-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE 2008 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:
•

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

•

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

•

Access to detainee personal funds to pay for legal services.”

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DEFICIENCY F&PP-2
In accordance with the ICE 2008 PBNDS, Funds and Personal Property, section (V)(D), the
FOD must ensure “Standard operating procedure shall include obtaining a forwarding address
from every detainee for use in the event that personal property is lost or forgotten in the facility
after the detainee’s release, transfer, or removal.”
DEFICIENCY F&PP-3
In accordance with the ICE 2008 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:
•

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;”

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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 2008
PBNDS.
A review of the facility’s policy and detainee handbook confirmed both address YCP’s informal
and formal grievance process, emergency grievances, the availability of assistance in filing a
grievance, procedures for appeal and the opportunity to file a complaint about officer
misconduct. YCP’s handbook does not provide notice about the procedure for filing a medical
grievance (Deficiency GS-1). Although YCP’s handbook includes guarantees against reprisal
for detainees who file a grievance, it also includes language stating that nuisance filers may be
placed on a grievance filing restriction for a maximum of 90 days in which they may be
restricted to filing no more than 1 grievance each 15 working days (Deficiency GS-2).
Detainees can appeal any grievance decision to the deputy warden. If a detainee is not satisfied
with the deputy warden’s decision it may be further appealed to the county solicitor and
Complaint Review Board. The response from the solicitor is recorded in the grievance log and a
copy is provided to the detainee. If the detainee is not satisfied with the decision an appeal can
be made to the York County Prison Board.
YCP provides detainees with envelopes in which to seal grievances, identifying them as sensitive
or medically sensitive; however, they are opened and recorded in the grievance log by the
grievance coordinator before they are routed to medical staff (Deficiency GS-3). This is a repeat
deficiency originally cited in ODO’s report from April 2012.
ODO’s review of the grievance log confirmed it was current and included the grievance number,
nature of the grievance and the date it was both received and resolved. The grievance log
contained a total of 917 grievances filed by detainees in the past year. Review of the grievance
log found 227 of the grievances involved complaints about not receiving mail. ODO reviewed
30 responses provided to detainees regarding issues with the receipt of mail and all involved
contents not allowed in the facility due to security or safety reasons. ODO found 12 grievances
filed by detainees for allegations of officer misconduct and confirmed copies were forwarded to
ERO and reported to the JIC. ODO found the remaining grievances involved miscellaneous
issues and no pattern or trend was otherwise observed.
Copies of grievance dispositions are provided to detainees; however, copies are not placed in
detention files (Deficiency GS-4). 5 ODO verified medical grievance responses are maintained
in the detainee medical records as required.

5

Priority Component

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
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 right to file a grievance, including medical grievances, both informal and formal.”

DEFICIENCY GS-2
In accordance with the ICE PBNDS, Grievance Systems, section (V)(F), the FOD must ensure
“if a detainee establishes a pattern of filing nuisance complaints or otherwise abusing the
grievance system, the facility administrator may identify that person, in writing, as one for whom
not all subsequent complaints have to be fully processed. However, feedback will be provided to
the detainee, and records will be maintained of grievances rejected.”
DEFICIENCY GS-3
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(3)(2)(c), 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.”
DEFICIENCY GS-4
In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure a
copy of the grievance disposition is placed in the detainee’s detention file.

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HUNGER STRIKES (HS)
ODO reviewed the Hunger Strikes standard at YCP to determine if the facility protects
detainees’ health and well-being by monitoring, counseling, and treating detainees on hunger
strikes, in accordance with the ICE PBNDS. ODO interviewed medical and correctional staff,
and reviewed the local policy,(b)(7)estaff training records, and the medical records of four
detainees.
A review of the YCP training program and detention staff training records found no hunger
strike training is provided (Deficiency HS-1). According to the HSA, there was one detainee
hunger strike in the past year. In addition, hunger strike protocols were invoked for three
detainees whose refusal of meals ultimately did not meet the threshold of 72 hours, or nine
consecutive meals. ODO’s review of the three detainees’ medical records found staff was
proactive in placing them under medical observation and monitoring meals and vital signs. A
review of the medical record of the one confirmed hunger strike confirmed management
consistent with policy and the PBNDS with one exception: a urinalysis was not performed as
part of an initial assessment by nursing staff (Deficiency HS-2). The policy requires this in one
section; however, in another, it stipulates urinalysis is ordered at the discretion of the physician.
ODO recommends revision of the policy to comport with the standard.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY HS-1
In accordance with the ICE PBNDS, Hunger Strikes, section (V)(A), the FOD must ensure, “All
staff shall be initially and annually trained to recognize the signs of a hunger strike and on the
procedures for referral for medical assessment, and on the correct procedures for managing a
detainee on a hunger strike.”
DEFICIENCY HS-2
In accordance with the ICE PBNDS, Hunger Strikes, section (V)(C)(1)(c), the FOD must ensure,
“During the initial evaluation of a detainee on a hunger strike, medical staff shall: Perform
urinalysis.”

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LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)
ODO reviewed the Law Library and Legal Material standard at YCP to determine if detainees
have access to a law library, legal materials, courts, counsel and supplies to facilitate the
preparation of legal documents, in accordance with the ICE 2008 PBNDS. ODO observed the
law libraries, interviewed staff and detainees and reviewed policies as well as the detainee
handbook.
YCP’s Deputy Warden for Treatment oversees the Law Library program. The facility has three
large law libraries located throughout the facility, two designated for male use and the other
designated for female use. Law libraries are also designated within the confines of most housing
units. Detainees that do not have designated law libraries within their housing units, use one of
the facility’s three larger law libraries. SMU detainees have access to the law library, and are
able to access it upon request. SMU detainees are afforded the same law library privileges as
general population detainees. Detainees are afforded five hours of law library access per week,
and can request additional time by submitting a request to detention officers.
Each of the law libraries is adequately equipped with computers, printers and other supplies.
LexisNexis is installed on each computer and was last updated in February 2014. Photocopies of
appropriate legal material are available upon request, as well as a public notary and writing
implements. Detainees must save progress of legal work on the desktop of the computer
workstation last used, and are not provided a means to save legal work in a secure or private
electronic format (Deficiency LL&LM-1).
The detainee handbook provides notice of various rules and procedures regarding use of the law
library, to include the law library schedule. However, the detainee handbook does not outline the
procedure for detainees to request legal reference materials that are not maintained in the law
library (Deficiency LL&LM-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY LL&LM-1
In accordance with the ICE 2008 PBNDS, Law Libraries and Legal Material, section (V)(D), the
FOD must ensure detainees are “provided with a means of saving any legal work in a secure and
private electronic format so that they may return at a later date to access previously saved legal
work product, consistent with the safety and security needs of the detainee and facility.”
DEFICIENCY LL&LM-2
In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(O)(5), the
FOD must ensure “the detainee handbook or supplement shall provide detainees with the rules
and procedures governing access to legal materials including the following information:
1. The procedure for requesting legal reference materials not maintained in the law library.”

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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 2008 PBNDS. ODO toured the clinic, reviewed policies and procedures, verified
medical staff credentials, and interviewed the Health Services Administrator (HSA) contractor
corporate staff, and the ERO Assistant Field Office Director. In addition, ODO examined
31medical records of detainees falling into the following categories: chronic care, suspect
tuberculosis, women, detainee complaints (addressed in another section of this report), hunger
strike, suicide watch, psychotropic medication, and random healthy. All records were checked
for sick call timeliness and reviewed for transfer documentation.
Medical services are provided by contractor, PrimeCare Medical, Inc. and the facility is
accredited by NCCHC. The clinic is open 24 hours a day, seven days a week and is administered
by the HSA. Clinical oversight is provided by the full time Medical Director who shares on-call
coverage with(b)(7)efull time and(b)(7)epart time midlevel providers and alternate corporate
providers. Additional staff includes the Director of Nursing(b)(7)eassistant Directors of Nursing, an
infection control nurse,(b)(7)e
registered nurses(b)(7)elicensed practical nurses,(b)(7)eemergency medical
technicians/certified medical assistants(b)(7)eas-needed licensed practical nurses, a pharmacy
technician, and(b)(7)edministrative staff. On-site dental care services are provided by(b)(7)epart-time
dentists, a dental assistant, and an oral surgeon. Mental health services are provided by a
psychiatrist on site 16 hours per week and on call 24 hours a day, 7 days a week,
full-time
(b)(7)e
licensed professional counselors(b)(7)epart-time licensed professional counselors and(b)(7)e
designated
mental health nursing staff. There were no vacancies at the time of the review. ODO found
staffing sufficient to provide basic medical services to all detainees housed at YCP. All
professional licenses were present and primary source verified with the issuing state boards for
authentication purposes.
The clinic is spacious with a nursing station, six examination/ treatment rooms within the unit
and satellite examination rooms in the Philadelphia Air and Transportation Hub (PATH) area
and female housing unit. YCP has a total of 36 cells used for medical/psychiatric observation,
including six negative air flow cells for tuberculosis isolation. A detention officer is present for
correctional supervision when detainees are in the clinic. If a language barrier exists, bi-lingual
staff or an interpretation service is used. Detainees who require a higher level of medical care
are sent to York Hospital or Memorial Hospital, both in York, PA. Emergency response
ambulance service is provided by the York United Fire Department or Memorial Hospital,
located approximately ten minutes away. The HSA stated that because of the size of the mental
health staff and number of available observation beds, hospitalization for psychiatric reasons is
rarely required; however, if necessary, York Hospital would be used for crisis intervention.
YCP has an electronic medical record system into which medical information is entered starting
at the point of intake and continuing throughout the period of detention, supporting continuity of
care. An initial chronic care appointment is automatically scheduled for detainees identified with
chronic conditions upon intake and thereafter. Regular follow up appointments are also
automatically scheduled by way of the electronic medical record, as are annual physical
examinations and tuberculosis testing.
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Detainees are processed into YCP in one of two ways: by way of the PATH program, or directly.
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 ICE Health Services Corps (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 upon arrival to rule out the presence of tuberculosis. Detainees who
are not processed through the PATH program are screened by PrimeCare nursing staff using an
in-house form to identify chronic care issues and medication needs. Tuberculosis screening is
completed by way of purified protein derivative skin test and detainees are housed in an
admission dormitory pending clearance. If a chest X-ray is required, a contract radiology
company is used. In all 31 reviewed cases, detainees underwent intake screening within
12 hours of admission, were screened for tuberculosis, and received necessary medications and
follow-up evaluations. Female detainees are tested for pregnancy and pre-natal services are
provided, as confirmed by the medical record review and interview of the HSA.
Although ODO’s medical record review did not identify any detainees who left YCP custody
before completing a course of anti- tuberculosis therapy, the facility policy does not specify that
at least a two week supply of medications must be provided to any detainee who is transferred,
released or deported. Although the infection control nurse stated this requirement of the PBNDS
is met in practice, ODO recommends that the policy be revised to comport with the standard.
Health appraisals, which include hands-on physical examinations, and dental screening are
conducted by registered nurses trained to perform this function. ODO verified registered nurses
training and completion of health appraisals between five and 14 days of detainee admission,
including review by a physician.
Detainees access health care services by completing sick call request slips available in English
and Spanish which are printed in duplicate. The original is scanned into the electronic medical
record and the copy is given to the detainee. A review of 13 requests confirmed all were triaged
within 48 hours to determine priority for care, and the detainees were seen for sick call in a
timely manner. Nursing staff conduct sick call on a daily basis using National Commission on
Correctional Healthcare protocols. Follow-up appointments and referrals were completed as
indicated. Chronic care treatment plans and chronic care clinic encounters were documented.
There was one documented occurrence of involuntary administration of psychotropic medication
reported in conjunction with review of the Use of Force and Restraints standard. A review of
the detainee’s medical record found the psychiatrist ordered the medication by injection and use
of four point restraints for no more than 12 hours, after other, less invasive and restrictive
interventions had been attempted without success. The restraints were applied for a period of
four hours with constant video documentation supporting 15 minute checks by nursing staff.
Although local policy states a physician, certified psychiatric nurse practitioner, or other
qualified healthcare professional may order restraints, the PBNDS Medical Care standard
stipulates, “Restraints for medical or mental health purposes may be authorized only by the
facility’s clinical medical authority.” While documentation clearly documents the order from the
psychiatrist, ODO could find no documentation the medical director co-signed authorization of
the restraints (Deficiency MC-1).
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Detainees sign a general consent for treatment form for the provision of healthcare services.
General consent forms were found in all 31 records reviewed. However, consent for specific
treatment was not consistently obtained. In three of five cases where psychotropic medications
were prescribed, the provider did not obtain a separate informed consent for the medications
(Deficiency MC-2). 6
The PBNDS requires a medical/ psychiatric alert for any detainee whose condition requires
clearance by medical staff prior to release or transfer, thereby preventing release without medical
clearance and ensuring notification of ERO. To support compliance with this requirement, a
listing of all detainees with medical holds and other pertinent health status information is
distributed by medical staff at a weekly meeting with ICE, IHSC, and YCP administrative
personnel. ODO cites this as a best practice, as it pro-actively supports awareness of all
detainees with chronic medical and psychiatric needs.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE PBNDS, Medical Care, section (V)(K)(6), the FOD must ensure,
“The use of restraints for medical or mental health purposes may be authorized only by the
facility’s clinical medical authority, after reaching the conclusion that less restrictive measures
are not appropriate.”
DEFICIENCY MC-2
In accordance with the ICE PBNDS, Medical Care, section (V)(T), the FOD must ensure, “As a
rule, medical treatment shall not be administered against a detainee's will. Upon admission at the
facility, documented informed consent will be obtained for the provision of health care services.
For any additional procedure, a separate documented informed consent will be obtained.”

6

Priority Component

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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 facilities act to prevent sexual abuse and assaults on detainees, provide prompt and
effective intervention and treatment for victims of sexual abuse and assault, and control,
discipline, and prosecute the perpetrators, in accordance with the ICE 2011 SAAPI. ODO
reviewed policies, the detainee handbook, and staff training records, and interviewed staff and
detainees.
The facility signed a contract modification to incorporate the 2011 SAAPI on
September 19, 2012. The Deputy Warden is the designated PREA Coordinator for the facility.
He maintains all of the case files associated with any allegation and is responsible for updating
the facility’s written policies. ODO reviewed the facility’s policy on Sexual Abuse and Assault
Prevention. The policy addresses definitions of sexual assault; availability of community based
resources for victims, data collection, reporting procedures, the investigations process and staff
training.
All staff and volunteers are required to attend initial and annual training on the SAAPI program,
completion of which was verified by review of(b)(7)estaff training records. The last training
iteration for SAAPI was conducted in January of this year. Through review of the lesson plan,
ODO found that the training does not include prevention, recognition and appropriate response
procedures to allegations of assault involving detainees with mental or physical disabilities
(Deficiency SAAPI-1). 7
Detainees are screened by intake staff for sexual abuse victimization history, and for a predatory
history to identify potential sexual aggressors. Detainees are then screened a second time by
medical staff to determine if there is a history of victimization or abuse.
The facility provides an orientation on the SAAPI program to detainees through the detainee
handbook and a pamphlet that is handed out to detainees and are required to sign, called “ICE
Detainee Orientation to Preventing and Reporting Sexual Assault and Abuse in the Correctional
Setting.” This pamphlet covers definitions of assault, the facility’s zero-tolerance policy,
disciplinary charges for perpetrators, confidentiality, prevention techniques, reporting
procedures, the medical exam and the investigation process. The pamphlet is available in both
English and Spanish. The handbook only states that a detainee can report an allegation of sexual
assault. Through review of 15 detention files, ODO found two files contained the ICE Detainee
Orientation form (Deficiency SAAPI-2). 8 A facility supervisor stated this was because the
facility only started issuing this pamphlet in February 2014. However, the facility was
contracted in 2012 to comply with having this detainee instruction form.
According to the Joint Integrity Case Management System (JICMS) and facility staff, there have
been 11 allegations of sexual assault within the past year at the facility. Eight cases are closed
and three remain open in JICMS. Out of the eight closed, five were unsubstantiated and two
7
8

Priority Component
Priority Component

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were substantiated by OPR. The last case involved a detainee reporting an allegation to YCP
staff for an incident that occurred at another facility. This allegation was substantiated by OPR,
but referred to another investigative agency. Through review of case files ODO found that in
one instance the facility waited 24 hours before reporting the allegation to ERO (Deficiency
SAAPI-3). 9 The deputy warden stated that the facility staff member was counseled for her
failure to immediately report the allegation to supervisors and to ERO.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SAAPI-1
In accordance with the ICE PBNDS, Sexual Abuse and Assault Prevention and Intervention,
section (V)(E)(8), the FOD must ensure, “Training shall include:
8.

prevention, recognition and appropriate response to allegation or suspicions of sexual
assault involving detainees with mental or physical disabilities.”

DEFICIENCY SAAPI-2
In accordance with the ICE PBNDS, Sexual Abuse and Assault Prevention and Intervention,
section (V)(F), the FOD must ensure that, “Following the intake process, the facility shall
provide instruction to detainees on the facility’s Sexual Abuse and Assault Prevention and
Intervention Program… The facility shall maintain documentation of detainee participation in
the instruction session.”
DEFICIENCY SAAPI-3
In accordance with the ICE PBNDS, Sexual Abuse and Assault Prevention and Intervention,
section (V)(I), the FOD must ensure that, “All incidents and allegations of sexual abuse or
assault shall be reported immediately.”

9

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SPECIAL MANAGEMENT UNITS (SMU)
ODO reviewed the Special Management Units standard at YCP to determine if the facility has
procedures in place to temporarily segregate detainees for disciplinary and administrative
reasons, in accordance with the ICE 2008 PBNDS. ODO toured the SMUs, interviewed staff
and detainees, and reviewed policies, log books and SMU documentation.
YCP has policies addressing removal of detainees from general population and multiple
segregation designations. YCP segregates detainees for administrative and disciplinary reasons
as described in the PBNDS; however, they do not refer to detainee segregation status as
“administrative” or “disciplinary.” YCP has 14 housing areas designated as SMUs, 10 for
male detainees and 4 for female detainees. Per policy and in practice, detainees may be assigned
to more than one segregation status at a time, and may concurrently be on mental health or
medical observation status.
Detainees assigned to segregated housing have the opportunity to shower three times a week.
They have access to reading materials, including legal reference materials from the facility
library and access to legal counsel. Indigent detainees are permitted to mail three pieces of
general mail and at least five pieces of legal mail per week, without charge. All meals are served
inside the cells unless detainees are specifically authorized to eat in the dayroom. One hour of
outside recreation is offered five times per week, weather permitting, with detainees of the same
status. Indoor recreation is provided in the dayroom one hour per day, five days per week.
Religious services are provided on the units by the chaplain. Detainees are permitted three
telephone calls per week unless they are assigned to disciplinary segregation status. Detainees
on disciplinary segregation are limited to one call for the first 30 days except for emergency and
legal calls. Medical rounds in segregation areas are conducted on a daily basis and mental health
rounds are conducted weekly. Logs are maintained to record activities.
Responsibility for reviewing the status of detainees in segregation is assigned to the facility’s
multi-disciplinary Program Review Committee. The committee reviews the status of every
detainee assigned to segregation within 72 hours of placement, and on a weekly basis.
YCP has 14 housing areas designated as SMUs, 10 for male detainees and 4 for female
detainees. ODO toured each SMU and verified the cells were appropriately equipped, well lit,
adequately ventilated, and maintained in a sanitary condition. Shower facilities were available
within the units.
During ODO’s inspection there were eight detainees housed in SMUs: four by order of health
care staff for medical and psychiatric reasons, three for disciplinary reasons, and one for
protective custody. A review of documentation for the four detainees segregated for health care
reasons found written orders were issued and required status reviews were conducted.
Documentation of monitoring and daily rounds by health care staff was present. The detainee on
protective custody requested placement on this status on December 16, 2013, having been the
victim of a physical assault by a county inmate. Review of documentation and interview of
facility and ERO staff confirmed a segregation order was issued and the required segregation
reviews were completed, to include reviews by ERO. The most recent review by ERO was
completed on March 14, 2014, and continued placement was supported. Segregation housing
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records documented fulfillment of requirements for basic living conditions required by the
PBNDS.
ODO’s review of the three disciplinary segregation cases found all three detainees were
originally placed on this status prior to hearing and adjudication by the IDP
(Deficiency SMU-1). Facility policy allows placement on disciplinary segregation status prior
to adjudication by the IDP, if infractions cannot be informally resolved by the captain who
investigates the incident. While awaiting hearing before the IDP, the detainees were subject to a
greater level or restriction of privileges than allowed for a non-punitive segregation status
(Deficiency SMU-2). All three detainees were subsequently found guilty of their infractions by
the IDP and sanctioned with disciplinary segregation terms ranging from 45 to 60 days.
Segregation reviews were completed by the Program Review Committee as required and ICE
was notified.
ODO reviewed 55 randomly selected SMU assignments, 25 of which were for disciplinary
segregation. All 25 disciplinary segregation placements preceded hearing before the IDP
(previously cited Deficiency SMU-1). ODO verified compliance with all other PBNDS
requirements for the 55 SMU placements reviewed.

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY SMU-1
In accordance with the ICE PBNDS, Special Management Units, section (V)(D), the FOD must
ensure, “To provide detainees in the general population a safe and orderly living environment,
facility authorities shall discipline anyone whose behavior does not comply with facility rules
and regulations. Such discipline may involve temporary confinement in the SMU apart from the
general population. A detainee may be placed in Disciplinary Segregation only by order of the
Institutional Disciplinary Panel (IDP), or its equivalent, after a hearing in which the detainee has
been found to have committed a prohibited act. Ultimately, the IDP may order the detainee’s
placement into Disciplinary Segregation, but only when alternative dispositions would
inadequately regulate the detainee’s behavior.”
DEFICIENCY SMU-2
In accordance with the ICE PBNDS, Special Management Units, section (V)(A), the FOD must
ensure, “A detainee may be placed in Disciplinary Segregation only after being found guilty,
through a formal disciplinary process, of a facility rule violation. Therefore, detainees in
Disciplinary Segregation generally have fewer privileges than those in non-punitive
Administrative Segregation. In particular, they are subject to more stringent controls, for
example, in regard to personal property and reading material. Additional limitations may also be
imposed upon their television viewing, commissary/vending machine privileges, etc.

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at the YCP to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and
others in the community, in accordance with the ICE 2008 PBNDS. ODO interviewed facility
staff and detainees, reviewed policy, procedures, and the detainee handbook, and conducted
functionality tests on the telephones located in detainee housing units.
YCP provides detainees with reasonable and equitable access to telephones from 7 a.m. to 10
p.m. on weekdays, and 7 a.m. to 11 p.m. on weekends and holidays. The telephone availability
ratio is roughly three detainees per phone. The facility has six operational TTY devices on hand
if needed. YCP allows detainees to setup a personal identification number to make collect calls
for domestic locations, but must purchase calling card for international calls. All phone calls are
limited to 20 minutes. Detainees are given emergency messages and allowed to return
emergency telephone calls without delay.
A review of the YCP Detainee Telephone Log confirmed facility personnel conduct daily
inspections of telephone. Additionally, ODO reviewed ERO Telephone Serviceability
Worksheets from December 2013 through March 2014 and confirmed weekly telephone
inspections by ERO staff. ODO reviewed 20 maintenance requests for telephone repairs and 20
work orders for those repairs. All 20 work orders were promptly reported to the service
provider.
ODO checked the operability of 25 telephones in detainee housing areas by speed dialing preprogrammed numbers for OIG, foreign consulates, and pro bono legal services and found them
to be in good working order. Notifications that calls are subject to monitoring were included in
the message on the phone in six different languages and were posted in English and Spanish on
the wall next to each telephone.
Access rules for use of the telephones was observed in the immediate vicinity of each designated
telephone location and explained in the detainee handbook. However, YCP did not have the
procedures for obtaining an unmonitored call to a court, a legal representative, or for the
purposes of obtaining legal representation posted or explained in the detainee handbook
(Deficiency TA-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE PBNDS, Telephone Access, section (V)(B), the FOD must ensure “at
each monitored telephone, place a notice that states:
•

The procedure for obtaining an unmonitored call to a court, a legal representative, or for
the purposes of obtaining legal representation.”

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USE OF FORCE AND RESTRAINTS (UOF&R)
ODO reviewed the Use of Force and Restraints standard at YCP to determine if necessary use of
force is utilized only after all reasonable efforts have been exhausted to gain control of a subject,
while protecting and ensuring the safety of detainees, staff and others, preventing serious
property damage, and ensuring the security and orderly operation of the facility, in accordance
with the ICE 2008 PBNDS. ODO toured the facility, inspected security equipment, and
reviewed the local policies, training records, and use-of-force documentation.
A review of(b)(7)erandomly selected staff training records confirmed YCP officers receive required
training in use-of-force principles and techniques, including confrontation avoidance, the use-offorce continuum, forced cell moves, and application of restraints. YCP has a Correctional
Emergency Response Team, members of which are available on all shifts in the event a
calculated use-of-force incident arises. ODO’s inspection found protective equipment is stored
in a secure room with staff-only access, and readily accessible to team members. Video cameras
are located in the control center and documentation reflects their operability is verified daily. In
addition, the requirement to video record calculated force incidents is supported by use of
cameras mounted on the helmets worn by team members. Correctional Emergency Response
Team members and YCP supervisory staff are authorized to carry Electronic Body Immobilizer
Devices and Tasers. ODO reviewed training documentation and verified training in their use and
deployment. Oleoresin Capsicum spray is authorized in accordance with facility policy and
certification of staff carrying Oleoresin Capsicum spray was verified by ODO. There were no
documented cases of Electronic Body Immobilizer Devices or Taser use on ICE detainees in the
past year.
According to staff interviews and based on review of documentation, there were no calculated
and 20 immediate use-of-force incidents involving detainees in the past year. ODO’s review of
documentation confirmed reports were written and forwarded to ERO; however, after-action
reviews were not conducted in any of the 20 cases. A review of facility policy and interview of
the Deputy Warden found YCP does not have written procedures for after-action review of useof-force incidents and applications of restraints (Deficiency UOF&R-1).
During review of the 20 immediate use-of-force incidents, ODO noted one involved involuntary
administration of psychotropic medication. Documentation reflects the psychiatrist ordered the
medication by injection and placement in four-point restraints because the detainee was inflicting
serious self-harm. Audio visual recording equipment was retrieved to record placement of the
detainee in the restraint chair for administration of the medication, and subsequent placement in
four-point restraints. The medical assessment of the detainee, placement in restraints, and reassessment by medical staff every 15 minutes was recorded. The detainee remained in fourpoint restraints for approximately four hours.
ODO’s review of the facility’s use-of-force policy found it does not address after- action
reviews. One additional policy omission was identified: the policy allows for use of deadly force
to prevent an escape or to affect the recapture of an escapee. This is contrary to the ICE PBNDS,
Use of Force and Restraints, section (V)(B)(15), which states, “Deadly force is not to be used on
detainees unless the officer has a reasonable suspicion that the detainee poses an imminent
danger of death or serious physical injury to the officer or to another person. Deadly force may
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not be used solely to prevent the escape of a fleeing suspect.” Deficiency is not cited because
there have been no deadly force incidents constituting violation of the standard; however, ODO
recommends revision of the policy to comport with the standard.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF&R-1
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(P)(1), the FOD
must ensure, “All facilities shall have ICE/DRO-approved written procedures for After-Action
Review of use-of-force incidents (immediate or calculated) and applications of restraints. The
primary purpose of an After-Action Review is to assess the reasonableness of the actions taken
and determine whether the force used was proportional to the detainee's actions.
IGSAs shall model their incident review process after ICE/DRO’s process and submit it to
ICE/DRO for DRO review and approval. The process must meet or exceed the requirements of
ICE/DRO’s process.”

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