Medical Processes and
Communication Protocols
Need Improvement at
Irwin County Detention
Center

Homeland
Security

January 3, 2022
OIG-22-14

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Washington, DC 20528 / www.oig.dhs.gov

January 3, 2022
MEMORANDUM FOR:

Tae D. Johnson
Acting Director
U.S. Immigrations and Customs Enforcement

FROM:

Joseph V. Cuffari, Ph.D.
JOSEPH V
Inspector General

CUFFARI

SUBJECT:

Digitally signed by JOSEPH
V CUFFARI
Date: 2022.01.03 15:09:13
-05'00'

Medical Processes and Communication Protocols Need
Improvement at Irwin County Detention Center

Attached for your information is our final report, Medical Processes and
Communication Protocols Need Improvement at Irwin County Detention Center.
We incorporated the formal comments provided by U.S. Immigrations and
Customs Enforcement in the final report.
The report contains five recommendations aimed at improving ICE’s oversight
of medical care and facility operations at Irwin County Detention Center
,&'&  Your office concurred with one recommendation but GLGQRWFRQFXU
ZLWKIRXUUHFRPPHQGDWLRQVDVLWQRORQJHUKRXVHVGHWDLQHHVDW,&'&DQGLWV
FRQWUDFWZLWK,&'&HQGHGRQ2FWREHUBased on information provided
in the response to the draft report, we consider one recommendation open and
resolvedWe have administratively closed four recommendations that cannot
be implemented due to the termination of the I&'& contract. Once your office
has fully implemented the recommendation, please submit a formal closeout
letter to us within 30 days so that we may close the recommendation. The
memorandum should be accompanied by evidence of completion of agreedupon corrective actions and of the disposition of any monetary amounts.
Please send your response or closure request to oigispfollowup@oig.dhs.gov.
Consistent with our responsibility under the Inspector General Act, we will
provide copies of our report to congressional committees with oversight and
appropriation responsibility over the Department of Homeland Security. We
will post the report on our website for public dissemination.
Please call me with any questions, or your staff may contact Thomas Kait,
Deputy Inspector General for Inspections and Evaluations, at (202) 981-6000.
Attachment

DHS OIG HIGHLIGHTS
Medical Processes and Communication Protocols
Need Improvement at Irwin County Detention Center
January  2022

Why We Did
This Inspection

In September 2020, DHS
OIG received complaints
concerning medical care,
response to COVID-19
protocols, retaliation against
employees and detainees,
and specific allegations
about detainees referred for
gynecological procedures at
ICDC. We sought to
determine whether ICDC
provided detainees adequate
medical care and adhered to
COVID-19 protections. This
inspection did not review the
gynecological procedure
approval process for
detainees at ICDC, which
has been referred to our
Office of Investigations.

What We
Recommend

We made five
recommendations to improve
ICE’s oversight of medical
care and facility operations
at ICDC.
For Further Information:

Contact our Office of Public Affairs at (202)
981-6000, or email us at
DHS-OIG.OfficePublicAffairs@oig.dhs.gov

www.oig.dhs.gov

What We Found

We determined Irwin County Detention Center (ICDC) in
Ocilla, Georgia, generally met U.S. Immigration and
Customs Enforcement (ICE) detention standards, which
specify that detainees have access to appropriate and
necessary medical, dental, and mental health care.
However, our contract medical team’s evaluation of
ICDC’s medical processes found the facility’s chronic
care, continuity of care, and medical policies and
procedures to be inadequate. The medical team
identified additional concerns in seven other areas:
health assessments, medication administration, sick
call, health records, program administration, emergency
care, and women’s health. We initiated a separate audit
which will focus on how surgical procedures are
authorized and approved for detainees across ICE
detention facilities.
Similar to our findings on the ICE detention standards,
the facility generally complied with Centers for Disease
Control and Prevention and ICE COVID-19 guidance,
but ICDC and ICE management did not adequately or
consistently keep facility employees, ICE staff, and
detainees informed of COVID-19 protocols and guidance.
We also found that detainees’ communication with, and
access to, their ICE deportation officers were limited.
Further, some ICE officers stated they were not
comfortable expressing concerns with detention
conditions.

ICE Response

ICE did not concur with four recommendations as it no
longer houses detainees at ICDC and its contract with
ICDC ended on October 7, 2021, but concurred with one
recommendation directed at enhancing communication
among Atlanta Field Office. We have administratively
closed four recommendations and consider one
recommendation resolved and open.
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Table of Contents
Introduction.................................................................................................... 3
Background .................................................................................................... 3
Results of Inspection....................................................................................... 6
Medical Care Provided to Detainees Generally Met Standards, but
Improvements Were Warranted .............................................................. 7
ICDC Generally Complied with CDC and ICE COVID-19 Guidance, but
Faced Challenges Implementing Protocols............................................ 12
Communication about COVID-19 to ICE Officers, Facility Staff, and
Detainees Was Inconsistent ................................................................. 17
Detainees’ Access to ICE Deportation Officers Was Limited during the
COVID-19 Pandemic ............................................................................ 19
Detainees and ICDC Staff Were Generally Comfortable Lodging
Concerns, but Some ICE Officers Were Hesitant to Voice Their
Concerns ............................................................................................. 21
Recommendations......................................................................................... 22
Management Comments and OIG Analysis .................................................... 23

Appendixes
Appendix A: Objective, Scope, and Methodology ................................. 26
Appendix B: ICE Comments to the Draft Report................................... 27
Appendix C: NCCHC Resources, Inc., Irwin County Detention Center
Inspection Report ................................................................................ 32
Appendix D: Office of Inspections and Evaluations Major Contributors
to This Report .................................................................. 64
Appendix E: Report Distribution .......................................................... 65

Abbreviations
ADP
CDC
COVID-19
www.oig.dhs.gov

average daily population
Centers for Disease Control and Prevention
coronavirus disease 2019
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DOJ
DRF
ERO
EUA
FDA
HIPAA
ICDC
ICE
IGSA
IHSC
LPN
NCCHC
NSAID
PBNDS
PPE
PRR
TDY
U.S.C.

www.oig.dhs.gov

Department of Justice
Detainee Request Form
Enforcement and Removal Operations
Emergency Use Authorization
Food and Drug Administration
Health Insurance Portability and Accountability Act
Irwin County Detention Center
U.S. Immigration and Customs Enforcement
intergovernmental services agreement
ICE Health Service Corps
licensed practical nurse
National Commission on Correctional Health Care
non-steroidal anti-inflammatory drug
Performance-Based National Detention Standards
personal protective equipment
Pandemic Response Requirements
temporary duty
United States Code

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Introduction
In September 2020, Project South, an advocacy group, filed a complaint with
Department of Homeland Security Office of Inspector General concerning the
Irwin County Detention Center (ICDC) in Ocilla, Georgia, which houses U.S.
Immigration and Customs Enforcement (ICE) detainees. We started our review
in October 2020. The complaint included allegations from ICE detainees and a
licensed practical nurse previously employed by ICDC about inappropriate
medical care, inadequate response to coronavirus disease 2019 (COVID-19),
and retaliation against employees and detainees.1 It also included specific
allegations about the rate at which intrusive gynecological procedures were
performed on ICE detainees in ICDC custody. In response to this complaint,
numerous hotline complaints DHS OIG recieved,2 and congressional requests,
we sought to determine whether ICDC provided adequate medical care to
detainees and whether COVID-19 protections were in place and adequate. This
inspection did not review the gynecological procedure approval process for
detainees at ICDC, which has been referred to our Office of Investigations.
We also initiated a separate audit which will focus on how surgical procedures
are authorized and approved for detainees across ICE detention facilities.

Background
ICE apprehends, detains, and removes noncitizens who are in the United
States unlawfully. ICE Enforcement and Removal Operations (ERO) oversees
the detention of noncitizens in approximately 150 detention facilities in
conjunction with private contractors or state or local governments. ICDC is
owned by LaSalle Corrections and operates under an intergovernmental service
agreement (IGSA) as an ICE detention facility.3 As of February 2021, ICDC
held 236 male and 9 female immigration detainees. In addition to ICE
detainees, the facility houses Federal prisoners for the U.S. Marshals Service
and Irwin County inmates. In May 2021, Secretary Mayorkas announced DHS
1 Allegations regarding reprisal or retaliation against employees were referred to another DHS
OIG office.
2
Between FY 2017 and FY 2020, the DHS OIG Hotline received 795 complaints referencing
ICDC. Many Hotline complaints originated from detainees in the facility, family members of
detainees within the facility, and those who had previously been detained at ICDC.
3 ICE uses DHS authority under the Immigration and Nationality Act to enter into IGSAs with
state or local entities (e.g., a county sheriff or a city government). These entities, in turn, may
contract with a private company to provide detention services, or provide the services using
local law enforcement entities (such as a local jail that holds local criminal populations and
ICE detainees). The Immigration and Nationality Act, as amended, grants ICE the authority to
enter into an agreement with a state or locality to provide necessary clothing, medical care,
requisite guard hire; and the housing, care, and security for detained individuals. See 8 United
States Code (U.S.C.) § 1103(a)(11)(A).

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plans to discontinue the use of ICDC as soon as possible and transfer all
detainees whose continued detention is necessary. ICE terminated the
contract with LaSalle Corrections effective October 7, 2021, and as of
September 3, 2021, ICE no longer houseddetainees at ICDC.
ICDC is required to follow the 2011 ICE Performance-Based National Detention
Standards (PBNDS).4 According to ICE, the PBNDS reflect ICE's ongoing effort
to tailor the conditions of immigration detention to its unique purpose while
maintaining a safe and secure detention environment for staff and detainees.
ICE detention standards require that all facilities provide detainees with access
to appropriate and necessary medical, dental, and mental health care,
including emergency services. These standards also require facilities to have
written plans that address the management of infectious and communicable
diseases, including, but not limited to, education, prevention, testing, and
isolation.
ICE Health Service Corps (IHSC) provides direct on-site medical services in at
least 20 facilities that house ICE detainees for more than 72 hours. At all
other detention facilities, including ICDC, local government staff or private
contractors deliver on-site care while IHSC provides general oversight of those
facilities’ medical services.5 ICE ERO also provides on-site management of
detention operations in an effort to ensure a safe and secure detention
environment for staff and detainees. At the time of our review, the ICE staff at
ICDC included a detention standards compliance officer from ICE ERO Custody
Management, as well as an ERO supervisory detention and deportation officer,
and three deportation officers, some on permanent and some on temporary
bases.6
On March 11, 2020, the World Health Organization declared the outbreak of
the infectious and communicable COVID-19 a pandemic. In March 2020, ERO
decided to reduce the population of all detention facilities to 75 percent
capacity or less, to allow for greater social distancing.7 When we initiated this
ICDC followed the 2008 PBNDS until June 15, 2020.
IHSC does not directly provide or direct the medical care in approximately 148 non-IHSCstaffed detention facilities. IHSC oversees those facilities’ compliance with national detention
standards and coordinates medical referrals through the Field Medical Coordinator Program.
In addition, IHSC oversees the financial authorization and payment for off-site specialty and
emergency care services for detainees in ICE custody.
6 In lieu of assigning all deportation officers at ICDC on a permanent basis, some ICE officers
have temporary duty (TDY) assignments to ICDC, which can be voluntary or mandatory, with
an average detail length of 60 days.
7 Since March 1, 2020, ICE ERO has decreased its detainee population by more than 7,000
individuals. In March 2020, ERO evaluated its detainee population and released more than
4
5

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review in October 2020, ICDC had an average daily population (ADP) of 406,
compared with 878 detainees in October 2019, a 54 percent reduction.
Although ICE reduced the ICDC ADP and the facility enhanced COVID-19
sanitation protocols, we were not able to determine if these actions had a direct
effect in mitigating the spread of COVID-19 in the facility. Table 1 shows the
reduced ADP at ICDC from October 2019 to March 2021.
Table 1. ICDC Average Detainee Population (ADP), October 2019 to May
2021
Month
October 2019
November 2019
December 2019
January 2020
February 2020
March 2020
April 2020
May 2020
June 2020
July 2020
August 2020
September 2020
October 2020
November 2020
December 2020
January 2021
February 2021
March 2021
April 2021
May 2021

Female ADP
344
324
296
292
297
277
189
140
127
119
113
100
85
71
50
24
9
5
1
0

Male ADP
533
495
462
453
420
354
395
393
352
391
369
336
321
298
319
296
236
180
111
271

Total ADP
878
819
758
745
717
631
583
534
479
510
482
436
406
369
369
320
245
185
113
271

Source: ICE Integrated Decision Support.
Note: Due to rounding, the total ADP may not equal the sum of the male and female ADP for
each month.

In response to the pandemic, the Centers for Disease Control and Prevention
(CDC) issued its Interim Guidance on Management of Coronavirus Disease 2019
900 individuals who might be at higher risk for severe illness as a result of COVID-19, after
evaluating their immigration history, criminal record, potential threat to public safety, flight
risk, and national security concerns. ERO continues to assess other potentially vulnerable
populations currently in ICE custody and all new arrestees. Additionally, ERO has fewer new
detainees coming from U.S. Customs and Border Protection, resulting from Title 42
restrictions. See https://www.ice.gov/coronavirus and 42 U.S.C. § 265, 268 (b).
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(COVID-19) in Correctional and Detention Facilities, to “ensure continuation of
essential public services and protection of the health and safety of incarcerated
and detained persons, staff, and visitors.”8 The CDC frequently updated this
guidance on its website between March 2020 and June 2021 as more
information about COVID-19 became available. Based on CDC guidance, ICE
provided Pandemic Response Requirements (PRR) to help facility operators
“sustain detention operations while mitigating risk to the safety and well-being
of detainees, staff, contractors, visitors, and stakeholders due to COVID-19.”9
ICE first issued the PRRs in April 2020 and subsequently released five updated
versions as COVID-19 protocols evolved.
The objective of our review was to determine whether ICDC provided adequate
medical care to detainees and whether COVID-19 protections were in place and
adequate.10 We conducted our work remotely, given the inherent risks
associated with on-site inspections during the COVID-19 pandemic.11 We
interviewed ICE personnel, ICDC officials, and detainees by telephone. We also
viewed surveillance video from common and housing areas. To assess medical
care, we utilized medical experts from the National Commission on Correctional
Health Care (NCCHC) Resources, Inc.12 to conduct a virtual tour of the ICDC
medical unit and medical records review.

Results of Inspection
We determined ICDC generally met ICE detention standards, which specify that
detainees have access to appropriate and necessary medical, dental, and
mental health care. However, the NCCHC Resources medical team’s evaluation
of ICDC’s medical processes found the facility’s chronic care, continuity of care,
and medical policies and procedures to be inadequate. The medical team
identified additional concerns in seven other areas: health assessments,
medication administration, sick call, health records, program administration,
emergency care, and women’s health. Similar to our findings on the ICE
detention standards, the facility generally complied with CDC and ICE COVID19 guidance, but ICDC and ICE management did not adequately or
https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidancecorrectional-detention.html.
9 ERO, COVID-19 Pandemic Response Requirements (Version 1.0, April 10, 2020).
10 DHS OIG is also conducting a separate, in-depth evaluation of ICE’s handling of COVID-19
in its detention facilities.
11
At the time of this review, COVID-19 vaccines were not widely available.
12 NCCHC Resources, Inc. works to strengthen the mission of its parent company (NCCHC), to
improve the quality of health care in prisons, jails, and juvenile detention and confinement
facilities. NCCHC Resources was created to manage the increasing demand for correctional
health care technical assistance and other consulting work through the provision of highquality consulting services. https://www.ncchc.org/work
8

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consistently keep facility employees, ICE staff, and detainees informed of
COVID-19 protocols and guidance. We also found that detainees’
communication with, and access to, their ICE deportation officers were limited.
Further, some ICE officers stated they were not comfortable expressing
concerns about detention conditions during the pandemic.

Medical Care Provided to Detainees Generally Met Standards,
but Improvements Are Necessary
We determined ICDC adhered to ICE 2011 PBNDS, which specify that
detainees have access to appropriate and necessary medical, dental, and
mental health care.13 Our contracted medical team assessed the adequacy of
medical processes and policies and the appropriateness of any actions taken to
address medical concerns.14 NCCHC Resources’ full report evaluating the 36
defined medical care processes is included as Appendix C. Of those 36
processes, NCCHC Resources determined 3 — chronic care, continuity of care,
and policies and procedures — were inadequate.15 The medical team identified
additional concerns in seven other areas: health assessments, medication
administration, sick call, health records, program administration, emergency
care, and women’s health.16 These results should be considered in the context
that medical care in fiscal year 2020 was provided to a detainee population in
ICDC that was significantly less than normal, due to the COVID-19 pandemic.
ICDC Medical Unit Needs to Improve Chronic Care Program Organization,
Continuity of Care, and Policies and Procedures
The contract medical team reviewed 37 medical files with chronic care
diagnoses. The team determined that care for chronic conditions, such as
hypertension, hyperlipidemia, diabetes, asthma, and menstrual disorders,
appeared adequate, but that the chronic care program itself was inadequate.17
Of the 37 medical files reviewed, the NCCHC Resources physician identified

ICE, Performance-Based National Detention Standards, 2011, § 4.3, Medical Care (Revised
Dec. 2016) (“PBNDS 2011”).
14 NCCHC Resources’ review included 195 medical records of detainees with stays at ICDC of
180 days or longer between FY 2017 and FY 2020, as well as the provision of care for 37
detainees who had chronic care conditions. NCCHC Resources also reviewed 5 medical records
resulting from our interviews with ICDC detainees.
15 See Appendix C, Policies and Procedures, pp. 38–39; Chronic Care, pp. 44–45; and Continuity
of Care, pp. 45–46.
16 See Appendix C, Health Assessments, pp. 40–41; Pharmacy Management/Medication
Management, pp. 49–50; Sick Call/Nursing Protocols, pp. 43–44; Health Records, p. 38; Program
Administration, p. 37; Emergency Care, p. 48; and Women’s Health, pp. 46–47.
17 See PBNDS 2011, § 4.3, Medical Care, W. Special Needs and Close Medical Supervision.
13

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issues in 15 files related to chronic care management.18 Our contract medical
team found the medical unit did not have consistent guidance or providerdeveloped guidelines for chronic care; rather, ICDC medical staff reported using
several different guidance documents for care. The contract medical team also
found provider staff were not monitoring and documenting the current status
or condition of detainees with chronic conditions. In addition, the contract
medical team identified records where providers acknowledged laboratory
results, but did not include interpretation of those results, actions taken
regarding those results, and proof of sharing the results with the detainee.
The NCCHC Resources physician identified issues regarding the continuity of
care process19 in 12 of the 37 detainee medical files reviewed.20 In nine of the
cases, the physician highlighted issues with both continuity of care and
chronic care. These issues included multiple medical files missing care
plans,21 records without planned chronic care visits,22 missing laboratory
results,23 and improper medications.24 We also found issues in medical
records, including unexplained orders, grievance responses, improper referrals,
and timeliness concerns.25
The contract medical team deemed ICDC’s policies and procedures process
inadequate because ICDC had not established facility-specific policies and
procedures. Instead, it relied on overarching policies and procedures
established by the facility contractor, LaSalle Corrections. For example, we
found the terminal illness policy references Louisiana state laws, even though
ICDC is located in the state of Georgia.26 Additionally, a detainee medical
restraint and seclusion policy exists despite ICDC reporting that the facility
does not use either method in the ICDC medical facility. Without clear written
policies and procedures specific to the facility, ICDC staff do not have adequate
guidance. As a result of the lack of facility specific policies, the facility was also
found to be delinquent on annual reviews of facility-specific policies and

For chronic care issues, see cases 1, 4, 8–9, and 13–20 in Appendix C.
PBNDS 2011, § 4.3, Medical Care, Z. Continuity of Care. Continuity of care requires the
facility Health Service Administrator to ensure a plan is developed that provides for continuity
of medical care in the event of a change in detention placement or status.
20 For continuity of care issues, see cases 2–4, 6, 8, 10–17, and 19–20 in Appendix C.
21 Appendix C, cases 6, 10–12, and 14–15.
22 Appendix C, cases 2, 4, 11, and 13.
23 Appendix C, cases 1, 9–10, 12, and 19–20.
24 Appendix C, cases 3, 5, 7–8, 11, 16, 18, and 20.
25 Appendix C, see case 20 for unexplained order, case 4 for issues with grievances, case 3 for
improper referrals, and case 17 for timeliness concerns.
26
It appears ICDC’s terminal illness policy referenced Louisiana state laws because ICDC was
using a policy from another LaSalle detention facility located in Louisiana.
18
19

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procedures, which are necessary to ensure appropriate updates are made when
said policies and procedures are in place.
ICDC Needs to Improve Health Assessments, Medication Administration,
Sick Call, Health Records, Program Administration, Emergency Care, and
Women’s Health
Health Assessments
The contract medical team reviewed 195 detainee intake records and found
that care was timely and complete, with only 3 records indicating minor issues
that were not reflections of an inefficient intake program.27 Overall, ICDC’s
compliance with standards in this area was adequate, but there is room for
improvement. For example, we found ICDC does not have defined health
assessment criteria to provide consistent and adequate periodic health
assessments.28 We also identified 7 records indicating the health assessment
occurred after the required 14-day timeframe, and 15 records missing health
assessment documentation. Additionally, the NCCHC Resources physician
found one case where a detainee reported at intake a history of asthma with
previous inhaler use, but the initial health assessment of the detainee, days
later, did not acknowledge that health history.29
Medication Administration Process
The 2011 PBNDS require prescriptions and medications to be ordered,
dispensed, and administered in a timely manner and as prescribed by a
licensed health care professional.30 Although the pharmacy and the
medication management processes were found to be adequate, some issues in
medication administration exist. For example, our medical contractors found it
“almost impossible to provide an accurate assessment of medication
administration practices based on the documentation provided in the health
record.”31 To complete the medication assessment review, the medical team
PBNDS 2011, § 2.1, Admission and Release. Intake occurs within 12 hours of a detainee’s
arrival at the facility and prior to placement in the general population. A more in-depth initial
health care assessment occurs after intake, approximately 14 days after a detainee’s arrival at
the facility. PBNDS 2011, § 4.3, Medical Care. Each detainee shall receive a comprehensive
health assessment, including a physical examination and mental health screening, by a
qualified, licensed health care professional no later than 14 days after entering into ICE
custody or arrival at facility.
28 See Appendix C.
29 Asthma is a chronic care condition that requires continuous and ongoing care. See
Appendix C, case 4.
30 PBNDS 2011, § 4.3, Medical Care.
31 Appendix C, report p. 16.
27

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needed the original order, documentation of first dose, and the medication
administration record, which were missing from the health records provided
from ICDC. To determine the quality of medication services, the contracted
medical team reviewed 37 chronic care health records. Of the 37 records, 22
indicated detainees were seen by a provider, received their medication
promptly, and were found to have properly taken the medication. The
remaining 15 records showed detainees’ general lack of compliance taking
medication. Nursing staff documented detainees who did not show up for pill
call, but the records did not have detainee signatures demonstrating refusal of
the medication.32 Additionally, only some detainees received provider’s
education on the importance of medication administration.
During our interviews, a detainee reported difficulty receiving medication, and
we referred the case to the NCCHC Resources physician for review.33 This
record revealed the detainee did not show up for medication pass34 to receive
the prescribed medication for most of July and part of August 2020. The
medical staff did not adhere to the facility policy requiring provider medication
counseling after 3 days of missed medication. The detainee was not seen by a
provider until August 9, 2020.
Sick Call and General Nursing Protocols
The NCCHC Resources team found co-related issues in the areas of sick call
and nursing protocols.35 They reviewed 195 health records with 236 sick call
visits. The team determined that care provided during 8 of the 236 visits could
have had been more appropriate. The team also found issues with nursing
protocols that allow the nursing staff to provide over-the-counter medications
without checking the current medications the detainee is prescribed. For
example, the nursing protocols allow nurses and licensed practical nurses
(LPN) to administer appropriate amounts of ibuprofen to detainees, resulting in
some detainees receiving ibuprofen while already on other non-steroidal antiinflammatory drugs (NSAID), which the NCCHC Resources team determined

PBNDS 2011, § 4.3, Medical Care. ICE requires facilities to maintain written records of all
prescribed medication given to or refused by detainees.
33 Appendix C, case B.
34 Medication pass is the administering of prescribed drugs by nurses or aides to a group of
patients or residents, in accordance with state and federal standards.
35 2011 PBNDS, § 4.3, Medical Care, S. Sick Call. Facilities are required to have sick-call
procedures that allow detainees unrestricted opportunity to freely request health care services
and that ensure sick-call requests are received and triaged by appropriate medical personnel
within 24 hours of the detainees’ requests. At ICDC, detainees are able to make sick-call
requests using electronic tablets or by submitting paper requests into a confidential lockbox.
32

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was inappropriate.36 An ICDC provider specifically stated in one medical
record that the detainee was not to be prescribed NSAIDs. However, the
detainee was prescribed an NSAID 3 days later during a sick-call visit by a
different provider. The current facility-established nursing protocols would not
identify this medication administration as inappropriate.37
During our interviews on February 24, 2021, one detainee reported being
referred to a provider during a sick-call visit but was restricted from seeing a
provider due to being under a quarantine. We referred this case to the NCCHC
Resources physician who reviewed the medical record and found the detainee
had been referred to a provider on February 12, 2021, but there was no
documentation indicating a provider had ever seen the detainee.38 On-site
medical staff assured the team that quarantine does not limit a detainee’s
ability to be seen by a provider. However, staff could not supply
documentation showing a provider saw the detainee.
Health Records
During the health records review, the contracted medical team was unable to
determine if a Health Insurance Portability and Accountability Act (HIPAA)
program was in place and properly applied. No evidence of HIPAA training was
provided to the medical team for evaluation, despite the team’s request.
Overall Program Administration
The program administration review found ICDC’s medical unit had not
developed a continuous quality improvement program. The purpose of a
continuous quality improvement program is to improve health care by
identifying problems, implementing and monitoring corrective action, and
studying the improvement program’s effectiveness. ICDC did not provide
documentation showing any organized approach to evaluate the delivery of
health care services.

Appendix C cases 3, 5, and 18. NCCHC Resources defines nursing protocols as written
instructions or guidelines that specify the steps to be taken to evaluate a patient’s health
status and provide intervention. These protocols include acceptable first-aid procedures and
care of ailments that would ordinarily be treated with over-the-counter medication or through
self-care.
37 Appendix C, case 18.
38 Appendix C, case A.
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Emergency Care
During the emergency care review, despite NCCHC Resources’ request, the
medical unit was unable to provide emergency response drill documentation,
making it unclear whether the drills were being conducted. Lack of emergency
preparation, such as conducting drills, could hinder proper response to
emergency situations at ICDC.
Women’s Health
Based on its medical records review, the NCCHC Resources team determined
women’s health care to be appropriate.39 However, off-site specialty provider
care information was not consistently returned to the ICDC medical unit.
Proper health assessments, medication administration, sick-call procedures,
and general nursing protocols are necessary to ensure that sufficient care is
provided to detainees. Appropriate documentation, procedures for health
records, and off-site documentation related to women’s health care ensure
adequate care is provided to each individual detainee. Continuous quality
improvement protocols ensure responsiveness to detainee needs. Additionally,
having emergency response plans ensures personnel and detainee safety while
in the medical unit.

ICDC Generally Complied with CDC and ICE COVID-19
Guidance, but Has Faced Challenges Implementing Protocols
The Project South complaint letter described allegations regarding the lack of
COVID-19 protections at ICDC. Specifically, the complaint alleged the facility:
x
x
x
x
x

did not implement social distancing;
did not provide sufficient face masks for detainees and allowed
employees to enter the facility without wearing personal protective
equipment (PPE);
allowed detainees with COVID-19 to transfer into the facility, and
transferred detainees with COVID-19 out of the facility;
failed to test detainees for COVID-19 who exhibited symptoms such as
coughing or fever; and
allowed employees with COVID-19 symptoms to report to work.

The NCCHC Resources team did not evaluate the specific allegations of inappropriate
gynecological care, as those have been referred to our Office of Investigations.

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We discussed these issues with detainees and staff, and reviewed records and
video footage from the facility to determine whether we could substantiate
these allegations. ICDC generally complied with guidance, but we identified
issues with social distancing, wearing of PPE, and routine testing for COVID19. Our findings for each of the allegations follow.
Allegation: ICDC Did Not Implement Social Distancing
The team found that ICDC did not adequately implement and enforce social
distancing protocols. CDC guidance recommends prevention practices for
detainees and staff in detention facilities to include implementing social
distancing strategies and wearing face masks to help reduce the risk of
transmission and severe disease from COVID-19.40 ICE’s PRR provide
additional social distancing measures for detention facilities to implement, if
practicable, such as housing detainees in individual rooms, rearranging beds
in housing areas to maintain 6 feet of separation, and having detainees sleep
“head-to-foot” in shared sleeping quarters. We found ICDC staff and detainees
did not always observe or enforce these protocols.
In our interviews, female detainees expressed concerns about being moved to a
dorm where they had difficulty social distancing. ICDC’s ADP of female
detainees decreased from 100 in September 2020 (when the complaint was
sent) to 9 in February 2021, with all females consolidated into two dorms.
Detainees described these dorms as double-wide trailers with the beds very
close together (2 feet apart), minimizing their ability to be 6 feet apart from
each other. The security camera footage from one of these dorms corroborated
the bunk beds had very little space between them. We also noted that female
detainees in the dorm did not wear masks or practice social distancing with
each other while in the common areas of the dorm.
During our review of ICDC security footage from cameras throughout the
facility, we observed instances of detainees and staff members near each other
while not wearing masks. Staff told us detainees are required to wear masks
outside dormitory areas and are encouraged to wear masks and practice social
distancing within the dorms, but detainees often choose not to do so within the
dorms. The September 2020 ICE guidance makes no distinction between the
need for mask-wearing inside or outside dormitory areas. The facility risks
additional COVID-19 spread by not ensuring detainees practice social
distancing and wear masks within the dormitory area and housing units.

CDC, Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in
Correctional and Detention Facilities Guidance for Correctional & Detention Facilities (July 2020).

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Allegation: ICDC Did Not Provide Sufficient Face Masks for Detainees and
Allowed Employees to Enter the Facility without Wearing PPE
The team confirmed that ICDC encountered problems obtaining and
distributing masks to detainees and staff at the beginning of the COVID-19
pandemic. As of April 2020, ICE PRR guidance recommended detainees and
staff wear cloth masks to help slow the spread of COVID-19. ICE updated the
PRR guidance in July 2020 to require facilities to provide cloth masks to
detainees at no charge, which the facility did beginning in May 2020. However,
we heard in numerous interviews that confusion at the beginning of the
pandemic made for a late and inconsistent implementation of mask
distribution and wearing. For example, an ICDC officer said that, at the
beginning of the pandemic, employees were instructed by management not to
wear masks. ICE officers also confirmed that, at the beginning of the
pandemic, the facility had limited numbers of masks and gloves available for
ICDC officers and detainees, but ICE provided masks and gloves for ICE
personnel. ICDC management acknowledged that its mask roll-out was slow,
which it attributed to confusion over guidance.
Most detainees and staff we interviewed told us the staff wore their masks
consistently. Staff also said they were required to wear masks and PPE or
would face disciplinary action. Our review found that ICDC did not
consistently ensure staff appropriately wore masks. We reviewed surveillance
video footage from February 22, 2021, and March 10, 2021, and observed
facility staff not wearing masks or practicing social distancing (see Figures 1
and 2).

Figures 1 and 2. ICDC staff not wearing masks and not practicing social
distancing on February 21, 2021.
Source: Video surveillance footage provided by ICDC.
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In addition, most ICDC staff we interviewed said they were comfortable
reporting to work with the COVID-19 protocols that were in place. Those who
expressed a degree of discomfort listed the following as potential concerns:
x
x
x
x

possibility of contact with asymptomatic detainees;
uncertainty of PPE protection when in direct contact with COVID-19
positive detainees;
lack of consistency enforcing facility entrance protocols; and
lack of COVID-19 testing for facility staff.

Allegation: ICDC Allowed Detainees with COVID-19 to Transfer into the
Facility, and Transferred Detainees with COVID-19 out of the Facility
The team found that ICE transferred a small number of COVID-19 positive
detainees in and out of ICDC during the COVID-19 pandemic. This was in line
with ICE guidance as an operational requirement. ICE PRR guidance allows for
the limited transfer, where possible, of ICE detainees to and from other
jurisdictions and facilities. The transfers may occur, if necessary, for medical
evaluation, medical isolation/quarantine, clinical care, extenuating security
concerns, to facilitate release or removal, or to prevent overcrowding.
According to ICE, between March 2020 and March 2021, one detainee
transferred out of ICDC to another facility, and two detainees transferred into
ICDC from another facility, while positive for COVID-19. Other detainees were
repatriated or released, including two detainees who were released after testing
positive for COVID-19. As of October 2020, CDC guidance did not require
detainees to be COVID-19 negative before transfer or release. We interviewed
ICDC intake officers and reviewed ICE PRR and ICDC intake policies and
procedures and determined that ICDC adhered to proper procedures when
transferring detainees with a positive COVID-19 test.
Allegation: ICDC Failed to Test Detainees for COVID-19 Who Exhibited
Symptoms Such as Coughing or Fever
We found that, although ICDC has implemented testing and other procedures
to slow the spread of COVID-19, it did not routinely test asymptomatic
detainees. CDC guidance states that detainees exhibiting COVID-19 symptoms
should be separated from other detainees and get tested. The guidance does
not dictate testing of asymptomatic detainees. However, it suggests facilities
consider strategies for testing asymptomatic detainees without known exposure
to COVID-19 for early identification of COVID-19 in the facility. As of July
2021, ICDC reported 146 detainees with confirmed COVID-19 infections, and
no detainee deaths in the facility were attributed to COVID-19.
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According to testing records we reviewed, ICDC tested a detainee for COVID-19
for the first time on March 31, 2020. During April and May 2020, ICDC tested
a total of 57 detainees. We were not able to determine the reason for testing
these detainees because ICDC did not track the reason for testing. However,
ICDC staff members told us that all detainees are tested upon intake and
whenever they present COVID-19 symptoms. In August 2020, ICDC tested 499
detainees; 461 of the detainees were tested on August 18 during a facility-wide
test. All 12 detainees we interviewed in February 2021 indicated they had been
tested for COVID-19 at least once while detained at ICDC.
Instead of testing asymptomatic detainees, the facility used a cohorting
approach.41 ICDC staff used the “cohort” term to refer to dorms that house
detainees during quarantine.42 Interviewees consistently stated that when a
detainee tested positive for COVID-19, the detainee was put in medical
isolation,43 and the rest of the dorm residents were quarantined together and
monitored for symptoms. The neighboring dorms were also monitored for
COVID-19 symptoms.
Allegation: ICDC Allowed Symptomatic Employees to Work
We were not able to confirm this allegation as the ICDC policy requires
employees and visitors to self-report COVID-19 symptoms. As of October 2020,
CDC guidance required symptomatic staff to self-quarantine. To ensure
continuity of operations, staff could continue to work following potential
exposure if they remained asymptomatic and additional precautions were
implemented to protect them and others. In order to enter the facility,
employees and visitors must have completed a COVID-19 questionnaire and
had their temperature taken by an automated temperature scanner.44 One
staff member described witnessing officers at the main entrance not taking
seriously their responsibility to perform temperature self-screenings and not
paying attention when the reader identified an abnormal temperature. All of
the other staff members we spoke with said employees with symptoms were not
allowed to work. Several staff we spoke with had either contracted COVID-19
ICE ERO’s PRR defines cohort as a group of persons with a similar condition grouped or
housed together for observation over a period of time.
42 Quarantine is the separation of a person or group of people reasonably believed to have been
exposed to a communicable disease but not yet symptomatic, from others who have not been
exposed, to prevent the possible spread of the communicable disease.
43 Isolation is the separation of a person or group of people known or reasonably believed to be
infected with a communicable disease and potentially infectious from others to prevent the
spread of the communicable disease.
44 ICDC COVID-19 Employee/Visitor/Attorney/Contractor Screening Form.
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or had close contact with a family member with COVID-19 and were familiar
with the protocols for self-identifying and not reporting to work.

Communication about COVID-19 to ICE Officers, Facility Staff,
and Detainees Was Inconsistent
Our review of ICDC’s response to COVID-19 identified issues with
communication to ICE officers, facility staff, and detainees. First, staff and
detainees reported not receiving consistent information regarding positive
COVID-19 cases within the facility. Additionally, confusion existed among staff
and detainees regarding access to PPE. Lastly, detainees reported not being
informed of their cohort or quarantine status, their COVID-19 test results, or
facility COVID-19 protocols.
Positive Cases of COVID-19 Were Not Appropriately Communicated to ICE
Officers, Facility Staff, and Detainees
At the time of our review, CDC guidelines stated facilities should provide clear
information to detainees and staff about the presence of COVID-19 in the
facility and the protections in place. However, opinions varied among ICE,
ICDC staff, and the detainees regarding the quality and extent of COVID-19
communication. Specifically, on-site ICE officers, ICDC staff, and detainees
complained about poor communication and a lack of transparency about
suspected and confirmed cases in the facility. One ICE officer described not
hearing about confirmed cases at the facility from ICE management or facility
staff prior to arriving for a TDY assignment. Another ICE officer said the ICE
field office would send ICE staff electronic notifications regarding potential
exposures to detainees with COVID-19, stating there were no exposures to
staff, but the officer did not believe ICE was asking the on-site ICE staff if they
had contact with those detainees, to confirm no exposure had occurred.
Facility staff also expressed concerns about the lack of communication
regarding positive COVID-19 cases in the facility. One ICDC officer described
an instance when officers and a supervisor on-duty unknowingly entered a
dorm that was housing detainees with confirmed COVID-19 cases.
During our interviews with 12 detainees, we heard similar concerns over
insufficient COVID-19 communication. Detainees reported learning about
COVID-19 protections, such as needing to wear PPE and social distance, from
a variety of external sources such as other facilities, news stations, or family
and friends. Only five detainees said they received some instruction from the
facility through staff or posters on the walls; two detainees claimed they never
received any instruction. One detainee described facility staff communication
with detainees as “poor,” explaining that, while their previous facility provided
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direct communication from the warden regarding the COVID-19 pandemic,
ICDC did not.
ICDC Staff Were Aware of COVID-19 Protocols, but Access to Respirator
Masks Varied
We found that ICDC had adequate policies related to COVID-19 protocols and
maintained an adequate supply of PPE, including face masks, gowns, and
gloves. These COVID-19 policies included intake procedures for detainees
entering the facility, employee screening procedures, facility sanitation
procedures, and general infectious disease protocols. ICDC staff we spoke to
understood that masks and gloves were required in the facility and that KN95
or N95 masks and gowns were required in dorms with confirmed COVID-19
cases.
Staff we spoke to reported receiving hands-on training for the use of masks and
gloves from facility medical staff, supervisors, or prior employers. However,
ICDC officers from various units in the facility gave inconsistent answers about
the availability of, and the protocols for, obtaining and using KN95 and N95
masks.45 For example, one ICDC officer said it was possible to get a new
respirator mask whenever one was needed. Another said ICDC officers were
issued a KN95 mask every 30 days and described replacing one as a “hassle.”
Yet another officer said respiratory masks were issued every 3 days. Despite
hands-on training and an adequate supply of all types of protective masks and
gloves, confusion remained among staff about their use and availability.
ICDC Did Not Consistently Ensure Detainees Were Notified of COVID-19
Quarantine, Cohorting, or Testing Status and Facility COVID-19 Protocols
We found detainees were not receiving results of their COVID-19 testing, and
some feared reporting COVID-19 symptoms. ICDC conducted facility-wide
COVID-19 testing in August 2020, but nine detainees we spoke with said they
were never provided the results of their test. We also found detainees were not
being informed of their quarantine or cohorting status. Of the 12 detainees we
interviewed, 11 described being cohorted for COVID-19 quarantine either upon
arrival or sometime during their stay at ICDC. However, only six of these

In April 2020 the Food and Drug Administration (FDA) approved an Emergency Use
Authorization (EUA) for use of KN95 respirator masks by health care personnel. KN95 masks
do not meet the National Institute for Occupational Safety and Health (NIOSH) standards for
approval as a level of respiratory protection. In June 2021, the FDA revoked the EUA.

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detainees were informed of their quarantine status, while five of the detainees
reported not having the situation explained to them.46
The lack of communication caused additional issues among detainees,
including fear of reporting symptoms. A detainee described an incident where
dorm residents witnessed another detainee report COVID-19 symptoms and get
removed from the dorm without explanation. After the incident, the detainee
explained that some detainees experienced possible COVID-19 symptoms but
refused to report the symptoms out of fear of segregation.47

Detainees’ Access to ICE Deportation Officers Was Limited
during the COVID-19 Pandemic
According to PBNDS, security, safety, and orderly operation of a detention
facility relies on a system that encourages and requires informal, direct, and
written contact among staff and detainees, as well as informal supervisory
observation of living and working conditions. Although the PBNDS are very
specific as to how ICE should interact with detainees, compliance with those
provisions was limited at ICDC due to COVID-19 travel restrictions and the
apparent reluctance of ICE officers to visit detainee dorms.
The 2011 PBNDS require ICE officers to respond to detainee questions and
requests in 3 to 5 business days, depending on the location of the ICE ERO
officer.48 Detainees’ requests normally include questions regarding
immigration case information, medical care, facility conditions, and assistance
locating family. In March 2020, ICE ERO notified detention centers and field
offices that detainees may experience increased feelings of fear and confusion
during the pandemic and should have frequent opportunities for interaction
with ERO field office staff.49 ICDC is located approximately 185 miles from the
Most detainees who were not aware of their cohort or quarantine status described living
conditions such as being placed in single cells, having meals brought to them, having their
temperatures checked daily, or being put into medical isolation. All descriptions matched the
ICDC incoming detainee procedures that required detainees to cohort prior to entering general
population.
47 Segregation is the process of separating certain detainees from the general population for
administrative or disciplinary reasons. Disciplinary segregation is a punitive form of
separation from the general population imposed after a finding by a disciplinary hearing panel
that the detainee is guilty of a serious prohibited act or rule violation. Administrative
Segregation is a nonpunitive status in which detainees are separated from the general
population to ensure the safety of detainees and others, the protection of property, or the
security or good order of the facility. PBNDS 2011, § 2.12 Special Management Units.
48 PBNDS 2011, § 2.13, Staff-Detainee Communication.
49 ICE Memorandum on Coronavirus Disease 2019 (COVID-19) Action Plan, Revision 1 (March
27, 2020).
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Atlanta ERO Field Office where the detainees’ deportation officers normally
work. Deportation officers we interviewed stated they had primarily performed
their duties by telework and had not visited ICDC during the COVID-19
pandemic due to travel restrictions.
At the time of our review, three ICE officers were assigned to the facility, and
up to three additional officers were detailed on a rotational basis. Detailed
officers we interviewed told us they perform a variety of duties to oversee
detainee detention, with one officer designated to collect and provide responses
to Detainee Request Forms (DRF). The detailed officer responsible for DRFs
normally collects them from the locked collection boxes located in each dorm.
The officer records all requests in a logbook and determines whether the
request can be answered locally. Many requests are for immigration case
information, which then are referred to the assigned deportation officer in the
Atlanta Field Office. Two of the detainees we interviewed stated that ICE
officers do not check the collection boxes on a regular basis and that DRFs
were not readily available in the dorm. Additionally, an ICE officer that was
TDY to ICDC stated that one of the assigned ICE officers refused to go to the
detainee dorms during the COVID-19 pandemic.
The 2011 PBNDS require the ICE ERO officer receiving the request to normally
respond in person or in writing as soon as possible and practicable, but no
later than within 3 business days of receipt, for facilities with ICE ERO staff
on-site, which is the case with ICDC.50 We reviewed 3,593 requests in the
ICDC Detainee Communication Log submitted between January and October
2020, and found that 284 did not receive a response within the 3-day period.
An ICE officer detailed to ICDC believed the 3-day response time was not being
met because of a mandate for field office staff to telework, which seemed to
create delays.
The 2011 PBNDS also require each detention center’s local supplement to the
detainee handbook to include contact information for the ICE ERO field office
and the scheduled hours and days that ICE ERO staff is available to be
contacted by detainees at the facility.51 The local detainee handbook
supplement must also include procedures to submit written questions,
requests, or concerns to ICE ERO staff, and to ensure the availability of
assistance to prepare such requests. Of 12 detainees we interviewed, 7
complained about not being able to get in touch with their assigned deportation
officers. One detainee who has been at ICDC since September 2020 reported
not knowing the name of the assigned ICE deportation officer and claimed to
50
51

PBNDS 2011, § 2.13, Staff-Detainee Communication.
PBNDS 2011, § 6.1. Detainee Handbook.

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have never spoken to him or her. Another detainee at ICDC since May 2020
also reported “never once” being able to communicate with an ICE deportation
officer about his/her immigration case, resulting in almost 10 months without
questions or requests being addressed. We reviewed the Lasalle Corrections
Southeast Inmate/Detainee Handbooks dated February and December 2020,
respectively, and found that neither version had contact information or the
scheduled hours and days that ICE ERO staff is available to be contacted by
detainees at the facility.

Detainees and ICDC Staff Were Generally Comfortable Lodging
Concerns, but Some ICE Officers Were Hesitant to Voice Their
Concerns
The Project South complaint letter described retaliation against staff for
reporting concerns about detention conditions at ICDC. We asked ICE and
ICDC staff about fear of retaliation for raising concerns about facility
operations. We also asked detainees to share any concerns about how they are
treated at the facility. We found that most of the ICDC staff we interviewed did
not report fear of retaliation; most said they were comfortable bringing their
concerns to either their supervisors or directly to the warden. Several of the
staff members reported their voices were not always acknowledged or concerns
were not always addressed, and that communication from management could
be better.
Several ICE officers were hesitant to speak up about conditions at ICDC,
specifically regarding COVID-19 protocols. Some did not feel comfortable
voicing concerns about the facility conditions. One ICE officer alleged that a
systemic issue existed within ICE leadership in the Atlanta Field Office that is
not willing to hear complaints or concerns about detention facilities. The
officer further noted that fellow officers were disinclined to complain about
ICDC because of the opportunity to receive additional money while TDY to
ICDC. The officer also believes there is reluctance to use other means to voice
concerns, such as filing an OIG Hotline complaint, due to the impression that
one’s identity would be compromised as the calls are recorded.
When asked whether detainees had complaints about how they were treated by
ICDC officers, detainees we interviewed had a range of opinions, describing
some officers as “good,” but others as “rude,” “bossy,” and “kind of crazy.”
None of the detainees we interviewed described experiencing physical abuse.
However, some detainees expressed discomfort with the way some facility
officers communicated with them, using rude language such as “shut your
mouth.” Detainees we spoke with did not provide any specific allegations
toward officers or staff and had not filed complaints alleging verbal abuse. One
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ICE officer we interviewed recalled, in visits over the course of several years,
staff being “very nasty” and “very unprofessional” in the way they addressed
detainees and hearing comments from facility and medical staff about
detainees that were “degrading and harsh.”
Between FY 2017 and FY 2020, detainees at ICDC filed 970 non-medical
grievances. In addition, the DHS OIG Hotline received 795 complaints
referencing ICDC. Many Hotline complaints originated from detainees in the
facility, family members of detainees within the facility, and those who had
previously been detained at ICDC. We found that detainees knew how to file
grievances and complaints and did so regularly. When asked about any
concerns they had, none referenced being afraid of complaining about facility
conditions. However, one detainee explained to us that detainees were afraid
to disclose possible COVID-19 symptoms for fear of being sent to isolation or
the “hole” as the detainee put it. The detainee said other detainees had
symptoms like lack of taste and smell or body aches or a high temperature but
did not want to disclose them and tried to hide their symptoms.

Recommendations
We recommend the Executive Associate Director of Enforcement and Removal
Operations direct the Atlanta Enforcement and Removal Field Office
responsible for Irwin County Detention Center to:
Recommendation 1: Ensure IHSC coordinates with ICDC medical unit to
update processes and documentation for chronic care cases and develop a
continuous quality improvement program.
Recommendation 2: Ensure IHSC conducts training with ICDC medical unit
about medication administration and health records documentation.
Recommendation 3: Coordinate with ICDC management staff to develop a
communication plan to keep detainees informed during a pandemic or other
emergency situations, and to include related policy and protocols, potential
exposures, quarantine/isolation status, and testing procedures.
Recommendation 4: Develop a plan to enhance communication among
Atlanta Field Office staff, permanent on-site ICE staff, and ICE detailed staff to
ensure awareness of pandemic-related policy, protocols, and conditions.
Recommendation 5: Coordinate with ICDC management staff to review and
update the ICDC Detainee Handbook to ensure it contains current contact

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information for the ICE ERO Atlanta Field Office and the scheduled hours and
days that ICE ERO staff are available to detainees.

Management Comments and OIG Analysis
ICE concurred with one recommendation but did not concur with four
recommendations, as it no longer houses detainees at ICDC and its contract
with ICDC ended on October 7, 2021. Appendix B contains ICE’s management
comments in their entirety. We also received technical comments to the draft
report and revised the report as appropriate. We have administratively closed
four recommendations; recommendation 4 is resolved and open. A summary of
ICE’s response and our analysis follows.
ICE Comments to Recommendation 1: Non-Concur. Because ICE no longer
uses ICDC, ICE is required to not concur with this recommendation for
procedural reasons, while acknowledging the importance of maintaining
appropriate conditions at its detention facilities. As of September 3, 2021, ICE
no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on
October 7, 2021. Therefore, ICE cannot implement this recommendation.
Should detainees again be housed at ICDC at some point in the future, ICE will
ensure that all applicable detention standards are followed, as appropriate.
OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on
October 7, 2021, and that ICE cannot reasonably implement this
recommendation, which we have administratively closed. However, we reserve
the option to reopen the recommendation should ICE reinstate a contract to
house ICE detainees at ICDC.
ICE Comments to Recommendation 2: Non-Concur. Because ICE no longer
uses ICDC, ICE is required to not concur with this recommendation for
procedural reasons, while acknowledging the importance of maintaining
appropriate conditions at its detention facilities. As of September 3, 2021, ICE
no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on
October 7, 2021. Therefore, ICE cannot implement this recommendation.
Should detainees again be housed at ICDC at some point in the future, ICE will
ensure that all applicable detention standards are followed, as appropriate.
OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on
October 7, 2021, and that ICE cannot reasonably implement this
recommendation, which we have administratively closed. However, we reserve
the option to reopen the recommendation should ICE reinstate a contract to
house ICE detainees at ICDC.

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ICE Comments to Recommendation 3: Non-Concur. Because ICE no longer
uses ICDC, ICE is required to not concur with this recommendation for
procedural reasons, while acknowledging the importance of maintaining
appropriate conditions at its detention facilities. As of September 3, 2021, ICE
no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on
October 7, 2021. Therefore, ICE cannot implement this recommendation.
Should detainees again be housed at ICDC at some point in the future, ICE will
ensure that all applicable detention standards are followed, as appropriate.
OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on
October 7, 2021, and that ICE cannot reasonably implement this
recommendation, which we have administratively closed. However, we reserve
the option to reopen the recommendation should ICE reinstate a contract to
house ICE detainees at ICDC.
ICE Comments to Recommendation 4: Concur. ICE acknowledges the
importance of strong communication practices to fully implement ICE’s policies
and protocols that protect employees and people detained by ICE from COVID19. To address this recommendation, the Atlanta Field Office will supplement,
reinforce, and enhance a communications plan and leadership will directly
engage in enhancements to that plan. To address the need for fulsome
communication, the Field Office Director conducts: (1) quarterly “town-halls”
for all employees; (2) daily meetings with his staff and Deputy Field Office
Directors; and (3) weekly meetings with the Assistant Field Office Directors
throughout the area of responsibility. In turn, Assistant Field Office Directors
regularly meet with their supervisory staff, as do supervisory staff with their
employees. In addition, the Atlanta Field Office has a full-time staff devoted to
messaging and sending communications throughout the Field Office, through
which all broadcast messages and policies from ICE Headquarters or Field
Office leadership are sent to ensure all communication is disseminated to the
appropriate parties.
All employees have access to all the broadcast messages and intranet and
internet information, and supervisors ensure that all messaging is understood
by the employees. Accordingly, on-site facility staff’s responsibility was to
ensure that the facility remained compliant with ICE policies and procedures,
including compliance with all COVID-19-related protocols.
Further, ICE broadcast messages are distributed to all supervisors with
COVID-19 decision trees, in accordance with the current communication plan,
to assist management with making educated decisions regarding potential or
confirmed exposures.

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ICE also distributes each new release of the PRR to all ICE employees and
shares these updates with all contractors operating ICE facilities. On March
24, 2020, prior to the first PRR, ICE ERO followed established communications
guidance to issue a broadcast message to all employees titled “CDC Interim
Guidance on Management of COVID-19 for Correctional and Detention
Facilities,” and similar broadcast messages and guidance are available to all
employees on the ICE intranet under the link “COVID-19 Coronavirus Updates & Guidance.”
In addition to reinforcing the communications practices that the Atlanta Field
Office already has in place, the Field Office Director will conduct mandatory biweekly meetings with individual detention facilities’ responsible ERO
management, senior contract management, IHSC, OPLA, and the COR and/or
Detention Standards Manager. At these meetings, the Field Office Director will
personally message select PRR requirements and confirm that relevant
stakeholders understand and are implementing those requirements. Moreover,
these meetings will allow for an open discussion of all concerns at the facility
with full stakeholder participation.
OIG Analysis: We consider these actions responsive to the intent of the
recommendation, which is resolved and open. We will close this
recommendation when we receive documentation showing the Atlanta Field
Office implemented the stated enhancements to the communications plan to
include evidence of the mandatory bi-weekly meetings with individual detention
facilities’ ICE personnel.
ICE Comments to Recommendation 5: Non-Concur. Because ICE no longer
uses ICDC, ICE is required to not concur with this recommendation for
procedural reasons, while acknowledging the importance of maintaining
appropriate conditions at its detention facilities. As of September 3, 2021, ICE
no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on
October 7, 2021. Therefore, ICE cannot implement this recommendation.
Should detainees again be housed at ICDC at some point in the future, ICE will
ensure that all applicable detention standards are followed, as appropriate.
OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on
October 7, 2021, and that ICE cannot reasonably implement this
recommendation, which we have administratively closed. However, we reserve
the option to reopen the recommendation should ICE reinstate a contract to
house ICE detainees at ICDC.

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Appendix A
Objective, Scope, and Methodology
The Department of Homeland Security Office of Inspector General was
established by the Homeland Security Act of 2002 (Pub. L. No. 107−296) by
amendment to the Inspector General Act of 1978.
We initiated this review in response to complaints requesting OIG investigate
the health and welfare of detainees at ICDC. We conducted the review
remotely, given the travel restrictions and inherent risks associated with onsite inspections during the COVID-19 pandemic. We focused on elements of
applicable standards that could be observed and evaluated remotely.
We conducted our fieldwork between October 2020 and May 2021. During this
period, we reviewed ICE 2011 PBNDS guidance, ICDC surveillance camera
footage, CDC and ICE COVID-19 guidance, and ICDC’s medical, grievance, and
complaint logs. We reviewed DHS OIG Hotline complaints from FY 2017
through FY 2020, totaling 795 allegations specific to ICDC. We excluded
hotline allegations related to the ongoing OIG investigation (25 allegations) from
our review. Additionally, we interviewed 12 detainees in ICDC custody; 26
ICDC staff members, including the warden, deputy warden, and corrections
officers; 12 ICE officers assigned or detailed to ICDC; and 6 ICE staff assigned
to the Atlanta Field Office.
We utilized a contracted medical team from NCCHC Resources, Inc., to conduct
medical record review and a virtual site tour of the ICDC medical unit. The
contracted medical team consisted of one physician and two registered nurses.
The medical team reviewed a total of 200 detainee records, including 195
randomly selected records for detainees at ICDC for 180 days or longer between
FY 2017 and FY 2020, with 5 more added as a result of OIG concerns during
detainee interviews. The nursing staff reviewed 158 records, focusing on
completeness, timeliness, and proper actions, while the physician focused on
37 chronic care detainees that were identified. We incorporated information
provided by the medical team into our findings and include the full report in
Appendix C.
We conducted this inspection under the authority of the Inspector General Act
of 1978, as amended, and according to the Quality Standards for Inspection
and Evaluation issued by the Council of the Inspectors General on Integrity and
Efficiency.

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Appendix B
ICE Comments to the Draft Report
Office of the Chief Financial Officer

U.S. lkp al'tmcnt of llom cland Security
500 12th Street, SW
Wushington. OC 20536

U.S. Immigration
and Customs
Enforcement
November 16, 2021

MEMORANDUM FOR : Joseph V. Cuffari, Ph.D.
Inspector General
FROM :

stephen A . Ron cone

Digitally signed by STEP
HENA

STEPHENA RONCONERONCONE

Chief Financial Officer and
Senior Component Accountable Official
SUBJECT:

Date, 202 1.11.16 m2 4,2s-0sw

Management Response to Draft Report : "Medical Processes
and Communication Protocols Need Improvement at Irwin
County Detention Center" (Project No. 21-001-SRE-ICE)

Thank you for the opportunity to comment on this draft report . U.S. Immigration and
Customs Enforcement (ICE) appreciates the work of the Office oflnspector General
(OIG) in planning and conducting its review and issuing this repo11.
ICE leadership is pleased to note the OTG' s acknowledgement ofTCE detention
standards, overarching efforts to mitigate the risk to the safety and well-being of
detainees and staff due to the COVlD-19 pandemic , and positive findings at Irwin County
Detention Center (TCDC), in Ocilla, Georgia . For example, OIG ' s draft report noted that
ICE detention standards require that all facilities provide detainees with access to
appropriate and necessaiy medical, dental, and mental health care, and that facilities must
have written plans that address the management of infectious and communicable
diseases. The OIG also acknowledged that ICE Enforcement and Removal Operations
(ERO) (1) provides on-site management of detention operations to ensure a safe and
secure environment for detention staff and detainees , and (2) issued Pandemic Response
Requirements {PRR) in April 2020, and subsequently updated the PRRs, to establish
clear expectations and assist ICE detention facility operators in sustaining detention
operations while mitigating risks due to COVID-19 .
Regarding ICDC specifically, on May 20, 2021, ICE gave notice of its intent to terminate
its contract with ICDC . This termination becaine effective on October 7, 2021. While
ICE no longer uses lCDC, ICE appreciates the OlG ' s acknowledgement that ( l) the
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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Management Response to Draft Report: "Medical Processes and CommunicationProtocols Need
Improvement at Irwin County Detention Center" (Project No. 21-001-SRE-ICE)
Page 2
facility generally met ICE detention standards for medical, dental , and mental health care,
and (2) ICE dramatically reduced the population ofICDC by releasing individuals who
might be at higher risk for severe illness due to COVID-19 , after ICE ERO evaluated
detainees immigration history , criminal record, potential threat to public safety , flight
risk, and national security concerns. The OIG also reported that ICDC complied with
Centers for Disease Control and Prevention and ICE COVID-19 guidance .
The draft report contained five recommendations. Approximately five months prior to
receiving the OIG's draft report, ICE had given notice to terminate its contract with
ICDC . By September 3, 2021, ICE was no longer using ICDC for detention purposes,
and on October 7 ICE ' s contract with ICDC ended . Because ICE no longer uses ICDC ,
ICE non-concurs with the recommendations directly related to facility operations , while
acknowledging the importance of maintaining appropriate conditions at its detention
facilities. ICE concurs with the fourth recommendation related to communication ofICE
policy and procedure.
Attached find our detailed response to each recommendation. ICE previously submitted
technical comments addressing several accuracy, contextual , and other issues under a
separate cover for OIG ' s consideration.
Again, thank you for the opportunity to review and comment on this draft report. Please
feel free to contact me if you have any questions.
Attachment

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Management Response to Draft Report: "Medical Processes and CommunicationProtocols Need
Improvement at Irwin County Detention Center" (Project No. 21-001-SRE-ICE)
Page 3

Attachment: Management Response for Recommendations
Contained in 21-001-SRE-ICE

OIG recommended that the Executive Associate Director of ERO direct the Atlanta
Enforcement and Removal Field Office responsible for Irwin County Detention Center :
Recommendation 1: Ensure IHSC [ICE Health Service Corps] coordinates with ICDC
medical unit to update processes and documentation for chronic care cases and develop a
continuous quality improvement program.
Response: Non-Concur. Because ICE no longer uses ICDC , ICE is required to nonconcur with this recommendation for procedural reasons , while acknowledging the
importance of maintaining appropriate conditions at its detention facilities . As of
September 3, 2021 , ICE no longer houses detainees at ICDC, and ICE ' s contract with
ICDC ended on October 7, 2021. Therefore , ICE cannot implement this
recommendation. Should detainees again be housed at ICDC at some point in the future ,
ICE will ensure that all applicable detention standards are followed, as appropriate . We
request that the OIG consider this recommendation resolved and closed.
Recommendation 2: Ensure IHSC conducts training with ICDC medical unit about
medication administration and health records documentation .
Response: Non-Concur. Because ICE no longer uses ICDC, ICE is required to nonconcur with this recommendation for procedural reasons , while acknowledging the
importance of maintaining appropriate conditions at its detention facilities . As of
September 3, 2021 , ICE no longer houses detainees at ICDC , and ICE's contract with
ICDC ended on October 7, 2021. Therefore , ICE cannot implement this
recommendation . Should detainees again be housed at ICDC at some point in the future,
ICE will ensure that all applicable detention standards are followed , as appropriate . We
request that the OIG consider this recommendation resolved and closed.
Recommendation 3: Coordinate with ICDC management staff to develop a
communication plan to keep detainees informed during a pandemic or other emergency
situations, and to include related policy and protocols, potential exposures,
quarantine /isolation status, and testing procedures .
Response: Non-Concur. Because ICE no longer uses ICDC , ICE is required to nonconcur with this recommendation for procedural reasons, while acknowledging the
importance of maintaining appropriate conditions at its detention facilities . As of
September 3, 2021, ICE no longer houses detainees at ICDC, and ICE's contract with
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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Management Response to Draft Report: "Medical Processes and CommunicationProtocols Need
Improvement at Irwin County Detention Center" (Project No. 21-001-SRE-ICE)
Page 4
ICDC ended on October 7, 2021. Therefore , ICE cannot implement this
recommendation . Should detainees again be housed at ICDC at some point in the future ,
ICE will ensure that all applicable detention standards are followed , as appropriate . We
request that the OIG consider this recommendation resolved and closed.
Recommendation 4: Develop a plan to enhance communication among Atlanta Field
Office staff, permanent on-site ICE staff, and ICE detailed staff to ensure awareness of
pandemic-related policy, protocols , and conditions.
Response: Concur. ICE acknowledges the importance of strong communication
practices to fully implement ICE ' s policies and protocols that protect employees and
people detained by ICE from COVID-19 . To meet this recommendation , the Atlanta
Field Office will supplement , reinforce , and enhance a communications plan and
leadership will directly engage in enhancements to that plan. To address the need for
fulsome communication, the Field Office Director conducts: (1) quarterly "town-halls"
for all employees ; (2) daily meetings with his staff and Deputy Field Office Directors;
and (3) weekly meetings with the Assistant Field Office Directors throughout the area of
responsibility. In tum , each Assistant Field Office Director regularly meets with their
supervisory staff, as do supervisory staff with their employees . In addition, the Atlanta
Field Office has a full-time staff devoted to messaging and sending communications
throughout the Field Office , through which all broadcast messages and policies from ICE
Headquarters or Field Office leadership are sent to ensure all communication is
disseminated to the appropriate parties.

All employees have access to all the broadcast messages and intranet and internet
information , and supervisors ensure that all messaging is understood by the
employees . Accordingly, on-site facility staffs responsibility was to ensure that the
facility remained compliant with ICE policies and procedures , including compliance with
all COVID-19-related protocols.
Further , ICE broadcast messages are distributed to all supervisors with COVID-19
decision trees, in accordance with the current communication plan , to assist management
with making educated decisions regarding potential or confirmed exposures .
ICE also distributes each new release of the PRR to all ICE employees and shares these
updates with all contractors operating ICE facilities. On March 24, 2020, prior to the first
PRR, ICE ERO followed established communications guidance to issue a broadcast
message to all employees titled "CDC Interim Guidance on Management ofCOVID -19
for Correctional and Detention Facilities ," and similar broadcast messages and guidance
are available to all employees on the ICE intranet under the link "COVID-19 Coronavirus
- Updates & Guidance ."
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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Management Response to Draft Report: "Medical Processes and CommunicationProtocols Need
Improvement at Irwin County Detention Center" (Project No. 21-001-SRE-ICE)
Page 5
In addition to reinforcing the communications practices that the Atlanta Field Office
already has in place , the Field Office Director will conduct mandatory bi-weekly
meetings with individual detention facilities ' responsible ERO management , senior
contract management , IHSC , OPLA , and the COR and/or Detention Standards Manager .
At these meetings , the Field Office Director will personally message select PRR
requirements and confirm that relevant stakeholders understand and are implementing
those requirements . Moreover , these meetings will allow for an open discussion of all
concerns at the facility with full stakeholder participation .
We request that the OIG consider this recommendation resolved and closed , as
implemented .
Recommendation 5: Coordinate with ICDC management staff to review and update the
ICDC Detainee Handbook to ensure it contains current contact information for the ICE
ERO Atlanta Field Office and the scheduled hours and that ICE ERO staff are available
to detainees.
Response: Non-Concur. Because ICE no longer uses ICDC , ICE is required to nonconcur with this recommendation for procedural reasons, while acknowledging the
importance of maintaining appropriate conditions at its detention facilities . As of
September 3, 2021, ICE no longer houses detainees at ICDC , and ICE ' s contract with
ICDC ended on October 7, 2021 . Therefore, ICE cannot implement this
recommendation . Should detainees again be housed at ICDC at some point in the future ,
ICE will ensure that all applicable detention standards are followed , as appropriate . We
request that the OIG consider this recommendation resolved and closed.

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Appendix C
NCCHC Resources, Inc., Irwin County Detention Center
Inspection Report

Final Report
Apri/2021

Irwin County Det ention ,Cent er

OFFICE OF INSPECTOR GE ERAL
I SPECTl ON REPORT

This repolf details findings from .a virtua l site tour
oonductedFe.bruary8, 2021, of Irwin Coumy Dl!temion
Center, Otilia, Georgia.

SOLUTIONS FROM THE MOST TRUSTED NAME IN

CORRECTl ,QNAL HEAL TH CARE

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

mvin County Detention Center
Office of h1speotor General Inspection Report
I~SPECTION REPORT
FACIUTYOVBRVlEW
•

•

•

1be Irwin, County Detention Center is in Oi:il la , 6em-gia 1 andi ils a, priva .te prison operated by !LaSal le
Corrediions . The ·faci lity is contrai::ted to oouse :andl provide care to lmmigrat i:on and lCustoms
lErnorcement IICE}d&ainees.
On the da,y of inspection thefa:ci lny reported a tota l "en~us ,of256 IOE detainees : 242 .males aoo 14
fema les. The census . is lower than normal bei::a.use of the impact ,of the 1COVID-:'.l.91
pandem ic.
1be faci l ity does 11ot ho ld accreditatioo ,fro:m 'the !Nationa l Commission on Co1T&tilllla l Heahh Care
Of" the Amenican Conectional lAs:sociation.

INS-PErno
•

•
•

PROCESS

Dr. Randa 'IISto ltz, MD, OOHP, BeclcyPinney ~ MSN, lilN, CCHP-RN, CCHP-A,and l Barbara IMarilano, RN,
ca-IP 1Jonducted the medical in!5,pE!c:1!ion
c
1be INCOHCResources team llo~eted
the insped!ion using a virtua l format .
1be team a lso intervi:ewed a number of heahlh staff~ incl'uding:
o
, IRNI, health se;n,ices .administrato .r ~HSAI
o
\ d1rector of nurs ·ng IDON)
,o
, MD, conectional l medical a.utilority (CJlilA)
o
D,psychi.nri ~
,o
D
0

D

,o
0

•

•
•

D
,LPN
We f;ompleted an extensive document review , indludin,g administrative documents and 200 health
reCOf"ds. fhis includes 195 :as.sign ed hea lth r-eoords and . an add itional l 5 hea'lth ref;ords r·evie-wed
baised on lega l inqu r.ries..
We have incorpOt'"ated l11hefinding)> of the record ,.re-view·into the appropriate sect i.ons :o,f the report.
Stiindar-dsused fortlhis inspection were the 20111Ope-ra,1iill'ru;Mlanua l ICE Perfonnance-Ha<Sed

Nationa ll Detemion Standar-ds and ltihe N'a'tional lCommilssill'.n on C'.o:rrectional Hea lth Care ' s 2018
Smndords jar ffeaith Services in Jails.

INSPECTIONR JDINGS
litepon Organization
This r,epollt i!!iorganized based ,on,tlhe Lead tnspector Woriibool. tlha,t was created for use when N:CCHC
Resources .persom1el l oonduct OIG !OE inspe-d!ions. 'The wod :boolc is organized to a llow for the ,col lec1iill'.n
,
of critica l data ,about the di11ical1proc:e'5Ses u~ to prDVide i:.rre to ICE det-ainees .. The wDFkbook
provocles for tihe g;uided interview of lcey ealth care persmmei l, the review of program dornments , the
reliliew of a srna lI samp 1e of healtlh c:a:rerecords, and lin some cases a vim.ia l tour of tlhe faoility. This
approach a!llaws tihe ill<Spe-ctoTto ,develop a d ear 111nd
erstand ing of how wetl ltihe hea 1th car-e program is
organiz.ed l and operating. for the ,Irwin County faoi lity ~ in,addition tD title typic:a'I inspedion activit!ies , the
Ol'G team :asl .ed tlhe NCCHC Reso111rcesteam to r-e,vje-w a s rgi ific:ant number- of health r-ecor,iils,tota'l"ng
195. 1he nurses on the i:n5'pection team reviewed lS8 of the reco:rds aml foc111Sed
,,on tlhe completeness:,

Irwin County Deten t ion Center - Inspection Repon

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33

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

tasp.ectioll' R.epan:

timefiness , a11d prope.- actions talien in the dai' ly hea lth care delive1y pr ,ocesses... The team physician
the records ,of identified ],clhronic ca.-e deta inees (37 .-ecomsl
and their documented
focused 1I111
conl!in11ity of ,c::are_

au.-

fmdi:ngs , 11herepon is d"rvooledl i:nto clearly defined care pnx:e.ss seobons.
Each~
, has :slllb.sectiions for ..iRe,ported Proo:es:sl!5 a:nd IDorument ]Review" ,a nd ..Hea 'lth Record
Re,.,iew _• The Reported Prooe,sse:s S1Jibseelicm:sdocument how cai-e is d'elillered as voioed by the
individ11a'ls interviewed :and based on the :adm inistrative d'oruments we reviewed !_1he Health IReca.rd
Re,.,iew wbseelioos prmi ide ~ght:s i-ega.-dingthe carederrve;red a,s docum!!il1t:ed in the hea 'lllh rec;ord:S.

To pr,o11i
de a dear picture ,of

For eadi sect!ion ther ,e may be "Rindin g~ m "SuggestiXlns. " Finell~ :ar,e p:rovided when the;re is :a lack of
com ,p lianc:e with the 2011 OperatiXlns Ma1111al ICE Perfonnance-Ha,sed Naliiona ll Detent ion Standanls
:aodf ar INOOHC's 2018 Stondords fer- Health Sentic.es in Jails. Sugg ,e:sl!ions :are provided ]when there is a:n,
.
is5!1.Jethat slhoold lbe :add'.-essedl, but ·Findings do not repr ,esent .a significant liad ,of m~i<ance

ASSIGNEDPERSONNEL
Repo .rt.eiJl'roc.esses and 'Doalment Review
•
Staffing is :adequate for tlhe faoi lity':s hea lth ca.-e miissicm :andl.av~g;e
repo:rts that :any ch:angl!5 to the
•

•

d:ai'ly popu laoon _ The ■
ea lth ca:re staffing p l':a111
a.-e ,addr ,:es:s:ed:andl resolved with the

w:arcen.
site Mcmdiary
lhere is a:n,,assigned ] he -a lllh, sent.ices .administrat:oi- :and]a director o.f n11rsi:ng·who .are ,0111
throud, , Friday ,and ,0111weelli!!i11dsas needed. Both individ'ua 'ls have served in,their positions for less
than 1 yea.- but have worked in the faci lity for same time .
[[)r- ___
serv ·e:s a,s the c:onl!Ctiiol!iil!m:edilca'I a11tholity and is ,0111
site 1 diary.a wee1c:.A
. Additilllna l nurse praelitioners
nurse praelitione.- is ,on site MD.nday 11hrough Frimiary
covl!iracge_The physiCJia n :supeniises all nurse practil! ioners: .

,p:rovoole week.end

•

A psychiatrist

•

[[)r- ___

•

week. ,and reachable for ca l I an a 24 /7 basis...There is ,rurrent ly ,one menta l hea lth vacancy_
INo ,denta l[servjoes are prou:idedon :site.. All dellltil 1 care is pnw ided in,the c;mnmunity thr ,.ou·gl,,.a
rnemora11dum ,ofunderst:.mding
with a loca' I denta 'I pro,.,ooler_

•
•

a11d a l~sed
c;.ou:nsel'o.- p:rovide men ta l he:al'th services_
p:sydii:atrist , is on site 2 days a v.ee:k. Menta l hea lth staff a.-e ,on site 6,dey:s a

, the

lhere is iooleq;uate nursing staff to provide r,:equired lsen,: ices . One m.1.-s
ing SllpeN i50f"posil!ion 0111the
night sh ift is v:ac:a11t_
Al I staff members ar ,e ,employees ,of 1 ..aiSa
l e_

Staff :safety is pro>,'ocledl bythe pre:semie ,of custody team members ]located in 11hemed1cal areas "
IR:adios :ar,e not pl"Cl"'
ided lto rnedoca l staff _Staff are .awai-e ,of :sl!Cllllityi-eq;uirements and l are ,expected
to adhere to those r,equi:rement:s_
Health Rerom .Review
•
1he health rero.-d .-eview yielded no ·findings that refiled a:ny ,ooncems .-elated to 11he:staffing plan.
Fi'ndinqs: INa.ne
Qrmllty af.l'roc.ess : Adequate
•

STAFFOH ENTATllOI\IAND TRAINING

&weamfrocgs;se;
and.Qqrume:ot
Reyjew
•

1he ■ reports that all n e w ,:emp loyees .are r,equired lto ,oompl 'ete 40 hour:s of ,rrustody tiain ing at
hire :and[annua ll'f_The oootent of clll:5tody tra-ning :is ,aJllprmied by'the .
:a nu a'll'y .

•

1he content ,of the program ilsbased on mnwany
specific to the fac i'lity_

1.-wi:n County Detentillln Center - lnspl!Ctiion Report

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34

po 'licy with the addition of topics .a nd processes

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8. I
•

•
•
•
•

tnspeaio,i ,Rep.on:

1be
reports that on'board train ing to the me1ificalldepartment iiSpr,D11:
i.ded over a 30-Gay period _
1be
a:ndlboth pnwide over.sidit fur ,each new employee .and ensure they are pTepared lto
work independently in their pos iti on betm-e bei111gassjg,med_

1be ■ and l.
re111iewthe onboard ing pro ,g:r:amon an , annlllilll basis_
Anm.1a'I ttaini n,g ours far .a ll hea lth staff are based on state l~&1S\J:re~ui:rements _
1be ■ prov ided a l iiSt,of training topics and att&1dam:e rosters fo.r in51pector re111iew_
CUrr ,ent custody aoo l hea lth staff tta inin,gs ·were verified th1rOUgha samp le document review _

Health Re.com Review
•
1be health record rev iew yielded no lii111din,
gs thait refilect an y ,concerns .re lated to the tta ini111g
and l

orientation pr,ocess..
Findings : No,ne

Quality of.Process : Adequilte

PEERREVIEW
Reported .Processes and .Domment Re'\liew
• On1y provider staff receive peer reviews_ LaSalle arranges pee;r re.vi:ews with .an off-site MD for the
IMDand the nurse practitiloners _
• lbe .
shares the findings of the revjews fu.rtihe nurse prac:tmDners _R.egjxinal med ica l leaders!h ip
provooles the and pcsydtliaittists with tihe rresu'lts o.f their peer re111iewrmdings _
Health Re.com .Review
•
1be health record rev iew yielded no ·liindin,gstihat reflect an y ,concerns n! lia,ted to ·the peer rev iew
procces,s.

:£uqqgstiqU5
N
• l \lu:rsing staff .are 111ot
.a part oifthe peel" n!"'iew proi::ess. ·we sugg~ tiha,t .a peer n!v iew pmgram fur
11ur:sesbe impl erm!illted L
• Sam e of the nurs e prachtiDner staff n!,ported lthat the results of the i:r peer re.views were ll'llltd eaJitysbar ,ed with ,tihem. Thi:s shou ld be add.-esse dl to ,en511re proper feedbadc to a'II i:nwhred staff
members _
Quality of.Process : Adequ:aate

MEDICALfAOJUTYPHYSICAlPLANT
Reported .Processes and ,Doarment Re'\liew
• lbere ilsa ,centra l medi!Cal department with adequate space for the de livery of' medi rr:a'Iservices .and
adm inistrative d'uties_
• lbere .are s iicmedica l observatio111oells. Two of these rooms are 11egati.vepress111rerooms and ltihree
are d'esig111edfor suicide preventiDn ,. The faci lity ,romp l1ance offiic:er,ir:lhedksth e hmctioning of tihe
negative pressure rooms d!aify_
•
1be ■ reports awcpnia.te ,equipment is present fur the d'.errYeryof health care. Thr<Sind udes the
cuffs , Ambu
presenoe ,of si::a'les, exam tab les, e lectr ,oc:a.Tdiogam IEKG) m achines , b lood pr,es:s111re
bags, oxy,g~ , allld pulse oicimetry-de¥i .oe:s_
•
1be ■ is respons · e fur obtaining .a lll111eededeqµiprnent and lSUl!IPlies. Items are obtained !tihrough
the submis:sion of .a n ordl!f" to a prorurement den wjt hin th e fari'lity_ The ■ CJ"eiltes these ,orders
based an a perperua l inv entory ,rreated and l mainta ined by-the _
_
•
1be fac · itv has five a:utomated e:rtenna l defilrri llator:s (AEDs)_ LOG1tia11sinc l'ude tihe m ed ica l .area , the
intake ar ,eat,.tihe ma in h all ofthe faci lity, and ltwo housi111glocatio,ns _
• lbere iisno denta l equ ipment as .a ll denta l services ar ,e provid'ed off~site _
• IB:asic:d1agnostic laboratary stll.ld'ie:sare prov ided !o:n,site _

Irwin County Deten t ion Center - lnspect io111
Repon

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

lnspect,ian , Report

ttwlthBernm
.flwiew
•

ihe health n!oonl r-eview yiekled no finding)>that reflect any ,oonc:erns rellated t!o tlhe med 1i::al aJ"eas.
ofthe ph~ii::a ll p1a:nt.
Findings: INcme
Quallty of.Physical 1',/a.m : Adequate
PROGRAM ADMIN ISlRATION

8€P9U€9'
.fypw:se5 and,Qerumeot
Reyigw
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•

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•

ihe medica l lea.der:ship team .appropriate ly manages. the hea'lt h ,i::ar,e pro,gram c
Job dE!!SOipoon!!ii
fur- the hea 'llh serv ic:e!!ii
.adminilstlrator-and l,oor-rceo iona l medica' I autlmliity ·were
provirledl .and Wen! appro,pr iate fur- the!!iiepossil!ions.
ihe ■ r-eports. no i!S:Sueswith medica'I autonomy . Ou!!iitody•su;pport!!iimedica'I dec isioos and SII.IP;ports
de live..-y-of-i::ar
,e effart!!ii.
Medica'I adminii.l!raticm,meeting:s oorur-q ,uarterf\r wi1!hdocl11Jl1entedminutes .and attendance ro!!iiters.
Staff meetings are appro,pniate,1tyhe l'd and documented .
IM1:mthly medilc:a'I statistics are ,romp· ed and pra.rided to fa □ility arlm inistiation. The types ,Df
stal!istics ,ooll.ected .are appr ,DiPfiate.
to detajnees fOII'the de livery ·of medica:1G!Te . Deta inees are
ihere .are no ,oonoems. with aoc:e!S:S
esoorted l1!o tlhe med ii::al department for tr ,eatment when requested LIt was. a lso r,eported that tlher,e
are no i!S:Sueswith off-site esool1: for med ical care.
All custody .and medka 'I staff r;ea;ive 11raining,on o.onfldentiia'lity and there we..-e no reported
amc:ems on this iissue_
Confident iality of medica 1infor-ma1!ion during d'etainee transport is ma intained us iJlg a sea 'led
envelope pr,ocess.
ihe contim.101.Js,qua lity improvement (CQI)program is. not well defined and i~ernented
l_lhe■
Wil1S un dlear a.bout oow
the pro~ .am is conducted and ldocumented .

Hm{th BewmReview
·
• ihe health reoonl review yielded no finding)>th'at reflect any ,oonc:erns re lated t!o tlhe program
adm inistration.
Findings; A ,oontimmu!!iiqualJty improvement pro,gram h'aS not been a;ppr,DiPfiat,ely deve l'oped and
imp lemented .
• Ctiterit1: 4.3. V.ElEAdministration of the Medica l IDep:artment; INCCH:CAc-06Continuous QualJty ·
Improvement P,rogam
•
Cl:1111
.se of Pnlbtem: The ■ and l.
have not property developed and impleml!il1ted a CUI progam c
Doclllll1enta1!ioo,,ooa OQI rogram cou l'd lnol be pmvided.
•
Effed: of Pnlblem : Thell'!!is no ,organm;!d a;p,proad1 in place to ,eval'ua.te the de live..-yof hea 'lth car,e
services..

S11g_gestBd Actions: The■ and l.
shou ld wort mgethl!il' ro piroperly·educate themsl!lve5 about
the r,equired l,elements ,ooan ,effective CW prog;ram. The IOE and INOOHCstand!ards listed l under
Oriteria ,i::anprcm,:ide the needed GJ.ridanc:e. On.Iletihelfl!i!!ii
an understanding ,D1fp«1gram needs, a CUI
pro,g_ram shouk!II be d'evel~
and imp lemented .
Qua llty of Process: Adequate
•

Ir-win C.Ounty Det.ent oot1Cente r - nspect ion R~

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Inspection Report

HEALTH RECORDS
Jfepotted Proce!/.5esand Document Review
• The facility uses tile CorrecTek electron ic hea lth record (EHRIsystem . A hea lth record is mainta ined
for each detainee.
• Medical and mental health use the s.1me EHR.Dental documentation is .scanned into the record as
those services are pro "ded ofhite.
• The EHRsystem enab es health records to be available for all providers during detainee enoounters .
• A designated and secure 10<:ation is used for health re-cord maintenance .
• Allhealth care d0<:umentation created outside of the EHRis scanned into the electron ic record and
then properly disposed of, based on facility and jurisdiction guidance . There is no reported backlog
for tfie :.canning of pa per documents .
• Evidence of Health Insurance Portabi lity and Accountability Act tHIPAA)tra ining was not provided
for inspector review and thus could not be confirmed.
• The ■ descr ibed a clear proc.ess for the detainee to receive a copy of their health record. The
records are provided after a written autho rization is obtained from the deta inee.
• There is a define d and implemented process for the release of health informat ion as needed.
Health Recotd Review
• The health record revie~ yielded no ndings that re ect any concerns related to the health record
system.
• The records reviewed were provided in a PDFformat , iJ. h some being difficultto read because of
the copying process .
• The documents provided covered severa l years wit h forms differing wit hin the records .
• The inspect ion team made every effort to obta in needed informat ion when it could not be located
in the health record. The.
did an outstand ing job assisting with these requests .
Findings : The presence of HIPAAtrain ing and its application was not presented for review. The
inspection team could not determine if the program is in place and approp riate ly applied .
• Cn'terio: 4.3.V.BB Medics Reoord s; NCCHCA-OSHealth Records
• Couse of Problem : No evidence ofa HIPAAprogram was provided to the inspection team .
• Elfert of Prob lem: If such a program is not in place, it creates a greater opportunity for breach of
confidentially.
•
Suggested Actions: The ■ must ensure that the HIPAAprogram is in place and proper ly app ied to
da ily hea h c.are activity,
Quolity of Health Records: Adequate, but the lack of a HIPAAprogram should be addressed.

POLICIESAND PROCEDURES
Repotted Processes and Document Re iew
• The ■ provided policies that were described as the site-specific policies to be fo lowed at the
Irwin County Detention Center.
• A review of the po icies and procedu re s found them to be genera lly well written. However, they
appear to be the generic LaSalle oompan~• policies that have not been made site-speci ,c for the
Irwin facility, For e1<ample, the y have a policy for restraint and seclusion when · was reported that
this is not used at the facility. The term inal illness policy cites state guide lines for the state of
Louisiana . There is a policy for infirm ary .services, but t hese i.ervice.sare not provided at the facility.
• We noted that the policies and procedures have been signed by the .
but do not inc ude a review
date .

Irwin County Detention Center -1 nspection Report

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

lrupedi!D'n ' Report

tlwah Hemm
-Revfew
•

The he alth reconl r-eviiew yiekl 'ed no ·fir11fi111
g;s;11hat reflect a:ny ,ooncems r-elated to po licies .a nd
proi:ed111res...
findings.: The polic ies and l prooedur ,es - , place .are not specific to the deliveiy ,of ca:re at 11hefa1wility
~ nor
hiill!ith e .a nmJ'ill re'Vi:ewbeen pr ,oper ly documented_
•
CriteriQ : 4-3_VJEEAdminiistr.mcm ,,of the Medi.ca l Dep -artment ; NOCHCA--05 Po lk i es a:ndll 'rnced111res
•
Ci:i11seof Pro-blemc Faci lity 1.ea de;rs!h\p h as not created a s>ite-s,pe1wificset of policies .a nd proced'ures_
• Effect of Problem: P,olicies an d p,-Medllln!S J}'rovide a m adma:p for the ,daif'to-d ay ,cper.nions of'the
medica l!dep artment. The pll"OIEdur,es pmvide gµid ance to staff abolll: how to imp lement a po licy_
They al5o ,Em5l!Jre,oomp lianoe with org:ani!zat ton al po1i1w
i es an d ICE r,~ lat tons...IFailllln! to harve de arly
written , po.'liiciesa nd prcocedures th at a:re :s;pe1wifa:
to the lrwm ,fadlity results in, l!alllc:
,of P,-0,Pl!f"
~id ancefCII' staff_
• Suggested Actions : The po licies and pr ,oc:ed'ures shoukl l be reviewed to ensure th at applicab le
po licies and l prooedur ,es that meet IOE standards .are put in place _This .a lso indllldes a pr ,ocess for th e
annual review ,of the policies and procedures willhi 111
,pd~tes made as needed l
Quality o.f Polities and Procedures : N'ot adeq uilite

RECEIVINGSOREENING
8€Pert€4.f'roqµwwR ,Qqglmcot
tfeyfm
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The .
~ th at the r,ec:eiving prooess is the s:a:mefor tol: detainees and l non -ICE d eta -nees.
A.des i~i!ited intalte a:rea in the faci lity has two rooms wher-e inta 'ke assessments ca n be ro:ndutted
in p.rilvate_
Two members ,of th e m1f'S'
i111
g staff are iliSSi,gned
to th e intak e .a rea to oDmplet:e the receiving
si:reen r_ng:s_,custod'y team memlbers do not 0100T1pletescreenings..
of receiving sa ,eenin,gs if req ,uired.
Translat ion se11Vtoesare ava ilab l'e far 11heoMDpletOCIII
Detainees ar ,:e pr ioliit~d for screen ing based on presa,ted cfiniul 'I need .

The reiceilvif\g s1wreenmg as>sesses med ii::al stab.ls , menta l!h ea 'ltih, medication , an d denta 'I need£.
A.review ,of the r,ece iivmg s:cr,eening :fwm ,shows that it is appr c~priat:e in content and smpe _
The nur.;e oDmpleti:ng 11heinta'ke pelfom:is a dental s:cr,eenif\g a:ndla nother denta l screening oomr.;.
during the hea lth aissessment . Deta:inees presenting with significant denta l needs are refel'Ted to the
off -site d enta l!provider_ The .
r,eporu that they are seen in, a time tv m anner_ It is reported that
ora l hygiene education isJ}'.rovidedd if\g inta'ke .
The ■ ~ th at staff ha'V:e been trained to com,p lete the medication a:ndl,denta l!s:crea, ing
port iollS of the rece i'llii
ng si::reenmg.
The fac ility as a 12.-lhour time frame for ,mmpletion of 'the receiving screening, but the ■ reports
th at the screen ings 0001.i:r ll"mJchsoone;r than , 12 hours_
Any urgent/emergent
issues identifi ed d uring the si:reeni:n g .are .ad 'dr ,:essed immedm:ery . If a medoca 1
s>itcan be done to
or menta: 1 he alth Jlf'O'i'iid
'er is re,q:u ired but not ,0111site , a phone ,or teleme<li1wine 'M:i
ellSlllre propel" ilSS'es5!ITlentand om ler ,ed acticm , If needed ., the d'etainee is tr.m5fened lto a !loca l
hospil:a 'I for tre at ment .
IRool!ine referr als to men ta l health a:re s>een, 11henext daiy ,or by te 1eihealth if menta l he alth staff a:re
not on !iiit:e.
IMedica ,ticm, needs are revi e wed .a t si:reeni:ng .a nd add 'ressed l.a s need 'ed .

lrwi:n Cou nty Deten t ion Center - nspE!O!ion Re,pon

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.
•

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tnspeaio,i ,Rep.on:

Tuber ,rulosis screening :aoo ltest ing ,oocur iliSa part of the receiving proc;ess._All detainees .entering
the faci lity r,l!{Jeive.a chest :X-r.av the same dav- The X-ra-ys ar ,e comp leted by a oDnt racted pr,ovjdl!f
who is.,oo,site da -ry ,or as needed _Staffmav house potenl!ia ll'y infectious detainees .in the two
negative pressure rooms in the mediul l unit unf proper dispositio:n ,aoo ltreatment are defined !_
test com ,p leted l.at intake _ 11MJSe
wit,h positive tests are referred
Al Ifema les have a wine p~ncv
to a pmv idl!f for fiurther t:esliin,g:aoo ltreatment . This wou ld indud'e treatment for reported opioid ]

use _

Hm:4h&,emBW&w
In the 11..95
intake records reviewed , the care was found to be t imely ·and comp lete_ We noted ]11hlllt
thr ,ee health records had minor issues at intalj,e but these fmdings are ot refl'ea:ille ,of an ineffilDient
intalj,e system s
•
12 hea lth records didl not indlude copiesoHhe
intal!iescr ,een ing _
• Overa ll]the inta'ke process is we l org~ized .and rum : tioos we!II.
Suggestions : We recommend that the time liness and l,IOOfflp
letenes:s of the inta'ke system be monitored
thr ,00!111the CQJ program ,,oolJe the progr .am is estab lished.
Quality of Care: Ad'eq;ua,te
•

HEAlTHASSESSMENTS
(INmAt ArJD PERIODIC)

&lRaffi'd&P9\'o¥/imrnrQeg,meot6:e:vim
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Initia l]hea.1th ilSSessments are to l:Je oompll!l:ed lwjthin 14 da -ys _ The■ raports that the hea 'tlh
assessments .are typ ica lly·comp leted ]within 24 hol.lf'S.
Trained nlllf'Sep.ractitioners or reg _iistered nurses mnw lete inil!i al hea lth illSSessments .
S~ff comp lete the initia l] hea 'lth .assessment using a f'onn in the IEHR. If the ,e,1ectronic: rellm-dlsystem ,
is not flllnctioning, the hea lth .assessment is documented ],on paP!!f and lscanned into the e!lectr ,ooic
hea lth reoont
The use of an ,electronic reoo-.rdenab les the nurse com ,p leung the hea hh assessm .ent to aoces s the
rece iilr
jng screening fur reference pmpo .ses _ The ■ reports that the nurses do 11!1e
11hereceiving
screening for med 1cation revjew but is unsure if the SCFeenin,g:is llls:edfor review and omnparison of
infurmal! ion shared dur ing the hea lth assessment .
Initia l]hea.1th ilSSessments are prio:miZ1!d at the point ,of the intake screening. If t he detainee
requ ires immed iate ,care or priority for the hea 'tlh .assessment , a provider is mntacted lfor immediate
GUiclance_Odll!fWise , d'etainees .areschedu led lthro~
the esta 1!Sihedprocess...
IP'e!lvic ,exams .are not routine 1v done as .a part ,of the initia l hea lth aiS!iessmE!Ilt_These wou ld be
ordl!fed l based ,on deta inee presen~tioo ,.a nd pem :mned l by an off-site specia lty prowler _

•
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lber ,e .are no r,eported badJogs for the completion of ·rnil!ial health illSSessments.
IP'eniodic health assessmeillts ar ,e reporteid ly·oompll!l:ed ,on an annua l ba:2is. The■ reports 11hat
detainees are trild:ed by med ica1 adminiiStril.uon for the timin,g of the alllflua'l health assessments.
• The shou ld define 11heti:rning and ],content ,of these ,exams , but that process iisnot ,ruJTI!lfltly in,
pl a.ce_
• We noted that the alllflUill exams were comp leted by RNIstaff rathl!f than a prov ider.. This is not best
prad! ioe, especia lly·far 11hose detainees who are ,enr ,o lled in chronic care services _
Heal th Remm .Review
•
Initia l]hea lth ilSSessments were found to be timely and omnplete except for a ·few deta inees.
• We ·faund se= , real!rds that ,exceeded the 14-dav time rrame .and l!5 recu.rds ,did not pmvide .a copy
ofthe he alth assessment. The ■ WiliS a e to provid'e most ofthe miss ing doruments.
•
In genE!r.1:I, the initia l hea lth =essment
pr ,ocess functions wel l!_The missin,g documents were d111efor
the most part to ,oo:pving issues _

Irw in Cou nty Deten t ion Cente r - Inspect ion Repon

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OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

tnspeaio,i ,Rep.on:

1be .
sltmuld determine the t iming .and omrl:ent of annua ll hea lth .assessments , but that iisnot
ament ly in plaoe_
•
We noted that the annua 1exams wer ,e ,romp leted by RNIstaff rathl!if than a provider . Thiis is not best
practioe , especia ly far thas.e detainees who .ar,e ,enr,olled in chronic ,care servic:e.s..
Findings: lber ,e are no deliined health assessment ,aiteria in platJe to provide consistent and arlequ!ilte
periodic health care a.s:ses.sments.
•
0-iteria : 4.3 _VJM Comprehensive Hea'ltlhAssessment ; 4 ..3.V.Q AnnuiallH'ea lllh, Examinaticm:s; NCCHCE~
M lnit ia'I H'ealllh,Assessment ; NOCI-IC8--03,>Cl
inica l Preventive Sein.1ioes
• cause oJ Problem: The ha,s not ,liJ'eated a set of ,expected ann'Ua.1 ea lth assessment
examination elements..
• Effect oJ Rrob.tem:'There is .a l ack of guidance ·for provider staff rega:n:ling ,expected examination ,
e lements _Lad of'deliinitinn leads to inoonsist:ent eva l1..1atioo
,,air detainees _
•
Sugge.st ,ed A.ctwns : Create .and imtpleme;nt dearly de.fined !.a nn'IJ'al assessment gJJidelines., to include
the timin g .a nd oootent of the examinetioos . ·wi, ile the initia l hea lth iliSSessme;ntprocess .ap,pea:r:sto
function we l~ w e suggest tlilat the process be monitored .as a pan of the newly ,em iished CUI
program_
Plursic.ilm Case .Rewews That Snow ,Ncmc;omp.lianc;e: ,case 4
Quality a.f Care: Adequate
•

NOTIFYINGDETAINEESABOUTHEM.THCARESERVIOES/rRANSlATION
AND lANGUAGE
ACCESS
Reported .Processes and ,Damment Review
• AlI d'etilinees ar ,e provided infuirmetio:n,,cm heahh ser"ll\ices.,ara lty and in wmt:en formats.
• Signage providing this infonnatilon is posted in,the intil'ke area as well l.as housi~ areas .
•
1be fa.d lit:yhas two trans lal!ion lines th at are used when these semces. ar ,e n.eeGed.
•
1be ■ reports that non-medica l and l mm.-menta l health staff are not med lto provide tr .a nsl ation
se,vices _

Health ReCDld .Review

1be health record n!v iew yielded no ·liimli~gs that reflect a.n y ,oonoerns re lia,ted to these serv ioes_
findi ngs: Na,ne
Quqlity qf.Proecas:
~Ad'equ~te
•

TRANSFERPROCESS
Reported .Processes and ,Damment Review
•
1be fa.d lit:ydoes perfon:n ,transfers to and ·from other ICEfaoifl1!ies.
• All detil in ees receinted a,t the rac:ifrtythrough transfer are treated a,s new intakes_
•
An iliSSignednurs e proc:e,sses a'IItransfers out of the fallil1ity.'.This individua l prapa:res a lI necessary
pa;peiwort., hea lth r-eam:1 dorume;nts , and l medications for oontioo ity ,DfGm! durin g the transfer
prMeSS.

•

1be ■ reports that notifical!ion or transfer or discharge is provided to medic.t i staff in,.a time frame
that a'llows ·for proper preparation ·for transfl!if _

Health ReCDld .Review

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1be health care record re11:
iew shows fallilro,,·stilff do an ad'equ!ilte job preparing transfer
d'ocumenta.ticm c
1be intent ,Dftfimsfl!if reviews is to enwre that d etainees beii~g t:ransferr,ed into the fac:irrty have
their -u.ansfer infmmaticm , r,e viewed' and acted upon in, a tiimely manner _

Irwin County Deten t ion Center - Inspection Repon

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OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.
•

tnspeaio,i ,Rep.on:

AlI detil inees tra :nsferred into tlhe Irwin faci lity ar ,e treated

as new intakes aoo lgo through tlhe intake

proEeSS.

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Given th at tra ·ns:fers in woukl l not be i111
the health FeCO.rd, the team looked at the transfer fonns
'ld be noted that not a l I detainees WCl'U
l d r,eq ,ui:re
mm ,p leted for deta.inees l ea1,1mgthe faciility. It sho111
a oo mpfeted tJrans:fe,r--0'\Jt·Jann .
IF-0'.r
those health records t hat did na,re .a transf ·er form , the forms fo11111d
wer ,e a,ppropr~te ly
mm ,p leted L

Fin.dings: "'1:one

Ougytyqf Qzw· Ad'e,q;ua,te

MEDICAIL
OBSERVATION
BEDS
Reported .f'roa!!sses amUmcument

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Review

The fad lity has no "mirm ary beds, detainees requiring this level or ,i:::areWOtifd be housed ,eilsewher ,e.
ll 11111it.
Two of'these oells are negative pressure
lhere .are ,6 medilCa.1 observati ion beds in,the med ii:::a
rooms aoo ltlhree are reported ly wiciide resistant .and used foc suicide wa.t.ch if needed.
Per the .
det a inees are admitted to aoo ldisch arg :ed fTOm med ii:::a
1 olMiervat io11bed lst atus ~ed
on the ,order of .a prnvi:d'er .
the deta inees hau5ed i111
medica 1
It was reporl!ed that nursing staff conduct we 'll'ness ,chem 0111
obseiv.11iio111
every ·2 hours with rounds documented in tlhe e!lectr ,onic hea lth record .

Hea l th ReCDrd Review

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We noted that there ilSli:tlile to 110docume,nt atiDn of ·c,ne provided in,tlhe med1i:::all,abservat ion
rooms ._There w.1S no ellid lence of'.a.dmi:ssion and disch arge orders nor of romine nursing rounds.
INo.t a ll detil inees WOtil'd l ha1,1erequired !medica l observation ,care and tlher ,e,fu.re not a ll WOtildl have
any documentat ion fu:r this leve l!,of ca:re .
Of the tota' I number oh.ecord!s reviewed., ,on'ly a few charts oontained any documentation
re!lated lto
medi .ca l ,observaticm ,care .

•

The very fewme111oons of ,i:::a.reon ly ,i:ont ained an ,occasiona i documented nursing ro und. There was
no admission a n.d/ or disdharge docwne111ta.tion foi.1001in, any of the records re11:
iewed.
fi n dings;
• Ct iteria : NCCHC f.-02 lnliirmary-1.eve l Care
•
Cause oJ Prnb Jem c The fa1D
ility did l not prov ide an y documentat ion for these savices so it ilsassumed
th at the .approach for documenting :this care has not beBn ,defined by tac · i.ty l eader:ship.
•
Effect oJ Prnblem c The fa.ol ity .states tlhat medica 'I obseiv.rl! ion servr c:;
.es a:re pr,ovid.edlbut there is no
d'ocume111ta,tion ,of thiis type of care being doruml!iflted lin the hea 'lth ,care rerords re -viewed . IF:ailure
to define an dldocumelllt tlhis ,i::are im,pacts ,i:ontinuity of care.
• Suggest;ed Actia .ns: A11pr ,wi.ded medica l o'bse;rvation ,,care , including ass0£iiated lorders , r,oun.ds, aoo l
care pr ,wi.ded ~ :sih.ou ld be docwnented in,the health record . The types o f care prov ided i111
these
l'ooms shou ld be defined in po licy .and pr,oi:edure. f.a d lity leader:shiP shou ld cr,.ea,te de,fmed l po/licy for
the delivery ,of medica l o'bs-tion
,,care aoo l,.enS'IJreall!.aspects ofthi:s care .a re documented in the
he alth reoord.
Q1.1alityaf Car,e:
•
There -was 1110documentation
to su~port assesSJIT1ent,of these senoces.. Th is documentation
!ilhoul'd
have been present in the hea lth reoords made av:atlable for r,evi.ew·.
•
We were un ab le to determine q ua'lity of care because of l!adc,of documentation , in the hea lth
l'eoords p.rovid 'ed for rev re-w.

Irw in Cou nty Oe,ten t ion Center - Inspect ion Repon

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OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

tnspeaio,i ,Rep.on:

Sl CKCALL/NURSlNG PROTOCOLS
Reported .Processes anal,Document Review
•

In ai:ldiiion to the .

, we interviewed

sick ca ll

nur:se
llll-

•LPN,.as a part of the sid:. call

rev iew .
•

Sick call se,rvkes ar,e provided 7 days a we~.

•

Detainees ,can r,equest
,call serv ioes either tfu,01.111!
1a 1!il e,t system or on a written form that is
1]4aoed in a ,oonfiidentia l l odked box in the[r housing area . The same iistrne for s~egated
detainees.

•

A nurse ,oo llem the written , requests ,on the evening/nigllt

so

wi l I i mmedia ,te l\r see an y detainee who has an urg~t
•

•
•

•

S!hift.This m..1rsere\l\iew:s the requests

and

need.

nurse who is responsible fur the sick ,c:a'IIpr ,oce:ss..
1be day S!hiftsid call nurse then reviews the requests .and proceeds to ,rondlllct sick cal ll viis,its. All
visits a:re oond 'ucted in,the med i cal! unit , induding tlhose far d etain .ees hoosed in segregation.
1be nurse intervi ewed reports that the m..1mberofvisitsvariesfrnm
a low ·of16 ,to .a igjl or
~p,proximately ·JO ,or <IO. We noted that the census is d'own due to tlhe COVI D-19 pandemic, which
lias red 'uoed the nwnber ,of sid calls.
ll1lan-,\Jrgellltrequests are scanned and l sent to the

Sidk call is ,oo.nducted l using nursing protocDl!s that .are i n,CDrreCTek. lber ,e .are ,a111proximatel'y 25
nursing protooo!ls tha ,t a l low the sick call l nurse to address tlhe typica l ,oomp l'aints that oorur in the
mnectiona1 healllh, ,i:a:re SBH!ing; Dorumentation w,as pro1rild'ed to vBrify that nurses are tra ined in
nursing promoo l use at the point oif new hir ,e orient atio n.

•
•

1be nursing pmtooo' ls indud e ,over-the-counter medications that have been ,.a111provedbythe •
.
1be sid call l nllf5E! refers an y detai nee that they deem to rcequ i:re prnvidE!f' ,care. It was reported that
these referra ls .are typica l ly seen,within 7 d~

un less urgl!-l t need ralll;uires t!hem to be seen soonl!T.

•

!Emergency protouol!s are in place that in dude prescription
a p.r,D11:iderbefore use ,of these med ications...

•

lber ce ·were no rreported bad l'qgs fCII"
sid:. ca'IIservioes.

medications.

N ursing Sl!ilff.arreto ,rontact

Hffllth Bernm
Bev&w
•

1be m..1rsingteam me,mbers focused on th e sick ,cal I process in,tile hea lth record rrev.iew.The 2811
ICEstandards requ i re that all sid call requests be triag ,edl within 24 hours, whi le the NOCHC
standards r,equ ire a face-to-face encounter within 24 hol.lfS of sid call ralll~est :submission. The
l'eOOf1fswer ,e reviewed !based l ,on ,tlhe ICEstandards.

•
•

two di~ I
We attempted to ·liind at east two sick call l em:ounters. in eac h rremrds re"llliewed, .altho11-1gjl
not exist in every rei::ord.
It was diffirult

to track time frames bec:a:use the .actua l d'ated r,eq~est was not a lways i n the

ea lth

record.
•

IFar those cases where that docwnenl!il ,tion ,·was ava i la e, care was genera lly comp leted wiithi'n 48
hours, but t!her,e wer ,e so m e outl1ers ·wherre ,care w,as de l'ayed .

•

In the 11.95health rremrds re"llliewed , tlhe team eva lu ated 236 si ck ,cal I 111
isits. Of'those 23 6 sick ,call
visits, t her ,e were ,8 viistt.s·with ,car,e th at cou ld hav e been mor e appr,q:iriat e , with,th e rremaining 111
isits
d'eem edl to be appro,pr iate.

•

Sid call ll'Ursing team me,mbers use nlll'S~

•

1be phV51
i C!iani nspectm- noted lth!atthe :sid cal l lLPN halillto place severa l provider r,eterra ls before a
detainee was seen!, ca=i~g a de lay ,of a rew weelcs.
One mni:em ,we noted l was that many ,of the nursing J)'rotocols a'llow tlhe nurs e to ,order ,a111propriate

•

J)'rotoco l's apprnpn i ate:ly·.

amounts of ibuprofen . However, some detaine es were a!r,ead y ,on,,other NSAJD.s(noncsteroooliil'I antii nflammatOfY medi~ions
) and the .addi tion ortlhe i blllPf'Ofen ·was not appropriate . The nlllf!1es
should l ,diedk tlhe detainee "s C11111TentrnediGl ,tio.ns befure omeri:ng ibuprofen.

Irwin County De,tent ion Center - lnspBct i on Repon

www.oig.dhs.gov

42

OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

lnspect,ian , Report

S.rmaeffigru
•

REfemi l's to pID11:ider-s
by mlfSing at s,idk ca ll soou ld be traded

•

an d 11ur5es ed ucated !
0.f!f" -th!!'-counter medication use in, nursing :protoa:lfs !Jlou l'dlbe r-e111iewecl
a'oout the prope,r instanoes to provide these medoc:atiom ..
Al I s ick calll req1.1em sho11'ld be scanned into tihe detil inee hea lth r-ecorn
_This ma.y be ,runent po licy
practice.
but the recants re -viewed spanned s,evera llyea:rs bade: and ma.y not irelilect Cl.ll"l'l!lllt

•
•
•

fcu timellnes:s_

Al I s ick calll req1.1em sho11'ld be tracked tD proper oomplBtixm witlh i11estab lished time fu!mes
Sid ca ll care sloou ~ be monitcned thr ,oudi ,t!he newly ·estabr1Shed lCQJ pro,gram _

ihe widesp.-ead use of i'bupirofen i11th e 111.1.-sing
protooo' ls shou'ld be rev.ie wed .
Cas;es 3 , 5, an d 18
Quality o.f Care: Sid ,ca ll is adeqllate but time fr.Imes need to be monitored through tlhe OQI program_
•

Phl!Sician Case Rewews That Show ,'1lonmmplianc;e-:

OIRON I C CARE
Review
ihe.-e .a.-e 110 site-speoific chronic care or-preventive ,care guidel ines _It was .-eported that la'boratory
aoo l,other test results a.-e shared lwith detainees at dlnmic ca:re visits . Sid G11I r,equem that .a .-e
l'eferred to the INPs a.-e r,epoirted fy seen within, n hours_

Reported .Processes anal ,Dl:lrument

•

•

In addil!io11to the■, we .a lso i11teniiewed chronic
chr ,ooic ,care re-view_

GITI!

nurse■-• ILPN, il<5 pan

of tihe

•

ihe l'lllr5e assigned to chro11ic ,care tracks .a ll detainees enr ,o11ed i11chronic ,care clinics , im::ilud~g
com ,p'le tion ,of required laboratmy tests, medication Fl!f'lewal's, .and illSSistanc:ewiilh sdied'u ling
chr ,ooic ,car ,e visill:S.

•

ihe chr ,cmic care nurse woru di.-edly with ·1t!h.enurse who 5?Upporu the -

•
•

to schBd 'ule th e ,dinmic

Gl:re vis its ..
REfemil's to d 1ronic care typic a lly beg .in, at i11talce but ca n oorur-wihen .a n issue is no.ted ldu.-in-g any
din'ica l encounter .
f 'rovirler st aff r-e,port that there .are st anding lia'boratairy testing orders for chron ic G1:redetainees
that are inititated a,t inta'Jlie_ Identified chronic GITI! detainees ar ,e to be seen by a provider- within
hours of inta'ke_

n

•
•

ihe timing :of chronic Gire v:isits is based 0'111provider order-, il<5 is as5'0Ciated diii!-gl"iOSIJic:
testing, bllt is
uwally eve.-y·3 months , per provide,- staff _
IPro-vider st a ff are to estab lish and l mam ta in,tlhe pr,ob lern , list duiri~g sid ca.111.and chronic ,care

enoounters a
•
ihere .are 110 rcepoirted b ad logs for- dniDn ic: ca r,.e sen/ices "
Health R&Drd Jleview ·
•
•
•

•
•

Overa llltfle m anagement of ,diron ic concflliions, including hVJlf!f"lens,ion, hyperilip'idemia, d ililbetes.,
asthma , and menstru a l disorders , -aP,pBaTSadequate..
Whi le car ,.e .appears ad~uat.e , tlhe organiiz at ion, ocm51
istency , an d denvery of the program is not
adequate aoo l requires a g,eat ,dea 1 of pr,ocess work.
ihere is no oons ii!itent guid ance for the treatmelllt ,of chronic illness du.e to a ladk of clhmnic care
fOI"us,e by provider-staff_ Sta ,ff provid111g
cuidelines_ 'These gui:de!lines have 110:tbeen devel~d
chr ,ooic ,car ,e services report using a num 'ber- of different guid a no.e dacuments_
. fo:r tho.se r-ecorns
We noted that m aster pro em l ists were 11ot pr ,es,ent in .a ll ofthe hea lth l"E!COTds
witlh, master- prob lem lists, they d id not a l'wa.ys reflect cun,ent d eta:inee sta.tus _
P-...ovixterstaff who tr ,ea t ,chronic care det ainees a:re not monil!o.-ing an d dowmenting the current

(l)OOI'",
fair, good ).
It wais diffia.ih to tradk tlhe oompletilon of laboratory studi:es ,ordered fm ,d,ronic ca.-e dBt ainees_ For
the lla'borato.-y res u lts th at were found in the reoord's , many we.-e s,jg,ied o.r .a ckOO'i\lle~g~ Iby ·!he

status l sta'!Jle, imp.roving, det:erioratingj o:r ,condctixln

•

Ir-win C.Ounty Det.en t ixJnCenter-

www.oig.dhs.gov

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11Specti on R~rt

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OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

lrupedi!D'n ' Report

ordering pr ,ovider , lbut there was no documental! ion m ,ting a.aions to he tak:en c Docu melllta1!ion th at
l a.boram:ry lll!S'l.111!:swere s!hared with detainees was a lso ladkli ng..
•
Chronic care viisi'tswere not sdhedu led with ,oons istl!flcy ·.
•
IMany prov ider do,cumental!ion entries .ar,e no .t pr-aper fy d ated . Th is is ,expected documen'lil ilicm,
praaioe .
Fin dings:
• Criteria: 4 .3.V .W ~pecia 'I INeeits and Close Medica l Supervis ion ; NCCHC IF-01 Patients With Chro nic
Disease and Other ~pec iia'I Needs
• Ci:i1.1
se oJ J'rnble m : Lad o f d efined d n,cmii: ,car ,e pru,gram guide lines .

•

Effect aJ Problem
,o

,o
,o

,o
,o

11...a.d;of chronic c.i:re ~ ide lines resu' lts in inconsistent

chro nic:care tr ,ea ilm!!illt.
In comp lete am l ,0111:datedl master prob lem nstsnega.mrely im;p.ict det.1inee care .acr ,oss
interacticms with a ll hea lth staff.
11...a.d;ofdorum!!illted deta inee hea lth starus in,.addition to the lack ,ofGUidelines res ults in
to ,c:are.
inconsistent and poor ly de fi ned ~aches
11...a.d;of response to labDratory res u lts d oes not provocle a, dear pktw-e of tre -at m ent appr ,oadhes .
11...a.d;of pr ,~per dorum!!illtatilon fw ,dates ,o f du,onic: c,ne provided also impedes understandi ~g of
treatment:.

•

Suggested Artians :
!Estab lish du ,onk ,car ,.e guide' Jines for use by pr ,ov,idE!ifstaff .
o Prov ider staff s!hou l'd be provirled l,dlea n'ly defined diredicm , regard ing the proper comp letion .a n d
maintenam:e ofthe mBISter prob lem list in t he hea lth .-eoords...
,o !Prov ider staff s!hou ldl be properl y ,ecifu cated o n how t o determ ine and d ocument the chronic care
p.1Jtient' s hea Jth status and l,oond ilia.n.
,o Pro v ider staff s!hou ldl be instructed to n ot on ly adcnow le d,c;etlhat l'aboratoi ry studies haive bee n
r-eviewed , but .a lso dorume;nt their intended l.ad!ion based o:nthefmdings . The ·fin di~sho
111
ld be
shared with the deta inee and t hat encounteF s h o u ld lbe docu m ented in the hea lth reami.
,o
IProv idE!ifstaffs!ho u ldlbe reminded o f tlh.e need to date and t ime all documented di n ica'I
encounters .
o The chr ,m, ic:,ca r,e pru,gram , requires ageat ,de · of' d Bfin iiticm,toens u r,ethatadeq
111
ate chronic
care is be in g provided . tnvofv ed staff shou' ld be p!Olliided d'ornmented ,ed u rcatiio:n and he ll!
acoountab le for alll req 111
il1edl arcticms in the d~ livery of' chro nic: care .
l'h l[Siciall Ci:ise Reilliews 1hat Sh ow .Nonoomp lia n oe: Cases 2, 3, 4 , 6,, 8:, 10, 11, 12 , 13-, 14, 15, 16, 17 , 1'9 ,
and l20
Qugljty qf Qmpic Cqw · Care -adequate ; progam ,,orga n i!Zilll
io:n - not adeci ,uate
,o

OONTINUIIYOF CARE
Reported ll"roc.e.ssesand .Docume n t Rev iew
•
A.defined process is in ,p laoe for diag,lost li.c testl ing:. The o:meri:ng p!Olliider enters the ,order into the
IEHR. These are pr inted a.nd pl ao.ed in a designated locat ion for use by the ev.e;ning nurse wl,o, will
ob t a· ,th e sipeoimens .
•
Al I !laboratory spec imens a.re tra111SpDrtedlto .a l oca ll hos ,p:ital fur prooess ing. This incl'udes both
roul!in e and stat l abor .atairy .stud 1es.
•
Critlircall an d St.It l a'boratDfY r,esults are ca lled in, to tlhe fac il"rty. A provider is notified for orders in, th is
circumstance and lorders are obta ined .as needed .
•
The ■ reports that !laboratory results are s!hared wiith det.1inees and lthat ,rcommunircatiion is
documented !mtlhe hea lth record .

nty Deten t ion Ce nter - nspect! ion Repon
Irw in C.OU

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OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.
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fospecticm Report

!Requests fur off.-5!itespecia lty care go thr ,DUglh,the ICE approv.a proi:ess . It was reported that 1!he
,urred from the
a:JJPl"Ova
l process ,u111vary fi,om 2 days to 2 weelc:s if additiona l information, is .--e,q
ordering pr ,ovjder _The ordering pmvider is r,espons iille for trad:i:ng t!he approvals and lprovic,fi~
informa1!io11ill5 req ,ui:red.
1Detainee5 ar ,e reportedly seen , ,every 30 days OT as needed 11milltlhe reqµested appointment is
com ,p leted L
1Detainee5 retwning from il"lp<iltientstays or emerg _ency room ·vi.sm; are ho11Sed in a medica 'I
observal! io111
room , 11111ti
l they can be seen by a provider.. These detainees r,eceive .a nurse we:I ess
died evety 2 oours.
It was reported that off,-51itespecia 'lty·prov iders return necessary informa"l!ion and papelWOflc for
.we a posiliiv·e ·wasting re lation~ ip with specia.'lty
co~ 'leted l.appo inttnents . The■ and l.
providers and emergency staff and can eil!Silymonit:or detainees and obtain , req11iredl p:aperwDll'lk
when , needed .
One member of the nul'Se practitioner staff noted that she seihedu 'les a,fu low-up appo intment at
the 1iime ,of a lab:orarory ocdE!il'to ,ensure review of la'ooratc:ny ·fmdings with the detainee _ It WiliS not
dea:r ttla ,t a ll proviider staff use this a;ppr,oaeihc

Health Reootd .Review

•

The health reca.rd review revealed a nmnber ,of inSltancceswhere ,oontinuity of care was 1110t
ap~priate.
•
In severa l!instanoes orders wer ,e 1110t
carried out en test re5!1.lltswere not appr ,~ately
a.ddr,essed _
Fin.dings: None for reported pr,ocesses...
Phv.sjcjqa fimewsUuuSbqwlllqn-Cqroplianw,cases: 1, 4, s, 9 , 13, 14 , 1s, 16, 11, 1.s, 19 1, and 20
Quality oj Care: Not adequate

cm

SPEaA.l NEEDSO:ETJIJNElES
Reported .fi'rocesses amU>ac:ument Review
• 1Detainee5 ar ,e provid'ed aids to impaument when ,,ordered by provoofer staff based on need L
•
If a detainee ,enters 11hefa1wilitywith an aid, 11hey·a:re referred !to .a provid 'er at the point ,of the intake
screening fur a decisOCIIIon am1ii111u.n
ion of 1JSe_
• IB:a.sic.aool!sto impairment are l!iept on site fur immediate use , but items such .as hea:ring aids ,or
delltllr ,es wou ld need to go through the requ ir,ed process for ob .taini!'lg these devia!s_
staff _
• Al I a ids to impain:nent ar ,.e appmved lfur use in the fad lity by ,1JU51i:ody
•
It was reported 1!hat hormalle therapy is ,aml!inued for tra~gl!illd!!if detainees who enter Olli the;ra:py
.
•
The ■ reports that she wofls with custody to arrange for specia l accommodal!ions .and l oous,ing f:or
s,pecia' I needs deta inees .

llmM hrnfP-BW&w
•

Ther.e·was no documental!ion

in, the

hea lth record to 5!1.ipportassessment

,of these sl!tVices..

Fin.dirrqs: None

Quality of Care: Meq;uate based on documentat ion review and interviews_

WOMEN'SHEALTH
Reported .Processes and ,Document Review
• Our rnsigltts and ldeterminations .about women ,' s health .are based solely on the health rero.rds
provirled lfur rev iew .and staff interviews.
•
The fac · litv houses fema 'les , with a census ,of 14 on the dary of the inspenionic
•
TI-.er.ehave been , no deliveries in the la.st 12 months and curre111tfythere .are no p:r,egnant fema 'les
housed .at the fa.cili;tv_

Irwin County Deten t OCIII
Center - nspect ion Repon

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45

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OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.
•

•
•
•
•
•
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fospecticm Report

AlI fema le deta inees r,e£eiYe .a urine pregnancy test during the intilb! screen ing,. If they test positive ,
th ey are r,eh!.-r,ed to a pr,ovide;r who wi lI arde;r ,oonfirmatmy
ood test i:ng. pn!llata llvit amins, d iet,
aoo l a lower bunk a,ssignmelllt . The provider would de liver pregnancy counse ling at thiis time .
be 1JSed during l abor and delivery.
It wais reported th at restraints would l 1110t
IMammogams aoo l ~ smears woufdl be provided ! as ,ordered blllt perfbnned l:J.ya n ofk!ite provider.
The ■ reports th at fem ales who deliver or miiscairy would be .a utomailica lly r,efet'FE!dfor ment al
he alth services .
The pregnant fema les are refewed to an O'Utside obsitetrics .a nd gynecology speci alty gir,oujp for
continued ca re .a nd delillteiry.
INo p.regi ant ·fem ales with o;pioidl.addiel!ion h ave en tNed the fa cility rer:emty ·. 'Tho.se who did wou ld
be ref erred! to 11hepr,ov.ider for ·runner orders for care and u ,eatment.
IBmerg:ency contraception wauld l be provided by the loc all hospit al.
!Females.,disdi arged from the fa cility ar ,e provid 'ed conti nued ,oontrar:e ,ption m e.thods and are
instructed to contact their lmca'I ea lth de ,partmen t .

Health ReCDm Review

•
•

Women's .he ahlhcare was deemed to be a;ppr,op.riate in the hea 'ltlh r,e1:on:ts revi ewed !.
The on ly issue noted w as 11h!ilt
the off,-s,ite s,peciia'lty·provida- ,did not consistently ratum ,dlinicall,care
informal! io:n to the fa cility.
Suq qestio.ns: Wad with ,off-site obste,troc:s a nd gynecology pIDll:ideB to ensur ,e proper sh aring ,of
informal!ion roll.mving specia lty care appoin t ments.
Quality of Care: Meq ;uate

COMMUNICABLE
DISEASEANDINFECTIONOONTROL/LEiNVi
RONMENTALHEALTH:M DICAl
OPERATIONS
Reported .Processes and ,Document Review
• The fa d lity has a written expC15'1.Jre
pl'an . The .
last rev.iewed it in,Ju l'y 20!20.
• AlI insln.lments . med on site are diisposable. Appr ,oved cle aning so ut ilons .a re used lto wipe ,dowi11
,
su rfa ces .a nd me<lica ll,equ ipment.
• Shii11'JIIS
.a nd bioh ;a!Zardo us waste are dilsposed of'througJi an ,outsid e vendor. IMe<licallstaff'transport
thes e items to 1111.e
pidup loca.ticm,within th e faci lity .. Detai'nees do not haoo le these items.
• He alth staff .a re tra ined !i:n,the use of st andard prec aul!ions an nu ally .a nd .a re expecte<I Ito observe
thes e standard:S as a p art of their da il'y r,outin.e.
• Deta inees suspected of ,o r ocmfinned as having a contag ious d"isease wou[d be p l'aced in ,one of the
two negative 1uessure rooms in the medic al unit.
• The fa cility comp liance offiue:r ,l!lheds the funct ion ing ,of these rooms daily ;
• The fa cility wads ,1]osely
:J
with the med1ca ll providers at the l oca ll he ahlh,,dep al'trnent .a nd r;eport alll
diseases they trad. as requi!ie<IL
•
The medic al! unit is reportedly ·cle aned daily . The■ w as .a bl'e to prod ul!e .a monthly inspeaion
chedfist but the fo11mdoes l'IIOt contain confirmatony ·signatures. Wes~
that the iooiYidual'5)
assigned to this duty r,eview and lsign this form.
• Detainees who ar ,e ,r:fischarg,ed lwith a ,oont c1gious diis!ease are instrocted lto contact the ir loca'I he alth
d'e;partmen t aoo l.a re provided current tre atment medicilitio:ns. Thrs is also r,eported to ICE.
Health ReCD-mReview

•

The he alth record rev iew yielded no liimli~gs that reifilectany ,oonr:ems reli!Jted t ,o th .e communocable
disease, infection ,,oontro/ 1, or enviromnenta:1 he alth far 11hefaoility .

Irwin County Deten t ion Center - nspect io:n Report

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14

OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

tnspeaio,i ,Rep.on:

Sqqq§tjqns · Consillilerediting the ,rurrant furm used to dorumeint medica l unit deaning to ,irilearly show
dates , times , and s i:gia ,tura{s ) ,of responsible imlivicifua'lls).
Phvsician Case .R1!11ti'ews
That Show ,Nonmmplianc;e: ,case 15
Quality af Clil'e/Process
: Adeq ,uate

EMERGENCY
CARE
Repartm f'rocesses and',Dacument ill!'lliew
•
1be ■ reports that medka leade:rs!hi,p appr ,ove the mediica'Ipo11!ionof 11heeimerg,e:ncy re5iponse
•
•

•
•
•

pl an. The pllan was l!ast approi,,ed in Aug,ust 2920 .
for the prnvilsion of'2.4-hour emergency care fur- med1ca ~ d'enta l, and l
menta 'I hea lth needs.
1be facr lity requ iH!Sa.4-mimrte re5iponse time fDII"
,emergency calIs within the faci lity .
Oustocfv
staff ar ,e trained in caRliopu lmonaiy r-e:sm11Jitaticm
and receive emergency tra ining annua 'lly..
lbey are e!Cpected to de liver care in ,eme,rgenliJVsituations unti l medica l staff arrive .
IDoc1111J1eintaoon
,of man-down and ma<SSdisa<Ster-d 'ri'll:swas not pr0111idedfDII"
r,eview .
Appropliia.te emergency response equipment is on S1
ite , inlrilur:li[lgoxygen, AEDs, Am'b111
ba,gs, and
l::ladboard:s . N'ursing staff ched a lI emergency equipment da ily.
1be facr lity has ammgements

Health ReCDrd Review

• l \lo,emeir'=1'
r,e5iJlOIISedorumE!il1tation was found in the rero:rds provililed ·fu.r review .
findings : The ,ooul'd l not prov ide oopie:s foca lI required mancdown and lmass ,r:fisa:ster-dri'lls.
• Criteria: 4 .3 .V .T: Emeirgency Medi .ca llSent.ices and Fll'St Aid; NOCHCStandard D-07 Eme,rgenliJV
Serviille:sand IRespon:se ~Ian ,
•
Cause oJf'robJem: The■ did not provide a ll r-eq;uired emerg:ency r-e:spm1sedlrill dllOl.lmeintation .
• Effect of Plublem c Lad of pre ,par.at ion can hind'.er pr,oper re5ipo-.nsein eirnerg,e:ncyS1ituations.
Quality of.Process : Ad'equa.te
Quality a.fEmgwngr Care: 1Cauld l not be determined became no dommenrnion
of ,eme,rgency ,care
was pr-ovooledl.

SUBSTANCEDEPENDENCEAND DETOXIFICATl
lON

8€Pert¢.fcernue;wd -Pemment6:cvim
•
•
•
•
•
•

IDetmcifocation aoo l·withdrawa l treatment rarely , i1fevN , oorur-s .at Ir-win became tlhe detainees were
pr-ev,io11Slylil005!E!dat anotheir !locat ion.
If .-eq,uired, ,detoxificil ,tion wou 'ld be provided under- the ,r:fir-ectionof provider- onh!if . 1 .aSa'lle provides
protocol l,r:lirectton to the .
Detainees being detoxed are ho11Sedlin 011e,of the medica'I obseivation rooms in the mer:li.ca ll
de ,partmeint.
Detainees entering tlhe ·fa1D
i lity on med1cat ion-as:sisted treatment are r-efl!ll"f"ed
lto the provide:r fur
immedraite orneG and pl'an,,of Gire.
ide tlhe leve l of car-e needed fu.r .a detainee n!11Jeillring
If the :staffdetenni:ne they ,i::am,ot pr,011:
d'eto!Cificatiu.n,treatment., the detainee ·wou ld be transferred to 11heloca'I emergency room.
1be ■ reports that :staff re()eil/e annua l training for the ide,ntmication of potentia l withdrawa l .and
the ,detOJC!ifical!ianproce:ss.

Hml'fth&wefPBev&w
•

1be physilDian and nl!ITTiil'l,G
:health recard review dooll110.t idE!flti
ify .any inlDidents of detoxiliical!ion
treatment.

Irwin County Deten t ion Center - Inspect ion Repon

www.oig.dhs.gov

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

fospecticm Report

fipdju,qs; None.,.as no documented inllid!!flrr:eof detolCfficaticmtr ,eatmE!illt was noted dur ing tlhe hea lth
reooni rev.iew.
Quality o.f Care: There was no docmnentaiticm ,to support illSSessmE!illt
oftliese types ,of serviCJe.S..
l llot:e
that this type of care wou 'ld be ve,y r.1rely required at the
·n fallirrty.

PHARMACY
MANA6EMENT/MEOJCATIONMANAGEMENT

nurse
---

Reported f'roc.esses and ,Dearment ill!'lliew
•
•
•

•

•
•
•
•
•

In :addiliion to the .
, we also im:enr,iewed medation
IJPNI, :as :a pan of the
phannacy r-evlew.
lhe fac rlh'tvhas two pharmacy p1011:ide15:[HS in Alabama :andl a loca l pharmacy.
lhe pr-ovider ente;rs medica .tion ,,orders into the BHR. Ord'ers for IHS are e1ectr ,onica lly·transmm:ed to
the phanma:cy. Orders for the loca1 ph.mma:cy :are printed !from the EHR and fa x:edlm ,emailed . The
l oca l phaHna:cy prov ides :all psychotropic medk:al!ions :andlis the oodup ·for- IHS.as needed.
IHSprovides medications in individua l, prefi led ( m'llhiidose p:adcsand the loca l pharmacy uses :a
bl ister pack sysl!em. While the mu'ltrdose packs save time , the use of two 5)!Stems re<j,u i:res :a ueat
d'ea ll,of trading ,effon bythe
IMedation , is stor ,ed in :a designated !area in,the med1ca ll unit. It is secured by a double lodc:for
contro lled !subst:anCJe.S..
IPa:r l'evels :are establlshed lfor stock medica1iions that a:re k:e,pt on site. Staff use a chedkout syst ,em fur
these medications .and wollk with the assigned !,dl!!il'lk
to rep l!:ac:edepleted !supplies .
l llursi~ staff .administer med1ca1iions twice a d:ay in the housing areas .
A pharmacy tech illSSignedto the tac mty hand es l!he rerum and / or dispos of medica ,tions.. Tbere is.
:a disposal !system ,on site for medications not retllllTled to tlhe pharmacy :.
Control ledsubstanlle5 .are kept under:a double lock sysl!em and l:ar,e:aocountedforat
,eveny s!hift

nurses.

change.

•

•
•
•
•

Some ,emerg!!flc:y med ic.i,tions are k:~t an site, bllll:it was reponed that no :antidotes are availab le.
lhe number for poisan mm:ro ll is posted. We Slllgge:st that the■ :andl,est:ab'lish whim
:antidotes should be lkept ,on silie :andl:arra1r1geto ,Dbtain them fo.r use. Staff should be trained !for their
pro,per use.
IKeep-on-penon medi .catrons :ar,e allowed :andl.are provided to detainees in the muhiidose p:adk:s
desa,ibed above. De,tainees can carry emergency medications if a;ppr,O'lled by the provider .
lhe IEHRnotifies prcov.id ers ,of impendi~ expirations.
lhe formula-I)' process is based on ICE policy :andl procedur ,e.
It was reported that the ,dironic care nurse tracks detainees ,on chronic G1Te med1Cill!ions for
co~ li:aoce.

Health Remm .Review
•
lhe nursing t:e:am found l it :al'most im,po55· e to provicl'e an .aorurate .assessment

•

•

•

•

of medication
:administration practroes based cm the document:al!ion p1011:idedin the health record.
'f;o mak:e a dear illSSessment the team needed' to see the ,or·gina l arder, the docum!!fltation of1Jhe
frrst dase :administered , .and a completed medication administr.ation record . Many ,of these
documents were not present in the hea' lth r,ecord!!i pmv id ed for r,eview.
Given this lad ofdocum!!fltat ron , the nursing ·team ,dec ided !to tal!le 37 c:hro.nii:,ICilrehealth l'ellO'l'ds
:andl review ·those ·with the■ to d'etermine 1Jhequality of medication services :as reiilected in the
l'eOOf'dsof detainees requiring more inten:si:l.recar,e..
lhe ■ reported that :she felt 1Jhat,ruffi!llt medica1iion servio:es were im;provedl :as ,ioompar,ed to the
medi .catio:n servoo:esdorumented in pr-e1iio111S
year5. Wnh 1Jhat in mind ~the nurse reviewing these
reoords forused on medica1Jion orders in 2020 or 202:!I.when pos:s,ib le.
Three ,of the r,ecord!!i were reported to be o ldlpaper charts and lnot :avaclable for r,eview .

Irwin County Deten t ion Center - nspect ion R~n

www.oig.dhs.gov

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48

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

fospecticm Report

Of the ~7 reaJnls, 22 of the detainees wer ce seen by a pr,ovjder , recewed thei:r medocation promptly ~
and ]were found ]to be com .p liant in,ta ing:their med1i::a1iio111S..
•
The r-emar_ning records s!howedldet ainees" g~era ll [ad: off com ,p li.mce to t ake their medic.it ion as.
ordered . The medica.tilon administra t ion records shov,ed the nursing mff repeated ly d'ocumenting
the det ainee .a s a no show bllt there were no documented rcefus al's with detainee srgiaturres . The
m any refiu:sali!iwi1!hon ly musing staff s\gJJatures .a nd no det a inee SJ\gJJ
ature is a amcemi .
• A providl!\1',educated some deta inees , and other.; do not harVedocumenta ,ticm,,of thiis ocairring.
•
In on e instance tlh.e nurses reported th at an,,order was not .a vail'a'ble for adm inistration "dlll! to
storms ."' These medications ,oou ld have been ,obtained fr ,mn,tlhe loca'I ph arm acy-f ar more timely
adm inistratiian .
• Genera lly, mediCal!io:nsar ,emade avall abre and l.adminiister ,ed in a time:ty·ma:nner .
findi ng s: Detainee noncomp liance witlh ,taking medicatilon is not consistently ·and l properity addressed ]m,
th e he a'lth r,ecards _
• Ofteria : 4 .3.V.G: Pharmacellltic:a'I Man agement ; 4..3:V.U: De livery-of Medic ations ; INOOHCC-05
IMedicaticm,Administra'llion Training; ID-Ol lPh arm aceut!ica l Operaliions ; D-02 Medication Ser...ices
• Car.ise of Problem: Lack o:f,compll ance by nu:rsing:and l provider staff in add:ressing noncomp liance
with taking medicatoons .
• Effect of Rrobtem : Lad of',compll ance and l mccmsi:stent docw:nentaticm ,,of medic ation administration
ma.Ices. it diffii.cultto de-termine the ,effec:tweness of ,care orde.red L
•

•

Suggested Actmns:
,o INu:rsingstaffshou

,o

,o

ld be instructed to meet w ith e ach ncmcornp' li:antdetamee to ensur ,eprope;r
edocation is provided a nd]signed refus als ar ,e obt a ined.
]Referra ls to pl'CIIV.iders
shou ld be m ade in a timely manner . Thes e shou ld be pro,perly·
do cumented mtlhe hea lth record , indudin g .a pl an of ad!ion far the medication [s~ being r,efused.
We noted that a,,conS1Ulliing
:ph arm acist i:sccmtracted to OYE!il"Se
e the ph ann a.cy-are a and lto
pe rf on:n , p'h!imJlacy inspections.. 18:ased ,on, provided dorument a tOC111
, these inspeaio:ns do not
oorur 011 , .a re,g)lllai/yscheduled ba<Si:s.We sugg~ tihat the inspect io:ll'iS
oorur 011 , .a more regular
baisis.

Phl/Sidan Case .illewews 1mtt Sh ow N onc;omplianc;e:Cases 5 a:nd 7

Quality of. Process for Obtain ing Pharmaceutimls ,and Mana qinq the .Pha.rml!lcy: Adequate
Qug/jty qf

tbe:Mgdicqti
qnAdmjqistrqtiqp ,Process
· Adeq uaite, but

requires im!PfOVement.

MENTAl HEALTHSEIRVICES
Rep o.rted .f'roa!sses amUJocument Review
•
The ■ reports th at th e mental ]he alth p.rogiram ,consists off eva uaticms , mdiMiduall,counse ling.
transfer to a mE!ll'lt
al hea lth raC!il1tyif needed ~and l.a suicide pr,eventicm , pro gram s
if needed .
•
It wa<Sreported th at desipl!ilted staff have been tra ined in and provide arisis int.er...E!il1toon
• ]Ment a l h ea 'lth evalua ,trons ,occur a5 a, p an ,of the ~ iving scr ,eening and tlhe he;alth iliSSeSSmE!ll'lts.
•
Any deta ine e ildentified as being :on mental ]he alth medicatoons at the time of the srree;n · ng is
~ported ly se en l:J.ymenta l he a.'ltlh,st a flfwitlhin, 24 to 48 hours.
•
The fa crlity P51,dliatrislt man ages p.sydlotr ,~pil!:medoca.ticms . Detamee-s ig,.ed consent is ob tain ed for
psydmtropic medi .c ations . The psychi!iltrist reports th at he sees every detain ee on psychotropic
medi .catio:ns montlh ly.
•
It wa<Sreported th at menta' I hea lth tr ,ea ,tment pl ans ar ,e ,esta' i:slhedfor e ach detainee on the menta 1
he alth rosters.
• Olmica'lly or,dered and ,rustody--ordered restr .aints .a nd semlusicm,.a re not used at the faoi lity.
•
lftherc.e i:sa need ]for invo lunta:ry treatment, it wou l'd be a;ddrressedlthrough ICEand ]tlh.e detain ee
woul 'd be transferred to an appropriate lo:cal!ionfur- treatment..

Irw in Cou nty Deten t ion Cente r - nspect ion Repon

www.oig.dhs.gov

49

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

lnspect,ian ,Report

ttwlthBernm
.flwiew
Mental hea lth car,e was.documelllted in tlh.e ea l.th reoords prnYi:ded for review .
findmgs; INone
Phvsidan Case .Rewews That.Shaw ,"1:onoomplianoe:.Ca!iE!B
Quality of Care: Adeq ,uate based on the lad ,of mental hea lth eocoum:ers re11:iewed in the health

reoonk.

SE F-HAHM/SUCIDE PHEVENJIONAND I llERVENTION

I

Reported .Processes anal ,Document Review
•
•
•

1he
reports th at there have . been no w i,:;ide attempts ,or ,compl 'eted suicides in the paiSI:
. 2 years.
1he
is respons" e for notifying ICE in the ,event ,of an .attempted or oample,ted suici:de .
Medica 'I staff ~eive suiride-p.-eventicm training .at hire and l amrua 'lty·.

•

Custody naff , medical !staff, and other-detainees

•
•

•
•
•

•
•

•
•

•

may a'III irlentify and l report suicida l detainees .
Suicida l deta ine es a:re transfen,ed to the medica'I unit. In the ,event ,of an .attempt and inj ulY, the
detainee woufd l!be transported to the emerg ,ency d~panment.
If a member of the mentil 'I he alth staff' ilson site , they immed iately ·il!SSess the detil · nee. tf no menta' I
he alth staff member is ,on site , a mem'ber-ofthe medi .ca l staff assesses .the potenti ally suici:da'I
detainee and l.a mentil l hea lth provider ilsthen co:ntacted l. A member ,of the mental hea lth staff is ,oo,
s ite ,6 days .a week .
Ident ified det a · nees are plaoed in a,suiride-pr-evemioo , , :;ell in the medic al observal!ion .area. The
1]5Ydli.rtrist will pr ,O\liideall orders indud" ng the U!iE!of wioidl!"-lp:revention smod :s.
Detainees requiring an elevated l eve l ,of mentil 'I health care a:re tiransfened to a IOG!'I emergency
room ·fur further tre atment .
Custody naff mon ito r the detainee and l nllT!iE!s,conduct we llness cheds on me de.tainee ,every 2
hours.
1he ■ and a.re ~d
to prov ide d ailv updates Kif' detainees ,oo,w atch.
Ca-re is til'ken to enslln! th at excessi.-e ,deplriiva0011sand r-estrictioos are not placed ,on suicidal !
detil .inees.
It Wil!S reported that only the psych@trist can re lease a det a inee from w icide watch.
Once re l!!ii115ied
lfrom dose watth , mental he alth staff see t!he detaine,e d aily. Care P' ans and
sdied uled enoounters are adjusted !based ,oo, ,det ainee ac uity ..
1he ■ cl'earty .an icula.ted the st:e,ps to be taken , in the ,event ,of a oompletBd lsuiride .

Health ReCDm .Rf!YieW

1he ca.re r-ep:resente d in the llmited m.1m'ber- of cases re-viewed in the health reoord!s was
appropriate.
filldmqs;INa.ne
Quality of Car,e: Adequate b ased on inteJ!Vjews with an underst amli~g of' limited documentation.
•

TERMINALIWNESSOR O:EATlH
OF A DETAINEE/ADVANCEDIRECTIVfSANODEATH
Reported .Processes anal ,Document Review
•
1he ■ reports th at there have been no deaths .at the faci lity in the last 3 ye ars..
•
lifthe fac· ity receives a seriously or-termina lly iiI detainee , ICEis notified and ltile d eta inee is
transfBITBd lto a mor,e .appropriiate ra,:;ility.The■ r,epom that she and the w!Jll'lktogether
aocom;p,lilsh that tralllSfer and that it lrappem in a, time'ly fasihiooc
• INo ,end-of- life pl'anning would ocrur at Irwin.
• Note mlf previous mention that this policy 011ly ..-effects state g;utde'lines and t 'hus needs to be
upd ated to a l!so r,eflect lm:a l jur-ilsdictioo,g;uirle'lines.

Irwin C.Ounty Deten t oot1Center-

www.oig.dhs.gov

to

18

nspect ion R~n

50

OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.
ff,eqlfh

tnspeaio,i ,Rep.on:

RBrntP
-Bev&w

•

INo termina l illness care was documented i111
the hea lth reoonls prov ided fur- r-eview .
Fin dings: None
Quality af Car,e: P,rooesses as re ,po:.l'ted mest the ,estab' liished standerds..

N0TIFJCATIONOF DETAINEES
Willi SERIOUS!ILLNESS
Reported .f'roa!!sses cmd',fmcument Review

•

1be ■ desmibed the pro<!l!'SS fClif111otificilltion
,,of desigllilted ICE personne l!when a detainee
presE!illts with .a serious medk:a 1 OT mental he alth illness.. 1be ■ reports, that thiis cootact wou 'ld lbe
docume111ted in the hea lth record.

•
1be ■ reports, one such incoolent in the pas,t 6 monllhs .
Health Re.CDW.Review
• lbere ·was no documentalii on of noti:fu:ilimns in,the hea lth .-ecords reiiiewed.
Findings: None

Quality af Car,e: P,rOCE'SSesas re ,po:rted mest the ,estab' lii!ihed standards .

HEAlTHEDUCATION
ANDWELLNESSPROGRAM

8cPaantPlPA:5¥'5
wrd'Pewmeot6Wim:

1be ■ reports, th at hea lth educ:atOCIIIis prov.ided in written fcm:n, inc:iludi~ ~ph
lets and l paster.; .
Spe □ific hea 'lth ,educ:allion is documented
in,the hl!!ill'thcare r,ecllifd at the time o1fthe encounlier .
Health Re.CDWReview·
• There 'Was no documentalii on of health ,ed uc:allion in the hl!!illth records re,iiewed.
Findings: None
Quality af Car,e: P,rooesses as repo:.l'ted mest the ,estab' liished standerds.
•
•

D'IS0HARGE LANNING
BePaffi'dfCQ®W'/i wraQeg,meot6:e:vim
An Rfillis .ass i~ed to complete ,di:s1:harge p lanning .
!Parameters ar ,e ass:igned lfor the types a:nd ammJnts of medicaitions that are pr ,ov.id ed to the
detainee at the poi'nt of' r,elease .a s well .as the hl!!ill'thinfcm:nation ,to be provooled .
• Detainees who wil l requir ,e ,ongoi111gcare in the cmnm1.1111ity
are Given i:nfunnatinn that directs them
to their pri:ma:ry ,care provider ,or their l'oca l h ea lth department .
•
1be ■ reports, th at med1c:a .staff recer.re notific:allion of liransfer ,Df ,disdl arge in a tim e frame that
:allows fur prope;r pre ,pam ion fur disch arge to the mmnnmily.
Health Re.CDW.Review
• Discnairce inform ation was not prov.ided in the health reco.rds re-vieweGL
Findings: None
Quality a.f,f'rocess: Adequate bas:ed on re ,poned pro«cess
•

•

S:EGREGATBD
DETAINEES
ReptJrted .Processes and ,fmcument Review

•
•

•
•
•

1be ■ reports, th at there are 24 segregated hous:i~ ce lls in the faci lity.
An assessment is mm ,pleted fur ea .ch deta:inee pllaced in,segrega ,tioni. The ,detainee may be bmught
to the medic.I '! unit OT tlhe nursing te am member goes to segreg ation to complete the assessment.
INuf"S!i~gstaff ,cornpletes munds in the .area twi~e dacly·. Round!s a:re dorumE!illtE!dlon indi111idua'
I
detainee obsellVilt!ion s!heets...lbese become part ,of the ,rust:ody remrn.

It is Feponed lthat the psychiatriist makes rmmd!s on the d~ he is on site _
Segregated detainees are afforded the same :access ro ,i:a:re :asnonsegrega,ted ldet ainees. .

Irwin County Deten t ion Center - Inspect ion Repon

www.oig.dhs.gov

51

19

OIG-22-

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

8.

tnspeaio,i ,Rep.on:

ff,eqlfh RB
rntP-Bev&w
•
1be nursing r-ecord f"elliew ·did not reve al any !health dearances

fu.r detainees

being p l'ai::ed in

seg,re,e.ited housing_

Findings; No11e
Qua/Jty of Care: Cou ld not be determined

based ,on hea1th r,E!{Joml review _Pir,ocess .as described

meets

staooaTds l'angua.gl!'.-

MEDICALDIETS
Reported .f'roa!sses amUmcument Review
•
IMedic:a 'I d1ets .are ,l!il"lacted 011ty, upon a pr-ovoofer ,ord'er _
•
1Medic:a1 staff r-epon medica 1 diet orders to food seavi()e daily_
•

A registered dietitian nllliriliionist rev iews the faci lity's diets annua l ly and l .addresses 11hemJ11riliiol"iill l
,of the d iets pmvided l

adequacy

•
•

The faci lity provides a heart - he althy d1et in ad 'diliion to o11her routine med1ica l and r-e'lrgious d1ets.
IMernbss

,of the nlllf'Sing and pll'Olllider- teams address detainee

IMedic:a 'I d1et nonoompl1 anoe i s addressed

refusa l of mediica lly omered l diets.

at tlie point of reponed

nonc:omplilaoce

and thl!il1 1at each

fo ll owing clirrcmic: ,icare visit. E.ducaticm ,.and r-efus als are docw:aelfl1i:ed in the health care H!()Ol!'dl.
!Refusals incl'ude detainee and staff srgi ·ature:s_
Health Re.oom Review
•
1be he alth reco..-ds showed med i ca'I diets blll1i:d1d not s!how d etainee oo~iilnce

wi'lh the ,o.rd'ered

diet_

Findings; None
Qua/Jty o.f Care: P,KIO!'SSes as re ,po.rted meet th e ,estab' liished standii!Tds.

D'ENTAlSERVICES
Reported .f'roa!sses and .Document Review
•
Denta l services are not prov ided ! on site _A oomm11111ityprovider-is ,contracted
1

to pn:l'l,lide a ll den ta l

care_ Ora l S!U:rgeiy se11V
ioes a:re avai'l ab le as needed L

•

1be ■ reports th at the ,off-site dl!illtiist provides ,8 hou..-s a week ,of denta 'I coverage with
ate:ly ·.30 d e,tainees seen , month l y_

appnHim

The mntratted l d'emist sets the denta l priori'lies based l ,on presented detainee need l.
1be ini"lial l ,denta ll screening ooru..-s at inta'ke_
•
Detainees ar ,e sdiedU: led l with the dema' I provilder .as needed a.nd l for thei:r .annua ll ,eva 'lu ation_
•
Detainees have aocess to tihe p.r,eventive benefits of"l ih11Df"ide_
Health R.e.CDm.Review
•
•

•

1be nursing health R!COrd review showed appr ,~ri ate .amcm ,for- denta 'l 51id; ca l ls b ased on the

•

Denta: 11i:leatment pl ans were .avai l!ab'le in ,tlhe he<alth r-emrd and ~ppe ar,ed ~ppropriaite.

~ppro,priaite

nursing jp'rotocols_

Findi ngs; N1me
Qua/Jty of .DentoJ Care: Aidequ'ate

GRIEVANCES

BePert
W .f'roqi'sw:r
wrcfQemme:ot tk vlew:
•

11-f'ealth care grievanues

•

At int ake d etainees are edUCillted l abolll1i:11heg..-ievan<ie system ,tlhrougj'I ora l and writt&i ,
m:mmunic:aticm

are to be .addr ,essed per ICE.pa icy and prooedure_

c

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Department of Homeland Security

8.
•
•

tnspeaio,i ,Rep.on:

G'.rievanoes can be S!Ubmitted orally ,orvi!a ata'i> let. Appeals .are to be 511.Jbmitted in writing_
It wa!Sreported th at girievances are addreiSsed lwithin estab lis!hedltim e frames_

Bevfew
fkqlth Bernffl
• The l \lCCHCIResour ,c:es inspectoon team physician reviewed fir.e ,cases from ,]lega l sources.. The
each case WaiS found to be .a ppropriate_
Findings : None
Quality of.Process:. Ad'equate

,[iil'fe

in

PRIVACYAND CHAPERONIES

&lRaffi'df'mws:w wraQowmeot tkvim
•

•

Care is provided in, a manner that ,l!iM'IJresprivacy .a nd a'llows for a same-gender provider ,or
ch apero ne _
The ■ reports th at care is provooled in,designated exam rooms in,11hemed1c::all area that prov .ide for
care to be de lillered in a private manner _

Health Reoord Review

• IDocumenratiDn ,Dffthis wou ld not be p.re5ent in the hea lth reoDrdL
.SIIQ
a,e.stions: A nur5e practitioner re ,poned that custody st aff are not a'IWays .ava ilai>le to mver medic::all
th at this be r,eviewed land ad 'dr,es.sed as needed .
appointme,n:ts 0'111the weekends. We S!UggES'I:
Quality o.f Care: Adequate ba .sed on reported comp liiaoce wilh the st and ard.

REFERRALS
FOR SEXUA.lA!BUSEVICTIMSAND ABUSERS
Reported .Processes and ,Damment Review
• The ■ reports th at a'II custod y and hea' lth staff receiilte P,risoo , Rape Elimina.tioo, Act IPREAI tra -ning
on an annua l b asis.. The trainin ,g i1111o'
lves both a d as:sroom and ].a n e-train ing CJDilll]P<lnent_
• The .
defined 11heprocedure that occurs in the ,event ,of a re]P(lned sexllJilll.as:sau lt.
to the ,emefG!!ncy dep art ment for forensic samp le co l l!!Cllion_
• Detainees ar ,e traruported
• IMenta l he,:a1thserv ioes: are pr ,DVided for 'the i1111o'
lved l,det ainee_
• The .
reports th at th e ,emergency dep anment wou Id pr,DVide prophy liactic treatment for sex:u:alty
tranS!ITiittedl infectioos a!Swe ll aiSemerge,ncy · CJOntra(leption_
Health R.eoom .Review
•
1be record rev iews did]not conta in inst ances ,Dffse:icual aiSSault ,i:a:re_

fiadi!19&
Na11e
Quality of.Process:. Adequ>1te based on reported comp liance with the standard .

INFORMEDCONSENT,REFUSA.lS,AND INVOLUNTARY
TREATMENT
Reported .Processes and ',Damment Review
• IEac h dBta ine e signs a genera l oonsent fo.r 11hepr cmr,is,ion ,of he alth sl!nlii::es...
• Spe1Difi1:
,a:msent is obtained ]for invasive procedures fo llowing the deliveny and dorumentatioo ,,Dff
detainee edu~tion and documenta1!ion of'g ;e;nera l ,c:ansent.
•
Interpretat ion services are provided ]for th e prooes:s of ga.ining informed consents: .
• Detainees wtio refuse Ueatme;nt are provided educ.d!ion an d counsel ling 11hatindudes: the impact of
not a:coepting the car ,e _
• A refusal ·fu:rm tha t im:iludes 11heS!ignatures ,of the ,det a inee .a nd the invo'lved l hea'lth staff member is
comp leted ]and s:cannedl into tihe IEHR.
•
lnw luntany tr,eatment woul 'd ooru:r ooly ·after ICE no:tific:a.tion
and oou:rt order_
1

Irwin County Deten t oon Cen1!E!r- Inspect ion Re]P<ln

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

inspection Report

HwM Be,0 wHwfew
•

IDocumem:ed l ,OO'J'lsentsfo:r surg ica l pr ,orredu:res were found in 1!he healtlh reomd:S r,evie-wed l

Findings : I1\lcme

Qua/Jty of the .Process:.Ad'equ<ate

MEDICAlIEXPERIMENJATJON
Reported Processes and ,Doarment Review
•

Polici es and l prooe-dur ,e-sstate tlha,t med ica eqieri m entat io n is a l lowed far detainees

housed in the

appr,ova ll proc ,ess"
fa .cili:ty ba.se-dcm,a111

Findings : INcme

CREDENTIALING

8€Perlt¥1.Pro9¥¥'5
wrd,P:erumc:ot
tkvim
of a'lll ,emp l'oyee-s is conw leted l by the I1..aSa
l e ,oompany offi:o:e_

•

The credentialing

•

Oun,ent oe-dl!illtiia ling foc a ll staff w as v ·erified through d'ocume111treview .

•

The cred 'entialing process far provid 'er staff in~ludes tlhe use oftlh .e INa'liicmall ~ctiticmer
Staff with lioensure restrictions .are not a l lowed to work.

•
•

The fac mty monitors

The ■ reports

lice.mes and required

1!he 1.15:e
,of job desaipticms

oertifocatiom

Data I11:alllk
.

for prov ider .and n11rSingstafff.

to ensure that staff work within their soope of practii::e.

HmltbBecefP
'.flev&rr
·
The health ~ review yielded no 'findings tlhat reflect an y ,~i::ems
process.
Findings; INone
•

rel:ated to the credentialing

Qua/Jty of.Process: Adequate

Irwin County Deten t Klll Center - l 111Sped!io111
Report

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

111-:AI.Tl l REC:O llD REV IE\ VS

-- /All;
SIT 1 - LEGAL-A SIG EDCASES

We were asked by the OIGteam to IO<J
k at five spec· c cases, Dr, Stoltz performed these revie1•1s,

•

caseA

Described Issues

•
•
•

■ · - submltt~ a couple of hea h service requests on siclccall paper forms.
He states tha t he received a response within three days of subm i.ssion, but he fee ls like it depends
on the mood ofthe health staff about ,,hen he would be seen.
Last year he submitted a health service request for pain in his chest . He was taken to see a doctor
but he did not feel that his issue wasresolved and submitted a not her req uesta few weeks ago.
He was told that he oould not go to the doctor because his dorm was under quarantine. He has not
heard anyth ing since then .

Case Review Findings

•
•
•
•
•
•

•

Intake was in November 2019 with no med ical iS-Suesnoted.
There is no hi:.tory of a:.thma .
No hea lth servi~ request for chest pain wai. found in the health record but rather for breath ing
problems off and on.
A nurse saw the deta inee in a ·mely fashion when the reques-ts were submitted .
The health service request submitted on February 12, 2021, not~ a compla int of breath ing
problems off and on for 7 months .
The nurse referred him to see a provider, but the re 1s no documenta · on that shows he ha:. been
seen by any pro11ider.
■· 1111• ·• does not understand why the detainee would not have been seen as there are no
noted that she will get him
restrict ion:. on seeing the pro·~1der because of a quarant ine . ■
set up to see the provider.

..i

/A#; •

•

•

CaseB

Medication Concerns
'·' The detainee has an issue w· h ho\• her med ication has been managed at the facility,
,_., June 2020- She arrived at the facility with 2 months of medication .
, When that supp ly ended she had to file a g ·evance because her medications were not being
adm iniste red .
'·' October 2020- She began rece iving the med ication again.
Physical conc,ern: Vaginal Bleeding
,-, She fee ls that she is lu11ing excessive vaginal ble~ ing and requires addit ional care .
,, July 2020 - She made a request to see health staff_
,_, October 2020-The doctor made a recommendation for a blood test .
,, December 2020- The nurse practitioner saw her. An obstetr ician also saw her and
recommended a sonogram.
,, Janu ry 2a, 2021- She started an additional medication.
,_, To date the sonogram has not been oompleted.
Physical Con~rn : Headaches
,, November 2020 - The detainee made a complaint about e,c:periencingconstant headaches,
descr ibing pain rad iating from her head to her back. Health staff prescr ibed Tylenol for 5 days
during one encounter and aspirin for 7 days du ring a not her encounter,
is diagnosing her and does not let her see the nurse practitioner .
,_., She believes LPN, She does not know ).that is wrong with her , She feels she needs a MRIto determine the cause of
her pain.

Irwin County Detention Center - 1nspectlon Report

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Department of Homeland Security

8.
S'he has described her issul!5 ·while being seen by mentil' I he aflih.'The mentil l hea lth nurse to ,1d
herto file a grievam ie ,on,her concerns. Sh e .said s!he is go ing to:,put in .a griievance tonj gJ'fl.
So far , she hii!!S
submiitted ltwo ,Grievances on the ta'b'let .a nd one us~ paper.
Case ,Rmew ·fi ndinq:s
• June 14, 20!20- lnta k_e501E!eningshowed o:n1y a history ,of anemia and GERiDr,eponed bythe
detainee .
• She Wili!istarted !cm, her med 's right away ; however , she did not s!how up ,fur med p.!iSS for mo.st of
Ju ly .a nd Au~st..
• Per po1iqr, a detilinee who misses 3 d ays of medicatilons is to be seen by a provider fur oomp li!ance
counseling. IEven though the missed doses ocourr ,ed in .Ju ly, she was not seen,by a prollililer unti ll
August 9, 2020.
•
The site w as not fo lIDwing:po licy re lated to medicatm nom:ompll ance .
•
The G¥11ecd.
logjca proil lem seems to , have •been manag~ appropria ,te 1y. She h ad an endo:menia 1
lbi1J!P5Y
on January 28, 2021 , .and a pelvic ultrasol!lfld on M arch 1,. 2021 .
•
The detainee
as not ocmti:nuedlto ,comp lain about hl!!ild'aches nor has s!he oDmplai:ned .a bout
he ad adhes during her gyneoa logjca1 provider ,E!l'loDUnters.
•
If-the detainee continu.es to experience headadhes , she !ihoukillsubmit another hea lth serviice
request ·fur this .issue.
• !December 1'2, 282.0 - Duling a mentil' I hea lth visit ii: was rerommended that she see the psychiatrist.
The deta inee ~d
this . reomnmendaticm .

-- /A#:
A:5-rrtPeP,Wi es
•
•

•

CaseC

!Detainee co:rnp!lains of ,dhronix::bad: pain .
She Wili!ipr,eviously housed in,,cmlilied'orm when they h ad mo:r,e feima'les in the fad lity. She h as
slllbmitted l health ,service requests cm,the tab let and on paper ..The paper request was p l'aced in,tlhe
Grievance bo:x because Charfie donn d1d not have .a medic al box.
She is prescr ibed ibuprofen daily but hili!igone without pain medkation ·fbrupto8 ,,days "

She has not been ,.a b le to see the nurse practit ioner and lthe nurse she sees puts i:n,the lll!q,Uest fur
medil:.ll!ion fu,r ,either 5 ,or 7 days at a time based on the associiated n111rsi:ng
protom .
• She has seen the m.1rsepractitmer ,on ly 3 dli!lysin a:lmDSt a vsr . S'he saw a new nurse •pr:ael!it ioner a
month ago,and lsaid this NP didl more ·fo:r her in 5 mi:nutes tlhan,anyone has done fur her in the ,E!l'ltire
time at the detention ,center because 5!he was able to gt X-rays.
• !However , her medica l issues are not remi,..ed l She now needs an , Mm off her bade:.
• She is experiencing sciatica pa in in her bade: and wears a bad brace but G1nnot deal lwith ii: without
medil:.ll!ion .
•
The detainee a lso has . hypel'tension but does not want to be on medication fu,r it.
• Per the deti!inee , she m anages er ·hypertens ioo,,oo, her own with bre athing exercises , but 5!h.e
cannot man age the bad: pain on her own .
• She said the M!~ponse time ·fur her health servooe r,equl!Sts ,r,iries.. It cou l'd l be•a day ,Df two ,ar tt cou'ld
be a week , and s!he has not gotten r,eso 'h1n ion ,of her problems .
• She described the medic a l care she reoe,ives ili!ivery poa,r_She h as been wail!ing:a month to ,see the
nurse prad!il!ioner and l iis;not ,oo,the schedu l'e.
Case Rewew findings
• June 3 , 2020- At inta'lie the d etainee omnpl ained ,of dm:mic bad pain.
• !Detainee was initia lly given ibuprofen or Tyleno l per nurs,ing:protoco ls .
1ibuprofen as needed lthree •um .es a day
• June 3 , 2020 ~inee
•was seen by·the provider and ~iV'!!il1
for 14 d'ays and la musde •rub•.
•

lrwi:n County Deten t m Center - nsped!ion Report

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

•

The provider a'lso,sawher ,on October 1.9 20211, November 23 , 2000 , December 7, 2020 , January 26,
21121, and February '1.7~ 2021.
January 26 , 202.1 - Slhe had a lumlb.ir X-ray.
The detainee is being seen and l manag:ed l.appropriate l:y.
1,

-- /A#:
•
•

Des:aibed ,lsrues

CaseD

•
•
•
•

She hilli d iiabetes .and receives d;a:il:y medaoons
.as we.Ill.as .a da ily·gil111oose ched..
Cunent ly the falDil"lly is Giving hl!f"medicat ions for he;r d iabetes and ld1olesterol.
She hilli ·fli ed a grievance through the tablet system about hl!f"medicat ion.
IPr-ev.iousl'y she took a li.q,u'iidl medication and l be lieves she is not r,ece,iYi:ngthe same medi .cation . .She
fee ls amciaus .and we<akafter t aking he,r medic:atOC111S
oo,w .and she is not SI\Jrei1rthis is a side ,effect or
these medi .catilons..
• She hilli l\'E!G!illt
l:y had blood wort done at t he ospita ll but is 111ns11J1"e
of'the result£.
• She sa id an off rol!f"to ld hl!f"the;re Willi.something .abm11rma l in her blood wllll'k bllll:hea lllh,staff didl 1110t
exp lain or t el11her this .
• Afte;r she ,i::ame bad: frcom tlhe hosp ita 'I, me aslied aboutthe ,different medications thr ,oud, ,tlhe
tablels aw ifa e in the h~ ing:pods to submit the q~est ion to he,alth staffi.
Case .Rewew fi ndings;
• June 7 , 2019- N'o ,medica l!issu es r,eponed a,t the inta'ke screening .
• She Wil!!idi!ilgnosed with ,diabetes .b.lsed l,oo, liaboratory tests ,oo:mpl'eted on December 11, 2020 .
• The detainee was started !,on a p:ill forrn ,of metfmm in with N PH ( neutra 'I rotamine Hageoom )
insulln ad'ded l December 15, 2020 .
• The detainee was presmbed Lipitor' for e levated lipoolsdllf"i~g a J anuary 12., 21121, milt.
• IHer blood glucose leve ls have been "'eJ'Yg:ood with a ·few bei~ in t he low range . This probab l'y
accounts for her feelings of ·weakness at t imes.
• She hilli never gone to tlhe hospi"lill.
• Slhe appears to •be iece iving proper management.
• !Better oa;mmunicat ion with,her wo u ld ease .er ODll10l!ITIS.

■/Alf:Des.aibed .lsrues
•
•
•
•

•

•
•
•
•

CaseE

The detainee is seeing t he fl5YChilillrist
for post-liril:uma,tic: stress dfu;ord'er .and is rece iMi~g med1iratiion
for tlhis...
The medicine is ..sl ow i~ things down ,. "
IHe waiStaking a medoc:i1i0011
1in !Folkston , because he was gping through ":alot ."
He sa id he .a llmost d ied The y wer ce giMing him , 2 to 3 da,ses of tlhis medicat ion and it wa;s too st r,JJ111g.
the restroom at midnight and fainted l badkward 's. The ,officer heard him and ,came
he wdlie LIPto 111Se
to ,his aid with .anotherdeta inee . He was; weak and l,c:o:uld'n,'t do anything ,
The next momi:ng he went to see the doctor . I-le· told lthe doctor the rnedicatoon is too strong .and he
needs someth ing e lse :and will not talie it ~in 1.
When he went to Stewan and they aS!ked him if' he was gping to take the medic.luon , he 'to ld them
about that incid'ent .and why he is not go ing to take it.
IHe waiSthe11e for a month and l,did not t ake t he med1iratiion.
At Irwin , things we11e going poorly for him with his menta 'I iilness .
IHe ~ested
to see the ·doctor and lwas .ab le to see the psydl iia'lrist within, 3,to 4 days. They gave
h im .a rowN dose of the same medicatio'l1 , and l in conj;una ion wi'th another med 1iratiion . He is st tll
;sick, but tlhe med iiratiion is stowing tlhe progressio n of his illness .

Repon
lrwi:n County Deten t Klll Center - l1115pectio111

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Department of Homeland Security

Aw: Hmewfindipqs
•
•

The detainee does not seem to •l'liliVEa oompl aint ~
ing his ,car ,e .at Irwin _
A.f"e\l\
iew ,of the h!!i!m1 r,.eoollillshows th at the detainee has bel!fl seen bythe psydi iavist ·a mmrber of
times with attempts to adj ust his med ications to ·find the appropriate dosl!'S that are most effedin/e _

•

IHismostrecent

·viisitwason 1Manh '9', 202.L

Sil 2 - ASSIGNED HEALlH RECORDREVIEWS
The OtG t !!ilm asked the phys ioian inspec.tor to review reoords oHhe 37 detainees .with known chr ,onic
illness_ The 20 ,cases below are -thooe wher.e he noted mncems during tlhe rrev.iew _

Casel: -~

jl

Fin dings of Concern
•
The fu llowi~ onler.. have no document .al!ion of ,romplel!il!m :
,o
IMay 16, 2.01:9'- X-ray of the fuot
,o June 27 , 2019 •- X-ray or the f111ger

November 24, 2019 - laboratory srudies
December B , 2019 - laboratory studies

,o
,o

Proc;ep IYPocqrn1Uaa,e
•

Cominuity of c,ne

Case

2:-111

1

Fin dings ofCiJncem
• Apri ll 25 , 2017-n ,e detainee was p l'aced on metformin ,and .a stat!in ford iabetesand l
liyperl ipidemia .
•
Octdbe.- 10,. 2017 - The detainee was seen fo1· chmn ii: car ,e with no note in the orders to monitor
their HghA'k or lipid's to fo llow-ml'ltr'OII based cm pr,evious med ii::ation,,ard 'er-;_

• INo r,egular chronic: ,care •v:isits were noted in the •he alth recon:i _
Process Non complia nce
• Chronic care

Case3: -~

11

Fin dings ofOJnce,:n

•

IDecembell" 17,.201B - rhe detainee WiliS seen ,.a t s,ick calllwith an elevated illood l pre=re
of 141/105 ,
which is .a concern . He was seen by·an lJPNI·wil,o,d1d not properi ty-n!fer tlhe detil .inee to a provide.- _

!December 1,8, 201B - fhe detainee was .seen ,.a nd ibupr •Df&111680mg twice a day fo.-14 days was
onleft!d ~this is not a sDUnd cllnica l decisicm , based lon ,the hilstory of hypertl!llsion .a nd ome.- fur tlh.e
lbloodlpressure medication,lisinopri t
• INo r,egular chronic: ,care •v:isits were noted in r:e,cord.
Process Noncompliance
• Chronic care
• INuJ"S!ing
:sld Gi lli

•

Case~: -~

t

fiadinm:WAn:rwrrn
•
•
•

The detainee reported a history ,of asdima .a nd using an inh ale.-at th .e •intake saeening .
This w as not noted lon 1tle inili a'I hea lth asses5!1Jlent th at waiS mmp letelill4 days . ra,ter .
The asthma history was not noted on til e maste.- prob lem list.

Irw in Cou nty Deten t oot1Center - lnsped!ion Repon

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Department of Homeland Security

•
•
•

Aprfll 1, 2017 - The dletainee was seen for a chronic ,care 11:isitfor dlE!iiriliSlhma but no ,peak flow
testii~g was mrnp 1eted LThiis S!h.ou l'd lbe don e at alll.a sthm a du ,ooic c.ne llis:its.
IM av 22 , 2017 - The det a inee submitted a, r,equl!51!:for glasses .a nd then five addil!iona ll requests
11:Jefur
,e being seen .
Aug11151:
17, 2017 - n 1e last request far gJ'asses.was submitted ~the resporne to ,thiis req~est shou lll
have oorurR!d in a mor ,e timely m anner .

Proce55 Noncomplia n a!

•
•
•

lniti all he,a_lth il!S'.Sessment
Chronic car,e
Conl!inuity of car ,e

easesllll ~

11

fi n dings ofO,ncem
•
•
•

IM av 24 , 2017 - Th e detainee was seen ·f<M'hypertensiion , pr ,esenting with lllood pressure or 190/9'8 ,
and lwas pla.oed on two ,medications: '50 mg of los arta n an d 25 m g ,offhydrochloroth iai!!ideIHCTZ).
We noted that the detainee Wil5 adlministerer:I an inooffect dose of 12 .5 milli~ms of HCTZ inste ad
25 m ilf\g.,ams ..as ,ordered .
October 10, 2017 - An LP,N order.Ed ibu,proFe n at sid c:;a'IIIwhen th e deta inee was a lre ady ·on a s:imilar
medication. The IJ>illlsneed to ched c1111TenUlird
'ers before pn,villifi ng ovN -th~ountermedic:ali
io:ns.

P«JiCE!55
·No n oompliana!

•
•

IMediGltion .a dminilstration ,
Sid: ca ll/ nursing protooo 'ls

ease,
111~
fi n dings ofCiJncem
•
•

Detainee hil!Sa diai:nmis of hypertension and diabetes.
June 20, 2017 - The detainee was seen for a c:t11u11ii::
,care visit with an ,,eilevated btood pr,essure of'
lSEi/ 86; theH~ was no documentat ion ,of ,cf15ea se •oontrol l,or an ad ju:stment al' blood pressure
medical!ions a

&cKc:»:Neo,Pmwiaoc;
:
•

Chronic car,e

ease,
.111 1
fi n dings o[CiJncem
•
•

Detainee hil!Sa hiis'l:oryof hypertens ion .a nd w as place d ,on medica ,tio11c 12.5 m ii ligrams of HCTZ.
INovernber 21, 201B -Th .e detainee had a mun: appearance and l 1.1ponn!lUm did not haYe ilis
medication restarted.

&ew8i Nnammviiaatrf
•

IMediGltion , maniij!l:ement

Irw in County Deten t iion Center - lll'ISped!ionReport

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Department of Homeland Security

cases
-Ill )
Fin dings ofOJncttn
•
•
•

!Detainee hlill!ia state d .a lle,rgy to NSAID.s,wh ich wot d dl include ibuprofen _
July 24, 201:9-The deta inee was seen at .a dm:miic car,e visit and was presaibed
the documented a'llergv _
The detainee sent in .a sick ,icall note stating "ibuprofen ~iiled l me.•

iblllprofen despite

Process No n compliana!
•
•

Chronic caie
Conl!inuity of ' car,e

case,
-~
Findings of
•
•

IMay 18, 2019 - Se:xua ly tran!SIIJlittedldiiseasie testin,i::was ordered, to im:ilude an RPR (rapid plasma
reg;i in) t est for syphins .
INo Rl'H r,E!5!1J
lt was fouoo l in the hea lth record.

Process No n compµa
•

t

O,ncern

n a!

Conl!inuity of car,e

Ca!>e10■

IIIIJ

Fin dings of OJIICE!f'R
• !Detainee hais a, documented histl!ll'Y,Dfihypert:en:s;,ionand hypertipidemiai .
• Theie is no doruml!illted e videnice t hat lipicll le vels wer ,e checked for proper contro l
Process No n c.o.mplia 11.c.e
• Chronic caie
Ca!>e11 ·-

Findings of OJflCE!f'R
• !Deta inee hlill!ia history of diabetes with no doruml!illted l,!Chroniccaie viis'i:ts ...
• The ·detainee was not pllai:ed 0 11 pmper med ical!ion for an ,e levated low -density lipoprotein ,
cho l'estero ll level and there wais no explanation of the dinoc:a'I thought prooess fo.r tha ,t d'~i:s;,ion.
Process No 11complia 11c.e
• Chronic caie

case
121111_ ,
Findings ofCiJncern
• July 21., 2018 - The detainee was noted lto have a histOif'Y,Dfihyperfipid 'emia ,.
• Theie is no documentation that lipids were cheded l and no chronic GITI! visits are noted_

&ew8i Nnammviiaatrf
•

Chronic caie

casel3
-IIII J
Fin dings ofOJ= n
•

!Deta inee is ,IJiO two •m.edi.cations tha ,t require ,icareful monitoring, y et no medication ll!-llell,diedcs were
documented in,11hehea lth record.

Process No n complia
•
•
•

11Cf

Chronic caie
M enta l hea lth :s;,ervioes
Conl!inuity of car,e

Irwin County Deten t ion Center - lnsped!ion Report

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Department of Homeland Security

case14
-lll
Findings ofOJncttn

t

•

August 22, 20.17 - Results.1of a1cholesterol check were high.,3:16_

•

There was no i:nterpr ,etatOCIIIof the resu lts , not" was a pl!an ,of ,care •created .

Process·Noncompliam:~

•
•

Chronic care
Conliinuity of car ,e

Case15 -~

fiadin,;u9tf.ql1900'J
•

The detainee received a ,ch.est X-ray .at the point ,of intallle_

•

The che-st X-r.ay showed abnoima 1fmdcngs an d the radilofogist recommended !fo llow-up care..
There •was. no documented fdll'ow ·-11Jp
,for the · a'bnonna l chest X-ray,
The detainee iKII a diagnosis of di!a'betes with fa · ure to ,fo11ow li,p:id leve ls.

•
•

Process Nonoompliance

•
•
•

Chronic care
Comm11111ica'il
le disease
Conliinuity of car ,e

case16
-IIII

fiactimn
,qfCQawa
•
•

)

Deta inee waes d~.-iosed with hypertensiD111.a nd dililgllO<Sed
with .a rash ·following mediic:i!Joon,
administration.
IMedntian was ,manged hut the medka liion list in the health reoard ld id not ise.flecl: the ,change of
medicaliion and why.

Process Nonoom,pliance

•
•

Chronic care
Conliinuity of car ,e

case
11-1111
Findings ofCiJncl!f'R
•
•
•

~

Ju ly 19, 20!2!0- This date maru .the ·first of m11'11iiple.-equests .fo r aiStlhmamedications:..
There ·was..a s ipi ific:ant de lav seeing a pmvJdl!f" and lthe detainee did not receive his in'h:al'er ullliill
September !2!0
, :WW.
The deta inee did not reoei!Je peak flow ,meas during :the perioo of diilay.
Care wa<S de'la,yed.

•
Process Nonco.mplia nce

•
•

Chronic care
Conliinuity of ' car ,e

ease18
-lll
Findings of

OJIICE!f'R

•
•
•

t

!Deta inee haes a history of hypertension.
!November 14, 2017 -The •provider noted "iNo NSAIDs" due to .an incr eased ,oreatin ine •leve ll
note.
!November 17, 2017 - An lPN I.at S1id ca ll p:rescliibed an NSA.ID dlespite the phV51iC!ian's

Proce ss Nona:i .mpljance

•
•

Sid call
Conliinuity of car ,e

Center - lnsped!ion Report
lrwi:n County Deten t OCIII

www.oig.dhs.gov

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

casel.9

1

-llll

l

Fin dings ofOJncttn
•

!Detainee hlill!ican:liilc history .

•
INo l!aboratory ·studies
Process·Non compliam:~

•

Chronic care

•

Conliinuity of car,e

ease20--

Of" EKG rrE!S'U
'lts were

i n the health reoord l e111e111
,though t hev w er,e ,ordered .

11

fiadin,;u9t f.ql1900'J
•
•

The he alth record furthisd eta ine e wasverydiffirult
t ofo ll ow .
September 6, 2018 - Th e detainee ~ .a istary ,of anemia . laboratory
r-esu lts ,oould l IKl1i:be found i n the he alth reCOl"d.

•

IDecember 27 , 281.8 - fhe detainee wa;s on:ler:-edlibuprofen despit e the histofy of anemia ,.and

•

Janu ary·24, 201.9 1- The detainee was Of"dl!ft!dl iron pi lls fur the b1eilitment of anemiilL

•

M ardi ,4 ,.2819 The detainee experienced lllterine b l.eeding so,a gynecology ref erra l fo .- .a pelvic
ultraesoond Will5 Of"den!d~the t est reS1JltsoDU] d not be tocated in t he he alth reronl .

•

M ardi , 27, 2019 - A nurse practitioner

•

IM ardi , 28:, 2019 - The deta i nee 'Was prescribelil .a di abe:tic mediic:atio.n,witlh no ,explanation of wh ,y in,

stud ies wer ,e ,a;rdered blllt the

stom ach issu es.

1 -

again on:l ered ibuprofen fur abdom ina l! pain,.

th e hea:lth reoord L
l'fOiCE!ssNon.co.mpljance

•

Chronic care

•

Conliinuity of ' car,e

Irw in County Deten t ion Center - Inspection Report

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

REPORT su~nvL\RY
•

•

•
•
•
•
•

•

FOR !\,IEDIC_'-\.LI:'.'JSPECTIO:\:

The medica l ins,11.emoo,,consist ,edofftwo appmadies:: (1.) interviews with members of the hea lth
c:a:re t.eam , induding leaclersh~ .and direct c:a:re peir:soone l aoo121thor ,ouglh, review ·of
adm inistrat iive doruml!ll'lt:s ,and 195 hea lth r-ec:ords_N'o virtua l tours were condocte,d l_
The health record ~ew
was oomp l'et ,ed by the physician and nurses .as.signed to thils project.
The nurse te.i m members focused on the lime .l ines ,s and appropriateness
of care for the ,core
processes ,Df c:a:re in the correel!iooa 1 setting.. This ind uded l intak.e, 'initia l health assessments , sid
c:a'II~medicatiion adm iniS'lr.ltilon, and medica l observaitioo ,,care _The phys i C!
ian forused on the
c:a:re pr ,D!fjded to ,detainees with chronic illness to •determine its .appropriateness_
We listed the heal .th c:are records witlh com:ems in this document _
We mrted the findings ·Joo all FeViewed d iniui 'I processes in,each sipet0ific sect ion ,Dfrthis report .
Fiindin,~ that require .attent ion a:re noted them in the specific sect ion being at1tdressed l_
Al I members of the Irwin medi .ca l te.im macle themselves fu lly aocess iiJle to the •inspect ion tE!ilm
aoo l participated in the inl!enriews in a c,oopera'l!ive manner_
The fadli"ty l eacler:shi;p team provided ,documentation arSreq1,1ested except in the few
circumstanCJeS as no'ted in the report.
Adequacy Df C!aTeis noted in each semoo Df the report

lrwt n County Deten t ion Cent e r - Insp ect ion Re;pon

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Appendix D
Office of Inspections and Evaluations Major Contributors to
This Report
Tatyana Martell, Chief Inspector
Kimberley Lake de Pulla, Supervisory Lead Inspector
Stephen Farrell, Senior Inspector
Erika Algeo, Senior Inspector
Rebecca Blaskey, Attorney Advisor
Jean Choi, Attorney Advisor
Stephanie Christian, Independent Referencer

www.oig.dhs.gov

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Appendix E
Report Distribution
Department of Homeland Security
Secretary
Deputy Secretary
Chief of Staff
Deputy Chiefs of Staff
General Counsel
Executive Secretary
Director, GAO/OIG Liaison Office
Under Secretary for Office of Strategy, Policy and Plans
Assistant Secretary for Office of Public Affairs
Assistant Secretary for Office of Legislative Affairs
ICE Liaison
Office of Management and Budget
Chief, Homeland Security Branch
DHS OIG Budget Examiner
Congress
Congressional Oversight and Appropriations Committees

www.oig.dhs.gov

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Additional Information and Copies
To view this and any of our other reports, please visit our website at:
www.oig.dhs.gov.
For further information or questions, please contact Office of Inspector General
Public Affairs at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov.
Follow us on Twitter at: @dhsoig.

OIG Hotline
To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click
on the red "Hotline" tab. If you cannot access our website, call our hotline at
(800) 323-8603, fax our hotline at (202) 254-4297, or write to us at:
Department of Homeland Security
Office of Inspector General, Mail Stop 0305
Attention: Hotline
245 Murray Drive, SW
Washington, DC 20528-0305