DEPARTMENT OF HOMELAND SECURITY

Office of Inspector General
ICE Policies Related to Detainee Deaths and the 

Oversight of Immigration Detention Facilities 


OIG-08-52

June 2008

Office of Inspector General
U.S. Department of Homeland Security
Washington, DC 20528

June 11, 2008

Preface
The Department of Homeland Security (DHS) Office of Inspector General (OIG) was established by
the Homeland Security Act of 2002 (Public Law 107-296) by amendment to the Inspector General
Act of 1978. This is one of a series of audit, inspection, and special reports prepared as part of our
oversight responsibilities to promote economy, efficiency, and effectiveness within the department.
This report addresses the strengths and weaknesses of U.S. Immigration and Customs Enforcement
(ICE) operations related to detainees who died in custody. We also analyzed certain medical
standards and ICE’s oversight of facilities that house immigration detainees. We based our report on
interviews with relevant agencies, direct observations, and a review of applicable documents and
data.
The recommendations herein have been developed to the best knowledge available to our office, and
have been discussed in draft with those responsible for implementation. It is our hope that this
report will result in more effective, efficient, and economical operations. We express our
appreciation to all of those who contributed to the preparation of this report.

Richard L. Skinner 

Inspector General 


Table of Contents/Abbreviations
Executive Summary .............................................................................................................................1 

Background…………………………………………………………………………………………...2 

Results of Review……………………………………………………………………………………..4 

An Analysis of Two Immigration Detainee Deaths……………………………………………….4 

Recommendations ………………………………………………………………………………..14


Management Comments and OIG Analysis……………………………………………………...14 

Oversight Can Be Improved at ICE Detention Facilities………………………………………...19 

Recommendations ………………………………………………………………………………..26
Management Comments and OIG Analysis……………………………………………………...26





Additional Efficiencies in Medical Operations Can Enhance 

Implementation of ICE’s Detention Standards………………………………………………… ..29 

Recommendations ………………………………………………………………………………..33


Management Comments and OIG Analysis……………………………………………………...34 

Appendices
Appendix A:
Appendix B:
Appendix C:
Appendix D:
Appendix E:
Appendix F:

Purpose, Scope, and Methodology.........................................................................35 

Management’s Comments to the Draft Report ......................................................36 

Recommendations..................................................................................................48 

Comparison of Various Detention Standards…………………………………….50 

Major Contributors to this Report............………………………………………..54 

Report Distribution……………………………………………………………….55 


Abbreviations
ABA
ACA
DHS
DIHS
EHRs
ICE
OFDT
OIG
OPR
RCC
VA

American Bar Association 

American Correctional Association

Department of Homeland Security 

Division of Immigration Health Services 

Electronic Health Records 

Immigration and Customs Enforcement 

Office of Federal Detention Trustee 

Office of Inspector General 

Office of Professional Responsibility 

Regional Correctional Center 

Department of Veterans Affairs 


ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

Detention Facilities 


OIG

Department of Homeland Security
Office of Inspector General

Executive Summary
Immigration and Customs Enforcement houses a daily average of 28,700
detainees in 353 facilities nationwide. Various types of detention facilities,
such as service processing centers, contract detention facilities, and state and
local jails, are used to house these individuals. Immigration and Customs
Enforcement detention standards are used to inform facilities on expectations
regarding medical care, detainee access to legal materials, and other areas
related to facility management. Between January 1, 2005, and May 31, 2007,
33 immigration detainees died.
We reviewed two cases where immigration detainees died in custody. One of
these incidents occurred in St. Paul, Minnesota. The second incident took
place in Albuquerque, New Mexico. We evaluated how the agency and its
detention partners dealt with the two cases. In addition, we examined policies
related to detainee deaths, medical standards, and other issues. We gathered
data from the two affected detention facilities, examined the agency’s reports
completed after its monitoring visits to various facilities, and had discussions
with public and private-sector experts on detention standards.
Although there are compliance problems related to certain medical standards
at various facilities, ICE adhered to important portions of the detainee death
standard in the two cases that were the focus of this review. Based on
information received from clinical experts and our analysis, the two detainees’
serious pre-existing medical conditions led to their deaths. Although ICE’s
detention standards are comparable to other organizations, such as the
American Correctional Association, we are making 11 recommendations to
improve the standards, strengthen ICE’s oversight of facilities, and enhance
clinical operations and detainee safety.

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Background
Immigration and Customs Enforcement (ICE), the largest investigative branch
of the Department of Homeland Security (DHS), was created in March 2003
by combining the law enforcement functions of the Immigration and
Naturalization Service and United States Customs Service. The Immigration
and Nationality Act authorizes ICE to arrest, detain, and remove certain aliens
from the United States.1 The agency’s average daily detainee population in
December 2007 was 28,702. This was a 61% increase compared to January
2006, as shown in Figure 1.
Figure 1: ICE's Average Daily Detainee Population, January 2006December 2007
35,000
30,000
25,000
20,000
15,000
10,000
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ICE is charged with ensuring that removable aliens depart the United States.
ICE uses three types of facilities to house its detainees until they are deported:
Service processing centers are owned and operated by ICE; private companies
operate ICE’s contract detention facilities; and state and local jails with
intergovernmental service agreements house ICE detainees. Most service
processing centers and contract detention facilities use Commissioned Corps
Officers in the Public Health Service to deliver onsite medical care. The
partnership between the Public Health Service and federal immigration
agencies was initially established in 1891. Local jails rely mainly on other
onsite clinicians, such as contractors or staff employed by a county public
health department.

1

8 USC §§ 1226, 1227, 1229, 1229(a), and 1357.
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ICE’s Detention Operations Manual stipulates the agency’s detention
standards, which are designed to ensure facilities provide services that will
protect detainees’ life and dignity. The standards contain rules on medical
care, food service, access to legal materials, and various other areas. Facilities
are to be inspected on an annual basis to ensure compliance with ICE’s
standards. ICE staff is also responsible for visiting each facility to interact
with detainees on a regular basis.
In November 2000, the Immigration and Naturalization Service established
detention standards to ensure the “safe, secure, and humane treatment” of
detained immigrants. Discussions among federal immigration officials, the
American Bar Association (ABA), the Department of Justice, and other
organizations helped create the standards. Several of ICE’s 36 standards have
been revised or expanded. Since the creation of DHS, two additional
standards have been issued: (1) staff-detainee communication requirements
were established in July 2003, and (2) detainee transfer policies were
approved in September 2004.
Other federal agencies have their own detention standards. The Office of
Federal Detention Trustee (OFDT) in the Department of Justice ensures that
federal agencies involved in detention operations provide for the safe and
humane confinement of persons who are awaiting trial. OFDT is responsible
for conducting annual facility reviews using Federal Performance-Based
Detention Standards. OFDT and ICE inspect some of the same facilities.
Private entities also have created detention standards. The American
Correctional Association (ACA) and the National Commission on
Correctional Health Care have more than 150 years of combined experience in
creating and revising detention standards. Both entities accredit national,
state, and local detention facilities that meet existing detention standards. In
some areas, such as the placement of first aid kits and defibrillators, ICE
requires adherence to ACA standards.
ACA’s purpose is to promote improvement in the management of correctional
agencies through the administration of a voluntary accreditation program and
the ongoing revision of its standards. As with ICE and OFDT standards, the
ACA covers a variety of subjects pertaining to the administration and
management of detention facilities. For facilities seeking accreditation, ACA
conducts onsite inspections every three years. According to ACA policy
facilities are required to document compliance with the standards for each
month over the three-year period.
The National Commission on Correctional Health Care works to improve the
quality of health care in correctional facilities. The Commission’s standards
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guide facilities on the delivery and management of health care in correctional
systems. ICE’s service processing centers and contract detention facilities are
required to maintain accreditation by the Commission.
As a stakeholder in developing ICE’s standards, ABA has created a
commission to help review detention standards at facilities housing
immigrants and asylum seekers. The ABA’s Commission on Immigration
ensures detainees are made aware of their rights, including access to legal
materials, telephones, and group presentations. Working with volunteer law
firms, the ABA visits facilities to review practices and suggest improvements.
The ABA shares its site visit reports with ICE.

Results of Review
This review examined two cases of detainee death, as well as ICE’s overall
standards related to detainee deaths and the medical treatment of immigration
detainees. The two detainees died as a result of serious pre-existing medical
conditions. Although there have been problems with adherence to medical
standards at the two facilities in question, ICE’s overall standards are
equivalent to other detention organizations. ICE has been taking steps to
enhance its ability to effectively monitor immigration detention facilities. Our
recommendations focus on how ICE can make further improvements to the
efficiency of clinical operations by developing better oversight procedures.

An Analysis of Two Immigration Detainee Deaths
The first detainee’s death occurred in April 2006, in St. Paul, Minnesota; the
second death happened in September 2006, in Albuquerque, New Mexico.
Although the two detainees were in ICE custody, the individuals were
hospitalized at the time of death. According to ICE’s standards, both the
agency and its detention partners are required to take certain actions when a
detainee dies. In both of these incidents, the procedures outlined in the
detainee death standard were performed, with the exception of a state
notification requirement that we describe in our discussion of the Albuquerque
incident. Pursuant to its statutory authority, the DHS Office for Civil Rights
and Civil Liberties investigated a complaint concerning the Minnesota
detainee death. The Office reviewed compliance with ICE’s medical care
standard at the detention facility and made recommendations to ICE for
possible improvements in detainee care.

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ICE’s Detainee Death Standard
In September 2000, the Immigration and Naturalization Service created a
standard for detainee deaths. This standard remains in place. Field office
personnel we interviewed reported satisfaction with the standard itself.
Detainees who die in custody do not always pass away in a detention facility;
therefore ICE has different rules for situations where detainees die in other
locations or in transit. From the notification of family to disposition of
remains and personal property, ICE standards address the sensitivity that
surrounds detainee deaths.
Notifying the family is an important part of ICE’s detainee death procedures.
Additionally, the standard requires notification of the applicable consulate.
ICE also must prepare a condolence letter for the family that describes the
circumstances of the death. After completing the necessary notification
requirements, ICE is required to assist in other areas, such as autopsy
arrangements. Before initiation of the autopsy, facilities must determine the
detainee’s religious affiliation. This is important because some religions have
specific restrictions involving autopsies, embalming, and cremation. When
family members cannot afford the costs associated with transporting the
remains, ICE may transport the remains to a location in the United States.
ICE’s Office of Professional Responsibility (OPR) reviews detainee death
cases. OPR’s management directive does not require the reporting of deaths
to the OIG, nor were we provided any ICE policy documents that require the
reporting of immigration detainee deaths to our office. However, OPR can
refer cases to the OIG when ICE determines an outside review is warranted.
An OPR manager informed us that the Joint Intake Center may report detainee
deaths to the OIG or OPR. Likewise, the OIG’s Office of Investigations may
refer various detainee death incidents to OPR. The DHS Office for Civil
Rights and Civil Liberties also has reviewed detainee deaths and compliance
with ICE standards.
OPR has helped ICE improve detention practices after some detainee deaths.
However, ICE should report all detainee deaths to the OIG. In the past, we
have received information about detainee deaths on a sporadic basis, mainly
through complaints to the OIG Hotline. Notifying the OIG of any detainee
death would keep the OIG better informed and allow it to determine whether
additional review is warranted in each case. A policy in this area could
outline procedures for providing relevant records to the OIG, as necessary.
ICE’s detainee death standard compares well to ACA and OFDT standards.
Both ACA and OFDT point out the importance of mortality reviews, which
can prompt changes to facility procedures and can potentially decrease the
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chance of additional deaths. Although ICE does not require mortality
reviews, we noticed evidence of such reviews in the files of several detainees
who died, including the two deaths that are the focus of this review.
Clinicians with the Division of Immigration Health Services usually complete
ICE’s mortality reviews.
The St. Paul, Minnesota Case
The immigration file of the detainee, who died in April 2006, shows an initial
hearing before an immigration judge in November 1997. An October 1998
letter instructed the individual to appear for deportation on November 3, 1998.
The detainee did not appear for deportation. Thereafter, ICE considered the
detainee a fugitive. ICE did not locate the detainee until February 2006, and
arrested the detainee for not departing the United States in 1998.
ICE held the detainee at the Ramsey County Law Enforcement Center. This
facility is located in downtown St. Paul, Minnesota, and houses various
individuals awaiting legal proceedings in the county. When this incident
occurred, the facility housed 70 immigration detainees on an average day. For
the first six months of 2007, the facility accepted 177 new ICE detainees.
ICE’s 2006 monitoring report for the facility showed an acceptable overall
rating.
On April 3, 2006, at approximately 2:30 p.m., the detainee fell from a bunk
bed and sustained a lump on the back of the head. The guard who arrived at
the cell ensured that a nurse would see the detainee during 4:00 p.m. medical
rounds. At that time, the detainee reported dizziness and headaches to the
nurse. The detainee’s medical file includes information from the nurse
reporting that the detainee was confused when the detainee returned to the
cell. Four hours later, the detainee’s condition had deteriorated, prompting a
nurse to order transportation to a nearby hospital.
After arriving at the hospital, physicians diagnosed a serious condition known
as neurocysticercosis, which is an infection of the brain by larva of the pork
tapeworm. This disease caused the detainee’s death on April 13, 2006.
Serious complications can result if the disease enters the central nervous
system. The detainee reported a history of headaches that were not relieved
by medication. The facility’s clinical protocols, which called for the use of
aspirin for headaches, do not account for other possibilities, such as serious,
pre-existing parasitic diseases as a cause of the problem. Although seizures
are a common symptom of the disease, there was no evidence of seizures in
the detainee’s medical file.

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We identified two important facts related to the detainee’s medical care.
Facility information we examined included a head trauma protocol. This
document justified the detainee’s expedited transportation to the hospital after
a nurse observed that the detainee was dizzy and confused. Additionally, the
detainee did not receive a physical exam, which ICE medical standards
require within 14 days of intake. However, after discussions with clinical
experts and a review of medical literature, we concluded that neither more
timely medical attention for the head trauma nor a more timely initial medical
exam would have ensured the detainee’s recovery from neurocysticercosis.
The case history showed that ICE did a commendable job implementing parts
of the detainee death standard. We examined two “significant incident”
reports prepared for ICE headquarters by the agency’s staff in Minnesota.
Field office personnel send these reports to headquarters after serious events
take place. ICE also left a message with the Consulate of Ecuador in Chicago.
ICE also notified the detainee’s spouse. This timely compliance with steps in
ICE’s detainee death standard did facilitate necessary actions, such as the
return of the remains. Documentation also showed that the detainee’s spouse
received some of the detainee’s personal property less than one week after the
death. The detention standards do not have a time requirement for the return
of property, but ICE made a good effort to ensure that this occurred.
The death led to a debate within the Ramsey County government regarding
whether to continue to house ICE detainees. The County Sheriff said that the
Law Enforcement Center may not be the best place for ICE to house
individuals longer than a few days. Media also reported that the sheriff was
concerned about the ability to care for immigration detainees on an ongoing
basis. “We’re not really prepared to translate, interpret, and assist that kind of
population,” he said.2 After further discussions, in December 2006, the
County Board of Supervisors voted four to three to maintain its agreement
with ICE.
Policy Improvements and Additional Education Efforts Would Help
Identify and Treat Cysticercosis
While ICE’s medical standards recognize the need to treat infectious diseases
in general, they do not specifically mention cysticercosis. Furthermore, nonemergency radiology services, such as computed tomography scans or
magnetic resonance imaging−methods of making detailed images of the body
to identify problems that are not readily apparent−are not included in the
Division of Immigration Health Services covered services package. Although
case-by-case requests for coverage and payment of diagnostic tests are
2

“No immigrant detainees in Ramsey County?,” Minneapolis Star-Tribune, December 19, 2006.
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possible, current policy does not specifically provide for proactive diagnosis
of cysticercosis.
The disease, which disproportionately affects Latin American immigrants, can
infect humans who come in contact with the tapeworm that causes
cysticercosis. The resulting cysts can migrate to various parts of the body,
including muscles, the eyes, or the brain. In the central nervous system, the
disease is known as neurocysticercosis, which was the cause of death in the
St. Paul case. We cannot determine with certainty whether this death could
have been avoided had the detainee received immediate medical attention for
head trauma. However, ICE, in conjunction with the DHS Office of Health
Affairs, should engage the Centers for Disease Control and Prevention to
review the medical screenings provided for detainees, with special
consideration of the origins of the population.
According to medical journals and experts we interviewed, cysticercosis is
expected to become more prevalent in the United States within the next
decade. A neurology professor informed us that she has seen many more
cases of the disease over the past five years. A leading journal also predicted
that cysticercosis “will grow in clinical and public health importance” in the
United States. This article reported that Latinos accounted for 85% of
individuals who died of cysticercosis in the United States from 1990 through
2002. After these deaths were studied, the authors wrote that the incidents
reflect “immigration patterns in states that include substantial populations of
immigrants from cysticercosis-endemic areas, particularly Mexico and other
areas of Latin America.”3
Based on ICE data for the period of October 2006 through November 2007,
individuals from Mexico, Honduras, El Salvador, and Guatemala, countries
where the disease is endemic, account for 79% of ICE’s total detainees, as
shown in Figure 2.

3

“Deaths from Cysticercosis, United States,” Emerging Infectious Diseases, February 2007, p. 230231, 233.
ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Figure 2: Country of Origin for ICE Detainees, October 2006November 2007


All others
21%

Mexico
49%

Honduras
11%

Guatemala
10%
El Salvador
9%

In a study of deceased neurocysticercosis patients in Oregon spanning six
years, it was determined that 44 of 57 fatalities (77%) occurred in people who
had been born in Mexico or Guatemala.4 A separate review of autopsies in
Mexico showed a prevalence of cysticercosis in about three percent of the
population.5 If three percent of ICE’s detainees from Mexico were infected,
nearly 5,000 Mexican nationals detained in fiscal year 2007 could be carrying
the parasite.
Currently, the standards used by the Office of Federal Detention Trustee
(OFDT) provide a logical process for the treatment of special needs
individuals. The Detention Trustee’s definition of special needs individuals
includes those with communicable diseases. ICE’s standard is less detailed,
and it should be revised to include individuals who carry the tapeworm that
can cause cysticercosis. There is also a specific Trustee standard6 that
requires “appropriate diagnostic testing” be done on detainees with special
needs.
ICE also can educate staff at facilities housing detainees to ensure
understanding of neurocysticercosis. One of the world’s leading experts on
immigrant health care informed us that neurocysticercosis is “the leading
cause of seizures” in adults from Mexico and Central America. Another
expert, who labeled seizures as the “hallmark” symptom of the disease,
informed us that the Centers for Disease Control developed an “extremely
4
5
6

“Neurocysticercosis in Oregon, 1995-2000.” Emerging Infectious Diseases, March 2004, 508-510.

“Deaths from Cysticercosis, United States,” p. 232. 

B.3.29a 

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simple” blood test that can reveal whether an individual has the tapeworms
capable of spreading the disease. The CDC has noted that the blood test may
not always be accurate, and other more definitive diagnostic tools, such as
brain imaging, exist. Through expanded educational efforts, as well as greater
use of available diagnostic tools when deemed appropriate, ICE could
facilitate faster identification of tapeworm carriers or instances of the disease
among detainees. This offers a chance to improve treatment of a disease more
likely found in ICE detainees than in United States citizens.
Another way ICE could better detect the disease is to ensure that questions
related to cysticercosis are asked during the initial health assessment and 14day physical exam. A neurologist who has treated neurocysticercosis said an
entire family should be treated if one individual in a household has the
disease. Records indicate that facility staff was informed that the detainee’s
mother had surgery four years before to treat “eggs of bugs inside her head.”
These comments may appear non-sensical, but they provided a clue that could
have led to further questioning or diagnostic testing. Adding intake and
medical screening questions about a family history of the disease would have
been useful.
Greater efforts to recognize neurocysticercosis may have expedited the care
the detainee received. More than a month before the detainee’s death, clinical
staff was told, “Tylenol or aspirin don’t do anything [to remedy my
headaches.]” Also, after falling from the bunk bed on April 3, 2006, the
detainee exhibited general confusion and dizziness. Neurocysticercosis was
quickly diagnosed after the detainee visited the emergency room.
The Albuquerque, New Mexico Case
In 2004, the Regional Correctional Center (RCC) in downtown Albuquerque
was leased to Cornell Companies, a private correctional firm based in
Houston, Texas. After making several renovations, Cornell began housing
ICE and U.S. Marshals detainees at the RCC. The RCC booked 10,026 ICE
detainees from July 1, 2005 through July 20, 2007.
The detainee, who died on September 11, 2006, was arrested as a result of an
ICE operation on the East Coast. The individual, along with 13 others, was
transferred in August 2006 to the RCC. Records show that the detainee was
sent to a hospital on September 4, 2006.
The detainee died of “widely metastatic” pancreatic cancer, which means that
cells broke away from the original cancerous tumor and spread to other parts
of the body. This type of cancer makes survival unlikely. A physician with
25 years of oncology practice said, “I have never seen a tumor marker that
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high,” after reviewing the detainee’s test results. Hospital clinicians who
treated the detainee recognized that the disease was at an advanced stage
before ICE took the detainee into custody. However, medical examinations
received after the detainee arrived at the RCC did not reveal the illness.
A Hotline complaint we received, an affidavit from another detainee, and
unsworn testimony from a former RCC employee, all alleged that the
facility’s personnel did not address the detainee’s medical issues.
Specifically, the Hotline complainant believed ICE and RCC staff gave “scant
attention” to the detainee’s medical needs. However, it appeared that
Cornell’s clinical staff addressed written medical requests identified in the
detainee’s records. The detainee received antacid tablets after complaining of
abdominal pain, so, like the Minnesota case, staff did not immediately
recognize a more serious condition. Based on documentation from hospital
staff, we concluded that the RCC’s medical team could not have saved the
individual’s life, even with quicker onsite treatment or expedited
transportation to the hospital.
ICE staff in Albuquerque notified managers at ICE headquarters of this
incident. ICE contacted the detainee’s family and the consulate of the
detainee’s country of origin. Local staff also placed a copy of the death
certificate in the detainee’s file, which is required by ICE standards.
In certain cases, ICE faces challenges locating family members of detainees.
This is inherent in the immigration detention process, especially when
detainees are often transferred across the United States. In this case, the
detainee’s son, the only family member identified in the case files, was
attending a university on the East Coast during the detainee’s time in New
Mexico. This led to difficulties coordinating post mortem activities, such as
the transfer of remains. The records show that ICE made appropriate efforts
to communicate with the family. The head of the consulate from the
detainee’s country of origin thanked ICE for the professionalism exhibited by
the agency’s staff during the incident.
Nonetheless, the Hotline complainant, other detainees, and a former RCC
employee asserted that the RCC was not dealing with some detainee sick call
requests of in a timely fashion. Based on facility data and a September 2006
site visit report by OFDT, there is merit to those concerns. OFDT reported
that, due to a nursing shortage, detainees were often waiting as many as 30
days for sick call requests to be answered. Additionally, OFDT reported that
only 11 of 20 detainees with chronic conditions were regularly scheduled for
chronic care clinics.

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This detainee’s death highlighted a limitation in ICE’s detainee death policy.
New Mexico law requires that any death of a person in the custody of law
enforcement be reported; however, New Mexico’s Office of the Medical
Investigator, which should have received this notification, did not have a
record of the detainee’s death. ICE staff said that the county should have
reported the death. State officials said that the hospital could have worked
with ICE to ensure compliance with the state’s requirements. ICE should
revise the detainee death standard to ensure that the agency and its detention
partners comply with laws requiring notification to state officials. The
standard requires the notification of family and the consulate, so adding
language about state reporting would be suitable. Regardless of who should
take the lead in contacting the state, ICE needs to ensure that detainee deaths
are reported to state governments if legally required.
RCC Site Visit Reports
ICE’s Office of Professional Responsibility (OPR) visited the RCC in June
2007. At that time, the facility housed 746 immigration detainees. OPR
reported a variety of problems, including inadequate suicide watch
observation, food service, records maintenance, and security procedures.
OPR considered the RCC’s overall security procedures to be “weak” and “in
dire need of improvement.” Based on its determinations, including the
discovery of illegal drugs in the facility, ICE decided to remove all of its RCC
detainees in early August 2007. We commend ICE for using its own process
to identify areas of concern at detention facilities.
Cornell management acknowledged problems at the RCC. A senior manager
said that a corporate audit team has helped identify and correct deficiencies.
Based on recent comments by the Chief U.S. District Court Judge in New
Mexico, the company’s efforts have led to some improvements.7 Cornell said
that ICE did not fully explain why all immigration detainees were transferred
to other locations. However, Cornell’s Chief Executive Officer said, “if we
had operated RCC as we do our best facilities, no one would have had any
basis for criticism. But we didn’t.”8
Prior to OPR’s report, evidence existed that showed the RCC was having
some difficulty in important areas. Within a six-week period in 2006, ICE
and OFDT completed separate monitoring visits at the RCC. OFDT assigned
the RCC an at-risk rating in its September 2006 monitoring report. This is the
7

“Bernalillo County’s Regional Correctional Center conditions improving,” Albuquerque Tribune, 

August 30, 2007, and “Red Flags Raised at Albuquerque’s Downtown Jail,” Albuquerque Tribune, 

September 25, 2007. 

8
“Jail CEO explains setbacks,” Albuquerque Tribune, August 11, 2007. 

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lowest possible overall rating, two levels below acceptable. ICE granted an
acceptable rating to the facility after its 2006 site visit. OFDT’s follow-up
report, based on a February 2007 site visit, determined that RCC’s operations
were acceptable, which suggested that the RCC made important corrections
after OFDT’s September 2006 report.
In September 2006, OFDT reported problems with the RCC’s compliance
with ICE’s detainee death policy. OFDT concluded that the RCC’s policies
did not address a requirement to notify the Departments of Justice or
Homeland Security in the event of detainee death. OFDT also reported that
the RCC’s policy did not address religious requirements or medical
circumstances regarding autopsies. Finally, the facility’s policy did not
address the need to gain the permission from federal agencies to release the
detainee’s body.
ICE’s November 2006 RCC report did not mention actual or pending
revisions to the detainee death policy. Limitations to the detainee death policy
should have been clearly written in ICE’s report, especially since an RCC
detainee died less than two months before ICE’s site visit.
OFDT’s report mentions other problems at the RCC of interest to ICE. In its
discussion of detainee classification, which pertains to separating individuals
by severity of their offenses, OFDT identified seven non-criminal ICE
detainees housed with 136 criminal detainees. Based on a recommendation in
our December 2006 report, Treatment of Immigration Detainees Housed at
Immigration and Customs Enforcement Facilities, ICE has taken steps to
address classification problems at its facilities.9 However, an assistant trustee
stated that OFDT has detected such problems at other ICE facilities, but there
are no procedures for sharing report findings with ICE.
ICE and OFDT have different standards, but some efficiency could be gained
if ICE engaged the detention trustee on facilities reviewed by both agencies.
OFDT could inform ICE about issues of interest to ICE, but ICE is not taking
advantage of this opportunity. No field office reported interaction with OFDT
on facility monitoring, though OFDT reports mention ICE standards.
Moreover, the two agencies do not share monitoring reports. The Assistant
Trustee we interviewed lamented such missed opportunities by saying that
there is “very minimal” information sharing between ICE and OFDT.
By developing a better relationship with OFDT, ICE could gain important
perspectives about its detention facilities. Problems of mutual interest, such
9

DHS OIG, Treatment of Immigration Detainees Housed at Immigration and Customs Enforcement
Facilities, OIG-07-01, December 2006, p. 48.
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as timeliness of health care delivery, could lead ICE to request more data
samples, interviews, or policies to ensure compliance. A more developed
relationship between the two agencies would be helpful, especially in
situations where OFDT’s standards differ from ICE.

Recommendations
We recommend that the Assistant Secretary for Immigration and Customs
Enforcement:
Recommendation #1: Work with the Office of Inspector General to create a
policy that would lead to the prompt reporting of all detainee deaths to the
Office of Inspector General.
Recommendation #2: Work with the Division of Immigration Health
Services, the Centers for Disease Control, and other experts, to enhance
existing medical standards, rules for special needs individuals, and coverage
guidance related to infectious disease.
Recommendation #3: Revise medical intake screening forms and physical
exam questionnaires at detention facilities to include questions regarding the
detainee’s family history of cysticercosis.
Recommendation #4: Revise the notification section of ICE’s detainee death
standard to ensure that the agency and its detention partners report a
detainee’s death in states that require notification in the event of a death in
custody. Documentation of this reporting should appear in a detainee’s file.
Recommendation #5: Seek to enter into a memorandum of understanding
with the Department of Justice, Office of Federal Detention Trustee that
establishes a process that enables OFDT and ICE to regularly share
information resulting from facility site visits.

Management Comments and OIG Analysis
ICE and the DHS Office of Health Affairs provided written comments on our
draft report. We evaluated these comments and have made changes where we
deemed appropriate. Below is a summary of ICE’s written response to the
report’s first five recommendations and our analysis. A copy of ICE’s
complete response is included as Appendix B.
ICE’s Comments to Recommendation #1

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ICE concurred with our recommendation. A March 13, 2008, memo that was
created by ICE’s Office of Professional Responsibility outlines the process
that will ensure OIG notification of each detainee death. ICE will make
telephone contact with the OIG as quickly as possible after the death. The
following day, additional details will be provided as part of an existing OIG
notification mechanism.
OIG Analysis
ICE’s new policy should facilitate interaction with our office on detainee
death cases. As needed, we will use this new process to gain additional
information about detainee death incidents.
The recommendation is resolved and closed.
ICE’s Comments to Recommendation #2
ICE concurred in part and disagreed in part with our recommendation. ICE
concurred with the recommendation to work with DIHS and other experts to
enhance the detention standard for detainee access to medical care. ICE is
updating all 38 standards and converting them into 41 performance-based
standards. These revisions are being reviewed by major governmental
organizations and DHS’ Office for Civil Rights and Civil Liberties. DHS
expects to publish the revised standards on September 1, 2008.
ICE stated that the current medical standard allows for special needs
individuals to receive appropriate medical care. Regarding “medical
standards,” ICE said it does not have the authority to establish or alter national
public health or medical health care industry standards, which are established
by professional medical researchers and medical practitioners in tandem with
public health and medical care governing and regulatory bodies.
Although ICE believes the current detention standard is sufficient to meet the
medical needs of detainees, it believes doctors and medical staff must be
cognizant of diseases. It has asked DIHS to develop a training tool to enhance
the medical field’s awareness and early detection of diseases that might be
prevalent in aliens from particular geographic locales.
OIG Analysis
We are not recommending that ICE attempt to expand its authority and role in
the development of national public health or medical care industry standards.
However, it is well within the agency’s authority, in consultation with experts,
to revise its own policies and the medical care standard in the Detention
Operations Manual. Special needs individuals may be getting adequate care,
but we reaffirm our recommendation that ICE augment its policy to call more
attention to those carrying infectious diseases, and help ensure that its medical
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care better reflects the needs of its population. Possible changes include
listing particular diseases that make someone a special needs individual, as
OFDT has done. Diseases that are more common to immigrant populations,
such as cysticercosis, can be the focus of such efforts. ICE’s decision to ask
DIHS to develop a tool to enhance the medical field’s awareness and early
detection of diseases is a positive step, but this tool would be most effective if
it is accompanied by needed policy enhancements that respect the particular
needs of ICE’s unique population of detainees.
DIHS clinicians, who are now ICE employees, are committed to serving
ICE’s needs. ICE should take a greater interest in discussing possible changes
to coverage rules for its population. The DHS Office of Health Affairs is
another resource that can help ICE in these areas.
ICE’s action plan should include information about its work with DIHS to
alter policies that increase the probability of expedited treatment for
individuals with infectious disease. Current coverage guidance does not
adequately allow for coverage of conditions that do not appear to be medical
emergencies. Through greater dialog with DIHS and ICE’s departmental
partners, the chances for improved health care outcomes will increase.
This recommendation is unresolved and open.
ICE’s Comments to Recommendation #3
ICE concurred in part and disagreed in part with our recommendation. ICE
agrees that DIHS should review its medical intake and physical exam forms,
presumably to assess whether the forms can be modified to allow for more
accurate and timely identification of certain diseases. ICE stated that present
health screening tools include questions concerning family history. The
agency stated that there is sufficient space on the forms to record any
information provided to alert medical professionals of any possible problems
that are not readily apparent. ICE’s current intake form is based largely on
questions that are not only related to family history of various diseases, but
symptoms that may lead medical professionals to diagnose an illness. Given
its large, diverse detainee population, it is not clear to ICE whether a specific
designation of family history of cysticercosis is warranted on medical intake
forms or that amending the form is the most appropriate manner to respond to
this particular disease. Furthermore, ICE questioned the OIG’s conclusions
regarding the scope and danger of cysticercosis. It stressed that the disease is
still quite rare, even after the large increase in Latin American immigrants
over the last 30 years. ICE reported that technological improvements, not a
prevalence of cysticercosis, led to increased detection of the disease.

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ICE noted that DIHS’ commitment to enhance the medical field’s awareness
and early detection of diseases that might be prevalent in aliens from
particular geographic locales is a major step forward. ICE believes the best
approach to address our concerns about cysticercosis or infectious diseases is
to request that DIHS reevaluate the current medical form in order to determine
whether amending these forms is appropriate.
OIG Analysis
ICE questioned the value of incorporating any family history of cysticercosis
on forms currently in use, but also agreed that DIHS should review its medical
intake forms and physical exam forms in order to better identify certain
diseases. ICE will request that DIHS review current medical forms in order to
determine whether amending these forms is appropriate. ICE did not indicate
how it would respond to a decision by DIHS to amend the forms, whether it
would revise any forms, or how such changes would be communicated to
local facilities, which often use their own screening forms. ICE should
provide documentation of its request, and the results of DIHS’ evaluation.
We do not expect ICE to make cysticercosis the focus of its health care
program. However, the disease, rare even in ICE’s population, is a far greater
risk to immigrants from Latin America than the general population, and
amending intake screening and physical exam forms is a step ICE can take to
help detect the disease.

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Greater awareness and detection of the disease might not decrease morbidity
or mortality in a specific case, but this is not a reason to omit specific
language related to cysticercosis on intake and physical exam forms. The
disproportionate risk of cysticercosis in ICE’s population is not “anecdotal,”
as ICE notes, but rather a well-documented fact, based on decades of research
by highly credible public health and medical experts. ICE should do more to
respect this risk and take steps to mitigate it through the possibility of quicker
detection and treatment for detainees carrying the disease.
Because cysticercosis remains rare, clinicians in various parts of the country
may have limited experience with diagnosis, as was evident in the Minnesota
case. No information in Ramsey County’s treatment protocols, ICE’s medical
standard, or the DIHS covered services package could help a facility diagnose
or proactively treat the disease, even though it is a disproportionate risk to the
bulk of ICE’s detainees. ICE can help its detention partners by providing
more details about the disease as well as enhanced means for facilities to
detect infected detainees.
This recommendation is unresolved and open.
ICE’s Comments to Recommendation #4
ICE did not concur with our recommendation. ICE believes that its standards
are appropriate in this area. The agency stated that a medical examiner, a
hospital, or a physician, is responsible for implementing any state notification
requirement. In the New Mexico case, ICE noted that any rule of its own
would not have facilitated action by state or local entities to make notification
to the proper authority.
OIG Analysis
We reaffirm our recommendation. ICE acknowledged the importance of state
notification, but believes it is not its responsibility to do so. ICE can rely on
other entities to ensure state notification. However, ICE’s standard currently
does not mention reporting detainee deaths to states. Although other officials
or a hospital can help satisfy the requirement, the detainee is ICE’s
responsibility. It is possible that some hospitals or medical examiners may
not realize that ICE is a law enforcement agency. ICE is not prohibited from
proactively ensuring that detainee death notification occurs, especially since
the agency’s standards require staff to comply with state rules on infectious
disease reporting and other areas. ICE could take the step of articulating the
importance of death notification. This would also provide ICE an additional
opportunity to collaborate with states.
This recommendation is unresolved and open.
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ICE’s Comments to Recommendation #5
ICE concurred with our recommendation. The agency is pursuing a
Memorandum of Understanding with OFDT. ICE also provided details on its
work with OFDT, as well as efforts to improve the compliance at the Regional
Correctional Center. ICE stated that our recommendation was incorrectly
based on a perception that OFDT provided information that led to ICE’s
decision to remove detainees from the facility. ICE stressed that it relied on
its own standards, rather than input from OFDT, in the decision to remove all
immigration detainees from the RCC.
OIG Analysis
Our recommendation is not based on a belief that OFDT has better standards.
We reported that OPR findings led to the removal of ICE’s RCC detainees.
The purpose for this recommendation was that OFDT had indentified medical
access problems that ICE did not. Without knowing about these problems,
ICE admitted nearly 3,500 detainees to the RCC. Through greater interaction
with OFDT, the two agencies can facilitate improvements across federal
detention facilities. A formalized partnership, along with the improvements
that ICE is making, can facilitate higher levels of compliance at facilities.
When the final MOU is completed, ICE should forward the document to the
OIG. We could close this recommendation at that time.
This recommendation is resolved and open.

Oversight Can Be Improved at ICE Detention Facilities
ICE conducts annual monitoring visits to determine a facility’s compliance
with the detention standards. Staff conducting routine oversight of facilities
has not been effective in identifying certain serious problems at facilities.
Moreover, ICE’s reports, based mainly on checklists that divulge little about
the area reviewed, do not provide much information to facilities or outside
reviewers. In December 2006 we reported that ICE did not find medical
access problems and other non-compliance at detention facilities. Although
ICE is taking steps to improve facility oversight, the agency should revise
certain policies and standards to gain a more complete understanding of
facilities’ compliance status. By improving its oversight methodology, ICE
will improve both standards compliance and detainee safety.
An Overview of ICE’s Detention Facility Monitoring Efforts
Each facility housing ICE detainees is scheduled to receive an annual
monitoring visit. Site visit teams use various worksheets to report on a
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facility’s adherence to ICE’s standards. For contract detention facilities and
service processing centers, a team from ICE headquarters leads the site visits.
Field office staff is charged with monitoring of facilities that house detainees
under an intergovernmental service agreement. Reviews usually take three or
four days to complete.
Within 14 days of completing a facility review, the team submits a report to
ICE’s Detention Standards Compliance Unit. The unit examines the report for
completeness and the soundness of the team’s conclusions. This leads to a
rating of the facility’s performance against general areas of the standards, such
as food service, the detainee handbook, and detainee access to medical care.
If the review team determines that there is a deficiency in a particular area, the
facility is required to undertake corrective action. After review of the report
by headquarters staff, the facility also receives one of five overall ratings:

•	 Superior – The facility exceeds expectations based on exceptional
performance and excellent internal controls.
•	 Good – The facility performs all of its functions with few deficient
procedures.
•	 Acceptable – The facility’s detention functions are performed
adequately. ICE considers this level the baseline for its facility
rating system.
•	 Deficient – The facility is not performing one or more detention
functions, with inadequate internal controls.
•	 At Risk – The facility’s detention operations are impaired to the
point where mission performance is not being accomplished.
ICE is strengthening its oversight of detention facilities. A manager in ICE’s
Office of Professional Responsibility informed us that a new unit, the
Detention Facilities Inspections Group, will focus on standards compliance at
detention facilities. The group will also conduct independent reviews of
certain incidents at detention facilities. At the time of our fieldwork, only six
employees were assigned to the new group, with projections for 12 additional
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staff members. ICE officials asserted that the Detention Facilities Inspections
Group is a “high priority.” The group must have sufficient resources to
inspect detention facilities. Figure 3 highlights the placement of ICE’s
detention facility monitoring units in the agency’s organizational structure.
Figure 3: Excerpt of ICE Organizational Chart Showing Detention Facility

Monitoring Units

IC E A s s is ta n t
S e c r e ta r y
O ffic e o f
P r o fe s s io n a l
R e s p o n s ib ility
D e te n tio n
F a c ilitie s
In s p e c tio n
G ro u p

O p e r a tio n s
D e p u ty
A s s is ta n t
S e c r e ta r y
D e te n tio n a n d
R em oval
O p e r a tio n s
D e te n tio n
S ta n d a r d s
C o m p lia n c e
U n it
S ite V is it
Team s

OPR participated in an ICE site visit after a March 2006 detainee death in
Texas. According to the review, which took place less than a week after that
incident, serious issues compromised detainee safety. A subsequent report
concluded that the facility “has experienced a complete breakdown in
communication, leadership, and supervision,” prompting difficulties “on every
level.” ICE no longer uses the facility to house detainees.
ICE is also in the process of contracting with outside experts to relieve ICE
staff of the annual onsite facility monitoring function. This new process is
now in place. ICE management believes that this new approach will be
similar to how OFDT implements its monitoring visits. ICE’s contractor will
use existing ICE monitoring instruments and protocols.
Better Review of Medical Exam Timeliness is Needed
ICE’s medical care detention standards require facilities to conduct a health
appraisal and physical examination on each detainee within 14 days of the
detainee’s arrival at the facility. This exam is designed to gather details about
a detainee’s health beyond the screening questions asked during the intake
process. The physical examination offers an important opportunity to gauge
the health status of detainees. Timely delivery of the physical exam enhances
a facility’s identification and treatment of communicable or chronic illnesses.

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We examined data on the timeliness of the 14-day exam from the Regional
Correctional Center and the Ramsey County Law Enforcement Center.
Because it had a considerably larger number of detainee intakes, we only
requested three months of data from the RCC, April through June 2007.
Ramsey County provided timeliness data for all detainees entering the facility
for the first six months of 2007. Both facilities had difficulty meeting ICE’s
physical exam timeliness standard. Officials at various detention facilities
reported that staffing shortages, overworked clinicians, or an excessive facility
intake can cause delays in delivery of this service.
There were 1,118 new ICE detainees booked at the RCC during our threemonth sample. Of these, 997 stayed longer than 14 days. We determined that
830 of the 997, or 83%, received a timely physical exam and 167, or 17%, did
not. During its September 2006 monitoring visit, OFDT determined that the
RCC met the 14-day standard in 18 of 20 cases, a 90% rate.
For the Ramsey County facility, only 43 ICE detainees admitted in the first 6
months of 2007 were housed for more than 14 days. Of the 43 detainees, 10,
or 23%, had information regarding a physical exam in their medical file.
Those with a completed physical often received the exam beyond 14 days.
Table 1 lists the 10 detainees who had medical exam information documented
in their file. In 3 of the 10 cases, no physical exam had been provided. For
the seven cases with an exam date, an average of 40 days elapsed between the
detainees’ intake and the exam.
Table 1. Ten Cases from the Physical Exam Timeliness Sample, Ramsey

County Law Enforcement Center 

Intake date Exam date
Days Elapsed Days Detained
Detainee #1
3/26/2007
3/27/2007
1
23
Detainee #2
3/29/2007
5/14/2007
46
94
Detainee #3
4/16/2007
6/18/2007
63
76
Detainee #4
4/16/2007
6/18/2007
63
76
Detainee #5
5/4/2007
5/22/2007
18
58
Detainee #6
5/4/2007
7/16/2007
73
Unknown
Detainee #7
5/15/2007
No exam
NA
47
Detainee #8
6/4/2007
No exam
NA
27
Detainee #9
6/11/2007
6/28/2007
17
20
Detainee #10 6/12/2007
No exam
NA
16

The data provided by Ramsey County showed additional problems with
timely tuberculosis screening. One element in ICE’s monitoring protocol asks
if the facility has ever needed more than one business day to conduct this
screening test. For the 43 individuals in our sample, only 14 cases showed a
date for the initial skin test used to detect tuberculosis. Ten of these detainees
were not given a test within one business day. In one of these cases, the
facility did not test a detainee for more than two months.
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ICE monitoring reports contained limited evidence that staff conducting site
visits actually reviewed facility compliance with the 14-day exam standard.
We concluded that sampling is not done on a consistent basis. A manager in
ICE headquarters said that sampling is discussed during reviewer training, but
ICE’s monitoring protocols do not require sampling to test a facility’s
compliance. ICE should examine sample data during each of its monitoring
visits to test compliance with the 14-day exam and other standards.
Our December 2006 report on detainee treatment discussed problems with the
14-day exam standard at two facilities. The Berks County Prison was
compliant on only 38 of 42 sample cases, while an ICE facility in San Diego
met the standard in only eight of 19 cases. Two other facilities met the
standard in all 50 cases examined.10 Using sampling to gain a better
understanding of a facility’s compliance level would be a valuable measure of
how well detainees receive services designed to improve health outcomes.
Since compliance can fluctuate over time, ICE needs to ensure that facilities
continuously comply with detention standards. Although we are not
recommending regular reporting by facilities, such information could be
helpful to discern the ability of a particular location to house more detainees.
ICE should also take larger and more frequent samples of other medical
standards at those facilities that have exhibited problems. Developing
sampling guidance in other areas would benefit ICE’s monitoring program.
ICE Can Improve Detention Facility Monitoring Reports
Questions regarding the materiality of findings are undermining the quality
and usefulness of ICE’s monitoring reports. Current policy emphasizes that
the materiality of a finding is based on the reviewer’s analysis of available
evidence, extent of the problem, risk to the program’s efficient and effective
management, review objectives and any other factors. This is a credible
approach, but additional policy is needed to ensure ICE reviewers, who must
determine whether a facility’s performance warrants deficient ratings, target
areas of particular importance. Improvements in this area would also make a
facility’s final rating more objective.
In some monitoring reports, reviewers deemed the facility’s performance on
certain elements acceptable, despite identifying notable deficiencies. For
example, the November 2006 report for Ramsey County said the facility did
not abide by ICE’s standards on tuberculosis screening. Screening for
10

DHS OIG, Treatment of Immigration Detainees Housed at Immigration and Customs Enforcement
Facilities, OIG-07-01, December 2006, pp. 3-4.
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tuberculosis is central to the safety of facility staff and other detainees.
Compliance in this area should be a leading factor in a facility’s overall rating
in the access to medical care area. However, the facility received an
acceptable rating for that general standard.
In its September 2006 report, OFDT raised concerns about the ability of the
RCC’s medical unit to provide timely care with the number of clinicians on
staff. ICE’s November 2006 report, on the other hand, simply gave a “yes”
answer, with no other comment, for the standard requiring all detainees have
access to and receive medical care. Had ICE been aware of the health care
access problems at the RCC, it might have considered different locations for
some of the 3,465 detainees who entered the facility from January through
July 2007.
There were some questionable conclusions in ICE’s November 2006 RCC
monitoring report. For several elements, no examples of a particular event
were evident, yet ICE concluded that the RCC met the standard. For such
situations, it would be more accurate to conclude that a particular element was
not applicable. ICE reported that the facility met other requirements, even
though reviewer comments suggested otherwise. For example, the RCC did
not have certain emergency plans, but the report concluded that the RCC met
the requirement for such plans. Also, ICE reported that the RCC met the
standard requiring storage of medical records in a locked area, even though
the reviewers found one cabinet unlocked. Although corrective action was
immediate, the issue was serious enough to warrant a finding that the RCC did
not meet the standard.
ICE drew questionable conclusions in monitoring reports of other facilities.
One report listed several deficiencies regarding a facility’s medical treatment,
even though ICE granted an acceptable rating in this area, including:
•	
•	
•	
•	

Absence of intake tuberculosis screening;
Absence of privacy blinds in exam rooms;
Insufficient oversight to ensure medical records were always secured;
The need to update certain policies, including 24-hour access to
emergency services; and,
•	 Improvements needed to policies related to special needs individuals.
Another ICE monitoring report graded a facility’s security inspections
acceptable, while noting the need for improvement in a non-compliant visitor
pass system, the absence of documentation showing vehicles entering or
departing secured areas, and incomplete vehicle searches. With such
information, we have determined that the facility was deficient in this area.
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Further explanation of these problems in an expanded narrative section in the
report would have been beneficial.
In comparing overall ratings given to facilities, changes are also needed to
explain why particular facilities receive a given rating. Some field offices
perceive the final rating process used by ICE headquarters as arbitrary. The
Ramsey County Law Enforcement Center received a good rating in 2005, but
only acceptable in 2006. The later report did not explain why the compliance
status fell one level. In another example, in June 2006, one facility with
uncorrected problems with staff-detainee communication still received a good
rating. Another facility without any notable deficiencies only received a
rating of acceptable. After reviewing the reports, we could not determine the
justification for the second facility receiving a lower rating.
Enhancements to site visit reports would permit a better understanding of a
facility’s particular rating. In most of the reports we examined, the review
team did not make use of the Remarks section found after each general
standard. The narratives that appear in OFDT reports offer a more detailed
assessment of a facility’s compliance status. This is especially important in
instances where a facility could use more guidance.
An ICE Standard on Internal Review at Facilities Would be Beneficial
ICE currently does not have a requirement that facilities perform assessments
of their operations. Through review of its own operations, a facility could
more quickly discover problems, such as untimely access to health care.
Developing a standard in this area would help ensure that facilities achieve
and maintain compliance improvements.
Both ACA and OFDT have standards that address the need for facilities to
review their operations continually. ACA’s policy on Health Care Internal
Review and Quality Assurance establishes the collecting, trending, and
analyzing of data as a central feature of a successful review program. On-site
monitoring of health service outcomes on a regular basis is the central
component of ACA’s standard. According to OFDT’s policy, a facility’s
internal review process is separate from external or continuous inspections or
reviews conducted by other agencies. These standards for internal review
could guide ICE’s development of its own standard in this area.
Notable problems at one facility demonstrate the utility of self assessments.
In March 2006, the facility received a deficient rating based on noncompliance in 11 of the 38 detention standards. Later that year, two detainees
died at the facility. ICE’s reviews of these two incidents discussed serious
problems with access to medical care and the oversight of clinical operations.
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ICE reported that the facility did not perform basic supervision and provide
for the safety and welfare of ICE detainees. Had the facility reviewed its own
operations, it might have uncovered issues related to insufficient medical
staffing, problems with staff training, or other deficiencies. ICE discovered
these issues only after two detainees died. ICE’s March 2007 monitoring
review at the facility noted that five detainee deaths had occurred in the
previous calendar year.
Two recent monitoring reports of another facility highlight the importance of
ongoing detention facility oversight. In August 2006, ICE granted a superior
rating to one facility after a routine monitoring visit. After the November
death of a detainee, ICE identified a variety of problems related to this
facility’s medical care. The review team noted that the facility does not
routinely do physical examinations on detainees who are in the facility more
than 14 days. Additionally, ICE’s review team concluded that the facility has
failed on multiple levels to perform basic supervision and provide for the
safety and welfare of ICE detainees. Further, the line of communication in the
medical department at this facility was deemed to be poor, placing detainee
health care in jeopardy.
Maintaining a complete and current picture of its facilities’ clinical operations
should become a priority for ICE and its detention partners. Detecting
deficiencies before problems arise is vital to detainee protection and standards
compliance. As one correctional expert wrote, “Delayed or inadequate
treatment of persons with medical conditions often results in liability exposure
and publicity.”11 Investments in internal reviews can diminish such negative
effects through continual corrective action by the facility itself, outside of
ICE’s regular monitoring process.

Recommendations
We recommend that the Assistant Secretary for Immigration and Customs
Enforcement:
Recommendation #6: Revise monitoring protocols and the medical
detention standard to require sampling and continuous oversight of the 14-day
physical exam standard across ICE’s detention facilities.
Recommendation #7: Revise monitoring policies and other guidance given
to reviewers regarding the materiality of site visit report findings to ensure
that standards, such as tuberculosis screening and others related to access to
medical care, weigh more heavily on a facility’s compliance level.
11

Clinical Practice in Correctional Medicine, 2nd ed., 2006, p. 42.
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Recommendation #8: Require reviewers preparing monitoring reports to use
narratives to illuminate special areas of concern and provide additional details
about issues relevant to a facility’s compliance status.
Recommendation #9: Develop a standard that requires facilities housing ICE
detainees to implement an internal review function.

Management Comments and OIG Analysis
ICE’s Comments to Recommendation #6
ICE concurred with our recommendation. The agency will use three steps to
improve oversight of the 14-day physical exam standard.
•	 Regular sampling by on-site clinical staff and remote sampling for
facilities served by a regional contractor.
•	 Findings of OPR’s Detention Facility Inspection Group inspections
through its facility oversight role, and
•	 Detention and Removal Operations will provide OPR information on
this recommendation during Self Inspection Program reporting.
OIG Analysis
In its action plan, ICE should provide sufficient evidence of the policy
revisions and site visit reports, showing that the required sampling is taking
place to satisfy the intent of this recommendation.
This recommendation is resolved and open.
ICE’s Comments to Recommendation #7
ICE concurred with our recommendation, noting that findings with significant
consequences are weighed more heavily in a facility’s overall compliance
rating. ICE’s pending performance-based standards will improve the accuracy
and credibility of performance ratings. ICE also relies on immediate
correction of serious life and safety issues found during monitoring visits.
OIG Analysis
Our recommendation focused on the scoring of particular elements in a way
that inaccurately reported a facility’s actual status. Examples in our report
showed facilities with obvious medical access problems still scoring at an
acceptable level for that specific element. In its action plan, ICE should
provide more detailed policy guidance and examples of site visit reports to
demonstrate that both overall and specific elements are more accurately
graded during the monitoring process. Upon doing so, we will close this
recommendation.
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This recommendation is resolved and open.
ICE’s Comments to Recommendation #8
ICE concurred with our recommendation. As a result of improvements made
in late 2007, ICE is expanding the use of narratives in its site visit reports.
This new process, which uses contracted experts in facility oversight, will lead
to greater use of narratives to expound on areas of concern. Such additional
information can clarify findings and enhance a facility’s ability to comply
with necessary standards.
OIG Analysis
ICE has taken positive steps in this area, as it now uses the narrative field in
its monitoring reports. We will close this recommendation on receipt of a
copy of an inspection that demonstrates the use of the report’s narrative
feature.
This recommendation is resolved and open.

ICE’s Comments to Recommendation #9
ICE concurred with the premise of our recommendation, but did not concur
with the need to create a standard on facility self-assessments. ICE is
concerned that a self-assessment policy could diminish the consistent
implementation of its national standards. The agency noted that it uses quality
assurance experts at large facilities to help ensure local compliance in key
areas. ICE believes that the participation of third party experts is necessary
for local conditions to be monitored appropriately. In addition, ICE relies on
its own monitoring practices to examine the compliance of facilities housing
immigration detainees.
OIG Analysis
We reaffirm our recommendation that ICE develop a facility self-assessment
policy. The agency’s response states, “We concur that there needs to be a
sound internal review mechanism, but we disagree to the extent that the
review process should be conducted by facility personnel.” In the health care
compliance field, self-assessments are performed by a facility’s own staff.
ICE’s regular site visit monitoring process and internal review are different
concepts, to be performed by different individuals. What we are
recommending in no way replaces those reviews. The Health Care
Compliance Association notes that internal reviews “test compliance with
internal policies and procedures and with federal, state, and local laws
regulations and rules.” These programs are “often critical” in finding a
problem before “it creates significant risk to the organization.” A facility can
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use a self assessment to measure current compliance, ensure correction of
deficiencies, or confirm ongoing compliance. Clinical staff at a local facility
has the expertise to determine whether rules on the timeliness of physical
exams and screenings have been met. Many standards do not require
interpretation or the intervention of outside experts. Thus, ICE should not be
concerned that self assessments are contrary to national consistency. It is also
important to note that an internal review need not place exorbitant demands on
detention facilities. For example, after receiving data from Ramsey County
and Cornell, we quickly judged the facilities’ timeliness in providing physical
exams and tuberculosis screening, two areas central to a facility’s medical
care access.
ICE’s quality assurance experts are not used in most local facilities. ICE
should help facilities use their own processes to ensure basic standards are met
on an ongoing basis – outside of the routine monitoring processes. Onsite
experts or ICE site visits do not provide this level of ongoing assessment.
Since ICE endeavors to follow ACA standards, it should create a facility self
assessment standard to match the mandatory nature of ACA’s guidance in this
area, which has existed since 2004.
This recommendation is unresolved and open.

Additional Efficiencies in Medical Operations Can Enhance
Implementation of ICE’s Detention Standards
ICE can develop a more efficient and productive oversight process for its
detention facilities and enhance the standards that are appropriate and
generally equivalent to the standards of ACA and OFDT. Further steps, such
as the creation of electronic health records and increased staffing of clinical
operations, offer additional means for ICE to strengthen standards compliance
and improve detainee care.
ICE’s Standards Are Credible Compared to Other Organizations
Our analysis of several ICE detention standards, compared to the ACA and
OFDT standards, is provided in Appendix E. In some instances, ICE’s
standards are more detailed than those of ACA and OFDT. For example, a
recent article noted that ICE’s standard on hunger strikes provides important
details that are missing from similar ACA standards.12 We found that ICE’s
standard on HIV/AIDS offers more specific guidance to facilities, as well.
ICE requires that only a licensed physician will make a diagnosis of AIDS
12

“What They Can Do About It: Prison Administrators’ Authority to Force-Feed Hunger-Striking
Inmates,” 24 Washington University Journal of Law and Policy 151 (2007).
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based on a medical history, current clinical evaluation of signs and symptoms,
and laboratory studies. ICE also identifies procedures for treating the detainee
within and outside the facility’s clinic. Staff responsibilities and precautions
are also outlined. ACA’s standard specifies only that the detention facility
will have a written plan that addresses the management of HIV infection and
procedures for dealing with the detainee. Specific procedures for treatment
and staff responsibility are not developed. OFDT’s standard simply classifies
HIV as a chronic medical condition, requiring regular treatment.
Additionally, the ICE standard on detainee grievances has important details
that are not discussed by ACA or OFDT. The ICE standard specifies a formal
and informal procedure for resolving detainee grievances. In the formal
process, the detainee completes a form that discusses in writing the particular
issue of concern. An informal grievance is delivered orally, offering detainees
the opportunity to resolve their concerns before resorting to the longer formal
procedure. Detainees can communicate their informal grievances to ICE staff,
and all grievances can be appealed. OFDT’s process is similar to that of ICE,
although an informal process is not developed. Based on ICE data, no
grievances were filed by the 33 detainees who died between January 1, 2005
and May 31, 2007.
ICE, ACA, and OFDT understand the importance of identifying detainees
with special medical needs. However, the three entities have different
definitions of a special needs individual. According to ICE’s standard in this
area, the facility’s officer in charge will be notified when detainees are
diagnosed with special needs. OFDT echoes this point, but it gives more
specific examples of types of conditions that affect individuals with special
needs. Additionally, OFDT requires additional health care for detainees
diagnosed with special needs.
The ABA has encouraged ICE to make the agency’s detention standards
enforceable through regulation. The ABA contends that, even though
intergovernmental services agreements require compliance with standards, the
standards currently in place are only advice to facilities on ensuring detainee
welfare. There may be merit to creation of a regulatory mechanism to enforce
ICE’s standards. We are not persuaded by the department’s memorandum in
reply to the ABA, which discussed problems this course would create, such as
staffing issues and the cumbersome regulatory update process. However, ICE
is considering the feasibility of making the standards regulatory.
ICE has already taken some steps to enhance its standards. The agency is
moving toward the creation of performance-based standards similar to those
used by ACA and OFDT. These standards provide an opportunity to
articulate more clearly the specific actions that facilities are expected to take.
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Performance-based standards are goal-oriented and include outcomes
measures, which can provide facilities with guidance on the implementation.
This should bring about improvements in facilities’ adherence to specific
goals. Improvements to ICE’s facility monitoring process should be enhanced
when the updated standards are finalized.
Electronic Medical Records Would Create Efficiencies for ICE
We reviewed the utility of electronic health records (EHRs) for ICE’s
detention facilities. EHRs digitally store individual health information, either
in a transferable card or a centralized database. ICE and its facilities currently
rely on traditional paper-based medical records. However, ICE, including its
Division of Immigration Health Services (DIHS), has taken preliminary steps
toward electronic records, including development of systems requirements.
ICE has spent more than $2.2 million on the development of an electronic
records system, including software and training expenses. DIHS determined
this initial systems design was less than sufficient. ICE has noted its interest
in making improvements on its initial system.
Efficiencies created by EHRs would provide ICE many advantages in the
management of detainee care, especially when detainees are transferred to
other facilities. For example, EHRs can be easily transmitted. An
individual’s records would be immediately available to clinical staff at a new
detention facility. This would allow for a more rapid assessment of a
detainee’s current medical needs, reduce duplication of intake screenings or
physical exams, and improve detainee safety. By expediting the development
of EHRs, ICE and its detainees would receive long-term benefits.
The Veterans Health Information Systems and Technology Architecture
enabled the Department of Veterans Affairs (VA) to create EHRs for
individuals receiving care at VA hospitals and clinics. The VA’s EHRs
provide patient-specific information that permits time and context sensitive
clinical decision-making. The VA has achieved important safety
improvements through its use of electronic information. For example,
electronic prescriptions have reduced medication errors and helped to identify
incompatible medications. The VA has reported a medication error rate of
0.003%, well below the three to eight percent national average.13
ICE facilities managed by the Correctional Corporation of America use EHRs.
When an ICE detainee is transferred between facilities managed by the
company, clinical staff can access an electronic records system. One of the
company’s facility wardens said that less paperwork and more timely
13

“The Best Medical Care in the U.S.,” Business Week, July 17, 2006.
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information about detainees has improved operations at the company’s
detention facilities. An ICE review of a Houston detainee’s suicide provides
an example of how rapid access to health records can be vital. According to
the incident report:
A major area of concern was a lack of medical records . . .
Following the death, the detainee’s health records from his
previous institution revealed the detainee had been diagnosed
and treated for Schizophrenia and had at least one
documented suicide attempt . . . Such information would have
been valuable to the mental health provider and medical staff
at Houston.
Although the individual was transferred from a Bureau of Prisons facility to
Houston, rather than from another ICE facility, the report provides keen
insight into the utility of EHRs.
Additionally, EHRs would not be subject to disruption or destruction. This
was especially important to the VA during Hurricane Katrina, when clinicians
around the country had electronic access to records of the 40,000 veterans
who had received care or ordered prescriptions at VA facilities in Louisiana
and Mississippi. A 2007 study by the State of California also discussed how
EHRs could ensure the maintenance of medical records during natural
disasters or other catastrophic events.14
ICE and DIHS have recently taken steps to create a system of electronic
health records. An ICE official suggested that more detailed discussions are
needed to define systems requirements, and ICE needs to understand DIHS’s
perspective on the limitations of the electronic records system. The proposed
integration of DIHS into ICE should enhance progress toward development of
EHRs for ICE detainees. This integration is anticipated in early FY 2008.
ICE is a natural candidate for implementation of EHRs. By enhancing the
efficiency of clinical operations, ICE would provide better care for its
detainees. We recognize that complicated systems decisions are necessary
before an effective electronic records system can be fully implemented,
including concerns about the privacy of electronic records. Thus, ICE should
consult outside experts, such as the VA, as needed.

14

The State of California, Legislative Analyst’s Office, “A State Policy Approach: Promoting Health
Information Technology in California,” February 2007.
http://www.lao.ca.gov/2007/health_info_tech/health_info_tech_021307.aspx
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Some ICE Facilities Are Experiencing Clinical Staffing Problems
Two ICE facilities included in our review have staffing problems, raising
concerns about not only the slow pace of hiring, but the agency’s ability to
provide proper health care. DIHS personnel said that they need a better
understanding of ICE’s vision for detention services. They said that
understanding the vision would help determine where additional or new
personnel resources should be placed.
Nationally, contract detention facilities and service processing centers using
Public Health Service clinicians had a 36% vacancy rate in October 2007.
The contract detention facility in Pearsall, Texas, which housed more than
1,500 detainees the day we visited, had 22 medical staff vacancies. Given its
rural location and the nation’s high demand for nurses, staff in Pearsall said
that they will endure medical staff shortages indefinitely.
Staff from the San Diego Field Office also expressed concern about recruiting
and retaining clinical staff for its contract detention facility. In its December
2006 ICE site visit report, the facility earned an overall rating of deficient
after receiving a good rating in 2005. Health care access problems caused by
insufficient medical staff were a primary reason for the low level of
performance. According to the site visit report, nearly 260 detainees did not
receive a physical examination during a three-month period in 2006. Field
office staff suggested that DHS’ lengthy security clearance process is an
obstacle to filling vacant medical staff positions. To offset not having
sufficient medical staff, the current staff work extended hours in an attempt to
improve compliance with ICE’s medical standards. ICE did provide data
showing that recent progress has been made on the issue of clearance
processing, but the general concerns expressed by staff in Pearsall and
elsewhere warrant further scrutiny by ICE management.
Immigration attorneys we interviewed said that their primary concern is ICE’s
ability to deliver timely health services. In June 2007, the American Civil
Liberties Union filed a class action suit against ICE as a result of problems at
the San Diego Detention Center. Agencies can be exposed to legal liability if
medical standards are not properly implemented. As one expert wrote, “Most
cases in which courts have found constitutional violations of inmates’ rights to
health care were fostered by the exigencies of an overburdened staff coping
with too few resources.”15 Even in those areas where ICE has a credible
treatment standard, such as care for detainees with AIDS, other organizations
have determined that medical care can be inadequate. A human rights group
recently alleged several examples of problems with ICE’s treatment of
15

Clinical Practice in Correctional Medicine, 2nd ed., 2006, p. 524.
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detained individuals with AIDS. This group’s report detailed cases where
detainees were denied medications or where needed care was delayed.16 We
did not review any of these cases for this report.
We discussed various medical access issues with Public Health Service
clinicians, who provide care at some of ICE’s facilities, and officials from
DIHS headquarters. Some DIHS officials believe that greater involvement in
ICE’s detention management strategic planning would help with staffing
problems. This would give DIHS a better idea of where clinical staff would
be needed. Although our interviewees described the relationship between ICE
and DIHS as very positive, ICE should ensure that clinical staffing efforts are
aligned with ICE’s strategic planning for detention management.

Recommendations
We recommend that the Assistant Secretary for Immigration and Customs
Enforcement:
Recommendation #10: Expedite all necessary discussions and resources to
develop a system of electronic health records for ICE detainees.
Recommendation #11: Work with the Division of Immigration Health
Services to identify all clinical staff shortages, then work with ICE’s clinical
partners to develop and implement a strategy to fill clinical staff shortages at
immigration detention facilities.

Management Comments and OIG Analysis
ICE’s Comments to Recommendation #10
ICE concurred with our recommendation. The agency continues to work with
DIHS and other experts to create the electronic records system. The
department’s Investment Review Board must approve the system.
OIG Analysis
In its corrective action plan, ICE should provide details on the progress it is
making regarding acquiring the necessary technology and designing the
protocols for the EHRs. Once we receive evidence of ICE’s commitment to
establishing an EHR system, we will close this recommendation.
This recommendation is resolved and open.

16

Human Rights Watch, Chronic Indifference: HIV/AIDS Services for Immigrants Detained by the
United States, December 2007.
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ICE’s Comments to Recommendation #11
ICE concurred with our recommendation. Through interaction with DIHS,
ICE is creating a strategic plan to examine a variety of issues related to the
recruitment and retention of clinical staff. This plan will include
improvements to the processing time of background investigations,
considerations for the use of incentives such as signing bonuses, student loan
repayment, hiring additional health care recruiters, and collaborating with the
U.S. Public Health Service for hiring and placing health care professionals to
support ICE detention operations.
OIG Analysis
We look forward to receiving ICE’s staffing strategic plan. This plan should
help ICE correct the difficult staffing problems that confront many health care
providers across the country. In its action plan, ICE should set a timetable for
completing the strategic plan.
This recommendation is resolved and open.

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Appendix A
Purpose, Scope, and Methodology

ICE provided data showing that 33 immigration detainees died in custody
between January 1, 2005 and May 31, 2007. We examined incident reports
and other data about these cases, and interviewed field office personnel to
gain further insight into some detainee deaths. The two instances of detainee
death that were the focus of this report were referred to us through the OIG
Hotline.
We examined:
•	 Documentation regarding detainee death cases, including detainees’
detention and medical files;
•	 Detention standards used by ICE and other entities;
•	 Legal cases and international human rights agreements; and
•	 Facility monitoring reports and data held by detention facilities.
We conducted 53 interviews, including discussions with ICE headquarters and
field office staff. Conversations with field office staff covered detention
standards, detainee death incidents, and resource issues. We interviewed staff
from DHS’ Office for Civil Rights and Civil Liberties, public and private
sector clinical experts, immigration attorneys, and experts in correctional
facility oversight.
We toured seven facilities that house ICE detainees. These facilities were:
•	
•	
•	
•	
•	
•	
•	

Ramsey County Law Enforcement Center, St. Paul, Minnesota;
Sherburne County Jail, Elk River, Minnesota;
El Paso Service Processing Center, El Paso, Texas;
Regional Correctional Center, Albuquerque, New Mexico;
Central Texas Detention Facility, San Antonio, Texas;
South Texas Detention Complex, Pearsall, Texas; and
Laredo Processing Center, Laredo, Texas.

We conducted our review between May 2007 and August 2007 under the
authority of the Inspector General Act of 1978, as amended, and according to
the Quality Standards for Inspections issued by the President’s Council on
Integrity and Efficiency.

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix B
Management’s Comments to the Draft Report

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Appendix C
Recommendations
Recommendation #1: Work with the Office of Inspector General to create a
policy that would lead to the prompt reporting of all detainee deaths to the
Office of Inspector General.
Recommendation #2: Work with the Division of Immigration Health
Services, the Centers for Disease Control, and other experts, to enhance
existing medical standards, rules for special needs individuals, and coverage
guidance related to infectious disease.
Recommendation #3: Revise medical intake screening forms and physical
exam questionnaires at detention facilities to include questions regarding the
detainee’s family history of cysticercosis.
Recommendation #4: Revise the notification section of ICE’s detainee death
standard to ensure that the agency and its detention partners report a
detainee’s death in states that require notification in the event of a death in
custody. Documentation of this reporting should appear in a detainee’s file.
Recommendation #5: Seek to enter into a memorandum of understanding
with the Department of Justice, Office of Federal Detention Trustee that
establishes a process that enables OFDT and ICE to regularly share
information resulting from facility site visits.
Recommendation #6: Revise monitoring protocols and the medical
detention standard to require sampling and continuous oversight of the 14-day
physical exam standard across ICE’s detention facilities.
Recommendation #7: Revise monitoring policies and other guidance given
to reviewers regarding the materiality of site visit report findings to ensure
that standards, such as tuberculosis screening and others related to access to
medical care, weigh more heavily on a facility’s compliance level.
Recommendation #8: Require reviewers preparing monitoring reports to use
narratives to illuminate special areas of concern and provide additional details
about issues relevant to a facility’s compliance status.
Recommendation #9: Develop a standard that requires facilities housing ICE
detainees to implement an internal review function.
Recommendation #10: Expedite all necessary discussions and resources to
develop a system of electronic health records for ICE detainees.
Recommendation #11: Work with the Division of Immigration Health
Services to identify all clinical staff shortages, then work with ICE’s clinical
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Appendix C
Recommendations
partners to develop and implement a strategy to fill clinical staff shortages at
immigration detention facilities.

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Appendix D
Comparison of Various Detention Standards

We compared various standards from ICE’s Detention Operations Manual, ACA’s PerformanceBased Standards for Adult Local Detention Facilities, Fourth Edition, and OFDT’s Federal
Performance-Based Detention Standards Review Book.
This analysis focused on standards of particular interest to this review. The following table outlines
and compares standards across the three organizations. The table is divided into three primary areas:
standards related to physical exams and access to care, standards related to detainee mortality, and
certain standards related to medical issues and grievances.

Standards Related to Physical Exams and Access to Care
Standard Element
Health Appraisals
In addition to general
requirements
regarding intake
screening when the
detainee is admitted
to a facility,
requirements include
a more detailed
medical exam of the
detainee within 14
days.

Emergency Services

ICE
A health care provider will
conduct a health appraisal
and physical examination on
each detainee within 14 days
of arrival at facility. All
appraisals will be performed
according to National
Commission on Correctional
Health Care and the Joint
Commission on the
Accreditation of Health
Organization standards.
Standards for these exams
are not detailed.
In Service Processing
Centers and Contract
Detention Facilities, the InProcessing Health Screening
Form (I-794) is followed up
and the health care provider
will provide treatment
accordingly.
In local jails, a written plan for
the delivery of 24-hour
emergency health care is
required. No standards are
specified. Service
Processing Centers and
Contract Detention Facilities
will prepare plan in
consultation with the facility’s
routine medical provider. The
plan will include an on-call
provider, contact information
for local ambulances and
hospitals; and procedures for

ACA
A health care provider
will conduct a health
appraisal on each
detainee within 14 days
of arrival at facility. In
addition to following up
on the intake screening,
criteria regarding the
appraisal are discussed.

OFDT
The facility director
ensures that medical,
dental, and licensed
health care professionals
complete mental health
assessments within 14
days of arrival. Criteria
are outlined by each
assessment for the
appraisals to be
conducted.

A plan to provide 24-hour
emergency medical,
dental, and mental health
services is required.
Emergency evacuation
procedure is also
required. Criteria are
identified that includes
use of an emergency
medical vehicle,
hospitals, on-call
physicians, dentists, and
mental health
professionals.

Ensures that written
policies and procedures
exist for emergency
health care, including
emergency evacuation
and transportation. A
plan to provide 24-hour
emergency response is
not identified. Criteria are
not identified for written
policies and procedures
that are to be in place.
However, staff will
practice medical

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Appendix D
Comparison of Various Detention Standards

Requests for Medical
Care

facility staff to use providers
consistent with security and
safety. Additionally, first aid
and medical emergency
standards and criteria are
identified.
Request slips will allow
detainees to request health
care services. Slips must be
received by medical facility in
a timely manner. If
necessary, detainees will be
provided with assistance in
filling out the request slip.
Clinical staff is to be available
on scheduled basis to
respond to requests.
In Service Processing
Centers and Contract
Detention Facilities, request
slips will be made freely
available for detainees to
request health care services
on a daily basis. Request
slips will be made available in
English, and the foreign
languages most widely
spoken among detainees. If
necessary, detainees will be
provided assistance in filling
out the request slip.

Additionally, back-up
facilities and providers
should be predetermined.

emergency plans; biannual trial runs are
documented.

All detainees are
informed about how to
access health care
services during the
admission/intake
process. This is
communicated orally and
in writing. Information is
translated into those
languages spoken by
significant numbers of
inmates. No member of
the correctional staff
should approve or
disapprove inmate
requests for health care
services.

Detainees have daily
opportunities to request
health care services.
Detainee requests are
documented and are
triaged by a healthcare
professional within 24
hours on weekdays.
Appropriate health care
professionals triage
requests in a timely
manner.

Standards Related to Detainee Mortality
Standard Element
Detainee Deaths

ICE
ICE’s detainee death
standards articulate a variety
of notification requirements
for the facility and ICE staff.
Although mortality reviews by
the facility are not specifically
required, the overall policy
includes commendable levels
of detail about how the facility
and ICE are to address
detainee death cases.

ACA
ACA’s policy focuses on
notification of proper
authorities. Also, the
mandatory internal
review policy requires
that all deaths in custody
are to be examined by
the facility.

Suicide Prevention
All three entities
recognize the

Staff training requirements
are similar to ACA and OFDT.
Staff is required to observe

Staff is required to be
trained on suicide risk
and intervention. Mental

OFDT
Like ICE and ACA, OFDT
stresses the importance
of notifying proper
authorities. Staff is to be
trained to respond to
serious illness or detainee
death. Examination of
required mortality reviews
are part of site visit
team’s assessment of
facility’s compliance.
Results of mortality
review are acted on
immediately.
Policy specifically
requires that the facility is
to have a sufficient

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Appendix D
Comparison of Various Detention Standards
importance of
training, observation,
and notification of
authorities.

“imminently suicidal”
detainees no less than every
15 minutes.

health appraisals are to
include assessment of
suicide risk. Continuous
observation required for
suicidal inmates until
intervention by clinicians.

number of clinicians to
deal with suicidal cases.
Family members are to
be notified of an
attempted suicide.

Certain Standards Related to Medical Issues and Grievances
Standard Element
Dental Care,
Assessments

ICE
Initial dental screening due
within 14 days. If dentist not
available, a physician,
physician’s assistant, or
nurse practitioner can
perform the assessment.

Dental Care, Routine

Routine care may be
provided for individuals
detained for more than 6
months
Kits are to be placed
according to ACA policy.

First Aid Kits

Grievances

ICE’s process is outlined in
more detail than ACA and
OFDT standards. Facilities
are to use an informal
grievance process in an
attempt to resolve concerns
quickly, but detainees have a
right to file a formal written
grievance. Also,
requirements at Contract
Detention Facilities and
Service Processing Centers
are more detailed than for
county detention facilities.
One specific difference for
contract detention facilities
and service processing
centers is that only detainees
can file a grievance.

ACA
Initial dental screening
due within 14 days. A
dentist or trained
personnel under the
supervision of a dentist
should perform the
screening.
Requires “defined scope
of services” for detainees
without reference to
length of stay.
Designated health
authority and facility
administrator collaborate
to determine locations for
kits. Health staff
determines contents of
kits. Defibrillator must be
available to facility staff.
ACA’s grievance
standard does not have
specificity. Facilities are
required to have
grievance procedures
that include one level of
appeal, but specific
requirements are not
outlined.

OFDT
Like ICE’s policy, OFDT
standard does not require
that a dentist perform the
assessment.

Routine care is to be
provided if the individual
is detained greater than
one year.
Not as specific as ACA.
Standard requires that
supplies for medical
emergencies are to be
readily available.

Grievance standard
includes many of the
elements found in ICE’s
standard, although an
informal process is not
specified. Standards in
other areas, such as
discrimination prevention,
require review of all
grievances alleging
discrimination based on
race, gender, religion,
and national origin.

ICE’s policy on staff-detainee
communication permits
detainees to make informal
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Appendix D
Comparison of Various Detention Standards

HIV/AIDS

Mental Health
In September 2006,
the Bureau of Justice
Statistics reported
that half of jail and
prison inmates have
mental health needs.

Special Needs
Individuals
Detainees who have
certain specific
medical issues are
considered to have
“special needs.” The
concept is mentioned
by all three entities,
but defined differently
by each.

grievances to ICE. Formal
grievances are to be resolved
by the facility.
A detailed standard for “the
accurate diagnosis and
medical management” of
HIV/AIDS. The standard
requires that detainees with
active tuberculosis should be
evaluated for HIV infection.
Facilities are also directed to
report cases per state and
federal rules.
According to DIHS coverage
policy, follow-up care is
covered. HIV testing is
covered if a clinician
documents the need.
Initial health screening is to
include mental health
assessment. Facility staff is
to be trained to recognize the
signs and symptoms of
mental illness as a means to
decrease suicide risk. The
standard establishes that
mental health care will
generally be provided in a
hospital or community setting,
rather than the detention
facility.
The Officer in Charge is to be
notified when individuals are
diagnosed with special
needs. Examples of
conditions requiring “special
attention” are pregnancy,
special diets, medical
isolation, and AIDS.

A mandatory standard
that is not as specific as
ICE’s HIV policy. The
written plan required
under the standard must
include procedures for
identification,
surveillance, treatment,
and other areas.

Policy on chronic
conditions requires that
individuals with AIDS are
to receive regular care by
physicians who provide
for individual treatment
plans.

Establishes that an
“appropriate mental
health authority”
approves mental health
services. Standards are
to ensure that facility staff
can identify mental health
needs, proper care is
provided (generally
through referrals for
outside care).

OFDT standards include
additional details on
specific mental health
policies. For example,
OFDT provides details on
the contents of mental
health appraisals and the
need to provide needed
medications for routine
and emergency
situations.

Clinical and facility
personnel are to ensure
“maximum cooperation”
on individuals who are
chronically ill, disabled,
geriatric, or seriously
mentally ill. Special
needs individuals are
granted a hearing and
additional due process
steps before transfer to
another facility.

OFDT has the most
specific policy in this
area, including steps to
providing health care for
the special needs
population. These
include targeted physical
exams, use of chronic
care clinics, necessary
subspecialty visits, and
preventive care.

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Appendix E
Major Contributors to this Report

William McCarron, Chief Inspector, Department of Homeland Security,
Office of Inspections
Darin Wipperman, Senior Inspector, Department of Homeland Security,
Office of Inspections
Jacob Farias, Inspector, Department of Homeland Security,
Office of Inspections

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Appendix F
Report Distribution
Department of Homeland Security
Secretary
Deputy Secretary
Chief of Staff
Deputy Chief of Staff
General Counsel
Executive Secretary
Director, GAO/OIG Liaison Office
Chief Security Officer
Assistant Secretary, U.S. Immigration and Customs Enforcement
U.S. Immigration and Customs Enforcement Audit Liaison
Assistant Secretary for Public Affairs
Assistant Secretary for Policy
Assistant Secretary for Legislative Affairs
Office of Management and Budget
Chief, Homeland Security Branch
DHS OIG Budget Examiner

Congress
Congressional Oversight and Appropriations Committees, as appropriate

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Additional Information and Copies
To obtain additional copies of this report, call the Office of Inspector General
(OIG) at (202) 254-4199, fax your request to (202) 254-4305, or visit the OIG web
site at www.dhs.gov/oig.

OIG Hotline
To report alleged fraud, waste, abuse or mismanagement, or any other kind of
criminal or noncriminal misconduct relative to department programs or
operations:
•
•
•
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Call our Hotline at 1-800-323-8603;
Fax the complaint directly to us at (202) 254-4292;
Email us at DHSOIGHOTLINE@dhs.gov; or
Write to us at:
DHS Office of Inspector General/MAIL STOP 2600, Attention:
Office of Investigations - Hotline, 245 Murray Drive, SW, Building 410,
Washington, DC 20528.

The OIG seeks to protect the identity of each writer and caller.