United States Government Accountability Office

GAO Testimony before the Subcommittee on 

Immigration, Citizenship, Refugees, 

Border Security and International Law, 

Committee on the Judiciary, House of 

Representatives

ALIEN DETENTION 

STANDARDS 

Observations on the 

Adherence to ICE’s Medical 

Standards in Detention 

Facilities 

Statement of Richard M. Stana 

Director, Homeland Security and Justice Issues 

For Release on Delivery

Expected at 2:00 p.m. EDT

Wednesday, June 4, 2008 

 

GAO-08-869T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

June 4, 2008

ALIEN DETENTION STANDARDS 

Observations on the Adherence to ICE’s Medical 

Standards in Detention Facilities

Highlights of GAO-08-869T, a testimony to 

the Subcommittee on Immigration,

Citizenship, Refugees, Border Security

and International Law, Committee on the 

Judiciary, House of Representatives 

In fiscal year 2007, Department of

Homeland Security’s (DHS) U.S.

Immigration and Customs

Enforcement (ICE) detained over 

311,000 aliens, with an average 

daily population of over 30,000 and 

an average length of stay of about

37 days in one of approximately

300 facilities. The care and 

treatment of aliens while in

detention is a significant challenge 

to ICE, as concerns continue to be

raised by members of Congress and 

advocacy groups about the

treatment of the growing number 

of aliens while in ICE’s custody.

This testimony focuses on (1) the

extent to which 23 facilities 

complied with medical care 

standards, (2) deficiencies found

during ICE’s annual compliance

inspection reviews, and (3) the

types of complaints filed by alien 

detainees about detention 

conditions. This testimony is based 

on GAO’s July 2007 report

evaluating, among other things, the 

extent to which 23 facilities 

complied with aspects of eight of 

ICE’s 38 National Detention 

Standards. This report did not 

address quality of care issues. 

What GAO Recommends

While this testimony contains no 

new recommendations, GAO made

recommendations to DHS to, 

among other things, establish 

improved internal control

procedures to help ensure that 

detainee complaints are properly 

documented and their disposition 

recorded. DHS agreed with GAO’s 

recommendations and is making

progress implementing them. 

At the time of its visits, GAO observed instances of noncompliance with ICE’s 

medical care standards at 3 of the 23 facilities visited. These instances related

to staff not administering a mandatory 14-day physical exam to approximately

260 detainees, not administering medical screenings immediately upon 

admission, and first aid kits not being available as required. However, these 

instances did not show a pervasive or persistent pattern of noncompliance 

across all 23 facilities. Officials at some facilities told GAO that meeting the 

specialized medical and mental health needs of detainees had been 

challenging, citing difficulties they had experienced in obtaining ICE approval 

for outside nonroutine medical and mental health care. On the other hand, 

GAO observed instances where detainees were receiving specialized care at 

the facilities visited. 

At the time of its study, GAO reviewed the most recently available ICE annual 

inspection reports for 20 of the 23 detention facilities that it visited; these 

reports showed that ICE reviewers had identified a total of 59 instances of 

noncompliance with National Detention Standards, 4 of which involved 

medical care. One facility had sick call request forms that were available only

in English whereas the population was largely Spanish speaking. Another did 

not maintain alien medical records on-site. One facility’s staff failed to obtain 

informed consent from the detainee when prescribing psychiatric medication. 

Finally, another facility did not have medical staff on-site to screen detainees

arriving after 5 p.m. and did not have a properly locked medical cabinet. 

GAO did not determine whether these instances of noncompliance were 

subsequently corrected as required. 

The types of grievances at the facilities GAO visited typically included the lack 

of timely response to requests for medical treatment, missing property, high

commissary prices, poor food quality and insufficient food quantity, high 

telephone costs, problems with telephones, and questions concerning 

detention case management issues. ICE’s detainee grievance standard states

that facilities shall establish and implement procedures for informal and 

formal resolution of detainee grievances. Four of the 23 facilities GAO visited 

did not comply with all aspects of ICE’s detainee grievance standards. For 

example, one facility did not properly log all grievances that GAO found in 

their facility files. Detainee complaints may also be filed with several

governmental and nongovernmental organizations. The primary way for 

detainees to file complaints is to contact the DHS Office of Inspector General 

(OIG). About 11 percent of detainee complaints to the OIG between 2005 and 

2006 involved medical treatment issues. However, we found that the OIG 

complaint hotline 1-800 number was blocked or otherwise restricted at 12 of 

the facilities we tested. OIG investigates the most serious complaints and 

refers the remainder to other DHS components. GAO could not determine the 

number of cases referred to ICE’s Detention Removal Office and concluded 

that ICE’s detainee complaint database was not sufficiently reliable. To view the full product, including the scope 

and methodology, click on GAO-08-869T. 

For more information, contact Richard M. 

Stana at (202) 512-8777 or stanar@gao.gov. 
Chairman Lofgren, Mr. King, and members of the Subcommittee: 

Thank you for inviting me here today to discuss our observations on the 

adherence to medical standards in alien detention facilities. According to

the Department of Homeland Security’s (DHS) U.S. Immigration and 

Customs Enforcement (ICE) officials, they maintain custody of one of the 

most highly transient and diverse populations of any correctional or 

detention system in the world. In fiscal year 2007, ICE detained over 

311,000 aliens, with an average daily population of over 30,000 and an 

average length of stay of about 37 days (50 percent stay 18 days or less). 

This diverse population includes individuals from different countries; with 

varying medical conditions and security risks (criminal and noncriminal); 

and includes males, females, and families of every age group. 

The care and treatment of aliens while in detention is a significant 

challenge to ICE, as concerns continue to be raised by members of 

Congress and advocacy groups about the treatment of the growing number 

of aliens while in ICE’s custody. ICE has 38 National Detention Standards 

to help ensure that alien detainees are housed under appropriate 

conditions of confinement. These standards relate to a range of detainee 

services, including medical services. ICE policy is to conduct annual 

compliance inspection reviews of all adult, juvenile, and family detention

facilities to check compliance with these standards. In doing so, ICE 

inspection staff are to review each detention facility’s compliance with 

about 300 factors that are related to these standards (e.g., whether under 

the medical care standard the facility established a policy and procedures 

for responding to a detainee hunger strike). In addition to being required 

to comply with ICE’s National Detention Standards, some ICE detention 

facilities are accredited by The Joint Commission, the predominant 

standards-setting and accrediting body in health care, and the National 

Commission on Correctional Health Care (NCCHC), which offers a health

services accreditation program to determine whether correctional 

institutions meet its standards in their provision of health services. 

From May 2006 through May 2007 we conducted a review to determine the 

extent to which selected facilities complied with aspects of 8 of the 38 

standards, whether similar deficiencies were disclosed by ICE’s annual 

compliance inspection review process, and the nature and disposition of 

complaints filed by aliens in detention facilities. We selected these eight 

National Detention Standards to review on the basis of interviews with 

officials from the United Nations High Commissioner for Refugees 

(UNHCR), the American Bar Association, and DHS Office of the Inspector

General (OIG). These eight standards we reviewed were telephone access, 

Page 1 GAO-08-869T 
medical care, hold room procedures, use of force, food services, 

recreation, access to legal materials, and detainee grievance procedures. 

During the course of our review we visited 23 detention facilities under 

ICE oversight—18 of 330 adult, 2 of 19 juvenile, and all 3 family detention 

facilities. Because we did not randomly select our detention facilities, the 

results of our field observations from these facilities cannot be generalized 

to the full universe of detention facilities nationwide. However, these 

observations provided us with an overview of compliance with detention 

standards at different sizes and types of facilities in various locations 

across the country. We reviewed policies, procedures, documents, and 

inspection and grievance reports pertaining to detainee conditions of 

confinement, and interviewed facility and ICE staff responsible for 

compliance with the eight standards that we reviewed. In addition, we 

interviewed some individual detainees concerning their treatment at 

detention facilities, particularly with respect to the eight standards, but did 

not independently assess the merits of detainee complaints. 

My statement today is based on our results regarding medical care 

standards that we reported in July 20071

 and addresses the extent to which 

the 23 facilities complied with ICE’s medical care standards, deficiencies 

found during ICE’s annual compliance inspections of these facilities, and 

the types of complaints filed by alien detainees about detention 

conditions. With respect to ICE medical care standards, we ascertained 

whether (1) a range of medical and mental health services specified in 

ICE’s standards were available, (2) detainees received initial medical 

screening upon admission and a more complete physical exam within 14 

days of admission,2

 (3) detainees had the opportunity to request medical 

services, (4) specialized medical and mental health services could be 

arranged, (5) procedures and facilities for suicide prevention were 

available, and (6) a plan for 24-hour emergency care was available. We did

not systematically review individual detainee medical cases or ICE 

decisions on the type or extent of nonroutine treatment that is medically 

necessary, nor did we otherwise investigate quality of care.

 1

GAO, Alien Detention Standards: Telephone Access Problems Were Pervasive at

Detention Facilities; Other Deficiencies Did Not Show a Pattern of Noncompliance, 

GAO-07-875 (Washington, D.C.: July 6, 2007). 

2

 ICE standards state that detainees are to receive an initial medical screening immediately 

upon admission and a more complete medical assessment within 14 days. The policy also 

states that a health care specialist shall determine needed medical treatment. 

Page 2 GAO-08-869T 
At the time of our visits, we observed instances of noncompliance with 

ICE’s medical care standards at 3 of the 23 facilities we visited. However, 

these instances did not show a pervasive or persistent pattern of 

noncompliance across the facilities like we those identified with the 

telephone system.3

 Detention facilities that we visited ranged from those 

with small clinics with contract staff to facilities with on-site medical staff, 

diagnostic equipment such as X-ray machines, and dental equipment. 

Medical service providers include general medical, dental, and mental 

health care providers that are licensed by state and local authorities. Some 

medical services are provided by the U.S. Public Health Service (PHS), 

while other medical service providers may work on a contractual basis. 

Some Instances of 

Noncompliance with 

Medical Care 

Standards Occurred 

At the San Diego Correctional Facility in California, an adult detention 

facility, ICE reviewers that we accompanied cited PHS staff for failing to 

administer the mandatory 14-day physical exam to approximately 260 

detainees. PHS staff said the problem at San Diego was due to inadequate 

training on the medical records system and technical errors in the records 

system. At the Casa de San Juan Family Shelter in California, we found 

that the facility staff did not administer medical screenings immediately 

upon admission, as required in ICE medical care standards. At the Cowlitz 

County Juvenile Detention Center in Washington state, we found that no 

medical screening was performed at admission and first aid kits were not 

available, as required. 

Officials at some facilities told us that meeting the specialized medical and 

mental health needs of detainees can be challenging. Some also cited 

difficulties they had experienced in obtaining ICE approval for outside 

nonroutine medical and mental health care as also presenting problems in 

caring for detainees. On the other hand, we observed instances where 

detainees were receiving specialized medical care at the facilities we 

visited. For example, at the Krome facility in Florida we observed one 

detainee sleeping with the assistance of special breathing equipment (C-

 3

The most persistent and pervasive problem we found was with the detention facility 

telephone systems. Many facilities used an ICE contractor-provided telephone system, 

known as the “pro bono telephone system,” to satisfy the standard that requires the 

facilities to provide a means for detainees to make calls to certain entities at no charge to 

themselves or the recipient. At 16 of the 17 facilities we visited that used this system, we 

had significant problems making connections to consulates, pro bono legal providers, and 

the DHS OIG complaint hotline. 

Page 3 GAO-08-869T 
PAP machine) to address what we were told was a sleep apnea condition.

At the Hampton Roads Regional jail in Virginia we observed a detainee

receiving treatment from a kidney dialysis machine. Again, assessing the 

quality of care and ICE’s decision—making process for approval of 

nonroutine medical procedures were outside the scope of our review. 

We reviewed the most recently available ICE annual inspection reports for 

20 of the 23 detention facilities that we visited. With the exception of the 

San Diego facility in California, the reports covered a different time period 

than that of our review.4

 The 20 inspection reports showed that ICE 

reviewers had identified a total of 59 instances of noncompliance, 4 of 

which involved medical care. According to ICE policy, all adult, juvenile, 

and family detention facilities are required to be inspected at 12-month 

intervals to determine that they are in compliance with detention 

standards and to take corrective actions if necessary. As of November 30,

2006, according to ICE data, ICE had reviewed approximately 90 percent 

of detention facilities within the prescribed 12-month interval. Subsequent 

to each annual inspection, a compliance rating report is to be prepared 

and sent to the Director of the Office of Detention and Removal or his 

representative within 14 days. The Director of the Office of Detention and 

Removal has 21 days to transmit the report to the field office directors and 

affected suboffices. Facilities receive one of five final ratings in their 

compliance report—superior, good, acceptable, deficient, or at risk.5 ICE 

officials reported that as of June 1, 2007, 16 facilities were rated 

“superior,” 60 facilities were rated “good,” 190 facilities were rated 

“acceptable,” 4 facilities were rated “deficient,” and no facilities were rated 

“at risk.” ICE officials stated that this information reflects completed 

ICE Compliance 

Inspections Also 

Show Some Instances 

of Noncompliance 

With Medical 

Standards 

 4

 Our review was done from May 2006 to May 2007, whereas the ICE inspection reports

were done at various times during 2004, 2005 and 2006. 

5

According to Detention Management Control Program policies and procedures, a superior

rating means that the facility is performing all of its functions in an exceptional manner,

has excellent internal controls, and exceeds expectations. A good rating means that a

facility is performing all of its functions, and there are few deficient procedures, but 

internal controls are not limited by these deficiencies. An acceptable rating means that 

detention functions are being adequately performed. Although deficiencies may exist, they

do not detract from the acceptable accomplishment of the vital functions. Deficient ratings 

mean that one or more detention functions are not being performed at an acceptable level. 

Internal controls are weak, thus allowing for serious deficiencies in one or more program 

areas. At-risk ratings mean the detention operations are impaired to the point that they are

not presently accomplishing their overall mission. That is, internal controls are not 

sufficient to reasonably ensure acceptable performance can be expected in the future. 

Page 4 GAO-08-869T 
reviews, and some reviews are currently in process and pending 

completion. Therefore, ICE could not provide information on the most 

current ratings for some facilities. 

Four inspection reports disclosed instances of noncompliance with 

medical care standards. The Wakulla County Sheriffs Office in Florida had 

sick call request forms that were available only in English whereas the 

population was largely Spanish speaking. The Cowlitz County Juvenile 

Detention Facility in Washington state did not maintain the alien juvenile 

medical records on-site. The San Diego Correctional facility staff, in 

addition to the deficiencies noted earlier in this statement, failed to obtain

informed consent from the detainee when prescribing psychiatric 

medication. Finally, the Broward Transitional Center in Florida did not 

have medical staff on-site to screen detainees arriving after 5 p.m. and did 

not have a properly locked medical cabinet. We did not determine whether 

these deficiencies were subsequently addressed as required. 

Our review of available grievance data obtained from facilities and 

discussions with facility management showed that the types of grievances 

at the facilities we visited typically included the lack of timely response to 

requests for medical treatment, missing property, high commissary prices, 

poor quality or insufficient quantity of food, high telephone costs, 

problems with telephones, and questions concerning detention case 

management issues. ICE’s detainee grievance standard states that facilities 

shall establish and implement procedures for informal and formal 

resolution of detainee grievances. Four of the 23 facilities we visited did 

not comply with all aspects of ICE’s detainee grievance standards. 

Specifically, Casa de San Juan Family Shelter in San Diego did not provide 

a handbook to those aliens in its facility, the Cowlitz County Juvenile 

Detention Center in Washington state did not include grievance 

procedures in its handbook, Wakulla County Sheriff’s Office in Florida did 

not have a log, and the Elizabeth Detention Center in New Jersey did not 

record all grievances that we observed in their facility files. 

Alien Detainee 

Complaints Included 

Concerns About 

Medical Care 

The primary mechanism for detainees to file external complaints is 

directly with the OIG, either in writing or by phone using the DHS OIG 

complaint hotline. Detainees may also file complaints with the DHS Office 

for Civil Rights and Civil Liberties (CRCL), which has statutory 

responsibility for investigating complaints alleging violations of civil rights

and civil liberties. In addition, detainees may file complaints through the 

Joint Intake Center (JIC), which is operated continuously by both ICE and 

U.S. Customs and Border Protection (CBP) personnel, and is responsible 

Page 5 GAO-08-869T 
for receiving, classifying, and routing all misconduct allegations involving 

ICE and CBP employees, including those pertaining to detainee treatment. 

ICE officials told us that if the JIC were to receive an allegation from a 

detainee, it would be referred to the OIG. OIG may investigate the 

complaint or refer it to CRCL or DHS components such as the ICE Office 

of Professional Responsibility (OPR) for review and possible action. In 

turn, CRCL or OPR may retain the complaint or refer it to other DHS 

offices, including ICE Office of Detention and Removal (DRO), for 

possible action. Further, detainees may also file complaints with 

nongovernmental organizations such as ABA and UNHCR. These external 

organizations said they generally forward detainee complaints to DHS 

components for review and possible action. 

The following discussion highlights the detainee complaints related to 

medical care issues where such information is available. We did not 

independently assess the merits of detainee complaints. 

• Of the approximately 1,700 detainee complaints in the OIG database 

that were filed in fiscal years 2003 through 2006, OIG investigated 173 

and referred the others to other DHS components. Our review of 

approximately 750 detainee complaints in the OIG database from fiscal 

years 2005 through 2006 showed that about 11 percent involved issues 

relating to medical treatment, such as a detainees alleging that they 

were denied access to specialized medical care.6

• OPR stated that in fiscal years 2003 through 2006, they had received

409 allegations concerning the treatment of detainees. Seven of these 

allegations were found to be substantiated,7

 26 unfounded,8 and 65 

 6

In connection with the persistent and pervasive telephone problems we found, the OIG

complaint hotline telephone number was blocked or otherwise restricted at 12 of the 23 

facilities that we visited. Therefore, while some detainees at these facilities may have filed 

written complaints with the OIG, the number of reported allegations may not reflect the

universe of detainee complaints. 

7

OPR defines “substantiated allegation” as an allegation for which the evidence would

cause a reasonable person to conclude that the alleged act of misconduct is likely to have 

occurred. 

8

An allegation is unfounded in OPR’s definition when the evidence would cause a 

reasonable person to conclude that the subject employee did not commit the alleged 

misconduct, or that, in fact, no misconduct occurred.

Page 6 GAO-08-869T 
unsubstantiated.9

 Four of the seven substantiated cases involved 

employee misconduct, resulting in four terminations. According to OPR 

officials, three cases were still being adjudicated and the nature of the 

allegations was not provided. Additionally, 200 of the allegations were 

classified by OPR as either information only to facility management, 

requiring no further action, or were referred to facility management for 

action, requiring a response. 

• CRCL also receives complaints referred from the OIG, 

nongovernmental organizations, and members of the public. Officials 

stated that from the period March 2003 to August 2006 they received 46 

complaints related to the treatment of detainees, although the nature of 

the complaints was not identified. Of these 46 complaints, 14 were 

closed, 11 were referred to ICE OPR, 12 were retained for investigation, 

and 9 were pending decision about disposition. 

• We could not determine the number of cases referred to DRO or their 

disposition. On the basis of a limited review of DRO’s complaints 

database and discussions with ICE officials knowledgeable about the 

database, we concluded that DRO’s complaint database was not 

sufficiently reliable for audit purposes. We recommended that ICE 

develop a formal tracking system to ensure that all detainee complaints 

referred to DRO are reviewed and the disposition, including any 

corrective action, is recorded for later examination. 

• We reviewed 37 detention monitoring reports compiled by UNHCR 

from the period 1993 to 2006. These reports were based on UNHCR’s 

site visits and its discussions with ICE officials, facility staff, and 

detainee interviews, especially with asylum seekers. Eighteen of the 37

UNHCR reports cited concerns related to medical care, such as 

detainee allegations that jail staff were unresponsive to requests for 

medical assistance and UNHCR’s concern about the shortage of mental 

health staff. 

• While American Bar Association officials informed us that they do not 

keep statistics regarding complaints, they compiled a list for us of 

common detainee complaints received through correspondence. This 

list indicated that of the 1,032 complaints it received from January 2003 

to February 2007, 39 involved medical access issues such as a detainee 

 9

An allegation is unsubstantiated in OPR’s definition when the evidence is not sufficient for 

a reasonable person to determine whether the subject employee committed the alleged 

misconduct. 

Page 7 GAO-08-869T 
alleging denial of necessary medication and regular visits with a 

psychiatrist, allegations of delays in processing sick call requests, and 

allegations of a facility not providing prescribed medications. 

Madam Chairman, this concludes my prepared remarks. I would be happy 

to answer any questions you or the members of the subcommittee have.

For further information on this testimony, please contact Richard M. Stana 

at (202) 512-8777 or by e-mail at stanar@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the 

last page of this statement. 

In addition to the contact named above, William Crocker III, Assistant 

Director; Minty Abraham; Frances Cook; Robert Lowthian; and Vickie 

Miller made key contributions to this statement. 

Page 8 GAO-08-869T 

Contacts and 

Acknowledgments 

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