ICE Needs to Address 

Concerns about Detainee 

Care and Treatment at 

the Howard County 

Detention Center 

October 28, 2020 

OIG-21-03 
 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Washington, DC 20528 / www.oig.dhs.gov

October 28, 2020 

MEMORANDUM FOR: The Honorable Tony H. Pham 

Acting Director 

U.S. Immigration and Customs Enforcement 

FROM: Joseph V. Cuffari, Ph.D. Digitally signed by JOSEPH V JOSEPH V CUFFARI Inspector General Date: 2020.10.27 CUFFARI 15:09:56 -04'00' 

SUBJECT: ICE Needs to Address Concerns about Detainee Care 

and Treatment at the Howard County Detention Center 

Attached for your information is our final report, ICE Needs to Address 

Concerns About Detainee Care and Treatment at the Howard County Detention 

Center. We incorporated the formal comments from U.S. Immigration and 

Customs Enforcement in the final report. 

Consistent with our responsibility under the Inspector General Act, we will 

provide copies of our report to congressional committees with oversight and 

appropriation responsibility over the Department of Homeland Security. We 

will post the report on our website for public dissemination. 

Please call me with any questions, or your staff may contact Tom Kait, 

Assistant Inspector for Special Reviews and Evaluations, at (202) 981-6000. 

Attachment 
 

 

 

 

 

DHS OIG HIGHLIGHTS 

ICE Needs to Address Concerns 

about Detainee Care and Treatment at the 

Howard County Detention Center 

October 28, 2020 

Why We 

Did This 

Inspection 

As directed by Congress, we 

conduct annual 

unannounced inspections of 

U.S. Immigration and 

Customs Enforcement (ICE) 

detention facilities to ensure 

compliance with detention 

standards. In December 

2019, we inspected Howard 

County Detention Center 

(HCDC) in Jessup, 

Maryland, to evaluate 

compliance with ICE 

detention standards. 

What We 

Recommend 

We made two 

recommendations to improve 

ICE’s oversight of detention 

facility management and 

operations at HCDC. 

For Further Information: 

Contact our Office of Public Affairs at (202) 

981-6000, or email us at 

DHS-OIG.OfficePublicAffairs@oig.dhs.gov 

What We Found 

During our December 2019 unannounced inspection of 

HCDC, we identified violations of ICE detention standards 

that threatened the health, safety, and rights of 

detainees. Although HCDC generally complied with ICE 

detention standards regarding communication, it did not 

meet the standards for detainee searches, food service, 

and record requirements for segregation and medical 

grievances. We determined HCDC excessively strip 

searched ICE detainees leaving their housing unit to 

attend activities within the facility, in violation of ICE 

detention standards and the facility’s own search policy. 

In addition, HCDC failed to provide detainees with two 

hot meals per day, as required. For those in segregation, 

HCDC did not consistently document that detainees 

received three meals a day and daily medical visits. 

Further, HCDC did not properly document the handling 

of detainee medical grievances. 

ICE Response 

ICE concurred with the two recommendations outlined in 

the report and has identified a corrective action plan to 

address the deficiencies we identified. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Table of Contents 

Introduction.................................................................................................... 2 

Background .................................................................................................... 2 

Results of Inspection....................................................................................... 4 

HCDC Generally Complied with Standards on Communication .............. 4 

HCDC’s Strip Searches of Low Custody Detainees Violated ICE Detention 

Standards and Facility Policy ................................................................. 5 

Lengthy Kitchen Renovations Hampered HCDC’s Ability to Meet Food 

Service Standards.................................................................................. 8 

Incomplete Detainee Records Raise Concerns about Detainee Care ...... 11 

Conclusion....................................................................................................13 

Recommendations......................................................................................... 14 

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

Appendixes 

Appendix A: Objective, Scope, and Methodology ................................. 16 

Appendix B: ICE Comments to the Draft Report ................................... 18 

Appendix C: Office of Special Reviews and Evaluations Major 

Contributors to This Report ................................................................. 21 

Appendix D: Report Distribution......................................................... 22 

Abbreviations 

DRCF Dorsey Run Correctional Facility 

DSM Detention Service Manager 

ERO Enforcement Removal Operations 

HCDC Howard County Detention Center 

HSA Health Services Administrator 

ICE U.S. Immigration and Customs Enforcement 

OIG Office of Inspector General 

PBNDS Performance-Based National Detention Standards 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Introduction 

U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 

200 facilities nationwide, but the conditions and practices at those facilities 

can vary greatly. Although treatment and care of detainees at facilities can be 

challenging, complying with ICE detention standards and establishing an 

environment that protects the health, safety, and rights of detainees are vital to 

detention. In recent years, such care and treatment have been the subject of 

increased congressional and public attention, and our program of 

unannounced inspections of ICE detention facilities has identified violations at 

facilities across the country. In December 2019, we launched our fiscal year 

2020 round of inspections with an unannounced visit to the Howard County 

Detention Center (HCDC) in Jessup, Maryland, and identified concerns 

regarding detainee care and treatment. 

Background 

ICE apprehends, detains, and removes aliens who are in the United States 

unlawfully. ICE Enforcement and Removal Operations (ERO) oversees the 

detention facilities that it manages in conjunction with private contractors or 

state or local governments. Owned and operated by the Howard County 

Department of Corrections, the HCDC has had an intergovernmental service 

agreement with ICE (or its predecessor, Immigration and Naturalization 

Services) to house detainees for the past 25 years. In addition to the maximum 

154 ICE detainees it can hold, HCDC houses county inmates and U.S. 

Marshals Service prisoners. HCDC houses only male detainees with criminal 

histories, classified by ICE as low or high custody.1 ICE pays HCDC $110 per 

day for each detainee held. 

ICE’s intergovernmental service agreement with HCDC requires the facility to 

comply with the 2011 Performance-Based National Detention Standards 

(PBNDS), as revised in December 2016. According to ICE, the 2011 PBNDS 

establish consistent conditions of confinement, program operations, and 

management expectations within ICE’s detention system. These standards set 

requirements for areas such as: 

 1 Low custody detainees have minor criminal histories with non-violent felony charges and 

convictions. High custody detainees have significant criminal histories, gang affiliation, or a 

history of violence and are always to be escorted around the facility by staff. Regardless of 

criminal history, ICE detainees are held in civil, not criminal, custody, which is not supposed 

to be punitive according to the 2011 PBNDS. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

x environmental health and safety — e.g., cleanliness, sanitation, security, 

detainee searches, segregation2 (Special Management Units), and 

disciplinary systems; 

x detainee care — e.g., food service, medical care, and personal hygiene; 

x activities — e.g., visitation and recreation; and 

x grievance systems. 

ICE’s 2011 PBNDS includes a range of facility compliance ratings from minimal 

to optimal. For facilities with deficient conditions that do not meet standards, 

facilities may request and ICE may issue waivers exempting them from 

complying with certain detention standards. From 2013 to 2016, ICE granted 

HCDC five waivers for compliance with 2011 PBNDS for mail and 

correspondence, visitation, strip searches, key and lock control, and razor 

usage. Further, in November 2018, ICE contractor for inspection services, the 

Nakamoto Group Inc. (Nakamoto), determined HCDC was deficient in the 

standards related to custody classification system, detainee handbook, 

environmental health and safety, special management units, and food service. 

As a result, ICE required HCDC to fix these deficiencies in a corrective action 

plan. HCDC reported it had finished addressing the deficiencies in February 

2019. 

On December 17, 2019, we made an unannounced visit to HCDC to determine 

whether HCDC complied with ICE’s 2011 PBNDS. At the time of our visit, 

HCDC housed 61 ICE detainees in different housing units within the facility. 

Low custody detainees were held in the facility’s east wing open dormitory with 

county inmates, and high custody detainees were held in cells within two units 

on the west wing. There were no inmates in the high custody detainee units. 

During our visit, we inspected HCDC facilities including detainee housing 

units, food service areas, the medical unit, and recreation and religious areas. 

We also interviewed ICE personnel, HCDC officials, and 10 detainees. 

 2 ICE, Performance-Based National Detention Standards, 2011, Section 2.12, Special 

Management Units (Revised Dec. 2016).Segregation is the process of separating certain 

detainees from the general population for administrative or disciplinary reasons. Detainees in 

segregation at Howard County are placed in individual cells. Detainees in disciplinary 

segregation can be held for no more than 30 days per incident, except in extraordinary 

circumstances. Detainees in disciplinary segregation are allowed out of their cells for 1 hour of 

recreation time at least 5 days a week. Detainees in administrative segregation are separated 

from the general population to ensure the safety of all detainees and can be held in segregation 

until their safety, and the safety of others, is no longer a concern. Detainees in administrative 

segregation are allowed out of their cells for up to 2 hours of recreation time at least 7 days a 

week. Detainees in both disciplinary and administrative segregation are also allowed time out 

of their cells for showers, phone calls, law library, visitation, and religious services.

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Results of Inspection 

Our December 2019 unannounced inspection of HCDC identified violations of 

ICE detention standards that threatened the health, safety, and rights of 

detainees. Although HCDC generally complied with 2011 PBNDS 

communication standards, it did not meet the standards for detainee searches, 

food service, and record requirements for segregation and medical grievances. 

We determined HCDC violated detention standards by excessively stripsearching low custody detainees leaving their housing unit to attend activities 

within the facility. Although HCDC received a waiver from ICE related to strip 

searches, HCDC’s current practice of strip-searching low custody detainees 

without documented reasonable suspicion exceeds the parameters of the 

waiver and contradicts facility policy. In addition, HCDC failed to provide 

detainees with two hot meals per day, as required. For those in segregation, 

HCDC did not document that detainees received three meals a day or daily 

medical visits, as required. Further, HCDC did not properly document the 

handling of detainee medical grievances. 

HCDC Generally Complied with Communication Standards 

After reviewing HCDC’s policies and guidance, we determined HCDC generally 

complied with the 2011 PBNDS for detainee communication.3 Nine of the 10 

ICE detainees we interviewed said they were able to communicate regularly 

with both ICE and HCDC personnel in person and electronically through HCDC 

communication kiosks, which are electronic devices provided in housing units 

for detainees to send messages to ICE and facility staff. HCDC’s Detainee 

Handbook4 instructs detainees on how to communicate with staff informally or 

formally by submitting written questions, requests, or concerns to facility or 

ICE personnel using the kiosks or detainee request forms. The Handbook also 

provides the address and phone number to the local ICE ERO Field Office and 

states ICE staff are scheduled to be at the facility once a week. 

 3 ICE, Performance-Based National Detention Standards, 2011, Section 2.13.V.A, Staff-Detainee 

Communication (Revised Dec. 2016). “ICE/ERO detainees shall not be restricted from having 

frequent informal access to and interaction with key facility staff members.... The local 

supplement to the detainee handbook shall include contact information for the ICE/ERO Field 

Office....” 

4 HCDC, ICE Detainee Handbook, October 21, 2019. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

HCDC’s Strip Searches of Low Custody Detainees Violated ICE 

Detention Standards and Facility Policy 

According to detainees and HCDC officials, HCDC strip searches5 low custody 

detainees to look for contraband6 anytime they leave their housing unit. This 

practice includes strip-searching low custody detainees when they visit the 

onsite medical unit, use outdoor recreation, attend religious services, receive 

contact and non-contact visits, or use the law library. ICE’s 2011 PBNDS 

permits strip searches of detainees only when a supervisor approves the strip 

search based on documented reasonable suspicion7 that contraband may be 

concealed on the detainee.8 However, low custody detainees at HCDC are 

routinely strip searched without documented reasonable suspicion and 

supervisory approval. HCDC officials indicated contraband is a concern 

because low custody detainees are housed with county inmates who are 

allowed to leave the facility for work release. HCDC officials said the facility’s 

practices are to prevent contraband from moving from the east wing to the rest 

of the facility. 

HCDC holds both low custody detainees and county inmates in Hendricks Hall, 

a two-story open floor dormitory with beds placed throughout the unit. Figure 

1 shows Hendricks Hall, which houses ICE detainees upstairs and county 

inmates downstairs. There is no barrier separating detainees from inmates 

and the two populations move unimpeded throughout the dorm. 

 5 ICE, Performance-Based National Detention Standards, 2011, Section 2.10.V.D.2, Searches of 

Detainees (Revised Dec. 2016). “A strip search is a search that requires a person to remove or 

arrange some or all clothing so as to permit a visual inspection of the person’s breasts, 

buttocks, or genitalia.” 

6 HCDC Policy E-402 - Searches defines “contraband” as any item not authorized or approved 

for receipt by an inmate/detainee and any other item specifically forbidden by law. 

7 ICE, Performance-Based National Detention Standards, 2011, Section 2.10.V.D.2.b, Searches 

of Detainees (Revised Dec. 2016) defines “reasonable suspicion” as “suspicion based on specific 

and articulable facts that would lead a reasonable officer to believe that a specific detainee is in 

possession of contraband. ... It must be based on specific and articulable facts — along with 

reasonable inferences that may be drawn from those facts—that the officer shall document....” 

8 ICE, Performance-Based National Detention Standards, 2011, Section 2.10.II.7, Searches of 

Detainees (Revised Dec. 2016). “A strip search shall be conducted only when properly 

authorized by a supervisor and only in the event that there is reasonable suspicion that 

contraband may be concealed on the person, or when an officer has reasonable suspicion that 

a good opportunity for concealment has occurred....” 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Figure 1. Hendricks Hall where low custody detainees are housed, as observed by DHS 

Office of Inspector General (OIG) on December 17, 2019. 

Source: OIG 

We reviewed HCDC’s strip-search log from August to December 2019 and 

found that HCDC staff conducted 35 strip searches of low custody detainees, 

with 1 detainee strip searched 13 times. In addition, HCDC staff did not 

consistently include the purpose for the strip search, and we were unable to 

identify why most of the strip searches occurred. The facility did not provide 

documentation showing reasonable suspicion that detainees were in 

possession of contraband or why leaving the housing unit created an increased 

risk of detainees transporting contraband to other parts of the facility. 

Because low custody detainees have minimal to no contact with high custody 

detainees or high-level inmates, even when outside the east wing, it was 

unclear why the facility believed detainees would spread contraband to other 

parts of the facility. Further, HCDC reported no incidents of low custody 

detainees caught with contraband. Figure 2 shows entries from HCDC’s stripsearch log. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Figure 2. Entries from HCDC’s Strip-Search Log showing HCDC strip searches ICE detainees9 

leaving their housing unit to go to chapel, for an attorney visit, and with no recorded 

explanation. 

Source: HCDC Strip-Search Log 

In December 2015, a Nakamoto inspection determined HCDC was deficient in 

the standard for detainee searches because HCDC routinely strip searched all 

detainees during the intake process and without the establishment of 

reasonable suspicion. Rather than correct the deficiency, HCDC sought, and 

ICE granted, a waiver10 in 2016 to expand its strip searches of detainees not 

only at intake, but also for any returning from outside visits including attorney 

visits. The waiver does not specify that low custody detainees can be strip 

searched when leaving their housing unit, without supervisor-approved and 

documented reasonable suspicion of contraband. 

Further, in October 2019, HCDC issued its policy on searches,11 which the 

facility also violates with its current practice of strip-searching low custody 

detainees. The policy requires officers to frisk search — examine a fully clothed 

detainee for contraband concealed under clothing — all detainees entering or 

exiting a housing unit, but does not state that detainees are to be strip 

searched for only leaving their housing unit. The policy specifies that strip 

searches shall be conducted on all detainees at intake or returning from 

kitchen duty, outside visits, and attorney visits. Otherwise, the policy allows 

strip searches of detainees only when staff have a reasonable suspicion of the 

immediate presence of contraband, notify their supervisor, and submit a report 

documenting the need for the strip search. HCDC did not produce any such 

documentation of supervisors approving strip searches of low custody 

detainees. 

 9 In the first entry, HCDC erroneously identified the detainee as an inmate. 

10 Waiver for Strip Searches – Howard County Detention Center signed on June 8, 2016, by 

ICE Assistant Director, Custody Management. 

11 HCDC Policy E-402 – Searches. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

HCDC’s strip searching of detainees also raises concerns about the comingling 

of detainee and inmate populations given intent of ICE detention.12 By housing 

ICE detainees with county inmates, HCDC inappropriately applied policies and 

practices intended for those in criminal custody to detainees meant to be held 

in civil custody while their immigration court proceedings are pending. HCDC 

should consider physically separating low custody detainees from inmate 

populations to ensure proper treatment and care as required by ICE’s 2011 

PBNDS. 

We determined HCDC’s practice of strip-searching low custody detainees 

whenever they leave their housing unit exceeds the authority provided by ICE’s 

waiver on strip searches and is not allowed by HCDC policy. Detainees told us 

HCDC’s strip-search practices deterred them from leaving their housing unit to 

go to the law library or attend religious services. HCDC’s practice of stripsearching low custody detainees leaving their housing unit is unnecessarily 

invasive and ultimately decreases detainee morale. 

Lengthy Kitchen Renovations Hampered HCDC’s Ability to 

Meet Food Service Standards 

The 2011 PBNDS requires detainees be served three meals every day, at least 

two of which are to be served hot.13 All meals must also accommodate the 

needs of its detained population accounting for differences in age, physical 

condition, ethnicity, gender, religious preference, and medical considerations. 

However, for more than 8 months, ICE detainees at HCDC were provided only 

one hot meal and two cold meals. At the time of our inspection, HCDC’s 

kitchen was undergoing renovations, as shown in Figure 3, due to persistent 

drainage issues, and could only be used for food storage, refrigeration, and 

freezer needs. Due to the renovations, HCDC obtained one hot meal (dinner) 

each day for detainees by contracting with Dorsey Run Correctional Facility 

(DRCF), a nearby state prison. 

 12 Although other ICE contracted facilities hold both detainees and inmates, this is the first 

facility we have inspected where they were housed together. 

13 ICE, Performance-Based National Detention Standards, 2011, Section 4.1.V.D.1, Food Service 

(Revised Dec. 2016). “Ordinarily detainees shall be served three meals every day, at least two 

of which shall be hot meals.” 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Figure 3. HCDC’s kitchen undergoing renovation as observed by DHS OIG on December 17, 

2019. 

Source: OIG 

The HCDC kitchen renovation began in June 2019, and was expected to be 

completed within 30 to 45 days, but was delayed several times because of the 

time it took HCDC to get kitchen equipment purchased, delivered, and 

installed. It was not until about 8 months after renovations began that the 

kitchen reopened. During this entire period, detainees at HCDC received only 

one hot meal per day. Of the 61 ICE detainees at HCDC during our visit, 36 

detainees had received only one hot meal per day for more than 30 days, with 2 

of those detainees receiving only one hot meal per day for more than 5 months. 

We asked HCDC officials why they did not work with DRCF to provide 

detainees with two hot meals. HCDC officials stated they lacked the budget to 

pay DRCF to produce another hot meal and DRCF could not handle the 

workload of producing and transporting two hot meals per day. 

We asked ICE officials if they were aware of the facility’s renovations and that 

detainees would only receive one hot meal daily. ICE officials said that HCDC 

informed ICE of the planned renovations in February 2019. According to ICE 

officials, HCDC said the renovations would begin in June 2019, last for 30 to 

45 days, and DRCF would provide HCDC with hot meals in the interim. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

However, ICE officials said HCDC did not inform them until after renovations 

began that DRCF would only provide one hot meal per day. Even after the 

kitchen’s completion was delayed by several months, ICE officials said they did 

not plan to make any adjustments regarding the housing of detainees at HCDC 

because the renovation was expected to be quick and there was limited bed 

space at other facilities within the Baltimore area. Further, ICE officials did 

not take any action to ensure detainees received two hot meals or request a 

temporary waiver for HCDC’s noncompliance with 2011 PBNDS’ expected 

practices for food services.14 

During the kitchen renovation, detainees repeatedly complained about the food 

served at the facility, including the lack of variety and the facility’s failure to 

meet dietary requirements. All 10 detainees we interviewed criticized the 

facility’s food and many said they often received the same meals for multiple 

days in a row. Detainees also filed grievances stating their medical and 

religious diets were not being met while the kitchen was under renovation. Of 

the 23 non-medical grievances we reviewed from the previous 6 months, 7 

grievances concerned detainee requests or complaints regarding a special diet. 

For instance: 

x A detainee claimed that, although the doctor ordered a 2,400-calorie diet, 

he did not receive it for 2 or 3 days at a time, and when he did receive it, 

it did not conform to the doctor’s instructions. The facility stated the 

oversight could have been due to switching to a new system. 

x A detainee said upon arrival he requested kosher meals but he did not 

receive them for 2 weeks. Once he did receive the meals, he was given 

the same food for 3 weeks straight. The facility stated the detainee’s 

grievance had merit and the dinner meal was not always rotated 

correctly. 

The lengthy kitchen renovations and the facility’s inability to provide detainees 

with the required hot meals per day during the renovations raised concerns 

regarding HCDC’s ability to continuously provide detainees a balanced diet and 

accommodate special diets based on medical, therapeutic, or religious needs. 

However, HCDC officials informed us that the kitchen reopened on February 

20, 2020, and that it resumed providing detainees the required two hot meals 

per day. 

 14 ICE, Performance-Based National Detention Standards, 2011, Section 4.1.V.D.1 (Revised 

December 2016). “Ordinarily detainees shall be served three meals every day, at least two of 

which shall be hot meals....” 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Incomplete Detainee Records Raise Concerns about Detainee 

Care 

During our inspection, we reviewed HCDC documentation related to detainee 

care, including records and logs for detainees held in segregation, and medical 

grievance records. We found that HCDC did not consistently record meals and 

medical visits for detainees in segregation. Consequently, we could not verify 

whether those detainees received three meals daily and received the necessary 

review by medical staff to ensure their suitability for continued stay in 

segregation. Further, HCDC was unable to provide an official medical 

grievance log with complete records. 

HCDC’s Records for Detainees in Segregation Were Incomplete 

ICE’s 2011 PBNDS require detainees in segregation be provided three 

nutritionally adequate meals per day15 and health care personnel conduct faceto-face medical assessments at least once a day.16 The standard also requires 

facilities log in the segregation housing record whether detainees received these 

medical assessments and ate each meal.17 We reviewed housing records for 5 

of the 13 detainees placed in segregation from June to December 2019, and 

identified incomplete documentation and logs. For instance, some logged 

activities indicated segregated detainees were not receiving three meals or a 

medical visit daily. 

All five detainee files reviewed were missing information to show detainees in 

segregation received or were offered three meals a day. Specifically: 

x Records for a detainee in segregation for 57 days18 were incomplete, only 

documenting that the detainee received three meals a day for 15 of the 

57 days (26 percent). 

 15 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.Q, Special 

Management Units (Revised Dec. 2016). “Detainees in SMU shall be provided three 

nutritionally adequate meals per day....” 

16 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.P, Special 

Management Units (Revised Dec. 2016). “Health care personnel shall conduct face-to-face 

medical assessments at least once daily for detainees in an SMU.” 

17 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.P, Special 

Management Units (Revised Dec. 2016). “Medical visits shall be recorded on the SMU housing 

record or comparable form....”; and ICE, Performance-Based National Detention Standards, 

2011, Section 2.12.V.D.3, Special Management Units (Revised Dec. 2016). “The special 

housing unit officer shall immediately record ... whether the detainee ate....” 

18 Each day represents a full day in segregation. We did not include partial days when the 

detainee entered or was released from segregation. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

x Records for a detainee in segregation for 15 days were incomplete, only 

documenting that the detainee received three meals a day for 5 of the 15 

days (33 percent). 

x Records for a detainee in segregation for 8 days were incomplete, only 

documenting that the detainee received three meals a day for 3 of the 8 

days (37 percent). 

x Records for a detainee in segregation for 3 days were incomplete, only 

documenting that the detainee received three meals a day for 1 of the 3 

days (33 percent). 

x Records for a detainee in segregation for 6 days did not show the 

detainee receiving three meals on any of the days. 

Additionally, segregation housing records for four of the five detainees we 

reviewed did not reflect required daily medical visits. Nakamoto found this 

same deficiency during its November 2018 inspection. Although HCDC 

reported fixing this deficiency in December 2018, we found the following: 

x Records for a detainee in segregation for 57 days indicated he only 

received a daily medical visit for 29 of the 57 days (51 percent). 

x Records for a detainee in segregation for 15 days indicated he received a 

daily medical visit for only 8 of the 15 days (53 percent). 

x Records for a detainee in segregation for 8 days indicated he received a 

daily medical visit for only 1 of the 8 days (12 percent). 

x Records for a detainee in segregation for 6 days indicated he received a 

daily medical visit for only 1 of the 6 days (17 percent). 

Because of the incomplete records, we could not verify that detainees in 

segregation received three meals a day or that HCDC’s medical personnel 

properly monitored these detainees. Facilities must demonstrate they are 

following standards, and providing food and proper care to detainees in 

segregation by recording all required activity in segregation logs. 

HCDC Was Unable to Provide an Official Medical Grievance Log with 

Complete Records 

ICE’s 2011 PBNDS require facilities to maintain accurate records for filed 

medical grievances and their resolution in a grievance log, the detainee’s 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

detention file, and keep them separate from other grievances.19 The standard 

also requires designated medical staff act on the grievance within 5 working 

days of receipt. 

During our inspection, we requested HCDC’s medical grievance log and 

responses to detainee grievances from June 1, 2019 to December 17, 2019. 

However, HCDC was unable to provide an official medical grievance log, and 

the only log available was the facility Health Services Administrator’s (HSA) 

personal log. HCDC provided forms for three medical grievances between those 

dates. We had concerns with two of the three medical grievances. One 

grievance was not resolved until 7 days after the grievance was received and 

after the detainee submitted a second grievance form. Another grievance 

showed HCDC medical did not receive a grievance until 3 days after the 

detainee submitted it. 

ICE detainees may submit grievances by placing a completed HCDC Grievance 

Form20 in the medical grievance mailbox, which the facility HSA or designee 

should check daily. Among other requirements, the HSA or designee is 

responsible for maintaining the medical grievance log according to ICE 

detention standards. The medical grievance log should include: (1) a grievance 

log number; (2) the date the grievance was filed; (3) the date the grievance was 

received by medical personnel; (4) the nature of the grievance; (5) the date a 

decision was provided to the ICE detainee, with the receipt; and (6) the 

outcome of the adjudication. 

Without a medical grievance log, we could not determine whether the three 

grievances represented all medical grievances submitted to HCDC during the 

relevant timeframe. Due to HCDC’s inability to provide us with a medical 

grievance log and complete records, we do not have assurance that HCDC 

efficiently and responsibly addressed detainee medical issues. 

Conclusion 

Complying with ICE’s PBNDS and establishing an environment that protects 

the rights, health, and safety of detainees are crucial to detention. ICE must 

ensure HCDC complies with detention standards through immediate attention 

and increased engagement with HCDC and its operations. 

 19 ICE, Performance-Based National Detention Standards, 2011, Section 6.2.II.7, Grievance 

System (Revised Dec. 2016). 

20 HCDC Grievance Form, H-707a. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Recommendations 

We recommend ICE’s Executive Associate Director of ERO: 

Recommendation 1: Review and reevaluate HCDC’s strip-search waiver, 

practices, and policies to ensure compliance with PBNDS requirements. 

Recommendation 2: Establish a process for routine oversight of HCDC to 

ensure it: 

a) provides, and records that detainees in segregation receive, three 

nutritionally balanced meals per day; 

b) completes and records daily medical visits for segregated detainees; and 

c) establishes and maintains a separate medical grievance log, per PBNDS 

requirements. 

Management Comments and OIG Analysis 

ICE concurred with our recommendations and described corrective actions to 

address the issues identified in this report. Appendix B contains ICE 

management comments in their entirety. We also received technical comments 

to the draft report and revised the report as appropriate. We consider the 

recommendations resolved and open. A summary of ICE’s response and our 

analysis follows. 

ICE Comments to Recommendation 1:Concur. ICE ERO will work with the 

ICE Office of the Principal Legal Advisor and DHS Office of Civil Rights and 

Civil Liberties to review HCDC’s strip-search policy, the 2016 waiver, and 

applicable court rulings that might affect the ability of county jails and local 

inter-governmental service agreement facilities to comply with the PBNDS, 

Section 2.10 “Searches of Detainees,” and make changes, as appropriate. 

Estimated Completion Date: May 30, 2021. 

OIG Analysis: We consider these actions responsive to the recommendation, 

which is resolved and open. We will close this recommendation when we 

receive documentation confirming that HCDC has completed appropriate 

changes. 

ICE Comments to Recommendation 2:Concur. ICE ERO is in the process of 

hiring an on-site federal Detention Service Manager (DSM) to conduct daily 

compliance reviews at HCDC. DSMs work with ICE ERO field office personnel 

and facility staff to identify deficiencies, provide “on the spot” resolution of 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

issues and concerns when possible, and monitor the facility’s implementation 

and maintenance of corrective action plans. In the interim, ICE ERO assigned 

a local DSM to temporarily visit the detention facility at least two weeks per 

month, beginning in November 2020. The DSM conducted a site assistance 

visit the week of September 20, 2020, to assess whether detainees in 

segregation are receiving three nutritionally balanced meals per day, 

documenting medical visits for segregated detainees, and utilizing and 

maintaining a medical grievance log. Estimate Completion Date: March 28, 

2021. 

OIG Analysis: We consider these actions responsive to the recommendation, 

which is resolved and open. We will close this recommendation when we 

receive documentation confirming the DSM that ICE ERO has put in place at 

HCDC has completed appropriate corrective actions. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix A 

Objective, Scope, and Methodology 

The Department of Homeland Security Office of Inspector General was 

established by the Homeland Security Act of 2002 (Public Law 107-296) by 

amendment to the Inspector General Act of 1978. 

DHS OIG initiated this inspection at Congress’ direction. As part of our 

unannounced inspections, we also review and analyze concerns raised by 

immigrant rights groups and complaints to the DHS OIG Hotline about 

conditions for aliens in U.S. ICE custody. We generally limited our scope to the 

2011 PBNDS for health, safety, medical care, mental health care, grievances, 

classification and searches, use of segregation, use of force, language access, 

and staff training. We focused on elements of these standards that we could 

observe and evaluate during our onsite inspections. Our visit to HCDC was 

unannounced so we could observe normal conditions and operations. 

Prior to our inspection, we reviewed relevant background information, 

including: 

• OIG Hotline complaints 

• ICE 2011 PBNDS 

• DHS Office for Civil Rights and Civil Liberties reports 

• ICE Office of Detention Oversight reports 

• Information from nongovernmental organizations 

• Information provided in congressional requests 

• Information provided from state and local governments requests 

We visited HCDC from December 17 to December 18, 2019. During the visit 

we: 

• inspected areas used by detainees, including intake processing areas; 

medical facilities; kitchens and dining facilities; residential areas, 

including sleeping, showering, and toilet facilities; legal services areas, 

including law libraries, immigration proceedings, and rights 

presentations; recreational facilities; and barber shops; 

• reviewed facility’s compliance with key health, safety, and welfare 

requirements of the 2011 PBNDS for classification and searches, 

segregation, access to medical care and mental health care, medical and 

nonmedical grievances, and access to translation and interpretation; 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

• interviewed ICE and detention facility staff members, including key ICE 

operational and detention facility oversight staff, detention facility 

wardens or someone in an equivalent position, and detention facility 

medical, classification, grievance, and compliance officers; 

• interviewed detainees held at the detention facility to evaluate 

compliance with 2011 PBNDS grievance procedures and grievance 

resolution; and 

• reviewed documentary evidence, including medical files, and grievance 

and communication logs and files. 

We conducted this review under the authority of the Inspector General Act of 

1978, as amended, and according to the Quality Standards for Inspection and 

Evaluation issued by the Council of the Inspectors General on Integrity and 

Efficiency. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix B 

ICE Comments to the Draft Report 

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Department of Homeland Security 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix C 

Office of Special Reviews and Evaluations Major Contributors 

to This Report 

John D. Shiffer, Chief Inspector 

Amy Burns, Chief Inspector 

Stephanie Christian, Lead Inspector 

Renita Caracciolo, Senior Inspector 

Ian Stumpf, Senior Inspector 

Erika Algeo, Independent Referencer 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix D 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chiefs of Staff 

General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs 

Assistant Secretary for Office of Legislative Affairs 

ICE Liaison 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees 

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Additional Information and Copies 

To view this and any of our other reports, please visit our website at: 

www.oig.dhs.gov. 

For further information or questions, please contact Office of Inspector General 

Public Affairs at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov. 

Follow us on Twitter at: @dhsoig. 

OIG Hotline 

To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click 

on the red "Hotline" tab. If you cannot access our website, call our hotline at 

(800) 323-8603, fax our hotline at (202) 254-4297, or write to us at: 

Department of Homeland Security 

Office of Inspector General, Mail Stop 0305 

Attention: Hotline 

245 Murray Drive, SW 

Washington, DC 20528-0305