Capping Report: 

Observations of 

Unannounced 

Inspections of ICE 

Facilities in 2019 

July 1, 2020 

OIG-20-45 
July 1, 2020 
 

 

 

 

 

 

 

DHS OIG HIGHLIGHTS 

Capping Report: Observations of Unannounced

Inspections of ICE Facilities in 2019

July 1, 2020 

Why We 

Did These 

Inspections 

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 2019, we 

inspected four detention 

facilities to evaluate their 

compliance with ICE 

detention standards. 

What We 

Recommend 

We made one 

recommendation to improve 

ICE’s oversight of detention 

facility management and 

operations. 

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 

Our 2019 unannounced inspections of four detention 

facilities identified violations of ICE detention standards, 

which set requirements for facilities housing detainees. 

Although the conditions varied among the facilities and 

not every problem was present at each, our observations, 

interviews with detainees and staff, and review of 

documents revealed several common issues. At three 

facilities, we found segregation practices that infringed on 

detainee rights. Detainees at all four facilities had 

difficulties resolving issues through the grievance and 

communication systems, including allegations of verbal 

abuse by staff. Two facilities had issues with classifying 

detainees according to their risk levels, which could affect 

safety. Lastly, we identified living conditions at three 

facilities that violate ICE standards. Overall, these areas 

of noncompliance with detention standards inhibit the 

facilities’ ability to establish environments that protect 

the rights, health, and safety of detainees. 

ICE Response 

ICE concurred with the report recommendation and 

described corrective actions to address the issues 

identified in this report. We consider the 

recommendation resolved and open. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security



Table of Contents 

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

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

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

Inappropriate Segregation Practices at Three Facilities Infringe on 

Detainee Rights ..................................................................................... 5 

Detainees Experienced Difficulties Resolving Issues through the 

Grievance and Communication Systems ................................................ 7 

Detainee Classification Issues at Two Facilities Could Affect Safety ........ 9 

Living Conditions at Three Facilities Violate ICE Standards .................. 11 

Recommendation .......................................................................................... 15 

Appendixes 

Appendix A: Objective, Scope, and Methodology ................................. 17 

Appendix B: ICE Comments to the Draft Report ................................... 19 

Appendix C: Locations of Facilities Visited ........................................... 22 

Appendix D: Office of Special Reviews and Evaluations Major 

Contributors to This Report ................................................................. 23 

Appendix E: Report Distribution.......................................................... 24 

Abbreviations 

CDF Contract Detention Facility 

ERO Enforcement Removal Operations 

ICE Immigration and Customs Enforcement 

IGSA Intergovernmental Service Agreement 

NDS National Detention Standards 

OIG Office of Inspector General 

PBNDS Performance-Based National Detention Standards 

RFID Radio Frequency Identification 

SPC Service Processing Center 

USMS IGA U.S. Marshals Service Intergovernmental Agreement 

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Introduction 

Currently, Immigration and Customs Enforcement (ICE) houses detainees at 

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

facilities can vary greatly. In recent years, the care and treatment of detainees 

have been the subject of increased congressional and public attention, and our 

program of unannounced inspections of ICE detention facilities has identified 

serious issues at several facilities. In fiscal year 2019, U.S. Immigration and 

Customs Enforcement (ICE) detained an average of 50,000 people per day. In 

2019, we continued our program of Congressionally-directed unannounced 

inspections at four adult detention facilities. During these inspections, we 

found violations of ICE detention standards that undermine the protection of 

detainees’ rights and the provision of a safe and healthy environment. 

Background 

ICE Enforcement and Removal Operations (ERO) oversees the detention of 

aliens in more than 200 facilities nationwide that it manages in conjunction 

with private contractors and government entities, including state and local 

governments. ICE uses the following types of detention facilities for adults: 

x 	 Service Processing Centers (SPC) owned by ICE, operated by ICE and 

contract employees, and dedicated to housing only ICE detainees; 

x 	 Contract Detention Facilities (CDF) owned and operated by private 

companies under contract with ICE, and dedicated to housing only ICE 

detainees; 

x 	 Dedicated Intergovernmental Service Agreement (IGSA) facilities — state 

and local facilities operating under an agreement with ICE, and 

dedicated to housing only ICE detainees; 

x 	 non-dedicated IGSA facilities — state and local facilities operating 

under an agreement with ICE, which house ICE detainees in addition to 

other confined populations (i.e., inmates), either together or separately; 

and 

x 	 U.S. Marshals Service Intergovernmental Agreement (USMS IGA) 

facilities — U.S.-Marshals-Service-contracted facilities also used by 

ICE, which house ICE detainees in addition to other confined 

populations (i.e., inmates), either together or separately. 

ICE holds detainees in civil, not criminal, custody, which is not supposed to 

be punitive. Contracts and agreements with facilities holding ICE detainees 

require adherence to the 2000 National Detention Standards (2000 NDS), 2008 

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Performance-Based National Detention Standards (2008 PBNDS), or the 2011 

PBNDS.1 Detention standards establish consistent conditions of confinement, 

program operations, and management expectations within ICE’s detention 

system. These standards set requirements for: 

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

detainee searches, segregation,2 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. 

As directed by Congress,3 we conduct annual unannounced inspections of ICE 

detention facilities to ensure compliance with detention standards. In addition 

to inspections conducted by OIG, ICE has various offices responsible for 

oversight and monitoring of detention standards. Specifically, ICE ERO 

contracts with a private company to inspect facilities, and ICE’s Office of 

Detention Oversight conducts inspections as well. In 2019, we made 

unannounced visits to four detention facilities between March and July. We 

visited the Northwest Detention Center (Northwest) in Tacoma, Washington; El 

Paso Processing Center (El Paso) in El Paso, Texas; Cibola County Correctional 

Center (Cibola) in Milan, New Mexico; and Baker County Detention Center 

(Baker) in Macclenny, Florida. 

According to ICE, these facilities collectively house a maximum of 3,207 

detainees. Each facility varies by type, owner, operator, standards followed, 

and housing capacity, as shown in table 1. 

 1 At the time of contracting, ICE and the contractor agree on which of the three sets of 

standards will apply to the facility. During the period OIG conducted the unannounced 

inspections discussed in this report, these were the operative standards applicable to facilities 

housing ICE detainees. ICE has since issued the new 2019 NDS. 

2 Segregation is the process of separating certain detainees from the general population for 

administrative, disciplinary, or protective reasons. 

3 Consolidated Appropriations Act, 2019, Pub. L. No. 116-6, Division A, Department of 

Homeland Security Appropriations Act, 2019; Joint Explanatory Statement, 164 CONG. REC. 

H2045, H2547 (daily ed. Mar. 22, 2018); H.R. Rep. No. 115-948, at 15 (2018); S. Rep. No. 115-

283, at 23 (2018). 

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Table 1. Inspected Facility Information 

Facility Type Owned By Operated 

By Standards Capacity 

Northwest CDF GEO Group 

Inc. 

GEO 

Group Inc. 

2011 

PBNDS 1,575 

El Paso SPC ICE 

Global 

Precision 

Systems 

2011 

PBNDS 840 

Cibola 

Nondedicated 

IGSA 

CoreCivic CoreCivic 2011 

PBNDS 500 

Baker 

Nondedicated 

IGSA 

Baker 

Correctional 

Development 

Corporation 

Baker 

County 

Sheriff’s 

Office 

2000 NDS 292 

Source: OIG analysis of ICE-provided data 

Results of Inspection 

Our inspections of the four detention facilities revealed violations of ICE’s 

detention standards and raised concerns about the environment in which ICE 

holds detainees in these facilities. Although the conditions varied among the 

facilities and not every problem was present at each, our observations, 

interviews with detainees and staff, and review of documents revealed several 

prevalent issues. As reflected in table 2, we found segregation practices that 

infringe on detainee rights at three facilities. Detainees at all four facilities had 

difficulties resolving issues through the grievance and communication systems, 

including allegations of verbal abuse by staff. Two facilities had issues with 

properly classifying detainees according to risk level, which could affect safety. 

Further, we identified living conditions at three facilities that violate ICE 

standards. 

Table 2. Snapshot of Issues Found by Facility 

Facility Segregation Grievances/ 

Communication Classification Living Conditions 

Northwest X X 

El Paso X X 

Cibola X X X X 

Baker X X X X 

Source: OIG observations and analysis 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security



Inappropriate Segregation Practices at Three Facilities Infringe 

on Detainee Rights 

Facilities may place a detainee in segregation when the detainee’s continued 

presence in the general population poses a threat to life, property, self, staff, 

or other detainees; for the secure and orderly operation of the facility; or for 

medical reasons.4 During our unannounced inspections, we identified 

serious issues with the administrative and disciplinary segregation of 

detainees at Cibola, Baker, and Northwest. Specifically, Cibola did not 

always include the relevant documents supporting segregation in the 

detainee’s file. At Baker, staff did not personally observe segregated 

detainees every 30 minutes, nor were all segregated detainee activities 

logged. Northwest used restraints to control segregated detainees during 

any movement outside their cells. These practices violate detention policies 

and standards, and infringe on detainee rights. 

Cibola Lacked Documentation Supporting the Use of Segregation 

Facilities are required to complete a written segregation order and attach all 

memoranda, medical reports, and other relevant documents to the order 

before placing a detainee in administrative segregation.5 Cibola placed 

detainees in administrative segregation, but did not always include relevant 

documentation supporting the use of segregation. For example, two 

detainees were in administrative segregation for medical observation for 4 

and 6 days, respectively. However, documentation was not included with the 

segregation orders supporting the need to observe the detainees in 

segregation rather than in the medical unit where they could be more closely 

monitored by medical staff. Another detainee had been in administrative 

segregation for 8 days at the time of our visit because the detainee was 

alleged to be a “security threat.” However, supporting documentation was 

not included with the order to support the claim and justify use of 

segregation. 

 4 ICE, Performance-Based National Detention Standards, 2011 (2011 PBNDS), Section 2.12.V.A, 

Special Management Units (Revised Dec. 2016). Administrative segregation is a form of 

separating a detainee from the general population when the continued presence of the detainee 

in the general population would pose a serious threat to life, property, self, staff, other 

detainees, or the security or orderly operation of the facility. 

5 ICE, Performance-Based National Detention Standards, 2011 (2011 PBNDS), Section 2.12.2, 

Special Management Units (Revised Dec. 2016). 

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Baker Staff Did Not Personally Observe Segregated Detainees or Log Their 

Activities Consistently 

The 2000 NDS require facilities to maintain a permanent segregation log 

recording detainee activities related to meals, recreation, visitors, and 

showers.6 In addition, Baker has implemented local guidelines for segregation, 

which include physically observing detainees at least every 30 minutes. We 

found Baker did not consistently log the activities of segregated detainees or 

conduct these 30-minute checks. Baker logged segregated detainee activities 

so poorly it was difficult to know whether detainees received meals, were 

allowed recreation or visitors, or were allowed showers. Additionally, Baker’s 

segregation logs showed instances in which the time between checks was up to 

3 hours, rather than 30 minutes as required. We also observed a 30-minute 

segregation check during which the guard passed by each cell with a Radio 

Frequency Identification (RFID)7 reader and scanned the RFID tag at each cell 

without physically observing the detainee. By not completing activity logs and 

timely physical checks, facility personnel violate applicable standards and 

guidelines, which are in place to promote detainee health and safety. Proper 

monitoring of detainees in segregation is particularly critical given that 

research has found segregation can have damaging psychological effects8 and 

is an established risk factor for suicide.9 

Northwest Used Restraints on Segregated Detainees for Any Movement 

Outside of Cells 

According to the 2011 PBNDS, placement in segregation alone does not 

constitute a valid basis for using restraints (i.e., handcuffs) on detainees. 

Further, restraints should only be used if necessary as a precaution against 

escape during transfer (e.g., to another facility, court, or hospital), when 

directed by the medical officer for medical reasons, or to prevent self-injury, 

injury to others, or serious property damage. During our visit at Northwest, we 

observed guards handcuffing detainees in segregation for every activity 

requiring detainees to be outside of their cells. For example, we observed 

guards handcuffing detainees to move them from the showers in segregation 

 6 ICE, National Detention Standards, 2000 (2000 NDS), Special Management Unit – 

Administrative Segregation. 

7 RFID technology enables RFID readers to capture data in RFID tags (e.g., meals, recreation, 

visitation, showers) and then store the data in a database.
 8 National Institute of Justice, Administrative Segregation in U.S. Prisons, March 2016, 

https://www.ncjrs.gov/pdffiles1/nij/249749.pdf. 9 R. Reeves and A. Tamburello, “Single cells, segregated housing, and suicide in New Jersey 

Department of Corrections,” The Journal of the American Academy of Psychiatry and the Law 

(December 2014), http://jaapl.org/content/42/4/484.long. 

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back to their cells in segregation — a distance of about 10 yards. Further, 

guards placed segregated detainees in handcuffs during interviews with an OIG 

inspector within the segregation unit. Northwest’s segregation supervisor and 

guards said it is GEO’s10 policy to place all detainees held in segregation in 

restraints whenever outside their cells regardless of whether an individual 

detainee had a demonstrated need for restraints. Physically restraining all 

segregated detainees whenever they are outside their cells does not comport 

with ICE standards. 

Detainees Experienced Difficulties Resolving Issues through 

the Grievance and Communication Systems 

ICE standards establish procedures for detainees to file grievances regarding 

any aspect of their detention. Detainees also have the opportunity to submit 

written questions, requests, or concerns to the facility and ICE ERO staff. 

These processes aim to protect detainees’ rights and enhance security, safety, 

and orderly facility operations. Resolution depends on facility and ICE staff 

handling and addressing grievances and detainee communications properly 

and in a timely manner, but we found issues at each of the four facilities we 

inspected. Specifically, Northwest and El Paso grievance logs did not include 

required information. Northwest and Baker did not meet prescribed deadlines 

to provide responses to detainee grievances or communications. Further, 

Cibola and the local ICE field office did not properly address allegations of staff 

verbal abuse. Without effective, compliant grievance and communication 

processes, facilities and ICE risk ignoring or worsening serious deficiencies. 

Northwest and El Paso Did Not Consistently Log Required Information 

The 2011 PBDNS require facilities to maintain grievance logs including all 

grievances and relevant information. Our inspections of Northwest and El Paso 

revealed grievance logs that did not include all required information. At 

Northwest, we found when detainees submit grievances electronically, the 

system automatically populates the grievance log, but the facility did not 

consistently log grievances submitted via paper. At El Paso, the medical 

grievance log did not track the “date decision provided to detainee” as required, 

and two medical grievances were not included in the log. El Paso medical staff 

told us they did not know they were required to document this information and 

include every medical grievance in the log. Because of the missing information, 

these facilities do not have a full picture of detainee grievances and may not 

take appropriate action to protect detainees’ rights and ensure fair treatment. 

 10 GEO Group, Inc., the facility owner-operator. 

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Northwest and Baker Did Not Respond to Grievances or Communications 

within Applicable Timeframes 

According to ICE standards, facilities must respond to grievances within 5 

calendar days11 and to all other detainee communications within 72 hours.12 

However, Northwest and Baker did not meet these required deadlines. Of the 

467 grievances13 filed from September 2018 to March 2019 at Northwest, 222 

(47 percent) did not meet the 5-calendar-day response requirement, with 144 

taking 10 days or longer to provide a response. Northwest staff told us they 

struggled to keep pace with the required response time due to the high volume 

of grievances they receive; with an average of 67 grievances per month during 

the period reviewed, Northwest had the highest grievance volume of the 

facilities we inspected.14 Additionally, we reviewed 180 communications15 

submitted by detainees at Baker from February 2019 to July 2019, and found 

45 (25 percent) did not meet the 72-hour response requirement, with 27 taking 

10 days or longer to provide a response. Baker staff also said they struggled to 

keep pace with communications because of the number of requests received. 

Cibola Did Not Properly Address Detainee Grievances of Staff Verbal Abuse 

ICE detention facilities are required to forward detainee grievances alleging 

verbal abuse by staff to the local ICE field office for appropriate action.16 At 

Cibola, 15 of the 62 grievances (24 percent) filed from January 2019 to June 

2019 contained allegations of staff verbal abuse toward detainees. In 

particular, these included complaints lodged by transgender detainees alleging 

staff used homophobic slurs and/or accused them of pretending to be 

transgender. Cibola forwarded the allegations to the local ICE field office, and 

both the local ICE field office and Cibola management told us they conducted 

an investigation, but neither could provide us documentation detailing what 

investigative steps were taken, whether the investigation substantiated the 

alleged misconduct, or the specific actions taken against staff members 

accused of verbal abuse. At the time of our visit in June 2019, detainees told 

us the verbal abuse was continuing. 

 11 2011 PBNDS, Section 6.2.V.C, Grievance System. 

12 2000 NDS, Staff-Detainee Communication.
 13 Common grievances concerned food, medical issues, and property. 

14 The average numbers of grievances per month for similar periods reviewed at the other 

facilities were El Paso 2, Cibola 10, and Baker 8.
 15 Common communications concerned visitation, case status, and requests for religious items. 

16 Memorandum from Alonzo Pena, ICE Deputy Director, Directing Complaints Appropriately to
 

the Joint Intake Center (JIC), the Office of Professional Responsibility (OPR), the Office of the 

Inspector General (OIG), or Local Management, November 10, 2010.
 

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Detainee Classification Issues at Two Facilities Could Affect 

Safety 

ICE detention facilities house detainees of various backgrounds, including 

some who served prison sentences following criminal convictions, and others 

with nonviolent, civil immigration violations awaiting resolution of their cases. 

Facilities must classify detainees according to risk level in order to assign 

housing with others of similar background and criminal or civil history, and 

ensure separation of high- and low-risk detainees. During our unannounced 

inspections, we found Baker and Cibola relied on initial classification levels 

noted on ICE detainee transfer forms rather than on full assessments of 

detainee information. In addition, Baker did not consistently conduct 

supervisory reviews, and its reassessment guidelines and practices did not 

comply with the required timeframes in the NDS. These deficiencies prevent 

facilities from ensuring detainees with comparable criminal histories are 

grouped together, which may expose noncriminal and nonviolent detainees to 

physical and psychological danger. 

Baker and Cibola Did Not Base Classification Levels on Full Assessments 

of Detainee Information 

Prior to detention, ICE ERO reviews each detainee’s criminal histories and 

classifies each in its system according to risk level.17 ICE ERO includes the 

classification level from its system on Form I-216, which documents the 

transfer of a detainee from one location to another.18 Once a detainee arrives 

at a facility, ICE standards require the classification specialist assigned to 

intake processing to review criminal, institutional, medical, and victimization 

information and complete a custody classification worksheet or equivalent in 

order to classify the detainee.19 Despite this requirement, our inspections of 

Baker and Cibola found the facilities relied solely on the level noted on the I216 to classify detainees. Accordingly, detainee classification levels did not 

reflect a full assessment of the detainee’s history. 

Baker’s classification specialist told us, for those detainees for whom ICE ERO 

provided a classification using the I-216 (approximately 85 to 90 percent of 

 ϭϳ ICE Performance-Based National Detention Standards, 2011, Section V.C, Custody 

Classification System, Section 2.2. B, Custody Classification Score and C. Classification 

Information, (Rev. 2016).

18 ICE ERO uses Form I-216, Record of Persons and Property Transferred, as a manifest when 

transporting people and property from one location to the next. The form includes information 

such as detainee alien number, name, gender, and ICE’s classification level for the detainee. 

19 ICE, National Detention Standards, 2000, Detainee Classification System, Section III.D. See 

also ICE Performance-Based National Detention Standards, 2011, Section V.C, Custody 

Classification System, (Rev. 2016). 

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detainees), she conducts the required criminal history checks and completes 

the classification worksheet as part of the initial assessment process. However, 

if her initial assessment differs from the I-216, she will change her own 

assessment to match the classification level provided by ICE ERO. The 

classification specialist did not use any other detainee history information to 

validate ICE ERO’s classification levels, such as the detention and immigration 

history. For instance, of the 28 detainee files we reviewed, we identified two 

female detainees who would have been assessed at a low classification level 

had an assessment been based on the detainee’s criminal history. Instead, the 

classification specialist assigned the two detainees a medium level because it 

was the level listed on ICE ERO’s I-216. Notably, the medium level 

classification was pending ICE ERO supervisor approval and was not final on 

the I-216 when it was reviewed. Baker’s classification specialist may be more 

likely to classify female detainees at the medium level and above because Baker 

had only one housing dorm for females, which was for medium- and high-level 

detainees, and NDS restricts the commingling of detainees classified at 

different levels. 

From our review of detention files, Cibola also appeared to base detainee 

classification levels on the I-216 instead of fully assessing the detainee’s 

history. The classification specialist at Cibola told us she conducts a review to 

ensure the ICE ERO classification is correct, but she does not document her 

review in the classification worksheets. Therefore, we were unable to validate 

the classification of any detainees at Cibola to evaluate whether detainee 

classifications and housing assignments were correct. 

Baker Did Not Always Conduct Supervisory Classification Reviews 

To ensure accurate classifications, facilities must conduct supervisory reviews 

of the initial classification assessment, reassessments, and overrides of ICE 

ERO classification levels.20 At Baker, supervisory reviews of classification 

assessments were not always completed. According to Baker’s local guidelines, 

intake and booking staff must complete the initial assessment before assigning 

housing. Then, the classification specialist must validate the initial 

assessment within 72 hours. We found the supervisor did not review the initial 

assessment in 6 of 28 (21 percent) classification files we reviewed. 

Additionally, of the 28 classification files we reviewed, 10 included 

reassessments, 9 of which (90 percent) did not undergo supervisory review to 

certify the accurate classification and housing of the detainees. Without proper 

supervisory review, Baker risks violating ICE classification standards and 

incorrectly classifying detainees, which affects housing assignments and, 

potentially, safety. 

 20 2000 NDS, Detainee Classification System. 

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Baker’s Local Guidelines and Practices Did Not Meet Required 

Reassessment Timelines 

The NDS Detainee Classification System requires facilities to complete the first 

classification reassessment 45 to 60 days after the date of the initial 

assessment, with subsequent reassessments completed at 60-to-90-day 

intervals. Although NDS allows IGSA facilities to adopt alternatives provided 

they meet or exceed the objectives, Baker’s local guidelines do not meet or 

exceed the timeframes for reassessments. Rather, Baker’s guidelines direct the 

classification specialist to complete the first reassessment at least 120 days 

after the initial assessment, with subsequent reassessments every 120 days 

thereafter.21 Of the 28 classification files we reviewed at Baker, 23 detainees 

were still at the facility at the time of our visit. Of those 23 detainees, 5 were 

overdue for their first reassessment (ranging from 30 to 164 days overdue), and 

1 of the 5 had been at the facility long enough that a second reassessment 

should have been done, based on the NDS requirements. 

Living Conditions at Three Facilities Violate ICE Standards 

We identified issues with living conditions at El Paso, Cibola, and Baker, such 

as torn mattresses, worn fitness equipment, leaking toilets and sinks, and 

inoperable hot water in detainee cells. These living conditions not only violate 

ICE detention standards, but, in some instances, may also pose a health and 

safety risk to detainees. 

El Paso 

According to the 2011 PBNDS, detainees shall have suitable, clean bedding.22 

However, during our site visit at El Paso, we found several housing unit 

mattresses with sizable tears along the seams (see figure 1). El Paso staff 

replaced all bedding we identified as unacceptable during our visit. 

 21 Baker County Sheriff’s Office Corrections Bureau Guidelines, Classification System, April 

2017. 

22 2011 PBNDS, Section 4.5, Personal Hygiene (Revised Dec. 2016). 

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Figure 1. Torn mattresses observed by OIG at El Paso on April 30, 2019. 

Source: OIG 

Although the 2011 PBNDS require “maintaining high facility standards of 

cleanliness and sanitation,”23 we observed toilets and sinks leaking water onto 

the floor in the housing units, which could lead to mold, mildew, or slips and 

falls (see figure 2). The standards also require facilities to complete preventive 

maintenance on issues such as water leaks.24 

Figure 2. Detainee sinks and toilets leaking water observed by OIG at El Paso on April 30, 

2019. Source: OIG 

The 2011 PBNDS also require the facility to provide operable exercise 

equipment for detainees,25 but we observed damaged fitness equipment in the 

recreation areas at El Paso (see figure 3). Damage made the exercise 

equipment difficult and unsafe for detainees to use. During our visit, El Paso 

 23 2011 PBNDS, Section 1.2, Environmental Health and Safety (Revised Dec. 2016). 

Ϯκ2011 PBNDS, Section 1.2, Environmental Health and Safety, V.A.1 (Revised Dec. 2016).

25 2011 PBNDS, Section 5.4, Recreation. 

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staff installed replacement parts for exercise equipment ordered prior to our 

inspection, and ordered additional parts for other exercise equipment that we 

identified as deficient. 

 Figure 3. Detainee exercise equipment with missing or worn arm pads observed by OIG at El 

Paso on April 30, 2019. Source: OIG 

Cibola 

Similar to El Paso, during our visit to Cibola we found several housing unit 

mattresses with tears (see figure 4). Cibola staff replaced torn mattresses 

during our visit. 

Figure 4. Torn mattresses observed by OIG at Cibola on June 20, 2019. 

Source: OIG 

Despite the requirement to provide detainees a standard issue of clothing, 

including at least two pairs of socks and one pair of footwear,26 Cibola issued 

most detainees flip-flops. We observed boxes of flip-flops and closed-toed 

 26 2011 PBNDS, Section 4.5, Personal Hygiene. 

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sandals in the storage room; however, detainees complained Cibola issues the 

closed-toed sandals to some detainees, but not others. After we pointed out 

the inconsistency, Cibola staff made an on-the-spot correction and issued 

detainees closed-toed sandals. 

Baker County 

Baker has adapted 2000 NDS and implemented guidelines for the maintenance 

of the facility. According to Baker’s guidelines,27 each cell must contain the 

following, among other requirements: 

x lavatory with cold and tempered [hot] running water; 

x faucets that are maintained and operational; and 

x showers that are maintained so each detainee may bathe daily. 

Despite these guidelines, we observed showers with inoperable hot water 

buttons. We also found faucets and showers that did not work properly, 

resulting in water leaking on the floor or spraying all over the immediate area. 

As shown in figure 5, detainees rigged the faucets with plastic straws in order 

to have an operable sink. 

Figure 5. Leaking faucet without plastic straw (left) and faucet with plastic straw (right) 

observed by OIG at Baker on July 30, 2019. 

Source: OIG 

 27 Baker County Sheriff’s Office Corrections Division Guidelines, Maintenance of Detention 

Facility, March 2019, Section IV. B. 

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Figure 6 shows an operable shower and a shower with a small shampoo bottle 

affixed to it in an effort to direct the spray of water. 

Figure 6. Operable shower (left) and shower with a small shampoo bottle affixed to it (right) 

observed by OIG at Baker on July 30, 2019. 

Source: OIG
 

Recommendation 

We recommend the Acting Director of U.S. Immigration and Customs 

Enforcement ensure Enforcement and Removal Operations field offices 

overseeing the detention facilities covered in this report address identified 

issues and ensure facility compliance with relevant detention standards. 

Management Comments and OIG Analysis 

ICE concurred with our recommendation 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 

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

analysis follows. 

ICE Comments to Recommendation 1:Concur. ICE ERO has reviewed each 

of the issues outlined in this report and directed field offices to take ongoing 

actions to address the deficiencies OIG identified. Specifically, according to 

ICE, ERO Field Operations will ensure that local field office personnel review 

this report and resolve identified issues. ERO Custody Management will 

arrange for Special Assessment Reviews (SARs) to be conducted at each of the 

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detention facilities covered in this report. As with prior SARs conducted to 

respond to OIG findings, these SARs will review each of the issues identified by 

the OIG unannounced inspections to document that each has been addressed, 

as appropriate. ICE will provide copies of the SAR reports to OIG to document 

facility compliance with ICE’s detention standards as part of its request for 

recommendation closure. Estimated Completion Date: December 31, 2020 

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 the SARs and other corrective actions 

have been completed. 

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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 and 2000 NDS 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 the 2011 

PBNDS and 2000 NDS that could be observed and evaluated without 

specialized training in medical, mental health, education, or corrections. Our 

visits to these four facilities were unannounced so we could observe normal 

conditions and operations. 

Prior to our inspections, we reviewed relevant background information, 

including: 

• OIG Hotline complaints 

• ICE 2011 Performance-Based National Detention Standards 

• ICE 2000 National Detention Standards 

• 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 four facilities: 

• Northwest Detention Center, Washington (March 19–21, 2019) 

• El Paso Service Processing Center, Texas (April 30–May 2, 2019) 

• Cibola County Correctional Center, New Mexico (June 18–20, 2019) 

• Baker County Detention Center, Florida (July 30–August 1, 2019) 

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During the inspections 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 facilities’ compliance with key health, safety, and welfare 

requirements of the PBNDS and NDS for classification and searches, 

segregation, use of force and restraints, medical care, mental health 

care, medical and nonmedical grievances, and access to translation and 

interpretation; 

• 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 facilities to evaluate 

compliance with 2011 PBNDS and 2000 NDS 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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Appendix B 

ICE Comments to the Draft Report 

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Appendix C 

Locations of Facilities Visited 

Source: OIG developed. 

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Appendix D 

Office of Special Reviews and Evaluations Major Contributors 

to This Report 

John D. Shiffer, Chief Inspector 

Erika Lang, Chief Inspector 

Carie Mellies, Lead Inspector 

Erika Algeo, Senior Inspector 

Donna Ruth, Senior Inspector 

Ian Stumpf, Senior Inspector 

Brittany Scott, Independent Referencer 

Anthony Crawford, Independent Referencer 

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Appendix E 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chiefs of Staff 

General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

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