Office of Inspector General 

DEPARTMENT OF HOMELAND SECURITY 

Treatment of Immigration Detainees 

Housed at Immigration and Customs 

Enforcement Facilities 

OIG-07-01 December 2006

Table of Contents/Abbreviations 

Executive Summary ............................................................................................................................. 1 

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

Results of Audit ................................................................................................................................... 3 

 

Health Care .................................................................................................................................... 3 

Recommendations .......................................................................................................................... 6 

Management Comments and OIG Analysis .................................................................................. 6 

Environmental Health and Safety .................................................................................................. 8 

Recommendations ........................................................................................................................ 10 

Management Comments and OIG Analysis ................................................................................ 10 

General Conditions of Confinement ............................................................................................ 12 

Recommendations ........................................................................................................................ 25 

Management Comments and OIG Analysis ................................................................................ 26 

ICE Procedures For Reporting Detainee Abuse .......................................................................... 28 

Recommendations ........................................................................................................................ 32 

Management Comments and OIG Analysis ................................................................................ 33 

Thoroughness of ICE Detention Facility Inspections .................................................................. 36 

Recommendations ........................................................................................................................ 36 

Management Comments and OIG Analysis ................................................................................ 36 

Appendices 

Appendix A: Purpose, Scope, and Methodology ....................................................................... 38 

Appendix B: OIG Flyer .............................................................................................................. 43 

Appendix C: Management Response to Draft ............................................................................ 44 

Appendix D: Major Contributors to this Report ........................................................................ 53 

Appendix E: Report Distribution ............................................................................................... 54 

Abbreviations 

ACA American Correctional Association 

BCP Berks County Prison 

CCA Corrections Corporation of America 

CDF Contract Detention Facility 

CO Correctional Officer 

CY Calendar Year 
Table of Contents/Abbreviations 

DHS U.S. Department of Homeland Security 

DIHS Division of Immigration Health Services 

DMCP Detention Management Control Program 

DOJ Department of Justice 

DRO Office of Detention and Removal Operations 

FODs Field Office Directors 

HCCC Hudson County Correctional Center 

ICE U.S. Immigration and Customs Enforcement 

IGSA Intergovernmental Service Agreement 

INS Immigration and Naturalization Service 

NDS National Detention Standards 

NGO Non-Governmental Organization 

OIC Officer-in-Charge 

OIG Office of Inspector General 

OPR Office of Professional Responsibility 

PCJ Passaic County Jail 

SCO Senior Correctional Officer 

SIEA Supervisory Immigration Enforcement Agent 

SPC Service Processing Center 

U.S. United States 
OIG 

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 1

Audit 

Report

Department of Homeland Security 

Office of Inspector General 

Executive Summary

This report presents the results of our audit of compliance with selected detention standards at five 

facilities used by U.S. Immigration and Customs Enforcement (ICE) to house immigration 

detainees: 

1. Berks County Prison (BCP), Leesport, Pennsylvania 

2. Corrections Corporation of America (CCA) Facility, San Diego, California 

3. Hudson County Correction Center (HCCC), Kearny, New Jersey 

4. Krome Service Processing Center (SPC), Miami, Florida 

5. Passaic County Jail (PCJ), Paterson, New Jersey 

We focused on detention standards regarding: (1) Health Care, (2) Environmental Health and 

Safety, (3) General Conditions of Confinement, and (4) Reporting of Abuse. We did not use 

statistical sampling for our sample selections, and the results of our testing should not be projected 

to the detainee population or other facilities. Our report focuses on highlighting the specific areas 

of non-compliance identified during the course of our audit. (See Appendix A.) 

Our audit identified instances of non-compliance with ICE Detention Standards at the five 

facilities. Regarding health care standards, we identified instances of non-compliance at four of the 

five detention facilities, including timely initial and responsive medical care. Also, we identified 

environmental health and safety concerns at three of five detention facilities reviewed. We 

identified instances of non-compliance with ICE Detention Standards regarding general conditions 

of confinement at the five facilities, including disciplinary policy, classifying detainees, and 

housing together detainees classified at different security levels. Two facilities also had inadequate 

inventory controls over detainee funds and personal property. 

We further noted that the ICE Detention Standard on Detainee Grievance Procedures does not 

provide a process for detainees to report abuse or civil rights violations. In addition, two detention 

facilities did not issue handbooks specifically addressing detainee’s rights, responsibilities, and 

rules; and three facilities did not translate handbooks and orientation material into Spanish and 

other prevalent languages. 

During our audit, we brought these concerns to the attention of the Office of Detention and 

Removal Operations (DRO) management and responsible facility officials. ICE took immediate 

action to address many of our concerns. We made 13 recommendations addressing the areas of 

non-compliance identified. ICE partially or fully concurred with 9 of the 13 recommendations and 

the proposed actions to implement the 9 recommendations are adequate. Based on ICE’s actions 

and comments, we have deleted recommendation 12 as presented in the draft report. 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 2

Background 

The primary responsibilities of ICE’s DRO are to provide adequate and appropriate 

custody management of immigration detainees until a decision is rendered 

regarding their removal. In this regard, ICE operates eight detention facilities 

called Service Processing Centers (SPCs). ICE augments its SPCs with seven 

Contract Detention Facilities (CDFs). Contractors operate CDFs, which house only 

detained immigrants. In addition, ICE uses state and local jails on a reimbursable 

basis through Intergovernmental Service Agreements (IGSAs) and uses, at times, 

joint Federal facilities with the Bureau of Prisons. Our audit included detention 

facilities in each of the three categories: SPC (Krome), CDF (CCA San Diego), 

and IGSA (Berks County Prison, Hudson County Correction Center, and Passaic 

County Jail). 

Under the Detention Management Control Program (DMCP), ICE personnel 

prescribe policies, standards, and procedures for ICE detention operations and 

review detainee facilities to ensure they are operated in a safe, secure, and humane 

condition for both detainees and staff. According to the DMCP, each SPC was to 

be reviewed beginning in Calendar Year (CY) 2002. In April 2002, all CDFs were 

required to fall under the provisions of the DMCP, and IGSA facilities were fully 

included beginning in fiscal year 2003. Due to the need to modify contractual 

agreements with CDFs and IGSA facilities, these types of facilities were not 

required at that time to meet all procedures and guidance outlined in the DMCP. 

However, they are required to meet the intent of the published detention standards. 

Also, IGSA facilities may adopt, adapt, or establish alternatives to the procedures 

specified for SPCs and CDFs, provided they meet the objective represented by each 

standard. ICE DRO conducts annual inspections for each detention facility used. 

In November 2000, the former Immigration and Naturalization Service (INS) 

established detention standards to ensure the “safe, secure, and humane treatment 

of individuals detained by INS.” The 36 detention standards contained in the 

Detention Operations Manual covered a broad spectrum of issues ranging from 

visitation policies to grievance procedures and food service. These detention 

standards applied to SPCs then operated by INS and CDFs. The majority of these 

detention standards were implemented on September 20, 2000. They established 

the minimal requirements that must be adhered to at all facilities, affording 

immigration detainees rights and protections specified. Two additional standards 

were issued subsequent to September 2000: (1) the detention standard regarding 

staff-detainee communication was issued in July 2003, and (2) the detention 

standard regarding detainee transfer was approved in September 2004. The 

National Detention Standards are the result of negotiations between the American 

Bar Association, the Department of Justice (DOJ), the (legacy) INS and other 

organizations involved in pro bono representation and advocacy for immigration 

detainees.
Treatment of Immigration Detainees Housed at ICE Facilities 

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Results of Audit 

Health Care 

The health care programs and medical facilities at SPCs (Krome) and CDFs 

(Corrections Corporation of America, San Diego) are managed and administered 

under the direction of the Division of Immigration Health Services (DIHS). The 

DIHS is located within the Bureau of Primary Health Care of the Public Health 

Service, under the Department of Health and Human Services. Health care 

contractors administer medical services at IGSA facilities (Berks County Prison, 

Hudson County Correctional Center, and Passaic County Jail). 

ICE established Detention Standards for Medical Care, Hunger Strikes, and Suicide 

Prevention and Intervention. We assessed the detention facilities for adherence to 

health care standards in the following four areas: 

• Initial medical screening and physical examination. 

• Sick call requests and medical treatment. 

• Hunger strike initial evaluation and monitoring. 

• Suicide watch monitoring. 

Initial Medical Screenings and Physical Examinations 

The ICE Detention Standard for Medical Care requires all new arrivals to receive 

initial medical and mental health screening, including tuberculosis screening, 

immediately upon arrival by a health care provider or an officer trained to perform 

this function. The health care provider must also conduct a health appraisal and 

physical examination on each detainee within 14 days of arrival. 

We reviewed 101 of 115 requested medical files for compliance with initial 

medical screening at 4 of the facilities. Eight detainees did not receive the required 

initial medical screening, and 14 files did not contain sufficient documentation to 

make a determination. Also, we reviewed 111 of 122 requested medical files for 

compliance with the physical examination requirement, 15 detainees did not 

receive the required examination, and 11 files contained insufficient documentation 

to make a determination. Krome complied with the standard for initial medical 

screening and physical examination. The results are summarized in Table 1. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Table 1 

Non-compliance With Initial Medical Screening and Physical Examination Standards 

Health Care 

Standard 

Berks County 

Prison 

CCA San Diego 

Facility 

HCCC Passaic County 

Jail 

Initial Medical 

Screening Upon 

Arrival 

4 of 42 detainees 

non-compliant. 

 0 of 10 detainees 

non-compliant, 

documentation 

missing for 2 

additional 

detainees. 

4 of 20 detainees 

non-compliant. 

Files for 11 

additional detainees 

missing 

documentation. 

0 of 29 detainees 

non-compliant, 1 

additional 

detainee’s file 

lacked 

documentation. 

Physical Exam 

Within 14 Days 

4 of 42 detainees 

non-compliant. 

11 of 19 detainees 

non-compliant. 

0 of 20 detainees 

non-compliant. 

Files for 11 

additional detainees 

missing 

documentation. 

0 of 30 detainees 

non-compliant. 

Response to Sick Call Requests 

The ICE Detention Standard for Medical Care requires each facility to have a 

mechanism that allows detainees the opportunity to request health care services 

provided by a physician or other qualified medical officer in a clinical setting. Each 

facility will have regular scheduled times, known as sick call, when medical 

personnel will be available to see detainees who have requested medical services. 

Sick call will be regularly scheduled according to the following minimum 

standards: 

• Facilities with fewer than 50 detainees - minimum of 1 day per week 

• Facilities with 50 to 200 detainees - minimum of 3 days per week 

• Facilities with over 200 detainees - minimum of 5 days per week 

The ICE standards regarding medical response to sick calls do not clearly define 

what should be considered a timely response to non-emergency sick call requests. 

In the absence of such standards, local detention facility health services have 

established differing policies regarding response to non-emergency health care 

treatment, listed in Table 2. 

At three of five detention facilities we visited, 196 of 481 immigration detainee 

non-emergency medical requests were not responded to in the timeframe allowed 

by the facility. Table 2 summarizes our findings at BCP, CCA, and PCJ. 

Table 2 

Non-compliance With Non –Emergency Sick Call Policy 

Facility Health Care 

Policy 

Berks County Prison CCA San Diego Facility Passaic County Jail 

Hours allowed to respond 

to sick call requests 

48 Hours (72 Hours on 

the Weekend) 

72 Hours 24 Hours (Monday 

through Friday) 

Non -Compliance 179 of 447 requests 

non-compliant. 

10 of 19 requests 

non-compliant. 

7 of 15 requests 

non-compliant. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Hunger Strikes 

The ICE Detention Standard on Hunger Strikes requires all facilities to follow 

accepted standards of care in the medical and administrative management of 

hunger-striking detainees. Among the standards are two key provisions: 

• Staff will consider any detainee refusing food for 72 hours to be on a hunger 

strike, and will refer him/her to the medical department for evaluation and 

possible treatment. 

• Medical staff will take and record weight and vital signs at least once every 

24 hours during the hunger strike. Other procedures will be repeated as 

medically indicated. 

We identified and assessed the treatment of eight detainees on hunger strikes at the 

five facilities. Krome complied with the standard for the one detainee on hunger 

strike included in our review. At the four other facilities, the medical staff did not 

record weight for three detainees on hunger strike. In addition, the four facilities 

did not monitor vital signs for five of these detainees at least once every 24 hours, 

as required. Table 3 summarizes the instances of non-compliance with the hunger 

strike standard. 

Table 3 

Non-compliance With Hunger Strike Standard 

Health Care 

Standard 

Berks County 

Prison 

CCA San Diego 

Facility 

HCCC Passaic County 

Jail 

Hunger Striker 

Weight Taken 

During Initial 

Evaluation 

1 of 1 detainee 

non-compliant. 

0 of 3 detainees 

non-compliant. 

Medical staff 

noted that 

detainee was 

uncooperative. 

Hence, did not 

record weight. 

2 of 2 detainees 

 non-compliant. 

Hunger Striker 

Weight and Vital 

Signs Monitored 

Every 24 Hours 

1 of 1 detainee 

 non-compliant. 

1 of 3 detainees 

non-compliant. 

1 of 1 detainee 

 non-compliant. 

2 of 2 detainees 

 non-compliant. 

Detainees on Suicide Watch

The ICE Detention Standard on Suicide Prevention and Intervention requires 

observation of imminently suicidal detainees by medical or detention staff to occur 

no less than every 15 minutes. We reviewed the medical records for 36 detainees 

on suicide watch: BCP-7, HCCC-7, CCA-5, PCJ-3, and Krome-14. At BCP, CCA 

San Diego, and HCCC, facility personnel did not record the required 15-minute 

security checks for five detainees, as shown in Table 4. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Table 4 

Suicide Prevention and Intervention Missing Documentation 

Health Care Standard Berks County Prison CCA San Diego 

Facility 

HCCC 

Suicide Watches / 

Precautions – Monitored 

Every 15 Minutes 

2 of 7 detainees 1 of 5 detainees 2 of 7 detainees 

Recommendations 

We recommend that the Assistant Secretary for ICE, in consultation with the 

Division of Immigration Health Services: 

1. Establish quality assurance measures to ensure the medical staff at detention 

facilities consistently follow all detention standards regarding 

• initial medical screening and subsequent physical examinations for new 

arrivals, 

• timeliness of responding to non-emergency sick call requests, 

• monitor detainees on hunger strikes, and 

• monitor detainees identified as a suicide risk. 

Management Comments: ICE concurs in part. ICE will convene a working group 

comprised of licensed medical practitioners from the U.S. Public Health Service 

DIHS. This working group will review current inspection worksheets for the 

purpose of determining whether any specific changes to the worksheets are 

required to guarantee an appropriate level of quality assurance in compliance with 

the National Detention Standards (NDS) requirements concerning medical 

screening, hunger strikes, and suicide prevention. This working group will 

complete its assessment within 90 days and any recommendations will be 

incorporated into the annual ICE detention review program, including the issuance 

of any appropriate policy changes. ICE did not agree with our findings since they 

were based on a small sample size and an “exception report” methodology, and did 

not reflect a systemic shortcoming in ICE’s detention practices. ICE also noted 

that it is critical that medical providers maintain the ability to prioritize care and 

treatment in order to ensure those requiring immediate medical treatment are seen 

first. ICE noted that the OIG did not report that any of the responses were 

medically inappropriate. 

OIG Analysis: Initial medical screening is important to identify immediate 

medical, emotional, and dental needs of the detainees. These concerns could 

include but are not limited to communicable or infectious diseases, nutritional 

status, indications of previous injuries or scars, physical handicap conditions, or 

special needs. ICE’s comments recognize our general conclusion that the current 

inspection worksheets should guarantee an appropriate level of quality assurance in 

compliance with the NDS to achieving the requirements, and ICE will form a 
Treatment of Immigration Detainees Housed at ICE Facilities 

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working group to determine whether any changes are required. ICE’s proposed 

actions address the intent of the recommendation. This recommendation is 

resolved but will remain open until the assessment performed by the working group 

and appropriate measures have been completed. 

2. Develop specific criteria to define reasonable time for medical treatment. 

Management Comments: ICE concurs in part. ICE contends that its medical 

program provides adequate detainee care and is consistent with industry standards 

but will nonetheless examine the merits of the issue raised in this report. As noted 

above, a working group of licensed medical experts will review the medical 

standards to determine if changes need to be made. 

OIG Analysis: ICE will form a working group to determine if changes need to be 

made. ICE’s proposed actions address the intent of the recommendation. This 

recommendation is resolved but will remain open until the assessment performed 

by the working group and appropriate measures have been completed. 

3. Establish measures to ensure medical records are clearly documented and the 

documentation is readily available for examination. 

Management Comments: ICE concurs in part. As noted in response to the prior 

two recommendations, ICE will examine the merits of the issue. The working 

group will conduct an assessment to determine if changes are needed. 

OIG Analysis: ICE will form a working group to determine if changes need to be 

made. ICE’s proposed actions address the intent of the recommendation. This 

recommendation is resolved but will remain open until the assessment performed 

by the working group and appropriate measures have been completed.
Treatment of Immigration Detainees Housed at ICE Facilities 

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Environmental Health and Safety 

ICE Detention Standard on Environmental Health and Safety requires 

environmental health conditions to be maintained at a level that meets 

recognized standards of hygiene.1

 It requires the ICE Health Service 

Administrator or IGSA equivalent to conduct activities that are designed to 

assist in the identification and correction of conditions that could adversely 

impact the health of detainees, employees, and visitors. The ICE sanitarian 

consultant is responsible for developing and implementing policies, 

procedures, and guidelines pertaining to activities of the environmental health 

program. 

During our audit, we received complaints from detainees regarding 

environmental health and safety issues. Detainees interviewed made 11 safety 

and 127 health complaints. Safety-related complaints involved excessively 

hot water and unsafe bunk beds; health-related complaints included pests and 

vermin, poor ventilation, and improperly prepared or served food. 

Safety Complaints

Two safety complaints were brought to our attention during interviews with 

detainees. We were able to validate these safety concerns involving 

excessively hot water, which was immediately remedied, and unsafe bunk 

beds, which remain unresolved. 

Excessively Hot Water. At PCJ, 2 of 6 female detainees interviewed 

complained that when toilets, showers, and sinks were in use at the same time, 

water temperature in the shower became excessively hot. We confirmed this 

unsafe condition in the female housing units during our review. On 

October 28, 2005, we told PCJ officials of the problem. PCJ officials took 

immediate actions to identify the cause of the problem, and on November 4, 

2005, a mixing valve was replaced which corrected the problem. 

Unsafe Bunk Beds. At BCP and PCJ, 5 of 25 and 4 of 32 detainees 

interviewed reported being injured from falling out of top bunks and while 

trying to get onto and off the top bunk, respectively. Our review of medical 

documentation at BCP and PCJ confirmed that detainees had fallen out of the 

top bunk and received medical treatment. BCP and PCJ did not have safety 

ladders to access the top bunk and a top bunk safety rail to prevent detainees 

from falling out of bed. We did observe, however, that ladder access and a 

 

1

 Recognized standards of hygiene include requirements accepted by the American Correctional Association, the 

Occupational Safety and Health Administration, the Environmental Protection Agency, the Food and Drug 

Administration, the National Fire Protection Association's Life Safety Code, and the National Center for Disease Control 

and Prevention. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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safety rail on the top bunk were in place on bunk beds in PCJ’s medical unit, 

as well as on triple-deck bunk beds in PCJ’s men’s housing units. During our 

exit meeting, BCP officials told us that they would look into getting ladders 

for top bunk beds. 

We confirmed two complaints regarding bottom bunk bed assignment. At 

BCP, a detainee with a back problem that required medical treatment stated 

that he was denied a request for a lower bed bunk for over four weeks. 

According to medical records, he was denied a lower bunk because he had not 

mentioned his back pain during his initial physical when he first arrived at the 

facility. In another case at PCJ, a delay of one week occurred in assigning a 

bottom bunk to a detainee who was prescribed medication that caused vertigo,

a form of dizziness often associated with a balance disorder. The detainee 

requested a bottom bunk due to concerns of falling. 

Health Related Complaints 

Three types of health complaints were received during our site visits, 

including complaints regarding pests and vermin, poor ventilation, and 

improperly prepared or served food. 

Pests and Vermin. Detainees at both BCP and PCJ complained of pest 

control problems. The ICE Environmental Health and Safety Detention 

Standard require the Officer-in-Charge to contract with licensed pest-control 

professionals to perform monthly inspections. During these routine 

inspections, they will identify and eradicate rodents, insects, and vermin. The 

contract will include a preventative spraying program for indigenous insects. 

IGSAs are required to meet the intent of this standard. 

BCP contracted with a professional commercial pest maintenance service to 

provide on-going pest inspections and treatments. Our review of BCP 

documentation suggested that BCP was aware of, and took action to address 

pest control issues. However, we could not determine whether treatment 

occurred in the areas housing detainees. 

According to PCJ’s extermination schedule, the facility should be inspected or 

treated 12 times per month. For September and October 2005, 9 of 24 

scheduled pest control service reports were available for our review; eight of 

the nine reports indicated evidence of rats/mice and cockroaches at PCJ. 

Also, because of incomplete documentation, we were unable to determine 

whether treatment by a pest control technician was made at PCJ between 

January 2004 through October 2005 for 17 special service requests for 

additional pest control treatments. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Ventilation. We received complaints at BCP, CCA, HCCC, and PCJ 

regarding poor ventilation problems. We observed obstructed air vents in the 

male units at PCJ, and several large industrial fans in front of male detainee 

units that were unplugged and had a substantial amount of dust build-up. 

Although these conditions indicated ventilation problems could exist, we 

could not confirm the complaints. 

Food Service. Detainees at HCCC and PCJ surfaced complaints regarding 

food service. Detainees complained about dirty food trays, which we did 

confirm by observation at both locations. However, we could not determine 

whether this was widespread or the frequency of occurrence. Also, at PCJ, 

complaints were lodged regarding “hot” food that was served cold. We 

observed detainees being served “hot” food that was cold, but we could not 

determine whether the problem was widespread or the frequency of 

occurrence. 

At PCJ, complaints were made regarding undercooked poultry. We identified 

two instances where undercooked poultry was served to PCJ detainees. In the 

first instance, on October 14, 2005, a detainee gave us a piece of undercooked 

poultry served on the previous day. When presented with the undercooked 

piece of poultry, both PCJ officials and PCJ food service contractor agreed it 

was undercooked. PCJ officials took corrective measures within three days, 

which included a new checklist with supplemental procedures to ensure food 

was properly cooked and an incident report and memorandum to all parties 

involved was issued. 

In the second instance, on October 28, 2005, a PCJ detainee gave us a 

grievance form, signed by 57 male detainees, stating that 10 people got sick 

from eating chicken. We reviewed the completed checklist for that day, 

which indicated that the oven temperature used to cook the poultry was not 

according to the new checklist procedures. 

Recommendations 

We recommend that the Assistant Secretary for ICE: 

4. Require detention facilities using double or triple bunk beds to include 

ladder access and a top bunk safety rail to ensure the safety of the 

detainees. 

Management Comments: ICE does not concur. The NDS and American 

Correctional Association (ACA) standards do not require ladders and safety 

rails for bunk beds. ICE believes that this requirement would be extremely 

expensive and will significantly reduce the amount of available bedspace 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 11

(particularly in areas of the country where IGSA bedspace is heavily relied 

upon), and could conceivably make it more difficult for detention officers to 

remove uncooperative detainees. ICE recommended that this 

recommendation be closed. 

OIG Analysis: We acknowledge that the ACA does not require the use of 

access ladders and safety rails for bunk beds. However, because we identified 

several instances where detainees were injured either accessing or falling off 

the top bunk, ICE should thoroughly evaluate the costs and benefits of 

implementing this recommendation and provide the analysis for our review. 

This recommendation is considered unresolved until ICE conducts this 

evaluation. 

5. Ensure that periodic oversight and inspection procedures are in place to 

determine that regular pest treatments are performed, ventilation is 

adequate, and food preparation and serving procedures are followed 

during their annual inspections. 

Management Comments: ICE concurs in part. ICE’s current inspection 

program already requires annual checks to ensure pest control services and 

appropriate food preparation at each facility. However, ICE will modify its 

Health and Safety inspections worksheet utilized during its annual inspections 

by adding a specific line item requiring detention reviewers to check each 

facility for adequate ventilation and will make improvements to its current 

inspectional tools and methodology to monitor adherence to health related 

requirements. Once completed and approved, these changes will be 

incorporated into the annual detention review program and appropriate policy 

will be issued. ICE estimates that these changes will take 90 days to 

implement. 

OIG Analysis: ICE’s proposed actions address the intent of the 

recommendation. This recommendation is resolved but will remain open until 

the appropriate measures have been implemented. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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General Conditions of Confinement 

Staff-Detainee Communication 

The ICE Detention Standard on Staff-Detainee Communication requires 

procedures to be in place to allow for formal and informal contact between 

key facility staff and ICE staff and ICE detainees and to permit detainees to 

make written requests to ICE staff and receive an answer in an acceptable 

time frame. Table 5 summarizes the areas of non-compliance at four 

facilities. 

Table 5 

Non-compliance With Staff-Detainee Communication Standard 

Staff-Detainee 

Communication Standard 

Berks County 

Prison 

CCA San Diego 

Facility 

HCCC Passaic County 

Jail 

Logbooks not kept by ICE 

DRO Field Office 

X X 

Logbooks Incomplete X X 

ICE visits not posted in 

housing units 

X X 

No Documentation for visits X X 

Documentation of ICE Visits to Facilities. The ICE standard requires a 

schedule of announced visits by ICE personnel to be posted in detainee living 

quarters, and to document these visits. ICE officials must also conduct and 

document weekly unannounced visits. 

Beginning in May 2005, logbooks were being kept by ICE Detention officers 

to record their visits to PCJ. In addition, ICE Deportation and Detention 

officers were instructed by the Field Office Director to perform only 

unannounced visits at PCJ. However, beginning in July 2005, both announced 

and unannounced visits were being conducted and schedules for announced 

visits were posted in housing units. Also, ICE DRO Newark Field Office 

detention officer logbook entries for HCCC made before September 2005 did 

not indicate whether the detention officer resolved detainee concerns or 

whether actions were taken in a timely manner. 

Documentation of Detainees’ Written Requests. We sampled 39 detainee 

request forms between January 1, 2005, and December 31, 2005, from files in 

PCJ’s Ombudsman’s office. ICE deportation officials could not substantiate 

that they responded to and answered 38 of 39 detainee request forms within 

72 hours as required by the ICE Standard. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Detention Files 

The ICE Detention Standard on Detention Files states that the creation of a 

detainee file is essential to maintaining a complete record of a detainee’s time 

in facility custody. The file will contain the classification level and any copies 

of receipts for items issued to/surrendered by the detainee. It will also 

document adverse behavior, special requests, complaints, and other 

information considered appropriate for the facility officials. 

Detention files were missing and documentation in some of the files were 

incomplete at four facilities, as summarized in Table 6. 

Table 6 

 Missing Files and Documentation 

Category Krome SPC BCP HCCC PCJ 

Files Requested 15 28 9 20 

Missing Files 4 2 1 3 

Files Missing Documentation 72 5 8 17 

Missing and incomplete information included: 

 Property receipts for clothes and valuables (HCCC); 

 Classification sheets (HCCC, PCJ); 

 Inmate processing forms (HCCC); 

 Transfer in or out forms (HCCC); 

 I-203 forms (form documents decision to detain or release an alien) 

(HCCC); 

 Charges and/or violations (HCCC); 

 Grievances (BCP, Krome); 

 Incident reports (Krome); 

 Handbook receipts (PCJ); and 

 Identifying marks forms (PCJ) 

Reasons for missing files included: 

 Poor recordkeeping (HCCC); 

 Archived files not dated and organized as required by ICE Standards 

(Krome, PCJ); and 

 Decentralized filing system (BCP, HCCC, PCJ). 

 

2

 Krome’s OIC agreed that detention files should contain grievances and incident reports. The OIC said the office would 

review the processes now in place and make changes where necessary to ensure that these reports are filed in detention 

files. 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 14

Disciplinary Policy

Our interviews surfaced complaints regarding the lockdown policy at BCP 

and reporting of incidents at HCCC and PCJ. 

Lockdown Procedures. The ICE Detention Standard on Disciplinary Policy 

requires each facility holding ICE detainees in custody to have a detainee 

disciplinary system. The disciplinary system must include progressive levels 

of reviews such as a disciplinary committee, appeal, and documentation 

procedures. 

According to the BCP detainee handbook, effective May 2002, non-severe 

actions could include counseling, a written warning or reprimand, loss of 

privileges up to four days, or confinement to cell up to 24 hours for violation 

of a rule. Of the 146 unit actions we reviewed, 120 imposed 24-hour lock 

downs. The violations associated with these lock downs included actions such 

as wearing a religious head garment. 

According to the HCCC detainee handbook, issued June 2005, under Detainee 

Discipline, the time the detainee is to remain in pre-hearing segregation will 

be no longer than is necessary to verify the detainee’s safety or the security of 

the facility. The detainee’s pre-hearing detention status will be reviewed by 

the warden/Facility Administrator or designee within 72 hours of placement 

including weekends and holidays. We reviewed the files for two HCCC 

detainees that had been placed in disciplinary segregation for allegedly 

fighting, and not given their disciplinary hearing until 48 hours past their 

72-hour requirement. HCCC officials said the hearing was delayed because 

HCCC could not form a committee to conduct the hearings. Both detainees 

were found not guilty, after serving five days in disciplinary segregation. 

Incident Reporting. The ICE Detention Standard on Disciplinary Policy 

requires officers who witness a prohibited act or have reason to suspect one 

has been committed to prepare and submit an incident report. All incident 

reports must state the facts clearly, precisely, and concisely, omitting no 

details that could prove significant. Reports also will identify the officer(s), 

the detainee(s), and all witnesses to the incident. Additionally, IGSAs must 

have procedures in place to ensure that all incident reports are investigated 

within 24 hours of the incident. 

In the case of the two HCCC detainees previously mentioned that were placed 

in disciplinary segregation allegedly for fighting, the incident report did not 

identify the witness, did not state that the officer observed the fight, and the 

dates were omitted. A HCCC official agreed that this report did not follow 

ICE Detention Standards on Disciplinary Policy. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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At PCJ, between January 2005 and July 2005, three disciplinary actions were 

taken and no incident report was prepared. When we brought this matter to 

the attention of PCJ officials, they provided us with one of the incident reports 

three months after it occurred. 

Hold Rooms 

The ICE Detention Standard on Hold Rooms for unprocessed detainees states 

that the maximum aggregate time an individual may be held in a hold room is 

12 hours. According to the Krome Hold Room logbooks for the period 

November 2, 2003, through April 10, 2004, 40 detainees were held from 13 to 

20 hours. 

We brought this issue to the attention of the Supervisory Immigration 

Enforcement Agent (SIEA), who acknowledged that sometimes detainees 

were held longer than the 12-hour policy. The SIEA explained that a detainee 

may be held longer than 12 hours because: (1) there might not be enough 

processing officers stationed at the in-processing duty station to handle a large 

group of newly admitted detainees; (2) when a woman is admitted into 

Krome, all other duties stop to admit the woman; and (3) the Officer in 

Charge (OIC) might order a priority task to be completed and all other duties 

are postponed. The SIEA advised that the new processing center would allow 

for the cross training of personnel so that when there is an overload of 

detainees to be processed, it can be done more timely. 

Also, hold rooms at Krome were not compliant with the Detention Standard 

criteria. Specifically, the benches inside the hold rooms do not provide 

adequate seating to accommodate the number of detainees being held; the 

light switches are located within the hold rooms; and there are no floor drains. 

ICE staff told us that they were aware of these non-compliance items and that 

they had been noted on a prior review, conducted by ICE in February 2004 

and documented in ICE’s Detention Management Control Programs annual 

report. These items were considered structural deficiencies, which will be 

corrected when Krome’s new processing center is operational. 

Special Management Units (Disciplinary and Administrative) 

Establishment of Special Management Unit. The ICE Detention Standards 

for Special Management Unit (Disciplinary and Administrative Segregation) 

requires each facility to establish a Special Management Unit that will isolate 

certain detainees from the general population. The Special Management Unit 

will have two sections, one for detainees in segregation for administrative 

reasons and the other for disciplinary reasons. A detainee may be placed in 
Treatment of Immigration Detainees Housed at ICE Facilities 

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disciplinary segregation only by order of the Institutional Disciplinary 

Committee, after a hearing in which the detainee has been found to have 

committed a prohibited act. Administrative segregation is a non-punitive 

form of segregation used to remove detainees from the general population 

when separation is necessary. 

On July 14, 2005, two detainees at HCCC were allegedly fighting. Both 

detainees were placed in disciplinary segregation before the hearing was held 

and a ruling by the Institutional Disciplinary Committee. These detainees 

were subsequently found not guilty. 

Similarly, during our review at PCJ, we determined that, in six instances, 

detainees were placed in disciplinary segregation before the hearing was held 

and a ruling rendered by the Institutional Disciplinary Committee. These 

detainees’ charges ranged from verbal altercations with correctional officers 

to physical altercations with other detainees. The detainees were subsequently 

found not guilty. 

Detainee’s Access to Legal Materials

Availability of Materials. The ICE Detention Standard for Access to Legal 

Material requires facilities holding ICE detainees to permit detainees access to 

a law library, and provide legal materials, facilities, equipment and document 

copying privileges, and the opportunity to prepare legal documents. Further, 

the standard requires the facility to designate an employee with the 

responsibility for updating legal materials, inspecting them weekly, 

maintaining them in good condition, and replacing them promptly, as needed. 

Detainees housed at HCCC did not have access to Lexis Nexis legal 

information software, until ICE installed two computers with the Lexis Nexis 

legal software in January 2005. According to HCCC officials, they posted an 

announcement in the detainee units in July 2005 notifying them of the 

availability of the Lexis Nexis computer software. 

At BCP, Lexis Nexis legal information software was not available to detainees 

for the entire month of March 2005. BCP officials said they were not aware 

that the software license had expired. Once notified, ICE renewed the 

software license in April 2005. 

At PCJ, detainees did not have access to legal materials for the month of 

November 2005 because the license for the material had expired. PCJ 

officials notified ICE of the expired license and ICE provided them with an 

updated version of Immigration Case Law library on disks. However, PCJ 
Treatment of Immigration Detainees Housed at ICE Facilities 

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officials could not locate the disks. ICE provided them with another copy on 

November 30, 2005, and the legal material was restored on December 1, 2005. 

Time Allotted In Library. The ICE Detention Standard for Access to Legal 

Material requires each detainee to be permitted to use the law library for a 

minimum of five (5) hours per week. The HCCC law library schedule 

indicated that detainees are allowed only one and half hours on Tuesday or 

Wednesday. PCJ did not have enough space to accommodate the detainee 

population requesting library use, so officials allowed four hours per week per 

detainee. However, detainees were allowed to submit a special request to 

increase their access to the library for more than four hours. 

Detainee Classification

The ICE Detention Standard on Detainee Classification System requires that 

all detainees be classified upon arrival in the facility, before they are admitted 

into the general population. All facilities are required to ensure that detainees 

are housed separately according to three classification levels. Level three 

detainees, for example, are considered a high-risk and require medium to 

maximum security housing. The standard also requires the facilities to 

establish procedures by which new arrivals can appeal their classification 

levels and the detainee handbook’s section on classification should include 

(1) an explanation of the classification levels, with the conditions and 

restrictions applicable to each; and (2) the procedures by which a detainee 

may appeal his/her classification. The standard does not include procedures to 

inform the detainee of his/her classification. 

During our interviews of 51 detainees at the CCA San Diego, 24 detainees did 

not know their classification level. Similarly, at BCP none of the 25 

detainees, at HCCC, 39 of 40 detainees, and at PCJ, 25 of 32 detainees knew 

their classification. 

Classification of Detainees. At PCJ, male detainees were not classified 

according to ICE Standards prior to June 2005 and females were not classified 

because PCJ did not have enough room to segregate them. Of the 159 records 

of male detainees that we reviewed as of October 20, 2005, 22 were not 

classified and 23 were not properly segregated. 

According to PCJ management, the facility was not informed that they had to 

classify male detainees until June 2005. In addition, the facility did not 

classify detainees because they believed it would alleviate the facility from 

potential lawsuits by detainees and advocacy groups. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Housing Detainees of Different Classifications

ICE Detention Standards for classification prohibits level one detainees from 

being housed with level three detainees. The ICE Detention Standard allows 

high-level two detainees to be housed with level three detainees when a 

facility is at or above full capacity. However, the standard prohibits low-level 

two detainees from being housed with level three detainees. 

Our review of 159 detainee records at PCJ showed that on October 20, 2005, 

13 detainees classified as a level one detainee were housed with level three 

detainees. Similarly, one detainee classified as a level two detainee was also 

housed with level three detainees. Further, three detainees classified as level 

three detainees were housed with level one detainees, and six were housed 

with level two detainees. 

We reviewed the classification levels for ICE detainees at BCP as of 

January 20, 2005, and determined that 8 of 59 detainees were classified as 

level three, with the remaining detainees classified as level two. BCP housed 

7 of the 8 level three detainees with level two detainees. Similarly, on 

March 21, 2005, 7 of 41 detainees were classified as level three; 4 of the 7 

detainees were housed with level two detainees. In each instance, BCP 

officials housed the level three and level two detainees together without 

determining whether the level two detainees were classified as high or lowlevel two. 

Correspondence and Other Mail

Handling of Special Mail. The ICE Detention Standard for Correspondence 

and Other Mail requires all facilities to implement procedures for inspecting 

special correspondence for contraband. The inspections are to be conducted 

in the presence of the detainee. At BCP, 9 of 25 detainees interviewed 

complained that their “special mails,” such as correspondence with counsel, 

were not opened in their presence. According to the BCP mailroom clerk, 

some special mails might have been opened because they were not clearly 

marked as containing legal materials. 

Writing Implements, Paper, and Envelopes. The ICE Detention Standard 

for Correspondence and other Mail requires the facility to provide writing 

paper, writing implements, and envelopes at no cost to detainees. Detainees at 

CCA were not provided free writing materials; these items were sold in the 

commissary. CCA officials stated that only indigent detainees were provided 

these items at no cost and CCA’s handbook indicated the same. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Unclaimed Mail. Krome established a practice to return mail if the detainee 

had not claimed it within two days. This practice was not documented in 

Krome’s policy manual or the detainee handbook. The OIC told us that this 

2-day time limit was not in their policy manual but was a practice carried 

forward from training that ICE personnel gave Krome’s mail contractor. The 

OIC assured us that this would either be written into policy and the detainees 

would be informed of this time limit, or it would be rescinded. After 

completion of our review, ICE officials provided documentation stating that 

mail will be "returned to sender" after five (5) business days when all 

reasonable efforts have been made to notify the detainee of mail received. 

Funds And Personal Property

Separation Of Duties. The ICE Detention Standard for Funds And Personal 

Property requires two officers to be present both to remove funds from a 

detainee’s possession and to inventory the property on the property-receipt 

form, G-589. The ICE standard also requires the property and valuables 

logbook to contain identification of the property removed from the detainee. 

BCP did not have adequate controls over the intake of detainees’ personal 

property. One individual controlled both the key to the safe box and the 

placement/removal of the detainees’ personal property. Also, no logbook was 

maintained to record property receipt numbers issued for the personal funds 

removed from detainees. A BCP official stated two officers would be used 

during admission when necessary. When only one detainee was being 

processed through admission, BCP did not see the need for two officers. 

Stolen Funds and Personal Property. Independent of our work at the five 

detention facilities, our Office of Investigations recently completed an 

investigation at the Monroe County Jail detention facility where they 

determined that detainees’ funds and personal property had been stolen. 

Specifically, the property control officer was convicted of theft of over 

$308,736 in U.S. currency, as well as numerous personal property items such 

as jewelry, watches, and credit cards. 

Quarterly Inventories. The ICE Detention Standard, Funds and Personal 

Property, requires each facility to have a written procedure for inventory and 

audit of detainee funds, valuables, and personal property. In addition, it 

stipulates that an inventory of detainee baggage and other non-valuables will 

be conducted by the OIC’s designee at least once each quarter; and the 

facility’s daily log will indicate the date, time, and name of the officer(s) 

conducting the inventory. Discrepancies are to be reported immediately to the 

OIC. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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HCCC officials did not perform inventories of detainee’s personal baggage 

and did not maintain a quarterly inventory log as required by the ICE 

standard. In addition, HCCC officials told us the quarterly inventory audits 

were being conducted “whenever time” allowed them. HCCC officials agreed 

that the inventory process needed to be addressed immediately. HCCC 

officials later told us the last personal property inventory audit was completed 

in May 2005; however, HCCC did not maintain an audit log or check-off list, 

and could not provide documentation showing that the inventory audit had 

actually been performed. 

Detainee Grievance Procedures

The ICE Detention Standards for Detainee Grievance Procedures requires 

each facility to devise a method for documenting detainee grievances. At a 

minimum, the facility must maintain a Detainee Grievance Log containing a 

copy of grievances, an assigned log number for each grievance, a receipt date, 

and the date of the disposition. Also, it requires that a copy of the formal 

grievance remain in the detainee’s detention file for at least three years. The 

standard also requires grievances to be acted on within five working days 

through informal or formal resolution. Further, the standards require that the 

facility will convene a grievance committee to study the grievance in the event 

the detainee does not accept the department head’s decision. 

Grievance Documentation and Filing. PCJ staff did not maintain a detainee 

grievance log. In addition, ICE detention staff at the DRO Field Office did 

not maintain a logbook of formal grievances prior to June 2005. We 

determined that formal detainee grievances at PCJ from June 2005 to January 

2006 were not filed in detainee detention files. Instead, they were filed with 

formal grievances against PCJ officials and ICE officials, along with detainee 

request forms and detainee personal property forms, located in the 

Ombudsman’s office. 

Timeliness of Grievance Actions. At BCP, we reviewed nine grievances filed 

from January 1, 2004, to December 31, 2004; none of the nine were acted on 

within 5 days. The response time ranged from 7 to 22 days with an average 

response time of 9 days. Similarly, we reviewed 17 grievances files at HCCC 

from January 2004 through July 2005; 13 of the 17 did not receive responses 

within the 5-day timeframe. An HCCC official stated they were not aware of 

the 5-day requirement to respond to grievances. However, according to the 

HCCC detainee handbook, “the facility Grievance Officer shall, within five (5) 

days of receipt of the grievance, conduct an investigation of the grievance and 

render a written response to the detainee.” At PCJ, we reviewed eight ICE 

grievances filed between January 1, 2005, and December 31, 2005; none of the 

eight were acted on within 5 days. In one instance, the grievance was faxed to 
Treatment of Immigration Detainees Housed at ICE Facilities 

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ICE on July 1, 2005, and ICE responded on July 25, 2005, 20 days beyond the 

prescribed time. 

Krome Grievance Process. According to Krome’s Standard Operating 

Procedures KRO/ /02-07 titled Detainee Grievance Procedures, “The Section 

Chief (SC)-Camp Operations will assign a Second-line Supervisory 

Immigration Enforcement Agent (SIEA) to the duties of Grievance Officer. 

The Grievance Officer will collect the grievances from the secured and 

marked grievance boxes in the facility and ensure that the complaint is 

directed to the proper department for resolution.” Contrary to this policy, the 

actual process used at Krome was for grievances to be collected by a first-line 

supervisor and reviewed to determine their nature. The first-line supervisor 

then tries to resolve the grievance informally. If the grievances cannot be 

resolved informally, they become formal, and the second-line supervisor 

handles them. We reviewed 146 grievances filed at Krome for CY 2004, 141 

were handled informally, and 5 were forwarded to the second line supervisor 

for formal review. Only five were actually resolved by the grievance officer 

as required by Krome’s grievance policy. 

Grievance Committee. PCJ does not have a detainee grievance committee. 

PCJ has one official responsible for answering and resolving all formal PCJ 

grievances. 

Access to Drop Boxes. PCJ had two padlocked drop boxes controlled by PCJ 

staff for all detainee correspondence, such as Ombudsman request slips, 

detainee grievances, detainee request forms, etc. One box was located in the 

cage room and the other was located in front of the Ombudsman’s office. 

Both were accessible only to PCJ staff. A detainee would have to request a 

PCJ staff member to place formal correspondence in one of the boxes. 

Without “drop boxes” accessible to ICE detainees, detainees can’t file 

anonymously and retaliation could occur. 

Issuance and Exchange of Clothing 

The ICE Detention Standard on Issuance and Exchange of Clothing, Bedding, 

and Towels requires each facility to have a policy and procedure for the 

issuance and regular exchange of clothing, bedding, linens, and towels. The 

standard requires all new detainees to be issued one uniform shirt and one pair 

of uniform pants or one jumpsuit; one pair of socks; one pair of underwear; 

and one pair of facility issued footwear. The standard also requires facilities 

to provide detainees with clean socks and undergarments daily and with clean 

outer garments at least twice weekly. IGSAs are required to meet the intent of 

this standard. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Issuing Required Clothing. PCJ officials stated that detainees are usually 

provided two uniforms except during shortages, when they are provided with 

only one uniform. PCJ officials stated that no socks or undergarments are 

issued and detainees are allowed to keep their socks and undergarments 

during intake or can purchase socks and undergarments from the PCJ 

Commissary. 

At HCCC, 23 of 40 detainees interviewed stated they had not received all 

clothing required to be issued. We reviewed of a sample of HCCC property 

records for 13 detainees; 7 did not receive all required items of clothing. 

HCCC officials indicated that because of HCCC’s low inventory of shoes, 

detainees were being allowed to keep and wear their own sneakers, but not 

dress shoes or boots. 

Dirty Clothing Exchange. HCCC officials informed us that clothes are only 

taken in for washing once or twice per week. They added that they could not 

recall the last time dirty clothes were exchanged for clean clothes, nor did they 

know whether HCCC has a policy that meets ICE Detention Standards for the 

exchange of clothes. Also, officials stated that socks and undergarments are 

not exchanged on a daily basis. 

At PCJ, we observed that when it is time for laundry to be done, detainees are 

not given clean clothes in exchange for dirty clothes. Instead, the detainees 

remain in their undergarments, or shorts, until their clean laundry is returned, 

which can take from 2 to 6 hours. Interviews with detainees confirmed that 

this was standard practice. 

Outdoor Recreation

The ICE Detention Standard for Recreation requires all facilities to provide 

ICE detainees with access to recreational programs and activities, under 

conditions of security and supervision that protect their safety and welfare. 

Furthermore, every effort shall be made to place a detainee in a facility that 

provides outdoor recreation. If outdoor recreation is available at the facility, 

each detainee shall have access for at least one hour daily, at a reasonable time 

of day, five days a week, weather permitting. 

At PCJ, 19 of 32 detainees interviewed complained they were not provided 

with the required outdoor recreation time. We sampled 24 weeks of 

recreation and movement logbooks at PCJ for CY 2005 for male detainees 

housed in low, medium and high risk units. During this timeframe the 

detainees should have received 120 days of outdoor recreation, 1 hour a day, 

5 days per week. Detainees housed in all three risk units did not receive the 

required outdoor recreation time. For example, male detainees housed in the 
Treatment of Immigration Detainees Housed at ICE Facilities 

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low risk unit received outdoor recreation 66 of 120 days, averaging only about 

3 days per week. Similarly, for female detainees housed in general 

population, we sampled 12 weeks in CY 2005. The data showed that female 

detainees received outdoor recreation 38 of 60 required days, averaging about 

3 days per week. 

At BCP, 14 of 25 of detainees interviewed stated they were denied recreation 

or did not receive outdoor recreation, as required by the ICE standard. We 

could not confirm the complaints since BCP does not maintain recreation logs. 

At CCA, 8 of 51 detainees complained that they did not receive the daily one 

hour recreation. According to CCA’s procedures, if one or more detainees 

violated a requirement, they would not be allowed the one-hour recreation as a 

disciplinary measure. The ICE standard specifically prohibits detainees from 

not being allowed to participate in recreation unless it impacts facility 

security. 

At HCCC, 27 of 40 detainees interviewed stated that they did not receive the 

daily one-hour recreation. According to HCCC’s Central Control logbook for 

periods December 12, 2004, through February 11, 2005, and April 8, 2005, 

through June 2, 2005, on ten occasions the logbooks lacked documentation 

showing that the one-hour minimum daily recreation requirement had been 

met. 

Telephone Access

The ICE Detention Standard for Telephone Access requires the facility to 

provide detainees with reasonable and equitable access to telephones during 

established facility waking hours. Key elements of the standards include: 

• The facility shall maintain detainee telephones in proper working order. 

Appropriate facility staff shall inspect the telephones regularly (daily in 

SPCs/CDFs), promptly report out-of-order telephones to the repair service, 

and ensure that required repairs are completed quickly. 

• Generally, telephone access will be granted within 8 waking hours of the 

detainee’s request, but will always be granted access within 24 hours of 

the request. Incidents of delays extending beyond 8 waking hours must be 

documented and reported to ICE. 

• The facility shall provide a reasonable number of telephones on which 

detainees can make calls regarding legal matters without being overheard 

by officers, other staff or other detainees. Privacy may be provided in a 

number of ways, including: 
Treatment of Immigration Detainees Housed at ICE Facilities 

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1. Privacy panels (side partitions) that extend at least 18 inches to prevent 

conversations from being overheard; 

2. Placement of telephones where conversations may not be readily 

overheard by other detainees or facility staff; or 

3. The use an office telephone to make confidential calls regarding their 

legal proceedings. 

ICE’s contract with the telephone service provider allows facilities to make 

available calling cards, collect calls, and free pre-programmed calls for 

detainee use. ICE will supply the telephone numbers that the contractor shall 

pre-program. ICE currently allows numbers related to detainee free legal 

services, phone calls to consular offices, and access to courts at no cost to the 

detainee. 

Telephones In Visitation Rooms. On October 21, 2005, 4 of 11 telephones 

located in the male visitation room at PCJ were not operational. On 

November 18, 2005, 1 of 11 telephones did not work. Similarly, on April 19, 

2005, 13 of 60 telephones located in the detainee visitor areas at CCA San 

Diego were not in working order. 

Privacy For Legal Matter Telephone Calls. At BCP, detainees used 

telephones located in a day room, where other detainees or staff can overhear 

conversations involving legal matters. At HCCC, the telephones used by 

detainees did not have privacy panels. At CCA, the telephones in the housing 

units were located under the wall-mounted television sets and did not include 

privacy panels. Also, CCA officials made available the telephone in the unit 

manager’s office for making calls regarding legal matters. However, CCA 

officials stated that the detainee is never left alone in the room, as a CCA 

official is always present. 

At PCJ, the Ombudsman’s office was designated for calls relating to legal 

matters. We observed that the calls were not private because a PCJ official is 

always in the office during the calls. 

Compliance with Requests for Telephone Access. We sampled request 

slips at PCJ for July, August, and September 2005. In six instances, detainees 

had to file a formal grievance to request an emergency telephone call to notify 

family of their detained status at PCJ. In one instance, the Ombudsman’s 

office took at least 16 business days to grant a detainee’s request to call an 

attorney as opposed to the 24 hour time frame required by the standard. 

Consulate and Legal Telephone Numbers. The telephone service contract 

between ICE and the service provider for the detainee phone system requires 

ICE to supply the telephone numbers that the contractor shall pre-program. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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According to the standards, the facility shall permit the detainee to make 

direct calls to legal service providers, in pursuit of legal representation or to 

engage in consultation concerning his/her expedited removal case. In 

November 2005, we tested 63 of 188 consulate numbers at PCJ, and were 

unable to reach a representative on 50 of the 63 numbers. For 10 of the tests, 

we were connected to an answering machine. It is necessary for the detainee 

to talk to a representative because it is not possible for the detainee to receive 

a return call. The phone system in the housing unit is not designed to receive 

incoming calls. In addition, we tested 12 pro bono legal representation 

telephone numbers, and were unable to make a connection for any of the 12 

numbers. The posted number either required a detainee to pay a fee (use a 

calling card), the number did not accept the call, or the call would not go 

through. ICE DRO was not aware of the problems the detainees had in 

contacting consulate or legal representatives. 

Telephone Maintenance Documentation. HCCC did not keep telephone 

maintenance records. PCJ staff responsible for telephone maintenance and 

repairs told us that they did not record telephone maintenance and repairs 

prior to June 2005. Consequently, were unable to determine whether the 

facilities monitored and repaired telephones as required by the ICE standard. 

Visitation 

Length of Visits. The ICE Detention Standard for Visitation requires 

facilities to allow detainees a minimum of 30 minutes visitation time under 

normal conditions. Detainees at PCJ were not allowed a minimum of 30 

minutes during family visitations. The PCJ Inmate Handbook allowed for at 

least two non-contact visits3 for a minimum of 15 minutes each per week 

depending on time and space availability. At PCJ 25 of 32 detainees 

interviewed said they did not have enough time to visit with family and 

friends. Also, we received complaints regarding the length of visiting time at 

BCP (7 of 25 detainees) and HCCC 23 of 40 detainees); however, we could 

not substantiate these complaints. 

Recommendations 

We recommend that the Assistant Secretary for ICE: 

6. Ensure detention facilities properly segregate high-risk, category three 

detainees from low-risk category one and two detainees. 

 

3

 A non-contact visit occurs when a detainee and visitor are allowed to speak to each other on the facility’s visitation 

phones, while separated by a glass partition, but are not permitted to touch one another. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Management Comments: ICE concurs. ICE will reissue its existing NDS on 

Classification to all Field Office Directors (FODs) and authorized detention 

compliance reviewers. ICE will reiterate the importance of compliance with 

the standard and require that all FODs review the current classification and 

housing assignment practices at detention facilities within their respective 

Field Offices. FODs will be required to take appropriate corrective action as 

necessary to ensure compliance, including certification that all responsible for 

classification have received the policy. These measures will take 180 days to 

complete. 

OIG Analysis: This recommendation is resolved but will remain open until 

implementation is completed. 

7. Ensure adequate separation of duties and other internal control procedures 

are implemented at detention facilities for detainee funds and personal 

property to reduce the risk of property being inadequately accounted for 

and to safeguard against theft. 

Management Comments: ICE concurs. ICE will modify the current review 

worksheet for Funds and Personal Property utilized in its annual review 

process to include a specific line item for IGSA facilities that do not have 

automated detainee funds systems addressing the requirement that two 

officers must be present during the processing of a detainee’s funds and 

valuables. Once completed and approved, any changes will be incorporated 

into our annual detention review program and appropriate policy issued. 

These measures will take 90 days for ICE to implement. 

OIG Analysis: This recommendation is resolved but will remain open until 

implementation is completed. 

8. Ensure that periodic oversight and inspection procedures are in place to 

address compliance with the Detention Standards in the following areas 

during its annual inspection process. 

• Staff-detainee communication 

• Documentation of detention files 

• Disciplinary policy 

• Special Management Units (Disciplinary and Administrative) 

• Access to legal materials 

• Correspondence and other mail 

• Detainee grievance procedures 

• Issuance and exchange of clothing 

• Outdoor recreation 

• Telephone access and privacy 

• Visitation 
Treatment of Immigration Detainees Housed at ICE Facilities 

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Management Comments: ICE concurs in part. ICE concurs with the need 

for inspection in the areas listed but does not concur with this 

recommendation since the NDS and ICE annual review process already 

addresses each of the items in the recommendation. ICE is confident that, 

through its annual inspections program, the appropriate level of oversight 

regarding compliance with the NDS exists. In addition, ICE’s practice of 

conducting annual reviews and weekly site visits to its detention facilities 

exceeds the industry standards set by the ACA, National Commission for 

Correctional Health Care, and Joint Commission on Accreditation of 

Healthcare Organizations. These organizations, nationally recognized as 

leaders in the detention industry, conduct inspections at three-year intervals. 

ICE requests that this recommendation be considered resolved and closed. 

OIG Analysis: Given the issues noted during our review as discussed in this 

report for each area, ICE should assess whether the methods used in their 

annual inspection process are adequate to surface these types of issues and 

ensure that corrections are implemented. Therefore, we consider this 

recommendation unresolved until such measures are taken. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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ICE Procedures For Reporting Detainee Abuse 

We reviewed complaints from detainees received by our Office of 

Investigations alleging that correctional staff physically, sexually, or verbally 

abused them while in custody at all five detention facilities. The ICE 

Detention Standards do not address detainee reporting of abuse or civil rights 

violations. However, ICE posts posters in the facilities informing detainees to 

report instances of abuse to the OIG Hotline. Also, detention facilities used 

handbooks developed for inmates instead of handbooks explicitly developed 

for detainees, as required. In some instances, facilities did not provide 

detainee handbooks, or they did not provide the handbooks and orientation 

materials in Spanish or other languages. 

Detainees Alleged Physical, Sexual, and Verbal Abuse by Corrections 

Officers

Immigration detainees have alleged that correctional staff physically, sexually, 

and verbally abused them while in custody at all five detention facilities. 

Although we were made aware of numerous instances where alleged physical 

abuse occurred, the following four represent some of the most egregious 

allegations received. 

• Rape allegation at CCA San Diego 

A female detainee at CCA San Diego alleged that during a work detail, a 

contract guard sexually assaulted her. Office of Investigations issued a 

final report of investigation regarding this case. As a result, the subject 

contract guard was fired, thus requiring no response from ICE. Both the 

local U.S. Attorney’s Office and the Civil Rights Division declined to 

prosecute. 

 

• Accusation of Abusive Search at CCA San Diego 

On December 27, 2004, an ICE Detention Officer filed a complaint on 

behalf of a detainee, alleging a female CCA Senior Correctional Officer 

(SCO) conducted a physically abusive "pat down" search that was 

followed up by a strip search conducted within view of other detainees. 

Both the SCO in question and another Correctional Officer (CO) provided 

written statements denying this allegation. Our Office of Investigations 

referred this case to ICE Office of Professional Responsibility (OPR) for 

their action. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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• Complaint from Wheelchair-Bound detainee at CCA San Diego 

On May 5, 2005, our Office of Investigations investigated a complaint 

from a handicapped detainee at the San Diego CCA, who alleged that a 

CO dislodged him from his wheelchair when he tried to enter another area. 

The detainee was examined by medical staff and did not sustain any 

injuries. The CO was put on administrative leave at that time. Our Office 

of Investigations referred this case to ICE OPR for their action.

• Suicide Death at PCJ 

On February 16, 2005, a PCJ officer found a detainee, who had been in 

ICE custody at PCJ for approximately 1 month, hanging in his cell from a 

noose made from a bed sheet. Our Office of Investigations is reviewing 

the case to determine whether there was any impropriety by PCJ officials. 

The case remains open. 

In addition to these cases, we identified the following two instances that 

indicate improper behavior by correctional officials. 

• Use of camera phone at HCCC

During interviews with HCCC detainees in July 2005, two detainees 

alleged that a correctional officer used a cell phone to take pictures of the 

detainees as they came out of the bathroom and shower, and as they slept 

in their cells. One detainee believed the correctional officer was taking 

pictures, because the correctional officer would hold his cell phone up, 

point it at them, and start laughing. 

We interviewed selected correctional officers including the one alleged to 

have taken the pictures. The correctional officer stated that he has never 

used a cell phone in the tier and that cell phones are not allowed in the 

building. Another correctional officer stated that while he personally has 

never used a cell phone in the tier, he has seen other correctional officers 

use personal cell phones while on the tiers, although it is against policy. 

HCCC staff members may wear or carry phones and beepers while on 

duty only if they are issued by the department, or authorized by the 

Director or his/her designee. Our Office of Investigations referred this 

allegation to ICE OPR for appropriate action. 
Treatment of Immigration Detainees Housed at ICE Facilities 

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• Appearance of Retaliation at Hudson County Correctional Center 

On July 14, 2005, HCCC staff transported a selected detainee to the ICE 

field office building for an interview with our audit team. At that time, the 

detainee refused to be interviewed for fear of retaliation from the HCCC 

staff, and was transported back to HCCC. Although confidential, the 

meeting with OIG staff was known to HCCC officials. Soon after, the 

detainee and another detainee were found allegedly fighting with each 

other. Both detainees were immediately placed in disciplinary 

segregation; however, the detainees were not given their disciplinary 

hearing for 5 days, which exceeded the standard of holding hearings 

within 72 hours. 

We observed the detainees in disciplinary segregation during this period; 

the detainees were in separate cells, housed with a non-ICE detainee. We 

inquired about this housing situation, and the correctional officer on duty 

told us that the detainees were housed with non-ICE detainees because 

there was not enough space to house the two detainees in separate cells. 

However, there were at least two empty cells that could have housed the 

two ICE detainees separately. An HCCC official indicated that the ICE 

detainees had similar classification levels as the non-ICE detainees and 

therefore the two (one ICE detainee and one non-ICE detainee) could be 

housed in the same cell. 

We attended the disciplinary hearings for both ICE detainees, 5 days after 

serving time in disciplinary segregation. During the hearings both 

detainees were found not guilty. 

 

ICE Detention Standard Does Not Address Detainee Reporting of Abuse 

or Civil Rights Violations

The ICE Detention Standard on Detainee Grievance Procedures does not 

explicitly address detainee rights for the reporting of abuse and civil rights 

violations. All five detention facilities reviewed distributed handbooks that 

did not properly explain the process for reporting allegations of abuse and 

civil rights violations. 

The Standard requires ICE staff to comply with the requirement to report 

allegations of officer misconduct to a supervisor or higher-level official in 

his/her chain of command, and/or to INS Office of Internal Audit and/or the 

DOJ Office of Inspector General. CDFs and IGSA facilities must forward 

detainee grievances alleging officer misconduct to ICE. ICE will investigate 

every allegation of officer misconduct. This reporting requirement applies 

without exception to all detainee allegations of officer misconduct, whether 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 31

formally or informally submitted. The ICE Standard has not been updated to 

reflect the creation of the Department of Homeland Security and the DHS 

Office of Inspector General. 

ICE detainees are in administrative custody versus punitive correctional 

custody and are afforded rights and privileges specifically germane to their 

custody status. For example, detainees are allowed a hearing before an 

immigration judge and can request voluntary departure. Also, pro bono legal 

services are made available to them. 

Five BCP officials informed us that they were not aware that there are specific 

ICE standards for detainees; therefore, correctional officers were trained to 

treat inmates and detainees the same. Also, four senior San Diego CCA 

Facility correctional officers informed us that officers had no knowledge of 

ICE’s policies and procedures pertaining to ICE detainees. 

Detainee Handbooks

ICE Detention Standard for the Detainee Handbook requires each facility to 

develop a detainee handbook that will specify the rules, regulations, policies, 

and procedures with which every detainee must comply. In addition, the 

handbook will list detainee rights and responsibilities. The handbook will list 

and classify prohibited actions and behaviors, along with disciplinary 

procedures and sanctions. Grievance and appeals procedures must also be 

included in the handbook. The ICE Detention Standard on Admission and 

Release requires every detainee to receive a copy of the handbook upon 

admission. 

Issuing Detainee Handbooks. Two facilities, HCCC and PCJ, did not issue 

handbooks specifically addressing detainee’ rights, responsibilities, and rules. 

We were unable to confirm if BCP or CCA San Diego issued handbooks to all 

detainees. 

The HCCC handbook was not issued until June 2005. Consequently, based on 

their admission dates into HCCC, 37 of 40 detainees interviewed did not 

receive the HCCC handbook. After HCCC published its handbook, 15 of 40 

detainees interviewed from June 2005 through October 2005 stated that they 

were not provided the handbook at admission. 

At PCJ, 16 of 32 detainees interviewed said they had not received a detainee 

handbook in compliance with ICE required standards. We observed that 

during the PCJ admissions process, detainees were issued a Passaic County 

Jail: Inmate Handbook, effective January 2005, which outlines the rules and 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 32

regulations that each inmate (not detainee) should follow while remaining in 

the facility. 

Handbooks Should Include Detainee Reporting Process. All five detention 

facilities distributed handbooks to detainees that did not explain the process 

for reporting allegations related to abuse or civil rights violations to the DHS 

OIG. Even with the hotline posters that we use to inform detainees to report 

instances of abuse to us, some detainees were not aware that they could report 

allegations related to abuse or civil rights violations to our office. Three 

facilities (BCP, CCA San Diego, and PCJ) did not address how to report 

officer misconduct to the OIG. HCCC and Krome briefly addressed how to 

report officer misconduct. 

Translating Handbooks and Orientation Materials Into Spanish and 

Other Languages 

ICE Detention Standard on Admission and Release requires each facility to 

have a medium, such as a video, to provide detainees an orientation to the 

facility. The Standard requires the orientation video to be in English and 

Spanish, or the most prevalent language(s) spoken by detainees at the facility. 

In addition, the ICE Detention Standard for the Detainee Handbook requires 

the facility to have English and Spanish versions of the handbook available for 

issuance to the detainees at admission. 

At BCP, during admission and release procedures, an orientation package was 

provided in English to English-speaking detainees in order to supplement the 

oral presentation. However, no orientation package was available in Spanish 

for the Spanish-speaking detainees. Instead, one of the bilingual officers on 

duty would verbally translate the oral presentation for the Spanish speakers in 

the back of the room. 

No Spanish version of a detainee handbook had been published at HCCC 

since April 3, 2003, although HCCC officials stated they planned to publish a 

Spanish version. 

Recommendations 

We recommend that the Assistant Secretary for ICE: 

9. Revise the ICE Detention Standard to: 

• explicitly address how detainees should report allegations of abuse and 

civil rights violations, along with violations of officer misconduct, 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 33

directly to ICE management or the DHS Office of Inspector General, 

and 

• require detention facilities to provide appropriate written guidance to 

correctional officers to ensure that treatment of immigration detainees 

is specifically germane to their custody status. 

Management Comments: ICE concurs in part. As noted in the report, ICE 

fully complies with the requirement to post the OIG notification in each 

housing unit. ICE will ensure that the OIG phone number is programmed into 

the ICE detainee phone system. In addition, ICE will revise its current 

worksheet regarding “Access to Telephones” to include a line item ensuring 

the OIG Hotline phone number is working. ICE will modify the NDS for 

Detainee Grievances and the Detainee Handbook to include specific 

instructions regarding how to report allegations of staff misconduct, abuse, 

and civil rights violations. The ICE Detainee Handbook standard will be 

modified to require that each handbook provide instructions to detainees on 

how to report allegations of officer misconduct, abuse, or civil rights 

violations. The telephone system programming will be completed within 30 

days. The other measures discussed will take 180 days to complete. 

OIG Analysis: This recommendation is unresolved until implementation is 

completed and ICE addresses the second part of the recommendation to 

require detention facilities to provide appropriate written guidance to 

correctional officers to ensure that treatment of immigration detainees is 

specifically germane to their custody status. 

10. Validate that each detention facility issues a handbook for immigration 

detainees that: 

• specifically identifies detainees’ rights, responsibilities, and rules, 

• includes a section on detainee’s rights regarding the reporting of 

allegations of abuse and civil rights violations, and 

• includes a provision that detainees may report allegations of abuse and 

civil rights violations directly to the DHS Office of Inspector General. 

Management Comments: ICE concurs in part. The ICE Detainee Handbook 

and Admissions and Release standards already require that: 

• detainees receive a comprehensive orientation to each facility; 

• each detainee receives a copy of the detainee handbook upon admission; 

• detainee handbooks are translated into Spanish or the most prevalent 

language spoken by detainees at their facility; and, 

• the detainee handbook identifies detainees’ rights, responsibilities, and 

rules. 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 34

Within the next 90 days, ICE will reemphasize to all NDS compliance 

reviewers that they must verify these requirements are being met during 

annual reviews. 

OIG Analysis: ICE’s proposed actions address the intent of the 

recommendation. This recommendation is resolved but will remain open until 

the appropriate measures have been implemented. 

11. Verify that all corrections facilities: 

• have procedures in place to verify that each detainee receives a copy of 

the detainee handbook upon admission, 

• translate detainee handbooks into Spanish or the most prevalent 

languages spoken by detainees at their facility, and 

• have an orientation video in English and Spanish, or the most 

prevalent language(s) spoken by detainees at the facility. 

Management Comments: ICE concurs in part. ICE currently requires all 

SPCs and CDFs to provide an orientation video in English and Spanish. The 

NDS also specifically requires that: 

• detainees receive a comprehensive orientation to each facility; 

• each detainee receives a copy of the detainee handbook upon admission; 

• detainee handbooks are translated into Spanish or the most prevalent 

language spoken by detainees at their facility; and, 

• the detainee handbook identifies detainees’ rights, responsibilities, and 

rules. 

However, the OIG recommendation to require every facility to provide a 

video orientation is not consistent with the NDS or other industry standards. 

Accordingly, for IGSA facilities, ICE will provide written orientation 

materials. To that end, ICE intends to develop an ICE detainee handbook that 

will provide access to information that is oriented towards ICE detainees 

regardless of their custodial location. At a minimum, it will contain the 

information recommended by OIG. ICE staff conducting site visits under the 

Staff Detainee Communication standard will be required to ensure these 

handbooks are being provided to each detainee. Within the next 90 days, ICE 

will reemphasize to all detention standards compliance reviewers that they 

must verify these requirements are being met during annual reviews. The 

handbook will be completed within the next 180 days. 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 35

OIG Analysis: ICE’s proposed actions address the intent of the 

recommendation. This recommendation is resolved but will remain open until 

the appropriate measures have been implemented. 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 36

Thoroughness of ICE Detention Facility Inspections 

Each SPC, CDF, and IGSA facility is reviewed annually for compliance with 

the ICE Detention Standards using procedures and guidance as outlined in the 

DMCP. At SPCs and CDFs, the ICE DRO headquarters staff conducts the 

review; at IGSA facilities, DRO field office staff conducts the review. 

We reviewed the latest available Annual Detention Review reports prepared 

by ICE DRO for the five detention facilities included in our audit sample: 

(1) BCP 2004 Annual Detention Review, (2) CCA Facility in San Diego 2004 

Annual Detention Review, (3) HCCC 2005 Annual Detention Review, 

(4) Krome SPC 2005 Annual Detention Review, and (5) PCJ 2005 Annual 

Detention Review. 

A final rating of Acceptable was given to all five detention facilities, meaning 

the detention facilities were determined to be adequate and operating within 

standards, with some deficiencies. However, our review of the five facilities 

identified instances of non-compliance regarding health care and general 

conditions of confinement that were not identified during the ICE annual 

inspection of the detention facilities. Other areas identified, although not 

specifically addressed by the standard, included environmental health and 

safety and reporting of abuse by detainees. 

This observation was beyond the planned scope of our work. However, we 

believe it needed to be brought to the attention of ICE management. ICE 

management believes the differences result from the in-depth nature of our 

review in contrast to the three to four day inspection process used by ICE. 

Recommendations 

We recommend that the Assistant Secretary for ICE: 

12. Take appropriate actions to improve the inspections process and ensure 

that all non-compliance deficiencies are identified and corrected. 

Management Comments: ICE concurs. ICE recognizes the need for 

independent review of its detention inspection process and is constantly 

looking at ways to improve its processes. The following steps have been 

authorized and are in progress: 

• DRO has provided three full-time, funded positions to the ICE Office of 

Professional Responsibility (OPR); 
Treatment of Immigration Detainees Housed at ICE Facilities 

Page 37

• OPR will provide oversight, management, and an independent review of 

all detention compliance reviews conducted by DRO; and 

• OPR will alert DRO to any deficient or at risk facilities as they relate to 

NDS compliance. 

ICE will report as to the status of these actions to the OIG as they are 

implemented. 

OIG Analysis: This recommendation is resolved but will remain open until 

implementation is completed. 
Appendix A 

Purpose, Scope, and Methodology

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 38

The purpose of our audit was to identify and investigate deficiencies from ICE 

detention standards related to facilities used by ICE to house immigration 

detainees. We evaluated Immigration and Customs Enforcement’s (ICE’s) 

implementation of its detention standards and detention facilities’ compliance 

with the standards; and examined reports and allegations related to detainees’ 

abuse. Our audit focused on ICE’s implementation and oversight of 22 of 38 

detention standards. 

We met with ICE and DRO officials responsible for establishing the detention 

standards, monitoring compliance with detention standards, reviewing and 

resolving allegations and complaints reported by detainees, and maintaining 

program information and statistics. We also met with U.S. Customs and 

Border Protection officials responsible for establishing policies and 

procedures, monitoring compliance with established policies and procedures, 

reviewing and resolving allegations and complaints reported by detainees, and 

maintaining program information and statistics. Our review coverage 

included program information and statistics from January 2004 through 

January 2006. Other periods were included as deemed necessary to address 

the audit objectives. 

We also met with Non-Governmental Organization (NGO) officials and 

representatives from advocacy groups to obtain their concerns and views 

regarding the treatment of detainees held on immigration charges at the 

facilities selected for review. 

We conducted fieldwork at the following five detention facilities, which 

consist of one SPC, one CDF, and three IGSA facilities. 

Detention Facilities

1. Berks County Prison, Leesport, Pennsylvania – an IGSA facility 

2. CCA Facility, San Diego, California – a CDF 

3. Hudson County Correction Center, Kearny, New Jersey – an IGSA 

facility 

4. Krome SPC, Miami, Florida 

5. Passaic County Jail, Paterson, New Jersey – an IGSA facility 

After the completion of our review, ICE removed all immigration detainees 

that had been housed at PCJ and transferred them to other facilities. 

We did not use statistical sampling methodologies based on random selection 

for the facility or sample selections. Accordingly, the results of our testing 

represent the characteristics of our judgmental sample and were not projected 
Appendix A 

Purpose, Scope, and Methodology

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 39

to the population from which it was selected to determine an overall 

compliance rate. 

We distributed flyers in English and Spanish to ICE, NGO, and civil rights 

groups to indicate the sites that we would visit. We provided the same 

information to ICE detainees at each facility that we visited. This afforded 

detainees the opportunity to contact us regarding allegations of mistreatment 

(see Appendix B). 

During our audit, we received responses to the flyer and we interviewed a 

sample of detainees at each facility. The detainees were selected based on the 

issues and concerns that they included in their response, length of time at the 

facility, and other variables. The other variables included our review of 

grievances, incident reports, post logbooks, after action reports, and other 

documents obtained directly from the detention facility, as well as some 

detainees identified by representatives from various civil rights groups. We 

made an attempt to select those detainees who included allegations related to 

abuse, unique medical concerns, special needs, and extraordinary issues 

regarding conditions of confinement. The table below shows the number of 

detainee responses that we received and the number of detainees interviewed 

at each location. 

Detention Facility 

Number of 

Detainee 

Responses 

Number of 

Detainees 

Interviewed 

Berks County Prison 22 a 25 

CCA Facility in San Diego 210 b 51 

Hudson County Correctional Center 47 c 40 

Krome SPC 99 d 20 

Passaic County Jail 94 e 32 

We also interviewed some detainees released from Passaic County Jail to 

obtain indications regarding whether detainees previously held were 

mistreated, i.e., physical, sexual, or verbal abuse, and to identify any 

additional concerns regarding their condition of confinement. We reviewed 

available documentation including videotapes, incident reports, medical 

reports, property logbooks, laundry logbooks, and other records in an attempt 

to corroborate allegations made by detainees. 

 

a

 20 in English and 2 in Spanish. 

b

 136 in English, 69 in Spanish, 4 in Chinese, and 1 in Korean. 

c

 40 in English, 6 in Spanish, and 1 in Portuguese. 

d

 68 in English and 31 in Spanish. 

e

 62 in English, 31 in Spanish, and 1 in Chinese. 
Appendix A 

Purpose, Scope, and Methodology

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 40

Using the structured questionnaire prepared by ICE DRO for its DMCP, we 

interviewed pertinent facility staff to gain an understanding of the facility 

operations, policies and procedures, practices, and to assess compliance with 

the following ICE Detention Standards as they pertain to the treatment of 

detainees being held on immigration charges: 

3⁄4 Staff-Detainee Communication; 

3⁄4 Detention Files; 

3⁄4 Disciplinary Policy; 

3⁄4 Hold Rooms In Detention Facilities (if any); 

3⁄4 Special Management Units (Disciplinary and Administrative); 

3⁄4 Use Of Force; 

3⁄4 Access To Legal Materials; 

3⁄4 Admission And Release; 

3⁄4 Classification System; 

3⁄4 Correspondence And Other Mail; 

3⁄4 Food Service; 

3⁄4 Funds And Personal Property; 

3⁄4 Detainee Grievance Procedures; 

3⁄4 Group Presentation on Legal Rights; 

3⁄4 Issuance And Exchange of Clothing, Bedding, And Towels; 

3⁄4 Recreation; 

3⁄4 Religious Practices; 

3⁄4 Detainee Access To Telephone; 

3⁄4 Visitation; 

3⁄4 Hunger Strike; 

3⁄4 Medical Care; and 

3⁄4 Suicide Prevention And Intervention. 

We toured each facility in an attempt to observe: 

3⁄4 Announced and unannounced visits made by officers from the 

appropriate ICE Field Office; 

3⁄4 In-processing and out-processing of detainees; 

3⁄4 Staff handling and documenting receipt of detainees’ funds and 

property (for both in-processing and out-processing) and the property 

room; 

3⁄4 Use of force; 

3⁄4 Mail processing; 

3⁄4 Law Library; 

3⁄4 Housing units for male and female detainees to include: (1) general 

housing units/pods, (2) temporary housing unit/pods, (3) safety cells, 
Appendix A 

Purpose, Scope, and Methodology

Treatment of Immigration Detainees Housed at ICE Facilities 

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(4) medical area, (5) segregation units, (6) telephone areas, and 

(7) hold rooms (if any); 

3⁄4 Visitation rooms and waiting areas (for social and attorney visits); 

3⁄4 Dining room activities (including storage and refrigeration areas); 

3⁄4 Laundry distribution (including washer areas); 

3⁄4 Detainee population at recreation time (both outdoor and indoor 

facilities); 

3⁄4 Detainees in segregation at recreation time (both outdoor and indoor 

facilities); and 

3⁄4 Religious services. 

To conduct the review of health care, we selected case files based on the 

following methodologies: 

• At BCP, we judgmentally selected 42 ICE detainees to review the initial 

medical screening for new arrivals and physical examination from various 

sources, including billing listings, detainees housed in disciplinary or 

mental health units, and housing logs. We reviewed 447 sick call requests 

submitted by 30 detainees. We interviewed 25 of the 30 detainees and the 

remaining five detainees were selected based on the variables, as 

explained on page 38. These sick call requests cover a period of July 2003 

to May 2005. In addition, we reviewed the medical file of one detainee on 

hunger strike, and seven detainees who had been placed under observation 

for suicidal precautions. 

• At the CCA San Diego Facility, we judgmentally selected 12 ICE 

detainees to review the initial medical screening for new arrivals from the 

hunger strikers list, suicide list, and randomly from current detainees. We 

subsequently reviewed an additional 19 detainees’ medical files for 

physical examinations based on detainee interviews. We reviewed 19 sick 

call requests submitted by 11 detainees. In addition, we reviewed the 

medical file of three detainees on hunger strike, and five detainees who 

had been placed under observation for suicide watch. 

• At HCCC, we judgmentally selected 32 ICE detainees to review the initial 

medical screening for new arrivals and physical examination from various 

sources including the billing listings, detainees housed in either 

disciplinary or mental health units, and housing logs. However, the 

medical care provider at HCCC was unable to provide us with one of the 

requested medical files. In addition, we could not determine whether 11 

of 31 detainees at HCCC received the initial medical screening 

immediately upon arrival or a physical examination within 14 days of 

arrival due to missing documents and incomplete forms. Therefore, we 

were only able to review 20 detainees. We reviewed a limited number of 

sick call requests submitted by 12 detainees. In addition, we reviewed the 
Appendix A 

Purpose, Scope, and Methodology

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 42

medical file of one detainee on hunger strike, and seven detainees who had 

been placed under observation for suicide watch. 

• At PCJ, we initially selected a total of 32 ICE detainees to review the 

initial medical screening for new arrivals and physical examination from 

the list of detainees we interviewed. However, PCJ was not able to locate 

the medical files for two detainees. Therefore, we were only able to 

review 30 detainees. We also reviewed 15 sick call requests submitted by 

six detainees. In addition, we reviewed the medical file of two detainees 

on hunger strike, and three detainees who had been placed under 

observation for suicide watch. 

• At Krome, we selected 39 ICE detainees to review the initial medical 

screening for new arrivals and physical examination from medical files 

maintained. We subsequently reviewed an additional 12 detainees’ 

medical files. We reviewed the medical file of one detainee on hunger 

strike, and 14 detainees who had been placed under observation for suicide 

watch. In addition, we received 27 medical concerns expressed by 

detainees. 

We conducted our audit from June 2004 through January 2006 under the 

authority of the Inspector General Act of 1978, as amended, and in accordance 

with generally accepted government auditing standards. 
Appendix B 

OIG Flyer

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 43

The DHS OIG is conducting a review of the treatment 

of aliens held on immigration charges at U.S. 

Immigration and Customs Enforcement (ICE) 

detention facilities. 

We are assessing the treatment of detainees and conditions of confinement at 

the following facilities: 

(1) Berks County Prison, Leesport, Pennsylvania 

(2) Corrections Corporation of America Facility, San Diego, California 

(3) Hudson County Correction Center, Kearny, New Jersey 

(4) Krome Service Processing Center (SPC), Miami, Florida 

(5) Passaic County Jail, Paterson, New Jersey 

If you feel that you have been physically or sexually abused or your conditions 

of confinement have been abusive, you or your representative can: 

 Fax DHS OIG Hotline at: (202) 254-4295 

 E-mail us at DHSOIGHOTLINE@dhs.gov 

 Or write: 

U.S. Department of Homeland Security/Stop 2600 

Attn: Office of Inspector General Hotline 

245 Murray Drive, S.W., Building 410 

Washington, D.C. 20528 

 

Your participation may contribute to improved living conditions at the detention 

facility. All contacts will be kept confidential. Your identity will not be made 

public without your consent, unless ordered by a court. Your participation will 

not have a negative effect on your immigration case. 
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

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Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 45
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 46
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 47
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 48
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 49
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 50
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 51
Appendix C 

Management Response to Draft

Treatment of Immigration Detainees Housed at ICE Facilities 

Page 52
Appendix D 

Major Contributors to this Report

Treatment of Immigration Detainees Housed at ICE Facilities 

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Alexander Best, Director 

Inez Jordan, Audit Manager 

Ethel Taylor, Audit Manager 

Brad Mosher, Audit Manager 

Patricia Alcaniz, Senior Auditor 

Irene Aultman, Senior Auditor 

Don Emery, Senior Auditor 

Melissa Jones, Program Analyst 

Maryann Pereira, Auditor 

Nadine Ramjohn, Senior Auditor 

Ronda Richardson, Senior Auditor 

Gary Stivers, Auditor 

Eno Ukih, Senior Auditor 

Wayne White, Auditor 
Appendix E 

Report Distribution

Treatment of Immigration Detainees Housed at ICE Facilities 

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Department of Homeland Security

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chief of Staff 

General Counsel 

Executive Secretariat 

Assistant Secretary for Policy 

Assistant Secretary for Public Affairs 

Assistant Secretary, Legislative and Intergovernmental Affairs 

Assistant Secretary, U.S. Immigration and Customs Enforcement 

Chief Privacy Officer 

DHS GAO/OIG Liaison 

ICE Audit Liaison 

Office of Management and Budget

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress

Congressional Oversight and Appropriations Committees, as appropriate 
Additional Information and Copies 

To obtain additional copies of this report, call the Office of Inspector General (OIG) at 

(202) 254-4100, fax your request to (202) 254-4285, or visit the OIG web site at 

www.dhs.gov/oig. 

OIG Hotline 

To report alleged fraud, waste, abuse or mismanagement, or any other kind of criminal 

or noncriminal misconduct relative to department programs or operations, call the 

OIG Hotline at 1-800-323-8603; write to DHS Office of Inspector General/MAIL 

STOP 2600, Attention: Office of Investigations - Hotline, 245 Murray Drive, SW, 

Building 410, Washington, DC 20528, fax the complaint to (202) 254-4292; or email 

DHSOIGHOTLINE@dhs.gov. The OIG seeks to protect the identity of each writer 

and caller.