Department of Homeland Security 

Office of Inspector General 

Immigration and Customs Enforcement's 


Tracking and Transfers of Detainees 


OIG-09-41 March 2009 
 

 

Office of Inspector General 

U.S. Department of Homeland Security

Washington, DC 20528 

March 17, 2009 

Preface 

The Department of Homeland Security (DHS) Office of Inspector General (OIG) was 

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

to the Inspector General Act of 1978. This is one of a series of audit, inspection, and 

special reports prepared as part of our oversight responsibilities to promote economy, 

efficiency, and effectiveness within the department. 

This report addresses the strengths and weaknesses of Immigration and Customs 

Enforcement’s Office of Detention and Removal Operations. It is based on interviews 

with employees and officials of relevant agencies and institutions, direct observations, 

and a review of applicable documents. 

The recommendations herein have been developed to the best knowledge available to our 

office, and have been discussed in draft with those responsible for implementation. We 

trust this report will result in more effective, efficient, and economical operations. We 

express our appreciation to all of those who contributed to the preparation of this report. 

Richard L. Skinner 


Inspector General
 
 

 

Table of Contents/Abbreviations 


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

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

Results of Audit ...................................................................................................................4
 

Detainee Tracking Has Improved, but More Can Be Done...........................................4 


Transfer Notification Procedures Should Be Improved.................................................6 


Medical Screenings and Physical Examinations Are Not Always Timely....................9 


Recommendations..............................................................................................................12
 

Management Comments and OIG Analysis ......................................................................12 


Appendices 

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

Appendix B: Management Comments to the Draft Report.................................20 

Appendix C: Data Entry into the Deportable Alien Control System ..................26 

Appendix D: Detainee Transfer Notification Form.............................................27 

Appendix E: Major Contributors to this Report..................................................28 

Appendix F: Report Distribution ........................................................................29 

Abbreviations 

DHS Department of Homeland Security 

ENFORCE Enforcement Case Tracking System 

FY Fiscal Year 

ICE Immigration and Customs Enforcement 

IGSA Intergovernmental Service Agreement 

OIG Office of Inspector General 

Immigration and Customs Enforcement’s Tracking and Transfers of Detainees 
OIG
 

Department of Homeland Security 

Office of Inspector General 

Executive Summary 

We conducted an audit of United States Immigration and Customs 

Enforcement’s detainee tracking and transfer processes. Our 

objectives were to determine to what extent the agency has: (1) 

improved its ability to track and monitor detainees; (2) properly 

notified detainees of transfers; and (3) provided detainees with 

timely initial medical screenings and physical examinations. 

Immigration and Customs Enforcement’s detainee tracking efforts 

have improved since our last report, dated November 2006 (OIG07-08), with accuracy rates increasing from 90% to 94%. 

Immigration and Customs Enforcement correctly accounted for 

433 (94%) of the 459 detainees we sampled. 

At the time of transfer, Immigration and Customs Enforcement 

does not always provide detainees the name of the facility to which 

they are being sent. The Detainee Transfer Notification form was 

not properly completed for 143 of the 144 transfers we tested. 

Agency staff interviewed generally considered completing and 

providing copies of the transfer forms to detainees a low priority. 

Also the staff interviewed did not know that they were responsible 

for informing detainees’ legal representatives of transfers. 

Medical staff at detention facilities did not always conduct 

physical examinations within 14 days, as required by the National 

Detention Standard for Medical Care; detainees received timely 

physical examinations in 248 (80%) of the 312 tested exams. 

Noncompliance can result in a higher incidence of untreated or 

undiagnosed illnesses and promote the spread of infectious 

diseases. 

The Immigration and Customs Enforcement concurred with four 

recommendations and concurred in part with three 

recommendations. We have incorporated Immigration and 

Customs Enforcement comments into the body of this report, and 

made changes where appropriate. These comments are included in 

their entirety as Appendix B. 

Immigration and Customs Enforcement’s Tracking and Transfers of Detainees 

Page 1 
Background 

In March 2003, U.S. Immigration and Customs Enforcement (ICE) 

became part of the Department of Homeland Security (DHS). 

ICE’s mission is to prevent acts of terrorism by targeting the 

people, money, and materials that support terrorist and criminal 

activities. ICE’s responsibilities are to: 

�	 

�	 

�	 

Provide adequate and appropriate custody management 

to support the processing of removable aliens; 

Facilitate the processing of removable aliens through 

the immigration court; and 

Enforce removal of aliens from the United States. 

ICE Detention and Removal Office is also responsible for the 

following key elements: 

�	 

�	 

�	 

Identify and remove all high-risk illegal alien fugitives 

and absconders; 

Ensure that those aliens who have already been 

identified as criminals are expeditiously removed; and 

Develop and maintain a robust removal program with 

the capacity to remove all final-order cases. 

In FY 2007, ICE detained more than 311,000 aliens, with an 

average daily population of more than 30,000 and an average 

length of stay of 37 days. In FY 2008, ICE had an estimated 

32,000 funded bed spaces for detainees. In FY 2007, ICE removed 

276,912 detainees from the United States and transferred 261,910 

detainees from one detention facility to another. 

ICE operates seven detention facilities, known as Service 

Processing Centers, in Aquadilla, Puerto Rico; Batavia, New York; 

El Centro, California; El Paso, Texas; Florence, Arizona; Miami, 

Florida; and Los Fresno, Texas. ICE augments its Service 

Processing Centers with seven Contract Detention Facilities in 

Aurora, Colorado; Houston, Texas; Laredo, Texas; Seattle, 

Washington; Elizabeth, New Jersey; Queens, New York; and San 

Diego, California. ICE also uses state and local jails on a fixed 

price basis through Intergovernmental Service Agreements 

(IGSAs). 

ICE National Detention Standards are designed to identify a 

minimum level of acceptable custody and conditions of 

confinement. The primary purpose of these standards is to provide 

Immigration and Customs Enforcement’s Tracking and Transfers of Detainees 

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uniform guidance regarding the detention, safety, and well-being 

of detainees in custody. These standards include guidance on a 

variety of topics, including detainee transfers and medical care. 

Only facilities housing detainees for more than 72 hours are 

required to meet these standards. ICE inspects these facilities 

annually to ensure compliance. 

Service Processing Centers and Contract Detention Facilities use 

commissioned corps officers in the Public Health Service to 

deliver onsite medical care. Local jails rely mainly on other onsite 

clinicians, such as contractors or staff employed by county public 

health departments. 

ICE facilities use a detainee classification system to ensure that, 

detainees are housed at appropriate levels and physically separated 

from each other, based on risk. There are three classification 

levels generally distinguished by criminal convictions, ranging 

from Level 1 (lowest risk) to Level 3 (highest risk). The 

classification system informs detention facility personnel of the 

level of security and attention required for each detainee. 

According to our November 2006 report, Review of U.S. 

Immigration and Customs Enforcement’s Detainee Tracking 

Process (OIG-07-08), the detainee tracking system was up-to-date 

90% of the time because information was not recorded in the 

Deportable Alien Control System within the first 5 days of 

detainment as required. In addition, ICE made incorrect contractor 

payments. We recommended that ICE: (1) issue formal 

instructions to field offices requiring timely Deportable Alien 

Control System entries and proper supervisory review; (2) perform 

daily or periodic reconciliations and train staff responsible for 

verifying the accuracy of Deportable Alien Control System 

records; and (3) obtain a reimbursement of $7,955 for the net 

overpayments to a detention facility. The three recommendations 

have been fully addressed. 

In response to our OIG-07-08 audit report, ICE issued a policy 

memorandum on February 1, 2007, requiring that the detention 

screen in the Deportable Alien Control System be updated within 

24 hours of detaining or transferring an alien. (See Appendix C for 

a copy of this memorandum.) Subsequently, on September 30, 

2007, ICE instituted the ENFORCE tracking system, the Alien 

Detention Module component, to replace Deportable Alien Control 

System, which ultimately provided a more efficient way to 

electronically process and track detainees in and out of ICE 

detention facilities. ENFORCE automated many of the 

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administrative control functions associated with the arrest, 

detention, and deportation of illegal aliens. In addition, on August 

11, 2008, ICE instituted the ENFORCE Alien Removal Module 

component, a case management system, to replace the Deportable 

Alien Control System and improve the efficiency of the detention 

and removal process. ICE immigration enforcement agents, 

deportation officers, and detention removal assistants have the 

responsibility to update ENFORCE when a detainee is taken into 

custody, transferred, or removed.1 ICE did not update its February 

2007 memorandum to reflect institution of the new tracking 

system. 

Results of Audit 

Detainee Tracking Has Improved, but More Can Be Done 

ICE detainee tracking has improved since the November 2006 

audit, but additional procedures are needed to ensure full 

compliance with ICE’s recording requirements. Despite institution 

of the new tracking system, ICE staff interviewed at the five 

detention facilities we visited did not always update ENFORCE 

properly or timely. See Appendix A for details of the five 

detention facilities selected for review. 

As summarized in Table 1, ICE correctly accounted for 433 (94%) 

of the 459 detainees we sampled in ENFORCE, which is an 

improvement over the 90% accuracy rate resulting from our 2006 

testing. 

1

 ICE procedures require ENFORCE to be updated within 24 hours of detainee book-ins, transfers, or 

removals, to provide an accurate snapshot of the detainee population. 

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Table 1 – ENFORCE Tracking Errors and Classification of Detainees 

Detention Facility 

ADP in 

FY 08* Sample 

Size 

Correct in 

ENFORCE Errors 

Classification 

N/A Level 1 Level 2 Level 3 

Suffolk County House of 

Corrections (IGSA) 

Boston, MA 

245 55 49 6 0 6 0 0 

Krome Service Processing 

Center 

Miami, FL 

646 100 94 6 0 1 1 4 

Eloy Detention Facility 

(IGSA) 

Eloy, AZ 

1,468 104 98 6 2 4 0 0 

Pinal County Jail (IGSA) 

Florence, AZ 

449 100 96 4 0 2 2 0 

Denver Contract Detention 

Facility 

Aurora, CO 

407 100 96 4 0 0 4 0

 Totals 3,215 459 433 26 2 13 7 4 

* Average Daily Population in Fiscal Year 2008 as of January 14, 2008. 

Information on the correct detention facility for the 26 detainees 

sampled was not input for up to 11 days, with detainees 

inaccurately accounted for an average of 3.7 days in the tracking 

system. In one case, according to the ENFORCE database, a 

detainee arrived at Arizona’s Pinal County Jail on May 1, 2008, 

but jail and billing records indicated that the detainee was not 

booked-in until May 12, 2008, 11 days late. 

We also identified four detainees who were transferred from three 

different Massachusetts IGSAs to Suffolk County House of 

Corrections during a long holiday weekend. The four detainees 

were subsequently deported, yet ENFORCE had no record of their 

stay at Suffolk County House of Corrections from February 15, 

2008, to February 16, 2008. 

At two other facilities tested, jail records accurately indicated that 

three detainees were deported, yet at the time of our review, 

ENFORCE recorded the detainees as still being in ICE custody. 

For example, one detainee was deported from the Denver Contract 

Detention Facility in Aurora, Colorado, on June 6, 2008, but 

ENFORCE was not updated to reflect the detainee’s deportation by 

the time of our visit on June 9, 2008. 

Continuous knowledge of each detainee’s location is imperative to 

ensure the safety of the public, detention facility staff, and other 

detainees. If ENFORCE is not updated in a timely and accurate 

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way, family members and legal representatives could be 

misinformed of the whereabouts of detainees. In addition, there is 

a potential risk of improperly accounting for dangerous detainees. 

For instance, 27% of the 26 detainees not properly tracked in 

ENFORCE were categorized as Level 2, and 15% were 

categorized as Level 3. 

For some facilities, ICE’s detainee information is recorded in 

various tracking systems, including log books, Excel spreadsheets, 

contractor records, and locally developed systems, created as an 

alternative to the Deportable Alien Control System. The 

information was considered more easily accessible and reliable in 

the locally developed tracking systems than in the Deportable 

Alien Control System. Although these alternative systems were 

designed to better track detainees, they inadvertently caused more 

work than necessary. For example, ICE staff interviewed at one 

IGSA facility used a locally developed system to augment 

Deportable Alien Control System entries. When ICE moved a 

detainee from one facility to another, an ICE official was 

responsible for updating three tracking systems with the same 

information. With the institution of ENFORCE, locally developed 

tracking systems should be eliminated. 

Reliable information is critical for informed decision making and 

effective management oversight. In turn, increased management 

oversight would greatly enhance ICE’s ability to meet detainee 

tracking requirements, identify emerging tracking issues, and 

assess the success of the overall detainee-tracking process. ICE 

can better administer its management oversight by implementing 

internal controls to strengthen the effectiveness of its tracking 

process. 

Transfer Notification Procedures Should Be Improved 

According to the National Detention Standard for Detainee 

Transfers, ICE is responsible for notifying a detainee, immediately 

prior to leaving the facility, of his or her new facility. A Detainee 

Transfer Notification form must include the new facility name, 

address, and telephone number. Also, the form advises the 

detainees of their responsibility to notify family members of their 

transfers. (See Appendix D for an example of a Detainee Transfer 

Notification form.) According to the Detainee Transfer Standard, 

the form should be given to the detainee at the time of transfer to 

the new facility. For security purposes, the specific plans and time 

schedules for transfers are not discussed with the detainee. A copy 

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of the transfer notification should be maintained in the detainee’s 

detention file. 

In FY 2007, ICE transferred 261,910 detainees because of 

specialized medical needs, requested changes of venue by the 

Executive Office of Immigration, recreational needs when a 

required recreation was not available, or security purposes. ICE 

staff at the five locations visited did not properly complete the 

Detainee Transfer Notification form for 143 of the 144 transfers 

we tested.2

 Interviews revealed that some ICE staff were not 

aware of transfer procedures required by the Detainee Transfer 

Standard. For example, ICE staff interviewed at one site visited 

were not aware that the Detainee Transfer Notification form was 

required until the facility began using the form in March 2008. 

Testing at this facility after March 2008 revealed the Detainee 

Transfer Notification forms were not used. 

ICE management at the sites visited had conflicting opinions on 

where the Detainee Transfer Notification forms should be stored 

and when they should be used. Contrary to the Detainee Transfer 

Standard, management officials at the five facilities said the forms 

should be placed in the detainees’ Alien File.3

 We tested available 

Alien Files at the five facilities and did not locate any Detainee 

Transfer Notification forms. 

ICE staff interviewed considered the Detainee Transfer 

Notification form a low priority. Safety considerations involved 

with transferring detainees are overriding. ICE management at one 

site visited considered the Detainee Transfer Notification form 

unnecessary if a detainee was being transferred to a new location 

to be deported, although the Detainee Transfer Standard does not 

indicate such exceptions. For example, ICE transferred a detainee 

from Pinal County Jail in Florence, Arizona to Los Angeles, 

California on May 28, 2008. ICE then deported the detainee from 

Los Angeles, California on May 29, 2008, but a Detainee Transfer 

Notification form was not documented. 

Further, according to the National Detention Standard for Detainee 

Transfer, when a detainee has legal representation, ICE is required 

to notify the representative of record that the detainee is being 

2

 The OIG exempted transfers between the Florence Service Processing Center and the Pinal County Jail 

from this test because ICE does not consider detainee movements between these facilities, located on the 

same campus, as transfers. 

3

 The detainee’s Alien File is the record that contains copies of information regarding all transactions 

involving an individual as he or she passes through the immigration and inspection process. The Alien File 

accompanies the detainee as they move through the immigration process. 

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transferred. This notification should be recorded in the detainee’s 

Alien File. ICE staff interviewed at the sites visited said they did 

not notify the detainee’s legal representative because they 

considered the notifications to be the detainee’s responsibility. 

Developing a screen in ENFORCE to identify legal representatives 

would facilitate compliance with legal representative notification 

procedures. 

It is important to the detainee population that ICE prepare Detainee 

Transfer Notification forms so that a detainee will know the name, 

address, and telephone number of the new facility and be able to 

advise family members and/or legal counsel who wish to visit. 

Detainees may be transferred anywhere in the United States, 

depending on a facility’s space availability. Failure to adhere to 

transfer notification procedures could create confusion for family 

members and legal representatives regarding the whereabouts of 

the detainee. 

ICE conducts inspections to determine overall compliance with the 

National Detention Standards, including the Detainee Transfer 

Standard. Inspection reports for the five following facilities that 

we tested inaccurately reported these facilities as compliant in 

using the Detainee Transfer Notification form: 

1.	 Suffolk County House of Corrections (Boston, MA) – 

Inspection report from June 6-8, 2007, conducted by 

two ICE staff. 

2.	 Krome Service Processing Center (Miami, FL) – 

Inspection report from April 17-19, 2007, conducted by 

four ICE staff, and inspection report from April 22-24, 

2008, conducted by Creative Corrections. 

3.	 Eloy Detention Facility (Eloy, AZ) – Inspection report 

from February 19-21, 2008, conducted by Creative 

Corrections. 

4.	 Pinal County Jail (Florence, AZ) – Inspection report 

from August 7-9, 2007, conducted by two ICE staff. 

5.	 Denver Contract Detention Facility (Aurora, CO) – 

Inspection report from October 2-4, 2007, conducted by 

Creative Corrections. 

We noted a similar finding regarding annual inspections in our 

May 2008 report, ICE Policies Related to Detainee Deaths and the 

Oversight of Immigration Detention Facilities (OIG-08-52). 

Although these inspections are a risk management tool and only 

show a snapshot of the facility, each inspection reported that 

transfer notification forms were reviewed and had no problems. 

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Inadequate management oversight decreases ICE's ability to ensure 

that facilities are complying with ICE National Detention 

Standards. 

Medical Screenings and Physical Examinations Are Not Always Timely 

According to the National Detention Standard for Medical Care, 

detainees are required to receive an initial medical screening 

within 24 hours of arrival and a physical examination within 14 

days after arrival. Initial medical screenings should include 

observation and interview questions related to a detainee’s physical 

well-being, potential suicide risk, and possible mental disabilities, 

including mental illness and mental retardation. New arrivals 

should receive a tuberculosis test as part of the medical screening 

to prevent the spread of this communicable disease. 

Table 2: Medical Evaluations Timeliness Discrepancies 

Facility 

Medical Screening 

Within 24 Hours 

Physical Exam Within 14 

Days 

Non

Compliance

Sample

Size

Non

Compliance

Sample

Size

Suffolk County House of Corrections 

(IGSA) 

Boston, MA 

5 34 16 34 

Krome Service Processing Center 

Miami, FL 

2 97 1 75 

Eloy Detention Facility (IGSA) 

Eloy, AZ 

3 92 28 77 

Pinal County Jail (IGSA) 

Florence, AZ * 

0 100 9 62 

Denver Contract Detention Facility 

Aurora, CO 

1 97 10 64 

Totals 

11 420 64 312 

3% 20% 

* Note: The OIG accepted medical screenings completed at the Florence Service Processing Center if 

they were performed within 24 hours of arrival, because of its proximity to the Pinal County Jail. 

As shown in Table 2, medical staff at detention facilities did not 

always provide initial medical screenings in a timely manner. In 

some instances, detainees did not receive a medical screening or 

there were delays between the date of arrival and the date a 

clinician conducted the screenings. Of the 11 instances of noncompliance with medical screenings, 3 detainees received a 

medical screening after the 24 hour requirement, and 8 detainees 

did not receive a medical screening at all or did not receive an 

updated screening when they were rebooked into the facility. 

Medical staff conducted the screenings from 1 to 12 days late. In 

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one instance, a detainee with a book-in date of December 14, 2007, 

did not receive an initial medical screening until December 27, 

2007. 

Some facilities did not conduct initial screenings during busy 

detainee book-in periods. In one case, a medical facility was not 

fully staffed to process a daily average of up to 90 arriving 

detainees. Officials at this facility said that medical staffing was at 

times 50%. As of June 2008, it was staffed at 80%. Because of 

staff shortages, detainees did not always receive timely medical 

screenings. For example, one detainee arrived at this facility on 

January 14, 2008, and received no initial medical screening. 

Additionally, the detainee did receive a physical examination until 

March 1, 2008, which was 32 days late. Noncompliance with the 

timeliness of medical evaluations can result in treatable illnesses 

going undetected and the spread of infectious diseases inside 

detention facilities. To ensure that medical evaluations are 

conducted on time, medical facilities must be fully staffed and 

ready to handle high influxes of detainees. 

In addition, health care providers at each facility are required to 

conduct a physical examination within 14 days of a detainee’s 

arrival. The physical examination allows for early detection and 

treatment of diseases and disorders. If there is documented 

evidence of a physical examination within the previous 90 days, 

the facility health care provider may determine that a new physical 

is not required. Four of the five facilities we visited had difficulty 

meeting ICE’s physical examination timeliness requirement. 

As illustrated in Table 2, we determined that 64 (20%) of 312 

detainees requiring a physical examination did not receive an exam 

within the 14-day requirement or did not receive one at all. 

Specifically, 43 (67%) of the 64 detainees sampled received 

physicals between 1 and 236 days late for an average of 56 days 

late, and 21 (33%) of 64 detainees did not receive a physical 

examination at all. 

Based on our review, hard-copy medical records can be unreliable. 

Medical staff interviewed at one ICE facility provided medical 

records in hardcopy form, but we were unable to determine if the 

medical screenings were performed timely because the dates 

appeared to be crossed out and changed. In contrast, Krome 

Service Processing Center used an electronic case management 

system and had significantly fewer delays in providing medical 

evaluations. The electronic system calculated the days a detainee 

was in custody and generated a reminder for medical staff when a 

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detainee’s 14-day physical was due. Instituting an electronic case 

management system at detention facilities could improve internal 

controls, decrease medical care timeliness issues, and offer a more 

accessible and effective method of record keeping nationwide. 

Generally, most of the facilities sampled complied with preparing 

medical transfer summaries. The Detainee Transfer Standard 

requires that when a detainee is transferred within the Detainee 

Immigration Health Service System, a medical transfer summary 

and an official health record should accompany the detainee. 

Medical transfer summaries are essential for a detainee’s safety 

while in transit because they contain the detainee’s current 

physical and mental status and current medications with 

instructions. Such information also aids the receiving facility in 

processing medical screenings. 

Sometimes the receiving medical staff interviewed did not have 

access to detainees’ medical transfer summaries, which resulted in 

excess work for the medical staff. For example, in one receiving 

detention facility, the staff interviewed had to re-do the medical 

history part of the initial medical screening process. ICE should 

conduct a survey to identify other facilities that have similar 

problems accessing medical transfer summaries. 

Overall, timely medical screenings and physical examinations are 

an important part of ICE medical care procedures. As previously 

stated, noncompliance with the Medical Care standard can result in 

a higher incidence of untreated or undiagnosed illnesses and 

promote the spread of infectious diseases. The ICE Medical Care 

standard recognizes the need to perform timely evaluations, yet 

oversight to ensure compliance is not always effective. 

For example, an ICE inspection report inaccurately gave one 

facility reviewed in 2007 an acceptable rating for the Medical Care 

standard. The inspection report gave acceptable ratings to portions 

of the report asking if physical examinations were performed 

within 14 days of detainee arrivals and if all detainees received 

mental health screenings upon arrival. During our testing, physical 

examinations and medical screenings at this facility were not 

always performed timely. ICE annual facility inspection reports 

did not identify noncompliance with the Medical Care standard in 

three of the five facilities we reviewed. By implementing internal 

controls to ensure compliance, ICE can improve the timeliness of 

health care provided to detainees. 

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Recommendations 

We recommend that the Assistant Secretary for Immigration and 

Customs Enforcement: 

Recommendation #1: Conduct a best practices study to 

determine how to improve ENFORCE data entry and distribute the 

results to all facilities. 

Recommendation #2: Eliminate the use of locally developed ICE 

detainee tracking systems in lieu of ENFORCE. 

Recommendation #3: Issue specific guidance outlining the 

proper use of the Detainee Transfer Notification form and develop 

procedures to hold appropriate management accountable for its 

use. 

Recommendation #4: Develop and implement internal controls to 

improve management oversight of the annual facility inspection 

process to ensure that if standards are not followed at a facility, the 

non-compliance is documented in the inspection report. 

Recommendation #5: Develop procedures to ensure that legal 

representative notifications are made as required. Also, develop a 

screen in ENFORCE to include information about the detainee’s 

representative of record to facilitate the attorney notification 

process. 

Recommendation #6: Implement internal controls to ensure that 

detention facilities comply with the National Detention Standard 

for Medical Care regarding the timeliness of initial medical 

screenings and physical examinations. In addition, implement an 

electronic case management system for ICE detainees to facilitate 

timely medical evaluations. 

Recommendation #7: Conduct a study and institute controls at 

medical facilities to ensure that all receiving medical staff have 

access to the medical transfer summaries. 

Management Comments and OIG Analysis 

ICE concurred with four recommendations and concurred in part with 

three recommendations. We consider recommendations 2, 3, 4, and 7 

resolved and closed. We consider the remaining three recommendations 

open until ICE provides details and documentation on corrective actions 

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taken so that we can determine whether the actions adequately address the 

substance of our findings and recommendations. 

Management Comments to Recommendation #1 

ICE concurred with our recommendation regarding conducting a best 

practices study to determine how to improve ENFORCE data entry. In 

October 2008, the Detention and Removal Office restructured the 

Executive Information Unit, which is responsible for ensuring 

accountability, consistency, and efficiency in statistical reporting. A new 

sub-unit, the Data Quality and Integrity Unit, will: (1) coordinate with the 

Detention and Removal Field Offices to provide guidance and instructions 

on effective utilization of Detention and Removal Office information 

systems; (2) develop data entry policies and standard operating 

procedures; and (3) conduct audits to monitor compliance with data entry 

requirements. The Data Quality and Integrity Unit will conduct a best 

practices study to ensure that data entry is completed in an appropriate and 

timely manner. 

OIG Analysis 

We consider ICE’s proposed actions responsive to the recommendation. 

However, this recommendation will remain open until the Data Quality 

and Integrity Unit provides the completed best practices study. 

Management Comments to Recommendation #2 

ICE concurred with our recommendation regarding eliminating use of 

locally developed detainee tracking systems. However, ICE believed that 

any local tracking systems the audit team observed in use at IGSAs are 

neither in ICE’s control nor relied upon by ICE for detainee tracking. 

Rather, IGSAs likely rely upon their own internal tracking of their 

detained populations. ICE will issue a policy memorandum stating that 

transfer, book-in, and book-out data must be entered within a reasonable 

time frame into the ENFORCE Alien Detention Module, and that 

ENFORCE and its components are the exclusive system of record for 

detainee tracking. This memo will replace the February 1, 2007, 

memorandum regarding data entry in the retired Deportable Alien Control 

System. 

OIG Analysis 

ICE issued a memorandum on February 12, 2009, eliminating the use of 

locally developed ICE detainee tracking systems in lieu of ENFORCE. 

We consider this recommendation closed. 

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Management Comments to Recommendation #3 

ICE concurred with our recommendation regarding issuing guidance 

outlining the proper use of the Detainee Transfer Notification form and 

stated that ICE’s standard operating procedures require that Detainee 

Transfer Notification forms be placed in the detainee files, including the 

Alien File. While proper use of the Detainee Transfer Notification forms 

is already mandated and is part of standard training, ICE will issue a 

reminder to field officers of this requirement. All employees, including 

management, are accountable for following these standard operating 

procedures. 

OIG Analysis 

ICE issued a memorandum on January 15, 2009, reminding field officers 

of their ongoing obligation with regard to Detainee Transfer Notification 

forms. We consider this recommendation closed. 

Management Comments to Recommendation #4 

ICE concurred in part with our recommendation to develop and implement 

internal controls to improve management oversight of the annual facility 

inspection process and stated that effective management oversight is 

critical to meeting ICE’s detention mission. ICE has contracted with the 

Nakamoto Group to provide on-site verification of compliance with the 

National Detention Standards and the new Performance-Based National 

Detention Standards for all ICE detention facilities. ICE has also 

contracted with Creative Corrections to conduct annual inspections of all 

detention facilities that house ICE detainees. By using third party 

reviewers, ICE will be able to objectively measure the performance of all 

facilities housing detainees. As part of the Detention and Removal 

Office’s yearly assessment, scheduled to take place in the second quarter 

of FY 2009, ICE will look for ways to continue to improve management 

oversight of the annual inspection process at the agency’s detention 

facilities. 

OIG Analysis 

ICE has proposed actions responsive to the recommendation by 

developing and implementing internal controls to improve management 

oversight of its annual inspection process. We consider this 

recommendation closed. 

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Management Comments to Recommendation #5 

ICE concurred with our recommendation to develop procedures to ensure 

that legal representative notifications are made and stated that prompt 

notification of legal representatives is imperative to facilitate ongoing 

attorney client communication. The new National Detention Standards 

provide that an alien’s legal representative of record must be notified as 

soon as practicable, but no later than 24 hours after a detainee has been 

transferred to a new detention location. Currently, ENFORCE Alien 

Removal Module contains a screen listing the alien’s attorney of record 

and contact information. As part of an upgrade review, ICE will look at 

the feasibility of integrating this data with the ENFORCE Alien Detention 

Module so that officers are prompted to contact legal representatives of 

record when transfers, book-ins, and book-outs take place. 

OIG Analysis 

We consider ICE’s proposed actions responsive to the recommendation. 

However, the recommendation will remain open until ICE provides 

evidence of steps taken to ensure that legal representative notifications are 

made. 

Management Comments to Recommendation #6 

ICE concurred in part with our recommendation to implement internal 

controls to ensure that detention facilities comply with National Detention 

Standards for Medical Care and stated that it is committed to improving 

efficiency in providing initial health screenings and 14 day health 

appraisals to detainees. Facilities that do not meet these standards, as 

identified through the annual inspection process, are rated as deficient and 

are required to take corrective action. Implementation of the recently 

issued National Detention Standards started on October 1, 2008, and will 

be completed by January 1, 2010. By July 1, 2010, all detention facilities 

will be evaluated against the new National Detention Standards. As part 

of this process, ICE will examine control activities that can be 

implemented to ensure its facilities are meeting the detention standards. 

With regard to the second part of the recommendation, ICE stated it has 

begun exploring the possibility of adopting an electronic health record 

system. 

OIG Analysis 

We consider ICE’s proposed actions responsive to the recommendation. 

However, the recommendation will remain open until ICE provides 

evidence that it has instituted controls to ensure that medical evaluations 

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are timely. With regard to the second part of the recommendation, we 

believe ICE should implement an electronic case management system at 

its service processing centers and contract detention facilities because it 

could improve internal controls, decrease medical care timeliness issues, 

and offer a more accessible and effective method of record keeping 

nationwide. 

Management Comments to Recommendation #7 

ICE concurred in part with our recommendation regarding conducting a 

study and instituting controls to ensure medical staff have access to 

medical transfer summaries and stated that such control activities are 

essential to providing efficient medical care. ICE stated that because a 

survey would have limited effect in ameliorating these inefficiencies, it 

will instead issue memoranda to all Detention and Removal Office and 

Department of Immigration Health Services personnel involved in 

detainee management reminding them of proper use, handling, and 

delivery of all medical records during ICE detainee transfers 

OIG Analysis 

ICE issued memoranda on December 22, 2008, to the Detention and 

Removal Office and the Department of Immigration Health Services 

reminding personnel of the proper use, handling, and delivery of medical 

records during transfers of ICE detainees. We consider this 

recommendation closed. 

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Appendix A 

Purpose, Scope, and Methodology 

Our objectives were to determine to what extent the agency has: 

(1) improved its ability to track and monitor detainees; (2) properly 

notified detainees of transfers; and (3) provided detainees with 

timely initial medical screenings and physical examinations. 

We conducted field work at ICE headquarters in Washington, DC, 

and site visits to five ICE detention facilities: (1) Suffolk County 

House of Corrections, Boston, Massachusetts; (2) Krome Service 

Processing Center, Miami, Florida; (3) Eloy Detention Facility, 

Eloy, Arizona; (4) Pinal County Jail, Florence, Arizona; and (5) 

Denver Contract Detention Facility, Aurora, Colorado. 

We interviewed personnel at all ICE locations visited. We 

reviewed detention files, medical records, Alien Files, and polices 

and procedures related to ICE, including the National Detention 

Standards, Detention Removal Operations Policies and Procedures 

Manual, Division of Immigration and Health Services Health 

Records Standard, and the ENFORCE Detention Module Instructor 

Guide. We also reviewed prior DHS OIG audit and inspection 

reports and Government Accountability Office reports. 

The ICE detention system consists of more than 400 local and state 

facilities under IGSAs, seven Service Processing Centers, and 

seven Contract Detention Facilities. We chose to visit facilities of 

various types, sizes, and locations across the United States. In 

addition, we considered the number of transfers at detention 

facilities when selecting our sites. We judgmentally selected five 

sites from the Deportable Alien Control System for testing using 

the following criteria: 

�	 

�	 

�	 

�	 

Suffolk County House of Correction, IGSA, in Boston, 

Massachusetts, because of its small size (average daily 

population of 245 detainees); 

Krome Service Processing Center in Miami, Florida, 

because it was a medium-sized Service Processing Center 

(average daily population of 646) and because it was 

ranked as the fifth highest in detainee transfers from 

October 2007 through January 2008; 

Eloy Detention Facility, IGSA, in Eloy, Arizona, because 

of its large size (average daily population of 1,468); 

Pinal County Jail, IGSA, in Florence, Arizona, (average 

daily population of 449) because of its proximity to the 

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Appendix A 

Purpose, Scope, and Methodology 

Eloy Detention Facility in Eloy, Arizona, and for its high 

detainee transfer rates; and 

� Denver Contract Detention Facility, in Aurora, Colorado, 

because it was a medium sized contract facility (average 

daily population of 407). 

ICE Boston provided the detainee universe from its locally 

developed tracking system, which reported 271 detainees housed at 

Suffolk County House of Correction from February 16, 2008, 

through February 18, 2008. From this universe, we randomly and 

judgmentally selected 55 detainees (20%) for testing; we visited 

the facility on February 20, 2008. In addition, we visited the ICE 

facility in Burlington, Massachusetts on February 21, 2008, March 

13, 2008, and June 30, 2008. 

ICE staff at the Krome Service Processing Center provided the 

universe of detainees by extracting data from ENFORCE reports 

for daily populations, then manipulated the data to determine the 

net number of detainees for March 24, 2008, through March 28, 

2008. This universe totaled 648 detainees. We randomly selected 

100 detainees (15%) from this universe, and we visited the facility 

from April 1-3, 2008. 

ICE staff at Eloy Detention Facility provided monthly reports of 

detainee populations for March 2008, April 2008, and May 2008 

from ENFORCE; this universe totaled 2,272 detainees. We 

randomly selected 104 (4%) for testing, and visited the facility 

from June 2-4, 2008. Similarly, at the Pinal County Jail, ICE staff 

provided the detainee population for May 2008, which totaled 

1,107 detainees. We randomly selected 100 (9%) detainees for 

testing from ENFORCE, and visited the facility from June 4-6, 

2008. 

Using ENFORCE, ICE staff at the Denver Contract Detention 

Facility provided the May 2008 detainee population, which totaled 

984 detainees, including 98 transfers. We randomly selected 50 

transfers and 50 detainees for a total sample of 100 (10%), and we 

visited the facility from June 9-10, 2008. 

We relied on computer processed data in ENFORCE to achieve 

our audit objectives. We compared ENFORCE to source data 

maintained by the jails to verify book-in and book-out dates. Our 

tests showed some ICE data input errors, as reported herein. 

However, we concluded that the data generally was reliable 

enough to support our audit findings. 

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Appendix A 

Purpose, Scope, and Methodology 

We conducted our audit between January 2008 and July 2008 

under the authority of the Inspector General Act of 1978, as 

amended, and according to generally accepted government 

auditing standards. Those standards require that we plan and 

perform the audit to obtain sufficient, appropriate evidence to 

provide a reasonable basis for our findings and conclusions based 

on our audit objectives. We believe that we met these standards. 

We would like to thank the Immigration and Customs Enforcement 

Agency for their cooperation and courtesies extended to our staff 

during this review. 

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Appendix B 

Management Comments to the Draft Report 

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Appendix B 

Management Comments to the Draft Report 

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Appendix B 

Management Comments to the Draft Report 

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Appendix B 

Management Comments to the Draft Report 

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Appendix B 

Management Comments to the Draft Report 

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Appendix B 

Management Comments to the Draft Report 

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Appendix C 

Data Entry into the Deportable Alien Control System 

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Appendix D 

Detainee Transfer Notification Form 

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Appendix E 

Major Contributors to this Report 

Washington, D.C. Office 

Richard T. Johnson,


 Director, Immigration and Customs Enforcement Division 


Boston, MA, Field Office 

Maureen Duddy, Auditor Manager 

 Colin Sullivan, Auditor-in-Charge 

 Lindsey Cabral, Auditor 

 Paul Exarchos, Program Analyst 

 Jeanne Genao, Program Analyst 

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Appendix F 

Report Distribution 

Department of Homeland Security 

Secretary 

Acting Deputy Secretary 

Chief of Staff for Operations 

Chief of Staff for Policy 

Acting General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

Acting Assistant Secretary for ICE 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs 

Assistant Secretary for Office of Legislative Affairs 

Audit Liaison for ICE 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees, as 

appropriate 

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ADDITIONAL INFORMATION AND COPIES 

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