Table of Contents 

Introduction ...........................................................................................................................................1 

Results in Brief .....................................................................................................................................3 

 

Background ............................................................................................................................................6 

Chapter 1 – Oversight and Coordination...............................................................................9 

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

Chapter 2 – Safety and Security................................................................................................14 

Serious Incidents ............................................................................................................................14 

 Fatalities..................................................................................................................................14 

 Attempted Suicides....................................................................................................................17 

 Escapes.....................................................................................................................................19 

Recommendations ..........................................................................................................................24 

Chapter 3 – Detention Facility Staffing.................................................................................26 

Recommendations ..........................................................................................................................29 

 

Chapter 4 – Detention Facility Maintenance......................................................................31 

Maintenance Funding .....................................................................................................................34 

Maintenance Accountability...........................................................................................................36 

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

Chapter 5 – Funding of the Detention Program...............................................................37 

Budget Projections and Planning....................................................................................................38 

Fund Designation ...........................................................................................................................38 

New Facility Funding.....................................................................................................................39 

Internal Controls.............................................................................................................................41 

Public Law 93-638 Contract Funding ............................................................................................42 

Recommendations ..........................................................................................................................44 

Chapter 6 – Detention Program Training............................................................................45 

Recommendations ..........................................................................................................................47 

Chapter 7 – Other Issues...............................................................................................................49 

Juveniles Housed at Adult Facilities ..............................................................................................49 

Overcrowding ................................................................................................................................50 

Policies and Procedures..................................................................................................................51 

Liability ..........................................................................................................................................52 

Recommendations ..........................................................................................................................52 

Chapter 8 – Positive Findings in the Detention Program ............................................54 

Recommendation............................................................................................................................56 

Chapter 9 – Conclusion..................................................................................................................57 
Introduction 

The Bureau of Indian Affairs (BIA) operates or funds 

detention facilities throughout Indian Country. For many 

years and in multiple forums, the BIA and the Department of

Justice (DOJ) have found these facilities to be understaffed, 

overcrowded, and underfunded. During the course of other 

work conducted by the Office of Inspector General (OIG), 

we received numerous anecdotal reports that reaffirmed these 

findings – years later. Therefore, as part of the ongoing 

effort of the OIG to examine law enforcement and security 

programs within the Department of the Interior (DOI or the 

Department), BIA’s detention program was selected for 

assessment in 2003. 

The OIG, Program Integrity Division, began the assessment 

of Indian Country detention facilities in September 2003. 

The focus of our assessment was to determine if Indian 

Country detention facilities were safe and secure, and if BIA 

appropriately used the funds it received to operate the 

detention program. We conducted actual site visits at 27 

detention facilities (also referred to as jails), scrutinized 

hundreds of detention and budget records, and conducted 

more than 150 interviews with BIA and tribal officials, as 

well as local and federal detention professionals throughout 

the United States. We conducted our assessment in 

accordance with the President’s Council on Integrity and 

Efficiency Quality Standards for Inspections. Accordingly, 

we included such tests or reviews of records that we 

considered necessary. 

We shared our observations with detention facility personnel 

during each visit. In addition, we provided regular updates to 

BIA Law Enforcement Services (BIA-LES) and Department 

management during the course of the assessment. 

Early in our assessment, it became abundantly clear that 

some facilities we visited were egregiously unsafe, 

unsanitary, and a hazard to both inmates and staff alike. 

BIA’s detention program is riddled with problems and, in our 

opinion, is a national disgrace with many facilities having 

conditions comparable to those found in third-world 

countries. In short, our assessment found evidence of a 

continuing crisis of inaction, indifference, and 

mismanagement throughout the BIA detention program. BIA 

- 1 -
appears to have had a laissez-faire attitude about these 

horrific conditions at its detention facilities. Because many 

of the conditions were potentially life–threatening, the 

Inspector General issued an Interim Report to the Secretary 

in April 2004 describing our most significant findings, and to 

provide an opportunity for her to take immediate and 

appropriate action. 

This report represents the general status of the detention 

program and facilities as we found them during our 

assessment. While recognizing some very recent attempts by 

the Department and BIA to correct deficiencies, we believe 

that anything short of strong leadership, rapt attention of 

senior management, and heroic efforts on the part of BIA 

personnel will fail to correct the deplorable conditions of 

Indian Country detention facilities. 

Throughout the report, we recommend actions that we 

believe will improve the security, safety, and efficiency of

detention facilities in Indian Country. Our anxiety over the 

detention program remains heightened, however, not only 

because of what we found during our site visits but, more 

importantly, because of what we fear remains undiscovered 

at the sites we did not visit. 

- 2 -
Results in Brief

BIA has failed to provide safe and secure detention facilities 

throughout Indian Country. Our assessment revealed a long 

history of neglect and apathy on the part of BIA officials, 

which has resulted in serious safety, security, and 

maintenance deficiencies at the majority of the facilities. 

Despite audits, inspections, reports, and other warnings about 

the woeful conditions of the detention program, BIA has 

utterly failed to remedy the problems. Whether it lacks the 

organizational will, or infrastructure, or both, BIA cannot 

sustain its focus on the problems at its detention facilities 

long enough to resolve them. Absent relentless pressure and 

the unflagging support of senior BIA management, we fear it 

is unlikely to do so in the future. 

Because we found the detention program without a credible 

reporting structure, or accountability, we also found that BIA 

was unaware of 98% of the serious incidents – including 

deaths and suicides – that occurred at the facilities we visited. 

In fact, our assessment was continuously hampered by BIA 

or jail officials who supplied us with incorrect, inconsistent, 

and often erroneous information regarding the detention 

program. 

With very few exceptions, the detention centers we visited 

are operating at below minimum staffing levels. Some of the 

understaffing takes facilities to the point of being unsafe; 

none are staffed at a level that detention managers consider 

optimal. 

The maintenance backlog at these facilities is significant. 

Jail administrators reported countless stories of neglect and 

delay on the part of BIA’s Office of Facilities Management 

and Construction (OFMC). Our review of OFMC

maintenance logs revealed numerous inaccurate, improper 

and erroneous entries. We found these logs to be of minimal 

value and were not surprised to learn that the Government 

Accountability Office (GAO) reached a similar conclusion 

when they reviewed the maintenance records in 2003. 

We found that detention program funding is haphazardly 

managed by BIA, and once distributed to the tribes, it 

becomes virtually unaccounted for. BIA could produce little 

evidence of basic budget planning, budget execution, or 

- 3 -
budgetary controls. Since BIA simply does not track 

expenditures made by tribes, our attempts to identify the total 

funding for the detention program proved futile. The neglect 

and mismanagement of detention program funding has not 

only exacerbated the systemic problems attendant to the 

detention program in Indian Country, but has also created an 

environment in which fraud can be perpetrated with impunity 

and waste can occur undetected. 

Training for detention personnel is inconsistent and 

unpredictable. The majority of the detention officers at the 

sites we visited have yet to attend mandatory basic training 

for detention officers at the Indian Police Academy (IPA) in 

Artesia, NM. Many officers failed to complete the training 

within 1 year of being hired, as mandated in BIA policy. We

even found officers who had been employed for as long as 12 

years without attending the required formal certification 

training. 

Basic jail administration procedures and standards are neither 

followed nor met at most facilities. Many of the 

management officials admitted that their detention facilities 

fail to even “come close” to meeting BIA standards for 

operation, which are derived from nationally recognized 

detention standards.1

 In fact, we found the majority of the 

jails make little or no effort to comply with even the most 

basic requirements. 

Unfortunately, we often found that complacency and 

resignation were the norm — at all levels of BIA 

management — with no evidence of a coordinated and 

comprehensive strategic plan to improve and manage the 

detention program. Without a dramatic shift in 

organizational culture and professionalism, any positive 

change will likely be short lived and the program will remain 

in a dismal status quo. A comprehensive overhaul 

necessitates an infusion of leadership that can address issues 

with creativity, decisiveness, and commitment throughout all 

levels of the detention program. 

We believe it is imperative that BIA take immediate action to 

alleviate potentially life-threatening situations at its detention

facilities. The haphazard response to DOJ, OIG, and other 

 

1

 BIA reported that detention standards were created using industry

specific information obtained from the American Correctional 

Association. 

- 4 -
reports must give way to a comprehensive and coordinated 

approach to address the systemic safety, security, and 

maintenance issues facing Indian jails. Mindful of other 

historical failures, however, we fear that once the attention 

wanes on the issues we identify here, the momentum and 

interest in the BIA detention program will diminish as 

quickly as it began. Many improvements and changes were 

anticipated when BIA published its detention standards in 

1996 and when DOJ published its report about the Indian 

Country law enforcement and detention program in 1997. As 

this report will reiterate, once again, little has changed. 

- 5 -
Background 

BIA’s mission is to fulfill trust responsibilities and promote 

self-determination on behalf of tribal governments, American 

Indians, and Alaska Natives. BIA provides services directly 

and through contracts, grants, or compacts for 1.5 million 

American Indians and Alaska Natives who are members of 

562 federally recognized Indian tribes in the 48 contiguous 

United States and Alaska. The expansive scope of BIA 

programs covers the full range of state and local government 

services, including law enforcement services. BIA is 

required to provide law enforcement services on reservations 

under the Indian Law Enforcement Reform Act (ILERA) of 

1990 (Public Law 101-379). BIA-LES provides direct 

assistance to tribes for law enforcement programs, including 

uniformed patrol, criminal investigations, detention, and 

dispatch on approximately 56 million acres of Indian Country 

in 35 states. 

Age of Indian Country Detention

Facilities 

• 33.0% (24) are over 30 years old 

• 28.0% (20) are 20-30 years old 

• 19.5% (14) are 10-20 years old 

• 19.5% (14) are under 10 years old 

As of August 2004, the detention program consisted of 72 

detention facilities2

 in Indian Country – 17 of which are 

operated by BIA-LES, 46 receive BIA funding for detention 

services under 638 contracts, and 9 are operated by tribes. 

Of the 72 facilities, 27 house adult inmates, 11 house 

juveniles, and 34 house a combination of both adults and 

juveniles. 

 

Most of the older detention facilities were built as holding 

facilities to accommodate approximately 10-20 inmates for 

short-term periods (48 hours or less). On average, the newer 

facilities have been designed to accommodate 60 inmates, 

with four new facilities having more than 100 beds, along 

with additional rooms and areas, making the facilities more 

suitable for longer periods of incarceration (12 months or 

less). Individuals incarcerated in these facilities usually have 

committed misdemeanors, such as public intoxication or

assault and battery. 

 

2

 BIA-LES has been unable to provide us with an exact number of 

facilities under its control despite numerous requests for an accurate list. 

For example, the Chemawa Indian School was originally included in this 

total; however, it no longer is being used by BIA to detain juveniles and 

was subsequently removed from its inventory. Similarly, the Mescalero 

detention facility was closed after we began our assessment. 

- 6 -
Individuals who have committed felonies, such as murder 

and burglary, are routinely incarcerated in state or federal 

facilities off reservations; however, there are times when 

felons are held in Indian jails. 

The DOJ Bureau of Justice Statistics (BJS) publishes an 

annual report containing statistical data about Indian Country 

jails. These reports provide information pertaining to jail 

populations, crimes committed by inmates, overcrowding, 

jail capacity versus inmate population, and jails under court 

orders or consent decrees to improve conditions. These and 

other DOJ reports have documented overcrowding and 

inadequate capacity as problems in Indian Country for many 

years. 

A number of other reports have also documented such 

problems in Indian Country jails. As early as 1994, the OIG 

reported that Indian Country detention facilities were poorly 

maintained and mismanaged. As a result of the 1994 report, 

BIA contracted for individual safety and security inspections 

at each of the jails in 1995. The inspection reports 

overwhelmingly documented a systemic pattern of 

overcrowding and poorly maintained and managed jails. 

BJS 2002 report 

In 1997, DOJ issued a report on Indian Country law 

enforcement that announced “a public safety crisis in Indian 

Country.” In addition to identifying shortages of law 

enforcement officers and resources, the DOJ report also 

noted that “[detention] staffing levels fall far short of those 

required for adequate inmate supervision, thus creating a 

threat to welfare of the community, staff and inmates.” DOJ 

recommended that BIA-LES be given line authority for law 

enforcement services, including the detention program, rather 

than leaving law enforcement services decentralized and 

under the supervision of the local BIA superintendent. BIA 

adopted this recommendation in 1999. 

On June 3, 1998, former Assistant Secretary - Indian Affairs 

Kevin Gover testified before the Senate Committee on Indian 

Affairs on the Department’s Indian Country law enforcement 

initiative. Gover testified about the lack of adequate 

detention facilities, their generally decrepit conditions, and 

the considerable problems in maintaining and staffing the 

- 7 -
jails. Gover made note of the lack of juvenile facilities, 

which resulted in numerous occasions where juveniles were 

temporarily placed in adult detention facilities because there 

was no other place to house them. 

Gover also testified about restructuring BIA law enforcement 

services to include detention services under the supervision 

of BIA-LES officials. The restructuring, which ultimately 

occurred in 1999, was designed to place these services under 

the control of law enforcement professionals to ensure that 

law enforcement services were directed by a central 

command structure, rather than by area managers with little 

or no law enforcement background. 

During this time period, many proposed that Indian Country 

law enforcement should be transferred to DOJ. This proposal 

was revisited in 2001 during the International Association of 

Chiefs of Police (IACP) summit with tribal communities and 

their justice systems. In its report, Improving Safety in 

Indian Country, the IACP suggested streamlining the federal 

agencies involved with law enforcement in Indian Country to 

improve coordination and delivery of services.4

 

In addition to these outside reports and recommendations, 

internal BIA inspection reports went on to highlight detention 

program problems and deficiencies. In 2001, a presentation 

to senior BIA-LES officials identified specific issues in the 

jails and provided an action plan to address each problem. 

According to the author of the presentation, BIA-LES 

managers appeared disinterested and subsequently no action 

was taken. 

After a thorough review of these previous reports and 

recommendations, we were disappointed, but not surprised, 

to find during our assessment that little implementation has 

taken place and the state of the detention program today is no

better, and arguably worse, than what it was a decade ago. 

 

4 International Association of Chiefs of Police, Improving Safety in

Indian Country: Recommendations From the IACP 2001 Summit, 

Alexandria, VA, October 2001. p.11. 

- 8 -
Chapter 1: Oversight and Coordination 

Senior BIA-LES officials have acknowledged that the 

detention program is severely understaffed, that facilities are 

overcrowded, and that neither has received the attention or 

funding to adequately address the numerous deficiencies. 

Not once during our assessment did BIA-LES officials gloss 

over or deny the dire condition of the program or the 

profound and serious maintenance issues at the facilities. 

These officials readily admit that they have placed a higher 

priority on fighting crime on the reservations and focusing on 

the policing aspect of law enforcement services after line 

authority was granted to BIA-LES in 1999. They 

consistently contend that a lack of funding and staffing has 

made it impossible to address both law enforcement and 

detention programs simultaneously. 

Despite this candid acknowledgement, these officials argue 

that the detention program has improved under their direct 

supervision and point out that BIA-LES is still in its infancy. 

Since receiving its authority, we found that BIA-LES has 

attempted to provide oversight and management for the 

detention program with very limited success, using a twopronged approach. 

Administratively, the detention program has been 

coordinated through a Detention Program Manager working 

out of the BIA-LES Central Office. The manager, a criminal 

investigator by background, was appointed in 2000, and 

provided with limited training, virtually no staff, and minimal 

authority to accomplish his duties. 

At the outset of our assessment, we discovered that the 

detention program manager had been assigned as the BIALES Acting Deputy Director of Operations. He conceded 

that much of his time was diverted from the detention 

program, effectively leaving that program without a 

functioning manager. 

In 2001, a detention specialist was hired as the lone staff 

member of the program manager. This single detention 

specialist was expected to provide tribal and BIA jails with 

technical advice as well as conduct compliance checks. 

Since the beginning of this assessment, three additional 

- 9 -
detention specialists have been added. 

 

Six BIA District Commanders are responsible for managing 

law enforcement services in their respective districts, and 

they rely mainly on BIA chiefs of police to oversee these 

functions on the reservations. Our assessment found the 

oversight of the detention program by these District 

Commanders to be virtually non-existent. In fact, several 

District Commanders had never visited some jails under their 

command or spoken with the jail administrators. Many of 

the Commanders acknowledged giving little or no attention 

to jail issues, but they also pointed out that neither did their 

superiors raise detention as a priority. One District 

Commander reported that he could not recall a single 

discussion on detention issues during any staff meeting or 

conference call for more than a year. 

The tribal 638-contract detention facilities are similarly 

managed and overseen by a chief of police. We found a 

greater number of dedicated jail administrators, however, 

overseeing the larger tribal detention programs. Because 

these jail administrators tend to be more extensively trained 

detention professionals, we found their jails to be more 

efficiently operated and managed than BIA-operated jails. 

D e p u ty B u re a u D ir e c to r *

O ffic e o f L aw

E n fo r cem e n t S e r v ic e s

A sso c ia te D ir e c to r

G S -15 

O ffic e o f C o rr e c tio n s

V a c a n t

C h ie f o f D e te n tio n *

G S -13/1 4

D iv isio n o f C o rr ectio n

S e r v ic e s

D istric t 1

D e te n tio n S p e c ia list 

G S -9 /11/12 

D e te n tio n S p e c ia list 

G S -9 /11/12 

V a c a n t

L a w E n fo r c e m e n t

S p e c ia list 

G S -7 /9 /1 1

P o sitio n s p r io r to 3 /2 0 0 4

N ew P o sitio n s a s o f 3/2 0 0 4

*T itle C h a n g e O n ly

D istric t 2

D e te n tio n S p e c ia list 

G S -9 /11/12 

D istric t 4

D e te n tio n S p e c ia list 

G S -9 /11/12 

D istric t 3

D e te n tio n S p e c ia list 

G S -9 /11/12 

D e ten tio n Po sitio n s

- 10 -
DOI’s Office of Law Enforcement and Security (DOI-OLES) 

is responsible for overseeing all Department law enforcement 

and security programs, including detention facilities in Indian 

Country. Since 2001, DOI-OLES has been responsible for 

coordinating and establishing departmental law enforcement 

policies and services. We found no evidence, however, of 

DOI-OLES providing any oversight of the Indian detention 

program. 

BIA-LES has proven incapable of providing the coordination 

and oversight of Indian Country jails without assistance. The 

detention program desperately needs a level of advocacy and 

support well beyond what BIA-LES is presently able to 

provide. 

In addition to the lack of DOI-OLES involvement, we found 

senior BIA management outside of law enforcement to be 

inexplicably uninformed about detention program 

deficiencies – despite annual funding requests specifically to 

improve jail facilities. One senior political appointee 

remarked that the law enforcement deputy director never 

brought the dismal state of Indian Country jails to the 

attention of the Assistant Secretary’s office. 

BIA-LES simply does not have the administrative 

infrastructure to properly manage and oversee the detention 

program. Detention staff at many of the 638-contract jails 

we visited told us that BIA-LES was essentially a non-entity. 

BIA-LES has failed to provide 638-contract jails with 

technical support or an accessible point-of-contact. The 

contempt for BIA was readily apparent in many of the 

discussions we had with detention staff and tribal members. 

One jail administrator met our team at the door by 

exclaiming, “I’ll tell you now I am not a fan of BIA.” 

The lack of a dedicated staff with the capability to develop, 

implement, and administer policies and procedures is a 

primary cause of BIA’s inability to effect change in the 

detention program. Absent appropriate staff to monitor 

compliance, safety issues go unreported and the truly 

deplorable conditions of the jails remain shrouded in secrecy. 

Having chiefs of police manage detention facilities has 

proven to be an operational failure. High crime rates and 

poor officer staffing demand the constant attention of the 

- 11 -
chiefs. Without a dedicated detention program manager on 

site, the needs of the jails will always remain secondary to 

fighting crime. 

 

Another significant challenge for management will be to 

overcome the frustration, cynicism, and apathy that infect 

Indian Country detention personnel. The overall 

mismanagement and neglect of the program has left many 

personnel with the attitude that management is not interested 

in the detention program and that nobody cares about the 

jails, the staff, or the inmates. We believe that BIA-LES 

management’s abdication of responsibility for the detention 

program significantly contributed to the overall malaise we 

encountered during our visits. That escapes are not taken 

seriously, vandalism is tolerated, or that there is little sense of

professionalism among detention officers should come as no 

surprise, given management’s inattention to the many serious 

problems found in the jails. 

Recommendations

1. For the purpose of providing the prominence and 

advocacy vital to ensuring that the focus on 

improving Indian Country jails does not diminish, the 

Deputy Assistant Secretary for Law Enforcement 

should become actively engaged in coordinating the 

oversight and management of the BIA-LES detention 

program. 

2. The Department should create a senior-level (GS14/15) full-time equivalent (FTE) position for a 

detention professional in DOI-OLES to help provide 

increased coordination and advocacy for the Indian 

Country detention program. 

3. DOI-OLES should conduct compliance inspections at 

BIA and 638-contract detention facilities on a 

scheduled and unscheduled basis. For the immediate 

future, it is recommended that the Department OLES 

and not BIA-LES be responsible for the compliance 

oversight of the detention program. 

4. BIA-LES should establish a senior-level (GS-15) 

detention program director with proper detention 

management credentials to manage the BIA and 638- 

contract detention facilities. This position should 

- 12 -
report directly to the BIA-LES director, coordinate 

actions with DOI-OLES, and be the BIA-LES liaison 

with OFMC for detention-related repairs. BIA should 

provide the appointee with adequate new staff to 

fulfill these responsibilities. At a minimum, the 

Central Detention office should be staffed with a 

Director, Deputy Director, secretary, and three 

management analysts. The six regions should be 

staffed with two detention specialists per region. 

- 13 -
Chapter 2: Safety and Security 

Serious Incidents We discovered there have been 11 fatalities, 236 attempted 

suicides, and 631 escapes at Indian Country jails over the last 

3 years.5

 We believe these numbers to be conservative given 

that 98% of these incidents have never been reported to BIALES. Our efforts to determine more precise numbers were 

hindered because local records are often inconsistent or 

poorly maintained by jail administrators. One jail 

administrator confirmed our concerns that incidents are 

underreported when he stated, “What happens on the 

reservation stays on the reservation.” 

“What happens 

on the 

reservation 

stays on the 

reservation.” 

The number of fatalities reported includes the recent suicide 

at the jail in Yakama, Washington, as well as the death of 

Cindy Gilbert, a 16-year old student who died of alcohol 

poisoning while in a detention cell at the Chemawa Indian 

School in Oregon.6

 

Fatalities 

On December 6, 2003, Gilbert (a.k.a. Cindy Lou Bright Star 

Gilbert Sohappy) was found dead in one of the school’s four 

cinderblock detention cells. She had been found intoxicated 

on school grounds and had been placed into a detention cell 

to sober up. Approximately 3 hours later, the school staff 

entered her cell, found her to be non-responsive and 

summoned the local emergency rescue squad. Gilbert was 

pronounced dead by the rescue staff. 

An autopsy determined that Gilbert’s death resulted from

complications of acute ethanolism. The medical examiner’s 

report indicated Gilbert’s blood alcohol level was .37, 

considerably over the .08 intoxication level for the state. 

 

5 We have limited our discussion of serious incidents to deaths and

suicides, attempted suicides, and escapes. The statistics cited above were 

obtained from BIA-LES and site visits. We note, however, that the 

accuracy of many statistics provided by BIA have proven unreliable when 

tested. 

6

 Although there is some question within BIA regarding supervisory 

responsibility over the Chemawa Indian School detention facility, BIALES included it on the “Inventory of Indian Country Detention 

Facilities—2003.” The school’s detention facility had four cells that 

were used to temporarily detain unruly or intoxicated students. These 

cells are no longer used. 

- 14 -
The OIG initiated an investigation into the death of Gilbert. 

The investigation, currently under DOJ review, revealed a 

history of inaction to correct a myriad of policy and safety 

issues at the school’s detention facility. In addition, we 

found that the school had no policy on having intoxicated 

students medically screened before incarceration. 

According to the 

Acting Lead 

Detention Officer, 

this occurred 

because the two 

officers on duty 

were “more 

interested in 

cleaning up the 

office” than 

observing 

inmates. 

In December 2003, an inmate at the BIA-operated Haulapai 

Detention Center in Arizona, who had been arrested for 

public intoxication, was found hanging in an apparent suicide 

attempt in his jail cell. Although the inmate was resuscitated, 

he died 6 days later in the hospital. A preliminary 

investigation determined that the inmate had been transferred 

from an intoxication cell where he would have received 

frequent monitoring to a single cell where the attempted 

suicide occurred. 

Another death occurred in December 2003 at the San Carlos 

638-contract facility in Arizona, when an inebriated inmate 

was placed in the intoxication cell and subsequently died of 

asphyxiation. 

Similarly, at the BIA-operated Hopi Adult and Juvenile 

Facility in Arizona, an intoxicated inmate died of 

asphyxiation in 2003. According to the Acting Lead 

Detention Officer, this occurred because the two officers on 

duty were “more interested in cleaning up the office” than 

observing inmates. 

Detention 

officers at the 

time were 

“off-line for 

approximately 

30 minutes,” 

handling other 

duties, and 

were not 

properly 

overseeing the 

cell 

population. 

In March 2003, a 16-year-old female hanged herself at the 

638-contract Zuni Adult and Juvenile Detention Facility in 

New Mexico. According to the facility administrator, 

detention officers at the time were “off-line for 

approximately 30 minutes,” handling other duties, and were 

not properly overseeing the cell population. 

In October 2002, a male inmate at the Rosebud jail in South 

Dakota was found dead in his cell. The inmate had been 

placed in the holding cell with other inmates the previous 

evening after he was arrested for public intoxication. 

Detention logs indicated that officers made regular 

observations of the cell and noted that the inmate was 

sleeping. An investigation by tribal investigators concluded 

that the inmate appeared to have died from asphyxia and/or 

poisoning after consuming anti-freeze or a similar substance. 

This death was reported to the FBI but not to BIA. 

- 15 -
In July 2002, a male inmate at the Blackfeet Adult Detention 

Center in Montana, who was arrested for intoxication, died 

approximately one hour after being placed in a cell. An 

autopsy ultimately attributed this inmate’s death to 

appendicitis. This death was reported to the FBI but not to 

“There are no BIA. 

written 

procedures for 

handling 

inmate 

deaths.” 

In March 2002, an inmate was found dead in his jail cell at 

the Pine Ridge facility in South Dakota due to an overdose of 

medication ingested prior to being incarcerated. The victim, 

along with another man, had been booked for intoxication. 

During the booking process, the victim informed the 

detention officer that the man accompanying him had 

ingested multiple pills. That inmate was immediately taken 

to the hospital for medical care; however, the victim inmate 

who remained at the jail had also taken multiple pills and 

later died. 

In July 2001, an inmate at the Blackfeet Adult Detention 

Center died as a result of a seizure. The inmate had an 

extensive history of seizures prior to being incarcerated. 

Since 2001, one suicide has occurred at the Shiprock Adult 

Detention Center, a 638-contract facility, in New Mexico. 

An inmate was placed in the isolation cell and left 

unobserved for 2 hours, during which time he hanged 

himself. According to the facility administrator, there are no 

written procedures for handling inmate deaths. 

A tragic example of BIA’s failure to remedy poor conditions 

at Indian Country detention facilities, despite the attention 

and publicity surrounding this issue, occurred on June 25, 

2004, when a 39-year old inmate at the Yakama detention 

facility committed suicide. The inmate, who had been 

incarcerated for violating a domestic violence no-contact 

order, was placed in isolation after attacking another inmate. 

He subsequently hanged himself from a broken light fixture 

in a corner of the cell out of view of a surveillance camera 

using a blanket and a bucket that had been left in the room. 

Only one person, a dispatcher, was on duty that night —

similar circumstances occurred when another inmate 

committed suicide at that facility in 1997. Due to the heavy 

volume of calls for service that night, the dispatcher did not 

conduct periodic rounds of the cellblock. The inmate’s body 

was not discovered until 8 hours later when jail staff went to 

check on him. 

Broken light fixture observed

during May 2004 Yakama site

visit. 

- 16 -
The inmate’s death occurred 1 month after we visited the 

Yakama site and 2 days after the Inspector General testified 

before the Senate Committee on Indian Affairs about the 

deplorable conditions we had discovered during our site 

visits. The Inspector General referred to his visit to Yakama

and the conditions he had personally witnessed there. The 

OIG’s Interim Report of April 2004 specifically addressed 

life-threatening issues comparable to those found at Yakama, 

such as poor physical conditions, inadequate staffing, and 

inattentive management, yet BIA-LES management failed to 

implement sufficient safeguards to prevent such an incident. 

According to detention officers, BIA-LES had not visited the 

Yakama jail in more than 5 years and had also failed to show 

up for an inspection they had scheduled for June 22, 2004, 

just 3 days prior to the inmate’s death. Detention staff also 

reported a second BIA inspection scheduled after the 

inmate’s death was cancelled without explanation. BIA 

detention specialists did not conduct a site inspection of this 

troubled detention facility until September 15, 2004. 

The same light fixture, used in 

June hanging, was again 

observed during August 2004 

Yakama site visit. 

Attempted Suicides Based on our own findings and observations noted in other 

reports, suicide attempts appear to be a regular occurrence at 

many of these facilities. Data obtained from our 27 site visits 

indicates a total of 236 suicide attempts over a 3-year period. 

The BJS reported there were 282 suicide attempts in Indian 

Country jails during the period of June 2001-2002 alone.7

 In 

addition, BJS further reported that while there had been an 

increase of jail admissions of 32 percent for the same period, 

suicide attempts had more than doubled. 

On more than one occasion, we found multiple suicide 

attempts had been made by the same inmate. For instance, a 

review of the incident log at the BIA-operated Mescalero 

Detention Facility in New Mexico revealed that from July 

2002 to January 2004, 5 of the 15 reported incidents involved 

the same female detainee who, on different occasions, 

attempted to inflict bodily harm on herself. According to the 

detention officer, the inmate was usually arrested for public 

intoxication and, after arriving at the detention facility, would 

attempt to slash her wrists or hang herself with articles of her 

clothing. 

 

7

 Minton, Todd D. “Jails in Indian Country, 2002,” Bureau of Justice 

Statistics Bulletin, U.S. Department of Justice, Office of Justice 

Programs, November 2003. 

- 17 -
Incredibly, an individual detained at the Shiprock facility in 

2001 attempted to hang himself seven times using articles of 

clothing and towels left in the cell. According to the facility

administrator, the detention officers’ response to these 

attempts was quite elementary -- if the inmate tried to hang 

himself with his socks, they would take his socks away; if he 

tried to hang himself with his towel, they would remove the 

towel - until the inmate remained in his cell without any 

clothing or towels. 

In spite of the 

disturbingly high 

number of 

suicide attempts 

at this facility, 

there are still 

many occasions 

where a lone 

dispatcher is on 

duty and unable 

to properly 

observe inmates. 

 

In March 2004, the Yakama detention facility reported that 

there had been an astounding 53 attempted suicides at the 

facility in the previous 3 years. In spite of the disturbingly 

high number of suicide attempts at this facility, there are still 

many occasions where a lone dispatcher is on duty and 

unable to properly observe inmates. 

Despite the prevalence of suicide attempts, BIA-LES is 

wholly lacking in procedures for handling and documenting 

these incidents. Jail administrators at a number of facilities 

were often unable to determine a precise number of suicide 

attempts at their respective facilities due to a lack of accurate 

recordkeeping. 

In contrast to most detention facilities in which inmate access

to any materials that might be crafted into a weapon is 

strictly monitored, in the Indian Country detention facilities 

we visited, we observed a common practice of allowing 

inmates uncontrolled access to knives as well as other 

utensils that could readily be used to harm themselves or 

others. 

We observed inmates at Tohono O’odham in Arizona and 

Rosebud in South Dakota using large knives to prepare food 

in the kitchens while only being supervised by a cook. We

also noted that kitchen knives are stored in unlocked drawers 

at many jails. At Sisseton/Wahpeton in South Dakota, we 

observed a hammer and a hunting knife on desks that were 

readily accessible to inmate workers who roamed freely 

throughout the facility. 

Kitchen knives are stored in

unlocked drawers. 

Sisseton/Wahpeton, SD 

In May 2003, a male inmate at the Rosebud jail attempted 

suicide by slitting his wrists with a knife that he obtained 

from the jail kitchen. A locking knife cabinet was purchased 

after this suicide attempt to prevent the theft of knives when 

jail staff are not present. During our site visit, however, we 

- 18 -
observed that the facility continues to allow inmates to use 

un-tethered knives while working in the kitchen. 

We could not identify any specific cause for what appears to 

be an unusually high rate of suicides and attempts in Indian 

Country jails. We note, however, that many inmates arrive at 

the jails intoxicated or under the influence of drugs. In the 

National Study of Jail Suicides: Seven Years Later8

 the 

authors reported that 60.3% of the suicide victims studied 

had been under the influence of alcohol, drugs, or both at the 

time of their incarceration. The study also noted that jail 

suicides are more prevalent when staff supervision is 

reduced. 

Inmate using knife in kitchen. 

Rosebud, SD This study, as well as others, has shown that careful and 

thorough screening is necessary to identify suicidal 

tendencies, and the importance of having properly trained 

personnel on duty to conduct suicide screening both during 

intake and in subsequent phases of the inmate’s 

incarceration. Intake screening is not intended to be an indepth, time-consuming evaluation, but meant to be more of a

triage to detect suicidal behavior and medical requirements. 

At many non-Indian jails, on-duty medical staff conduct the 

screening, which also serves to detect most medical and 

mental health problems and classification needs. 

During our site visits, we observed that there was no 

consistent method of screening inmates for suicide or 

medical purposes. Often times, the inmate was considered 

too intoxicated to screen at intake and inadequate staffing 

precluded later screening, thus the facility never was able to 

gauge any potential suicidal behavior. We also found that 

none of the 27 jails we visited had medical staff on duty 

during any time. In addition, we learned that the jails do not 

have an established threshold for blood alcohol level for 

detention officers to use in determining the need for medical 

screening of intoxicated inmates. Several deaths may have 

been prevented with either on-site medical staff and/or BAC 

threshold protocols. 

Hunting knife on desk. 

Sisseton/Wahpeton, SD 

Escapes For the most part, the detention officers at the jails we visited 

convey stories of inmate escapes with an air of casual 

inevitability. In fact, our impression is one of collective 

 

8

 Hayes, Lindsay M. and Joseph R. Rowan, National Study of Jail 

Suicides: Seven Years Later, National Center on Institutions and

Alternatives, February 1988. 

- 19 -
acceptance. In our interviews, detention officers who 

discussed escapes told us that it is just not possible to prevent 

inmates from escaping. Since the majority of these facilities 

function with only a single officer on duty, officers explained 

that they simply cannot “keep an eye” on everyone. In 

addition, we found that some facilities do not notify local law 

enforcement of inmate escapes. This is not only 

disconcerting, it is irresponsible to allow escaped inmates to 

freely travel in a community and surrounding areas while the 

local law enforcement authorities have no information 

regarding their escapes. Use of handcuffs over cipher

lock in recreation yard. 

Tohono O’odham, AZ Physically rundown and deplorably maintained, many of the 

facilities provide ample opportunity for escape. At one 

facility, the chain-link fence surrounding the outdoor 

recreation yard was held together and locked by a set of 

handcuffs because inmates had learned the combination to 

the cipher lock on the gate. While many of the recreation 

yards at these facilities are fenced-in and topped with barbed 

wire, there seems to be a universal acceptance among the 

detention officers that if inmates want to climb over the fence 

and escape, they will. 

For example, male inmates at the BIA-operated Mescalero 

facility were allowed to exercise in an outside confinement 

area unobserved. Although this area is surrounded by a 12-

foot cyclone fence with two additional feet of concertina 

barbed wire at the top, one inmate, who wanted to see his 

girlfriend, merely climbed up the cyclone fence, cutting 

himself on the concertina wire in the process, and left the 

premises. Only one detention officer, who was inside the 

facility, was on duty at the time. 

Recreation yard. 

Yakama, WA 

At the Northern Cheyenne jail in Montana, an unguarded 

inmate escaped from an outdoor recreation yard by climbing 

a fence topped with barbed wire. The strands of barbed wire 

were damaged and pulled together by the inmate. No effort 

has been made to repair the barbed wire or to replace it with 

concertina wire to prevent additional escapes. A detention 

officer at Crow Creek in South Dakota stated, “You give 

inmates some exercise freedom and then they take off. It was 

easy to get out.” 

“You give 

inmates some 

exercise freedom 

and then they take 

off. It was easy to 

get out.” 

At the Sisseton/Wahpeton jail, we observed that the 

recreation yard wall was only topped with poorly maintained 

strands of barbed wire. The recreation yard contained chairs 

- 20 -
and freestanding wooden benches that could be used by 

inmates to escape over the wall. When we inquired about the 

escape potential created by these items, we were told of an 

inmate who had recently escaped over the wall utilizing a 

chair and a door handle to climb out of the yard. Detention 

personnel did not appear to be alarmed that additional 

escapes were likely to occur if the benches and chairs 

remained in the recreation yard. 

Unsupervised inmates at the Medicine Root detention facility 

in South Dakota escaped from the recreation yard by 

climbing an electrical conduit onto the roof of the main 

building, which has no fence or barriers to prevent escape. 

Detention officers expressed frustration that they could not 

let inmates use the recreation yard because maintenance 

personnel have not taken any action to move the conduit or 

install effective barriers along the roof to prevent future 

escapes. Another inmate escaped because a door was left 

open when police officers brought an individual to the jail. 

Chairs line recreation yard. 

Sisseton/Wahpeton, SD 

From weakened and deteriorating locks on cell doors to 

broken windows in inmate dormitories, the interiors at many 

of these facilities are in extremely poor condition and do not 

deter inmates who set out to escape. For example, the wiremeshed windows in many of the cells at the White Buffalo 

Youth Detention Center in Montana are loosely encased in a 

crumbling wall and, with the application of some pressure, 

can be easily removed from their housing. According to the 

acting administrator, these “removable windows” have, in the 

past, provided an avenue of escape for a number of detained 

youths. As recently as February 2004, three male detainees 

escaped through one of the windows in the day room of the 

male dormitory after obtaining two fire extinguishers and 

using them to spray the two on-duty detention officers. 

Electrical conduit used to

escape. 

Medicine Root, SD

Perhaps even more disturbing than the actual circumstances 

and frequency of inmate escapes at these facilities are the 

lack of response and importance placed on these incidents by 

both detention officers and facility administrators alike. At 

one detention facility, the administrator recounted an incident 

of a juvenile escaping by stating that they “haven’t seen him

since.” At another facility, the administrator casually 

attributed several prior escapes to poor perimeter security. A 

third jail administrator in Arizona simply stated that there are 

too many escapes to count. 

Loosely encased wire-meshed 

windows.

White Buffalo Home, MT

- 21 -
One officer at the Shiprock Adult Detention Center chuckled 

in response to our question about escapes and said, “Oh yeah, 

they happen.” She then recounted a story about an inmate 

who had escaped from her in June 2003. The inmate 

escaped on foot and in ankle-shackles while she was ushering 

a line of inmates from the facility to the courthouse across 

the courtyard. Since she was the only officer on duty at the 

time, she could not pursue the fleeing inmate and leave the 

other inmates unattended. The officer told us that she 

believed that the inmate had not yet been apprehended. A 

review of facility logs indicated no record of the escape or of 

the inmate being returned. 

One officer 

chuckled in

response to our 

question about 

escapes and 

said, “Oh yeah, 

they happen.” 

A number of inmates have escaped by just by walking away, 

yet the jail staffs continue to allow them to work or loiter 

while unguarded in areas where they can easily escape. We

observed unguarded inmate workers at Sisseton/Wahpeton 

and Medicine Root routinely exit the jails while they work in 

non-secure areas. At Yakama, we observed an unguarded 

inmate sitting against a wall outside the jail in an unfenced 

area adjacent to the parking lot. The inmate remained 

outside of the jail several hours later. We observed another 

unguarded inmate loitering outside the front entrance to the 

jail during a subsequent visit to this facility several months 

later. At Pine Ridge, we noticed four unguarded inmates 

loitering outside of the sally port in a non-secure area only a 

short distance from the highway. A detention officer at Pine 

Ridge summed the problem up by stating “inmate workers 

escape a lot — also from the hospital and from the 

courthouse.” 

Unguarded inmate outside

Yakama jail. 

During a visit to the BIA-operated Blackfeet Adult Detention 

Center, the district commander told our investigators that he 

had personally seen unsupervised inmates milling about in 

the recreation yard from which unsupervised inmates had 

previously escaped; however, he did not seem concerned 

about this and had done nothing to rectify the situation. At 

this same facility, in April 2002, an inmate worker, 

commonly known as a trustee, escaped and committed a 

murder before he was eventually apprehended. 

Several inmates at Rosebud also escaped by climbing 

through the suspended ceiling in the dining area into a nonsecure area and walking out the door. This escape route has 

not been blocked or corrected although it has been identified 

for some time. To our amazement, inmates continue to use 

- 22 -
the dining area with little or no supervision. 

We were told that 

the exterior door 

had been propped 

open because the 

jail gets “stuffy.” 

Incredibly, we 

observed the 

same door that 

the inmate used to 

escape was 

propped open 

during our visit. 

Detention personnel at Pine Ridge told us that an inmate 

escaped the night prior to our visit. The inmate kicked a cell 

door when it was opened by an officer, ran around the 

startled officer, and escaped through an unlocked door. We

were told that the exterior door had been propped open 

because the jail gets “stuffy.” Incredibly, we observed the 

same door that the inmate used to escape propped open 

during our visit. We also learned that unsupervised inmate 

workers are routinely tasked to conduct work and are allowed 

to loiter in unfenced areas outside of the jail. The Pine Ridge 

jail continues to allow this practice despite their high number 

of escapes. 

Of the escapes we were able to document during our 

assessment, 144 (23%) of the 631 occurred when unguarded 

inmates simply walked away while awaiting medical 

treatment at clinics or hospitals. For instance, many of the 37 

reported escapes at the Rosebud detention facility occurred 

when inmates walked away from the hospital. 

Inmates are regularly left in the care of medical staff or 

hospital security personnel who are not trained to handle or 

restrain inmates. An officer at Pine Ridge said, “We don’t 

have enough people to escort them to the hospitals.” At the 

Yakama detention facility, inmates who require medical care, 

for which the jail cannot afford to pay, are actually released 

from custody with the hope that they will return on their own 

after treatment. Not surprisingly, Yakama detention officers 

commented that inmates have learned to feign illness because

they know that they will be released if they claim a need for 

medical treatment. 

Door used during escape still 

propped open.

Pine Ridge, SD

- 23 -
 Serious Incidents Chart 

Blackfeet, MT (BIA)

Chemawa, OR 1 (BIA)

Crow, MT (BIA)Crow Creek (Ft. Thompson), SD (BIA)

Gila River Juv, AZ (638)

Gila River Adult, AZ (638)

Haulapai (Peach Springs), AZ (BIA)

Hopi, AZ (BIA)

Kyle Juv (Kiysuska Otipi), SD (638)

Kyle Adult (Medicine Root), SD (638)

Mescalero, NM (BIA)

Nisqually, WA (638)

N.Cheyenne, MT (BIA)

Pine Ridge, SD (638)Puyallup, WA (638)

Quinault, WA (Tribal-BIA owned)Rosebud, SD (638)Salt River, AZ (638)San Carlos, AZ (638)

Shiprock, NM (638)

Sisseton, SD (638)

Tohatchi, NM (638)

Tohono O'odham, AZ (638)

Ute Mountain Ute, CO (BIA)

White Buffalo, MT (638)

Yakama, WA (638)Zuni, NM (638)

Totals

Deaths

Non-Suicide 2 1 1 0 000 0 1 0 0 0 0 0 0 0000 1 0000 000 0 5

Suicide 000 000 1 0 0 0 0 0 0 1 0 0 1 0 0 1 000 0 0 1 1 6

Suicide Attempts 9 0 8 2 0 0 4 4 9 1 17 3 41 16 0 0 12 1 4 763 18 1 12 53 5 236

Escapes 64 0 6 17 8 0 2 26 3 116 1 1 11 69 2 2 37 1 184 3 9 0 2 0 19 42 6 631

Totals 75 1 14 19 8 0 7 31 12 117 18 4 52 86 2 2 50 2 189 11 15 3 20 1 31 96 12 878 1 Chemawa Indian Boarding School has detention cells and reported by BIA as a Detention Facility.

Incidents reported to OIG from detention facilities.

No Incidents Discovered.

Out of the 878 incidents, BIA-LES's Incident Log only reflected 22 of those incidents. 

Therefore, BIA-LES was unaware of 98% of incidents reported to the OIG.

Revised as of August 2004

Recommendations 

5. DOI-OLES should ensure that BIA-LES establishes 

and implements clear reporting protocols for serious 

incidents occurring at all BIA and 638-contract 

detention facilities. At a minimum, all officer safety 

issues, inmate deaths, attempted suicides, assaults, 

and escapes should be reported promptly through an 

established chain of command ending with the 

Director of BIA with copies to the DOI-OLES. 

6. BIA and 638-contract detention administrators should 

ensure that any escape is immediately reported to 

surrounding local, tribal, and state law enforcement 

authorities. 

7. BIA-LES criminal investigators should immediately 

respond and conduct a preliminary inquiry to 

determine if a full investigation is warranted on any 

reported serious incident. Their findings, in every 

case, should then be reported to the Director of BIALES with a copy to the DOI-OLES. All death cases 

at BIA or 638-contract detention facilities, not 

investigated by the FBI, should be investigated by a 

BIA-LES criminal investigator. 

- 24 -
8. BIA and tribes should explore alternatives to 

detention for intoxicated inmates. When it is 

necessary to incarcerate intoxicated inmates, 

additional detention officers should be on duty to 

assist with the additional monitoring required. 

9. DOI-OLES should work with the tribes and BIA to 

establish a Memorandum of Understanding (MOU) 

with the Indian Health Service to provide on-site 

medical assistance at all detention facilities with more 

than 20 inmates incarcerated. Detention staffs should 

be adequately staffed and scheduled to accommodate 

for medical transport to hospitals when necessary. 

- 25 -
Chapter 3: Detention Facility Staffing 

Determining the appropriate detention staff ratio for a jail is 

extremely complex with many variables to consider. No two 

facilities are exactly alike. Thus, staffing requirements 

should be determined by considering the physical size and 

layout of the facility, inmate population, types of inmates, 

including the need for isolation, length of average stay by 

inmate, technology available, and the competency of the 

staff. 

When conducting our site visits, we learned that most of the 

facilities operated below their authorized staffing levels, and 

they operated below what the managers would consider 

optimum. We discovered that 79% of the facilities fell below 

minimum staffing levels on a regular basis. One manager 

remarked, “We are often down to none” when asked if they 

ever fell below minimum staffing levels. 

One manager 

remarked, 

“We are often 

down to none” 

when asked if 

they ever fell 

below 

minimum 

staffing levels. 

Most managers and detention professionals we spoke with 

believe there generally should be a minimum of one 

detention officer per shift who is dedicated for the sole 

purpose of providing security and observation of inmates. 

There are other more scholarly views including an author in 

one prominent correction publication who writes “The ratio 

of staff to inmates should not be the central issue. Instead, 

the issue should be making sure the right number of properly 

trained staff, are in the right places, at the right time, doing 

the right things. What is important is the way the staff are 

trained, assigned, and managed, not just how many there 

are.”9

 The author goes on to remark, “that if the detention 

staffs are not competent or productive, simply increasing 

their numbers will not improve facility operations.”10

 

In fact, we found that the majority of the detention facilities 

we visited operated with only one detention officer per shift 

and often times the officer had several collateral duties that 

took his/her attention away from the inmates. Even more 

disturbing was our discovery that a number of jails have 

shifts with no detention officers on duty. In these instances, 

dispatchers, cooks, or police officers fill in while continuing 

to do their primary jobs. 

 

9

 Krauth, Barbara. Staff Inmate Ratios: Why It’s So Hard to Get to the 

Bottom Line, L.I.S.I., September 1988. 10 Ibid. 

- 26 -
For example, the dispatcher at the Crow Creek detention 

facility is regularly called upon to watch the inmates while 

performing dispatch duties and must prepare meals for the 

inmates as well. One Crow Creek employee commented, 

“The dispatcher works as an officer, the dispatcher cooks. 

Everyone shuffles around. We’re jacks of all trades.” The 

Northern Cheyenne detention facility normally has only one 

detention officer on duty. The cook fills in for the detention 

officer two or three times weekly when the detention officer 

transports inmates for medical treatment or court 

appearances. At the 55-bed Blackfeet Adult Detention 

Center, the lone detention officer stands in for other 

personnel several times a week and must physically leave the 

jail to prepare meals, leaving the inmates unsupervised. 

“The 

dispatcher 

works as an 

officer, the 

dispatcher 

cooks. 

Everyone 

shuffles 

around. 

We’re jacks of 

all trades.” 

The San Carlos facility in Arizona has only four correctional 

officers on staff to operate what they feel is an overcrowded 

facility. To address this situation, the facility has placed a 

24-hour, 7-day a week “lockdown” on inmates. Although 

lockdown is not unusual as a short-term solution for an acute 

problem in a detention facility, it could lead to an unsafe and 

dangerous environment long-term. The detention officer on 

duty has no one for back up if a medical emergency or 

conduct problem arises. When an officer is working alone, 

he or she must either wait for assistance or act independently, 

both of which place officers and inmates in a potentially lifethreatening situation. 

Indian Country jails currently range in size from 2 to 120 

beds. While we recognize that small jails, which are often no 

more than temporary holding cells, may be able to operate 

with one detention officer/dispatcher on duty as long as they 

are supported by other law enforcement personnel, in most 

instances, the practice of operating a jail that houses inmates 

more than 48 hours with only one detention officer on duty is 

a recipe for disaster. 

Detention officers must book and process new inmates 

brought to the jail, intercede when altercations occur, make 

regular rounds of the jail to keep inmates under surveillance, 

manage/watch suicidal or violent inmates, respond to 

emergencies or injuries, transport inmates for medical care, 

oversee visitors, log activities, and manage other operational 

functions of the jail. It is unreasonable to expect one 

detention officer to perform all of these duties under normal 

- 27 -
conditions. During periods of increased inmate population, 

such as weekends and holidays or when jails are 

overcrowded, the challenges faced by a single detention 

officer become overwhelming. 

Lone detention officers are also at great risk of being 

assaulted, injured, or even killed during the performance of 

their duties. Inmates may be encouraged to attack a lone 

detention officer since they know that many of these officers 

have nobody to come to their rescue. Occasionally, other 

inmates intervene to help a detention officer, as occurred at 

Mescalero where a lone female detention officer was 

confronted at knife-point by a former inmate who entered the 

facility through an unlocked door. Tragedy was averted 

when the officer locked herself into a detention cell while a 

trustee convinced the intruder to move to another part of the 

jail and to leave the officer alone. Another inmate then 

summoned the police. At the Blackfeet Adult Detention 

Center, a dispatcher was alerted to an assault on the lone 

detention officer by inmates pounding on the walls. 

Unfortunately, this incident does not appear to be an 

exceptional case; the BIA district commander told us, “Every 

officer here has been assaulted.” Detention officers should 

not have to place their hopes of being rescued on inmates if 

they are assaulted or attacked. 

Sign indicating staffing

shortage. 

Crow Creek, SD 

Inadequate staffing greatly increases the potential for BIA 

liability when injuries, deaths, or escapes happen. We

believe there is a direct correlation between insufficient staff

and the number of serious incidents and escapes that occur at 

Indian Country jails. 

In most cases, Indian Country jail staffing levels are so low 

that there are no detention officers available to fill in when 

officers are sick or otherwise unable to be on the job. Many 

unfilled vacancies further contribute to the inability of jails to

have a sufficient number of detention officers on duty and 

require detention officers to work unsafe levels of overtime. 

A detention officer at Crow Creek claimed it is not 

uncommon to work up to 16 hours per day. Detention 

officers at other jails similarly reported that they must work 

double shifts when co-workers are sick or vacancies remain 

unfilled for long periods of time. 

Several detention officials reported that it is not uncommon 

for vacancies to go unfilled because of a lack of qualified 

- 28 -
applicants. Not surprisingly, we were told that many 

applicants are not willing to move to remote areas with poor 

housing, low pay, and undesirable working conditions. 

 

The National Institute of Corrections (NIC) in Longmont, 

CO, notes that on average, it takes 5 FTEs to staff one post 

on an 8-hour shift, 7 days per week. In contrast, BIA jails 

have approximately one FTE per shift for each jail. BIA 

management’s failure to fill vacancies and/or increase 

staffing to sufficient levels directly impacts the poor 

operation and management of the jails for which it has 

responsibility. 

BIA management has been aware of the unsafe conditions 

created by insufficient staffing for more than 6 years with 

little evidence to indicate that there has been more than a 

token effort to take corrective action. In his June 3, 1998 

testimony, former Assistant Secretary Gover testified about 

the danger of inadequate staffing. Gover stated, “Most of the 

facilities have limited staff on duty at any given time to 

adequately manage inmates. For example, during a shift, the 

same person may serve as jailor, dispatcher, receptionist and 

cook. Clearly, this frequent predicament causes an 

unreasonably dangerous situation for the employees as well 

as the inmates.” Gover’s testimony echoed many of the 

findings noted in the 1997 DOJ report. 

Recommendations

10. Staffing shortages at BIA and 638-contract detention 

facilities that are related to officer safety should be 

identified by the BIA-LES and corrected 

immediately. DOI-OLES should oversee this effort. 

11. BIA-LES in collaboration with 638-contract 

programs should develop staffing models and 

methodologies for BIA and 638-contract detention 

facilities. DOI-OLES should oversee this 

developmental effort. 

- 29 -
12. The DOI Law Enforcement and Security Board of

Advisors should develop recruiting standards and 

guidelines for BIA detention officers. BIA-LES 

should then assist tribal detention programs in 

developing recruiting standards and guidelines for 

tribal detention officers. 

 

- 30 -
Chapter 4: Detention Facility Maintenance

We found the condition of the majority of the jails we visited 

to be abysmal — the result of years of neglect and failure to 

perform even routine repairs in a timely manner. In contrast, 

local county jails we visited for benchmarking purposes are 

in significantly better condition than the Indian Country jails 

of the same age. 12 In general, the county jails, which 

received sufficient upkeep, clearly had many more years of 

service remaining while many of the Indian Country jails are 

dilapidated to the point of condemnation. 

Records reflect that BIA and the tribes have consistently 

failed to maintain their detention facilities. In the OIG Audit 

Report, Maintenance of Detention Facilities, Bureau of 

Indian Affairs, issued in August 1994, the findings reflected, 

in part: 

Inoperable sinks in cells. 

Mescalero, NM 

“The Bureau of Indian Affairs and Indian tribes have not 

adequately maintained detention facilities or corrected 

hazardous health and safety conditions at these detention 

facilities. Most of the facilities we visited were in unsanitary 

conditions and/or disrepair.” 

Ten years 

from our 

earlier audit, 

conditions 

remain the 

same. 

 

The 1994 audit determined the lack of maintenance and 

repairs at the facilities were attributed to BIA and the tribes 

not (1) having established and implemented preventive 

maintenance programs, (2) specifically assigning and holding 

personnel accountable for correcting deficiencies at BIAoperated facilities, or (3) adequately monitoring tribal

contractors to ensure proper maintenance of tribally operated 

facilities. The audit also reported that the conditions and lack 

of attention had been on-going for several years prior to the 

audit. 

BIA OFMC is responsible for the maintenance and repair of 

BIA-owned detention facilities. OFMC is tasked to manage 

maintenance funding and to coordinate repairs for all 

structures owned by BIA. OFMC operates independently of

BIA-LES; consequently, jail administrators have no direct 

authority over local maintenance personnel and do not have 

the authority to prioritize maintenance and repair work at 

Broken glass in cell window.

Hopi, AZ 

 

12 We visited seven jails in nearby communities off the reservation. 

- 31 -
their facilities. OFMC personnel determine repair scheduling 

and prioritization for all BIA buildings with little thought of 

the unique needs of detention facilities. This diminishes any 

sense of ownership that jail administrators and detention 

officers have for the maintenance and upkeep of their facility. 

Missing pump/leaking

water. 

Medicine Root Jail, SD

The prevailing attitude of the detention personnel we 

encountered is that problems reported to OFMC, once made, 

are no longer their concern. This results in little, if any, 

follow-up to determine prioritization or repair status. 

Additionally, few jail administrators conduct formal weekly 

or even monthly inspections of their facilities as required 

under current BIA standards for operation. These are the 

very standards that were implemented to address and respond 

to the findings of the 1994 OIG Audit. 

Unless this trend is reversed, many of the newer jails in 

Indian Country will prematurely deteriorate due to a similar 

lack of upkeep and maintenance. Relatively new jails we 

visited are already showing signs of accelerated aging and 

wear due to delay of necessary repairs. For instance, the 

main control panel for monitoring access at the 4-year-old 

Ute Mountain detention facility has not worked for more than 

2 years. Although this problem was reported to OFMC 2 

years ago, it is still broken. 

An egregious example of a deteriorating newer jail was 

found at the juvenile detention facility at the Kiyuska O’Tipi 

Reintegration Center, which was constructed in 1995. Door 

lock indicator lights do not function properly, failed hot 

water heaters have not been replaced, trim pulled from the 

roof by a storm has gone unrepaired for several years leaving 

parts of the structure exposed to the elements, the entry gate 

to the jail compound is non-functional, a leaking water 

recirculation pump leaves puddles of water in a utility room, 

external security light fixtures remain broken, and showers 

and fire sprinkler heads damaged by inmates are in disrepair. 

We noted that many 

of the maintenance 

shortcomings have a 

direct impact upon 

officer and inmate 

safety; yet there is 

little indication that 

OFMC or detention 

personnel place any 

emphasis on

expediting repairs 

affecting safety. 

We noted that many of the maintenance shortcomings have a 

direct impact upon officer and inmate safety; yet there is little 

indication that OFMC or detention personnel place any 

emphasis on expediting such repairs. For example, virtually 

all of the Plexiglas in the jails at Rosebud and at Zuni in New 

Mexico, as well as other locations, has been scratched, 

burned, and damaged to the point that it is extremely difficult 

for detention officers to see into cells to check on inmates 

- 32 -
prior to entry. According to Rosebud personnel, this 

condition has been reported to OFMC for years, but nothing 

has been done to repair the Plexiglas. 

Fire sprinkler heads at a number of facilities were inoperable. 

Even more disturbing, detention officers at Yakama reported 

the entire fire suppression system had not functioned for 

years. We observed that some fire extinguishers at Yakama

had not been inspected since 2001. We also discovered that 

many cameras and inmate monitoring systems did not work 

or worked poorly. At Tohono O’odham, the camera 

monitoring a cell for high risk inmates is pointed to the 

ceiling while at the Crow jail, several cameras cease 

functioning on an intermittent basis. In addition, the keys to 

the cells at Tohono O’odham are so worn that they do not 

reliably unlock or lock the cell doors. This could easily 

result in a tragedy in the event of a fire. 

Scratched and burned

Plexiglas. 

Rosebud Sioux, SD

We also found that many maintenance shortcomings 

impacted sanitation. In all too many instances we observed 

toilets that do not flush, showers and sinks that do not work, 

and inoperative hot water heaters that have not been replaced. 

At Pine Ridge, the toilet in the “drunk tank” has been 

inoperable for months. This situation causes sanitation 

concerns because intoxicated inmates in the “drunk tank” 

frequently need to urinate and may not be able to wait until 

officers can move them to other cells. This also places 

detention officers at risk because they must frequently move 

inmates to other occupied cells. According to detention 

personnel at both Pine Ridge and Crow detention facilities, 

they experience instances in which waste flushed down one 

toilet surfaces in another toilet. The plumbing issues at 

Shiprock are so severe that health inspectors closed the jail 

for several months in 2003. We learned that the Shiprock jail 

was again closed for sanitation reasons in June 2004. Health 

inspectors have since allowed a small portion of the jail to be 

reopened. Camera in high-risk cell 

faces ceiling. 

 Tohono O’odham, AZ

We encountered numerous instances in which even routine 

maintenance was not being accomplished. It was not 

uncommon for us to observe broken light fixtures, peeling 

paint, broken door locks, inoperable or malfunctioning 

kitchen equipment, and ventilation problems at many of the 

detention centers. We noted that several air vents at 

Northern Cheyenne and Crow Creek were so clogged with 

dust and debris that little air could flow through them. 

- 33 -
Detention personnel at the Kiyuska O’Tipi Reintegration 

Center reported that a replacement water recirculation pump 

sat uninstalled for almost 6 months while a malfunctioning 

pump continued to leak water into a utility room. We were 

also told that a commercial grade toaster and fryer have 

remained unused since the jail was constructed in 1995 

because OFMC personnel have not installed a 220-volt 

circuit. 

Maintenance 

Funding

There is an enormous backlog of items that require repair, 

but little to no effort has been made to correct the majority of

these problems. BIA officials originally reported that they 

had approximately $1.4 million available in FY2004 for 

facility upkeep but had identified approximately $30 million 

in necessary repairs. BIA subsequently reprogrammed funds 

to increase the money available for detention facility 

maintenance to approximately $4 million to address 

maintenance issues and deficiencies publicized as a result of 

media attention from our interim assessment. 13 This not only 

demonstrates that BIA failed to take a proactive approach in 

managing the detention program prior to OIG interest, it also

confirms that BIA had the means to accomplish additional 

repairs, but not the will. 

...BIA had the 

means to 

accomplish 

additional 

repairs, but not 

the will. 

Our examination of the Facility Management Information 

System (FMIS) found that there are many duplicate and 

inaccurate entries. We found that the data provided to us, 

which OFMC personnel claimed represented jail repair and 

maintenance needs, included new construction data. For 

example, we discovered one entry in FMIS in the amount of 

$979,802 was for the construction of a new jail. We further 

found there were monetary values attributed to facility 

maintenance, such as a jail’s failure to have a written 

evacuation plan, inadequate staffing, no fire drills, fire 

extinguisher training for staff, security study, and 

overcrowding that are clearly more operational than 

maintenance issues. 

Our review of the FMIS data that was initially provided to us 

disclosed outstanding maintenance requirements totaling 

$30.4 million. Subsequent to our request for this data, BIA 

OFMC personnel began to analyze its information and 

provided revised FMIS data showing outstanding 

 

13 Anderson, David W., Hearing on Indian Tribal Detention Facilities, 

Statement to U.S. Senate Committee on Indian Affairs, June 23, 2004. 

- 34 -
maintenance backlog costs of $27.8 million and eventually 

$26.6 million. This $3.8 million discrepancy represents, yet 

again, BIA’s neglect and mismanagement of the detention 

program. 

We discussed our concerns about these inaccuracies with 

senior OFMC personnel and provided them with examples of 

questionable entries attributed to maintenance or repair. In 

response, OFMC provided revised data approximately 1 

week later showing maintenance and repair backlog costs of

$23.2 million reducing the total yet another $3.4 million. We 

believe that additional analysis of FMIS would result in a 

further reduction of the estimated maintenance costs by 

another $1 or $2 million. Regardless, the many inconsistent 

and questionable entries significantly diminish the value of 

FMIS as a management tool for OFMC and for BIA-LES. 

In July 2003, GAO expressed concerns about the quality of 

data being entered into FMIS. In its report on Indian School 

Maintenance, GAO observed that “most measures for 

controlling the quality of new data BIA employees are 

entering into the system for individual schools are not 

working well” and that “nearly half of the proposed data 

entries coming through the system are inaccurate and 

incomplete.”14 Given that our own examination of FMIS 

identified so many inaccuracies, we must conclude that BIA 

management simply does not have an accurate accounting of 

the maintenance needs or estimated repair costs. Our 

findings also indicate that BIA is clearly not effectively 

addressing GAO’s recommendations that “BIA establish 

better guidance and performance expectations for employees 

who are responsible for entering and reviewing the accuracy 

and completeness of FMIS data” and “periodically analyze 

the extent and type of data errors being found during review 

in order to identify training needs and other strategies for 

addressing any continuing problems.”15

It remains clear that BIA does not have sufficient funds to 

correct known maintenance deficiencies. With appropriate 

management and oversight, however, many of the identified 

problems might have been prevented and the severity of 

many others could have been reduced if repairs were made in 

 

14 Government Accountability Office, Bureau of Indian Affairs Schools, 

New Facilities Management Information System Promising, but Improved

Data Accuracy Needed, GAO-03-692, Washington, DC, July 2003. 15 Ibid.

- 35 -
a timely manner. 

The poor coordination and communication between BIALES and OFMC personnel at all levels leaves maintenance at 

detention facilities an orphan. Clearly, the unique 

maintenance needs at the jails has not been recognized. For 

example, jail administrators at Pine Ridge purchased gun 

lockers months ago for police to secure their firearms before 

entering the jail. Detention personnel advised that the gun 

lockers still remain uninstalled, and police officers who bring

prisoners to the jail have nowhere to secure their weapons. 

Maintenance 

Accountability

Vandalism by inmates has caused a significant amount of the 

maintenance issues reported by jail staff. This destruction of 

property is costly, adversely impacts the safety of inmates 

and staff, and diminishes the comfort and cleanliness of the 

facility. Rarely are inmates who cause damages held 

accountable. With no consequences for their actions, inmates 

are not deterred from causing further damage. There is no 

incentive for inmates to change their behavior. In contrast, 

we observed that local county jails we visited had virtually 

no graffiti or noticeable damage because inmates knew there 

were consequences for damaging the facility. The sheer 

volume of damage caused by inmates at Indian Country jails 

indicates that vandalism is accepted and cannot be prevented. 

We found no indication that BIA management held jail 

administrators or detention staff accountable for preventing 

vandalism damage. 

One jail 

administrator 

commented that 

“the staff sets the 

atmosphere” at 

the jail. 

We noted a few facilities, such as Ute Mountain, Gila River, 

and Salt River, where little or no vandalism was observed. 

The management at these facilities required detention staff 

and prisoners to keep the facility clean and to properly 

dispose of trash. One administrator commented that “the

staff sets the atmosphere” at the jail.

Recommendations

13. BIA OFMC and BIA-LES should immediately 

establish an effective system for prioritizing repairs 

that have any impact on inmate or detention officer 

safety. They should also review FMIS to identify and 

remedy inaccurate and redundant entries and 

implement quality control measures to reduce the risk 

and occurrence of improper entries. 

- 36 -
BIA is required to provide law enforcement services on 

reservations under the Indian Law Enforcement Reform Act 

of 1990 (Public Law 101-379). Detention facilities are 

operated and funded by the BIA, tribes, or a combination of 

both. BIA and 638-contract programs are funded under the 

law enforcement budget through the Department’s annual 

appropriation. 

In the last 4 years, BIA received $637 million for law 

enforcement services. In addition, since 1999, BIA-LES has 

also received supplemental funding totaling $31.5 million 

specifically designated for hiring detention officers and 

preparing new facilities for operation. This supplemental 

funding includes $10 million allocated from FY1999 to 

FY2001 to hire an additional 305 detention officers as a 

result of the Presidential Initiative for Law Enforcement in 

Indian Country; $5 million in FY2002, to hire detention staff 

needed for new facilities; $5.1 million in FY2003 was 

reprogrammed by BIA-LES; and an additional $11.4 million 

in FY2004 to prepare new facilities for operation.

We discovered that BIA-operated facilities actually only 

received $3 million of the $10 million allocated to hire 94 

additional detention officers. They had only hired 58 officers 

as of the end of FY2001. BIA was unable to determine if the 

remaining $7 million, which was specifically designated for 

hiring additional detention officers for the 638-contract and 

self-governed facilities, was in fact used for that purpose. 

Detention Program 

Supplemental Funding 

Presidential Initiative: 

o FY 1999 - $1.8 million 

o FY 2000 - $4.0 million 

o FY 2001 - $4.2 million

 $10 million 

New Facilities Funding: 

o FY 2002 - $ 5.0 million 

o FY 2003 - $ 5.1 million 

o FY 2004 - $11.4 million

 $21.5 million 

TOTAL $31.5 million

 

Bureau of Indian Affairs 

Law Enforcement Services

Annual Funds 

 

o FY 2001 - $149 million 

o FY 2002 - $158 million 

o FY 2003 - $160 million 

o FY 2004 - $170 million 

Chapter 5: Funding of the Detention Program 

Since 2002, BIA has only filled a mere 13 positions at BIAoperated facilities. Furthermore, BIA-LES told us funds 

remaining from budgeted but unfilled positions are ultimately

absorbed into the law enforcement program for non-detention

activities. 

BIA-LES failed to provide us with their budget submissions 

for the last 3 years when we requested them. BIA-LES 

officials indicated that they were unable to locate documents 

or documentation pertaining to their budget requests. An 

inquiry with BIA budget personnel revealed that they also 

- 37 -
could not locate any budget requests or projections for BIALES. A BIA budget official advised BIA-LES may not have 

submitted budget proposals if they were not requesting an 

increase in their budget. We later learned that BIA-LES 

managers use historical funding levels with little or no 

increases for their budget requests. BIA-LES managers 

indicated that there has been no change in the level of their 

operating funds for the last 3 years with the exception of 

increases associated with new facilities. 

Budget Projections 

and Planning

BIA-LES does not seek to obtain accurate or realistic budget 

projections or plans from responsible local officials, such as 

police chiefs or detention administrators. We found that 

most jail administrators and police chiefs we interviewed 

make no effort to conduct an accurate budget analysis or 

construct a realistic budget projection. They simply expect to 

receive the same level of funding that was received in prior 

years with little or no variation. For instance, an official at 

one BIA-operated facility stated that they look at the 

previous years’ funding to figure out the current budget 

because “the funds stay the same each year — there are no 

increases.” Another official stated, “They give us what they 

want to give us.” 

“The funds stay 

the same each 

year -- there are 

no increases.” BIA’s failure to make any effort to assess the true cost of 

operations or to create an accurate budget projection becomes 

a self-fulfilling prophecy. This failure not only impacts the 

detention program but also impacts the other three 

components that fall under BIA’s law enforcement budget. 

We believe that the true operational cost of the BIA detention 

and law enforcement programs is much greater than their 

current appropriations. BIA cannot address any of its 

funding difficulties without advocacy. Successful advocacy 

requires accurate cost assessments and budget projections. 

Our efforts to determine the percentage or amount of BIALES funding used for detention were unsuccessful because 

BIA-LES does not designate separate budget line items for 

detention. We found that funding is allocated to local 

officials by BIA-LES, usually to police chiefs, who 

determine the amount of funding to provide to each of the 

programs under their responsibility. Typically, no 

methodology is applied to the percentage allocated to each 

program nor is there an accurate recording of how the money 

is used. In most instances, the largest percentage of the funds 

are used for uniformed police and criminal investigation 

Fund Designation

- 38 -
leaving inadequate funds for detention operations. 

An official at the 638-contract Rosebud detention facility 

reported that only 16% of the local law enforcement budget 

is allocated for detention services. Most of that funding 

supports personnel costs, leaving very little money for other 

needs such as food for inmates and training for detention 

officers. One chief of police, who is also responsible for 

detention services, told us that 90% of the funds his 

department receives support salaries, with the remaining 

funds used for major needs such as equipment. This same

chief also noted that if he had to choose between his police 

department or detention needs, he would most likely fulfill 

the police department’s needs first. A detention officer at 

San Carlos in Arizona summed his plight up well by stating, 

“We wind up on the short end of the allocation table.” 

“We wind up on 

the short end of 

the allocation 

table.” 

We find it troubling that BIA-LES management exercises so 

little oversight of these budgeted monies and simply 

distributes funds without any guidelines to ensure that all the 

programs for which they are responsible receive sufficient 

and balanced funding. Although we recognize the difficulty 

of balancing the funding needs of a police department with 

the needs of a detention program, the gross inequities that we 

observed at many locations incapacitates detention managers 

to adequately staff, operate, and maintain their facilities. We

believe that the designation of specific funds for detention is 

imperative for the efficient and effective operation of 

detention facilities. 

 

New Facility Funding Since 1997, DOJ has provided over $150 million in 

construction grants to tribes for building new detention 

facilities. These grants cover facility construction only. BIA 

is then responsible for funding a facility’s operational 

requirements. As noted earlier, BIA-LES has received $21.5 

million since 2002 for staffing and operating new facilities. 

Given the poor coordination and planning of new jails 

between BIA and DOJ, however, facilities have been built 

that cannot be opened. 

New Facility Funding

FY 1997-2003 

1997 - 2

1998 - 2

1999 - 13 

2001 - 2

2002 - 3

2003 - 2

 Beds in New Facilities 

 30% 1-35 beds 

 40% 35- 70 beds 

 15% 70-105 beds

 5% 105-130 beds

 10% 130-160 beds

According to an April 2004 status report, DOJ was scheduled 

to have completed 13 jails; yet today only 2 of those 

completed jails are actually opened and occupied. Nine 

completed jails are not occupied because of staffing 

shortfalls. For example, a new jail at San Carlos was 

completed in May 2004, but remains unoccupied. BIA-LES 

- 39 -
managers reported that it will be another 6 to 10 months 

before this jail can be utilized even though San Carlos 

received $2.7 million in FY2004 to fund facility operations. 

The Ute Mountain detention facility, which is less than 5 

years old, was constructed with 54 beds for adult inmates and 

22 beds for juvenile inmates. We found the juvenile section 

of this facility vacant and unused due to lack of staffing. 

When we inquired about this idle facility, BIA-LES 

management reported that they plan to open the juvenile 

section in the next few months. 

The Eastern Nevada detention center in Owyhee, Idaho, 

which was built under a $4.2 million DOJ grant, remains 

vacant because it failed, unexplainably, to be built to Federal 

standards. An additional $250,000 was awarded by DOJ in 

September 2003 to correct deficiencies related to fire walls, 

sprinkler systems, and alarm systems. BIA detention staff 

that had been hired for this facility are being utilized at other 

jails until the facility can be opened. We believe that BIALES management’s lack of a comprehensive plan to recruit, 

hire, and train staff for these new facilities, along with failing 

to properly supervise construction of new facilities, further 

illustrates their overall indifference to the detention program. 

BIA-LES could 

not provide us 

with expenditure 

data for $9.8 

million of the 

$11.4 million 

received in 2004 

for opening new 

facilities. BIA-LES officials complained that once DOJ became 

involved in constructing new facilities, BIA priorities for 

these jails were not considered. According to them, new jails 

went to the best grant writers, not those with the most need. 

In addition, BIA officials also noted the lack of coordination 

between DOJ, BIA, and the tribes. The lack of cooperation 

and communication between DOJ and DOI was further 

emphasized in the IACP Indian Country summit comment 

and recommendation that both Departments should improve 

and strengthen their interagency cooperation and 

communication to provide more effective services in Indian 

Country.16 

In August 2003, BIA reprogrammed $5.1 million to tribes 

that were currently constructing detention facilities using 

DOJ grants. These funds were distributed so that the tribes 

could prepare the facilities for occupation. BIA specifically 

noted that the funds would be tracked to ensure that they 

were used exclusively for hiring detention staff and 

 

16 Improving Safety in Indian Country, p. 11.

- 40 -
purchasing the necessary equipment to open facilities in a 

timely manner. When asked, BIA-LES was unable to 

provide data showing how the reprogrammed funds were 

spent because they had not actually tracked the funds. 

Additionally, BIA-LES could not provide us with 

expenditure data for $9.8 million of the $11.4 million 

One BIA-LES received in 2004 allocated for opening new facilities. 

official noted, “It 

would probably 

be a good idea to 

track those funds, 

wouldn’t it?” 

BIA-LES management officials stated that tribes under 638-

contracts and self-governance tribes have never been 

required to provide BIA with reports on how any law 

enforcement funds are spent. As a result, BIA does not 

know whether funding designated for pre-occupancy needs 

for new jails was actually used for the detention program. 

One BIA-LES official noted, “It would probably be a good 

idea to track those funds, wouldn’t it?” in response to our 

inquiries. We are gravely concerned that this failure to 

provide oversight has or will result in the actual misuse of the 

funds. 

Internal Controls We are also concerned about internal controls in this area. 

We noted several inconsistencies in reported amounts of 

expenses between BIA-LES and the detention facilities when 

reviewing BIA-operated facility records. Moreover, when 

comparing expense data obtained from individual facilities 

with BIA-LES information, we found that none of the facility 

amounts were consistent with the BIA-LES figures for 2002 

and only one amount matched 2003 data.

We further found that BIA was unable to accurately 

determine if $7 million of the $10 million of supplemental 

monies it received from FY1999 to FY2001 to hire additional 

detention officers was actually used for its intended purpose. 

BIA-LES managers indicated that, once again, they had not 

required contract or self-governed detention facilities to 

document or report how these funds were used. Even more 

disturbing, BIA-LES managers also told us that if any of the 

funded positions are not filled, the money is automatically 

absorbed into the law enforcement program for other uses, 

which is, of course, contrary to the designated appropriation 

specified by the Congress. 

Theft and misuse of funds historically occur when there are 

no internal controls and the threat of discovery is minimal. 

From an accounting standpoint, BIA-LES does not use sound 

business practices for planning, accounting for, and 

- 41 -
monitoring the use of detention funds, nor is anyone held 

accountable for the proper management of detention program

funds. This overall neglect of detention program funding 

oversight has created an environment in which fraud can be 

perpetrated with impunity and waste can continue 

undiscovered, because nobody at BIA is paying attention. 

Without the implementation of an internal control system

where detention funding and expenditures can be accurately 

tracked and reported on a regular basis, misuse or theft of 

designated funds will likely, or may already have, occurred. 

We find no excuse for BIA-LES’ inattention to funding 

issues and yet another unfortunate example of inattention and 

neglect of the detention program. 

Public Law 93-638 

Contract Funding

Of the 72 detention facilities in Indian Country, 46 receive 

funding for law enforcement services under Public Law 93-

638. During our assessment, we reviewed 16 detention 

facilities that are operated under 638-contracts. We found 

that funds for the detention program are not specified and 

contract terms and conditions are not always enforced. Tribal 

agencies are often not held accountable for failing to comply 

with contract terms and conditions. For example, a FY2001 

Single Audit Report for the Rosebud Sioux Tribe identified 

$2.5 million in questionable costs regarding federal funds 

used for tribal programs that were not in compliance with the

contract agreement and related laws and regulations. The 

report recommended that specific terms or controls and 

procedures be implemented to ensure that these funds were 

safeguarded from unauthorized use. 

In another similar situation, a BIA contracting officer 

reported that she was unable to enforce the terms of a 

contract because the tribe refused to allow her access to their 

juvenile facility for 7 years. Only after the contracting 

officer threatened to withhold funding was she allowed to 

conduct this review. We find it remarkable that no action 

was taken for 7 years and that BIA-LES took no action to 

intervene on her behalf. 

We are equally concerned that BIA’s failure to enforce the 

terms of the contracts or to provide adequate oversight over 

638-contract funds has created an environment in which 

fraud can thrive and exacerbates the potential liability for 

BIA and the Department. During our visit to the White 

Buffalo Home, a detention officer reported that the Tribal 

Council Chairman authorized the use of 638-contract money 

- 42 -
in November 2003 to fund a horse trip for students who were 

not detainees or affiliated with the detention facility in any 

way. We subsequently found support for the officer’s 

allegation when we discovered a check written on the White 

Buffalo Home account for the event. 

We also found that a male detention officer at the White 

Buffalo Home raped a 17-year old female inmate in October 

2002 when he was tasked to transport her for medical 

treatment. The detention officer was convicted after 

confessing to the crime. According to the report of 

investigation, the perpetrator had a prior criminal record but 

an “appropriate background investigation” had not been 

conducted according to the requirements of the contract. We

learned that the perpetrator was related to a tribal council 

member. BIA’s ineffective oversight of this particular 

contract is especially disturbing since BIA had to take over 

control of the nearby adult jail and police department due to 

serious problems associated with the tribe’s operation of the 

law enforcement and detention programs. 

Funding for detention services is generally not specified in 

the terms and conditions of 638-contracts. A review of the 

sixteen 638-contracts determined that the BIA had allocated 

at least $61 million for law enforcement program 

management from FY2001 through FY2003. However, we 

were only able to trace funds totaling about $7 million 

(11%), which had been budgeted for contract-managed 

detention facilities. 

In our opinion, language used in the majority of 638-

contracts directly contributes to the inadequate funding and 

operation of detention programs. BIA cannot ensure that 

necessary detention services are provided for without 

establishing and implementing specific funding, expenditure, 

and operational requirements. Specific contract requirements 

would not only improve the ability of BIA to monitor these 

programs and to verify that designated funds were actually 

used for detention services but would also prevent tribes 

from reallocating much needed detention program funds or 

exerting undue influence on the operation of the program. 

- 43 -
Recommendations

14. BIA should establish and implement a single line item

budget for all BIA-LES detention facilities and 

expenses. BIA-LES should require 638-contract 

detention facilities to implement similar cost tracking 

practices. 

15. BIA should utilize accurate budget projections that 

incorporate future funding requirements when 

preparing funding requests rather than just using 

historical data. As part of future funding 

requirements, BIA-LES senior officials and local 

detention administrators should identify any existing 

needs and/or deficiencies so that these issues can be 

properly addressed. 

16. DOI-OLES should work with BIA, tribes, and DOJ to 

develop strategic plans for jail replacement and 

renovation. DOI-OLES should assist BIA-LES with 

developing a comprehensive needs assessment to 

ensure that jails are built and sized appropriately. 

17. BIA should implement internal control procedures 

and proper management oversight to ensure that BIA 

funding and expenditures are accurately tracked and 

reported on a regular basis. 

18. A standard law enforcement and detention service 

clause should be developed and used in each and 

every Public Law 93-638 contract for BIA law 

enforcement and detention services. The clause 

should require at a minimum that: (1) law 

enforcement and detention funding be accounted for 

and used for its intended purpose and (2) serious 

incidents be promptly reported to BIA-LES as a 

condition of the contract. 

- 44 -
Chapter 6: Detention Program Training 

Providing detention officers with certified training is also a 

critical element in ensuring that detention facilities are able 

to operate safely and securely, in addition to reducing 

potential liability for acts of untrained personnel. 

Specifically, we found that 52% of all the detention officers 

at the sites we visited had not received detention officer 

training. We also discovered numerous situations where 

detention officers were working for long periods of time 

without having attended the required IPA detention officer 

training. Examples of BIA-LES management’s disregard for 

timely training include instances where one detention officer 

at Haulapai and one detention officer at the Kiyuska O’Tipi 

Reintegration Center (juvenile) in Kyle, SD, who were 

employed for 12 years and 7 years respectively before either 

attended detention officer training, and a detention officer at 

Shiprock, who was hired in 1999 and still has not attended 

detention officer training. Sign restricting firearms 

into the Yakama cell area. 

With few exceptions, there seems to be an overall lack of 

emphasis on formal certification training of detention 

officers. We found that many jail administrators place little 

importance on sending newly hired personnel to training at 

the IPA. We also found there is hardly any emphasis on 

refresher training or skills enhancement training for detention 

officers. The prevailing attitude in most instances is that no 

additional training is necessary after an officer attends basic 

detention officer training. One exception to this attitude was 

found at the Tohono O’odham detention facility where they 

have a Field Training Officer (FTO) program, along with a 

FTO manual. 

Utilization of untrained or poorly trained personnel places 

inmates and officers at great risk and obviously raises 

concern about the overall safety and security of many of the 

detention facilities. For example, detention personnel at 

Yakama and Pine Ridge allow police officers to enter the jail 

cellblocks with their firearms contrary to nationally accepted 

standards and common sense. Furthermore, we observed the 

detention supervisor at Yakama carry his firearm into the 

main cellblock despite posted signs prohibiting them. This 

practice, which we believe is attributable to lack of training 

Yakama jail supervisor

carrying firearm into the 

cell area. 

- 45 -
and lackadaisical attitude, places everyone within the jail at 

significant risk. 

We received conflicting information regarding the 

availability of basic training at the IPA. Several jail 

administrators claimed that they are unable to send new 

personnel to the IPA for training because classes are 

infrequent and are often full; however, IPA personnel 

indicated that they routinely have vacancies for these classes 

and hold regional or local training sessions when asked to 

provide them. According to IPA officials, the IPA attempts 

to hold three detention program courses per year although 

only two were held last year due to budgetary constraints. 

“We’ve never 

received any 

training on 

how to operate 

a detention 

facility.” 

We learned there are two detention programs offered at the 

IPA - one for officers working in an adult facility and another 

for officers working in juvenile facilities. We noted that 

much of the curriculum is the same; however, IPA requires 

that a detention officer who has completed one course attend 

the other entire course in order to be certified in that 

program. This is often seen as an increased burden for 

officers who work at facilities that provide both adult and 

juvenile detention services. We also find it wasteful to 

require a detention officer to attend a second course that 

repeats most of the information taught in the original course 

when a shorter, supplemental course that covers the 

differences between adult and juvenile detention could easily 

be developed. Another option would be to combine both 

courses and develop one certification program. 

We also noticed consistent problems with proper 

documentation and adherence to standards at detention 

facilities. Some administrators have attributed this to a lack 

of training. One District Commander stated, “We’ve never 

received any training on how to operate a detention facility.” 

When asked if their facility followed BIA standards, that 

same individual quipped, “Most BIA standards can’t be met, 

so why even try?” 

“Most BIA 

standards 

can’t be met, 

so why even 

try?” 

Our assessment determined that the poor management of 

many of the Indian Country jails can be directly attributed to 

the failure of BIA-LES to provide and require that jail 

administrators receive supervisory and financial management

training. Most jail administrators we interviewed had 

received little or no training beyond basic detention officer 

training; however, there were some notable exceptions. We

- 46 -
found that the jail administrators at the more proficiently run 

facilities, such as Salt River, Gila River, and Tohono 

O’odham in Arizona and Ute Mountain in Colorado, had 

experience and formal training obtained from working in 

other detention programs. 

At Salt River, for example we interviewed the jail 

administrator who has an extensive detention management 

background with numerous professional certifications. The 

manager, who is a non-Indian, explained that he viewed his 

responsibilities to include training and preparing his Native 

American staff to eventually take his place. 

NIC holds one or two training conferences per year for 

Indian Country jail administrators to attend at no cost other 

than transportation and lodging. We found that only 25 jails 

were represented at the most recent conference in May 2004. 

NIC personnel and attendees indicated that it is usually the 

same one third of the Indian Country jail administrator 

population that participates in these conferences. 

NIC also maintains a comprehensive library of reference and 

training material, which includes workbooks for budget 

planning, jail staffing analysis, and many other pertinent 

issues. NIC has published a bibliography of all library 

holdings about or referencing Indian Country jails. We were 

surprised to learn that many of the BIA detention specialists 

we spoke to did not know about the bibliography and few jail 

administrators had taken advantage of this learning 

opportunity. 

 

Recommendations

19. BIA-LES and the IPA should take immediate action 

to identify and train all current detention officers who 

have not received the basic IPA detention officer 

training. 

20. Appropriate measures to track and ensure 

compliance/certification of training by detention 

officers should be developed by DOI-OLES, BIALES, and tribes. 

- 47 -
21. DOI-OLES should work with BIA-LES and the IPA 

to develop training standards and modules for BIA 

and tribal detention officers that would, at a 

minimum, eliminate the need for separate adult and 

juvenile detention courses. 

- 48 -
 

 Chapter 7: Other Issues 

The placement of juveniles in adult detention facilities is 

limited by the Juvenile Justice and Delinquency Prevention 

Act of 1974.17 The Act states in part, “...juveniles alleged to 

be or found to be delinquent...shall not be detained or 

confined in any institution in which they have contact with 

adult[s] incarcerated because they have been convicted of a 

crime or are awaiting trial on criminal charges...” 

Juveniles Housed 

at Adult Facilities

The Act allows for combined adult/juvenile jails if the 

juvenile and adult inmates cannot see each other and no 

conversation between them is possible.18 This requirement is 

commonly referred to as “sight and sound separation.” 

During our site visits, we were troubled to learn of instances 

where juveniles were being housed with adults or held in 

adult facilities. This unlawful practice not only creates 

significant potential liability concerns, it significantly 

increases the likelihood that juveniles will be harmed by 

others or themselves. No matter what the reason or the 

duration of confinement, this practice would make major 

media headlines were it happening elsewhere in America. 

“One inmate 

raped another 

inmate in 1997. 

It was due to 

understaffing and 

the guard was not 

certified. The boy 

was 13... The boy 

should not have 

been there.” 

A detention officer at one facility stated, “One inmate raped 

another inmate in 1997. It was due to understaffing and the 

guard was not certified. The boy was 13....The boy should 

not have been there.” The officer added that the 13-year-old 

victim was being held in the jail for social services because 

there was no other place to hold him.

19 

According to officials at the Rosebud adult detention facility, 

juveniles are routinely held in violation of the sight and 

sound separation mandate because there is no juvenile 

facility on the reservation and staffing shortages prohibit 

detention staff or police from transporting juveniles off the 

reservation. 

 

17 The Act exempts juveniles held in secure adult facilities if being tried 

as an adult. 

18 Modification to the Act, effective December 1996, clarified the sight

and sound separation requirement and provided that brief and inadvertent

or accidental contact in non-residential areas is not a reportable violation. 

19 BIA records indicate the settlement in the case was for $150,000. 

- 49 -
In addition, we were told that while the juveniles are 

physically separated from the adult population, they are still 

able to hear and communicate with adults in other parts of 

the jail. Detention officials attempt to comply with the spirit 

of the law by holding and feeding the juveniles in their 

individual cells because they cannot be taken to the central 

dining area without passing through the adult cellblock. 

Rosebud personnel also attempt to work with the tribal courts 

to keep the duration of juvenile stays to a minimum amount 

of time, usually a few days. We note that the Rosebud Sioux 

tribe is constructing a new juvenile facility at another 

location on the reservation under a DOJ grant. The new 

juvenile facility is expected to open later this year. Hallway and bench used to

hold juveniles. 

Sisseton/Wahpeton, SD At the Sisseton/Wahpeton detention facility, juveniles are 

held in a locked hallway between the police department and 

the jail’s outdoor recreation area. This hallway was not 

intended to house inmates, has no toilet facilities, and has 

glass doors that could easily be broken with one of the many 

chairs in the hallway. Recently a juvenile detainee attempted 

to escape from this hallway by climbing into the jail attic 

through an access panel in the ceiling. Detention personnel 

were able to apprehend her before she could manage to 

escape from the jail. As a result, however, juveniles are now 

shackled to a bench in the hallway to prevent future escapes. 

One officer stated “We’re not supposed to hold juveniles... 

but sometimes we have to.” Detention personnel indicated 

that they have no choice but to hold arrested juveniles since 

there is no juvenile facility on the reservation and they do not 

have enough personnel to transport juveniles to other 

locations without advance planning. One officer advised that 

juveniles are usually only held for a few hours until they can

be released to relatives or social services personnel. There 

are occasions, however, when a juvenile is held overnight 

because relatives cannot be contacted.

“We’re not supposed 

to hold juveniles... 

but sometimes we 

have to.” 

Overcrowding Frequently, many of the jails in Indian Country operate at, or 

over, their intended capacity. Of the facilities visited, 53% of 

jail personnel remarked they were habitually overcrowded, 

whereas the others only became overcrowded on holiday 

weekends or during tribal events. At some of the facilities, 

overcrowding has become a health and sanitary issue. Many 

inmates sleep on mats on the floor because the jails hold two 

or three times their rated capacity on a regular, recurring 

basis. For example, the Tohono O’odham jail has a rated 

capacity of 34 but routinely holds more than 110 inmates. 

Consequently, more than half the inmates at this jail sleep on 

- 50 -
mats on the cell floors, increasing the potential for 

altercations and injuries because inmates cannot move 

without stepping over and around one another. Only a 

handful of jails transport inmate to other facilities to alleviate 

overcrowding. Most simply pack more and more inmates 

into the cells and hope that the overcrowding does not last 

too long. Some jail administrators we interviewed discussed 

the potential benefits of having a regional jail or jails within 

Indian Country as one option to alleviate overcrowding. For 

example, we learned that the Ute Mountain detention facility,

which often has more beds than inmates, has been accepting 

inmates from the Mescalero Apache Tribe in order to gain 

the most use of the facility. Additionally, BIA-LES officials 

indicated that they have been researching the concept of 

constructing regional detention facilities to house long-term

inmates which would have the added benefit of reducing the 

inmate populations at local jails. 

Overcrowded cells. 

Tohono O’odham, AZ. 

During our site visits, we discussed the benefit of building 

regional jails. We found that there was varying support for 

the concept; however, the most common impediment to a 

regional concept noted was the resulting loss of tribal 

identity. Others expressed no concern for mixing members 

of different tribes together in a regional facility. 

Policies and 

Procedures By their own admission, BIA managers have failed to follow 

their own guidelines for the detention program. In October 

1996, BIA published detention facility handbooks, which 

established policies and procedures for Indian Country jails. 

The policies and procedures were derived from national 

corrections industry standards. The handbooks initially 

established 48 mandatory standards for adult facilities and 47 

mandatory standards for juvenile facilities. Detention 

facilities were required to comply with mandatory standards 

by the end of 1998. The remaining 201 adult standards and 

219 juvenile standards were designed to be phased-in over an 

8-year period after publication so that by the end of 2005, 

detention facilities would be 90 percent compliant with all of

the published standards. Alarmingly, we found that none of 

the jails we visited were compliant with the original 

mandatory standards, let alone the remaining ones. We also 

found BIA managers made little effort to adhere to the 

compliance schedule or ensure that jails even worked toward 

compliance with the original mandatory standards. 

BIA’s approach to development and implementation of its 

- 51 -
detention standards held all BIA-operated and 638-contract 

jails accountable for each of the standards without regard for 

the size and operation of individual facilities. This flawed 

plan required that a jail with ten beds be held to the same

standards as a jail ten times its size, unnecessarily

overloading smaller facilities with needless and inappropriate 

requirements in a situation where simple, basic detention 

procedures should be sufficient. 

Under the compliance schedule published in the detention 

handbooks, these jails were held to the same implementation 

timetable regardless of operational considerations, staff size, 

or inmate population. It appears that BIA simply adopted 

American Correctional Association (ACA) jail standards 

without giving any consideration to the variety of detention 

facilities under its jurisdiction. 

Liability BIA’s neglect and mismanagement of the detention program

increases the liability potential to BIA and to the Department. 

BIA has paid out $855,000 to settle several lawsuits in the 

last 3 years alone and there is another $11 million claim

pending. We believe that federal, state, or county jails 

operating under the same conditions we discovered at Indian 

Country detention facilities would be inundated with legal 

actions and most would likely have been shut down by court 

order long ago. 

We also found that detention officers at the majority of the 

jails we visited are dispensing prescription medications to 

inmates with little, if any, training, inadequate safeguards, 

and no formal process to ensure legal and medical 

requirements are met. 

BIA is sitting on a liability time bomb and must act to diffuse 

it now so that modest funds available can be used for their 

intended purpose, instead of potentially being consumed by 

legal fees, fines, and judgments. 

Recommendations

22. DOI-OLES should conduct routine scheduled and 

unscheduled inspections to determine compliance 

with the juvenile sight and sound restriction wherever 

adult and juvenile offenders are co-located. 

- 52 -
23. DOI-OLES should assist BIA-LES with the 

development and implementation of appropriate 

standards for Indian Country detention facilities. 

Consideration for size, capacity, and type of facility 

should be taken into account. Standards should, at a 

minimum, identify core health and safety 

requirements that would be applicable to all jails 

regardless of size and capacity. 

24. DOI-OLES and BIA-LES should consult with the 

tribes and continue to explore using regional 

detention facilities to accommodate longer-term

inmates and to reduce overcrowding at smaller 

facilities. 

- 53 -
Chapter 8: Positive Findings in the Detention Program 

As a result of our Interim report, the Secretary immediately 

charged a senior Department official with overseeing BIA 

actions to remedy the conditions at Indian Country jails. The 

Secretary also promptly requested assistance from the DOJ, 

Bureau of Prisons (BOP), which resulted in a senior-level 

detention professional being detailed to the Department to 

assist BIA-LES senior management with the identification 

and implementation of actions to correct the deficiencies we 

discovered during our assessment. 

BIA-LES senior officials readily acknowledged the 

deplorable conditions at the detention facilities and expressed 

grave concern over our findings. They have already made 

management and staffing changes at various levels of the 

detention program. 

In early September 2004, BIA-LES conducted a strategic 

planning conference to deal with the significant deficiencies

noted in our April 2004 Interim report. BIA-LES 

subsequently published the Indian Country Detention 

Strategic Planning Summary, which contained a task 

management plan when, if implemented as designed, may 

address some of the safety, security, and health-related 

concerns we observed during our site visits. 

BIA-LES has assigned a number of its own personnel to 

accomplish these tasks and has either requested outside 

resources to assist them in addressing these issues or has 

developed a plan to obtain outside assistance from 

professional corrections organizations, such as the Bureau of 

Prisons, American Correctional Association, American Jail 

Association (AJA), and Nation Institute of Corrections. In 

addition, BIA-LES is in the process of developing plans to 

ensure that health, safety and maintenance issues are 

promptly communicated and addressed by OFMC as well as 

an inspection process to confirm that these issues are being 

dealt with promptly. 

In response to our concerns about overall non-compliance 

with standards that were voiced in our Interim Report, BIALES began to review its current standards as they applied to 

- 54 -
each type of facility. BIA-LES reported that they are 

working with ACA and AJA to develop new standards that 

will apply to detention facilities based upon their size, staff, 

and inmate population and which will be implemented 

through a gradual compliance schedule. 

It should also be noted that during our assessment we did 

discover some instances in which detention personnel were 

being proactive and had implemented procedures with a goal 

of managing jails more effectively and where positive results 

have truly been achieved. 

As previously noted, the Tohono O’odham detention facility 

has established a Field Training Officer program to ensure 

that new detention officers are mentored and veteran 

detention officers are provided with refresher and skills 

enhancement training. 

The Gila River juvenile detention facility has established a 

program in which juveniles receive counseling and education 

as they progress through a program of self-improvement. 

Additionally, inmates are held accountable for their behavior 

with established consequences for vandalism and for upkeep 

of uniforms, furniture, and other equipment issued to them. 

The White Buffalo Home juvenile detention facility obtained 

a grant to establish a home detention program to reduce the 

detainee population while encouraging rehabilitation of firsttime offenders. The program has been so successful that they 

hope to extend the program by obtaining another grant. 

We also found that the detention facility at the Nisqually 

reservation in Washington was constructed as a minimum

security jail utilizing modular buildings, resulting in

significant cost savings over traditional construction 

methods. 

We were also surprised to discover that all of the positive 

innovations noted above occurred at detention facilities 

operated by the tribes under the 638-contract programs. We

found that the Tohono O’odham and White Buffalo facilities 

share many of the maintenance problems and staff shortages 

found at other jails, yet they still managed to make program

improvements and achieve meaningful results. 

Another positive effort was noted in Arizona where detention 

- 55 -
personnel from the Hualapai Indian Nation, San Carlos 

Apache Tribe, Gila River Indian Community, Salt River 

Pima-Maricopa Indian Community, and the Tohono 

O’Odham Nation created the Arizona Tribal Justice and 

Rehabilitation Coalition (ATJRC). ATJRC was formed to 

benefit member tribes through cooperative initiatives 

involving resource development, education, and coordination 

of detention and related services. Presently, 12 of the 22 

Arizona tribes are members of ATJRC.20 The coalition holds 

regular meetings where detention issues are discussed and 

members share experiences and best practices. 

Recommendation

25. BIA-LES should facilitate regular regional meetings 

for all BIA and tribal detention administrators to 

encourage collaborative efforts and discussions on 

detention best practices. 

 

20 Only two of the four BIA-operated jails in Arizona are members of this

organization. 

- 56 -
Conclusion 

BIA has failed their responsibility for providing safe and 

secure detention facilities. The detention program has 

essentially been ignored by BIA-LES managers and allowed 

to languish while attention and funds have been focused on 

other more traditional law enforcement operations. 

At the beginning of this assessment, BIA indicated that the 

majority of their problems could be attributed to a lack of 

funding. While we believe that more funding is needed, we 

also believe that BIA is not effectively utilizing the funds it is 

being given now. BIA must get its fiscal house in order 

through establishment of sound budget and accounting 

practices as well as oversight processes before any additional 

funds are sought or given. 

We firmly believe that BIA must overcome the self-imposed 

paralysis that results from the often-used excuse that BIA 

simply needs more money. Much can be accomplished when 

managers and staff apply a sensible attitude to overcome

challenges. Oversight has minimal costs and, if practiced, 

would correct many of the deficiencies that were found. 

Simply put, a little attention goes a long way. 

The responsibility for the conditions and failings we have 

found at Indian Country detention facilities cannot be 

attributed to any particular individual or administration. 

Some of these problems are decades old. Thus, the solutions 

will not be easy to achieve and may take considerable time, 

effort and funding. However, nothing less than Herculean 

effort to turn these conditions around would be morally 

acceptable. 

 

- 57 -
 

 

Appendix 1

REPORT RECOMMENDATIONS 

Recommendations 

No. Page

 1. For the purpose of providing the prominence and advocacy vital to 

ensuring that the focus on improving Indian Country jails does not 

diminish, the Deputy Assistant Secretary for Law Enforcement 

should become actively engaged in coordinating the oversight and 

management of the BIA-LES detention program. 

12 

2. The Department should create a senior-level (GS-14/15) full-time 

equivalent (FTE) position for a detention professional in DOIOLES to help provide increased coordination and advocacy for the 

Indian Country detention program. 

12 

3. DOI-OLES should conduct compliance inspections at BIA and 638-

contract detention facilities on a scheduled and unscheduled basis. 

For the immediate future, it is recommended that the Department 

OLES and not BIA-LES be responsible for the compliance

oversight of the detention program. 

12 

4. BIA-LES should establish a senior-level (GS-15) detention program 

director with proper detention management credentials to manage 

the BIA and 638- contract detention facilities. This position should 

report directly to the BIA-LES director, coordinate actions with 

DOI-OLES, and be the BIA-LES liaison with OFMC for detentionrelated repairs. BIA should provide the appointee with adequate 

new staff to fulfill these responsibilities. At a minimum, the Central 

Detention office should be staffed with a Director, Deputy Director, 

secretary, and three management analysts. The six regions should 

be staffed with two detention specialists per region. 

12 

5. DOI-OLES should ensure that BIA-LES establishes and 

implements clear reporting protocols for serious incidents occurring 

at all BIA and 638-contract detention facilities. At a minimum, all 

officer safety issues, inmate deaths, attempted suicides, assaults, and 

escapes should be reported promptly through an established chain 

of command ending with the Director of BIA with copies to the 

DOI-OLES. 

24 
 

 

Recommendations 

No. Page

 6. BIA and 638-contract detention administrators should ensure that 

any escape is immediately reported to surrounding local, tribal and 

state law enforcement authorities. 

24 

7. BIA-LES criminal investigators should immediately respond and 

conduct a preliminary inquiry to determine if a full investigation is 

warranted on any reported serious incident. Their findings, in 

every case, should then be reported to the Director of BIA-LES with 

a copy to the DOI-OLES. All death cases at BIA or 638-contract 

detention facilities, not investigated by the FBI, should be 

investigated by a BIA-LES criminal investigator. 

24 

8. BIA and tribes should explore alternatives to detention for 

intoxicated inmates. When it is necessary to incarcerate intoxicated 

inmates, additional detention officers should be on-duty to assist 

with the additional monitoring required. 

25 

9. DOI-OLES should work with the tribes and BIA to establish a 

Memorandum of Understanding (MOU) with the Indian Health 

Service to provide on-site medical assistance at all detention 

facilities with more than 20 inmates incarcerated. Detention staffs 

should be adequately staffed and scheduled to accommodate for 

medical transport to hospitals when necessary. 

25 

10. Staffing shortages at BIA and 638-contract detention facilities that 

are related to officer safety should be identified by the BIA-LES 

and corrected immediately. DOI-OLES should oversee this effort. 

29 

11. BIA-LES in collaboration with 638-contract programs should 

develop staffing models and methodologies for BIA and 638-

contract detention facilities. DOI-OLES should oversee this 

developmental effort. 

29 

12. The DOI Law Enforcement and Security Board of Advisors should 

develop recruiting standards and guidelines for BIA detention 

officers. BIA-LES should then assist tribal detention programs in 

developing standards and guidelines for tribal detention officers. 

30 
 

 

Recommendations 

No. Page

13. BIA OFMC and BIA-LES should immediately establish an effective 

system for prioritizing repairs that have any impact on inmate or 

detention officer safety. They should also review FMIS to identify 

and remedy inaccurate and redundant entries and implement 

quality control measures to reduce the risk and occurrence of 

improper entries. 

36 

14. BIA should establish and implement a single line item budget for all 

BIA-LES detention facilities and expenses. BIA-LES should 

require 638-contract detention facilities to implement similar cost 

tracking practices. 

44 

15. BIA should utilize accurate budget projections that incorporate 

future funding requirements when preparing funding requests 

rather than just using historical data. As part of future funding 

requirements, BIA-LES senior officials and local detention 

administrators should identify any existing needs and/or 

deficiencies so that these issues can be properly addressed. 

44 

16. DOI-OLES should work with BIA, tribes and DOJ to develop 

strategic plans for jail replacement and renovation. DOI-OLES 

should assist BIA-LES with developing a comprehensive needs 

assessment to ensure that jails are built and sized appropriately. 

44 

17. BIA should implement internal control procedures and proper 

management oversight to ensure that BIA funding and expenditures 

are accurately tracked and reported on a regular basis. 

44 

18. A standard law enforcement and detention service clause should be 

developed and used in each and every Public Law 93-638 contract 

for BIA law enforcement and detention services. The clause should 

require at a minimum that: (1) law enforcement and detention 

funding be accounted for and used for its intended purpose and (2) 

serious incidents be promptly reported to BIA-LES as a condition 

of the contract. 

44 

19. BIA-LES and the IPA should take immediate action to identify and 

train all current detention officers who have not received the basic 

IPA detention officer training. 

47 
 

 

Recommendations 

No. Page

20. Appropriate measures to track and ensure compliance/certification 

of training by detention officers should be developed by DOI-OLES, 

BIA-LES and tribes. 

47 

21. DOI-OLES should work with BIA-LES and the IPA to develop 

training standards and modules for BIA and tribal detention 

officers that would, at a minimum, eliminate the need for separate 

adult and juvenile detention courses. 

48 

22. DOI-OLES should conduct routine scheduled and unscheduled 

inspections to determine compliance with the juvenile sight and 

sound restriction wherever adult and juvenile offenders are colocated. 

52 

23. DOI-OLES should assist BIA-LES with the development and 

implementation of appropriate standards for Indian Country 

detention facilities. Consideration for size, capacity, and type of 

facility should be taken into account. Standards should, at a 

minimum, identify core health and safety requirements that would 

be applicable to all jails regardless of size and capacity. 

53 

24. DOI-OLES and BIA-LES should consult with the tribes and 

continue to explore using regional detention facilities to 

accommodate longer-term inmates and to reduce overcrowding at 

smaller facilities. 

53 

25. BIA-LES should facilitate regular regional meetings for all BIA and 

tribal detention administrators to encourage collaborative efforts 

and discussions on detention best practices. 

56