DEPARTMENT OF HOMELAND SECURITY 

Office of Inspector General 

ICE Policies Related to Detainee Deaths and the 

Oversight of Immigration Detention Facilities 

OIG-08-52 June 2008
June 11, 2008 

Preface 

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

the Homeland Security Act of 2002 (Public Law 107-296) by amendment to the Inspector General 

Act of 1978. This is one of a series of audit, inspection, and special reports prepared as part of our 

oversight responsibilities to promote economy, efficiency, and effectiveness within the department. 

This report addresses the strengths and weaknesses of U.S. Immigration and Customs Enforcement 

(ICE) operations related to detainees who died in custody. We also analyzed certain medical 

standards and ICE’s oversight of facilities that house immigration detainees. We based our report on 

interviews with relevant agencies, direct observations, and a review of applicable documents and 

data. 

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

have been discussed in draft with those responsible for implementation. It is our hope that this 

report will result in more effective, efficient, and economical operations. We express our 

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

 

Office of Inspector General 

U.S. Department of Homeland Security 

Washington, DC 20528 

Richard L. Skinner 

Inspector General 
 

 

 

 

Table of Contents/Abbreviations 

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

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

Results of Review..................................................................................................4 

An Analysis of Two Immigration Detainee Deaths.......................................................4 

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

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

Oversight Can Be Improved at ICE Detention Facilities................................................19 

 Recommendations ............................................................................................26 

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

Additional Efficiencies in Medical Operations Can Enhance 

Implementation of ICE’s Detention Standards...........................................................29 

 Recommendations ............................................................................................33 

Management Comments and OIG Analysis...............................................................34 

Appendices 

Appendix A: Purpose, Scope, and Methodology.........................................................................35 

Appendix D: Comparison of Various Detention Standards...........................................50 

Appendix F: Report Distribution.........................................................................55 

Appendix B: Management’s Comments to the Draft Report ......................................................36 

Appendix C: Recommendations..................................................................................................48 

Appendix E: Major Contributors to this Report...........................................................54 

Abbreviations 

ABA American Bar Association 

ACA American Correctional Association
 

DHS Department of Homeland Security 

DIHS Division of Immigration Health Services 

EHRs Electronic Health Records 

ICE Immigration and Customs Enforcement 

OFDT Office of Federal Detention Trustee 

OIG Office of Inspector General 

OPR Office of Professional Responsibility 

RCC Regional Correctional Center 

VA Department of Veterans Affairs 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

Detention Facilities 
 

 

OIG
 Department of Homeland Security 

Office of Inspector General 

Executive Summary 

Immigration and Customs Enforcement houses a daily average of 28,700 

detainees in 353 facilities nationwide. Various types of detention facilities, 

such as service processing centers, contract detention facilities, and state and 

local jails, are used to house these individuals. Immigration and Customs 

Enforcement detention standards are used to inform facilities on expectations 

regarding medical care, detainee access to legal materials, and other areas 

related to facility management. Between January 1, 2005, and May 31, 2007, 

33 immigration detainees died. 

We reviewed two cases where immigration detainees died in custody. One of 

these incidents occurred in St. Paul, Minnesota. The second incident took 

place in Albuquerque, New Mexico. We evaluated how the agency and its 

detention partners dealt with the two cases. In addition, we examined policies 

related to detainee deaths, medical standards, and other issues. We gathered 

data from the two affected detention facilities, examined the agency’s reports 

completed after its monitoring visits to various facilities, and had discussions 

with public and private-sector experts on detention standards. 

Although there are compliance problems related to certain medical standards 

at various facilities, ICE adhered to important portions of the detainee death 

standard in the two cases that were the focus of this review. Based on 

information received from clinical experts and our analysis, the two detainees’ 

serious pre-existing medical conditions led to their deaths. Although ICE’s 

detention standards are comparable to other organizations, such as the 

American Correctional Association, we are making 11 recommendations to 

improve the standards, strengthen ICE’s oversight of facilities, and enhance 

clinical operations and detainee safety. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Jan-06

Mar-06 

May-06 

Jul-06 

Sep-06 

Nov-06 

Jan-07

Mar-07 

May-07 

Jul-07 

Sep-07 

Nov-07 

Background 

Immigration and Customs Enforcement (ICE), the largest investigative branch 

of the Department of Homeland Security (DHS), was created in March 2003 

by combining the law enforcement functions of the Immigration and 

Naturalization Service and United States Customs Service. The Immigration 

and Nationality Act authorizes ICE to arrest, detain, and remove certain aliens 

from the United States.1 The agency’s average daily detainee population in 

December 2007 was 28,702. This was a 61% increase compared to January 

2006, as shown in Figure 1. 

Figure 1: ICE's Average Daily Detainee Population, January 2006-

December 2007 

0 

5,000 

10,000 

15,000 

20,000 

25,000 

30,000 

35,000 

ICE is charged with ensuring that removable aliens depart the United States. 

ICE uses three types of facilities to house its detainees until they are deported: 

Service processing centers are owned and operated by ICE; private companies 

operate ICE’s contract detention facilities; and state and local jails with 

intergovernmental service agreements house ICE detainees. Most service 

processing centers and contract detention facilities use Commissioned Corps 

Officers in the Public Health Service to deliver onsite medical care. The 

partnership between the Public Health Service and federal immigration 

agencies was initially established in 1891. Local jails rely mainly on other 

onsite clinicians, such as contractors or staff employed by a county public 

health department. 

1

 8 USC §§ 1226, 1227, 1229, 1229(a), and 1357. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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ICE’s Detention Operations Manual stipulates the agency’s detention 

standards, which are designed to ensure facilities provide services that will 

protect detainees’ life and dignity. The standards contain rules on medical 

care, food service, access to legal materials, and various other areas. Facilities 

are to be inspected on an annual basis to ensure compliance with ICE’s 

standards. ICE staff is also responsible for visiting each facility to interact 

with detainees on a regular basis. 

In November 2000, the Immigration and Naturalization Service established 

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

detained immigrants. Discussions among federal immigration officials, the 

American Bar Association (ABA), the Department of Justice, and other 

organizations helped create the standards. Several of ICE’s 36 standards have 

been revised or expanded. Since the creation of DHS, two additional 

standards have been issued: (1) staff-detainee communication requirements 

were established in July 2003, and (2) detainee transfer policies were 

approved in September 2004. 

Other federal agencies have their own detention standards. The Office of 

Federal Detention Trustee (OFDT) in the Department of Justice ensures that 

federal agencies involved in detention operations provide for the safe and 

humane confinement of persons who are awaiting trial. OFDT is responsible 

for conducting annual facility reviews using Federal Performance-Based 

Detention Standards. OFDT and ICE inspect some of the same facilities. 

Private entities also have created detention standards. The American 

Correctional Association (ACA) and the National Commission on 

Correctional Health Care have more than 150 years of combined experience in 

creating and revising detention standards. Both entities accredit national, 

state, and local detention facilities that meet existing detention standards. In 

some areas, such as the placement of first aid kits and defibrillators, ICE 

requires adherence to ACA standards. 

ACA’s purpose is to promote improvement in the management of correctional 

agencies through the administration of a voluntary accreditation program and 

the ongoing revision of its standards. As with ICE and OFDT standards, the 

ACA covers a variety of subjects pertaining to the administration and 

management of detention facilities. For facilities seeking accreditation, ACA 

conducts onsite inspections every three years. According to ACA policy 

facilities are required to document compliance with the standards for each 

month over the three-year period. 

The National Commission on Correctional Health Care works to improve the 

quality of health care in correctional facilities. The Commission’s standards 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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guide facilities on the delivery and management of health care in correctional 

systems. ICE’s service processing centers and contract detention facilities are 

required to maintain accreditation by the Commission. 

As a stakeholder in developing ICE’s standards, ABA has created a 

commission to help review detention standards at facilities housing 

immigrants and asylum seekers. The ABA’s Commission on Immigration 

ensures detainees are made aware of their rights, including access to legal 

materials, telephones, and group presentations. Working with volunteer law 

firms, the ABA visits facilities to review practices and suggest improvements. 

The ABA shares its site visit reports with ICE. 

Results of Review 

This review examined two cases of detainee death, as well as ICE’s overall 

standards related to detainee deaths and the medical treatment of immigration 

detainees. The two detainees died as a result of serious pre-existing medical 

conditions. Although there have been problems with adherence to medical 

standards at the two facilities in question, ICE’s overall standards are 

equivalent to other detention organizations. ICE has been taking steps to 

enhance its ability to effectively monitor immigration detention facilities. Our 

recommendations focus on how ICE can make further improvements to the 

efficiency of clinical operations by developing better oversight procedures. 

An Analysis of Two Immigration Detainee Deaths 

The first detainee’s death occurred in April 2006, in St. Paul, Minnesota; the 

second death happened in September 2006, in Albuquerque, New Mexico. 

Although the two detainees were in ICE custody, the individuals were 

hospitalized at the time of death. According to ICE’s standards, both the 

agency and its detention partners are required to take certain actions when a 

detainee dies. In both of these incidents, the procedures outlined in the 

detainee death standard were performed, with the exception of a state 

notification requirement that we describe in our discussion of the Albuquerque 

incident. Pursuant to its statutory authority, the DHS Office for Civil Rights 

and Civil Liberties investigated a complaint concerning the Minnesota 

detainee death. The Office reviewed compliance with ICE’s medical care 

standard at the detention facility and made recommendations to ICE for 

possible improvements in detainee care. 

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ICE’s Detainee Death Standard 

In September 2000, the Immigration and Naturalization Service created a 

standard for detainee deaths. This standard remains in place. Field office 

personnel we interviewed reported satisfaction with the standard itself. 

Detainees who die in custody do not always pass away in a detention facility; 

therefore ICE has different rules for situations where detainees die in other 

locations or in transit. From the notification of family to disposition of 

remains and personal property, ICE standards address the sensitivity that 

surrounds detainee deaths. 

Notifying the family is an important part of ICE’s detainee death procedures. 

Additionally, the standard requires notification of the applicable consulate. 

ICE also must prepare a condolence letter for the family that describes the 

circumstances of the death. After completing the necessary notification 

requirements, ICE is required to assist in other areas, such as autopsy 

arrangements. Before initiation of the autopsy, facilities must determine the 

detainee’s religious affiliation. This is important because some religions have 

specific restrictions involving autopsies, embalming, and cremation. When 

family members cannot afford the costs associated with transporting the 

remains, ICE may transport the remains to a location in the United States. 

ICE’s Office of Professional Responsibility (OPR) reviews detainee death 

cases. OPR’s management directive does not require the reporting of deaths 

to the OIG, nor were we provided any ICE policy documents that require the 

reporting of immigration detainee deaths to our office. However, OPR can 

refer cases to the OIG when ICE determines an outside review is warranted. 

An OPR manager informed us that the Joint Intake Center may report detainee 

deaths to the OIG or OPR. Likewise, the OIG’s Office of Investigations may 

refer various detainee death incidents to OPR. The DHS Office for Civil 

Rights and Civil Liberties also has reviewed detainee deaths and compliance 

with ICE standards. 

OPR has helped ICE improve detention practices after some detainee deaths. 

However, ICE should report all detainee deaths to the OIG. In the past, we 

have received information about detainee deaths on a sporadic basis, mainly 

through complaints to the OIG Hotline. Notifying the OIG of any detainee 

death would keep the OIG better informed and allow it to determine whether 

additional review is warranted in each case. A policy in this area could 

outline procedures for providing relevant records to the OIG, as necessary. 

ICE’s detainee death standard compares well to ACA and OFDT standards. 

Both ACA and OFDT point out the importance of mortality reviews, which 

can prompt changes to facility procedures and can potentially decrease the 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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chance of additional deaths. Although ICE does not require mortality 

reviews, we noticed evidence of such reviews in the files of several detainees 

who died, including the two deaths that are the focus of this review. 

Clinicians with the Division of Immigration Health Services usually complete 

ICE’s mortality reviews. 

The St. Paul, Minnesota Case 

The immigration file of the detainee, who died in April 2006, shows an initial 

hearing before an immigration judge in November 1997. An October 1998 

letter instructed the individual to appear for deportation on November 3, 1998. 

The detainee did not appear for deportation. Thereafter, ICE considered the 

detainee a fugitive. ICE did not locate the detainee until February 2006, and 

arrested the detainee for not departing the United States in 1998. 

ICE held the detainee at the Ramsey County Law Enforcement Center. This 

facility is located in downtown St. Paul, Minnesota, and houses various 

individuals awaiting legal proceedings in the county. When this incident 

occurred, the facility housed 70 immigration detainees on an average day. For 

the first six months of 2007, the facility accepted 177 new ICE detainees. 

ICE’s 2006 monitoring report for the facility showed an acceptable overall 

rating. 

On April 3, 2006, at approximately 2:30 p.m., the detainee fell from a bunk 

bed and sustained a lump on the back of the head. The guard who arrived at 

the cell ensured that a nurse would see the detainee during 4:00 p.m. medical 

rounds. At that time, the detainee reported dizziness and headaches to the 

nurse. The detainee’s medical file includes information from the nurse 

reporting that the detainee was confused when the detainee returned to the 

cell. Four hours later, the detainee’s condition had deteriorated, prompting a 

nurse to order transportation to a nearby hospital. 

After arriving at the hospital, physicians diagnosed a serious condition known 

as neurocysticercosis, which is an infection of the brain by larva of the pork 

tapeworm. This disease caused the detainee’s death on April 13, 2006. 

Serious complications can result if the disease enters the central nervous 

system. The detainee reported a history of headaches that were not relieved 

by medication. The facility’s clinical protocols, which called for the use of 

aspirin for headaches, do not account for other possibilities, such as serious, 

pre-existing parasitic diseases as a cause of the problem. Although seizures 

are a common symptom of the disease, there was no evidence of seizures in 

the detainee’s medical file. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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We identified two important facts related to the detainee’s medical care. 

Facility information we examined included a head trauma protocol. This 

document justified the detainee’s expedited transportation to the hospital after 

a nurse observed that the detainee was dizzy and confused. Additionally, the 

detainee did not receive a physical exam, which ICE medical standards 

require within 14 days of intake. However, after discussions with clinical 

experts and a review of medical literature, we concluded that neither more 

timely medical attention for the head trauma nor a more timely initial medical 

exam would have ensured the detainee’s recovery from neurocysticercosis. 

The case history showed that ICE did a commendable job implementing parts 

of the detainee death standard. We examined two “significant incident” 

reports prepared for ICE headquarters by the agency’s staff in Minnesota. 

Field office personnel send these reports to headquarters after serious events 

take place. ICE also left a message with the Consulate of Ecuador in Chicago. 

ICE also notified the detainee’s spouse. This timely compliance with steps in 

ICE’s detainee death standard did facilitate necessary actions, such as the 

return of the remains. Documentation also showed that the detainee’s spouse 

received some of the detainee’s personal property less than one week after the 

death. The detention standards do not have a time requirement for the return 

of property, but ICE made a good effort to ensure that this occurred. 

The death led to a debate within the Ramsey County government regarding 

whether to continue to house ICE detainees. The County Sheriff said that the 

Law Enforcement Center may not be the best place for ICE to house 

individuals longer than a few days. Media also reported that the sheriff was 

concerned about the ability to care for immigration detainees on an ongoing 

basis. “We’re not really prepared to translate, interpret, and assist that kind of 

population,” he said.2

 After further discussions, in December 2006, the 

County Board of Supervisors voted four to three to maintain its agreement 

with ICE. 

Policy Improvements and Additional Education Efforts Would Help 

Identify and Treat Cysticercosis 

While ICE’s medical standards recognize the need to treat infectious diseases 

in general, they do not specifically mention cysticercosis. Furthermore, nonemergency radiology services, such as computed tomography scans or 

magnetic resonance imaging−methods of making detailed images of the body 

to identify problems that are not readily apparent−are not included in the 

Division of Immigration Health Services covered services package. Although 

case-by-case requests for coverage and payment of diagnostic tests are 

2

 “No immigrant detainees in Ramsey County?,” Minneapolis Star-Tribune, December 19, 2006. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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possible, current policy does not specifically provide for proactive diagnosis 

of cysticercosis. 

The disease, which disproportionately affects Latin American immigrants, can 

infect humans who come in contact with the tapeworm that causes 

cysticercosis. The resulting cysts can migrate to various parts of the body, 

including muscles, the eyes, or the brain. In the central nervous system, the 

disease is known as neurocysticercosis, which was the cause of death in the 

St. Paul case. We cannot determine with certainty whether this death could 

have been avoided had the detainee received immediate medical attention for 

head trauma. However, ICE, in conjunction with the DHS Office of Health 

Affairs, should engage the Centers for Disease Control and Prevention to 

review the medical screenings provided for detainees, with special 

consideration of the origins of the population. 

According to medical journals and experts we interviewed, cysticercosis is 

expected to become more prevalent in the United States within the next 

decade. A neurology professor informed us that she has seen many more 

cases of the disease over the past five years. A leading journal also predicted 

that cysticercosis “will grow in clinical and public health importance” in the 

United States. This article reported that Latinos accounted for 85% of 

individuals who died of cysticercosis in the United States from 1990 through 

2002. After these deaths were studied, the authors wrote that the incidents 

reflect “immigration patterns in states that include substantial populations of 

immigrants from cysticercosis-endemic areas, particularly Mexico and other 

areas of Latin America.”3 

Based on ICE data for the period of October 2006 through November 2007, 

individuals from Mexico, Honduras, El Salvador, and Guatemala, countries 

where the disease is endemic, account for 79% of ICE’s total detainees, as 

shown in Figure 2. 

3

 “Deaths from Cysticercosis, United States,” Emerging Infectious Diseases, February 2007, p. 230-

231, 233. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Honduras 

11% 

Figure 2: Country of Origin for ICE Detainees, October 2006-

November 2007
 

All others 

21% 

Mexico 

49% 

Guatemala 

10% 

El Salvador 

9% 

In a study of deceased neurocysticercosis patients in Oregon spanning six 

years, it was determined that 44 of 57 fatalities (77%) occurred in people who 

had been born in Mexico or Guatemala.4 A separate review of autopsies in 

Mexico showed a prevalence of cysticercosis in about three percent of the 

population.5 If three percent of ICE’s detainees from Mexico were infected, 

nearly 5,000 Mexican nationals detained in fiscal year 2007 could be carrying 

the parasite. 

Currently, the standards used by the Office of Federal Detention Trustee 

(OFDT) provide a logical process for the treatment of special needs 

individuals. The Detention Trustee’s definition of special needs individuals 

includes those with communicable diseases. ICE’s standard is less detailed, 

and it should be revised to include individuals who carry the tapeworm that 

can cause cysticercosis. There is also a specific Trustee standard6

 that 

requires “appropriate diagnostic testing” be done on detainees with special 

needs. 

ICE also can educate staff at facilities housing detainees to ensure 

understanding of neurocysticercosis. One of the world’s leading experts on 

immigrant health care informed us that neurocysticercosis is “the leading 

cause of seizures” in adults from Mexico and Central America. Another 

expert, who labeled seizures as the “hallmark” symptom of the disease, 

informed us that the Centers for Disease Control developed an “extremely 

4

 “Neurocysticercosis in Oregon, 1995-2000.” Emerging Infectious Diseases, March 2004, 508-510.
 5

 “Deaths from Cysticercosis, United States,” p. 232. 6

 B.3.29a 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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simple” blood test that can reveal whether an individual has the tapeworms 

capable of spreading the disease. The CDC has noted that the blood test may 

not always be accurate, and other more definitive diagnostic tools, such as 

brain imaging, exist. Through expanded educational efforts, as well as greater 

use of available diagnostic tools when deemed appropriate, ICE could 

facilitate faster identification of tapeworm carriers or instances of the disease 

among detainees. This offers a chance to improve treatment of a disease more 

likely found in ICE detainees than in United States citizens. 

Another way ICE could better detect the disease is to ensure that questions 

related to cysticercosis are asked during the initial health assessment and 14-

day physical exam. A neurologist who has treated neurocysticercosis said an 

entire family should be treated if one individual in a household has the 

disease. Records indicate that facility staff was informed that the detainee’s 

mother had surgery four years before to treat “eggs of bugs inside her head.” 

These comments may appear non-sensical, but they provided a clue that could 

have led to further questioning or diagnostic testing. Adding intake and 

medical screening questions about a family history of the disease would have 

been useful. 

Greater efforts to recognize neurocysticercosis may have expedited the care 

the detainee received. More than a month before the detainee’s death, clinical 

staff was told, “Tylenol or aspirin don’t do anything [to remedy my 

headaches.]” Also, after falling from the bunk bed on April 3, 2006, the 

detainee exhibited general confusion and dizziness. Neurocysticercosis was 

quickly diagnosed after the detainee visited the emergency room. 

The Albuquerque, New Mexico Case 

In 2004, the Regional Correctional Center (RCC) in downtown Albuquerque 

was leased to Cornell Companies, a private correctional firm based in 

Houston, Texas. After making several renovations, Cornell began housing 

ICE and U.S. Marshals detainees at the RCC. The RCC booked 10,026 ICE 

detainees from July 1, 2005 through July 20, 2007. 

The detainee, who died on September 11, 2006, was arrested as a result of an 

ICE operation on the East Coast. The individual, along with 13 others, was 

transferred in August 2006 to the RCC. Records show that the detainee was 

sent to a hospital on September 4, 2006. 

The detainee died of “widely metastatic” pancreatic cancer, which means that 

cells broke away from the original cancerous tumor and spread to other parts 

of the body. This type of cancer makes survival unlikely. A physician with 

25 years of oncology practice said, “I have never seen a tumor marker that 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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high,” after reviewing the detainee’s test results. Hospital clinicians who 

treated the detainee recognized that the disease was at an advanced stage 

before ICE took the detainee into custody. However, medical examinations 

received after the detainee arrived at the RCC did not reveal the illness. 

A Hotline complaint we received, an affidavit from another detainee, and 

unsworn testimony from a former RCC employee, all alleged that the 

facility’s personnel did not address the detainee’s medical issues. 

Specifically, the Hotline complainant believed ICE and RCC staff gave “scant 

attention” to the detainee’s medical needs. However, it appeared that 

Cornell’s clinical staff addressed written medical requests identified in the 

detainee’s records. The detainee received antacid tablets after complaining of 

abdominal pain, so, like the Minnesota case, staff did not immediately 

recognize a more serious condition. Based on documentation from hospital 

staff, we concluded that the RCC’s medical team could not have saved the 

individual’s life, even with quicker onsite treatment or expedited 

transportation to the hospital. 

ICE staff in Albuquerque notified managers at ICE headquarters of this 

incident. ICE contacted the detainee’s family and the consulate of the 

detainee’s country of origin. Local staff also placed a copy of the death 

certificate in the detainee’s file, which is required by ICE standards. 

In certain cases, ICE faces challenges locating family members of detainees. 

This is inherent in the immigration detention process, especially when 

detainees are often transferred across the United States. In this case, the 

detainee’s son, the only family member identified in the case files, was 

attending a university on the East Coast during the detainee’s time in New 

Mexico. This led to difficulties coordinating post mortem activities, such as 

the transfer of remains. The records show that ICE made appropriate efforts 

to communicate with the family. The head of the consulate from the 

detainee’s country of origin thanked ICE for the professionalism exhibited by 

the agency’s staff during the incident. 

Nonetheless, the Hotline complainant, other detainees, and a former RCC 

employee asserted that the RCC was not dealing with some detainee sick call 

requests of in a timely fashion. Based on facility data and a September 2006 

site visit report by OFDT, there is merit to those concerns. OFDT reported 

that, due to a nursing shortage, detainees were often waiting as many as 30 

days for sick call requests to be answered. Additionally, OFDT reported that 

only 11 of 20 detainees with chronic conditions were regularly scheduled for 

chronic care clinics. 

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This detainee’s death highlighted a limitation in ICE’s detainee death policy. 

New Mexico law requires that any death of a person in the custody of law 

enforcement be reported; however, New Mexico’s Office of the Medical 

Investigator, which should have received this notification, did not have a 

record of the detainee’s death. ICE staff said that the county should have 

reported the death. State officials said that the hospital could have worked 

with ICE to ensure compliance with the state’s requirements. ICE should 

revise the detainee death standard to ensure that the agency and its detention 

partners comply with laws requiring notification to state officials. The 

standard requires the notification of family and the consulate, so adding 

language about state reporting would be suitable. Regardless of who should 

take the lead in contacting the state, ICE needs to ensure that detainee deaths 

are reported to state governments if legally required. 

RCC Site Visit Reports 

ICE’s Office of Professional Responsibility (OPR) visited the RCC in June 

2007. At that time, the facility housed 746 immigration detainees. OPR 

reported a variety of problems, including inadequate suicide watch 

observation, food service, records maintenance, and security procedures. 

OPR considered the RCC’s overall security procedures to be “weak” and “in 

dire need of improvement.” Based on its determinations, including the 

discovery of illegal drugs in the facility, ICE decided to remove all of its RCC 

detainees in early August 2007. We commend ICE for using its own process 

to identify areas of concern at detention facilities. 

Cornell management acknowledged problems at the RCC. A senior manager 

said that a corporate audit team has helped identify and correct deficiencies. 

Based on recent comments by the Chief U.S. District Court Judge in New 

Mexico, the company’s efforts have led to some improvements.7

 Cornell said 

that ICE did not fully explain why all immigration detainees were transferred 

to other locations. However, Cornell’s Chief Executive Officer said, “if we 

had operated RCC as we do our best facilities, no one would have had any 

basis for criticism. But we didn’t.”8 

Prior to OPR’s report, evidence existed that showed the RCC was having 

some difficulty in important areas. Within a six-week period in 2006, ICE 

and OFDT completed separate monitoring visits at the RCC. OFDT assigned 

the RCC an at-risk rating in its September 2006 monitoring report. This is the 

7

 “Bernalillo County’s Regional Correctional Center conditions improving,” Albuquerque Tribune, 

August 30, 2007, and “Red Flags Raised at Albuquerque’s Downtown Jail,” Albuquerque Tribune, 

September 25, 2007. 

8

 “Jail CEO explains setbacks,” Albuquerque Tribune, August 11, 2007. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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lowest possible overall rating, two levels below acceptable. ICE granted an 

acceptable rating to the facility after its 2006 site visit. OFDT’s follow-up 

report, based on a February 2007 site visit, determined that RCC’s operations 

were acceptable, which suggested that the RCC made important corrections 

after OFDT’s September 2006 report. 

In September 2006, OFDT reported problems with the RCC’s compliance 

with ICE’s detainee death policy. OFDT concluded that the RCC’s policies 

did not address a requirement to notify the Departments of Justice or 

Homeland Security in the event of detainee death. OFDT also reported that 

the RCC’s policy did not address religious requirements or medical 

circumstances regarding autopsies. Finally, the facility’s policy did not 

address the need to gain the permission from federal agencies to release the 

detainee’s body. 

ICE’s November 2006 RCC report did not mention actual or pending 

revisions to the detainee death policy. Limitations to the detainee death policy 

should have been clearly written in ICE’s report, especially since an RCC 

detainee died less than two months before ICE’s site visit. 

OFDT’s report mentions other problems at the RCC of interest to ICE. In its 

discussion of detainee classification, which pertains to separating individuals 

by severity of their offenses, OFDT identified seven non-criminal ICE 

detainees housed with 136 criminal detainees. Based on a recommendation in 

our December 2006 report, Treatment of Immigration Detainees Housed at 

Immigration and Customs Enforcement Facilities, ICE has taken steps to 

address classification problems at its facilities.9

 However, an assistant trustee 

stated that OFDT has detected such problems at other ICE facilities, but there 

are no procedures for sharing report findings with ICE. 

ICE and OFDT have different standards, but some efficiency could be gained 

if ICE engaged the detention trustee on facilities reviewed by both agencies. 

OFDT could inform ICE about issues of interest to ICE, but ICE is not taking 

advantage of this opportunity. No field office reported interaction with OFDT 

on facility monitoring, though OFDT reports mention ICE standards. 

Moreover, the two agencies do not share monitoring reports. The Assistant 

Trustee we interviewed lamented such missed opportunities by saying that 

there is “very minimal” information sharing between ICE and OFDT. 

By developing a better relationship with OFDT, ICE could gain important 

perspectives about its detention facilities. Problems of mutual interest, such 

9

 DHS OIG, Treatment of Immigration Detainees Housed at Immigration and Customs Enforcement 

Facilities, OIG-07-01, December 2006, p. 48. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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as timeliness of health care delivery, could lead ICE to request more data 

samples, interviews, or policies to ensure compliance. A more developed 

relationship between the two agencies would be helpful, especially in 

situations where OFDT’s standards differ from ICE. 

Recommendations 

We recommend that the Assistant Secretary for Immigration and Customs 

Enforcement: 

Recommendation #1: Work with the Office of Inspector General to create a 

policy that would lead to the prompt reporting of all detainee deaths to the 

Office of Inspector General. 

Recommendation #2: Work with the Division of Immigration Health 

Services, the Centers for Disease Control, and other experts, to enhance 

existing medical standards, rules for special needs individuals, and coverage 

guidance related to infectious disease. 

Recommendation #3: Revise medical intake screening forms and physical 

exam questionnaires at detention facilities to include questions regarding the 

detainee’s family history of cysticercosis. 

Recommendation #4: Revise the notification section of ICE’s detainee death 

standard to ensure that the agency and its detention partners report a 

detainee’s death in states that require notification in the event of a death in 

custody. Documentation of this reporting should appear in a detainee’s file. 

Recommendation #5: Seek to enter into a memorandum of understanding 

with the Department of Justice, Office of Federal Detention Trustee that 

establishes a process that enables OFDT and ICE to regularly share 

information resulting from facility site visits. 

Management Comments and OIG Analysis 

ICE and the DHS Office of Health Affairs provided written comments on our 

draft report. We evaluated these comments and have made changes where we 

deemed appropriate. Below is a summary of ICE’s written response to the 

report’s first five recommendations and our analysis. A copy of ICE’s 

complete response is included as Appendix B. 

ICE’s Comments to Recommendation #1 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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ICE concurred with our recommendation. A March 13, 2008, memo that was 

created by ICE’s Office of Professional Responsibility outlines the process 

that will ensure OIG notification of each detainee death. ICE will make 

telephone contact with the OIG as quickly as possible after the death. The 

following day, additional details will be provided as part of an existing OIG 

notification mechanism. 

OIG Analysis 

ICE’s new policy should facilitate interaction with our office on detainee 

death cases. As needed, we will use this new process to gain additional 

information about detainee death incidents. 

The recommendation is resolved and closed. 

ICE’s Comments to Recommendation #2 

ICE concurred in part and disagreed in part with our recommendation. ICE 

concurred with the recommendation to work with DIHS and other experts to 

enhance the detention standard for detainee access to medical care. ICE is 

updating all 38 standards and converting them into 41 performance-based 

standards. These revisions are being reviewed by major governmental 

organizations and DHS’ Office for Civil Rights and Civil Liberties. DHS 

expects to publish the revised standards on September 1, 2008. 

ICE stated that the current medical standard allows for special needs 

individuals to receive appropriate medical care. Regarding “medical 

standards,” ICE said it does not have the authority to establish or alter national 

public health or medical health care industry standards, which are established 

by professional medical researchers and medical practitioners in tandem with 

public health and medical care governing and regulatory bodies. 

Although ICE believes the current detention standard is sufficient to meet the 

medical needs of detainees, it believes doctors and medical staff must be 

cognizant of diseases. It has asked DIHS to develop a training tool to enhance 

the medical field’s awareness and early detection of diseases that might be 

prevalent in aliens from particular geographic locales. 

OIG Analysis 

We are not recommending that ICE attempt to expand its authority and role in 

the development of national public health or medical care industry standards. 

However, it is well within the agency’s authority, in consultation with experts, 

to revise its own policies and the medical care standard in the Detention 

Operations Manual. Special needs individuals may be getting adequate care, 

but we reaffirm our recommendation that ICE augment its policy to call more 

attention to those carrying infectious diseases, and help ensure that its medical 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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care better reflects the needs of its population. Possible changes include 

listing particular diseases that make someone a special needs individual, as 

OFDT has done. Diseases that are more common to immigrant populations, 

such as cysticercosis, can be the focus of such efforts. ICE’s decision to ask 

DIHS to develop a tool to enhance the medical field’s awareness and early 

detection of diseases is a positive step, but this tool would be most effective if 

it is accompanied by needed policy enhancements that respect the particular 

needs of ICE’s unique population of detainees. 

DIHS clinicians, who are now ICE employees, are committed to serving 

ICE’s needs. ICE should take a greater interest in discussing possible changes 

to coverage rules for its population. The DHS Office of Health Affairs is 

another resource that can help ICE in these areas. 

ICE’s action plan should include information about its work with DIHS to 

alter policies that increase the probability of expedited treatment for 

individuals with infectious disease. Current coverage guidance does not 

adequately allow for coverage of conditions that do not appear to be medical 

emergencies. Through greater dialog with DIHS and ICE’s departmental 

partners, the chances for improved health care outcomes will increase. 

This recommendation is unresolved and open. 

ICE’s Comments to Recommendation #3 

ICE concurred in part and disagreed in part with our recommendation. ICE 

agrees that DIHS should review its medical intake and physical exam forms, 

presumably to assess whether the forms can be modified to allow for more 

accurate and timely identification of certain diseases. ICE stated that present 

health screening tools include questions concerning family history. The 

agency stated that there is sufficient space on the forms to record any 

information provided to alert medical professionals of any possible problems 

that are not readily apparent. ICE’s current intake form is based largely on 

questions that are not only related to family history of various diseases, but 

symptoms that may lead medical professionals to diagnose an illness. Given 

its large, diverse detainee population, it is not clear to ICE whether a specific 

designation of family history of cysticercosis is warranted on medical intake 

forms or that amending the form is the most appropriate manner to respond to 

this particular disease. Furthermore, ICE questioned the OIG’s conclusions 

regarding the scope and danger of cysticercosis. It stressed that the disease is 

still quite rare, even after the large increase in Latin American immigrants 

over the last 30 years. ICE reported that technological improvements, not a 

prevalence of cysticercosis, led to increased detection of the disease. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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ICE noted that DIHS’ commitment to enhance the medical field’s awareness 

and early detection of diseases that might be prevalent in aliens from 

particular geographic locales is a major step forward. ICE believes the best 

approach to address our concerns about cysticercosis or infectious diseases is 

to request that DIHS reevaluate the current medical form in order to determine 

whether amending these forms is appropriate. 

OIG Analysis 

ICE questioned the value of incorporating any family history of cysticercosis 

on forms currently in use, but also agreed that DIHS should review its medical 

intake forms and physical exam forms in order to better identify certain 

diseases. ICE will request that DIHS review current medical forms in order to 

determine whether amending these forms is appropriate. ICE did not indicate 

how it would respond to a decision by DIHS to amend the forms, whether it 

would revise any forms, or how such changes would be communicated to 

local facilities, which often use their own screening forms. ICE should 

provide documentation of its request, and the results of DIHS’ evaluation. 

We do not expect ICE to make cysticercosis the focus of its health care 

program. However, the disease, rare even in ICE’s population, is a far greater 

risk to immigrants from Latin America than the general population, and 

amending intake screening and physical exam forms is a step ICE can take to 

help detect the disease. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Greater awareness and detection of the disease might not decrease morbidity 

or mortality in a specific case, but this is not a reason to omit specific 

language related to cysticercosis on intake and physical exam forms. The 

disproportionate risk of cysticercosis in ICE’s population is not “anecdotal,” 

as ICE notes, but rather a well-documented fact, based on decades of research 

by highly credible public health and medical experts. ICE should do more to 

respect this risk and take steps to mitigate it through the possibility of quicker 

detection and treatment for detainees carrying the disease. 

Because cysticercosis remains rare, clinicians in various parts of the country 

may have limited experience with diagnosis, as was evident in the Minnesota 

case. No information in Ramsey County’s treatment protocols, ICE’s medical 

standard, or the DIHS covered services package could help a facility diagnose 

or proactively treat the disease, even though it is a disproportionate risk to the 

bulk of ICE’s detainees. ICE can help its detention partners by providing 

more details about the disease as well as enhanced means for facilities to 

detect infected detainees. 

This recommendation is unresolved and open. 

ICE’s Comments to Recommendation #4 

ICE did not concur with our recommendation. ICE believes that its standards 

are appropriate in this area. The agency stated that a medical examiner, a 

hospital, or a physician, is responsible for implementing any state notification 

requirement. In the New Mexico case, ICE noted that any rule of its own 

would not have facilitated action by state or local entities to make notification 

to the proper authority. 

OIG Analysis 

We reaffirm our recommendation. ICE acknowledged the importance of state 

notification, but believes it is not its responsibility to do so. ICE can rely on 

other entities to ensure state notification. However, ICE’s standard currently 

does not mention reporting detainee deaths to states. Although other officials 

or a hospital can help satisfy the requirement, the detainee is ICE’s 

responsibility. It is possible that some hospitals or medical examiners may 

not realize that ICE is a law enforcement agency. ICE is not prohibited from 

proactively ensuring that detainee death notification occurs, especially since 

the agency’s standards require staff to comply with state rules on infectious 

disease reporting and other areas. ICE could take the step of articulating the 

importance of death notification. This would also provide ICE an additional 

opportunity to collaborate with states. 

This recommendation is unresolved and open. 

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ICE’s Comments to Recommendation #5 

ICE concurred with our recommendation. The agency is pursuing a 

Memorandum of Understanding with OFDT. ICE also provided details on its 

work with OFDT, as well as efforts to improve the compliance at the Regional 

Correctional Center. ICE stated that our recommendation was incorrectly 

based on a perception that OFDT provided information that led to ICE’s 

decision to remove detainees from the facility. ICE stressed that it relied on 

its own standards, rather than input from OFDT, in the decision to remove all 

immigration detainees from the RCC. 

OIG Analysis 

Our recommendation is not based on a belief that OFDT has better standards. 

We reported that OPR findings led to the removal of ICE’s RCC detainees. 

The purpose for this recommendation was that OFDT had indentified medical 

access problems that ICE did not. Without knowing about these problems, 

ICE admitted nearly 3,500 detainees to the RCC. Through greater interaction 

with OFDT, the two agencies can facilitate improvements across federal 

detention facilities. A formalized partnership, along with the improvements 

that ICE is making, can facilitate higher levels of compliance at facilities. 

When the final MOU is completed, ICE should forward the document to the 

OIG. We could close this recommendation at that time. 

This recommendation is resolved and open. 

Oversight Can Be Improved at ICE Detention Facilities 

ICE conducts annual monitoring visits to determine a facility’s compliance 

with the detention standards. Staff conducting routine oversight of facilities 

has not been effective in identifying certain serious problems at facilities. 

Moreover, ICE’s reports, based mainly on checklists that divulge little about 

the area reviewed, do not provide much information to facilities or outside 

reviewers. In December 2006 we reported that ICE did not find medical 

access problems and other non-compliance at detention facilities. Although 

ICE is taking steps to improve facility oversight, the agency should revise 

certain policies and standards to gain a more complete understanding of 

facilities’ compliance status. By improving its oversight methodology, ICE 

will improve both standards compliance and detainee safety. 

An Overview of ICE’s Detention Facility Monitoring Efforts 

Each facility housing ICE detainees is scheduled to receive an annual 

monitoring visit. Site visit teams use various worksheets to report on a 

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facility’s adherence to ICE’s standards. For contract detention facilities and 

service processing centers, a team from ICE headquarters leads the site visits. 

Field office staff is charged with monitoring of facilities that house detainees 

under an intergovernmental service agreement. Reviews usually take three or 

four days to complete. 

Within 14 days of completing a facility review, the team submits a report to 

ICE’s Detention Standards Compliance Unit. The unit examines the report for 

completeness and the soundness of the team’s conclusions. This leads to a 

rating of the facility’s performance against general areas of the standards, such 

as food service, the detainee handbook, and detainee access to medical care. 

If the review team determines that there is a deficiency in a particular area, the 

facility is required to undertake corrective action. After review of the report 

by headquarters staff, the facility also receives one of five overall ratings: 

•	 Superior – The facility exceeds expectations based on exceptional 

performance and excellent internal controls. 

•	 Good – The facility performs all of its functions with few deficient 

procedures. 

•	 Acceptable – The facility’s detention functions are performed 

adequately. ICE considers this level the baseline for its facility 

rating system. 

•	 Deficient – The facility is not performing one or more detention 

functions, with inadequate internal controls. 

•	 At Risk – The facility’s detention operations are impaired to the 

point where mission performance is not being accomplished. 

ICE is strengthening its oversight of detention facilities. A manager in ICE’s 

Office of Professional Responsibility informed us that a new unit, the 

Detention Facilities Inspections Group, will focus on standards compliance at 

detention facilities. The group will also conduct independent reviews of 

certain incidents at detention facilities. At the time of our fieldwork, only six 

employees were assigned to the new group, with projections for 12 additional 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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staff members. ICE officials asserted that the Detention Facilities Inspections 

Group is a “high priority.” The group must have sufficient resources to 

inspect detention facilities. Figure 3 highlights the placement of ICE’s 

detention facility monitoring units in the agency’s organizational structure. 

Figure 3: Excerpt of ICE Organizational Chart Showing Detention Facility
 

Monitoring Units
 

O ffice of 

P rofessional 

R esponsibility 

D etention 

F acilities 

Inspection 

G roup 

IC E A ssistant 

S ecretary 

O perations 

D eputy 

A ssistant 

S ecretary 

D etention and 

Removal 

O perations 

D etention 

S tandards 

C om pliance 

U nit 

S ite V isit 

Teams 

OPR participated in an ICE site visit after a March 2006 detainee death in 

Texas. According to the review, which took place less than a week after that 

incident, serious issues compromised detainee safety. A subsequent report 

concluded that the facility “has experienced a complete breakdown in 

communication, leadership, and supervision,” prompting difficulties “on every 

level.” ICE no longer uses the facility to house detainees. 

ICE is also in the process of contracting with outside experts to relieve ICE 

staff of the annual onsite facility monitoring function. This new process is 

now in place. ICE management believes that this new approach will be 

similar to how OFDT implements its monitoring visits. ICE’s contractor will 

use existing ICE monitoring instruments and protocols. 

Better Review of Medical Exam Timeliness is Needed 

ICE’s medical care detention standards require facilities to conduct a health 

appraisal and physical examination on each detainee within 14 days of the 

detainee’s arrival at the facility. This exam is designed to gather details about 

a detainee’s health beyond the screening questions asked during the intake 

process. The physical examination offers an important opportunity to gauge 

the health status of detainees. Timely delivery of the physical exam enhances 

a facility’s identification and treatment of communicable or chronic illnesses. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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We examined data on the timeliness of the 14-day exam from the Regional 

Correctional Center and the Ramsey County Law Enforcement Center. 

Because it had a considerably larger number of detainee intakes, we only 

requested three months of data from the RCC, April through June 2007. 

Ramsey County provided timeliness data for all detainees entering the facility 

for the first six months of 2007. Both facilities had difficulty meeting ICE’s 

physical exam timeliness standard. Officials at various detention facilities 

reported that staffing shortages, overworked clinicians, or an excessive facility 

intake can cause delays in delivery of this service. 

There were 1,118 new ICE detainees booked at the RCC during our threemonth sample. Of these, 997 stayed longer than 14 days. We determined that 

830 of the 997, or 83%, received a timely physical exam and 167, or 17%, did 

not. During its September 2006 monitoring visit, OFDT determined that the 

RCC met the 14-day standard in 18 of 20 cases, a 90% rate. 

For the Ramsey County facility, only 43 ICE detainees admitted in the first 6 

months of 2007 were housed for more than 14 days. Of the 43 detainees, 10, 

or 23%, had information regarding a physical exam in their medical file. 

Those with a completed physical often received the exam beyond 14 days. 

Table 1 lists the 10 detainees who had medical exam information documented 

in their file. In 3 of the 10 cases, no physical exam had been provided. For 

the seven cases with an exam date, an average of 40 days elapsed between the 

detainees’ intake and the exam. 

Table 1. Ten Cases from the Physical Exam Timeliness Sample, Ramsey
 

County Law Enforcement Center 

Intake date Exam date Days Elapsed Days Detained 

Detainee #1 3/26/2007 3/27/2007 1 23 

Detainee #2 3/29/2007 5/14/2007 46 94 

Detainee #3 4/16/2007 6/18/2007 63 76 

Detainee #4 4/16/2007 6/18/2007 63 76 

Detainee #5 5/4/2007 5/22/2007 18 58 

Detainee #6 5/4/2007 7/16/2007 73 Unknown 

Detainee #7 5/15/2007 No exam NA 47 

Detainee #8 6/4/2007 No exam NA 27 

Detainee #9 6/11/2007 6/28/2007 17 20 

Detainee #10 6/12/2007 No exam NA 16 

The data provided by Ramsey County showed additional problems with 

timely tuberculosis screening. One element in ICE’s monitoring protocol asks 

if the facility has ever needed more than one business day to conduct this 

screening test. For the 43 individuals in our sample, only 14 cases showed a 

date for the initial skin test used to detect tuberculosis. Ten of these detainees 

were not given a test within one business day. In one of these cases, the 

facility did not test a detainee for more than two months. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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ICE monitoring reports contained limited evidence that staff conducting site 

visits actually reviewed facility compliance with the 14-day exam standard. 

We concluded that sampling is not done on a consistent basis. A manager in 

ICE headquarters said that sampling is discussed during reviewer training, but 

ICE’s monitoring protocols do not require sampling to test a facility’s 

compliance. ICE should examine sample data during each of its monitoring 

visits to test compliance with the 14-day exam and other standards. 

Our December 2006 report on detainee treatment discussed problems with the 

14-day exam standard at two facilities. The Berks County Prison was 

compliant on only 38 of 42 sample cases, while an ICE facility in San Diego 

met the standard in only eight of 19 cases. Two other facilities met the 

standard in all 50 cases examined.10 Using sampling to gain a better 

understanding of a facility’s compliance level would be a valuable measure of 

how well detainees receive services designed to improve health outcomes. 

Since compliance can fluctuate over time, ICE needs to ensure that facilities 

continuously comply with detention standards. Although we are not 

recommending regular reporting by facilities, such information could be 

helpful to discern the ability of a particular location to house more detainees. 

ICE should also take larger and more frequent samples of other medical 

standards at those facilities that have exhibited problems. Developing 

sampling guidance in other areas would benefit ICE’s monitoring program. 

ICE Can Improve Detention Facility Monitoring Reports 

Questions regarding the materiality of findings are undermining the quality 

and usefulness of ICE’s monitoring reports. Current policy emphasizes that 

the materiality of a finding is based on the reviewer’s analysis of available 

evidence, extent of the problem, risk to the program’s efficient and effective 

management, review objectives and any other factors. This is a credible 

approach, but additional policy is needed to ensure ICE reviewers, who must 

determine whether a facility’s performance warrants deficient ratings, target 

areas of particular importance. Improvements in this area would also make a 

facility’s final rating more objective. 

In some monitoring reports, reviewers deemed the facility’s performance on 

certain elements acceptable, despite identifying notable deficiencies. For 

example, the November 2006 report for Ramsey County said the facility did 

not abide by ICE’s standards on tuberculosis screening. Screening for 

10 DHS OIG, Treatment of Immigration Detainees Housed at Immigration and Customs Enforcement 

Facilities, OIG-07-01, December 2006, pp. 3-4. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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tuberculosis is central to the safety of facility staff and other detainees. 

Compliance in this area should be a leading factor in a facility’s overall rating 

in the access to medical care area. However, the facility received an 

acceptable rating for that general standard. 

In its September 2006 report, OFDT raised concerns about the ability of the 

RCC’s medical unit to provide timely care with the number of clinicians on 

staff. ICE’s November 2006 report, on the other hand, simply gave a “yes” 

answer, with no other comment, for the standard requiring all detainees have 

access to and receive medical care. Had ICE been aware of the health care 

access problems at the RCC, it might have considered different locations for 

some of the 3,465 detainees who entered the facility from January through 

July 2007. 

There were some questionable conclusions in ICE’s November 2006 RCC 

monitoring report. For several elements, no examples of a particular event 

were evident, yet ICE concluded that the RCC met the standard. For such 

situations, it would be more accurate to conclude that a particular element was 

not applicable. ICE reported that the facility met other requirements, even 

though reviewer comments suggested otherwise. For example, the RCC did 

not have certain emergency plans, but the report concluded that the RCC met 

the requirement for such plans. Also, ICE reported that the RCC met the 

standard requiring storage of medical records in a locked area, even though 

the reviewers found one cabinet unlocked. Although corrective action was 

immediate, the issue was serious enough to warrant a finding that the RCC did 

not meet the standard. 

ICE drew questionable conclusions in monitoring reports of other facilities. 

One report listed several deficiencies regarding a facility’s medical treatment, 

even though ICE granted an acceptable rating in this area, including: 

•	 Absence of intake tuberculosis screening; 

•	 Absence of privacy blinds in exam rooms; 

•	 Insufficient oversight to ensure medical records were always secured; 

•	 The need to update certain policies, including 24-hour access to 

emergency services; and, 

•	 Improvements needed to policies related to special needs individuals. 

Another ICE monitoring report graded a facility’s security inspections 

acceptable, while noting the need for improvement in a non-compliant visitor 

pass system, the absence of documentation showing vehicles entering or 

departing secured areas, and incomplete vehicle searches. With such 

information, we have determined that the facility was deficient in this area. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Further explanation of these problems in an expanded narrative section in the 

report would have been beneficial. 

In comparing overall ratings given to facilities, changes are also needed to 

explain why particular facilities receive a given rating. Some field offices 

perceive the final rating process used by ICE headquarters as arbitrary. The 

Ramsey County Law Enforcement Center received a good rating in 2005, but 

only acceptable in 2006. The later report did not explain why the compliance 

status fell one level. In another example, in June 2006, one facility with 

uncorrected problems with staff-detainee communication still received a good 

rating. Another facility without any notable deficiencies only received a 

rating of acceptable. After reviewing the reports, we could not determine the 

justification for the second facility receiving a lower rating. 

Enhancements to site visit reports would permit a better understanding of a 

facility’s particular rating. In most of the reports we examined, the review 

team did not make use of the Remarks section found after each general 

standard. The narratives that appear in OFDT reports offer a more detailed 

assessment of a facility’s compliance status. This is especially important in 

instances where a facility could use more guidance. 

An ICE Standard on Internal Review at Facilities Would be Beneficial 

ICE currently does not have a requirement that facilities perform assessments 

of their operations. Through review of its own operations, a facility could 

more quickly discover problems, such as untimely access to health care. 

Developing a standard in this area would help ensure that facilities achieve 

and maintain compliance improvements. 

Both ACA and OFDT have standards that address the need for facilities to 

review their operations continually. ACA’s policy on Health Care Internal 

Review and Quality Assurance establishes the collecting, trending, and 

analyzing of data as a central feature of a successful review program. On-site 

monitoring of health service outcomes on a regular basis is the central 

component of ACA’s standard. According to OFDT’s policy, a facility’s 

internal review process is separate from external or continuous inspections or 

reviews conducted by other agencies. These standards for internal review 

could guide ICE’s development of its own standard in this area. 

Notable problems at one facility demonstrate the utility of self assessments. 

In March 2006, the facility received a deficient rating based on noncompliance in 11 of the 38 detention standards. Later that year, two detainees 

died at the facility. ICE’s reviews of these two incidents discussed serious 

problems with access to medical care and the oversight of clinical operations. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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ICE reported that the facility did not perform basic supervision and provide 

for the safety and welfare of ICE detainees. Had the facility reviewed its own 

operations, it might have uncovered issues related to insufficient medical 

staffing, problems with staff training, or other deficiencies. ICE discovered 

these issues only after two detainees died. ICE’s March 2007 monitoring 

review at the facility noted that five detainee deaths had occurred in the 

previous calendar year. 

Two recent monitoring reports of another facility highlight the importance of 

ongoing detention facility oversight. In August 2006, ICE granted a superior 

rating to one facility after a routine monitoring visit. After the November 

death of a detainee, ICE identified a variety of problems related to this 

facility’s medical care. The review team noted that the facility does not 

routinely do physical examinations on detainees who are in the facility more 

than 14 days. Additionally, ICE’s review team concluded that the facility has 

failed on multiple levels to perform basic supervision and provide for the 

safety and welfare of ICE detainees. Further, the line of communication in the 

medical department at this facility was deemed to be poor, placing detainee 

health care in jeopardy. 

Maintaining a complete and current picture of its facilities’ clinical operations 

should become a priority for ICE and its detention partners. Detecting 

deficiencies before problems arise is vital to detainee protection and standards 

compliance. As one correctional expert wrote, “Delayed or inadequate 

treatment of persons with medical conditions often results in liability exposure 

and publicity.”11 Investments in internal reviews can diminish such negative 

effects through continual corrective action by the facility itself, outside of 

ICE’s regular monitoring process. 

Recommendations 

We recommend that the Assistant Secretary for Immigration and Customs 

Enforcement: 

Recommendation #6: Revise monitoring protocols and the medical 

detention standard to require sampling and continuous oversight of the 14-day 

physical exam standard across ICE’s detention facilities. 

Recommendation #7: Revise monitoring policies and other guidance given 

to reviewers regarding the materiality of site visit report findings to ensure 

that standards, such as tuberculosis screening and others related to access to 

medical care, weigh more heavily on a facility’s compliance level. 

11 Clinical Practice in Correctional Medicine, 2nd ed., 2006, p. 42. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Recommendation #8: Require reviewers preparing monitoring reports to use 

narratives to illuminate special areas of concern and provide additional details 

about issues relevant to a facility’s compliance status. 

Recommendation #9: Develop a standard that requires facilities housing ICE 

detainees to implement an internal review function. 

Management Comments and OIG Analysis 

ICE’s Comments to Recommendation #6 

ICE concurred with our recommendation. The agency will use three steps to 

improve oversight of the 14-day physical exam standard. 

•	 Regular sampling by on-site clinical staff and remote sampling for 

facilities served by a regional contractor. 

•	 Findings of OPR’s Detention Facility Inspection Group inspections 

through its facility oversight role, and 

•	 Detention and Removal Operations will provide OPR information on 

this recommendation during Self Inspection Program reporting. 

OIG Analysis 

In its action plan, ICE should provide sufficient evidence of the policy 

revisions and site visit reports, showing that the required sampling is taking 

place to satisfy the intent of this recommendation. 

This recommendation is resolved and open. 

ICE’s Comments to Recommendation #7 

ICE concurred with our recommendation, noting that findings with significant 

consequences are weighed more heavily in a facility’s overall compliance 

rating. ICE’s pending performance-based standards will improve the accuracy 

and credibility of performance ratings. ICE also relies on immediate 

correction of serious life and safety issues found during monitoring visits. 

OIG Analysis 

Our recommendation focused on the scoring of particular elements in a way 

that inaccurately reported a facility’s actual status. Examples in our report 

showed facilities with obvious medical access problems still scoring at an 

acceptable level for that specific element. In its action plan, ICE should 

provide more detailed policy guidance and examples of site visit reports to 

demonstrate that both overall and specific elements are more accurately 

graded during the monitoring process. Upon doing so, we will close this 

recommendation. 

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This recommendation is resolved and open. 

ICE’s Comments to Recommendation #8 

ICE concurred with our recommendation. As a result of improvements made 

in late 2007, ICE is expanding the use of narratives in its site visit reports. 

This new process, which uses contracted experts in facility oversight, will lead 

to greater use of narratives to expound on areas of concern. Such additional 

information can clarify findings and enhance a facility’s ability to comply 

with necessary standards. 

OIG Analysis 

ICE has taken positive steps in this area, as it now uses the narrative field in 

its monitoring reports. We will close this recommendation on receipt of a 

copy of an inspection that demonstrates the use of the report’s narrative 

feature. 

This recommendation is resolved and open. 

ICE’s Comments to Recommendation #9 

ICE concurred with the premise of our recommendation, but did not concur 

with the need to create a standard on facility self-assessments. ICE is 

concerned that a self-assessment policy could diminish the consistent 

implementation of its national standards. The agency noted that it uses quality 

assurance experts at large facilities to help ensure local compliance in key 

areas. ICE believes that the participation of third party experts is necessary 

for local conditions to be monitored appropriately. In addition, ICE relies on 

its own monitoring practices to examine the compliance of facilities housing 

immigration detainees. 

OIG Analysis 

We reaffirm our recommendation that ICE develop a facility self-assessment 

policy. The agency’s response states, “We concur that there needs to be a 

sound internal review mechanism, but we disagree to the extent that the 

review process should be conducted by facility personnel.” In the health care 

compliance field, self-assessments are performed by a facility’s own staff. 

ICE’s regular site visit monitoring process and internal review are different 

concepts, to be performed by different individuals. What we are 

recommending in no way replaces those reviews. The Health Care 

Compliance Association notes that internal reviews “test compliance with 

internal policies and procedures and with federal, state, and local laws 

regulations and rules.” These programs are “often critical” in finding a 

problem before “it creates significant risk to the organization.” A facility can 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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use a self assessment to measure current compliance, ensure correction of 

deficiencies, or confirm ongoing compliance. Clinical staff at a local facility 

has the expertise to determine whether rules on the timeliness of physical 

exams and screenings have been met. Many standards do not require 

interpretation or the intervention of outside experts. Thus, ICE should not be 

concerned that self assessments are contrary to national consistency. It is also 

important to note that an internal review need not place exorbitant demands on 

detention facilities. For example, after receiving data from Ramsey County 

and Cornell, we quickly judged the facilities’ timeliness in providing physical 

exams and tuberculosis screening, two areas central to a facility’s medical 

care access. 

ICE’s quality assurance experts are not used in most local facilities. ICE 

should help facilities use their own processes to ensure basic standards are met 

on an ongoing basis – outside of the routine monitoring processes. Onsite 

experts or ICE site visits do not provide this level of ongoing assessment. 

Since ICE endeavors to follow ACA standards, it should create a facility self 

assessment standard to match the mandatory nature of ACA’s guidance in this 

area, which has existed since 2004. 

This recommendation is unresolved and open. 

Additional Efficiencies in Medical Operations Can Enhance 

Implementation of ICE’s Detention Standards 

ICE can develop a more efficient and productive oversight process for its 

detention facilities and enhance the standards that are appropriate and 

generally equivalent to the standards of ACA and OFDT. Further steps, such 

as the creation of electronic health records and increased staffing of clinical 

operations, offer additional means for ICE to strengthen standards compliance 

and improve detainee care. 

ICE’s Standards Are Credible Compared to Other Organizations 

Our analysis of several ICE detention standards, compared to the ACA and 

OFDT standards, is provided in Appendix E. In some instances, ICE’s 

standards are more detailed than those of ACA and OFDT. For example, a 

recent article noted that ICE’s standard on hunger strikes provides important 

details that are missing from similar ACA standards.12 We found that ICE’s 

standard on HIV/AIDS offers more specific guidance to facilities, as well. 

ICE requires that only a licensed physician will make a diagnosis of AIDS 

12 “What They Can Do About It: Prison Administrators’ Authority to Force-Feed Hunger-Striking 

Inmates,” 24 Washington University Journal of Law and Policy 151 (2007). 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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based on a medical history, current clinical evaluation of signs and symptoms, 

and laboratory studies. ICE also identifies procedures for treating the detainee 

within and outside the facility’s clinic. Staff responsibilities and precautions 

are also outlined. ACA’s standard specifies only that the detention facility 

will have a written plan that addresses the management of HIV infection and 

procedures for dealing with the detainee. Specific procedures for treatment 

and staff responsibility are not developed. OFDT’s standard simply classifies 

HIV as a chronic medical condition, requiring regular treatment. 

Additionally, the ICE standard on detainee grievances has important details 

that are not discussed by ACA or OFDT. The ICE standard specifies a formal 

and informal procedure for resolving detainee grievances. In the formal 

process, the detainee completes a form that discusses in writing the particular 

issue of concern. An informal grievance is delivered orally, offering detainees 

the opportunity to resolve their concerns before resorting to the longer formal 

procedure. Detainees can communicate their informal grievances to ICE staff, 

and all grievances can be appealed. OFDT’s process is similar to that of ICE, 

although an informal process is not developed. Based on ICE data, no 

grievances were filed by the 33 detainees who died between January 1, 2005 

and May 31, 2007. 

ICE, ACA, and OFDT understand the importance of identifying detainees 

with special medical needs. However, the three entities have different 

definitions of a special needs individual. According to ICE’s standard in this 

area, the facility’s officer in charge will be notified when detainees are 

diagnosed with special needs. OFDT echoes this point, but it gives more 

specific examples of types of conditions that affect individuals with special 

needs. Additionally, OFDT requires additional health care for detainees 

diagnosed with special needs. 

The ABA has encouraged ICE to make the agency’s detention standards 

enforceable through regulation. The ABA contends that, even though 

intergovernmental services agreements require compliance with standards, the 

standards currently in place are only advice to facilities on ensuring detainee 

welfare. There may be merit to creation of a regulatory mechanism to enforce 

ICE’s standards. We are not persuaded by the department’s memorandum in 

reply to the ABA, which discussed problems this course would create, such as 

staffing issues and the cumbersome regulatory update process. However, ICE 

is considering the feasibility of making the standards regulatory. 

ICE has already taken some steps to enhance its standards. The agency is 

moving toward the creation of performance-based standards similar to those 

used by ACA and OFDT. These standards provide an opportunity to 

articulate more clearly the specific actions that facilities are expected to take. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Performance-based standards are goal-oriented and include outcomes 

measures, which can provide facilities with guidance on the implementation. 

This should bring about improvements in facilities’ adherence to specific 

goals. Improvements to ICE’s facility monitoring process should be enhanced 

when the updated standards are finalized. 

Electronic Medical Records Would Create Efficiencies for ICE 

We reviewed the utility of electronic health records (EHRs) for ICE’s 

detention facilities. EHRs digitally store individual health information, either 

in a transferable card or a centralized database. ICE and its facilities currently 

rely on traditional paper-based medical records. However, ICE, including its 

Division of Immigration Health Services (DIHS), has taken preliminary steps 

toward electronic records, including development of systems requirements. 

ICE has spent more than $2.2 million on the development of an electronic 

records system, including software and training expenses. DIHS determined 

this initial systems design was less than sufficient. ICE has noted its interest 

in making improvements on its initial system. 

Efficiencies created by EHRs would provide ICE many advantages in the 

management of detainee care, especially when detainees are transferred to 

other facilities. For example, EHRs can be easily transmitted. An 

individual’s records would be immediately available to clinical staff at a new 

detention facility. This would allow for a more rapid assessment of a 

detainee’s current medical needs, reduce duplication of intake screenings or 

physical exams, and improve detainee safety. By expediting the development 

of EHRs, ICE and its detainees would receive long-term benefits. 

The Veterans Health Information Systems and Technology Architecture 

enabled the Department of Veterans Affairs (VA) to create EHRs for 

individuals receiving care at VA hospitals and clinics. The VA’s EHRs 

provide patient-specific information that permits time and context sensitive 

clinical decision-making. The VA has achieved important safety 

improvements through its use of electronic information. For example, 

electronic prescriptions have reduced medication errors and helped to identify 

incompatible medications. The VA has reported a medication error rate of 

0.003%, well below the three to eight percent national average.13 

ICE facilities managed by the Correctional Corporation of America use EHRs. 

When an ICE detainee is transferred between facilities managed by the 

company, clinical staff can access an electronic records system. One of the 

company’s facility wardens said that less paperwork and more timely 

13 “The Best Medical Care in the U.S.,” Business Week, July 17, 2006. 

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information about detainees has improved operations at the company’s 

detention facilities. An ICE review of a Houston detainee’s suicide provides 

an example of how rapid access to health records can be vital. According to 

the incident report: 

A major area of concern was a lack of medical records . . . 

Following the death, the detainee’s health records from his 

previous institution revealed the detainee had been diagnosed 

and treated for Schizophrenia and had at least one 

documented suicide attempt . . . Such information would have 

been valuable to the mental health provider and medical staff 

at Houston. 

Although the individual was transferred from a Bureau of Prisons facility to 

Houston, rather than from another ICE facility, the report provides keen 

insight into the utility of EHRs. 

Additionally, EHRs would not be subject to disruption or destruction. This 

was especially important to the VA during Hurricane Katrina, when clinicians 

around the country had electronic access to records of the 40,000 veterans 

who had received care or ordered prescriptions at VA facilities in Louisiana 

and Mississippi. A 2007 study by the State of California also discussed how 

EHRs could ensure the maintenance of medical records during natural 

disasters or other catastrophic events.14 

ICE and DIHS have recently taken steps to create a system of electronic 

health records. An ICE official suggested that more detailed discussions are 

needed to define systems requirements, and ICE needs to understand DIHS’s 

perspective on the limitations of the electronic records system. The proposed 

integration of DIHS into ICE should enhance progress toward development of 

EHRs for ICE detainees. This integration is anticipated in early FY 2008. 

ICE is a natural candidate for implementation of EHRs. By enhancing the 

efficiency of clinical operations, ICE would provide better care for its 

detainees. We recognize that complicated systems decisions are necessary 

before an effective electronic records system can be fully implemented, 

including concerns about the privacy of electronic records. Thus, ICE should 

consult outside experts, such as the VA, as needed. 

14 The State of California, Legislative Analyst’s Office, “A State Policy Approach: Promoting Health 

Information Technology in California,” February 2007. 

http://www.lao.ca.gov/2007/health_info_tech/health_info_tech_021307.aspx 

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Some ICE Facilities Are Experiencing Clinical Staffing Problems 

Two ICE facilities included in our review have staffing problems, raising 

concerns about not only the slow pace of hiring, but the agency’s ability to 

provide proper health care. DIHS personnel said that they need a better 

understanding of ICE’s vision for detention services. They said that 

understanding the vision would help determine where additional or new 

personnel resources should be placed. 

Nationally, contract detention facilities and service processing centers using 

Public Health Service clinicians had a 36% vacancy rate in October 2007. 

The contract detention facility in Pearsall, Texas, which housed more than 

1,500 detainees the day we visited, had 22 medical staff vacancies. Given its 

rural location and the nation’s high demand for nurses, staff in Pearsall said 

that they will endure medical staff shortages indefinitely. 

Staff from the San Diego Field Office also expressed concern about recruiting 

and retaining clinical staff for its contract detention facility. In its December 

2006 ICE site visit report, the facility earned an overall rating of deficient 

after receiving a good rating in 2005. Health care access problems caused by 

insufficient medical staff were a primary reason for the low level of 

performance. According to the site visit report, nearly 260 detainees did not 

receive a physical examination during a three-month period in 2006. Field 

office staff suggested that DHS’ lengthy security clearance process is an 

obstacle to filling vacant medical staff positions. To offset not having 

sufficient medical staff, the current staff work extended hours in an attempt to 

improve compliance with ICE’s medical standards. ICE did provide data 

showing that recent progress has been made on the issue of clearance 

processing, but the general concerns expressed by staff in Pearsall and 

elsewhere warrant further scrutiny by ICE management. 

Immigration attorneys we interviewed said that their primary concern is ICE’s 

ability to deliver timely health services. In June 2007, the American Civil 

Liberties Union filed a class action suit against ICE as a result of problems at 

the San Diego Detention Center. Agencies can be exposed to legal liability if 

medical standards are not properly implemented. As one expert wrote, “Most 

cases in which courts have found constitutional violations of inmates’ rights to 

health care were fostered by the exigencies of an overburdened staff coping 

with too few resources.”15 Even in those areas where ICE has a credible 

treatment standard, such as care for detainees with AIDS, other organizations 

have determined that medical care can be inadequate. A human rights group 

recently alleged several examples of problems with ICE’s treatment of 

15 Clinical Practice in Correctional Medicine, 2nd ed., 2006, p. 524. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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detained individuals with AIDS. This group’s report detailed cases where 

detainees were denied medications or where needed care was delayed.16 We 

did not review any of these cases for this report. 

We discussed various medical access issues with Public Health Service 

clinicians, who provide care at some of ICE’s facilities, and officials from 

DIHS headquarters. Some DIHS officials believe that greater involvement in 

ICE’s detention management strategic planning would help with staffing 

problems. This would give DIHS a better idea of where clinical staff would 

be needed. Although our interviewees described the relationship between ICE 

and DIHS as very positive, ICE should ensure that clinical staffing efforts are 

aligned with ICE’s strategic planning for detention management. 

Recommendations 

We recommend that the Assistant Secretary for Immigration and Customs 

Enforcement: 

Recommendation #10: Expedite all necessary discussions and resources to 

develop a system of electronic health records for ICE detainees. 

Recommendation #11: Work with the Division of Immigration Health 

Services to identify all clinical staff shortages, then work with ICE’s clinical 

partners to develop and implement a strategy to fill clinical staff shortages at 

immigration detention facilities. 

Management Comments and OIG Analysis 

ICE’s Comments to Recommendation #10 

ICE concurred with our recommendation. The agency continues to work with 

DIHS and other experts to create the electronic records system. The 

department’s Investment Review Board must approve the system. 

OIG Analysis 

In its corrective action plan, ICE should provide details on the progress it is 

making regarding acquiring the necessary technology and designing the 

protocols for the EHRs. Once we receive evidence of ICE’s commitment to 

establishing an EHR system, we will close this recommendation. 

This recommendation is resolved and open. 

16 Human Rights Watch, Chronic Indifference: HIV/AIDS Services for Immigrants Detained by the 

United States, December 2007. 

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ICE’s Comments to Recommendation #11 

ICE concurred with our recommendation. Through interaction with DIHS, 

ICE is creating a strategic plan to examine a variety of issues related to the 

recruitment and retention of clinical staff. This plan will include 

improvements to the processing time of background investigations, 

considerations for the use of incentives such as signing bonuses, student loan 

repayment, hiring additional health care recruiters, and collaborating with the 

U.S. Public Health Service for hiring and placing health care professionals to 

support ICE detention operations. 

OIG Analysis 

We look forward to receiving ICE’s staffing strategic plan. This plan should 

help ICE correct the difficult staffing problems that confront many health care 

providers across the country. In its action plan, ICE should set a timetable for 

completing the strategic plan. 

This recommendation is resolved and open. 

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Appendix A 

Purpose, Scope, and Methodology 

ICE provided data showing that 33 immigration detainees died in custody 

between January 1, 2005 and May 31, 2007. We examined incident reports 

and other data about these cases, and interviewed field office personnel to 

gain further insight into some detainee deaths. The two instances of detainee 

death that were the focus of this report were referred to us through the OIG 

Hotline. 

We examined: 

•	 Documentation regarding detainee death cases, including detainees’ 

detention and medical files; 

•	 Detention standards used by ICE and other entities; 

•	 Legal cases and international human rights agreements; and 

•	 Facility monitoring reports and data held by detention facilities. 

We conducted 53 interviews, including discussions with ICE headquarters and 

field office staff. Conversations with field office staff covered detention 

standards, detainee death incidents, and resource issues. We interviewed staff 

from DHS’ Office for Civil Rights and Civil Liberties, public and private 

sector clinical experts, immigration attorneys, and experts in correctional 

facility oversight. 

We toured seven facilities that house ICE detainees. These facilities were: 

•	 Ramsey County Law Enforcement Center, St. Paul, Minnesota; 

•	 Sherburne County Jail, Elk River, Minnesota; 

•	 El Paso Service Processing Center, El Paso, Texas; 

•	 Regional Correctional Center, Albuquerque, New Mexico; 

•	 Central Texas Detention Facility, San Antonio, Texas; 

•	 South Texas Detention Complex, Pearsall, Texas; and 

•	 Laredo Processing Center, Laredo, Texas. 

We conducted our review between May 2007 and August 2007 under the 

authority of the Inspector General Act of 1978, as amended, and according to 

the Quality Standards for Inspections issued by the President’s Council on 

Integrity and Efficiency. 

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Appendix B 

Management’s Comments to the Draft Report 

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Appendix B 

Management’s Comments to the Draft Report 

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Appendix B 

Management’s Comments to the Draft Report 

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Appendix B 

Management’s Comments to the Draft Report 

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Appendix B 

Management’s Comments to the Draft Report 

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Appendix B 

Management’s Comments to the Draft Report 

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ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

 

Appendix B 

Management’s Comments to the Draft Report 

Detention Facilities 

Page 43
 
 

 

Appendix B 

Management’s Comments to the Draft Report 

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ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

 

Appendix B 

Management’s Comments to the Draft Report 

Detention Facilities 

Page 45
 
 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

 

Appendix B 

Management’s Comments to the Draft Report 

Detention Facilities 

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Appendix B 

Management’s Comments to the Draft Report 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Appendix B 

Management’s Comments to the Draft Report 

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Appendix C 

Recommendations 

Recommendation #1: Work with the Office of Inspector General to create a 

policy that would lead to the prompt reporting of all detainee deaths to the 

Office of Inspector General. 

Recommendation #2: Work with the Division of Immigration Health 

Services, the Centers for Disease Control, and other experts, to enhance 

existing medical standards, rules for special needs individuals, and coverage 

guidance related to infectious disease. 

Recommendation #3: Revise medical intake screening forms and physical 

exam questionnaires at detention facilities to include questions regarding the 

detainee’s family history of cysticercosis. 

Recommendation #4: Revise the notification section of ICE’s detainee death 

standard to ensure that the agency and its detention partners report a 

detainee’s death in states that require notification in the event of a death in 

custody. Documentation of this reporting should appear in a detainee’s file. 

Recommendation #5: Seek to enter into a memorandum of understanding 

with the Department of Justice, Office of Federal Detention Trustee that 

establishes a process that enables OFDT and ICE to regularly share 

information resulting from facility site visits. 

Recommendation #6: Revise monitoring protocols and the medical 

detention standard to require sampling and continuous oversight of the 14-day 

physical exam standard across ICE’s detention facilities. 

Recommendation #7: Revise monitoring policies and other guidance given 

to reviewers regarding the materiality of site visit report findings to ensure 

that standards, such as tuberculosis screening and others related to access to 

medical care, weigh more heavily on a facility’s compliance level. 

Recommendation #8: Require reviewers preparing monitoring reports to use 

narratives to illuminate special areas of concern and provide additional details 

about issues relevant to a facility’s compliance status. 

Recommendation #9: Develop a standard that requires facilities housing ICE 

detainees to implement an internal review function. 

Recommendation #10: Expedite all necessary discussions and resources to 

develop a system of electronic health records for ICE detainees. 

Recommendation #11: Work with the Division of Immigration Health 

Services to identify all clinical staff shortages, then work with ICE’s clinical 

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Appendix C 

Recommendations 

partners to develop and implement a strategy to fill clinical staff shortages at 

immigration detention facilities. 

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Appendix D 

Comparison of Various Detention Standards 

We compared various standards from ICE’s Detention Operations Manual, ACA’s PerformanceBased Standards for Adult Local Detention Facilities, Fourth Edition, and OFDT’s Federal 

Performance-Based Detention Standards Review Book. 

This analysis focused on standards of particular interest to this review. The following table outlines 

and compares standards across the three organizations. The table is divided into three primary areas: 

standards related to physical exams and access to care, standards related to detainee mortality, and 

certain standards related to medical issues and grievances. 

Standards Related to Physical Exams and Access to Care 

Standard Element ICE ACA OFDT 

Health Appraisals 

In addition to general 

requirements 

regarding intake 

screening when the 

detainee is admitted 

to a facility, 

requirements include 

a more detailed 

medical exam of the 

detainee within 14 

days. 

A health care provider will 

conduct a health appraisal 

and physical examination on 

each detainee within 14 days 

of arrival at facility. All 

appraisals will be performed 

according to National 

Commission on Correctional 

Health Care and the Joint 

Commission on the 

Accreditation of Health 

Organization standards. 

Standards for these exams 

are not detailed. 

In Service Processing 

Centers and Contract 

Detention Facilities, the InProcessing Health Screening 

Form (I-794) is followed up 

and the health care provider 

will provide treatment 

accordingly. 

A health care provider 

will conduct a health 

appraisal on each 

detainee within 14 days 

of arrival at facility. In 

addition to following up 

on the intake screening, 

criteria regarding the 

appraisal are discussed. 

The facility director 

ensures that medical, 

dental, and licensed 

health care professionals 

complete mental health 

assessments within 14 

days of arrival. Criteria 

are outlined by each 

assessment for the 

appraisals to be 

conducted. 

Emergency Services In local jails, a written plan for 

the delivery of 24-hour 

emergency health care is 

required. No standards are 

specified. Service 

Processing Centers and 

Contract Detention Facilities 

will prepare plan in 

consultation with the facility’s 

routine medical provider. The 

plan will include an on-call 

provider, contact information 

for local ambulances and 

hospitals; and procedures for 

A plan to provide 24-hour 

emergency medical, 

dental, and mental health 

services is required. 

Emergency evacuation 

procedure is also 

required. Criteria are 

identified that includes 

use of an emergency 

medical vehicle, 

hospitals, on-call 

physicians, dentists, and 

mental health 

professionals. 

Ensures that written 

policies and procedures 

exist for emergency 

health care, including 

emergency evacuation 

and transportation. A 

plan to provide 24-hour 

emergency response is 

not identified. Criteria are 

not identified for written 

policies and procedures 

that are to be in place. 

However, staff will 

practice medical 

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Appendix D 

Comparison of Various Detention Standards 

facility staff to use providers 

consistent with security and 

safety. Additionally, first aid 

and medical emergency 

standards and criteria are 

identified. 

Additionally, back-up 

facilities and providers 

should be predetermined. 

emergency plans; biannual trial runs are 

documented. 

Requests for Medical 

Care 

Request slips will allow 

detainees to request health 

care services. Slips must be 

received by medical facility in 

a timely manner. If 

necessary, detainees will be 

provided with assistance in 

filling out the request slip. 

Clinical staff is to be available 

on scheduled basis to 

respond to requests. 

In Service Processing 

Centers and Contract 

Detention Facilities, request 

slips will be made freely 

available for detainees to 

request health care services 

on a daily basis. Request 

slips will be made available in 

English, and the foreign 

languages most widely 

spoken among detainees. If 

necessary, detainees will be 

provided assistance in filling 

out the request slip. 

All detainees are 

informed about how to 

access health care 

services during the 

admission/intake 

process. This is 

communicated orally and 

in writing. Information is 

translated into those 

languages spoken by 

significant numbers of 

inmates. No member of 

the correctional staff 

should approve or 

disapprove inmate 

requests for health care 

services. 

Detainees have daily 

opportunities to request 

health care services. 

Detainee requests are 

documented and are 

triaged by a healthcare 

professional within 24 

hours on weekdays. 

Appropriate health care 

professionals triage 

requests in a timely 

manner. 

Standards Related to Detainee Mortality 

Standard Element ICE ACA OFDT 

Detainee Deaths ICE’s detainee death 

standards articulate a variety 

of notification requirements 

for the facility and ICE staff. 

Although mortality reviews by 

the facility are not specifically 

required, the overall policy 

includes commendable levels 

of detail about how the facility 

and ICE are to address 

detainee death cases. 

ACA’s policy focuses on 

notification of proper 

authorities. Also, the 

mandatory internal 

review policy requires 

that all deaths in custody 

are to be examined by 

the facility. 

Like ICE and ACA, OFDT 

stresses the importance 

of notifying proper 

authorities. Staff is to be 

trained to respond to 

serious illness or detainee 

death. Examination of 

required mortality reviews 

are part of site visit 

team’s assessment of 

facility’s compliance. 

Results of mortality 

review are acted on 

immediately. 

Suicide Prevention 

All three entities 

recognize the 

Staff training requirements 

are similar to ACA and OFDT. 

Staff is required to observe 

Staff is required to be 

trained on suicide risk 

and intervention. Mental 

Policy specifically 

requires that the facility is 

to have a sufficient 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Appendix D 

Comparison of Various Detention Standards 

importance of “imminently suicidal” health appraisals are to number of clinicians to 

training, observation, detainees no less than every include assessment of deal with suicidal cases. 

and notification of 15 minutes. suicide risk. Continuous Family members are to 

authorities. observation required for 

suicidal inmates until 

intervention by clinicians. 

be notified of an 

attempted suicide. 

Certain Standards Related to Medical Issues and Grievances 

Standard Element ICE ACA OFDT 

Dental Care, Initial dental screening due Initial dental screening Like ICE’s policy, OFDT 

Assessments within 14 days. If dentist not 

available, a physician, 

physician’s assistant, or 

nurse practitioner can 

perform the assessment. 

due within 14 days. A 

dentist or trained 

personnel under the 

supervision of a dentist 

should perform the 

screening. 

standard does not require 

that a dentist perform the 

assessment. 

Dental Care, Routine Routine care may be 

provided for individuals 

detained for more than 6 

months 

Requires “defined scope 

of services” for detainees 

without reference to 

length of stay. 

Routine care is to be 

provided if the individual 

is detained greater than 

one year. 

First Aid Kits Kits are to be placed 

according to ACA policy. 

Designated health 

authority and facility 

administrator collaborate 

to determine locations for 

kits. Health staff 

determines contents of 

kits. Defibrillator must be 

available to facility staff. 

Not as specific as ACA. 

Standard requires that 

supplies for medical 

emergencies are to be 

readily available. 

Grievances ICE’s process is outlined in 

more detail than ACA and 

OFDT standards. Facilities 

are to use an informal 

grievance process in an 

attempt to resolve concerns 

quickly, but detainees have a 

right to file a formal written 

grievance. Also, 

requirements at Contract 

Detention Facilities and 

Service Processing Centers 

are more detailed than for 

county detention facilities. 

One specific difference for 

contract detention facilities 

and service processing 

centers is that only detainees 

can file a grievance. 

ICE’s policy on staff-detainee 

communication permits 

detainees to make informal 

ACA’s grievance 

standard does not have 

specificity. Facilities are 

required to have 

grievance procedures 

that include one level of 

appeal, but specific 

requirements are not 

outlined. 

Grievance standard 

includes many of the 

elements found in ICE’s 

standard, although an 

informal process is not 

specified. Standards in 

other areas, such as 

discrimination prevention, 

require review of all 

grievances alleging 

discrimination based on 

race, gender, religion, 

and national origin. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

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Appendix D 

Comparison of Various Detention Standards 

grievances to ICE. Formal 

grievances are to be resolved 

by the facility. 

HIV/AIDS A detailed standard for “the 

accurate diagnosis and 

medical management” of 

HIV/AIDS. The standard 

requires that detainees with 

active tuberculosis should be 

evaluated for HIV infection. 

Facilities are also directed to 

report cases per state and 

federal rules. 

According to DIHS coverage 

policy, follow-up care is 

covered. HIV testing is 

covered if a clinician 

documents the need. 

A mandatory standard 

that is not as specific as 

ICE’s HIV policy. The 

written plan required 

under the standard must 

include procedures for 

identification, 

surveillance, treatment, 

and other areas. 

Policy on chronic 

conditions requires that 

individuals with AIDS are 

to receive regular care by 

physicians who provide 

for individual treatment 

plans. 

Mental Health Initial health screening is to Establishes that an OFDT standards include 

In September 2006, include mental health “appropriate mental additional details on 

the Bureau of Justice assessment. Facility staff is health authority” specific mental health 

Statistics reported to be trained to recognize the approves mental health policies. For example, 

that half of jail and signs and symptoms of services. Standards are OFDT provides details on 

prison inmates have mental illness as a means to to ensure that facility staff the contents of mental 

mental health needs. decrease suicide risk. The 

standard establishes that 

mental health care will 

generally be provided in a 

hospital or community setting, 

rather than the detention 

facility. 

can identify mental health 

needs, proper care is 

provided (generally 

through referrals for 

outside care). 

health appraisals and the 

need to provide needed 

medications for routine 

and emergency 

situations. 

Special Needs 

Individuals 

Detainees who have 

certain specific 

medical issues are 

considered to have 

“special needs.” The 

concept is mentioned 

by all three entities, 

but defined differently 

by each. 

The Officer in Charge is to be 

notified when individuals are 

diagnosed with special 

needs. Examples of 

conditions requiring “special 

attention” are pregnancy, 

special diets, medical 

isolation, and AIDS. 

Clinical and facility 

personnel are to ensure 

“maximum cooperation” 

on individuals who are 

chronically ill, disabled, 

geriatric, or seriously 

mentally ill. Special 

needs individuals are 

granted a hearing and 

additional due process 

steps before transfer to 

another facility. 

OFDT has the most 

specific policy in this 

area, including steps to 

providing health care for 

the special needs 

population. These 

include targeted physical 

exams, use of chronic 

care clinics, necessary 

subspecialty visits, and 

preventive care. 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

Detention Facilities 

Page 54
 
 

 

Appendix E 

Major Contributors to this Report 

William McCarron, Chief Inspector, Department of Homeland Security, 

Office of Inspections 

Darin Wipperman, Senior Inspector, Department of Homeland Security, 

Office of Inspections 

Jacob Farias, Inspector, Department of Homeland Security, 

Office of Inspections 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

Detention Facilities 

Page 55
 
 

 

Appendix F 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chief of Staff 

General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

Chief Security Officer 

Assistant Secretary, U.S. Immigration and Customs Enforcement 

U.S. Immigration and Customs Enforcement Audit Liaison 

Assistant Secretary for Public Affairs 

Assistant Secretary for Policy 

Assistant Secretary for Legislative Affairs 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees, as appropriate 

ICE Policies Related To Detainee Deaths and the Oversight of Immigration 

Detention Facilities 

Page 56
 
Additional Information and Copies 

To obtain additional copies of this report, call the Office of Inspector General 

(OIG) at (202) 254-4199, fax your request to (202) 254-4305, or visit the OIG web 

site at www.dhs.gov/oig. 

OIG Hotline 

To report alleged fraud, waste, abuse or mismanagement, or any other kind of 

criminal or noncriminal misconduct relative to department programs or 

operations: 

• Call our Hotline at 1-800-323-8603; 

• Fax the complaint directly to us at (202) 254-4292; 

• Email us at DHSOIGHOTLINE@dhs.gov; or 

• Write to us at: 

DHS Office of Inspector General/MAIL STOP 2600, Attention: 

Office of Investigations - Hotline, 245 Murray Drive, SW, Building 410, 

Washington, DC 20528. 

The OIG seeks to protect the identity of each writer and caller.