Department of Homeland Security 

Office of Inspector General 

Management of Mental Health Cases in 
 

Immigration Detention
 


OIG-11-62 March 2011 
March 28, 2011

Office ofInspector General

U.S. Department of Homeland Security

Washington, DC 20528

Homeland

Security

Preface

The Department ofHomeland Security (DHS) Office ofInspector General (OIG) was

established by the Homeland Security Act of2002 (Public Law 107-296) by amendment

to the Inspector General Act of1978. 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 Immigration and Customs Enforcement's management ofmental

health cases in immigration detention. It is based on interviews with employees and

officials ofrelevant agencies and institutions, direct observatwns, and a review of

apphcable documents.

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

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

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

express our apprecIation to all ofthose who contributed to the preparation ofthis report.

C --12LO'V\~~ Carlton I. Mann

ASSIstant Inspector General
Table of Contents/Abbreviations 

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


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


Results of Review ................................................................................................................5
 


IHSC’s Oversight as ICE’s Medical Authority Needs to Extend to All Facilities 
 

Providing Health Care for ICE Detainees ......................................................................5
 


Recommendation ...........................................................................................................6
 


Management Comments and OIG Analysis ..................................................................7
 


Reducing Staffing Shortages Can Improve the Mental Health Care Environment .......7
 


Recommendation .........................................................................................................10
 


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


ICE Needs to Establish Staffing Models for Managing Mental Health Care Needs ...11
 


Recommendation .........................................................................................................12
 


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


Space Limitations and Remote Locations May Reduce the Effectiveness of Mental 
 

Health Care ..................................................................................................................12
 


Recommendations........................................................................................................18
 


Management Comments and OIG Analysis ................................................................18
 


Facility Designation Should Be A Factor in Resource Allocation and Planning ........20 
 

Recommendation .........................................................................................................21
 


Management Comments and OIG Analysis ................................................................21
 


Additional Information Can Provide Assistance in Determining Detainees’ Mental 
 

Health Care Needs .......................................................................................................21
 


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


Management Comments and OIG Analysis ................................................................24
 


ICE Needs to Designate Decision-making Responsibility for Transferring Mentally 
 

Ill Detainees .................................................................................................................25
 


Recommendations........................................................................................................28
 


Management Comments and OIG Analysis ................................................................28
 


Mental Health Conditions Can Hamper Legal Proceedings ........................................29
 


Recommendations........................................................................................................31
 


Management Comments and OIG Analysis ................................................................31
 


Private Facilities Can Fill Critical Roles in Providing Mental Health Care for 
 

Detainees with Mental Illness......................................................................................33
 


Recommendation .........................................................................................................34
 

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


Evolving Clinical Practices May Offer Greater Flexibility to Support Mental Health 
 

Care Needs...................................................................................................................34 
 

Recommendations........................................................................................................35
 


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


Electronic Medical Records Have Not Been Implemented .........................................37 
 

Recommendation .........................................................................................................37 
 

Management Comments and OIG Analysis ................................................................38
 


Appendices 

Appendix A: Purpose, Scope, and Methodology.......................................................39
 


Appendix B: Management Comments to the Draft Report .......................................41 
 

Appendix C: Major Contributors to this Report........................................................50
 


Appendix D: Report Distribution ..............................................................................51
 


Abbreviations 

CBP Customs and Border Protection 
 

DHS Department of Homeland Security 
 

DOJ Department of Justice 
 

EOIR Executive Office of Immigration Review 
 

ICE Immigration and Customs Enforcement 
 

IHSC ICE Health Service Corps 
 

ODPP Office of Detention Policy and Planning 
 

OIG Office of Inspector General 
 

OPLA Office of Principal Legal Advisor 
 

PHS Public Health Service 
 
OIG
 


Department of Homeland Security 

Office of Inspector General 

Executive Summary 

Immigration and Customs Enforcement apprehends, detains, and 

removes illegal aliens from the United States. Aliens in custody 

must be provided with appropriate medical treatment and care. 

The Health Service Corp serves as the medical authority for 

Immigration and Customs Enforcement, and provides direct care 

or arranges for outside health care services to detained aliens in 

custody. 

The Immigration and Customs Enforcement’s Health Service 

Corps staffs only 18 of the nearly 250 detention centers nationwide 

and has limited oversight and monitoring for mental health cases 

across immigration detention centers. As a result, Immigration and 

Customs Enforcement is not fully aware of all detainees with 

mental health conditions, or the level of care being provided. 

The Health Service Corps has experienced persistent vacancies in 

mental health positions which have raised concerns about the 

effectiveness of provider care. As of August 2010, vacancy rates 

at 11 of the 18 facilities staffed with Health Service Corps 

employees were 50% or more. In addition, facilities were not 

always well-equipped to support the needs of detainees with 

mental illness or located in areas with access to community mental 

health care facilities. 

Immigration and Customs Enforcement needs to (1) establish a 

staffing plan that aligns staffing with the facilities’ mental health 

caseload, (2) make appropriate space available to provide needed 

treatment, (3) develop a classification system for facilities to 

determine the level of care that can be provided, (4) make timely 

requests for mental health information, (5) clarify decision-making 

authorities for detainee transfer decisions, (6) establish protocols 

for handling mental health information, (7) release guidance on 

custodians, and (8) develop field guidance for using specialty 

facilities. 

We are making 20 recommendations to improve the management 

of mental health cases. 

Management of Mental Health Cases in Immigration Detention 

Page 1 
Service Processing Centers - owned by DHS ICE and 

staffed with federal and contract employees, 

Contract Detention Facilities - owned and operated by 

private companies under contract with ICE, and 

Intergovernmental Service Agreement - State and local jails 

operating under an agreement with ICE. 

Background 

United States Immigration and Customs Enforcement (ICE) 

apprehends, detains, and removes individuals who are in the 

United States unlawfully. ICE places non-U.S. citizens who are 

apprehended and determined to need custodial supervision in 

detention facilities maintained by its Office of Enforcement and 

Removal Operations. The Supreme Court has held that, consistent 

with the Eighth Amendment and common law principles, the 

government is obligated to provide medical care to those whom it 

is incarcerating.1 Pursuant to ICE detention standards, 

Enforcement and Removal Operations is responsible for providing 

detainees with medical care. 

Mental Health Care in Immigration Detention 

Within Enforcement and Removal Operations, the ICE Health 

Service Corps (IHSC) serves as ICE’s medical authority, and 

oversees, provides, and arranges for detained aliens’ medical care, 

including mental health care. IHSC has diagnosed and treated 

detained aliens for a range of mental health conditions including 

schizophrenia, substance abuse, adjustment disorder, and posttraumatic stress disorder. Some detainees are seriously impaired 

by mental illness and may be unable to coexist with others in 

detention or participate in immigration proceedings. In addition, 

detainees may present a risk of harm to others or themselves, 

including suicide.2 

To address mental health cases, IHSC staff includes psychiatrists, 

psychologists, and social workers at the following types of ICE 

detention facilities: 

1 Estelle v. Gamble, 429 U.S. 97, 103-104 (U.S. 1976) (holding that deliberate indifference to serious 

medical needs of prisoners constitutes the "unnecessary and wanton infliction of pain," proscribed by the 

Eighth Amendment) (citing Gregg v. Georgia, 428 U.S. 153, 173 (U.S. 1976)). 2

 Since 2004, 17 detainees in ICE custody have committed suicide. There has not been a detainee suicide 

in IHSC care for the past 2 years. 

Management of Mental Health Cases in Immigration Detention 

Page 2 
 

IHSC provides medical and mental health care at 18 of the 

approximately 250 ICE detention facilities nationwide, including 

all six service processing centers, and 12 of the contract detention 

facilities and facilities operating under an intergovernmental 

service agreement. 

Of the 821 IHSC employees, 266 are United States Public Health 

Service (PHS) officers, with the remaining 555 personnel being 

civilian or contracted employees.3

 Figure 1 shows 18 facilities 

where IHSC has a clinical presence, 4 facilities where IHSC only 

screens detainees, and IHSC’s headquarters location in 

Washington, D.C. 

Figure 1: IHSC Headquarters and Field Locations 

Source: IHSC, http://www.icehealth.org/Facilities/LocationsMap.shtm 

The contract detention facilities and facilities operating under an 

intergovernmental service agreement functioning without IHSC 

personnel employ their own staff or contract with local 

practitioners to provide medical services, including mental health 

care. ICE also uses local hospitals and other facilities to treat 

detainees whose mental health needs exceed a detention facility’s 

capability. As of August 2010, contract detention facilities, service 

processing centers, and facilities operating under an 

intergovernmental service agreement were using the services of 52 

off-site mental health facilities. 

3

 A 2007 Memorandum of Understanding provides for detailed PHS officers to serve within DHS. 

Management of Mental Health Cases in Immigration Detention 

Page 3 
Develop a single, integrated medical system across the 

national network of detention facilities, 

Classify detainees based on medical need and assign them 

to appropriately staffed and equipped facilities, and 

Discontinue the use of segregation cells for medical 

isolation or observation. 

Since October 2009, ICE has implemented the following reforms: 

Hired and placed detention service managers in field 

positions, 

Piloted a medical classification system for detained aliens, 

Revised detention standards, known as Performance Based 

National Detention Standards 2010, and 

Established a medical advisory group. 

Mental health services from an outside provider require IHSC 

approval. Field personnel submit treatment authorization requests 

to ensure that outside visits are approved and cleared for payment. 

While field-based clinical directors may approve most treatment 

authorization requests, those for mental health treatment require 

headquarters’ review and approval. In emergency situations, 

treatment authorization requests may be submitted after treatment 

has been provided. IHSC has developed a new referral processing 

and approval system called the Medical Payment and 

Authorization Request System to replace the treatment 

authorization request process. This system is intended to 

decentralize processing and approval of treatment requests 

submitted by providers when treatment is deemed medically 

necessary. 

Mental Health Care and Immigration Detention Reform 

In October 2009, ICE’s Office of Detention Policy and Planning 

(ODPP) completed a report on immigration detention that included 

recommendations to guide reform efforts as follows: 

In June 2010, ICE’s Office of Professional Responsibility also 

completed a congressionally mandated review of the detention 

healthcare system. The review issued additional recommendations 

to improve detainee healthcare throughout ICE as follows: 

Management of Mental Health Cases in Immigration Detention 

Page 4 
 Station medical personnel in detention facilities to help 

provide additional oversight, 

 Establish and disseminate guidance about medical 

personnel staffing models for various types of facilities 

housing ICE detainees, 

 Enforce the requirement to name a clinical or 

administrative authority at every facility, and 

 Develop a standardized medical transfer form and include a 

medical standard that specifies what information should be 

included in the medical transfer form. 

Results of Review 

IHSC’s Oversight as ICE’s Medical Authority Needs to Extend to 

All Facilities Providing Health Care for ICE Detainees 

IHSC is designated as the medical authority for ICE. In this role, IHSC 

provides primary health care for detainees housed in IHSC-staffed 

detention centers and oversees the financial authorization and payment for 

off-site specialty and emergency care for detainees in ICE custody. 

However, we observed inconsistencies in the way IHSC oversight was 

exercised between IHSC-staffed facilities and those facilities without an 

IHSC presence on site. Specifically, oversight exercised by IHSC at nonIHSC staffed facilities does not provide ICE with a means for (1) 

maintaining statistics on the overall population of detainees with mental 

health conditions, (2) updating the mental health status of detainees and 

related treatments, and (3) maintaining an awareness of the level of care 

that each facility can provide. 

In the absence of such information, ICE’s ability to monitor the overall 

status of ICE detainees with mental illnesses is hindered. Maintaining a 

broad-based knowledge of information regarding detainees’ mental health 

status would assist ICE in making well-informed decisions regarding (1) 

the allocation of health care resources needed for an appropriate level of 

care, and (2) the ability of each facility to provide specific care. 

IHSC has clinical staff at 18 of the approximately 250 immigration 

detention centers nationwide, though an October 2009 ICE report, entitled 

Immigration Detention Overview and Recommendations, showed that 

IHSC-staffed facilities detain approximately half of the ICE detainees.4 

4

 http://www.ice.gov/doclib/about/offices/odpp/pdf/ice-detention-rpt.pdf 

Management of Mental Health Cases in Immigration Detention 

Page 5 
IHSC is able to monitor and track the condition and treatment provided to 

detainees with mental disabilities at IHSC-staffed detention facilities. In 

August 2010, ICE reported 1,496 mental health patients in IHSC-staffed 

detention centers. However, ICE was unable to provide comparable 

information for mentally ill detainees in non-IHSC staffed facilities since 

such data is not tracked or maintained. 

IHSC headquarters has limited tools for monitoring mental health care in 

facilities that are not staffed with IHSC personnel. These include: 

 Treatment authorization requests - IHSC headquarters reviews and 

approves requests for mental health care; however, these only alert 

the division to cases requiring treatment outside of a detention 

facility and are largely used to approve and ensure payment. 

 ICE’s Health Benefits Package - Revised in FY 2010, ICE’s benefits 

package outlines what the agency will pay for outside care as 

required and provides direction to all outside facilities that must 

provide mental health care to detainees. 

 Significant Illness Reports - Reports filed with ICE through IHSC 

summarize critical cases of mental illness that tend to be acute or 

require hospitalization. These depend, however, on the ability of 

field personnel to recognize a problem and bring it to headquarters’ 

attention for discussion and monitoring. 

These sources provide IHSC with information on cases of mental illness 

which tend to be acute and require hospitalization. However, IHSC does 

not receive any information regarding detainee cases that may not require 

intensive treatment. Therefore, the mental health conditions and care of 

ICE’s detainee population, as a whole, cannot be fully monitored by 

IHSC. These types of information could be used by ICE as part of efforts 

to ensure an appropriate level of oversight for mentally ill detainees. 

In FY 2010, ICE’s Office of Professional Responsibility’s report on 

medical care in detention recommended that ICE station medical 

personnel in detention facilities to help provide additional oversight. To 

ensure an appropriate level of oversight, ICE needs to define the specific 

responsibilities that will allow IHSC to increase oversight of mental health 

cases. 

Recommendation 

We recommend that Immigration and Customs Enforcement: 

Management of Mental Health Cases in Immigration Detention 

Page 6 
Recommendation #1: Establish and implement IHSC’s role in 

monitoring and providing oversight to all ICE detention facilities. 

At a minimum, this should include IHSC’s responsibility for 

monitoring and tracking the mental health condition of ICE’s 

detained population. 

Management Comments and OIG Analysis 

We evaluated ICE’s written comments and have made changes to the 

report where we deem appropriate. A summary of ICE’s written 

responses to our recommendations and our analysis of the responses 

follow each recommendation. A copy of ICE’s response, in its 

entirety, appears in Appendix B. 

ICE Response: ICE concurred with Recommendation #1. 

Division of Immigration Health Services, now called ICE Health 

Service Corps (IHSC), has already established new Field Case 

Manager positions to provide medically-related consultation to 

each of the 24 Enforcement and Removal Operations Field Office 

Directors and monitor care provided to detainees in non-IHSC 

staffed facilities, with particular emphasis on mental health issues. 

As of December 1, 2010, IHSC has assigned Field Case Managers 

to 12 Enforcement and Removal Operations Field Offices to 

provide critical support and is recruiting to fill the remaining 12 

Field Offices in FY 2011. 

OIG Analysis: This recommendation is resolved and open 

pending our receipt of documentation showing the specific duties 

and responsibilities of the newly established Field Case Manager 

positions, and ICE’s completion of the recruitment and assignment 

of the 24 Field Case Managers. 

Reducing Staffing Shortages Can Improve the Mental Health 

Care Environment 

IHSC employs psychiatrists, psychologists, and social workers 

who work together to diagnose mental illnesses, prescribe 

medications, provide counseling, and evaluate mental health 

patients’ progress. However, because of ICE’s inability to attract 

and retain clinicians, there is less assurance that ICE has sufficient 

staff to provide an appropriate level of mental health care. 

Management of Mental Health Cases in Immigration Detention 

Page 7 
Vacancies in Mental Health Positions 

Since 2008, vacancies for mental health positions across IHSCstaffed facilities have ranged from 21% to 47%. In January 2008, 

IHSC had 36 mental health positions, of which 17, or 47%, were 

vacant. IHSC has added mental health positions over the past two 

years, for a total of 63 positions in August 2010, of which 26 

positions, or 41%, were vacant. 

Figure 2: IHSC Mental Health Position Vacancy Rates 

Source: IHSC Staffing Rosters 

IHSC officials from headquarters and field locations cited staffing 

shortages as a critical challenge. In addition, health service 

administrators and clinical directors throughout IHSC expressed 

the need for more mental health providers. 

As of August 2010, vacancy rates at 11 of the 18 facilities staffed 

with IHSC employees were 50% or higher. For specific positions 

across IHSC, vacancy rates were 46% for psychiatrists, with 6 of 

13 positions unfilled; 37% for psychologists, with 7 of 19 positions 

unfilled; and 42% of social workers, with 13 of 31 positions 

unfilled. 

IHSC administrators and clinicians expressed concern about the 

effectiveness of provider care with the extent of existing vacancies. 

Vacant positions burden not only existing mental health staff, but 

also non-mental health staff who assume duties that may extend 

beyond their areas of expertise. For example, IHSC officials said 

that facilities without a psychiatrist must rely on other medical 

professionals qualified to prescribe any medications, even though 

they may not be knowledgeable of specific psychiatric 

Management of Mental Health Cases in Immigration Detention 

Page 8 
medications. According to some IHSC staff, insufficient mental 

health staff increases their reliance on community providers who 

can offer limited time to accommodate mental health patients. 

Vacant IHSC clinical director positions also result in clinical 

oversight and administrative duties being performed by existing 

staff, or a clinical director located at another facility. As a medical 

doctor, the clinical director supervises clinical operations and staff, 

including mental health providers, and prescribes medications. As 

of August 2010, nine of 18 clinical director positions were vacant. 

Three health service administrators noted that the clinical director 

position at each of their facilities has been vacant for several years. 

Barriers to Minimizing Staffing Shortages 

IHSC officials cited several contributing factors for staffing 

challenges, including a competitive job market for mental health 

providers, remote location of facilities, administrative processing 

delays, and low employee morale. 

 Competition for mental health providers - High demand in 

public and private sectors for mental health professionals 

affects IHSC’s ability to recruit and retain providers. 

 Non-competitive salaries - IHSC’s inability to offer 

competitive salaries, especially for psychiatrist positions, 

was cited as a reason for hiring difficulties. 

 Undesirable locations - Some detention facilities are located 

in rural and remote locations where candidates do not want 

to relocate. 

 Administrative delays - An often lengthy security clearance 

process at ICE discourages candidates from waiting for an 

offer, especially when applicants receive other offers. 

Several PHS officers said that required credit checks 

eliminate qualified candidates, which mostly impacts 

facilities in remote, rural locations, with fewer medical 

professionals. 

Also, the recently-enacted Patient Protection and Affordable Care 

Act eliminated the limit on commissioned corps officers,5

 and 

deemed all PHS Reserve Corps officers on active duty to be 

commissioned officers of the Regular Corps, which expanded the 

5

 Section 5209, Patient Protection and Affordable Care Act, Public Law 111-148, March 23, 2010. Section 

5209 is codified at 42 U.S.C. § 238f note. 

Management of Mental Health Cases in Immigration Detention 

Page 9 
ranks of active duty PHS officers.6 Officers of the Regular Corps 

must be appointed to their positions by the President with the 

advice and consent of the U.S. Senate.7 However, these 

appointments have not occurred to date; therefore, new PHS 

officers cannot be hired. 

 Low morale - Staff expressed dedication to the IHSC 

mission, but cited low morale when asked about staffing 

problems. Some officers said that IHSC’s reputation has 

suffered due to constantly changing or absent leadership, and 

a lack of direction. Since 2007, IHSC had nine acting or 

permanent directors. 

Because of staffing shortages and persistent vacancies, IHSC has 

continued to recruit and hire to address staffing concerns. IHSC 

has also temporarily transferred mental health staff to facilities 

needing mental health providers, and named a new acting director. 

IHSC had also used the Assignment Incentive Pay Program, which 

paid a premium to certain types of providers accepting positions, 

including mental health providers, at specific IHSC locations that 

have difficulties attracting staff. While the plan was successful for 

those who applied and qualified, only $236,000 of the allotted 

$1,053,000 was spent, and the program has been discontinued. 

Recommendation 

We recommend that Immigration and Customs Enforcement: 

Recommendation #2: Prioritize hiring a permanent director and 

mental health staff. This should include maximizing the use of 

available hiring incentives, and minimizing processing delays to 

the extent practicable. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #2. 

Interviews for a permanent Senior Executive Service Director have 

been completed and final selection is pending. However, remote 

geographic locations impact IHSC's ability to recruit or retain 

qualified staff at certain facilities, particularly psychiatrists. To 

6

 Section 5210, Patient Protection and Affordable Care Act. This particular provision is codified at 42 

U.S.C. § 203(b). 7

 42 U.S.C. 203(a)(3). 

Management of Mental Health Cases in Immigration Detention 

Page 10 
mitigate this problem, IHSC is exploring the use of Title 38 

authority and partnering with the Veteran's Administration to help 

fill vacancies. 

OIG Analysis: This recommendation is resolved and open 

pending (1) the selection and hiring of a permanent director, and 

(2) the outcome of IHSC’s use of available hiring tools including 

efforts to determine whether Title 38 and partnering with the 

Veterans Administration can be used to fill mental health staffing 

vacancies. 

ICE Needs to Establish Staffing Models for Managing Mental 

Health Care Needs 

In our 2008 report, entitled ICE Policies Related to Detainee 

Deaths and the Oversight of Immigration Detention Facilities, we 

stressed the importance of aligning clinical staffing with ICE 

strategic planning for detention management.8 However, ICE has 

not established an allocation plan that aligns staffing with the 

detention facilities’ mental health case load. Without such staffing 

allocation plan, ICE cannot be assured of each facility’s ability to 

provide detainees with an acceptable level of health care. 

Mental health staff at facilities also commented that the standard 

for staffing plans should be aligned with the workload of each 

facility, the number of patients requiring medical services, and 

available bed space at each facility. While ICE does not have a 

standard definition for a mental health team, one clinical director 

identified a psychiatrist, psychologist, and social worker as key 

members of such team. 

Of the 18 IHSC-staffed facilities, 11 facilities were allocated 

positions for a minimum of one psychiatrist, psychologist, and 

social worker. However, the remaining seven facilities were not 

allocated at least one position for each of these disciplines. Three 

of the seven facilities were allocated one social worker position, 

even though two of these facilities housed 76 and 59 mentally ill 

detainees, respectively. 

However, there are facilities that receive ICE detainees with 

chronic mental illnesses who may require hospitalization or forced 

medication. For these facilities, we identified variances in mental 

8 http://www.dhs.gov/xoig/assets/mgmtrpts/OIG 08-52 Jun08.pdf . 

Management of Mental Health Cases in Immigration Detention 

Page 11 
health providers to mentally ill detainees that ranged from a ratio 

of 1:8 to a ratio of 1:53. 

Demands of mental health patients can vary significantly and 

staffing ratios cannot solely determine an optimum staffing level. 

IHSC administrators and clinicians said that even a small number 

of detainees with mental illnesses can demand significant time and 

attention for treatment based on the type of mental illness. This 

emphasizes the need for a staffing allocation plan aligned with 

mental health caseloads, and a baseline number of providers to 

determine the necessary mental health care for detainees. 

Recommendation 

We recommend that Immigration and Customs Enforcement: 

Recommendation #3: Establish and implement a system that 

aligns staffing levels at each facility with their respective mental 

health caseload. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #3. 

ICE has already begun to analyze appropriate staffing internally, 

and implemented a system to align staffing levels through 

submission and action of the priority staffing plan. Once analysis 

and approval of the staffing plan are complete, IHSC will fully 

implement realignment based on each facilities mental health 

caseload. Full implementation of the priority staffing plan is 

currently subject to available funding. 

OIG Analysis: This recommendation is resolved and open 

pending completion of the analysis, approval, and implementation 

of the staffing plan. 

Space Limitations and Remote Locations May Reduce the 

Effectiveness of Mental Health Care 

Detainees with acute mental illness or suicidal tendencies may 

require treatment that includes on-going clinical attention, 

separation from other detainees, and either periodic or constant 

observation. To assist with these needs, short stay units provide an 

environment for continuous health care, as well as medical 

Management of Mental Health Cases in Immigration Detention 

Page 12 
isolation for mentally ill detainees who are at risk for violent or 

suicidal behavior. 

Psychiatric hospitals and private practitioners can provide services 

for detainees requiring specialized care and treatment for mental 

illnesses. However, in certain locations, the access and availability 

of these services is limited. Without appropriate treatment areas, 

mental health care providers have limited options for providing 

care to detainees with mental illnesses. 

Structure of Detention Facilities Needs to Facilitate Mental 

Health Care Treatment 

ICE detention facilities should include appropriate areas for 

treating detainees with specific mental health needs. Of the eight 

ICE detention facilities we visited, four facilities did not have short 

stay units, but were treating between 46 and 226 detainees with 

mental health diagnoses, including those who needed to be 

separated from the other detainees. 

The short stay units that we observed contained two to four beds. 

One facility had ten beds in four short stay units for mentally ill 

detainees. However, this situation does not accommodate a 

detainee whose condition requires isolation from other detainees. 

Three facilities that we visited had short stay units with single cell 

rooms, although in most cases, isolation rooms were primarily 

used for tuberculosis patients. One of these facilities had isolation 

rooms not dedicated to tuberculosis cases, and one facility had a 

padded room. 

At facilities with short stay units, IHSC staff expressed concern 

regarding the volume of mental health cases in comparison to the 

capacity of the medical units, and a shortage of short stay units and 

padded rooms. One health service administrator said the medical 

unit had a short stay unit, but only one of three medical cells was 

available since two were used for storage and a medical laboratory. 

In addition, four facilities that we visited did not have single cell 

rooms or padded cells that could be used for mental health 

observations or suicide watches. 

Use of Transitional Pods: One facility that did not have a short 

stay unit used smaller pods housing several detainees for some 

mental health patients. The pods helped mentally ill detainees 

needing supervision transition from isolation to general 

population. 

Management of Mental Health Cases in Immigration Detention 

Page 13 
Based on telephone interviews with officials at 11 IHSC-staffed 

facilities, three of the facilities did not have short stay units even 

though they housed several detainees with mental health conditions 

that required separation, isolation, or in some cases periodic 

hospitalization. Four of the eleven facilities did not have single 

cells, and six did not have padded rooms to accommodate mental 

health care needs. 

IHSC providers expressed concern that the absence of a 

therapeutic, non-punitive environment interferes with mental 

health care, and limits their ability to stabilize detainees with 

serious mental illnesses. Without areas to care for detainees 

requiring suicide watch rooms or other special needs, clinicians 

must provide treatment in environments that may not foster 

improvements in mental health conditions. Treatments under such 

conditions have resulted in cases where symptoms have been 

exacerbated. 

Segregation Cells Used for Mentally Ill and Suicide Watch 

In some facilities that do not have short stay units or sufficient 

medical isolation rooms, special management units were used to 

house detainees with serious mental illnesses. 

Special Management Units, commonly known as segregation, 

are typically used as a disciplinary measure, or for 

administrative purposes such as protective custody. They are 

called special housing units in some facilities. 

ICE’s Performance Based National Detention Standards allow 

placement in administrative segregation for detainees who require 

separation for medical reasons. However, an October 2009 ODPP 

report noted that segregation is “not conducive to recovery” and 

recommended that ICE stop using segregation cells for medical 

isolation or observation. 

Four of the eight ICE detention facilities we visited did not have 

short stay units and used special management units for housing 

mentally ill detainees, and conducting suicide watch and mental 

health observations. One additional facility that had a short stay 

unit also housed detainees on suicide watch in special management 

units. Those with limited or no short stay unit space used the 

special management units for housing mentally ill detainees 

needing separation or for overflow once short stay units were full. 

Management of Mental Health Cases in Immigration Detention 

Page 14 
Advocacy groups and researchers have related concerns that 

segregation can exacerbate mental illnesses. In addition, mental 

health care providers at ICE facilities we visited provided the 

following comments regarding special management units: 

 Segregation is never an appropriate setting for long-term 

placement of mentally ill detainees. 

 Segregation often exacerbates mental illness and is 

counterproductive to the goal of stabilizing a detainee. 

 Segregation is not a good environment for those with 

mental health concerns because detainees reported 

increased levels of depression and anxiety when held in a 

short stay unit. 

 It is not possible to make segregation into a therapeutic 

setting in which a mentally ill detainee’s condition would 

improve. 

 Special management units should only be used at the 

detainee’s request, or for short periods when these units are 

the only option. 

 A detainee’s placement in special management units for 

more than 24 hours warrants an immediate evaluation by 

the facility’s psychiatric consultant, who should consider 

hospitalizing the detainee. 

In addition to potential negative effects on a detainees’ mental 

health, special management units may pose several additional 

challenges. 

 They are often separate from the facility’s medical unit and 

are not immediately accessible to medical staff. 

 Some do not have a continuous medical presence, though 

medical providers told us that they visit the segregation 

units at least daily to check the status of mentally ill 

detainees. 

 They are often controlled by correctional staff rather than 

medical personnel, which creates additional layers of 

security required for disciplinary cases, but not needed for 

mental health cases. In one facility, for example, a health 

service administrator said procedures for opening cells of a 

Management of Mental Health Cases in Immigration Detention 

Page 15 
special management unit can delay care to a detainee 

needing treatment. 

Detention Facility Locations Limit Access to Community 


Mental Health Care 


ICE’s Performance Based National Detention Standards require 

facilities to identify and make available mental health crisis 

intervention services for detainees experiencing acute mental 

health episodes. Facilities must directly or contractually provide 

detainees with necessary hospitalization in the local community. 

While ICE can easily access community mental health care in 

some locations, other facilities with significant mental health cases 

do not have access to community mental health providers. 

Off-site consultants provide mental health services to detainees 

whose needs cannot be addressed by mental health providers at 

detention facilities. In addition, hospitalization may be required 

when mentally ill detainees’ symptoms require in-patient care. 

Among the eight facilities that we visited, community hospitals for 

ICE detainees were readily available to four facilities, with one 

facility having access to four nearby hospitals. However, the 

remaining four facilities that did not have short stay units relied on 

segregation areas for serious mental health cases. Detainees at 

these facilities also had limited access to off-site consultants and 

mental health hospitals. Three of the facilities were located 40 to 

60 miles from the nearest hospital, where sending detainees to the 

emergency room was the only option available. 

Access to community mental health providers is generally more 

available in urban areas. Alternatively, as an Enforcement and 

Removal Operations manager acknowledged, detention facilities 

with limited access to community providers tend to be located in 

remote areas with minimal local infrastructure. 

IHSC staff from ICE facilities with access to mental health 

resources attributed some of their success for stabilizing seriously 

ill mental health patients to their proximity to community 

resources. An IHSC clinician at one of these facilities said that 

access to four community hospitals enables the facility to provide 

care to patients requiring more specialized treatment. Another 

IHSC clinician said that each detention facility should have a 

process for accessing a psychiatric hospital, adding that if there is 

no ability to move psychotic patients to a hospital setting, it is not 

feasible to give them proper treatment options. 

Management of Mental Health Cases in Immigration Detention 

Page 16 
Relationships with Community Providers Can be Strengthened 

Several detention facilities’ access to community providers was 

limited by local hospitals’ reluctance to accept immigration 

detainees. At one facility, an official said that a local hospital had 

responded by saying that hospitals are mostly for county inmates, 

not ICE detainees. Several officials said that hospitals were not 

willing to take ICE detainees, one of them adding that the hospital 

voiced concerns about detainees appearing in the waiting area in 

shackles and prison uniforms and scaring or intimidating other 

patients. The official added that when IHSC sends mental health 

patients to local hospitals, the hospitals send them right back. 

Late payments for services may risk relationships with community 

providers. IHSC staff and community providers noted that 

payments for medical services by ICE are sometimes late. Staff 

that we spoke with at one facility anticipated that ICE payments 

would be late. Two IHSC officials expressed concern that late 

payments will result in future services being refused. 

An IHSC manager told us that ICE’s contracts with local providers 

have expired and were not renewed. ICE may not require contracts 

with every mental health service provider, and facilities have 

cultivated good relationships in some areas. However, contracts 

can help to ensure continued service over extended periods of time, 

and establish mutually agreeable terms under which ICE patients 

will be admitted to hospitals. 

Conclusion 

The availability of treatment areas within detention facilities, along 

with accessible community providers, is significant in the wellbeing of detainees with mental health conditions. ICE needs to 

minimize the risk of reversing any improvements in detainees’ 

mental health capacity, which could result in prolonged detention. 

Management of Mental Health Cases in Immigration Detention 


Page 17 

Recommendations 

We recommend that Immigration and Customs Enforcement: 

Recommendation #4: Place detainees with mental illnesses in 

facilities that have necessary space and resources available to 

provide needed services. At a minimum, such facilities should 

maintain appropriate areas for specialized treatment, and be 

accessible to community providers. 

Recommendation #5: Establish time limits for holding mentally 

ill detainees in segregation outside of medical units, and identify 

recourses for detention facilities when segregated detainees are 

approaching set time limits. 

Recommendation #6: Establish procedures for timely evaluating 

and transferring detainees requiring separation or isolation for 

mental health conditions, but who are in facilities that cannot 

accommodate such needs. 

Recommendation #7: Identify detention facility sites with 

minimal or no community resources, and develop IHSC mental 

health resources as needed to ensure the availability of proper care. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #4. 

IHSC and Enforcement and Removal Operations Field Offices 

have conducted an initial analysis of IHSC and non-IHSC staffed 

facilities to identify detainees with active acute or sub-acute 

diagnosis. Once this analysis has been finalized, IHSC and 

Enforcement and Removal Operations Headquarters Field 

Operations will provide recommendations regarding appropriate 

placement based on availability of care. Prospectively, IHSC and 

Enforcement and Removal Operations Headquarters Field 

Operations are currently developing a process to identify and 

report detainees with acute or sub-acute diagnosis. This report and 

tracking system will focus on identifying the patient's mental 

health needs and placing them in a facility consistent with 

providing the best possible care based on their mental health 

diagnosis and clinical needs. IHSC has taken steps to increase 

access to available mental health resources and facilities 

throughout the country. 

Management of Mental Health Cases in Immigration Detention 

Page 18 
OIG Analysis: This recommendation is resolved and open 

pending completion of (1) the analysis of all facilities to identify 

detainees with active acute or sub-acute diagnosis, and (2) the 

implementation of a process to identify, track, and appropriately 

place detainees with a mental health diagnosis. 

ICE Response: ICE concurred with Recommendation #5. 

Detainees with mental health issues housed in segregation units 

outside of medical units are reassessed by appropriate health care 

personnel on a daily basis. Any modifications in treatment and 

conditions of confinement are made at that time, if appropriate. 

IHSC is completing the Medical Classification System, which will 

also address this recommendation regarding identifying and 

placing detainees based on medical and mental health need and 

diagnosis. The Medical Classification System is comprised of two 

components: identification of detainee health care needs and 

identification of health care resources available in detention 

facilities, to include immediate outside health care surrounding the 

facility. Detainee placement will be contingent upon detainee 

needs and resources available at or near the facility. ICE will 

review industry standards and consult health care authorities to 

establish time limits for holding mentally ill detainees in 

segregation. 

OIG Analysis: This recommendation is resolved and open 

pending (1) IHSC’s implementation of the Medical Classification 

System, and (2) the establishment of time limits for holding 

mentally ill detainees in segregation outside of medical units. 

ICE Response: ICE concurred with Recommendation #6. 

IHSC will establish procedures to identify detainees with mental 

health conditions requiring transfer to appropriate ICE facilities or 

to contracted care facilities. Enforcement and Removal Operations 

will consider IHSC's recommendation and, coupled with 

conditions of confinement, make a decision on the best location to 

house the detainee to provide appropriate care. ICE will 

incorporate this requirement in the new Medical Classification 

System, which will identify the type of services available at each 

of ICE's facilities. 

OIG Analysis: This recommendation is resolved and open 

pending implementation of the Medical Classification System that 

includes this requirement. 

Management of Mental Health Cases in Immigration Detention 

Page 19 
ICE Response: ICE concurred with Recommendation #7. 

Development and implementation of the aforementioned Medical 

Classification System will address this recommendation. 

OIG Analysis: This recommendation is resolved and open 

pending ICE’s implementation of the Medical Classification 

System. 

Facility Designations Should Be a Factor in Resource Allocation 

and Planning 

Developing a classification system for immigration detention centers 

based on mental health care capabilities can provide a more effective 

means of allocating resources and placing detainees in facilities that can 

offer an appropriate level of mental health care. At the time of our 

fieldwork, ICE had introduced a pilot classification system for detainees’ 

health status, but not for detention facilities. 

Formally designating the capability of IHSC-staffed facilities to treat 

detainees with mental illnesses allows management to prioritize staffing 

and mental health resources. However, a process to ensure that detainees 

are placed in facilities with resources commensurate with their assessed 

needs has not been established. 

An example provided by IHSC officials to convey the need for facility 

designations was that more challenging mental health cases were being 

transferred to two specific facilities. However, these facilities were not 

officially designated as mental health care facilities. 

Some Enforcement and Removal Operations staff at these facilities 

recognized increases in mental health case transfers, but were uncertain as 

to why their facility had been designated to receive these types of cases. 

Detention and removal officers and medical personnel expressed a desire 

for a clearer understanding of how facilities were viewed with respect to 

handling mentally ill detainees, especially those requiring more focused 

attention. 

Facility designations would allow ICE to align the capability of each 

facility with the detainees’ health care needs, and provide required levels 

of care. As a result, ICE would benefit from a well-managed health care 

system for detainees requiring various levels of mental health care 

treatment. 

Management of Mental Health Cases in Immigration Detention 

Page 20 
Recommendation 

We recommend that Immigration and Customs Enforcement: 

Recommendation #8: Establish a classification system for 

detention facilities that takes into consideration the facilities’ 

ability to handle detainees with varying mental health needs. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #8. 

Current procedures match the capabilities of IHSC-staffed 

facilities with patient needs. The Medical Classification System, 

as explained in response to recommendation 5, is in the final stages 

of development, and when implemented, will further expand this 

capability to include available intergovernmental services 

agreement resources. 

OIG Analysis: This recommendation is resolved and open 

pending implementation of the Medical Classification System. 

Additional Information Can Provide Assistance in Determining 

Detainees’ Mental Health Care Needs 

Mentally ill aliens enter ICE custody through either direct apprehension by 

ICE or Customs and Border Protection (CBP), or ICE programs that 

identify those already held in local, state, and federal jails and prisons. 

Enforcement and Removal Operations determines whether and where to 

detain an individual and transfers detainees among its detention facilities. 

Medical personnel use intake screenings to identify incoming detainees’ 

mental health concerns and make referrals to mental health providers. 

However, information that could provide assistance with the intake and 

transfers of mentally ill detainees is not always obtained. 

Intake Process Should Expand Data Collection Requirements 

ICE policy advises field officers to use discretion when 

apprehending aliens with a severe medical or psychiatric condition 

that would make detention problematic and removal highly 

unlikely. As aliens enter ICE custody, the agency identifies or 

documents any mental health concerns as follows: 

Management of Mental Health Cases in Immigration Detention 

Page 21 
 An apprehending officer or agent documents information 

regarding an alien’s mental state, usually on Form I-213, 

Record of Deportable Alien/Inadmissible Alien, used to record 

an encounter with an alien. 

 Mental health records from a non-ICE detention center or 

institution may be considered, if available, and 

 Intake screenings are conducted by medical staff at the ICE 

detention center. 

Officers’ notes on Form I-213 can identify a detainee’s potential 

mental health condition and medication. However, this is an 

informal method for identifying detainees with mental health 

concerns because mentally ill individuals can be difficult or 

impossible to identify, and apprehending officers may not be 

trained to recognize signs of mental illness. Only 10 of 85 A-files 

we reviewed for detainees with mental illnesses had apprehending 

officers’ notes related to their mental health observations. 

Mental health records from a non-ICE detention center or 

institution are more reliable than Form I-213. However, medical 

staff in ICE detention facilities cannot always obtain these records 

for several reasons: 

Records are not requested. In some cases, ICE does not 

obtain the detainee’s medical records before he or she arrives 

because ICE officers do not ask for health information. One 

medical administrator said that apprehension officers could be 

better trained and do not always understand how the 

apprehension of mentally ill detainees affects the agency. 

Requests for records are refused. After detainees arrive, 

clinical staff at an ICE facility request medical records. 

However, local jails or prisons transferring individuals into 

ICE custody refuse to release medical information due to 

privacy concerns. 

ICE cannot demand mental health records from non-ICE facilities. 

However, ICE staff noted that efforts by some health service 

administrators and clinical directors to develop relationships with 

local facilities have helped encourage them to submit medical 

information for incoming detainees. 

The absence of a detainees’ prior mental health information can 

result in an impediment to continuity of care. In addition, mental 

Management of Mental Health Cases in Immigration Detention 

Page 22 
health providers must be more dependent on a detainee’s 

willingness and ability to accurately report on their health 

condition and related medications for use in making health care 

decisions. 

Additional Data Collection Could Facilitate Mental Health 

Diagnosis and Treatment 

ICE’s October 2009 ODPP report stated that ICE screening 

methods did not lend themselves to early identification and 

intervention for detainees with mental health concerns. The types 

of information collected during mental health screening varied 

between non-IHSC facilities and IHSC-staffed facilities. The 

following represents examples of information obtained to facilitate 

mental health care treatment. 

 Personal Information: Intake screening at one detention 

facility we visited considers detainees’ answers to questions 

about their personal circumstances and family history in the 

context of mental health. This approach was preferred by the 

facility’s medical staff over IHSC’s form and medical staff 

re-screened detainees already screened by IHSC. 

 Criminal History: Several clinicians mentioned the value 

of knowing a mentally ill detainee’s criminal history, which 

is not included on IHSC’ screening form. A questionnaire at 

a contract detention facility inquired about a detainee’s 

history of violence and criminal history. We were told that 

the questions pertaining to criminal history are included to 

maintain American Correctional Association accreditation. 

According to health care providers, including questions 

about a detainee’s criminal history and violent behavior can 

help in some cases to tend to identify mental illness and 

inform providers’ diagnosis. While ICE gathers detainees’ 

criminal charges, it is not included in their medical files. 

Conclusion 

As ICE apprehends more aliens from local and state jails and 

prisons, its ability to obtain mental health information from nonICE facilities becomes increasingly important. Ensuring that 

apprehending officers make appropriate and timely requests for 

mental health records from local and state institutions can increase 

the likelihood that facilities will comply. Also, by routinely 

collecting data from a broader spectrum of alternate sources, 

Management of Mental Health Cases in Immigration Detention 

Page 23 
clinicians could prepare a more complete assessment of detainees’ 

mental health conditions. 

Recommendations 

We recommend that Immigration and Customs Enforcement: 

Recommendation #9: Direct field offices to request mental health 

information for incarcerated aliens before they arrive in detention, 

and establish a requirement for sending the information to medical 

personnel before detainees arrive in ICE detention. 

Recommendation #10: Identify additional data that could be 

collected as part of the mental health screening process that would 

assist in determining the health history and treatment needed for 

incoming detainees with mental illnesses. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #9 to the 

extent operationally viable. 

ICE believes that a few issues must be considered prior to 

implementing this recommendation. As noted in the Draft Report, 

some jails and prisons will not release medical or mental health 

information prior to transfer of aliens into ICE custody. ICE lacks 

the authority to demand such information from non ICE-owned 

facilities. However, IHSC liaison may bridge this gap. Also, there 

are large numbers of aliens transferred into ICE custody where 

there is insufficient time to access the mental health information 

prior to the alien entering ICE custody. 

ICE will create a policy requiring ICE officers to request 

medical/mental information before they arrive in ICE detention. 

This policy will contain the following protocols: 

 In cases where medical reports indicate significant mental 

health issues, Field Office Directors will be required to 

notify Headquarters IHSC prior to accepting the alien into 

ICE custody. 

 Within 24 hours of receiving requests, IHSC Field Case 

Managers will provide the Field Office Director with (1) 

assessments of whether ICE has the resources to properly 

Management of Mental Health Cases in Immigration Detention 

Page 24 
house aliens, and (2) the facility aliens should be detained 

based on clinical need. 

 The Field Office Directors will be reminded to exercise 

prosecutorial discretion and cancel immigration detainers 

or elevate cases to Enforcement and Removal Operations 

Headquarters when necessary, and as appropriate. 

OIG Analysis: This recommendation is resolved and open 

pending the establishment and implementation of new policy 

protocols for field offices to request mental health information for 

incarcerated detainee, and send to medical personnel before 

detainees arrive in detention. 

ICE Response: ICE concurred with Recommendation #10. 

IHSC is in the process of revising IHSC Form 795A, Intake 

Screening Form, to include additional information that would 

assist in determining the health history and treatment needed for 

incoming detainees with mental illnesses. The form is currently 

being routed through the approval process, and should be fully 

implemented soon. 

OIG Analysis: This recommendation is resolved and open 

pending implementation of the new intake form. 

ICE Needs to Designate Decision-making Responsibility for 

Transferring Mentally Ill Detainees 

ICE field offices maintain responsibility for coordinating detainee 

transfers. Coordination and interaction among medical personnel, 

detention facility staff, attorneys, and ICE headquarters affects the 

detention facilities’ ability to transfer a detainee for mental health reasons. 

Clarification regarding the responsibility for approving mental health 

transfers and identifying facilities to send detainees is needed among ICE 

and IHSC personnel at headquarters and in the field. 

Specific responsibility for making the final decision regarding transfers 

and placement has not been assigned. As a result, significant delays have 

occurred in transfers for mentally ill detainees, as decisions are being 

made in the absence of a process or a designated decision-making official. 

At many facilities operating under an intergovernmental services 

agreement, ICE officers do not have local IHSC staff to help evaluate 

mental health cases, and make expedient decisions regarding their 

Management of Mental Health Cases in Immigration Detention 

Page 25 
placement. In one intergovernmental services agreement facility that we 

visited, IHSC staff assigned to the facility could not assist ICE with case 

management because that IHSC team was only responsible for screening, 

and could not advise ICE on transfers. 

The Performance Based National Detention Standards instruct field offices 

to coordinate transfers, and only involve headquarters as a last resort. 

Without any form of oversight or intermediary, an Enforcement and 

Removal Operations field office can deny any request from another 

Enforcement and Removal Operations field office to transfer a mentally ill 

detainee. ICE staff reported that Enforcement and Removal Operations 

field offices were not always willing to receive mental health transfers 

since the detention, removal, or release of mentally ill detainees can be 

very complicated and difficult to manage. 

IHSC officials explained that transfers for medical or mental health 

reasons can take weeks or months to coordinate with medical and ICE 

staff to find available space. In more serious cases, IHSC administrators 

and clinicians said that ICE risks detainees deteriorating when the 

detainees are not transferred to facilities that are able to provide needed 

medical services. Also, when the time frame for arranging the transfer is 

extensive, detainees who are cleared and ready for transfer may 

decompensate, and require treatment at a local emergency room. 

To facilitate the timely transfer of detainees, ICE should designate a 

central authority with primary responsibility for detainee transfer 

decisions. Such actions would encourage a more cohesive relationship 

among field offices regarding the transfer of detainees. In addition, it 

would also minimize delays in the transfer process that could otherwise 

result in diminished mental health care for detainees. 

In FY 2010, ICE’s Office of Professional Responsibility recommended 

that ICE station medical personnel in detention facilities to help provide 

additional oversight. Such a move would support IHSC’s position as 

ICE’s medical authority and help it acquire greater oversight for individual 

mental health cases. Also, an ICE official suggested centralizing authority 

for making decisions regarding detainee transfers, to limit field offices 

ability to refuse to accept a detainee based on the facility requesting the 

transfer. 

Information Sharing for Internal Transfers Can Improve 

Effective information sharing among ICE facilities helps ensure 

continuity of care. ICE’s Performance Based National Detention 

Standards prescribe notification and coordination procedures 

among facilities transferring and accepting ICE detainees. The 

Management of Mental Health Cases in Immigration Detention 

Page 26 
transferring facility is responsible for preparing the detainee and 

required documents, which include a medical transfer summary 

and records. ICE must notify the receiving facility sufficiently in 

advance, which should include the medical staff. Since the 

medical staff must determine and provide for any associated 

medical needs, notification is integral to allow the medical staff to 

research the illness to ensure proper treatment. 

The detention standards require providing advanced notice of a 

mentally ill detainee’s arrival and ensuring his or her mental health 

records are sent. 

Advanced Notice - ICE Detention Standards require medical 

providers to be notified in advance of incoming detainees with 

health conditions to ensure the facility has the appropriate 

resources available. One IHSC official said that before moving 

a detainee, IHSC headquarters has teleconferences with health 

service administrators, field office directors, and physicians. 

However, ICE personnel at seven sites told us that they receive 

minimal advanced notice on detainee transfers. Three other 

HSAs stated that they were usually notified. 

Mental health providers said that advanced notice would be 

helpful in developing a continuity of care plan, coordinating 

local providers, and preparing the detainee for travel by 

maintaining medication levels. 

Medical Records - ICE Detention Standards require medical 

summaries and official health records during transfers. In 

addition to receiving verbal notification regarding a detainee 

transfer, ICE policy recognizes the importance of having 

medical records or transfer summaries. Detainees transferred 

between IHSC-staffed facilities must have medical records and 

a completed transfer summary, which includes information 

about the detainee’s current mental status and medication 

instructions. However, detainees transferring from facilities 

operating under an intergovernmental service agreement are 

only required to have a transfer summary. 

An IHSC official said receiving medical records would be costeffective because the receiving facility could avoid duplicate 

testing. 

IHSC personnel said that a major challenge is maintaining 

continuity of care for detainees entering a facility without 

information. An IHSC official acknowledged problems which 

Management of Mental Health Cases in Immigration Detention 

Page 27 
occur when a detainee changes facilities, and the division was 

working on improving the process. 

Conclusion 

ICE needs to ensure that its medical authority has involvement in 

field decisions throughout all phases of the detention process. This 

will strengthen IHSC medical authority, and facilitate case 

management and information exchange. 

Recommendations 

We recommend that Immigration and Customs Enforcement: 

Recommendation #11: Designate a central authority for directing 

transfers for mentally ill detainees. 

Recommendation #12: Assign IHSC case managers in field 

positions to provide direct oversight and advice to ICE field and 

sub-offices, and expedite transfers of mentally ill detainees. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #11. 

ICE indicates that Enforcement and Removal Operations is the 

central authority for directing the transfer of all detainees in ICE 

custody, and IHSC Social Services Branch provides 

recommendations for the transfer of mentally ill detainees. 

OIG Analysis: This recommendation is resolved and open 

pending our receipt of documentation designating Enforcement 

and Removal Operations as the central authority for directing the 

transfer of all detainees in ICE custody. 

ICE Response: ICE concurred with Recommendation #12. 

ICE has partially implemented this recommendation through the 

assignment of Field Case Managers to 12 of the 24 Enforcement 

and Removal Operations Field Offices. It is anticipated that full 

staffing of Enforcement and Removal Operations Field Offices 

will be completed during FY 2011. 

OIG Analysis: This recommendation is resolved and open 

pending our receipt of documentation showing the specific duties 

Management of Mental Health Cases in Immigration Detention 

Page 28 
and responsibilities of the newly established Field Case Manager 

positions, and ICE’s completion of the recruitment and assignment 

of the 24 Field Case Managers. 

Mental Health Conditions Can Hamper Legal Proceedings 

The Executive Office of Immigration Review (EOIR), within the 

Department of Justice, administers the U.S. immigration court system. 

EOIR adjudicates civil immigration cases through proceedings to 

determine immigrants’ removability from the country. As appropriate, 

some immigrants in detention are placed in removal proceedings in 

immigration court where ICE attorneys will prosecute them if they are 

unlawfully present. Certain detainees may be released during immigration 

proceedings as appropriate by law. However, with some exceptions, ICE 

must release or remove detainees once proceedings have ended. 

A detainee’s mental illnesses can hinder the government’s ability to 

resolve an immigration case when the detainee cannot participate in 

proceedings because of his or her condition. 

ICE Needs Protocols For Relaying Mental Health Information via 

Alien Files 

ICE attorneys cited an ethical duty to acknowledge to the court any 

suspected or identified mental health condition that would affect 

mental competency. However, a process does not exist for 

formally identifying such cases. ICE attorneys said that a 

respondent’s mental health problems are usually discovered either 

through their behavior in court or in information received from 

Enforcement and Removal Operations in documents, in the Alien 

registration files, or in conversation with an Enforcement and 

Removal Operations officer. 

Documentation of a mental illness offers a reliable and descriptive 

source; however, such information is not always available in a 

mentally ill respondent’s Alien registration file. In the 85 Alien 

registration files that we reviewed, 44 contained evidence of a 

detainee’s mental health condition. Types of documentation 

included records of the alien’s statements to apprehending officers, 

medical records from previous jails or prisons, and records of 

hospitalization. Some files included no information even though 

the respondent had been diagnosed with a mental health condition 

while in ICE detention. There was no consistency in the 

information included in the Alien registration files. In addition, 

psychiatric alerts, specifically IHSC Form 834, were used rarely. 

Management of Mental Health Cases in Immigration Detention 

Page 29 
ICE needs to ensure that mental health information that attorneys 

should be privy to is included in the Alien registration files, and 

that attorneys are notified accordingly. Protocols that consider 

privacy concerns should be taken into account when developing 

information sharing procedures for detainees’ mental health 

information. 

ICE Needs to Provide Guidance on Custodians for Incompetent 

Respondents 

Regulations allow qualified individuals to appear in immigration 

court on behalf of respondents when the respondent is unable to be 

present due to mental incompetency.9

 Regulations also permit the 

respondent’s custodian to appear when another qualified individual 

cannot be found or fails or refuses to attend.10 When Enforcement 

and Removal Operations and immigration judges cannot find 

family, friends, or pro bono attorneys to appear with the 

respondent, a custodian is asked to appear in court with the 

respondent. In these cases, however, there is no guidance or 

finalized direction from ICE to its attorneys or officers on how to 

use custodians. ICE’s Office of Principal Legal Advisor (OPLA) 

is currently working to provide such guidance. 

Attorneys we interviewed in five of the seven regions we visited 

reported that they have used custodians for mentally incompetent 

respondents. Among the regions that have used custodians, the 

role has been assumed by ICE field office directors, assistant field 

office directors, or an Enforcement and Removal Operations 

officer, or less commonly a warden or a correctional officer 

representing the warden. However, attorneys across all seven 

regions expressed misgivings about the practice, and cited a 

potential conflict of interest in having Enforcement and Removal 

Operations personnel participate in removal proceedings. 

Regulations restrict judges from accepting an admission of 

removability from officers at a respondent’s detention facility.11 

According to ICE attorneys, when officers act as custodians for 

mentally incompetent respondents, the officers are instructed to 

deny charges on behalf of the respondent. In these cases, ICE 

attorneys must establish alienage to the judge’s satisfaction based 

on documentary evidence. 

9

 8 CFR § 1240.4. These include an attorney, legal representative, legal guardian, near relative, or friend 
 

who was served with a copy of the notice to appear. 


10 8 CFR § 1240.4. 
 

11 8 CFR § 1240.10(c). 
 

Management of Mental Health Cases in Immigration Detention 

Page 30 
ICE attorneys and staff need clarification regarding how to handle 

custodial issues. Officers serving as custodians should be guided 

by a formal policy and structure for handling these cases. 

Recommendations 

We recommend that Immigration and Customs Enforcement: 

Recommendation #13: Establish protocols for retaining and 

sharing mental health information in Alien registration files. At a 

minimum, protocols should include: requirements for documenting 

detainees’ mental health status to be used by Enforcement and 

Removal Operations officers and ICE attorneys; and, guidance for 

ensuring detainees’ privacy rights. 

Recommendation #14: Publish guidance on eligible custodians. 

Recommendation #15: Publish internal procedures for handling 

cases where custodians must be used for mentally incompetent 

detainees. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #13. 

ICE will determine what medical and mental health information 

can be placed in Alien registration files that do not violate Health 

Insurance Portability and Accountability Act guidelines. 

ICE notes that generally, privacy considerations limit, and in some 

cases, prohibit, the retention of medical information in Alien 

registration files. Medical information may, however, be 

introduced into the immigration court record. More specifically, 

either the alien or their counsel may introduce this information into 

the court record for a variety of reasons. ICE counsel may also 

introduce medical information into the record to enable the 

immigration judge to make a legal finding as to the alien's 

competency to participate in immigration proceedings. Of note, 

however, the alien's medical information is not required for an 

immigration judge to make such a determination. Only after that 

medical information has been introduced into the court's record, 

may that same information be retained in the Alien registration 

file. 

Management of Mental Health Cases in Immigration Detention 

Page 31 
ICE acknowledged that our report has not drawn a clear distinction 

between legal and medical determinations, which is an important 

consideration when discussing matters involving aliens with 

mental health issues. A person who has a mental illness or 

disability is not necessarily legally incompetent to participate in 

immigration proceedings. Regardless of the circumstances leading 

to a finding that an alien is mentally incompetent, the legal 

determination is made by an Immigration Judge based on an 

assessment of the facts and circumstances of each case; it is not a 

medical determination. Consequently, in the absence of other 

credible relevant information, if an unrepresented alien has a 

mental health illness, but nevertheless appears to understand and 

respond to questions asked by the immigration judge, the judge can 

find the alien to be mentally competent for the purpose of removal 

proceedings. 

OIG Analysis: This recommendation will remain unresolved and 

open pending ICE’s decision on whether to establish protocols for 

retaining and sharing mental health information in Alien 

registration files. 

ICE Response: ICE concurred with Recommendation #14. 

ICE's OPLA is considering whether to issue guidance addressing 

the issue of aliens who are or may be mentally incompetent, 

unrepresented and in removal proceedings. Such guidance may 

include a discussion of eligibility and how a government attorney 

should handle custodial appearances before the immigration court. 

OIG Analysis: This recommendation will remain unresolved and 

open pending OPLA’s decision on whether to issue guidance 

addressing the issue of aliens who are or may be mentally 

incompetent, unrepresented, and in removal proceedings. 

ICE Response: ICE concurred with Recommendation #15. 

OPLA is considering whether to issue guidance addressing aliens 

who are or may be mentally incompetent, unrepresented and in 

removal proceedings. Such guidance may include a discussion of 

how a government attorney should handle custodial appearances 

before the immigration court. 

OIG Analysis: This recommendation will remain unresolved and 

open pending OPLA’s decision to issue guidance addressing aliens 

who are or may be mentally incompetent, unrepresented, and in 

removal proceedings. 

Management of Mental Health Cases in Immigration Detention 

Page 32 
 

Private Facilities Can Fill Critical Roles in Providing Mental 

Health Care for Detainees with Mental Illness 

ICE faces major challenges in managing detainees with mental health 

concerns who are unable to be released to the community while continuing 

through immigration proceedings, removed to their country of origin, or 

released into the community when ICE cannot effect removal. 

These cases place ICE in a difficult position since ICE cannot hold 

detainees indefinitely.12 However, their release might not be practicable 

while options for alternatives to detention are limited. ICE has 

encountered difficulties in accommodating acute mental health patients, in 

part, because no dedicated mental health facility exists within its detention 

network. Most of ICE’s detention facilities are not equipped to handle 

detainees with persistent and acute mental illnesses. 

To address cases that require attention beyond those services available 

through ICE or local providers, ICE has relied on a privately-owned 

detention healthcare facility. The facility is a valuable resource for ICE 

since it is the only nationally available site that is capable of treating longterm mentally ill and acutely psychotic detainees. 

IHSC decides which detainees to transfer to this facility. However, 

guidelines which outline the criteria for detainees that should be sent to 

this facility and a process for transferring detainees have not been 

established. According to ICE officials, it can take from several weeks to 

a few months to arrange a detainee’s transfer to the facility, and how 

detainees are approved or denied placement is unclear. 

IHSC officials said that ICE only uses this specialty facility for 

exceptionally difficult mental health and chronically ill medical detainees 

due to cost considerations. Some IHSC administrators commented that a 

detainee with a chronic mental health condition, who is unable to be 

among other detainees and cannot be deported or released to the 

community, is a candidate for such a transfer. According to other ICE and 

IHSC employees, when IHSC receives a request for transfer and 

information on detainees’ mental health diagnoses, it tries to place them at 

a less costly facility before considering the specialty facility. 

Transfers out of this facility can also be problematic. Since this specialty 

facility has a reputation for treating detainees with the most serious cases 

of mental illness, it is difficult to return the detainee to their former ICE 

12 See, for example, Zadvydas v. Davis, 533 U.S. 678, 690, 699, 701 (2001) (holding that once removal is 

no longer reasonably foreseeable, continued detention is not authorized by the post-removal period 

detention statute; the U.S. may hold aliens only for a period “reasonably necessary” to secure removal; and 

a statute permitting indefinite detention of an alien would raise a “serious constitutional problem”). 

Management of Mental Health Cases in Immigration Detention 

Page 33 
facility when they have undergone treatment and received medical 

clearance. 

Enforcement and Removal Operations personnel commented that some 

ICE facilities do not accept returning detainees because of facilities’ 

inability to sustain mental health treatment. ICE officers also said that 

Enforcement and Removal Operations field offices may be reluctant to put 

a challenging mental health case back on its docket. These cases are 

demanding since a majority of detainees who are sent to this specialty 

facility are under a post final order of removal and are difficult to deport. 

Conclusion 

Since ICE field offices often face limited options for community 

placement or state-run mental health facilities, mentally ill 

detainees can potentially remain longer in detention. More 

proactive use of private facilities could help alleviate the prolonged 

detention because of more effective mental health care. 

Recommendation 

We recommend that Immigration and Customs Enforcement: 

Recommendation #16: Develop and implement guidance that 

outlines the process and criteria for using specialty facilities. 

Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #16. 

ICE will develop and implement guidance that outlines the process 

and criteria for using specialty facilities. 

OIG Analysis: This recommendation is resolved and open 

pending implementation of guidance that outlines the process and 

criteria for using specialty facilities. 

Evolving Clinical Practices May Offer Greater Flexibility to 

Support Mental Health Care Needs 

IHSC managers and field personnel have implemented several approaches 

to supplement mental health care as follows: 

Management of Mental Health Cases in Immigration Detention 

Page 34 
Mental Health Nurses: IHSC designated a psychiatric mental 

health nurse position at one of its 18 detention facilities. A 

psychiatric mental health nurse administers psychiatric medication; 

communicates with mentally ill patients about their medication and 

participation in recreation activities; and helps to manage acutely 

psychotic or aggressive detainees. However, at three facilities we 

visited, nurses who were not trained in psychiatric mental health 

were assigned to perform these duties. A clinical director said that 

the needs of mental health patients require non-psychiatric nurses 

to extend beyond their capabilities. Staff at several IHSC facilities 

said psychiatric mental health nurses are needed as their 

specialized education and experience in mental health care adds 

much value. 

Tele-psychiatry: IHSC is using tele-psychiatry, which allows offsite psychiatrists to diagnose mental illnesses and prescribe 

medication after an interview via a tele-video connection. While 

IHSC staff preferred on-site psychiatrists, tele-psychiatry can be 

useful in locations without easy access to a psychiatrist. 

Some facilities have a tele-psychiatry connection and a 

psychiatrist. One facility had a psychiatrist on staff, and paid for 

tele-psychiatry connections that were not used. Other facilities 

have acquired tele-psychiatry equipment without connectivity. 

IHSC officials believe that current staffing shortages make telepsychiatry a viable alternative for diagnosing and treating mental 

illness. However, IHSC must establish and implement a process to 

ensure the efficient and economic use of tele-psychiatry. 

Recommendations 

We recommend that Immigration and Customs Enforcement: 

Recommendation #17: Include the use of psychiatric-mental 

health nurses in formal staffing plans. 

Recommendation #18: Expand the use of tele-psychiatry to those 

facilities located in areas with limited access to psychiatrists. 

Recommendation #19: Establish procedures to ensure that telepsychiatry is used efficiently. At a minimum, this should include a 

review of current tele-psychiatry connections, equipment, and any 

overlaps with existing mental health services. 

Management of Mental Health Cases in Immigration Detention 

Page 35 
Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #17. 

To enhance the effectiveness of the Mental Health Program within 

IHSC-staffed medical facilities, senior management and 

psychiatric subject matter experts are developing an organizationwide training program to prepare registered nurses with the 

training and skills to address the specific mental health needs of 

the detainees. Development of the training program and 

coordination with external programs will be completed by the end 

of calendar year 2011. 

ICE requests that OIG consider this recommendation resolved and 

open pending implementation of the staffing and training plan. 

OIG Analysis: This recommendation is resolved and open 

pending the development and implementation of a nurse’s training 

program to address specific mental health needs of the detained 

population. 

ICE Response: ICE concurred with Recommendation #18. 

IHSC has established a position, and hired a Tele-Medicine Branch 

Chief, who is currently evaluating and expanding this capability. 

ICE requests that OIG consider this recommendation resolved and 

open pending completion of the evaluation and expansion plan by 

the Tele-Medicine Branch Chief. 

OIG Analysis: This recommendation will remain resolved and 

open pending completion of the evaluation, and our review of the 

tele-psychiatry expansion plan to facilities located in areas with 

limited access to psychiatrists. 

ICE Response: ICE concurred with Recommendation #19. 

IHSC began development of the policy and procedures necessary 

for tele-psychiatry prior to the completion of this report. 

OIG Analysis: This recommendation is resolved and open 

pending completion of the policy and procedures to ensure the 

efficient use of tele-psychiatry. 

Management of Mental Health Cases in Immigration Detention 

Page 36 
Electronic Medical Records Have Not Been Implemented 

In our report, ICE Policies Related to Detainee Deaths and the Oversight 

of Immigration Detention Facilities, we concluded that electronic medical 

records would create a more efficient system for transferring and 

accessing medical records, which would result in a rapid assessment of 

medical needs and improve detainee safety.13 We recommended that ICE 

expedite the development of electronic medical records. To date, ICE 

continues to develop an electronic medical records system scheduled for 

implementation by 2012 or 2013. Until that time, ICE relies on a record 

keeping system of paper and computer-based records. 

Of the facilities we visited, five use paper records, while three employ 

some form of electronic records. Among the IHSC-staffed facilities we 

visited, two use electronic files while four are still using paper records. 

ICE’s current system, CaseTrakker, is not used at all facilities. Some, 

however, access the “Quick Print” feature of CaseTrakker, which permits 

a facility to print a detainee’s entire medical record. 

Implementing electronic medical records would facilitate communication 

of medical information in detention facilities. One IHSC official said 

accessing the file electronically would allow the receiving facility to know 

about and prepare for the detainee entering their facility ahead of time. 

Among the providers who were still working from paper files, some noted 

that they were not able to locate them quickly because they were 

circulating throughout the clinic. 

Currently, an IHSC working group is attempting to develop and 

implement an electronic medical records system. According to one 

participant, the group has been working to define the system’s purpose and 

capabilities, and identify ways to transition to a new system. We continue 

to emphasize the importance of implementing an electronic medical 

records system, which will help ICE address challenges in transferring and 

accessing detainee medical records in IHSC facilities. 

Recommendation 

We recommend that Immigration and Customs Enforcement: 

Recommendation #20: Expedite efforts to develop and implement 

an electronic medical record system. 

13 http://www.dhs.gov/xoig/assets/mgmtrpts/OIG 08-52 Jun08.pdf. 

Management of Mental Health Cases in Immigration Detention 

Page 37 
Management Comments and OIG Analysis 

ICE Response: ICE concurred with Recommendation #20. 

IHSC has begun developing the requirements for an electronic 

medical record system. ICE published a Request for Information 

to collect information on contractors with capabilities to develop 

the system and have held an industry day to gather additional 

information and respond to comments. The Statement of Work for 

an electronic medical record system is in the final stages of 

development. However, given the amount of work that remains to 

be done, ICE does not believe an electronic medical record system 

will be deployed by the end of calendar year 2011. 

OIG Analysis: This recommendation is resolved and open 

pending ICE’s implementation of an electronic medical record 

system. 

Management of Mental Health Cases in Immigration Detention 


Page 38 

Appendix A 

Purpose, Scope, and Methodology 

We conducted this review to determine ICE’s ability to manage 

cases of detained aliens with mental health conditions. Our review 

included three objectives: 

 Determine the utility of ICE’s guidance and training efforts 

relating to the treatment of detainees with mental health 

conditions, 

 Determine ICE’s ability to identify detainees with mental 

health conditions and provide access to appropriate treatment 

and detention settings, and 

 Determine what provisions exist to help assure detainees with 

mental health conditions are granted expedient removal or 

release. 

We conducted fieldwork from February 2010 to July 2010 in 

Washington, D.C.; Columbia, South Carolina; Miami, Florida; 

Phoenix, Arizona; York, Pennsylvania; and Harlingen, Texas. 

We conducted more than 120 interviews with personnel from ICE 

headquarters, field offices, and detention facilities. Our 

interviewees included policymakers, managers, deportation and 

detention officers, medical personnel, attorneys, and 

representatives of immigrant advocacy groups. We also held 

telephonic interviews with ICE personnel, including IHSC staff at 

11 locations throughout the country. 

We toured eight ICE detention facilities and two private facilities 

that care for ICE detainees with mental health conditions. The 

facilities visited included service processing centers, contract 

detention facilities, and facilities operating under an 

intergovernmental service agreement, as well as facilities with 

IHSC staff and those with other medical providers. 

We analyzed documentary and numerical data on ICE policies 

regarding detainees with mental health conditions. We reviewed 

emerging data on ICE’s detention reform initiative. We conducted 

a file review of alien and medical files of detainees with diagnosed 

mental illnesses. Our samples were judgmentally selected to 

acquire a range of mental health diagnoses at each site. Our 

sample is not statistically representative of the detained population. 

This review was conducted under the authority of the Inspector 

General Act of 1978, as amended, and according to the Quality 

Management of Mental Health Cases in Immigration Detention 

Page 39 
Appendix A 

Purpose, Scope, and Methodology 

Standards for Inspections issued by the President’s Council on 

Integrity and Efficiency. 

Management of Mental Health Cases in Immigration Detention 


Page 40 

Appendix B 

Management Comments to the Draft Report 

Page 41 


OfficI! of/hI' Chh,!Fil/fl/lcitllOffiar

lJ.S.l)erl:lrtlllcnl urllullIdlllllJ Seeurit)'

suo IZlhStl\.'"CI.SW

Wll$hillgton. D.C. 2U536

u.s. Immigration

and Customs

Enforcement

January II, 20 II

MEMORANDUM FOR: Carlton I. Mann

Assistant Inspcctor General for Inspcctions

Oflice of Inspector ~G al

FROM: Radha C. Sekar I

Chief Financial Ofr~cer

U.S, Immigration al1d~ list

SUBJECT: Comments to OIG DraCt Report "Management of Mental Health Cases in

Immigration Detention - For Official Use Only (FOUOt. dated November 17,2010

u.s. Immigration and Customs Enforcement (ICE) appreciatcs thc opportunity to commcnt on

the dral"t rcport.

ICE concurs with all of the rccomlllcndations and has already begun to correct its management

of mental health cases.

Should you have any questions or concerns, please contact Michael May, DIG Portfolio

Manager at (202) 732-6263 or bye-mail al MichacI.Moy@dhs.gov.

Attachment

www.icc.gov
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 42
 


U.S. Immigration and Customs Enforcement

Responses to OIG Draft Report Recommendations

"Management of Menial Health Cases in Immigrafion Detention"

Recommendation 1#1: Establish and implement DIHS's role in monitoring and providing

oversight to all ICE detention facilities. At a minimum, this should include DIHS's

responsibility for monitoring and tracking the mental health condition ofICE's detained

population.

ICE Response: ICE Concurs. D1HS is now called ICE Health Service Corps (IHSC). ICE's

IHSC has already established new Field Case Managers (FCMs) positions to provide medically

related consultation to each of the 24 ERO Field Office Directors (FODs) and monitor care

provided to detainees in non·IHSC staffed facilities, with particular emphasis on mental health

issues. As ofDecember I, 2010, IHSC has FCMs assigned to 12 ERO Field Office locations

providing critical support and is proceeding to recruit to fill the remaining 12 Field Offices in

FYll.

ICE requests that OlG consider this recommendation resolved and open, pending completion of

the recruitment ofthe 24 Field Case Managers.

Recommendation 1#2: Prioritize hiring a pennanent director and mental health staff. This should

include maximizing the use of available hiring incentives, and minimizing processing delays to

the extent practicable.

ICE Response: ICE Concurs. Interviews for a permanent Senior Executive Service (SES)

Director position have been completed and final selection is pending. However, remote

geographic locations impact IHSC's ability to recruit or retain qualified staff at certain facilities,

particularly psychiatrists. To mitigate this problem, IHSC is exploring the use ofTitie 38

authority and partnering with the Veteran's Administration to help fill vacancies.

ICE requests that OIG consider this recommendation resolved and open, pending complction of

the recruitment ofthe pennanent Director.

Recommendation 1#3: Establish and implement a system that aligns staffing levels at each

facility with their respective mental health caseload.

ICE Response: ICE Concurs. ICE has already begun to analyze appropriate staffing levels

internally and has implemented a system to align staffing levels through submission and action

of the priority staffing plan. Once analysis and approval ofthe staffing plan are complete, IHSC

will fully implement realigrunent based on each facilities mental health caseload. Full

implementation ofthe priority staffing plan is currently subject to available funding.

ICE requests that OIG consider this recommendation resolved and open, pending approval ofthe

staffing plan.

Page I
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 43
 


U.S. Immigralion and Customs Enforremenl

Responses 10 OIG Drafe Report Rerommendations

"Maaagement of Menial Health Cases in Immigration Delealioo"

Reeommeodalionl#4: Place detainees with mental illnesses in facilities that have nec:essary

space and rerources available to provide needed services. At a minimum, such facilities should

maintain appropriate areas for specialized trealment, and be accessible to comnllUlity providers.

ICE Response: ICE concurs. IHSC and ERO Field Offices have conducted an initial analysis

ofIHSC and non-IHSC statTcd facilities to identify detainees with active acute or sub-acute

diagnosis. Once this analysis has been finalized, recommendations will be provided regarding

appropriate placement based on availability ofcare. Prospectively, IHSC and ERO HQ Field

Operations are currently developing a process to identify and report detainees with acute or subacute diagnosis. IHSC has taken steps to increase access to available mental health resources and

facilities throughout the country. This report and tracking system will be focused on identifying

the patient's mental health needs and placing them in a facility consistent with providing the best

possible care based on their mental health diagnosis and clinical needs.

ICE requests that OIG consider this recommendation resolved and open, pending completion of

the analysis of all facilities, and the establishment of a process to identify, track, and placemenl

ofdetainees with a mental health diagnosis.

Recommendalion #5: Establish time limits for holding mentally ill detainees in segregalion

outside of medical units, and idcnlify recourses for detention facilities when segregated detainees

are approaching set time limits.

ICE Response: ICE concurs. Those detainees with mental health issues housed in segregation

units outside of medical units are reassessed by appropriate health care persolUlel on a daily

basis. Any modifications in treatment plan and conditions ofconfinement are made at that lime,

if appropriate. IHSC is in the final process of completing the Medical Classification System,

which will also address this recommendation with regard to identification and placement of

detainees based on medical and mental health need and diagnosis. The Medical Classification

System is comprised oftwo components: identifieation ofthe health care needs ofthe detainee

and identification ofthe health care resources that are available in the detention facility, and the

immediate outside health care community surroWlding Ihe facility. Detainee placement will be

contingent on the needs ofthe detainee and the resources available allnear the facility. ICE will

review industry standards and consult health care authorities in an effort to establisb time limits

for holding mentally ill detainees in segregation.

ICE requests thaI OIG consider this recommendation resolved and open, pending deployment of

the Medical Classification System.

Page 2
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 44
 


U.S. Immigration and Customs Enforcement

Responses to OIG Draft Report Recommendations

"Management of Mental Health Cases in Immigration Detention"

Recommendation #6: Establish procedures for timely evaluating and transferring detainees

requiring separation or isolation for mental heahh conditions, but who are in facilities that cannot

accommodate such needs.

ICE Response: ICE concurs. IHSC will establish procedures to identify detainees with mental

health conditions requiring transfer to appropriate ICE facilities or to contracted care facilities.

ERO will consider JHSC's recommendation and, coupled with conditions of confinement, make

a decision on the best location to house the detainee to provide appropriate care. ICE will

incorporate this requirement in the new Medical Classification System, which will identify the

type ofservices available at each of ICE's facilities.

ICE requests that OlG consider this recommendation resolved and open, pending deployment of

the Medical Classification System.

Recommendation #7: Identify detention facility sites with minimal or no community resources,

and develop lHSC mental health resources as needed to ensure the availability ofproper care.

ICE Response: ICE concurs. Development and implementation ofthe Medical Classification

system will address this recommendation once implemented as outlined in the response to

recommendation

ICE requests that OlG consider this recommendation resolved and open, pending deployment of

the Medical Classification System.

Recommendation #8: Establish a classification system for detention facilities that takes into

consideration the facilities' ability to handle detainees with varying mental health needs.

ICE Response: ICE concurs. Current internal procedures match the capabilities ofIHSC

staffed facilities with patient needs. The Medical Classification System, as explained in

Response #5, is in the final stages of development and is scheduled for implementation, and will

further expand this capability include available resources in the lGSAs.

ICE requests that OlG consider this recommendation resolved and open, pending deployment of

the Medical Classification System.

Recommendation #9: Direct field offices to request mental health infonnation for incarcerated

aliens before they arrive in detention, and establish a requirement for sending the infonnation to

medical personnel before detainees arrive in ICE detention.

ICE Response: ICE concurs to the extent operationally viable. ICE believes that a few issues

must be considered prior to implementation. As noted in the Draft Report some jails and prisons

Page 3
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 45
 


U.S. Immigration and Customs Enforcement

Responses to OIG Draft Report Recommendations

"Management of MeDtal Health Casu in Immigrafion Delention"

will not release medical or mental health infonnation prior to the transfer ofthe alien into ICE

custody. ICE is not in the position to demand such infonnation from non ICE-owned facilities.

However, as indicated in the report, liaison by IHSC may be able bridge this gap. Also. there are

large numbers of aliens that are transferred into ICE custody within 24 hours or less from the

lodging of an immigration detainer against them. In such cases, there is no time to meaningfully

access the mental health infonnation prior 10 the alien entering ICE custody.

ICE will work to create a policy requiring ICE officers to request medicaVmental infonnation

before they arrive in ICE detention. This policy will contain the following protocols;

• In cases where medical reports indicating significant mental health issues are obtained.

the FOD will be required to notify HQ IHSC prior to accepting the alien into ICE

custody.

• IHSC FCMs assigned to ERO Field Offices will provide the FOD. within 24 hour of

receiving the request, with an assessment of whether ICE has the resources to properly

house the alien and at what facility the alien should be detained based on clinical need.

• The FODs will be reminded oftheir ability to exercise prosecutorial discretion and cancel

immigration detainers or elevate cases to ERO HQ, when necessary and as appropriate.

ICE re1:Juests that 010 consider this recommendation resolved and open, pending implementation

ofthe new policy protocols.

Recommendalion NI0: Identify additional data that could be collected as part oCthe mental

health screening process that would assist in detennining the health history and treatment needed

for incoming detainees with mental illnesses.

ICE RupoDse: ICE concurs. IHSC is in the process of revising the IHSC Fonn 795A. Intake

Screening Fonn to include additional infonnation specific to the recommendation in the report.

The fonn is cUITently being routed through the approval process and should be fully

implemented soon.

ICE requests that oro consider this recommendation resolved and open, pending implementation

ofthe new intake fonn.

Recommendation 1#11: Designate a central authority for directing transfers for mentally ill

detainees.

Page 4
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 46
 


u.s. Immigration and Customs Enforcement

Responses to OIG Draft Report Recommendations

"Management of Mental Health Cases in Immigration Detention"

ICE Response: ICE concurs. ERO is the central authority for transfer of all detainees in ICE

custody; IHSC Social Services Branch provides recommendations for transfer ofmenially ill

detainees to ERO based on medical necessity.

ICE requests that ora consider this recommendation resolved and closed.

Recommendation NI2: Assign IHSC case managers in field posilions 10 provide direct oversight

and advice 10 ICE field and sub-offices, and expedite transfers of mentally ill detainees.

ICE Response: ICE concurs. ICE has already partially implemented this recommendation

Ihrough the assignment of FCMs to 12 ERO Field Offices, with 12 additional offices remaining

to be staffed. It is anticipated that full staffing ofERO Field Offices will be completed during

FY 2011.

ICE requests that Ola consider this recommendation resolved and open, pending completion of

the recruitment ofthe 24 Field Case Managers.

RecommendatioD NI3: Establish protocols for retaining and sharing mental health information

in A-files. At a minimum, protocols should include: requirements for documenting detainees'

mental health status to be used by ERO officers and ICE attorneys; and, guidance for ensuring

detainees' privacy rights.

ICE Response: ICE concurs and will work with the appropriate entities to see what medicaV

mental health information might be appropriate for placement in a-files that do not violate

HIPAA guidelines. ICE notes that generally, privacy considerations limit, and in some cases,

prohibit, the retention of medical information in an Alien registration file (A-File). Medical

information may, however, be introduced into the immigration court record. More specifically,

either the alien or hislher counsel may introduce this information into the court record for a

variety ofreasons, including but not limited to as part of a request for immigration benefits under

the Immigration and Nationality Ac!. Likewise, aliens who have previously applied for and

adjusted their immigration status to that of a lawful permanenl resident before the immigration

court or the Department of Homeland Security could have vaccination and physical examination

records in their A-file. ICE counsel may also introduce medical information into the record to

enable the immigration judge to make a legal finding as to the alien's competency to participate

in immigration proceedings. Of note, however, the alien's medical information is not required

for an immigration judge (IJ) 10 make such a determination. Only after that medical information

has been introduced into the coun's record, though, may that same infonnation be retained in the

A-file.

Page 5
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 47
 


U.S. Immigration and Customs Enforcement

Responses to OIG Draft Report Recommendatioos

"Management of Menial Health CasC5 in Immigralion DelcDlion"

It should be also noted that this report has not drawn a clear distinction between legal and

medical detenninations, which is an important consideration when discussing maners involving

aliens with mental health issues. A person who has a mental illness or disability is not

necessarily legally incompetent for purposes of participating in immigration proceedings.

Additionally, a person may be incompetent to appear in immigration proceedings for a variety of

reasons, not just due to the presence of a mental health condition. For instance, the person may

have a cognitive or developmental disability or a drug or alcohol addiction that substantially

interferes with their ability to understand and respond to questions during immigration

proceedings. Regardless ofthe circumstances leading to a finding that an alien is menially

incompetent, that legal detennination must be made by an Immigration Judge, based upon their

assessment ofthe facts and circumstances ofeach case; it is not a medical detennination.

Consequently, in the absence ofother credible relevant infonnation, if an unrepresented alien has

a menial health illness, but nevertheless appears to understand and respond to questions asked by

the immigration judge, an Immigration Judge can find the alien to be mentally competent for the

purpose ofremoval proceedings.

ICE requests that 010 consider this recommendation resolved and open, pending the decision to

issue or not issue guidance addressing the issue of aliens who are or may be mentally

incompetent, unrepresented, and in removal proceedings.

Recommendation #14: Publish guidance on eligible custodians.

ICE Response: ICE concurs. ICE's Office ofthe Principal Legal Advisor (OPLA) is currently

considering whether or not, and in what fonn, to issue guidance addressing the issue of aliens

who are or may be mentally incompetent, unrepresented and in removal proceedings. Such

guidance may include a discussion of eligibility and how a government attorney should handle

custodial appearances before the immigration court.

ICE requests that 010 consider this recommendation resolved and open, pending the decision to

issue or not issue guidance addressing the issue of aliens who are or may be menially

incompetent, unrepresemed, and in removal proceedings.

Recommendation #15: Publish internal procedures for handling cases where custodians must be

used for mentally incompetent detainees.

ICE ReJpoDse: ICE concurs. OPLA is currently considering whether or not, and in what fonn,

to issue guidance addressing the issue of aliens who are or may be mentally incompetent,

unrepresemed and in removal proceedings. Such guidance may include a discussion of how a

government attomey should handle custodial appearances before the immigration court.

Page 6
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 48
 


U.S. Immigration and Customs Enforcemenl

Responses 10 OIG Draft Report Recommendallons

"Managemenl orMenlal Health Cases in Immigration Delention"

Additionally, ICE notes that generally, privacy considerations limit, and in some cases, prohibit,

the retention ofmedical information in an alien registration file (A-File). Medical information

may, however, be introduced into the immigration court record. More specifically, either the

alien or hislher counsel may introduce this information into the court record for a variety of

reasons, including but not limited to as part of a request for immigration benefits under the

Immigration and Nationality Act. Likewise, aliens who have previously applied for and

adjusted their immigration status to that of a lawful permanent resident before the immigration

court or the Department of Homeland Security could have vaccination and physical examination

records in their A-file. ICE counsel may also introduce medical information into the record to

enable the immigration judge (11) to make a legal finding as to the alien's competency to

participate in immigration proceedings. Of note, however, the alien's medical information is not

required for an IJ to make such a determination. Only after that medical information has been

introduced into the court's record, though, may that same information be retained in the A-file.

ICE requests that DIG consider this recommendation resolved and open, pending the decision to

issue or not issue guidance addressing the issue of aliens who are or may be mentally

incompetent, unrepresented, and in removal proceedings.

Recommendation #116: Develop and implement guidance that outlines the process and criteria

for using specialty facilities.

ICE Response: ICE concurs. ICE will develop and implement guidance that outlines the

process and criteria for using specialty facilities.

ICE requests that DIG consider this recommendation resolved and open, pending implementation

or guidance that outlines the process for using specialty facilities.

Recommendation #17: Include the usc of psychiatric.mental health nurses in formal staffing

plans.

ICE Response: ICE concurs. In an effort to enhance the effectiveness ofthe Mental Health

Program within IHSC staffed medical facilities. senior management and psychiatric subject

matter experts are developing an organization wide training program to prepare Registered

Nurses (RN) with the training and skill set to address the specific mental health needs of the

detained population. Development of the training program and coordination with external

programs will be completed by the end of calendar year 20 II.

ICE requests that DIG consider this recommendation resolved and open, pending implementation

of the staffing and training plan.

Page 7
Appendix B 

Management Comments to the Draft Report 

Management of Mental Health Cases in Immigration Detention 
 

Page 49
 


U.S. Immigration and Customs Enforcement

Responses 10 OIG Draft Report Recommendations

"Management of Mental Heallh Cases in Immigralion Detention"

Recommendation H18: Expand the use oftele-psychiatry to those facilities located in areas with

limited access to psychiatrists.

ICE Response: ICE concurs. IHSC has established and hired a Tele·Medicine Branch Chief,

who is currently evaluating and expanding this capability.

ICE requests that DIG consider this recommendation resolved and open, pending completion of

the evaluation and expansion plan by the Tele·Medicine Branch Chief

Recommendation #19: Establish procedures 10 ensure Ihat telepsychialry is used efficiently. At

a minimum, this should include a review of current telepsychiatry connections, equipment, and

any overlaps with existing mental health services.

ICE Response: ICE concurs. IHSC began development ofthe policy and procedures necessary

for telepsychiatry prior 10 the completion ofthis report.

ICE requests that DIG consider this recommendation resolved and open, pending completion of

the report and policy for telepsychiatry.

Recommendation #20: Expedite efforts to develop and implement an EMR system.

ICE Response: ICE concws. IHSC has already begWl the process ofdeveloping the

requirements for an e1eclronic medical record system. We have published a Request for

Infonnation to collect infonnation on contractors with capabilities to develop the system and

have held an industry day to gather additional infonnation and respond to comments. The

Statement of Work for EMR is in the final stages ofdevelopment and given the amoWlt of work

that remains to be done, ICE does not believe an EMR will be deployed by the end of calendar

year 201 I.

ICE requests that DIG consider this recommendation resolved and open, pending implementation

ofits electronic medical records system.

Page 8
Appendix C 

Major Contributors to this Report 

Deborah Outten-Mills, Chief Inspector 

Andrew Schmidt, Senior Inspector 

Morgan Ferguson, Inspector 

Tatyana Martell, Inspector 

Demetrius Moore, Inspector 

Management of Mental Health Cases in Immigration Detention 


Page 50 

Appendix D 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chief of Staff 

General Counsel 

Executive Secretariat 

Director, GAO/OIG Liaison Office 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs 

Assistant Secretary for Office of Legislative Affairs 

Director of ICE 

ICE Audit Liaison 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees, as 

appropriate 

Management of Mental Health Cases in Immigration Detention 
 

Page 51
 

ADDITIONAL INFORMATION AND COPIES 

To obtain additional copies of this report, please call the Office of Inspector General (OIG) at (202) 254-4100, 

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.