Alien Detention Standards: Observations on the Adherence to ICE's Medical Standards in Detention Facilities
Published: 2008-06-04T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In fiscal year 2007, Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement (ICE) detained over 311,000 aliens, with an average daily population of over 30,000 and an average length of stay of about 37 days in one of approximately 300 facilities. The care and treatment of aliens while in detention is a significant challenge to ICE, as concerns continue to be raised by members of Congress and advocacy groups about the treatment of the growing number of aliens while in ICE's custody. This testimony focuses on (1) the extent to which 23 facilities complied with medical care standards, (2) deficiencies found during ICE's annual compliance inspection reviews, and (3) the types of complaints filed by alien detainees about detention conditions. This testimony is based on GAO's July 2007 report evaluating, among other things, the extent to which 23 facilities complied with aspects of eight of ICE's 38 National Detention Standards. This report did not address quality of care issues.
section_title: What GAO Found
paragraphs: At the time of its visits, GAO observed instances of noncompliance with ICE's medical care standards at 3 of the 23 facilities visited. These instances related to staff not administering a mandatory 14-day physical exam to approximately 260 detainees, not administering medical screenings immediately upon admission, and first aid kits not being available as required. However, these instances did not show a pervasive or persistent pattern of noncompliance across all 23 facilities. Officials at some facilities told GAO that meeting the specialized medical and mental health needs of detainees had been challenging, citing difficulties they had experienced in obtaining ICE approval for outside nonroutine medical and mental health care. On the other hand, GAO observed instances where detainees were receiving specialized care at the facilities visited. At the time of its study, GAO reviewed the most recently available ICE annual inspection reports for 20 of the 23 detention facilities that it visited; these reports showed that ICE reviewers had identified a total of 59 instances of noncompliance with National Detention Standards, 4 of which involved medical care. One facility had sick call request forms that were available only in English whereas the population was largely Spanish speaking. Another did not maintain alien medical records on-site. One facility's staff failed to obtain informed consent from the detainee when prescribing psychiatric medication. Finally, another facility did not have medical staff on-site to screen detainees arriving after 5 p.m. and did not have a properly locked medical cabinet. GAO did not determine whether these instances of noncompliance were subsequently corrected as required. The types of grievances at the facilities GAO visited typically included the lack of timely response to requests for medical treatment, missing property, high commissary prices, poor food quality and insufficient food quantity, high telephone costs, problems with telephones, and questions concerning detention case management issues. ICE's detainee grievance standard states that facilities shall establish and implement procedures for informal and formal resolution of detainee grievances. Four of the 23 facilities GAO visited did not comply with all aspects of ICE's detainee grievance standards. For example, one facility did not properly log all grievances that GAO found in their facility files. Detainee complaints may also be filed with several governmental and nongovernmental organizations. The primary way for detainees to file complaints is to contact the DHS Office of Inspector General (OIG). About 11 percent of detainee complaints to the OIG between 2005 and 2006 involved medical treatment issues. However, we found that the OIG complaint hotline 1-800 number was blocked or otherwise restricted at 12 of the facilities we tested. OIG investigates the most serious complaints and refers the remainder to other DHS components. GAO could not determine the number of cases referred to ICE's Detention Removal Office and concluded that ICE's detainee complaint database was not sufficiently reliable.

section_title: Letter
paragraphs: Chairman Lofgren, Mr. King, and members of the Subcommittee:  Thank you for inviting me here today to discuss our observations on the  adherence to medical standards in alien detention facilities. According to  the Department of Homeland Security’s (DHS) U.S. Immigration and  Customs Enforcement (ICE) officials, they maintain custody of one of the  most highly transient and diverse populations of any correctional or  detention system in the world. In fiscal year 2007, ICE detained over  311,000 aliens, with an average daily population of over 30,000 and an  average length of stay of about 37 days (50 percent stay 18 days or less).  This diverse population includes individuals from different countries; with  varying medical conditions and security risks (criminal and noncriminal);  and includes males, females, and families of every age group.
The care and treatment of aliens while in detention is a significant  challenge to ICE, as concerns continue to be raised by members of  Congress and advocacy groups about the treatment of the growing number  of aliens while in ICE’s custody. ICE has 38 National Detention Standards  to help ensure that alien detainees are housed under appropriate  conditions of confinement. These standards relate to a range of detainee  services, including medical services. ICE policy is to conduct annual  compliance inspection reviews of all adult, juvenile, and family detention  facilities to check compliance with these standards. In doing so, ICE  inspection staff are to review each detention facility’s compliance with  about 300 factors that are related to these standards (e.g., whether under  the medical care standard the facility established a policy and procedures  for responding to a detainee hunger strike). In addition to being required  to comply with ICE’s National Detention Standards, some ICE detention  facilities are accredited by The Joint Commission, the predominant  standards-setting and accrediting body in health care, and the National  Commission on Correctional Health Care (NCCHC), which offers a health  services accreditation program to determine whether correctional  institutions meet its standards in their provision of health services.
From May 2006 through May 2007 we conducted a review to determine the  extent to which selected facilities complied with aspects of 8 of the 38  standards, whether similar deficiencies were disclosed by ICE’s annual  compliance inspection review process, and the nature and disposition of  complaints filed by aliens in detention facilities. We selected these eight  National Detention Standards to review on the basis of interviews with  officials from the United Nations High Commissioner for Refugees  (UNHCR), the American Bar Association, and DHS Office of the Inspector  General (OIG). These eight standards we reviewed were telephone access,  medical care, hold room procedures, use of force, food services,  recreation, access to legal materials, and detainee grievance procedures.  During the course of our review we visited 23 detention facilities under  ICE oversight—18 of 330 adult, 2 of 19 juvenile, and all 3 family detention  facilities. Because we did not randomly select our detention facilities, the  results of our field observations from these facilities cannot be generalized  to the full universe of detention facilities nationwide. However, these  observations provided us with an overview of compliance with detention  standards at different sizes and types of facilities in various locations  across the country. We reviewed policies, procedures, documents, and  inspection and grievance reports pertaining to detainee conditions of  confinement, and interviewed facility and ICE staff responsible for  compliance with the eight standards that we reviewed. In addition, we  interviewed some individual detainees concerning their treatment at  detention facilities, particularly with respect to the eight standards, but did  not independently assess the merits of detainee complaints.
My statement today is based on our results regarding medical care  standards that we reported in July 2007 and addresses the extent to which  the 23 facilities complied with ICE’s medical care standards, deficiencies  found during ICE’s annual compliance inspections of these facilities, and  the types of complaints filed by alien detainees about detention  conditions. With respect to ICE medical care standards, we ascertained  whether (1) a range of medical and mental health services specified in  ICE’s standards were available, (2) detainees received initial medical  screening upon admission and a more complete physical exam within 14  days of admission, (3) detainees had the opportunity to request medical  services, (4) specialized medical and mental health services could be  arranged, (5) procedures and facilities for suicide prevention were  available, and (6) a plan for 24-hour emergency care was available. We did  not systematically review individual detainee medical cases or ICE  decisions on the type or extent of nonroutine treatment that is medically  necessary, nor did we otherwise investigate quality of care.
subsections: section_title: Some Instances of Noncompliance with Medical Care Standards Occurred
paragraphs: At the time of our visits, we observed instances of noncompliance with  ICE’s medical care standards at 3 of the 23 facilities we visited. However,  these instances did not show a pervasive or persistent pattern of  noncompliance across the facilities like we those identified with the  telephone system. Detention facilities that we visited ranged from those  with small clinics with contract staff to facilities with on-site medical staff,  diagnostic equipment such as X-ray machines, and dental equipment.  Medical service providers include general medical, dental, and mental  health care providers that are licensed by state and local authorities. Some  medical services are provided by the U.S. Public Health Service (PHS),  while other medical service providers may work on a contractual basis.
At the San Diego Correctional Facility in California, an adult detention  facility, ICE reviewers that we accompanied cited PHS staff for failing to  administer the mandatory 14-day physical exam to approximately 260  detainees. PHS staff said the problem at San Diego was due to inadequate  training on the medical records system and technical errors in the records  system. At the Casa de San Juan Family Shelter in California, we found  that the facility staff did not administer medical screenings immediately  upon admission, as required in ICE medical care standards. At the Cowlitz  County Juvenile Detention Center in Washington state, we found that no  medical screening was performed at admission and first aid kits were not  available, as required.
Officials at some facilities told us that meeting the specialized medical and  mental health needs of detainees can be challenging. Some also cited  difficulties they had experienced in obtaining ICE approval for outside  nonroutine medical and mental health care as also presenting problems in  caring for detainees. On the other hand, we observed instances where  detainees were receiving specialized medical care at the facilities we  visited. For example, at the Krome facility in Florida we observed one  detainee sleeping with the assistance of special breathing equipment (C- PAP machine) to address what we were told was a sleep apnea condition.  At the Hampton Roads Regional jail in Virginia we observed a detainee  receiving treatment from a kidney dialysis machine. Again, assessing the  quality of care and ICE’s decision—making process for approval of  nonroutine medical procedures were outside the scope of our review.
section_title: ICE Compliance Inspections Also Show Some Instances of Noncompliance With Medical Standards
paragraphs: We reviewed the most recently available ICE annual inspection reports for  20 of the 23 detention facilities that we visited. With the exception of the  San Diego facility in California, the reports covered a different time period  than that of our review. The 20 inspection reports showed that ICE  reviewers had identified a total of 59 instances of noncompliance, 4 of  which involved medical care. According to ICE policy, all adult, juvenile,  and family detention facilities are required to be inspected at 12-month  intervals to determine that they are in compliance with detention  standards and to take corrective actions if necessary. As of November 30,  2006, according to ICE data, ICE had reviewed approximately 90 percent  of detention facilities within the prescribed 12-month interval. Subsequent  to each annual inspection, a compliance rating report is to be prepared  and sent to the Director of the Office of Detention and Removal or his  representative within 14 days. The Director of the Office of Detention and  Removal has 21 days to transmit the report to the field office directors and  affected suboffices. Facilities receive one of five final ratings in their  compliance report—superior, good, acceptable, deficient, or at risk. ICE  officials reported that as of June 1, 2007, 16 facilities were rated  “superior,” 60 facilities were rated “good,” 190 facilities were rated  “acceptable,” 4 facilities were rated “deficient,” and no facilities were rated  “at risk.” ICE officials stated that this information reflects completed  reviews, and some reviews are currently in process and pending  completion. Therefore, ICE could not provide information on the most  current ratings for some facilities.
Four inspection reports disclosed instances of noncompliance with  medical care standards. The Wakulla County Sheriffs Office in Florida had  sick call request forms that were available only in English whereas the  population was largely Spanish speaking. The Cowlitz County Juvenile  Detention Facility in Washington state did not maintain the alien juvenile  medical records on-site. The San Diego Correctional facility staff, in  addition to the deficiencies noted earlier in this statement, failed to obtain  informed consent from the detainee when prescribing psychiatric  medication. Finally, the Broward Transitional Center in Florida did not  have medical staff on-site to screen detainees arriving after 5 p.m. and did  not have a properly locked medical cabinet. We did not determine whether  these deficiencies were subsequently addressed as required.
section_title: Alien Detainee Complaints Included Concerns About Medical Care
paragraphs: Our review of available grievance data obtained from facilities and  discussions with facility management showed that the types of grievances  at the facilities we visited typically included the lack of timely response to  requests for medical treatment, missing property, high commissary prices,  poor quality or insufficient quantity of food, high telephone costs,  problems with telephones, and questions concerning detention case  management issues. ICE’s detainee grievance standard states that facilities  shall establish and implement procedures for informal and formal  resolution of detainee grievances. Four of the 23 facilities we visited did  not comply with all aspects of ICE’s detainee grievance standards.  Specifically, Casa de San Juan Family Shelter in San Diego did not provide  a handbook to those aliens in its facility, the Cowlitz County Juvenile  Detention Center in Washington state did not include grievance  procedures in its handbook, Wakulla County Sheriff’s Office in Florida did  not have a log, and the Elizabeth Detention Center in New Jersey did not  record all grievances that we observed in their facility files.
The primary mechanism for detainees to file external complaints is  directly with the OIG, either in writing or by phone using the DHS OIG  complaint hotline. Detainees may also file complaints with the DHS Office  for Civil Rights and Civil Liberties (CRCL), which has statutory  responsibility for investigating complaints alleging violations of civil rights  and civil liberties. In addition, detainees may file complaints through the  Joint Intake Center (JIC), which is operated continuously by both ICE and  U.S. Customs and Border Protection (CBP) personnel, and is responsible  for receiving, classifying, and routing all misconduct allegations involving  ICE and CBP employees, including those pertaining to detainee treatment.  ICE officials told us that if the JIC were to receive an allegation from a  detainee, it would be referred to the OIG. OIG may investigate the  complaint or refer it to CRCL or DHS components such as the ICE Office  of Professional Responsibility (OPR) for review and possible action. In  turn, CRCL or OPR may retain the complaint or refer it to other DHS  offices, including ICE Office of Detention and Removal (DRO), for  possible action. Further, detainees may also file complaints with  nongovernmental organizations such as ABA and UNHCR. These external  organizations said they generally forward detainee complaints to DHS  components for review and possible action.
The following discussion highlights the detainee complaints related to  medical care issues where such information is available. We did not  independently assess the merits of detainee complaints.
Of the approximately 1,700 detainee complaints in the OIG database  that were filed in fiscal years 2003 through 2006, OIG investigated 173  and referred the others to other DHS components. Our review of  approximately 750 detainee complaints in the OIG database from fiscal  years 2005 through 2006 showed that about 11 percent involved issues  relating to medical treatment, such as a detainees alleging that they  were denied access to specialized medical care.
OPR stated that in fiscal years 2003 through 2006, they had received  409 allegations concerning the treatment of detainees. Seven of these  allegations were found to be substantiated, 26 unfounded, and 65  unsubstantiated. Four of the seven substantiated cases involved  employee misconduct, resulting in four terminations. According to OPR  officials, three cases were still being adjudicated and the nature of the  allegations was not provided. Additionally, 200 of the allegations were  classified by OPR as either information only to facility management,  requiring no further action, or were referred to facility management for  action, requiring a response.
CRCL also receives complaints referred from the OIG,  nongovernmental organizations, and members of the public. Officials  stated that from the period March 2003 to August 2006 they received 46  complaints related to the treatment of detainees, although the nature of  the complaints was not identified. Of these 46 complaints, 14 were  closed, 11 were referred to ICE OPR, 12 were retained for investigation,  and 9 were pending decision about disposition.
We could not determine the number of cases referred to DRO or their  disposition. On the basis of a limited review of DRO’s complaints  database and discussions with ICE officials knowledgeable about the  database, we concluded that DRO’s complaint database was not  sufficiently reliable for audit purposes. We recommended that ICE  develop a formal tracking system to ensure that all detainee complaints  referred to DRO are reviewed and the disposition, including any  corrective action, is recorded for later examination.
We reviewed 37 detention monitoring reports compiled by UNHCR  from the period 1993 to 2006. These reports were based on UNHCR’s  site visits and its discussions with ICE officials, facility staff, and  detainee interviews, especially with asylum seekers. Eighteen of the 37  UNHCR reports cited concerns related to medical care, such as  detainee allegations that jail staff were unresponsive to requests for  medical assistance and UNHCR’s concern about the shortage of mental  health staff.
While American Bar Association officials informed us that they do not  keep statistics regarding complaints, they compiled a list for us of  common detainee complaints received through correspondence. This  list indicated that of the 1,032 complaints it received from January 2003  to February 2007, 39 involved medical access issues such as a detainee  alleging denial of necessary medication and regular visits with a  psychiatrist, allegations of delays in processing sick call requests, and  allegations of a facility not providing prescribed medications.
Madam Chairman, this concludes my prepared remarks. I would be happy  to answer any questions you or the members of the subcommittee have.
section_title: Contacts and Acknowledgments
paragraphs: For further information on this testimony, please contact Richard M. Stana  at (202) 512-8777 or by e-mail at stanar@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement.
In addition to the contact named above, William Crocker III, Assistant  Director; Minty Abraham; Frances Cook; Robert Lowthian; and Vickie  Miller made key contributions to this statement.
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