Immigration Detention: Additional Actions Needed to Strengthen Management and Oversight of Detainee Medical Care
Published: 2016-02-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: DHS is responsible for providing safe, secure, and humane confinement for detained aliens who may be subject to removal or have been ordered removed from the United States. GAO was asked to examine the provision and oversight of medical care in immigration detention facilities. This report examines the extent to which DHS (1) has processes for administering detainee medical care and maintaining cost information for care, (2) monitors and assesses compliance with medical care standards, and (3) oversees processes to obtain and address complaints about detainee medical care.
GAO reviewed ICE data and information on costs, detention population, standards, and oversight for 165 facilities that held detainees for more than 72 hours in fiscal year 2015. GAO also reviewed complaint processes, interviewed DHS and ICE officials, and visited 12 facilities selected based on detainee population and facility type, among other factors. The visit results are not generalizable, but provided insight to the provision of medical care.
section_title: What GAO Found
paragraphs: The Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement (ICE) oversees basic on-site medical care at all facilities, as required by ICE detention standards, but does not maintain complete information about medical care costs. The ICE Health Service Corps (IHSC) provided direct care to detainees at 19 over-72-hour facilities and oversaw care at the remaining 146 non-IHSC-staffed facilities in fiscal year 2015. At all facilities, IHSC uses an electronic system, the Medical Payment Authorization (MedPAR) system, to approve or deny off-site care requests for detainees; such requests could include dental visits or surgical needs. IHSC uses a system different from MedPAR to track costs or amounts paid for off-site care. The use of separate systems limits ICE's ability to link approvals and payments. For example, the number of claims paid for fiscal years 2012 through 2014 did not correspond to the number of IHSC MedPAR approvals for requested services for the same time period. While there are valid reasons for these differences, such as that approvals and claims could be made in different fiscal years, establishing a mechanism to more fully ensure that payments for off-site care are supported by the appropriate authorizations could help ICE monitor medical care costs and better validate payments.
ICE conducts medical care compliance inspections at individual facilities, but conducts limited analyses of inspection data across facilities and over time. ICE uses seven oversight mechanisms to monitor facilities' compliance with medical care detention standards, such as facility inspections and on-site detention monitors. The combined use of these oversight mechanisms resulted in more than 99 percent of ICE's average daily population (ADP) of approximately 28,000 detainees being covered by two or more mechanisms in fiscal year 2015. ICE's priority has been to focus on local, facility-specific issues rather than perform overarching analyses. For example, ICE does not utilize the data gathered through these mechanisms in a way that examines overall trends in medical care deficiencies. Conducting analysis of oversight data over time, by detention standards, and across facilities, consistent with internal control standards, could strengthen ICE's ability to manage and oversee the provision of medical care across facility types.
DHS has various processes to obtain and address the hundreds of medical care complaints it receives annually. Specifically, detainees can submit complaints regarding medical care directly to facilities or to one of various DHS entities, including the Office of Inspector General and Office for Civil Rights and Civil Liberties. These entities generally determine whether to take their own action on the complaints or forward them to ICE for resolution. These entities maintain complaint data in various ways, and IHSC, which is ultimately responsible for addressing medical complaints received, is developing and piloting a new system for managing tasks, including addressing complaints. However, internal control standards call for evaluation of performance over time, and it is unclear whether IHSC's new system will capture all medical complaints received by DHS or facilitate analyses of complaints over time and across facilities. Ensuring that a new tasking system would capture all complaints and facilitate analysis could improve DHS's decision-making for detainee medical care.
section_title: What GAO Recommends
paragraphs: GAO recommends that DHS, among other things, ensure payments for medical care are supported by authorizations, conduct trend analyses of oversight data, and track all medical complaints received by DHS entities. DHS concurred with the recommendations and identified planned actions to address the recommendations.

section_title: Letter
paragraphs: The Department of Homeland Security’s (DHS) U.S. Immigration and  Customs Enforcement (ICE) is responsible for the apprehension,  detention, and removal of aliens from the United States. Related to  detention in particular, ICE has a responsibility to provide safe, secure,  and humane confinement for detained aliens in the United States who  may be subject to removal while they await the resolution of their  immigration cases or who have been ordered removed from the United  States. ICE detained an average daily population (ADP) of approximately  38,000 detainees in fiscal year 2014 and approximately 32,000 detainees  in fiscal year 2015. ICE addresses the medical needs of the detained  population through a range of medical care services—from routine exams  and tuberculosis screenings to off-site emergency room visits and chronic  disease interventions. Non-governmental organizations and immigration  advocacy groups have expressed concerns with the provision, quality,  and oversight of medical care for detainees in ICE custody. For example,  in July 2015, six non-governmental organizations jointly filed a complaint  to DHS on behalf of women and children setting forth allegations of  inadequate medical care at ICE’s family residential centers.
ICE is responsible for overseeing medical care at immigration detention  facilities, which are confinement facilities operated by or pursuant to a  contract or agreement with ICE that routinely hold persons for over 24  hours pending resolution or completion of immigration removal operations  or processes. Within ICE, Enforcement and Removal Operations (ERO)  oversees the confinement of ICE detainees across facilities in accordance  with immigration detention standards. ERO’s Custody Management  Division (CMD) manages the planning and acquisition of detention  facilities and oversees the regular monitoring and inspection of facilities  for standards compliance. The ICE Health Service Corps (IHSC), within  ERO, oversees the administration and costs of medical care at all  detention facilities and directly provides care to approximately 40 percent  of detainees. IHSC also addresses complaints regarding detainee  medical care received by other DHS components. The Office of Detention  Oversight (ODO), within ICE’s Office of Professional Responsibility  (OPR), serves as an oversight body for ERO and conducts periodic  inspections of a sample of detention facilities. The Joint Intake Center  (JIC), operated by OPR and U.S. Customs and Border Protection (CBP)  Internal Affairs, receives allegations of misconduct involving ICE and CBP  employees and contractors and assigns the information for appropriate  action or investigation. The JIC also receives complaints from detainees,  as does the ICE Detention and Reporting Information Line (DRIL)  helpline. Within DHS, both the Office of the Inspector General (OIG) and  the Office for Civil Rights and Civil Liberties (CRCL) receive complaints  through telephone, mail, and electronic communication regarding  detainee medical care at facilities.
In October 2014, we reported on ICE’s management and oversight of  immigration detention facility standards and costs. Specifically, we found  that, while ICE had various mechanisms to collect and assess data on  detention costs, it did not have complete data for the tracking and  managing of costs across facilities and facility types. Errors in the  recording of data by ICE field operators produced limitations that made it  difficult for ICE to accurately record expenditures for all facilities, including  those for medical care. We also found that ICE’s oversight mechanisms  resulted in differing inspection results, and that ICE offices did not have  sufficient communication about inspection results to determine whether  the oversight mechanisms functioned as intended. We recommended that  ICE assess the extent to which it has appropriate internal controls for  tracking and managing detention facility costs and develop additional  controls as necessary, and that ICE review the reasons for differences  between inspection results and assess the extent to which differences  reflect broader issues with the inspection mechanisms themselves to help  ensure that the mechanisms work as intended. DHS concurred and  subsequently reported on ongoing actions taken to address these  recommendations.
You asked us to review DHS’s allocation of medical care resources, its  assessment of compliance with medical standards in detention facilities,  and its processes for addressing medical care complaints filed by or on  behalf of detainees. This report addresses the following questions: To  what extent does DHS (1) have processes for administering medical care  to immigration detainees and maintaining information on costs associated  with care, (2) monitor and assess compliance with medical care  standards at detention facilities, and (3) oversee processes to obtain and  address complaints about medical care in immigration detention facilities?
To address these questions, we assessed DHS’s cost maintenance,  oversight, and grievance processes at 165 facilities used by ICE in fiscal  year 2015 to hold detainees for periods longer than 72 hours. This report  focuses on over-72-hour facilities because detainees are more likely to  need medical attention when held for longer periods of time. We visited a  purposive, non-generalizable sample of 12 detention facilities in Arizona,  California, Illinois, Maryland, Missouri, Texas, and Wisconsin. We  selected these facilities to reflect a mix of factors, such as facility type,  detention standards governing the facility, the ICE Field Office Area of  Responsibility, ADP, and recommendations made by DHS and non- governmental organizations that work with immigration detainees. We  interviewed ERO field office officials, facility personnel, and detainees  about medical care at facilities. The information we obtained from our  facility visits cannot be generalized to all facilities or detainees, but offers  insight into the processes used by DHS to provide and oversee detainee  medical care.
To determine the processes of administering medical care to detainees,  we reviewed ICE documents, including the IHSC Policy Manual, a July  2015 IHSC Operational Memorandum, and other documentation related  to its mission of overseeing and providing medical care to detainees. In  addition, we interviewed relevant ICE headquarters and regional officials,  as well as ICE and detention facility officials associated with visits to 12  facilities about the processes of providing medical care. To determine the  extent to which DHS maintains information on the costs associated with  medical care, we reviewed information about authorizations and  payments for off-site care for over-72-hour facilities operating in fiscal  years 2012 through 2014. To determine the reliability of medical claims  and expenditure data, we reviewed documentation and a prior GAO  report, and interviewed agency officials. We determined that some of  these data were sufficiently reliable to provide a general indication of  approximate costs for some, but not all, medical care expenditures. We  discuss these data in more detail later in the report. We assessed ICE  practices for administering off-site medical care and the agency efforts to  track and utilize cost data against Standards for Internal Control in the  Federal Government.
To determine the extent to which DHS monitors compliance with medical  care standards, we analyzed the percentage of ADP covered by each of  ICE’s oversight mechanisms in 2015, the year for which the most recent  data were available. Specifically, we determined which individual over-72- hour facilities utilized various oversight mechanisms—detention  standards inspections, medical care audits, ODO inspections, and on-site  monitoring—and calculated their ADP as a percentage of ICE’s total fiscal  year 2015 ADP using ICE population data. To determine the reliability of  these data, we reviewed ICE documentation and interviewed officials  knowledgeable about the creation, use, and storage of the data. We  determined that these data were sufficiently reliable for our purposes. We  also identified overlapping oversight mechanisms to determine the  percentage of ADP covered by multiple forms of oversight. We reviewed  ICE documents and interviewed agency officials to determine how each  oversight mechanism is intended to function. To determine the extent to  which DHS assesses medical care compliance at facilities, we reviewed  ICE documents and interviewed agency officials to determine use of  inspection results, and assessed whether DHS uses results in  accordance with Standards for Internal Control in the Federal  Government.
To determine the extent to which DHS oversees immigration detention  medical care complaint mechanisms, we analyzed and compared CRCL,  DRIL, IHSC, JIC, and OIG processes for obtaining and addressing  complaints; analyzed fiscal year 2014 complaint data—the most recent  data maintained by these DHS entities’ data systems at the time of our  review; and reviewed ICE detention and family residential standards that  govern facility grievance systems. We also reviewed and analyzed CMD,  ODO, and Operational Review Self-Assessment (ORSA) grievance  standard inspection data for calendar and fiscal year 2014 to assess the  extent to which inspections found deficiencies in grievance standards. To  determine the reliability of the complaint and inspection results data, we  reviewed documentation, interviewed agency officials, and conducted  testing. We determined that CRCL, DRIL, JIC, and OIG complaint data,  and CMD, ODO, and ORSA inspection data were sufficiently reliable for  our purposes. We chose not to use IHSC’s data on complaints because  IHSC’s system did not include all complaints IHSC addressed in fiscal  year 2014. Specifically, DRIL complaints addressed by IHSC were not  included in IHSC’s data system until fiscal year 2015. We also  interviewed DHS, ICE, and facility officials about their guidance,  procedures, and any complaint data maintained; and assessed processes  against applicable detention standards and Standards for Internal Control  in the Federal Government. Additional details on our scope and  methodology are contained in appendix I.
We conducted this performance audit from October 2014 to February  2016 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: ICE confines detainees in civil custody, not criminal custody or in a  punitive manner, for the administrative purpose of holding, processing,  and preparing them for removal from the United States. According to ICE  data, during fiscal year 2015, the agency housed an average of 28,000  detainees each day and held those detainees for an average of about 34  days. ICE detains a mixture of men, women, and children, and in fiscal  year 2015, approximately 84 percent of ICE’s 28,000 ADP was male and  16 percent was female.
In fiscal year 2015, ERO oversaw the detention of aliens held by ICE in  165 over-72-hour facilities managed in conjunction with private  contractors and state and local governments. The fiscal year 2015 ADP  in these facilities totaled approximately 28,000 detainees. Table 1  describes the types of facilities utilized by ICE, and shows the number of  such facilities in operation during fiscal year 2015 and the percentage of  the over-72-hour ADP located at each facility type during that period.
ICE utilizes detention facilities located across the United States. Facilities  housing larger populations or exclusively ICE detainees are generally  concentrated along the southern border of the United States. Other  facilities are distributed throughout the rest of the country. Figure 1 shows  the size, type, and locations of ICE’s detention facilities that house  detainees for periods longer than 72 hours.
ICE uses four sets of detention standards to manage the conditions of  confinement, including the provision of on-site and off-site medical care,  for detainees at over-72-hour facilities—the 2000 National Detention  Standards (NDS), the 2007 Family Residential Standards, and the 2008  and 2011 Performance-Based National Detention Standards (PBNDS).  The applicable set of standards used at each facility is included in the  facility’s contract or agreement. Facilities of the same type, therefore, may  follow different sets of detention standards depending on the applicable  set of standards specified in the facility’s contract or agreement. Table 2  provides information about each set of standards used by ICE, as well as  the number of facilities following those standards and the percentage of  the over-72-hour ADP covered by each set of standards during fiscal year  2015. For a discussion about how these standards have evolved over  time, see appendix II.
During the entire fiscal year 2015 period, IHSC was responsible for  providing direct medical care to detainees in 19 over-72-hour facilities  used by ICE, comprising approximately 48 percent of the over-72-hour  ADP. Facilities serviced by IHSC included service processing centers,  contract detention facilities, dedicated intergovernmental service  agreement facilities, and family residential centers. IHSC medical  personnel are to provide medical, dental, mental health care, and public  health services to detainees at these facilities. Similar services are to be  provided by local government staff or private contractors at the remaining  facilities, which are not directly operated by ICE. Although ICE delegates  the on-site provision of medical care to other entities at these non- dedicated facilities, multiple ICE offices exercise oversight of medical care  provided to all detainees, as discussed in more detail later in this report.  In addition to on-site care, facilities may send detainees for emergency or  specialty care to an off-site provider. In non-emergency situations, IHSC  officials are to utilize a data system to review and approve off-site care  requests prior to appointments. For emergency off-site visits, information  is to be recorded in the same data system after care is provided.
Numerous DHS components are responsible for obtaining and  addressing detainee complaints, and multiple ICE offices manage the  oversight of detention standards. Table 3 identifies the key DHS  components involved with detainee medical care and their primary roles  and responsibilities in that context.
section_title: DHS Has Established Processes for Providing Detainee Medical Care, but Does Not Have Complete Data on Costs for Care
subsections: section_title: All Detention Facilities Provide On-site Medical Care
paragraphs: DHS has established processes for the provision of routine medical care  on-site at both IHSC and non-IHSC staffed facilities. Federal law  authorizes the provision of medical care to immigration detainees, and  ICE detention standards require facilities to implement actions to provide  for the general safety and health of individuals held in civil immigration  detention. As such, all facilities that house detainees for over 72 hours— whether a small county jail that contracts with ICE to hold 10 detainees or  an ICE-operated facility with 1,000 detainees—maintain and operate  some type of on-site clinic. At a minimum, facilities must maintain a  clinical setting that serves as an area to conduct required physical exams,  as well as treatment for routine non-emergency conditions required by  ICE detention standards. Although not generalizable to all detention  facilities, in our site visits to 12 detention facilities, we observed a range of  clinical areas that reflected differing levels of on-site care capability.  Figures 2 and 3 depict detention facility medical clinics. See appendix III  for a fuller analysis of our site visit observations, including the results of  our interviews with 120 detainees at 12 facilities.
In addition, all facilities regardless of size or facility type must employ  credentialed healthcare professionals, such as registered nurses and  physicians, according to ICE detention standards. ICE detention  standards provide specific professional requirements for facility staff that  perform particular tasks. For example, trained facility corrections officers  can ask standardized medical intake questions to detainees upon their  arrival, but 2011 ICE standards state that only qualified licensed health  providers may conduct comprehensive health assessments, including a  physical examination and mental health screening.
section_title: ICE Has Varying Information about On-site Medical Care Costs and Could Better Link Approvals for Off-site Care to Costs
paragraphs: ICE has varying information about the costs of providing on-site medical  care to detainees across the types of facilities ICE uses to house  detainees; that is, medical care provided to detainees within the facilities.  ICE also has data on requests for off-site medical care, including whether  those requests were approved or denied, but could improve the  mechanisms and processes associated with linking data on approved  requests to costs paid for off-site services.
On-site medical care costs. The amount and type of information that  ICE maintains on costs for medical care provided on-site varies by facility  type. For example, at the 19 over-72-hour facilities where IHSC provided  direct medical care to detainees in fiscal year 2015, ICE maintained  medical expenditure data in its accounting system of record, the Federal  Financial Management System. Based on these data, the total cost of  providing medical care to detainees at IHSC-staffed facilities was about  $150 million in fiscal year 2013, $212 million in fiscal year 2014, and $206  million in fiscal year 2015. At the other approximately 140 facilities utilized  in fiscal year 2015 where IHSC did not directly employ medical staff,  costs for medical care are typically included in each facility’s per diem  rate for housing detainees. In these instances, ICE pays a set fee per day  per detainee. As we noted in our October 2014 report on immigration  detention costs and standards, however, limitations in ICE’s data on  overall facility costs, including costs for medical care, preclude using the  data to track and manage costs across individual facilities and facility  types. Furthermore, our 2014 report found significant coding errors in  cost data entered to the Federal Financial Management System, raising  questions about the reliability of the medical care expenditures figures  cited above. In our 2014 report, we recommended that ICE assess the  extent to which it has appropriate internal controls for tracking and  managing detention facility costs and develop additional controls as  necessary. ICE concurred and subsequently reported on actions taken to  address these recommendations. For example, DHS reported in February  2015 that ICE had created a tool to help track costs for each detention  facility, but as of January 2016, ICE had not fully assessed the extent to  which the tool is an appropriate internal control for tracking and managing  detention facilities costs and whether additional controls are necessary. In  addition, ICE reported that it is planning upgrades to the Federal Financial  Management System that could mitigate data reliability issues, but ICE  had not yet completed these updates as of January 2016. We continue to  believe that ICE should take efforts to better track and maintain reliable  overall detention cost information, including medical care expenditures.
Off-site medical care process and costs. ICE has established  processes and uses an electronic system to manage off-site care  provided to detainees, and through this system, ICE maintains data on  requests for off-site medical care and approvals or denials of those  requests. ICE also uses a separate data system to maintain information  on costs for approved services. However, ICE’s system for managing the  provision of off-site medical care does not provide ICE with the  information needed to identify and assess trends across the types of off- site care requested or approved over time or across facility types, and  ICE could better link data on approvals and amounts paid to improve ICE  oversight of the costs of providing off-site medical care to detainees. First,  with regard to ICE’s system for managing off-site care provided to  detainees, IHSC officials utilize the Medical Payment Authorization  Request (MedPAR) system to approve or deny all individual detainee  visits to off-site medical providers. This basic process is used for all  detainees housed in all facility types. Figure 4 depicts the general process  by which an on-site facility provider requests off-site care from IHSC  approving officials.
According to IHSC officials, the majority of requests for off-site medical  care are adjudicated by IHSC Field Medical Coordinators (FMC), who are  responsible for coordinating medical services for ICE detainees.  However, in some instances a higher level of review is needed, such as  for surgical procedures, and requests are adjudicated by an IHSC  Regional Clinical Director or Regional Dentist. ICE has developed and  issued various guidance documents related to the provision of off-site  medical care for detainees. For example, IHSC issued a July 2015  Operations Memorandum that outlines the MedPAR request process.  Moreover, the IHSC Detainee Covered Services guidance, issued in 2010  and under revision in fiscal year 2016, provides information about the  MedPAR process and states that ICE “must provide medically appropriate  treatment to ICE detainees who have identified any serious medical  needs.” The guidance goes on to define “serious medical need” as a  condition that when left untreated could result in further significant injury  or unnecessary pain. According to IHSC data, from fiscal years 2012  through 2014, IHSC approved an average of about 45,000 MedPAR  requests per year for ICE detainees to receive off-site care or services.
Although ICE uses the MedPAR system for recording requests for off-site  medical care and approval or denial of those requests, limitations in the  MedPAR system hinder ICE’s ability to use data in the system for  identifying and assessing trends in off-site medical care for detainees,  including emergency care. Specifically, the MedPAR system does not  allow IHSC officials to search for or identify types of procedures or off-site  medical care visits that were requested, approved, or denied, which limits  ICE’s ability to analyze trends across types of care and facilities and  make decisions about resource allocations for outside medical care.  Thus, IHSC officials have visibility over individual MedPAR requests, but  cannot sort or examine data by procedure or facility type. IHSC officials  noted that in response to specific information requests, they sometimes  manually search through MedPAR data, and acknowledged that more  systematic, regular analysis would be useful for decision-makers. For  example, a robust analysis of off-site care could better ensure that off-site  care requests are adjudicated consistently across ICE areas of  responsibility and facility types. This is important because MedPAR  approvals and denials are primarily based on the professional judgment  of the reviewer—there is currently no specific written clinical guidance on  which to base approval decisions, according to IHSC officials. Although  approval decisions are made on a case-by-case basis and dependent on  the specific circumstances of the individual seeking care, representatives  from two immigration advocacy groups cited cases of surgical  procedures, such as hernia operations, being approved in some  instances but not in others, which they said was problematic.
Standards for Internal Control in the Federal Government notes that  internal controls are an integral part of each system that management  uses to regulate and guide its operations. The standards also state that  control activities and communication of information are integral parts of an  entity’s planning, implementing, review, and accountability for  stewardship of government resources and achieving effective results.  Furthermore, the standards state that control activities, which include a  wide range of diverse actions and maintenance of related records, need  to be clearly documented and help to ensure that all transactions are  completely and accurately recorded. Developing and implementing a  mechanism to identify and assess trends in off-site medical care  procedures across types of procedures and facilities would better position  ICE to oversee off-site medical care provided to detainees and help  ensure consistent decisions regarding such care are made.
Second, with regard to the linking of data on off-site medical care  approvals with payments made to off-site providers, ICE detainee medical  claims and payments to outside providers are managed by the Veterans  Affairs Financial Services Center (VAFSC), but this system is not linked to  IHSC’s MedPAR system, according to IHSC officials. The VA system  tracks monetary amounts for all payments to outside medical providers  for services rendered to detainees—thus providing ICE with information  for these costs. According to IHSC officials, from fiscal years 2012  through 2014, approximately 93,000 claims per year were paid to off-site  providers for ICE detainee medical care. The total amount paid for this  time period was approximately $27 million per year, according to IHSC  officials. However, the number of claims paid for fiscal years 2012  through 2014 did not correspond to the number of IHSC MedPAR  authorizations, or approvals for requested services, for the same time  period. Overall, there were approximately 144,000 more claims paid in  VAFSC than approvals in MedPAR. Comparing figures for individual  facilities during this period, in some cases VAFSC claims exceeded  MedPAR approvals, and in some cases the MedPAR approvals were  greater than VA claims. For example, in fiscal year 2012, 2,187 MedPAR  requests were approved for detainees in a county jail facility and 63  claims were paid. At one IHSC-staffed facility, 326 MedPAR requests  were approved in fiscal year 2012, and 9,675 claims were paid. In  explaining these apparent discrepancies, IHSC officials noted differences  in provider billing practices and that some claims may not be paid in the  same fiscal year that they were authorized. Officials also stated that  multiple claims could be associated with individual authorizations. For  example, an emergency room visit may require one MedPAR approval,  but claims may be paid to multiple providers associated with the visit. We  acknowledge these reasons for different numbers of claims and  approvals; however, a mechanism to ensure that payments for off-site  care are supported by the appropriate authorizations could provide DHS  better assurance that the amount paid for claims corresponds to  authorized services. In addition, by not connecting the types and  frequency of authorized services with their actual costs, ICE is not well  positioned to analyze larger trends related to off-site care and make  resource allocation decisions.
IHSC officials acknowledged that the MedPAR system does not enable  IHSC to track off-site care requests by procedure type, which could  provide useful information about the magnitude and types of services  needed across detention facilities and regions, and thus impact resource  decisions. IHSC officials also noted that ICE does not routinely audit or  systematically cross-check MedPAR authorizations and claims paid due  to data system limitations. Standards for Internal Control in the Federal  Government notes that internal controls are an integral part of each  system that management uses to regulate and guide its operations, and  that communication of information and control activities are an integral  part of an entity’s planning, implementing, review, and accountability for  stewardship of government resources and achieving effective results.  Furthermore, the standards state that control activities, which include a  wide range of diverse actions and maintenance of related records, need  to be clearly documented and help to ensure that all transactions are  completely and accurately recorded. Developing and implementing a  mechanism to better link approved requests for off-site medical care to  data on amounts paid for off-site care would better position ICE to  oversee and manage resources for detainee medical care. In addition,  establishing stronger internal controls to ensure that payments for off-site  care are supported by the appropriate authorizations could help ICE  monitor medical care costs and better validate payments.
section_title: ICE Uses Various Oversight Mechanisms and Collects Medical Care Compliance Data at Individual Facilities, but Conducts Limited Analyses of Data across Facilities
subsections: section_title: ICE Uses Various Mechanisms to Oversee Facilities’ Compliance with Medical Care Standards
paragraphs: ICE has various mechanisms to oversee medical care at facilities, and it  uses a combination of these mechanisms to monitor conditions within a  facility, including the quality of medical care. The primary mechanism  used by ICE to monitor compliance with standards is the periodic  inspection of facilities, overseen by CMD, against the NDS, PBNDS, or  Family Residential Standards. These inspections covered approximately  74 percent of over-72-hour facilities used by ICE and more than 99  percent of ADP in fiscal year 2015. In accordance with ICE policy, in  most cases, a contractor with CMD assesses the conditions in a facility by  inspecting a list of items that correspond with detention standards. The  contractor identifies deficiencies to monitor the facility’s compliance with  an overall detention standard. For instance, a facility may be found  deficient for the line item requirement concerning the storage of medical  records, as seen in table 4 below, but still be found compliant with the  overall Medical Care standard. Table 4 shows a sample of line items that  fall under the Medical Care standard in the 2007 Family Residential  Standards, as well as language used in the inspection tool to assess  compliance with those line items.
ICE uses various other oversight mechanisms, like Field Medical  Coordinator (FMC) site visits and on-site Detention Service Managers  (DSM), to assess compliance with detention standards in more detail. For  example, FMC site visits and IHSC quality improvement audits look at the  quality of medical care at facilities in relation to detention standards by  reviewing medical care processes in more detail than the CMD  inspections described above, according to IHSC officials. Table 5 shows  each mechanism that ICE uses, including a description of required  frequency, where the mechanisms are used, and the type of oversight  conducted. For a more detailed description of each mechanism, including  recent results, see appendix IV.
The use of these oversight mechanisms helps to ensure that more than  99 percent of the over-72-hour ADP is annually subject to at least two  forms of medical care oversight—typically a detention standards  inspection and a medical inspection. Small facilities, those with an ADP of  fewer than 10 detainees, are to complete an annual Operational Review  Self-Assessment (ORSA), and FMCs may visit the facilities approximately  every six months for medical care inspections. The remaining adult and  family residential facilities also are to have periodic checklist inspections,  and IHSC staff are to conduct either FMC site visits or quality  improvement audits for medical care. DSMs assess compliance at larger  facilities in an effort to use their limited resources to oversee the  conditions of confinement for more detainees than they could at small  facilities, according to CMD officials. ODO prioritizes inspection sites  based on facility risk factors, such as number and type of allegations,  previous inspection deficiencies, and ADP, according to officials  Figure 5 shows the percentage of ADP covered by the various ICE  oversight mechanisms in fiscal year 2015 and how those mechanisms  overlapped. As seen in the figure, more than 99 percent of the fiscal year  2015 ADP was covered by two or more oversight mechanisms.  Approximately 65 percent of the ADP was covered by a detention  standards inspection, a medical care inspection, and a third mechanism,  either ODO inspection or DSM presence. An additional 22 percent of the  ADP was covered by four mechanisms—detention standards inspection,  medical care inspection, ODO inspection, and DSM presence—so that  approximately 87 percent of the ADP was covered by three or four  different oversight mechanisms during fiscal year 2015.
ICE can gain a comprehensive view of the conditions of confinement at  individual facilities, including the provision of detainee medical care, by  examining the combined results of multiple oversight mechanisms,  according to CMD officials. For example, ODO inspectors use weekly  DSM reports to gain a situational awareness of facility conditions before  an inspection. Similarly, DSMs collaborate with FMCs at  intergovernmental service agreement facilities to resolve medical-related  issues because DSMs are not medical experts, and DSMs may review  FMC site visit results to better understand the medical care issues at a  facility. At IHSC-staffed facilities, DSMs collaborate with health service  administrators to resolve medical-related issues. When medical care  deficiencies are found through CMD or ODO inspections, action plans to  resolve those deficiencies are to be sent to IHSC to help ensure that the  action plan will sufficiently address the issue. In this way, IHSC may know  of the medical care deficiencies found through other oversight  mechanisms. Rather than using the results of oversight mechanisms in a  punitive manner, ICE offers facilities opportunities to resolve deficiencies  before the issuance of results or reports. For instance, inspectors at the  family residential facilities can offer technical guidance to facilities for on- the-spot corrections to deficiencies. Similarly, ODO is to share its  preliminary results with the facility at the conclusion of each inspection so  that corrections can be initiated before the issuance of the final report.  IHSC’s quarterly quality improvement audits identify local issues at the  facility level, and IHSC can use the results to coach individual facilities  about ways to improve their medical care. In these ways, facilities can  resolve issues and improve the conditions of confinement for detainees in  a timely manner.
section_title: ICE Conducts Some Analysis of Oversight Data across Facilities, but Could Benefit from Expanded Analysis
paragraphs: ICE collects medical care compliance data through its various oversight  mechanisms; however, ICE does not utilize this information in a way that  facilitates decision-making across all detention facilities. ODO and the  IHSC Medical Quality Management Unit both conduct analyses across  facilities to identify systemic issues or leading practices, but their  analyses do not cover all facilities. ODO inspects select facilities and  IHSC conducts quality improvement audits only in the 19 IHSC-staffed  facilities; these inspections and audits covered approximately 57 percent  of the ADP in fiscal year 2015. ODO provides ICE leadership with  narrative annual reports that describe trends in deficiencies and identify  leading practices that may assist in the decision-making process  regarding facilities. Decisions made using ODO reports could include  contractual issues, as well as additional training for ICE officers or facility  staff, according to ODO officials. ODO reports trends in deficiencies by  detention standards, by facility type, and over time. IHSC conducts  analyses of quality improvement audit results across the 19 IHSC-staffed  facilities in order to identify levels of low compliance among clinics. If  compliance rates fall below 90 percent across the 19 clinics, each clinic is  required to conduct a study about the issue. These studies help IHSC  determine whether a specific administrative process change or medical  care intervention could improve the quality of care at clinics.
According to ICE officials, ICE uses its oversight mechanisms to help  obtain a more complete picture of compliance at individual facilities at a  given point in time, but ICE has not fully assessed the results of these  oversight mechanisms across facilities. For instance, FMC site visit  inspection results are stored and tracked, but FMCs’ numerous  responsibilities limit their ability to perform overarching analyses of the  data, and the Medical Case Management Unit of IHSC, which manages  the FMC program, does not have the resources necessary to perform  additional analyses of the data, according to an IHSC official. The official  also noted that FMCs are more focused on resolving local, facility-specific  medical care issues than looking at issues across facilities. Similarly,  CMD officials stated that their priority has been to address issues at  individual facilities rather than to conduct analyses of data across  facilities. The officials acknowledged the benefit of conducting such  analyses, and stated that they planned to explore the possibility of doing  so in future inspection cycles but did not have any specific plans for  analysis.
Moreover, ICE has not assessed ORSA and DSM compliance results  across facility types. Though small facilities began conducting annual  ORSAs in 2012, ICE has not used the information gathered to conduct an  analysis of results over time or across facilities. For example, unlike  inspection results for larger adult facilities, ORSA results are not stored in  a database, and staff members do not conduct additional analysis or  follow-up after a corrective action plan is completed for deficiencies,  according to CMD officials. That is, ORSA inspection worksheets are  scanned and stored electronically, but the format does not facilitate  tracking or analysis. Additionally, the ORSA form contains sections in  which the inspector can identify any repeat findings from previous years,  but CMD officials stated that they do not currently track any repeat  findings noted on ORSA forms. CMD officials did not provide specific  plans to improve the tracking of ORSA results. Similarly, CMD officials  noted that DSMs had difficulty documenting their daily oversight  interactions with facility staff because they happen so frequently, though  efforts to do so began in fiscal year 2016. Standards for Internal Control  in the Federal Government calls for the assessment of agency  performance over time, but without tracking the results of its oversight,  ICE cannot conduct analyses of information over time or across  facilities. Without such analysis, ICE management is not well-positioned  to assess the medical care performance of facilities over time, by  contracted standards, or by facility type; thereby, limiting ICE’s ability to  plan and manage overarching changes to detainee medical care.  Expanding analysis of oversight data across facilities would strengthen  ICE’s ability to manage and oversee the provision of medical care across  facility types.
section_title: DHS Headquarter Offices and ICE Detention Facilities Have Various Processes to Obtain and Address Medical Care Complaints; However, DHS Has Limited Oversight over the Universe of Complaints
paragraphs: DHS provides detainees with multiple avenues for filing medical care  complaints related to immigration detention. First, detainees can file  complaints directly at immigration detention facilities. ICE detention  standards call for detention facilities to have both informal and formal  processes for obtaining and addressing detainee complaints and for  complaints to be addressed at the lowest level possible. ICE and facility  officials we spoke with told us that detainees are informed of the  complaint processes through detainee handbooks and orientation  sessions. In addition, ICE Detention and Reporting Information Line  (DRIL) helpline and OIG hotline information posters provide contact  information for reporting concerns. ICE detention standards and guidance  call for informal resolution of detainee complaints through oral  communication with ICE facility or contractor staff or medical personnel  as appropriate. ICE detention standards further state that detainees may  be able to more expediently resolve complaints through informal  procedures. Unlike formal complaints, informal complaints do not require  detainees be provided a written response, as they are typically resolved  immediately; if not satisfied with an informal response, detainees can  submit formal, written complaints to facility officials. ICE detention  standards call for facilities to maintain grievance logs to document  complaints filed and their resolution—both formal and informal—and  inspectors are to review these grievance logs during facility inspections.
CMD and ODO help oversee the complaint processes at the facility level  by conducting inspections and determining whether processes are in  place and functioning as intended. Our analysis of CMD inspection data  showed that during fiscal years 2011 through 2014, approximately 12  percent of CMD over-72-hour facility inspections (58 of 496) identified 76  detainee grievance standard deficiencies. However, in fiscal year 2014,  two detainee grievance standard deficiencies were noted in the 96  inspections conducted. In addition, of the 32 inspections conducted by  ODO during fiscal year 2014, 22 facilities had a total of 48 grievance  standard deficiencies. In calendar year 2014, 31 over-72-hour facilities  completed ORSA inspections, which resulted in two detainee grievance  standard deficiencies reported at two ORSA facilities. Similar to medical  standard deficiencies, grievance standard deficiencies found through  CMD and ODO inspections may go through a corrective action plan  process to help insure that deficiencies are corrected.
Second, detainees can file complaints through various DHS entities  including CRCL, JIC, the OIG hotline, and the DRIL helpline. Complaints  can be submitted by phone, e-mail, mail, or fax. Each DHS entity has a  different focus and process for obtaining and addressing the complaints.  For example, the OIG’s responsibility is to investigate DHS employee and  contractor misconduct, including civil rights abuses, while the DRIL  helpline’s focus is on addressing immigration detention related questions  and concerns, including conditions of confinement. According to DHS  officials, complaints can be reported through any of these entities, and the  same complaint can be reported through the various options. Medical  complaints obtained by each DHS entity in fiscal year 2014 ranged from  about 100 by CRCL to approximately 550 by OIG. Examples of  complaints obtained by the different entities include medical treatment not  timely; request for medical care refused; scheduled for but not taken to  doctor visit; and inadequate dental care, among others. Table 6 shows  the different DHS entities through which detainees and others can file  complaints, including their primary focus, process for obtaining and  addressing complaints, and medical complaints obtained and addressed  in fiscal year 2014.
As shown in figure 6, various DHS entities obtain complaints, and IHSC  ultimately receives and is responsible for addressing medical complaints  obtained by those entities. DRIL sends medical-care-related complaints it  obtains to field deportation officers and the officers forward the complaints  to IHSC to be addressed. CRCL, JIC, and Hotline complaints declined for  review by OIG are forwarded to IHSC through other ICE units. CRCL  forwards medical-care-related immigration detention complaints to ICE’s  Office of Diversity and Civil Rights for vetting, which assigns a tier level to  help prioritize complaints by level of urgency—from emergent (Tier 1) to  important but less urgent (Tier 3). JIC, and Hotline complaints involving  ICE that are passed through JIC, are sent to ERO’s Administrative Inquiry  Unit. This unit vets and submits medical-care-related complaints to IHSC  for review and resolution.
CRCL, DRIL, and JIC maintain complaint data in their respective data  systems; however the data, in most cases, is not tracked or analyzed for  trending purposes. Only CRCL is required to review and report on the  number of complaints it receives and their disposition. For example,  CRCL tracks data in its data management system and can report on the  number of complaints it obtains, including medical care complaints related  to immigration detention. DRIL and JIC maintain their data in a  SharePoint System and automated case management system,  respectively. Both can determine the number of medical complaints  received and forwarded to IHSC for resolution. A JIC official told us that  the system is not designed for trend analysis. While the DRIL system can  be used to perform trend analysis, ICE officials do not currently use DRIL  to analyze medical care complaints because these complaints represent  a small number of the total DRIL complaints received each year. OIG’s  database includes CRCL and JIC complaints that are passed through  OIG for a determination of whether or not to investigate. Consequently,  OIG’s database contains numerous complaints, including medical-related  complaints. The OIG database, however, is essentially a repository of  data and is not designed for tracking medical care related complaints.  Further, it would be difficult to readily identify medical complaints from  among all the types of complaints OIG receives because, according to  OIG officials, complaint descriptions are captured in narrative format. To  identify possible medical complaints, a key word search of the complaint  narratives’ medical related terms would be needed. Such searches are  typically done on request by officials. While OIG maintains a database  that collects complaint data, according to OIG officials it is difficult to use  the database for determining the volume of medical complaints and  conducting analysis of complaint data.
According to IHSC officials, IHSC employs a tasking system to document  receipt of medical care related immigration complaints obtained from  other entities and the tasking of those complaints to IHSC personnel for  review and resolution. IHSC officials stated that, by practice, these  entities that receive complaints—DHS OIG, JIC, and CRCL—do not send  complaints directly to IHSC, but notify IHSC, through ERO or another ICE  entity, of medical care-related immigration complaints. IHSC maintains  records of these notifications in an IHSC tasking e-mail inbox, and the  notifications are saved in specific folders. IHSC officials told us that all  complaints received are processed through this tasking system. IHSC  officials also told us that in fiscal year 2014, their tasking system included  CRCL and JIC complaints, but not DRIL complaints; however, in fiscal  year 2015, IHSC began including DRIL complaints in the tasking  process.
As the entity ultimately responsible for addressing medical-care-related  complaints, IHSC officials acknowledged the need to have a more robust  task management system and to maintain more comprehensive data on  complaints. IHSC officials also told us that in cases when a count of  complaints received is needed, IHSC tasking staff transfer the  notifications maintained in the e-mail folders located in the tasking  mailbox to an Excel spreadsheet and generate a count or list of the  complaints. While IHSC officials can generate a count of complaints, they  told us it is very cumbersome to review all message notifications to  generate such counts. IHSC officials told us that this process for  maintaining data on medical-care-related complaints is not  comprehensive. They further told us that they are uncertain how many  complaints come from different sources, such as NGOs, attorneys,  detainees, and others, without going through complaint message  notifications to determine the sources.
IHSC officials acknowledged that having the ability to identify information  such as complaint volume and source, among other complaint  information, would be useful for conducting various analyses. ERO and  IHSC officials informed us they plan to have a new tasking system in  place in 2016 and expect the new system will allow IHSC to monitor  tasks, such as addressing CRCL, DRIL, and JIC complaints, and maintain  a history of IHSC responses to the tasks. Further, they told us that the  task management system intends to help streamline, centralize, and  organize the current tasking system, including complaint resolution. IHSC  officials provided us with a draft operations memorandum that discusses  the planned system. Specifically, the draft memorandum lays out policies  and procedures for receiving, initiating, and responding to tasks—from  task origination to task closure. The memorandum also states that  maintaining tasks in the new system would allow IHSC management to  monitor compliance with tasking due dates, have visibility over tasking  workloads, and provide the ability to obtain task status reports. The  system is currently being piloted in an ICE ERO area of responsibility and  a guide for system use is being developed.
While changes to IHSC’s current tasking process should provide greater  tasking management capabilities, including keeping track of its complete  tasking workload, the operations memorandum for the new management  system has not been finalized, a user guide is still in development, and  the pilot program is underway. It is therefore too early to tell the extent to  which this task management system will provide all of the desired tasking  capabilities. The draft memorandum also does not specify whether all  complaints obtained by IHSC will be included in the new tasking system,  such as those that do not require action by IHSC. Further, it does not  state whether a comprehensive set of complaint data will be  systematically captured in the system, such as volume of complaints  obtained and addressed, sources of complaints, and facilities where  complaints originate. This information could enable ICE to conduct broad  analyses of medical care complaints and potentially inform operational  decision making. However, the draft memorandum and IHSC officials did  not indicate that data in the new task management system would be used  for such analyses. Rather, the planned task system would function  primarily as a tool for assigning and monitoring the progress of internally  generated tasks, including medical complaints requiring IHSC action.
Standards for Internal Control in the Federal Government calls for there to  be procedures in place to monitor performance of regular operations over  time and that there be clearly defined roles and responsibilities for  carrying out operating activities as well as effective communication within  and across agencies to help ensure appropriate decisions are made.  Developing and implementing a mechanism to consolidate and maintain  complete data on medical complaints received by DHS entities, including  volume of complaints, sources of and top reasons for complaints, could  better position DHS to analyze trends and assess the overall process for  obtaining and addressing complaints; information that could be useful for  management. While DHS provides various avenues for detainees to file  complaints, DHS does not have a mechanism to readily determine the  overall volume of complaints it receives, their status, or outcome.  Developing a system that would allow IHSC to have data readily available  to conduct trend analyses, including analysis of complaint volume,  facilities where complaints are filed, and differences across facility type,  and one that can monitor IHSC responses, and amount of time to resolve  complaints, could be useful for management decision making.
section_title: Conclusions
paragraphs: Ensuring that the tens of thousands of men, women, and children that are  held in ICE detention facilities are provided with appropriate and timely  medical care is an important responsibility of ICE. Because of this  importance, DHS and ICE have implemented multiple levels of oversight  as well as mechanisms for detainees and others to report medical  grievances. In addition, ICE has established processes to provide  detainees with medical treatment outside the detention facilities, such as  in cases of emergencies or when specialty treatment is needed.  Regarding these areas—off-site medical care, oversight mechanisms,  and complaint mechanisms—ICE collects data and other information.  However, ICE does not systematically utilize these data to analyze larger  trends. For example, ICE has a data system that allows officials to review  and approve requests for off-site care, but the system does not allow  officials to track the number of requests and approvals or denials by  procedure type. Furthermore, the authorizations for off-site care in this  data system are not fully linked to claims paid to off-site providers. In  terms of oversight, ICE uses seven different mechanisms that employ a  variety of techniques to help ensure medical policies are followed and  detention standards are met. Although these different mechanisms are  effective for addressing specific medical issues at individual facilities, ICE  does not systematically connect and use oversight results to examine any  overarching medical issues over time and across all facilities. Similarly,  there are multiple avenues for detainees or others to file medical  complaints, such as toll-free telephone hotlines or formal written  complaints, and all medical complaints eventually are received by IHSC  for resolution. However, IHSC has limited oversight and tracking  capability over the universe of complaints, making it difficult for DHS to  analyze trends in medical care complaints and assess the extent to which  changes to medical care may be needed across facilities. Taking  additional actions in accordance with federal internal control standards to  facilitate better analysis of off-site care, oversight, and complaint  information would enhance ICE’s ability to make more effective clinical  and business decisions across immigration detention facilities.
section_title: Recommendations for Executive Action
paragraphs: To enhance Department of Homeland Security’s (DHS) U.S. Immigration  and Customs Enforcement’s (ICE) ability to make more effective business  decisions across immigration detention facilities with respect to the  provision of medical care, we recommend that the Secretary of Homeland  Security direct ICE to take the following actions: develop and implement a mechanism to identify and assess trends in  off-site medical care procedures across types of procedures and develop and implement a mechanism to ensure that payments for off- site care are supported by the appropriate authorizations; and track inspection results and conduct analyses of oversight data over  time, by standards, and by facility type.
Additionally, we recommend that the Secretary of Homeland Security  ensure that IHSC’s planned new tasking system includes all medical- care-related complaints received by DHS entities, and that this system  facilitates the tracking and analysis of complaints over time and across  facilities.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to DHS and the Department of Justice  for their review and comment. The Department of Justice indicated that it  did not have any comments on the draft report in a February 9, 2016  email from the department’s Audit Liaison. DHS provided written  comments, which are noted below and reproduced in full in appendix V,  and technical comments, which we incorporated as appropriate.
DHS concurred with all four recommendations in the report and described  actions underway or planned to address them. With regard to the first two  recommendations related to the provision of off-site medical care, DHS  concurred and stated that ICE will collaborate on actions with the  Veterans Affairs entity that is responsible for handling ICE detainee  medical claims. For example, DHS stated that ICE will work with Veterans  Affairs to determine if trends in off-site medical care procedures can be  incorporated into an existing medical claims database, and will review  processes and develop routine reports to help ensure that claims paid  correspond to appropriate authorizations. With regard to the third  recommendation that ICE track facility inspection results and conduct  analyses of oversight data, DHS concurred and stated that ICE has  begun to summarize facility site visit findings that will enable trending and  analysis over time and across facilities. With regard to the fourth  recommendation that IHSC track and analyze medical-care related  complaints received by DHS entities, DHS concurred and stated that  IHSC has already commenced building a limited tracking system and will  work to build as robust a system as resources will allow. DHS also stated  that IHSC will request DHS entities involved in all medical complaints  related to ICE detainees ensure that IHSC receives the complaint  information for entry into its database, even for complaints that IHSC  does not handle. These planned actions, if fully implemented, should  address the intent of the four recommendations contained in this report.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Homeland Security, the Attorney General of  the United States, and other interested parties. In addition, the report is  available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions, please contact me at (202) 512- 8777 or gamblerr@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made significant contributions to this report  are listed in appendix VI.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: This report addresses to what extent does the Department of Homeland  Security (DHS):  1.  have processes for administering medical care to immigration  detainees and maintaining information on costs associated with care,  2.  assess and monitor compliance with medical care standards at  3.  oversee processes to obtain and address complaints about medical  care in immigration detention facilities?
To address these questions, we assessed DHS’s cost maintenance,  oversight, and grievance processes at 165 facilities used by U.S.  Immigration and Customs Enforcement (ICE) to hold detainees for  periods longer than 72 hours in fiscal year 2015. We visited a purposive,  non-generalizable sample of 12 detention facilities in Arizona, California,  Illinois, Maryland, Missouri, Texas, and Wisconsin. We selected these  facilities to reflect a range of several factors, including facility type,  detention standards governing the facility, the ICE Field Office Area of  Responsibility, average daily population (ADP) of detainees, and  recommendations made by DHS and organizations that work with  immigration detainees. Data regarding facility type, detention standards,  and ADP were obtained from ICE. To determine the reliability of these  data, we reviewed ICE documentation and interviewed agency officials  about the data systems, and determined that the data were sufficiently  reliable for our purposes. For our site visits, we selected detention  facilities in five Areas of Responsibility (AOR) that provided diversity  across facility types, standards in use, and ADP. We interviewed ICE  Enforcement and Removal Operations (ERO) field office officials, ICE  Health Service Corps (IHSC) Field Medical Coordinators (FMC), facility  administrators, medical personnel, and detainees about medical care at  facilities. We interviewed a non-generalizable sample of 120 detainees to  determine their perception of medical care at each facility and their  knowledge of filing medical care grievances, among other things. We  randomly selected detainees to interview at each of the 12 facilities, and  we interviewed between 6 and 12 detainees per visit depending on the  time allotted for interviews. Since detainees speak various languages,  and not all are proficient in English, we interviewed detainees in both  English and Spanish, and we used a translation service for interviews  conducted in other languages, such as Punjabi or Burmese. We also  observed facilities’ practices regarding medical care and grievance  systems, such as the posting of required DHS hotline information, the  placement of grievance boxes, and the layout of medical care areas. The  information we obtained from our facility visits cannot be generalized to all  facilities or detainees, but offers insight into the operational settings at  facilities, such as how medical care standards are applied and assessed  and the management of medical care grievance processes. Prior to each  site visit, we spoke with at least one local or non-governmental  organization in each ICE Field Office Area of Responsibility to understand  their impressions of detainee medical care at each facility that we visited.  We identified these organizations through recommendations provided by  two national organizations—the American Civil Liberties Union and the  National Immigrant Justice Center. While not generalizable, this sample  of organizations provided us with helpful insights into the perspectives of  local detainee advocacy groups regarding medical care at detention  facilities.
To determine the processes of administering medical care to detainees,  we reviewed ICE documents, including the IHSC Policy Manual, a July  2015 IHSC Operational Memorandum, and other documentation related  to its mission of overseeing and providing medical care to detainees. In  addition, we interviewed relevant ICE headquarters and regional officials,  as well as ICE and detention facility officials associated with visits to 12  facilities about the processes of providing medical care. To determine the  extent to which DHS maintains information on the costs associated with  medical care, we reviewed information about authorizations and  payments for off-site care for over-72-hour facilities operating in fiscal  years 2012 through 2014. To determine the reliability of medical claims  and expenditure data, we reviewed documentation and a prior GAO  report, and interviewed agency officials. We determined that some of  these data were sufficiently reliable to provide a general indication of  approximate costs for some, but not all, medical care expenditures. We  assessed ICE practices for administering off-site medical care and the  agency efforts to track and utilize cost data against Standards for Internal  Control in the Federal Government.
To determine the extent to which DHS monitors compliance with medical  care standards, we analyzed the percentage of ADP covered by each of  ICE’s oversight mechanisms in 2015, the year for which the most recent  data was available. Specifically, we analyzed the extent to which ICE  utilized the following oversight mechanisms at over-72-hour detention  facilities:
Custody Management Division (CMD) Inspections,
Operational Review Self-Assessments (ORSA),
Family Residential Inspections,
Field Medical Coordinator (FMC) Site Visits,  IHSC Quality Improvement Audits,
Office of Detention Oversight (ODO) Inspections, and
Detention Service Managers (DSM).
We determined which of 165 over-72-hour facilities utilized the various  oversight mechanisms and calculated each facility’s ADP as a percentage  of ICE’s total fiscal year 2015 ADP using ICE population data. To  determine the reliability of ICE’s ADP and population data, we reviewed  ICE documentation and interviewed officials knowledgeable about the  creation, use, and storage of the data. We determined that these data  were sufficiently reliable for our purposes. We also identified overlapping  oversight mechanisms to determine the percentage of ADP covered by  multiple forms of oversight. We reviewed ICE documents and interviewed  agency officials to determine how each oversight mechanism is intended  to function. We also analyzed recent results for the various oversight  mechanisms, from years 2011 through 2015, depending on the  availability of inspection results and data. To determine the extent to  which DHS assesses medical care compliance at facilities, we reviewed  ICE documents and interviewed agency officials to determine use of  inspection results, and assessed whether DHS uses results in  accordance with Standards for Internal Control in the Federal  Government.
To determine the extent to which DHS oversees immigration detention  medical care complaint mechanisms, we analyzed and compared Office  for Civil Rights and Civil Liberties (CRCL), Detention and Reporting  Information Line (DRIL), IHSC, Joint Intake Center (JIC), and Office of the  Inspector General (OIG) processes for obtaining and addressing  complaints; analyzed fiscal year 2014 complaint data maintained by these  DHS entities’ data systems; and reviewed ICE detention and family  residential standards that govern facility grievance systems. We also  reviewed and analyzed CMD, ODO, and ORSA grievance standard  inspection data for calendar and fiscal year 2014—the most recent data  available at the time of our review—to assess the extent to which  inspections found deficiencies in grievance standards. To determine the  reliability of the complaint and inspection results data, we reviewed  documentation, interviewed agency officials, and conducted testing.  Based on our review of CRCL, DRIL, JIC, and OIG information and data,  and CMD, ODO, and ORSA inspection data, as well as the officials’  responses to our questions, we determined the data were sufficiently  reliable for our purposes. We reviewed IHSC fiscal year 2014 data on  complaints tasked to IHSC from other DHS entities for review and  resolution; and reviewed official’s responses to our questions. We chose  not to use specific IHSC data on complaints in fiscal year 2014 because,  according to agency officials, all complaints were not included. IHSC  addressed, but did not include DRIL complaints in its tasking data system,  and therefore these complaints were not included in the count of  complaints addressed by IHSC in fiscal year 2014. IHSC began including  DRIL complaints in its tasking system in fiscal year 2015. We also  interviewed DHS, ICE, and facility officials about their guidance,  procedures, and any complaint data maintained; and assessed processes  against applicable detention standards and Standards for Internal Control  in the Federal Government.
We conducted this performance audit from October 2014 to February  2016 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix II: Description of Changes to U.S. Immigration and Customs Enforcement (ICE) Detention Standards over Time
paragraphs: ICE’s National Detention Standards (NDS) were first issued in 2000 as a  means to facilitate consistent conditions of confinement, access to legal  representation, and safe and secure operations across the immigration  detention system. The standards include requirements for the provision of  detainee medical care, access to legal representation, and grievance  procedures, among other topics, to help ensure the safe and secure  operation of detention facilities. The 2000 NDS were formed through a  collaborative effort among former Immigration and Naturalization Service  officials, Department of Justice officials, and representatives of non- governmental organizations, according to ICE documents that describe  changes to detention standards over time. The standards were modelled  after standards for detention facilities issued by the American Correctional  Association.
In 2004, the American Correctional Association updated its standards and  issued the 4th Edition Performance-Based Standards for Adult Local  Detention Facilities. ICE then began to revise its own detention standards  to more fully align with those of the American Correctional Association,  according to ICE documents. The revision of ICE’s standards continued  through 2007 and resulted in the formulation of the 2008 Performance- Based National Detention Standards (PBNDS). The Division of  Immigration Health Services, now the ICE Health Service Corps,  contributed to the development of the medical care and other health- related standards. The draft PBNDS were reviewed by the Detention  Standards Compliance Unit of ICE, Division of Immigration Health  Services, Office of the Principal Legal Advisor. Those offices then  finalized the draft PBNDS with input from the ICE Office of Detention  Policy and Planning, and the Department of Homeland Security’s Office  of Civil Rights and Civil Liberties. Following this review of the new  standards, ICE solicited input from interested non-governmental  organizations, according to ICE documents.
In addition to requirements dictating how detention facilities should  operate, the PBNDS outline expected outcomes, or results that the  required procedures found in the standards are expected to accomplish.  These expected outcomes align with outcome measures found on  inspection worksheets, which guide and document facility inspections.  According to ICE documents, the outcome measures indicate how well a  facility is doing what the standards require and how well the facility is  achieving the expected results found in the standards.
ICE further revised the PBNDS for a 2011 version to improve conditions  of confinement, including the improvement of medical and mental health  services and the process for reporting and responding to detainee  complaints, as stated in ICE documentation. In the 2000 NDS and the  2008 PBNDS, some requirements applied only to Contract Detention  Facilities and Service Processing Centers. The 2011 PBNDS expanded  those requirements to dedicated intergovernmental service agreement  facilities to make conditions of confinement more uniform at facilities  housing only ICE detainees. Non-dedicated intergovernmental service  agreement facilities following the 2011 PBNDS must conform to the  procedures required of dedicated facilities, or must adopt procedures that  meet the intent of those requirements. In the 2011 PBNDS, ICE made  some of those required standards of the 2008 PBNDS applicable to all  facilities. “Medical facilities within the detention facility shall achieve and maintain current  accreditation with the standards of the National Commission on Correctional Health Care,  and shall maintain compliance with those standards.”
According to ICE documents, facilities following the 2011 standards are  not required to maintain National Commission on Correctional Health  Care accreditation, but ICE intends optimal medical care processes to  follow practices for such accreditation, as this accreditation would help to  ensure that facilities meet the expected outcome of providing a continuum  of health care services. “The facility’s provision of gynecological and obstetrical health care shall be in compliance  with standards set by the National Commission on Correctional Health Care.”
section_title: Appendix III: Analysis of Site Visit and Detainee Interview Data
paragraphs: We visited a purposive, non-generalizable sample of 12 over-72-hour  detention facilities in Arizona, California, Illinois, Maryland, Missouri,  Texas, and Wisconsin. We selected these facilities based on a mix of  factors, such as facility type, detention standards governing the facility,  the U.S. Immigration and Customs Enforcement (ICE) Field Office Area of  Responsibility, average daily population (ADP) of detainees, and  recommendations made by the DHS and organizations that work with  immigration detainees. We interviewed a non-generalizable sample of  120 detainees to determine their perception of medical care at each  facility and their knowledge of filing medical care complaints, among other  things. We randomly selected detainees to interview at each of the 12  facilities, and we interviewed between 6 and 12 detainees per visit  depending on the time allotted for interviews. Detainees spoke various  languages, and some detainees were not proficient in English. We  interviewed detainees in both English and Spanish, and we used a  translation service for interviews conducted in other languages, such as  Punjabi and Burmese. We did not require each detainee to answer every  question during the interviews. We did not verify detainees’ claims  following interviews. For instance, we did not conduct reviews of  detainees’ medical files to determine whether they had received medical  screenings upon arrival at a facility. The non-generalizable sample of  detainees interviewed is not reflective of the current population of ICE  detainees. We also observed facilities’ practices regarding medical care  and grievance systems, such as the posting of required DHS hotline  information, the placement of grievance boxes, and the layout of medical  care areas. The information we obtained from our facility visits cannot be  generalized to all facilities or detainees, but offers insight into the  operational settings at facilities, such as how medical care standards are  applied and assessed and the management of medical care grievance  processes.
The detainees that we interviewed reported that they had been in  detention at the sample of facilities for varying amounts of time. Figure 7  shows the approximate length of time that the sample of detainees had  been in detention at the time of our interviews. Of the 119 detainees who  reported the length of their detention at each facility, 47—approximately  40 percent—said they had been in detention for less than 1 month, and  86—approximately 70 percent—said they had been in detention for less  than 3 months at the time of the interviews. The remaining 33  detainees—approximately 30 percent—said they had been in detention  for at least 3 months at the time of our interviews.
ICE requires that, upon admission, facilities provide detainees with  information regarding facility rules and procedures, as well as medical  care services and the grievance system. When asked about materials  received upon arrival at the detention facilities, 118 detainees responded  whether they had or had not received written materials or participated in  an orientation session that described medical care services. Of these  detainees, 65 said that they did receive information regarding medical  care services at the facility. Another 42 detainees said that they did not  receive information about medical care, and 11 said that they received  general facility information but did not recall whether or not it described  medical care services.
When asked, 117 detainees responded about whether they knew how to  file a complaint about medical care received at the detention facilities, and  50 stated that they knew how to report complaints about medical care at  the facility, while the remaining 67 said that they did not know how to file  complaints. Table 7 shows the number of respondents at facilities  following ICE’s four different detention standards who said that they did or  did not know how to file a medical care complaint. The table shows that  detainees at facilities using the 2011 Performance-Based National  Detention Standards (PBNDS) reported higher rates of knowledge of the  complaint process than at facilities using any of ICE’s other detention  standards.
One facility that we visited had been found deficient in a fiscal year 2014  inspection in the standard requiring facility handbooks to provide  guidance regarding how detainees may appeal a grievance decision.  When we spoke to detainees at this facility, eight of nine were generally  unfamiliar with grievance processes, and said that they did not know how  to file a complaint.
ICE detention standards require that detainees receive a medical  screening within 12 hours of arrival at a detention facility. We asked  detainees whether they had received a medical screening upon arrival  and whether facility staff had provided an explanation for the screening.  Of 108 detainees, 67 said that staff did explain the reasons for the  screening, 34 stated that staff did not explain the reasons for the  screening, and 7 could not recall if an explanation had been given. Table  8 shows the number of detainees at each facility type who reported  receiving an initial medical screening within the same day of arrival, after  the first day of arrival, or not at all. The table shows that detainees at  facilities with intergovernmental service agreements (IGSA) reported  more instances of receiving screenings after their first day at the facility or  of not receiving medical screenings.
One facility that we visited had been found deficient in the detention  standard requiring medical screenings to occur within 12 hours of arrival  during a fiscal year 2014 inspection. When we visited that facility, 11 of  the 12 detainees we spoke with stated that they had received an initial  screening within the same day of arrival. The twelfth respondent at this  facility stated that he had received a screening but did not specify when.
During a fiscal year 2015 inspection of a family residential facility that we  visited, inspectors noted that all medical files reviewed for residents  indicated that medical screenings had been performed within the required  12-hour period after arrival at the facility. During our interviews with 12  residents at this facility, all 12 stated that they had received a medical  screening on the same day as their arrival at the facility.
ICE detention standards also require facilities to conduct in-depth medical  examinations of detainees within 14 days of arrival at a facility. We spoke  with 96 detainees who reported whether or not they received an in-depth  medical examination and who specified when that examination took  place. Of 19 detainees who had been at the facility for 14 or fewer days,  18 had received a medical examination within that time and 1 was still  awaiting his examination. Of the 77 detainees who had been at the facility  for longer than 14 days, 48 stated that they had received a medical  examination within 14 days. The remaining 29 detainees stated that they  did not receive a medical examination within 14 days, either because they  had received an examination after 14 days, or because they had never  received a medical examination.
During a fiscal year 2015 inspection of a family residential facility that we  visited, inspectors noted that all medical records reviewed for residents  indicated that medical examinations had occurred within two working  days of arrival. When we spoke to residents at this facility about when  they received a medical examination, all nine responded that they had  received it within 14 days of arrival.
Our analysis of interview responses found that 50 detainees had  requested additional medical care while at the detention facilities and that  25 had requested this care during medical clinic hours, known as sick  call. Another 9 detainees visited the medical clinic during walk-in hours, 2  asked for care verbally, 4 used a kiosk system to request care, and 1  requested care during the medical examination. The remaining 9  detainees did not specify how they had requested additional medical  care. Of the 50 detainees who had requested care, 9 reported having to  wait an unspecified amount of time to receive care, while 1 detainee  stated that he was still waiting for care. Figure 8 shows the amount of  time that the other 40 detainees reported having to wait to receive care.  The figure shows that more than half of detainees interviewed who  requested medical care at a facility reported receiving that care by the  following day.
Of those who received additional medical care, 22 indicated that they  were generally satisfied with the wait time or felt that the wait time was  acceptable. Another 12 respondents indicated that they were unsatisfied  with the amount of time it took to receive medical care. The remaining 15  respondents did not indicate their levels of satisfaction with their wait  time.
One facility that we visited received a deficiency during a fiscal year 2015  inspection for the detention standard that requires detainees’ medical  information to remain protected. Inspectors found that detainees  submitted medical care request slips to nursing or detention staff, which  did not ensure patient privacy since the request slips contained medical  information. During our site visit to this facility, we observed medical care  request slips (i.e., “sick call” slips) inserted through door frames by  detainees without a confidential envelope to protect the medical  information present on the request slips.
Overall, the majority of detainees who expressed their opinions about  medical care received at the facilities felt generally positive or neutral  about their care. Of 55 detainees who expressed their views, 20 felt  generally positive about their medical care services, 9 felt generally  negative, 23 felt neutral or “okay,” and 3 stated that their medical  problems were not treated, as seen in Figure 9.
Table 9 shows detainees’ reported satisfaction with medical care received  by facility population type (i.e., mixed adult, ICE-only adult, or ICE-only  family populations). The table shows that detainees housed at ICE-only  facilities reported fewer instances of negative perceptions of their medical  care than detainees housed at facilities holding other detained individuals,  such as state or county prisoners.
During our interviews with detainees, 42 respondents provided  suggestions for improving medical care at detention facilities, as seen in  figure 10. Approximately half of the detainee responses suggested that  facilities could improve their timeliness of responses to requests for  medical care and medication, as well as more regular check-ups to  ensure that detainees remain healthy while in detention. Approximately  one quarter of responses suggested more appropriate and adequate  medical care. That is, the detainees suggested that facilities have more  services available, as well as provide treatment that addresses detainees’  medical issues. The remainder of responses suggested improved  communication from and among medical staff, as well as improved  translation, better record keeping of treatments, and better coordination  with outside providers. Of the detainees that we spoke to, 13 stated that  language barriers exist for filing complaints and requesting medical care  at facilities, specifically because guidance is provided to detainees in  English rather than Spanish or other relevant languages.
section_title: Appendix IV: Description of U.S. Immigration and Customs Enforcement (ICE) Medical Care Oversight Mechanisms
paragraphs: Based on our review of ICE policy, ICE uses the following seven  oversight mechanisms to assess facility compliance with medical care  detention standards and to inspect the quality of medical care at facilities:
Custody Management Division (CMD) Inspections
Operational Review Self-Assessments (ORSA)
Field Medical Coordinator (FMC) Site Visits  ICE Health Service Corps (IHSC) Quality Improvement Audits
Office of Detention Oversight (ODO) Inspections
Detention Service Managers (DSM)
During fiscal year 2015, more than 99 percent of ICE’s average daily  population (ADP) was covered by two or more of these oversight  mechanisms.
subsections: section_title: Custody Management Division Inspections
paragraphs: The Custody Management Division of ICE Enforcement and Removal  Operations (ERO) employs a contractor to conduct inspections of  detention facilities against the National Detention Standards (NDS) and  Performance-Based National Detention Standards (PBNDS). The  contractor utilizes a checklist inspection form to identify line item  deficiencies at a facility. The form also provides space for the contractor  to make notes about line items within a standard, allowing the contractor  to clarify why an item is or is not deficient. Line items represent smaller  parts of an overall standard, and facilities can receive deficiencies for  individual line items without receiving a deficiency on the standard overall.  Inspections are conducted annually or biennially at facilities that are  authorized to house detainees for more than 72 hours, and that have an  ADP of 10 or more detainees. After two consecutive years of overall  passing ratings for annual inspections, those facilities with an ADP of  fewer than 50 detainees may be moved to a biennial inspection schedule.  Following the inspection, the contractor submits deficiencies to CMD for  the development of uniform corrective action plans to help ensure that the  deficiencies are addressed, according to a CMD official, and CMD  records the implementation of these action plans. In 2014, 90 over-72- hour facilities underwent inspections by CMD contractors. Inspectors  found 62 medical care line item deficiencies at 30 facilities. Table 10  shows the frequency of line item deficiencies found at over-72-hour  facilities in 2014. Two-thirds of facilities had no medical care line item  deficiencies that year. No facilities inspected in 2014 had overall deficient  medical care standards.
section_title: Operational Review Self-Assessments
paragraphs: Over-72-hour facilities with an ADP of fewer than 10 detainees complete  an annual ORSA. This inspection process began in 2012. Like the CMD  inspections, ORSAs are checklist inspections that assess facility  compliance against the NDS or a sub-set of the NDS. ORSAs are  completed by ERO Field Office staff, facility staff, or both. Deficiencies  found also require action plans for resolution, and officials stated that they  record the implementation of those action plans. Table 11 shows the  number of over-72-hour facilities that conducted ORSAs from 2012  through 2014, as well as the number of medical care line item  deficiencies found. In 2012, one facility had three line item medical care  deficiencies, one facility had two deficiencies, and one facility had one  deficiency.
section_title: Family Residential Inspections
paragraphs: The Juvenile and Family Residential Management Unit within CMD  oversees inspections of family residential facilities, and employs an  inspections contractor other than that utilized for adult facility inspections.  Family residential facilities receive monthly, semiannual, and annual  inspections, which use a checklist to assess compliance against the 2007  Family Residential Standards. The family residential inspection process  uses a checklist format, and also includes a narrative aspect to describe  the substance of deficiencies. Juvenile and Family Residential  Management officials stated that this narrative aspect allows for more in- depth analyses of results than those performed using only a compliance  checklist. For instance, officials cited an example of a detention standard  that requires a response to medical issues within 72 hours. Inspectors  using only a checklist might validate whether there was any response  regarding the issue within that 72-hour timeframe. The family residential  inspections contractor, however, could use the narrative inspection fields  to describe how the response was or was not substantially responsive to  the issue, allowing for a more detailed validation of compliance, according  to officials. Action plans for deficiencies found during inspections are  developed and implemented by the Juvenile and Family Residential  Management Unit. During inspections in February 2015 and September  2014, respectively, two family residential facilities each had one medical  care line item deficiency.
section_title: Field Medical Coordinator Site Visits
paragraphs: IHSC uses FMCs to conduct semiannual site visit inspections of medical  care at facilities that house detainees for over 72 hours where IHSC does  not directly provide care to detainees. During these inspections, FMCs  assess a facility’s compliance with medical care standards found in the  NDS and the PBNDS. FMCs conduct reviews of detainees’ medical  records using a set of audit worksheets developed in conjunction with the  Department of Homeland Security’s Office for Civil Rights and Civil  Liberties (CRCL). Compliance with an indicator requires that 90 percent  of files reviewed for that indicator meet requirements set forth on the audit  worksheet. FMCs conduct these inspections approximately every 6  months, visiting each over-72-hour facility within their respective  geographical areas of responsibility during that period. FMCs visit a  facility more frequently if the facility has many deficiencies regarding  medical care. If numerous deficiencies are found at a facility, FMCs send  their findings to ERO and request an action plan for resolution of each  deficiency. Full results for fiscal year 2015 site visit inspections were not  available at the time of this report’s issuance, but IHSC provided an  example of results for review. This example, while not inclusive or  representative of all results, showed that IHSC intends to track site visits  by date, noting overall compliance level with the medical care standard,  as well as recommendations and facility actions to be taken.
section_title: IHSC Quality Improvement Audits
paragraphs: IHSC conducts quarterly quality improvement audits at the approximately  20 IHSC-staffed medical clinics in detention facilities. These audits use  worksheets similar to those used by FMCs, and Quality Improvement  Coordinators conduct medical record file reviews to assess the quality of  care at each clinic. Facilities are compliant in an indicator when 90  percent or more of the files reviewed satisfy the requirements of the  respective audit worksheet. If an indicator falls below the established  threshold for compliance, the facility is required to submit a corrective  action plan and consider conducting a study about the issue, according to  an IHSC official. In fiscal year 2014, IHSC identified nine indicators that  fell below this 90 percent compliance threshold when viewed across all  IHSC-staffed facilities. That is, the aggregated compliance across the  total number of IHSC-staffed facilities, rather than compliance of  individual facilities, fell below 90 percent for these nine indicators. Of  these nine deficient indicators, the lowest compliance score was 73  percent. According to officials, IHSC also conducts random continuous  quality improvement “spot check” audits via medical records reviews to  help determine the accuracy of quarterly facility audits. These audits are  conducted monthly at the headquarters level. The quarterly audits identify  local issues at the facility level, and IHSC officials stated that they use the  results to improve healthcare delivery by monitoring and identifying high- risk, high-volume, or problem-prone process or systemic issues and  developing and implementing strategies for improvement. Results are  shared internally at IHSC and are sent to ERO upon request for the  development of a corrective action plan.
section_title: Office of Detention Oversight Inspections
paragraphs: ODO, within ICE’s Office of Professional Responsibility, conducts annual  inspections at a risk-based sample of over-72-hour facilities with an ADP  of more than 10 detainees, according to a senior ODO official and ODO  documentation. ODO gives a risk score to each facility to reflect a  facility’s risk and probability of being deficient with detention standards.  Risk factors used in scoring facilities include the following: deficiencies found in CMD inspections; number of deficiencies found; number and type of complaints and allegations;  record of significant incidents, such as detainee deaths, hunger  strikes, or suicide attempts; operation by ICE contractors;  last date of ODO inspection; and last date of CMD inspection.
ODO conducts as many inspections per fiscal year as the budget allows,  and the office prioritizes inspections by facility risk score, according to a  senior ODO official. ODO’s goal, starting in fiscal year 2016, is to modify  its risk-based methodology and prioritize facilities for inspections based  on their last ODO inspection date and to inspect all over-72-hour facilities  with an ADP of more than 10 detainees within a three-year period. During  these inspections, ODO assesses facility compliance with a core set of  standards, including medical care. These standards are ones that, if  found to be deficient, could have the greatest impact on detainee health,  safety, and civil rights and civil liberties. ODO may inspect facilities  against additional standards based on trends and areas of concern found  in various sources, such as CMD inspection reports and previous ODO  inspection findings. The inspections also include interviews with a  representative sample of detainees. ODO staff lead all inspections, and  they use contract subject matter experts as needed. Medical care subject  matter experts accompany ODO staff on all facility inspections to conduct  an inspection of the medical care-related detention standards.  Deficiencies found are sent to ERO in the form of a narrative facility  report. ERO is then responsible for the development and implementation  of corrective action plans for each deficiency. Table 12 shows the  frequency of deficiencies found at facilities inspected by ODO during  fiscal years 2011 through 2014. In each year, the majority of facilities  received two or fewer medical care line item deficiencies. In fiscal years  2012 and 2014, 67 and 53 percent of facilities inspected, respectively,  received at most one medical care line item deficiency.
section_title: Detention Service Managers
paragraphs: DSMs have a continuous presence at facilities to provide informal, on-the- spot guidance for corrections of minor deficiencies, that is, those  deficiencies that are isolated or non-life-threatening. DSMs speak with  detainees on a regular basis to help identify issues within a facility, and  they collaborate with facility staff to identify and fix deficiencies. In fiscal  year 2015, DSMs operated in 53 of the 165 over-72-hour facilities that we  analyzed. Of these facilities, 42 had a permanent DSM, while 11 used a  roving DSM that oversaw multiple facilities. The ADP of facilities with a  DSM was generally over 50 detainees in fiscal year 2015; four facilities  had an ADP of 39, 43, 45, and 49, according to ICE data. DSMs send  their findings to regional management each week through a narrative  report that offers a more formal description of the work done and  deficiencies found by the DSM, and provides details of the conditions of  confinement at a facility. DSMs may request corrective action plans for  any severe deficiencies found in a facility. At the start of fiscal year 2016,  DSMs began tracking key metrics from weekly narrative reports, such as  the number of compliance monitoring deficiencies found and the number  of on-the-spot corrective actions logged by facilities, according to a senior  CMD official.
section_title: Appendix V: Comments from the Department of Homeland Security
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Jeanette Espinola (Assistant  Director), Alyssia Borsella, Carla Brown, Sarah Harvey, Eric Hauswirth,  David Lutter, Robin Marion, Jon Najmi, Tovah Rom, and Cynthia  Saunders made key contributions to this report.