At the time of our visits, we observed instances of noncompliance with ICE’s medical care standards at 3 of the 23 facilities we visited. However, these instances did not show a pervasive or persistent pattern of noncompliance across the facilities like we those identified with the telephone system. Detention facilities that we visited ranged from those with small clinics with contract staff to facilities with on-site medical staff, diagnostic equipment such as X-ray machines, and dental equipment. Medical service providers include general medical, dental, and mental health care providers that are licensed by state and local authorities. Some medical services are provided by the U.S. Public Health Service (PHS), while other medical service providers may work on a contractual basis. At the San Diego Correctional Facility in California, an adult detention facility, ICE reviewers that we accompanied cited PHS staff for failing to administer the mandatory 14-day physical exam to approximately 260 detainees. PHS staff said the problem at San Diego was due to inadequate training on the medical records system and technical errors in the records system. At the Casa de San Juan Family Shelter in California, we found that the facility staff did not administer medical screenings immediately upon admission, as required in ICE medical care standards. At the Cowlitz County Juvenile Detention Center in Washington state, we found that no medical screening was performed at admission and first aid kits were not available, as required. Officials at some facilities told us that meeting the specialized medical and mental health needs of detainees can be challenging. Some also cited difficulties they had experienced in obtaining ICE approval for outside nonroutine medical and mental health care as also presenting problems in caring for detainees. On the other hand, we observed instances where detainees were receiving specialized medical care at the facilities we visited. For example, at the Krome facility in Florida we observed one detainee sleeping with the assistance of special breathing equipment (C- PAP machine) to address what we were told was a sleep apnea condition. At the Hampton Roads Regional jail in Virginia we observed a detainee receiving treatment from a kidney dialysis machine. Again, assessing the quality of care and ICE’s decision—making process for approval of nonroutine medical procedures were outside the scope of our review. We reviewed the most recently available ICE annual inspection reports for 20 of the 23 detention facilities that we visited. With the exception of the San Diego facility in California, the reports covered a different time period than that of our review. The 20 inspection reports showed that ICE reviewers had identified a total of 59 instances of noncompliance, 4 of which involved medical care. According to ICE policy, all adult, juvenile, and family detention facilities are required to be inspected at 12-month intervals to determine that they are in compliance with detention standards and to take corrective actions if necessary. As of November 30, 2006, according to ICE data, ICE had reviewed approximately 90 percent of detention facilities within the prescribed 12-month interval. Subsequent to each annual inspection, a compliance rating report is to be prepared and sent to the Director of the Office of Detention and Removal or his representative within 14 days. The Director of the Office of Detention and Removal has 21 days to transmit the report to the field office directors and affected suboffices. Facilities receive one of five final ratings in their compliance report—superior, good, acceptable, deficient, or at risk. ICE officials reported that as of June 1, 2007, 16 facilities were rated “superior,” 60 facilities were rated “good,” 190 facilities were rated “acceptable,” 4 facilities were rated “deficient,” and no facilities were rated “at risk.” ICE officials stated that this information reflects completed reviews, and some reviews are currently in process and pending completion. Therefore, ICE could not provide information on the most current ratings for some facilities. Four inspection reports disclosed instances of noncompliance with medical care standards. The Wakulla County Sheriffs Office in Florida had sick call request forms that were available only in English whereas the population was largely Spanish speaking. The Cowlitz County Juvenile Detention Facility in Washington state did not maintain the alien juvenile medical records on-site. The San Diego Correctional facility staff, in addition to the deficiencies noted earlier in this statement, failed to obtain informed consent from the detainee when prescribing psychiatric medication. Finally, the Broward Transitional Center in Florida did not have medical staff on-site to screen detainees arriving after 5 p.m. and did not have a properly locked medical cabinet. We did not determine whether these deficiencies were subsequently addressed as required. Our review of available grievance data obtained from facilities and discussions with facility management showed that the types of grievances at the facilities we visited typically included the lack of timely response to requests for medical treatment, missing property, high commissary prices, poor quality or insufficient quantity of food, high telephone costs, problems with telephones, and questions concerning detention case management issues. ICE’s detainee grievance standard states that facilities shall establish and implement procedures for informal and formal resolution of detainee grievances. Four of the 23 facilities we visited did not comply with all aspects of ICE’s detainee grievance standards. Specifically, Casa de San Juan Family Shelter in San Diego did not provide a handbook to those aliens in its facility, the Cowlitz County Juvenile Detention Center in Washington state did not include grievance procedures in its handbook, Wakulla County Sheriff’s Office in Florida did not have a log, and the Elizabeth Detention Center in New Jersey did not record all grievances that we observed in their facility files. The primary mechanism for detainees to file external complaints is directly with the OIG, either in writing or by phone using the DHS OIG complaint hotline. Detainees may also file complaints with the DHS Office for Civil Rights and Civil Liberties (CRCL), which has statutory responsibility for investigating complaints alleging violations of civil rights and civil liberties. In addition, detainees may file complaints through the Joint Intake Center (JIC), which is operated continuously by both ICE and U.S. Customs and Border Protection (CBP) personnel, and is responsible for receiving, classifying, and routing all misconduct allegations involving ICE and CBP employees, including those pertaining to detainee treatment. ICE officials told us that if the JIC were to receive an allegation from a detainee, it would be referred to the OIG. OIG may investigate the complaint or refer it to CRCL or DHS components such as the ICE Office of Professional Responsibility (OPR) for review and possible action. In turn, CRCL or OPR may retain the complaint or refer it to other DHS offices, including ICE Office of Detention and Removal (DRO), for possible action. Further, detainees may also file complaints with nongovernmental organizations such as ABA and UNHCR. These external organizations said they generally forward detainee complaints to DHS components for review and possible action. The following discussion highlights the detainee complaints related to medical care issues where such information is available. We did not independently assess the merits of detainee complaints. Of the approximately 1,700 detainee complaints in the OIG database that were filed in fiscal years 2003 through 2006, OIG investigated 173 and referred the others to other DHS components. Our review of approximately 750 detainee complaints in the OIG database from fiscal years 2005 through 2006 showed that about 11 percent involved issues relating to medical treatment, such as a detainees alleging that they were denied access to specialized medical care. OPR stated that in fiscal years 2003 through 2006, they had received 409 allegations concerning the treatment of detainees. Seven of these allegations were found to be substantiated, 26 unfounded, and 65 unsubstantiated. Four of the seven substantiated cases involved employee misconduct, resulting in four terminations. According to OPR officials, three cases were still being adjudicated and the nature of the allegations was not provided. Additionally, 200 of the allegations were classified by OPR as either information only to facility management, requiring no further action, or were referred to facility management for action, requiring a response. CRCL also receives complaints referred from the OIG, nongovernmental organizations, and members of the public. Officials stated that from the period March 2003 to August 2006 they received 46 complaints related to the treatment of detainees, although the nature of the complaints was not identified. Of these 46 complaints, 14 were closed, 11 were referred to ICE OPR, 12 were retained for investigation, and 9 were pending decision about disposition. We could not determine the number of cases referred to DRO or their disposition. On the basis of a limited review of DRO’s complaints database and discussions with ICE officials knowledgeable about the database, we concluded that DRO’s complaint database was not sufficiently reliable for audit purposes. We recommended that ICE develop a formal tracking system to ensure that all detainee complaints referred to DRO are reviewed and the disposition, including any corrective action, is recorded for later examination. We reviewed 37 detention monitoring reports compiled by UNHCR from the period 1993 to 2006. These reports were based on UNHCR’s site visits and its discussions with ICE officials, facility staff, and detainee interviews, especially with asylum seekers. Eighteen of the 37 UNHCR reports cited concerns related to medical care, such as detainee allegations that jail staff were unresponsive to requests for medical assistance and UNHCR’s concern about the shortage of mental health staff. While American Bar Association officials informed us that they do not keep statistics regarding complaints, they compiled a list for us of common detainee complaints received through correspondence. This list indicated that of the 1,032 complaints it received from January 2003 to February 2007, 39 involved medical access issues such as a detainee alleging denial of necessary medication and regular visits with a psychiatrist, allegations of delays in processing sick call requests, and allegations of a facility not providing prescribed medications. Madam Chairman, this concludes my prepared remarks. I would be happy to answer any questions you or the members of the subcommittee have. For further information on this testimony, please contact Richard M. Stana at (202) 512-8777 or by e-mail at stanar@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. In addition to the contact named above, William Crocker III, Assistant Director; Minty Abraham; Frances Cook; Robert Lowthian; and Vickie Miller made key contributions to this statement. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

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