OIG-18-67 - ICE's Inspections And Monitoring Of Detention .

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security x Inspections by the Office of Detention Oversight (ODO): ODO is unit ofthe ICE’s Office of Professional Responsibility, Inspections and DetentionOversight Division. ODO is institutionally separate from ERO. As such, ODOinspections aim to provide ICE executive leadership with an independentassessment of detention facilities. About once every 3 years, ODO alsoinspects detention facilities that hold ICE detainees more than 72 hours(and have an average daily population of more than 10 detainees). ODOadjusts its inspection schedule based on perceived risk, ICE direction, ornational interest. ODO leadership determines the facilities to review eachyear based on staffing budget, agency priorities, and special requests by ICEleadership. Contract staff from Creative Corrections, LLC support ODOteams. ODO inspects facilities to determine compliance with 15 to 16 “core”standards, identified in appendix D. ODO inspected 23 facilities in FY 2015,29 in FY 2016, and 33 in FY 2017. ODO also inspects all types of facilitieslisted in table 1, but less frequently.x Monitoring by the Detention Service Managers (DSM): ICE ERO CustodyManagement also has a Detention Monitoring Program through which onsiteDSMs at select facilities, covering each facility type listed in table 1,continuously monitor compliance with ICE detention standards. InDecember 2017, 35 DSMs monitored compliance with ICE detentionstandards at 54 facilities holding more than 70 percent of detainees. BothNakamoto and ODO still inspect facilities that have DSMs as the inspectionprocesses are separate from the onsite monitoring.The responsibility for monitoring follow-up and corrective actions resultingfrom ICE’s detention oversight falls to the Detention Standards and ComplianceUnit (DSCU), also within ICE ERO Custody Management, and to ICE ERO fieldoffices. Detention facilities develop Uniform Corrective Action Plans (UCAP)when either Nakamoto or ODO inspections find instances of noncompliance.DSCU and ICE ERO field office managers work with facilities to resolve theissues.We evaluated policies, procedures, and inspection practices, and we observedNakamoto and ODO inspections of detention facilities. Between April andAugust 2017, we observed Nakamoto inspections at Irwin County DetentionCenter in Ocilla, Georgia, and at Johnson County Detention Center inCleburne, Texas. We observed ODO inspections at Eloy Detention Center inEloy, Arizona, and at Stewart Detention Center in Lumpkin, Georgia. We alsoreviewed a sample of Nakamoto and ODO inspection reports and UCAPs toevaluate how ICE reports on and corrects identified deficiencies. For ourobservations, we used a limited judgmental sample and relied on ourwww.oig.dhs.gov 3OIG-18-67

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security professional judgment as inspectors to draw conclusions when we observedpractices of Nakamoto and ODO inspection teams. We also interviewed nineDSMs from various types of facilities. In this review we sought to determine theeffectiveness of both ICE’s immigration detention inspection and follow-upprocesses as well as its monitoring of detention facilities.Results of InspectionNeither type of inspection ICE uses to examine detention facilities ensuresconsistent compliance with detention standards or comprehensive correction ofidentified deficiencies. Specifically, because the Nakamoto inspection scope istoo broad, ICE’s guidance on procedures is unclear, and Nakamoto’s inspectionpractices are not consistently thorough, its inspections do not fully examineactual conditions or identify all compliance deficiencies. In contrast, ODO useseffective methods and processes to thoroughly inspect facilities and identifydeficiencies, but the inspections are too infrequent to ensure the facilitiesimplement all corrections. Moreover, ICE does not adequately follow up onidentified deficiencies or systematically hold facilities accountable for correctingdeficiencies, which further diminishes the usefulness of both Nakamoto andODO inspections. In addition, ICE ERO field offices’ engagement with onsiteDSMs is inconsistent, which hinders implementation of needed changes.Although ICE’s inspections, follow-up processes, and DSMs’ monitoring offacilities help correct some deficiencies, they do not ensure adequate oversightor systemic improvements in detention conditions; certain deficiencies remainunaddressed for years.As some of our previous work indicates, ICE’s difficulties with monitoring andenforcing compliance with detention standards stretch back many years andcontinue today. In 2006, the Office of Inspector General (OIG) identified issuesrelated to ICE detention facility inspections and implementation of correctiveactions. In our 2006 report, we recommended that ICE “improve the inspectionprocess and ensure that all non-compliance deficiencies are identified andcorrected.”7 In a December 2017 report, which related to OIG’s unannounced Treatment of Immigration Detainees Housed at Immigration and Customs EnforcementFacilities, OIG-07-01, December 20067www.oig.dhs.gov 4OIG-18-67

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security inspections of five detention facilities, we identified problems in some of thesame areas noted in the 2006 report.8Nakamoto Inspections Are Significantly Limited and Office ofDetention Oversight Inspections Are Not Frequent EnoughAfter observing Nakamoto and ODO inspections in detention facilities andevaluating their inspection methods, practices, and reports, we determined thatICE detention facility compliance enforcement is lacking because Nakamoto’sinspection scope is too broad; ICE does not provide clear guidance onprocedures; and the Nakamoto inspectors are not always thorough. In contrast,ODO’s inspections are better scoped and more comprehensive, but are tooinfrequent to ensure compliance and effect regular and consistent changes indetention conditions. Both sets of inspections have value, but their weaknessesrender them inadequate to promote effective oversight. In the followingparagraphs we detail the inspections’ strengths and weaknesses.Pre-inspection: ICE only requires the Nakamoto teams to review previousoversight reports and inspection results for a facility during pre-inspectionresearch. Therefore, Nakamoto inspectors typically limit their pre-inspectionresearch to reviewing previous Nakamoto inspection reports and UCAPs for theinspected facility. Prior to each inspection, according to a Nakamoto manager,an introductory letter, inspection notification letter, and a blank facilityincident form are sent to the detention facility. When applicable, the detentionfacilities complete the incident form, detailing any incident that may haveoccurred during the year between inspections.In contrast, before visiting a detention facility, ODO policies direct ODOinspection teams to research and compile information from the facility and therelevant ERO field office.9 We reviewed ODO’s pre-inspection packages, whichincluded documents from the facility and ICE ERO, such as contracts, facilityrecords, local ERO policies and procedures, complaints the ICE Joint IntakeCenter received about the facility, and any detainee death reports. The preinspection materials also included policies on emergency response, safetyinspections, and use of force. Through this research, ODO teams check forpotential deficiencies before they arrive at the facility, which allows more timeon site to assess detention conditions instead of reviewing policies andprocedures. Concerns about ICE Detainee Treatment and Care at Detention Facilities, OIG-18-32, December2017 9 ICE ERO has 24 field offices that manage detention operations in their geographic area. 8www.oig.dhs.gov 5OIG-18-67

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security Scope: The Nakamoto inspection scope is too broad to be completed by a smallteam in a short timeframe. Under its Statement of Work (SOW) with ICE,Nakamoto must determine compliance with all 39 to 42 applicable detentionstandards by examining more than 650 elements of the standards at more than100 facilities a year. Typically, three to five inspectors have only 3 days tocomplete the inspection, interview 85 to 100 detainees, brief facility staff, andbegin writing their inspection report for ICE. Even with a full 5-memberinspection team, each of four inspectors has to evaluate compliance with about10 standards. The fifth inspector completes a Quality of Medical CareAssessment,10 when applicable, which includes using 20 checklists, eachrequiring review of 10 to 20 patient records. Nakamoto inspectors also told usthat it was difficult to complete their work in the allotted time.Under ODO’s guidance, ODO teams assess compliance with 15 or 16 “core”standards selected because deficiencies in these standards could mostsignificantly impact a detainee’s health, safety, civil rights, and civil liberties.11Hence, ODO inspections appear to be appropriately scoped for the size of theteams performing the work. A typical ODO team has six or seven inspectors,consisting of three ODO employees and three or four contractors from CreativeCorrections, LLC. Each member of the ODO team has 3 days to assesscompliance with either two or three detention standards. We observed anadequate number of ODO inspectors and contractors, who appeared to have areasonable workload and enough time to thoroughly inspect facilities, as wellas observe and validate actual detention conditions. However, although it helpsto narrow the scope, by limiting its inspections to assessing just the “core”standards, ODO is scrutinizing compliance with fewer than half of the NDS orPBNDS standards. Guidance and Inspection Practices: ICE provides Nakamoto with detentionreview summary forms and inspection checklists to determine compliance withdetention standards, but it does not give Nakamoto clear procedures forevaluating detention conditions. In general, the Nakamoto inspection practiceswe observed fell short of the SOW requirements. Specifically, we saw someinspectors observing and validating “the actual conditions at the facility,” perthe SOW, but other Nakamoto inspectors relied on brief answers from facility In 2016, ICE added a Quality of Medical Care Assessment to Nakamoto’s inspection of “over72 hour” facilities. ICE Health Service Corps and the DHS Office for Civil Rights and CivilLiberties developed a standardized quality of care audit toolkit. Most of the measures are notdetention standard requirements.11 ODO may review standards outside of the “core” standards based on conditions at the facilityor at the request of ICE leadership. Appendix D contains details on the core standards.10www.oig.dhs.gov 6OIG-18-67

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security staff and merely reviewed written policies and procedures instead of observingand evaluating facility conditions. Some inspectors did not consistently look atdocumentation to substantiate responses from staff or ensure the facility wasactually implementing the policies and procedures.12 For example:x An inspector documented that A-files13 contained required identificationdocuments without checking the actual files.x Facility staff told inspectors that drivers had commercial driving licensesas required, but the inspectors did not review records to confirm.x An inspector encountered two detainees held in administrativesegregation14 because, according to the facility officer, they arrived late thenight before and no space was available in the general population area ofthe facility. The inspector did not follow up to ensure the placement inadministrative segregation was properly documented as required.x Some Nakamoto inspectors relied on responses from facility employees whowere not responsible for the areas and functions the inspectors wereinquiring about, such as asking a classification officer responsible foradmissions about the standards relating to Visitation and Law Library,instead of asking staff responsible for those areas.In contrast, ODO has developed clear procedures and effective tools to helpinspectors thoroughly inspect facilities. During the two inspections weobserved, each ODO inspector used the checklist to determine “line-by-line”compliance with two or three detention standards. In addition, the inspectorsdevoted most of their time to observing facility practices, validatingobservations through records review, and interviewing ICE and facilityemployees and detainees.ODO teams consistently identify more deficiencies than Nakamoto when thetwo groups inspect the same facilities. For example, in FY 2016, for the same Several ICE employees in the field and managers at ICE ERO headquarters commented thatNakamoto inspectors “breeze by the standards” and do not “have enough time to see if the[facility] is actually implementing the policies.” They also described Nakamoto inspections asbeing “very, very, very difficult to fail.” One ICE ERO official suggested these inspections are“useless.”13 A-file refers to an Alien File, a file that identifies a non-citizen by unique personal identifiercalled an Alien Registration Number. A-Files are official files for all immigration andnaturalization records.14 Detention facility staff sometimes segregate detainees from a detention facility’s generalpopulation using two types of segregation disciplinary and administrative. Although separatedfrom other detainees, detainees in segregation are permitted daily contact with detention andmedical staff, as well as time for recreation, library, and religious activities. 12www.oig.dhs.gov 7OIG-18-67

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security 29 facilities ODO and Nakamoto inspected, ODO’s teams found 475deficiencies while Nakamoto teams reported 209 deficiencies. Given that ODOlooks at 15 to 16 standards and Nakamoto inspects 39 to 42 standards, themuch larger number of deficiencies identified by ODO is surprising.Detainee Interviews: For the two inspections we observed, Nakamoto reportedinterviewing between 85 and 100 detainees, but the interviews we saw duringthese two inspections did not comply with the SOW and we would notcharacterize them as interviews. The SOW requires detainee interviews toinclude “private conversations with individual detainees (in a confidentialarea),” but we did not see any interviews taking place in private settings.Instead, inspectors had brief, mostly group conversations with detainees intheir detention dorms or in common areas in the presence of detention facilitypersonnel, generally asking four or five basic questions about treatment, food,medical needs, and opportunities for recreation. Describing these discussionsbetween Nakamoto inspectors and detainees as “interviews” is not consistentwith the SOW requirements.The SOW also requires Nakamoto inspectors to interview detainees who do notspeak English, but we did not observe any interviews Nakamoto inspectorsconducted in a language other than English, nor any interviews in whichinspectors used available DHS translation services. In fact, inspectors selecteddetainees for interviews by first asking whether they spoke English. During oneinspection, a facility guard translated for a detainee. Inspectors did notconsistently follow up with the facility or ICE staff on issues detainees raised.Conversely, we observed ODO teams closely following ODO guidance oninterviewing a representative sample of detainees, in confidential settings, andin languages detainees understand. ODO teams used an interview form thatincluded a wide range of questions about the living conditions, safety, and wellbeing of detainees and elicited candid responses and insight on facilityconditions. According to ODO policy, depending on the size of the facility,inspectors interview between 10 and 40 detainees, including all detainees insegregation. We observed ICE ODO staff interviewing about 30 detainees oneon-one in a confidential setting, separate from facility staff and ICE employees.We also observed ODO inspectors interviewing every detainee in segregation.Inspectors selected detainees to interview based on a number of factors, suchas length of detention, age, medical history, and the detainee’s country oforigin. ODO used the DHS language telephone line for translation andinterviewed some detainees in Spanish and other languages. ODO teamsdiscussed every issue raised during these interviews with facility and ICEwww.oig.dhs.gov 8OIG-18-67

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security officials and identified a number of deficiencies that may have gone undetectedwithout these interviews.Onsite Briefings: Both Nakamoto and ODO inspectors briefed facility staff atthe end of each day. As a result, we identified some deficiencies that werecorrected while inspectors were onsite, such as discontinuing the practice ofcharging ICE detainees for medical co-payments, requiring more privacy formedical examinations, repairing inoperable telephones, and updating facilityhandbooks. Although Nakamoto does not track such onsite corrective actions,ODO does — for example, in FY 2016, ODO recorded 106 onsite corrections to475 identified deficiencies at 29 facilities. Initiating onsite corrections is a goodpractice.Reporting: Following each inspection, Nakamoto sends ERO a completedchecklist with an assessment of each element of the evaluated standards and asummary of the inspection. We identified inaccuracies in Nakamoto’s summaryreports and checklists we selected for our sample. In some instances,Nakamoto’s reports misrepresented the level of assurance or the workperformed in evaluating the actual conditions of the facility and the informationin the reports was inconsistent with what we observed during inspections. Forexample:x Nakamoto reported “Detainees were familiar with ICE officers andunderstood how to obtain assistance from ICE officers and the casemanagers. Interviews yielded positive comments regarding access to libraryservices, access to case managers and visiting opportunities.” However, weheard detainees tell inspectors they did not know the identity of their ICEdeportation officer or how to contact the officer. We did not observeinspectors asking any detainees about law library services or visitingopportunities.x At one facility, we discovered it was impossible to dial out using any tollfree number, including the OIG Hotline number, due to telephone companyrestrictions on the facility. We alerted the facility, which started working tocorrect this facility-wide issue by modifying the directions for dialing tollfree numbers. Although the issue was not corrected until the third day ofthe inspection, a Nakamoto inspector wrote on a checklist that aninspector could reach the OIG Hotline from several units on the second dayof the inspection.x At another facility, Nakamoto inspectors questioned an ICE employeeabout the facility’s correction officer duties, instead of actually interviewingwww.oig.dhs.gov 9OIG-18-67

OFFICE OF INSPECTOR GENERALDepartment of Homeland Security correction officers. Yet, Nakamoto insp

Management also has a Detention Monitoring Program through which onsite DSMs at select facilities, covering each facility type listed in table 1, continuously monitor compliance with ICE detention standards. In December 2017, 35 DSMs monitored compliance with ICE detention standards at 54 f