COMMISSION ON ACCREDITATION FOR CORRECTIONS
STANDARDS COMPLIANCE REACCREDITATION AUDIT
Department of Homeland Security
El Paso Service Processing Center
El Paso, Texas
October 16-18, 2006
VISITING COMMITTEE MEMBERS
Chairperson
Correctional Consultant
713 Moraine Avenue
Midwest City, Oklahoma 73130
(405)
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C

t

1958 Parallel Road
Lexington, Kentucky 40511
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(859)
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Correctional Consultant
1229 Westward Drive
Miami Springs, Florida 33166
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(305)

A.

Introduction
The audit of the Department of Homeland Security El Paso Service Processing Center
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was conducted on October 16-18, 2006 by the following team:
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Chairperson;
Member; and
Member.
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B.

Facility Demographics
Rated Capacity: 1.070
Actual Population: 771
Average Daily Population for the last 12 months: 771
Average Length of Stay: 1 month (no average stay at this time, new mission goal)
Security/Custody Level: Federal Administrative Detainees
Age Range of Offenders: 22-59 years
Gender: Male/Female detainees
Full-Time Staff: 234
76 Administrative, 113 Security, Program staff 16, and 29 other

C.

Facility Description
The El Paso Processing Center is a part of the Homeland Security, Bureau of
Immigration and Customs Enforcement, Detention and Removal Operations. The
facility is located in the city of El Paso, Texas. The facility is located approximately half
miles south of the El Paso International Airport. The El Paso Processing Center and
the United States Border Patrol occupies and shares 27 acres of land. The facility is
the holding and processing facility for detainees while they are processed regarding their
right to remain in the United States.
The facility was opened in 1968 under the Bureau of Immigration and Custom
Enforcement. The name of the facility and its’ mission was changed twice with the last
change to Immigration and Customs Enforcement El Paso Processing Center in 2003
and was placed under the Department of Homeland Security by an act of congress. The
normal rated capacity for the facility is 861 and the emergency capacity is 1,221. El
Paso Processing Center houses both male and female detainees with each being housed
separately.
The El Paso Processing Center (EP/ICE) is enclosed by a double wire fence which is
has razor wire on both the top and bottom. There are no towers or roving vehicles. The
facility houses, classifies and remove detainees from other countries who have not be
authorized to stay in America. The average stay of a detainee is 20-45 days.
There are 33 buildings, three single cells with 90 square footage, 17 segregation cells
and 14 open bay dormitories. Buildings seven and eight are housing units that consist
2

of four pods, each with the capacity to house sixty-four detainees. Buildings one to four
are barrack style living units with the same capacity. Buildings five and six are special
housing and temporary housing units. The new Special Housing Unit was opened on
the second day of this audit.
The mission of the facility is: To promote public safety and national security by
ensuring the departure from the United States of all removable aliens through the fair
and effective enforcement of the nation’s immigration laws.
D.

Pre-Audit Meeting
The chairperson divided standards into the following groups:
Standards # 4ALDF-1A-01 to # 4ALDF-2C-06
Standards # 4ALDF-2D-01 to # 4ALDF-5A-10
Standards # 4ALDF-5B-01 to # 4ALDF-7F-07

E.

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Chairperson
Member
, Member

The Audit Process
1.

The team reviewed the pre-audit materials provided by the facility, and met in the
City of El Paso on October 15, 2006 to discuss the information.
The team was escorted to the facility by
Officer.

2.

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, Health and Safety

Interview
The audit team proceeded to the office of
Officer in Charge
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(OIC). The team expressed the apprec
ssociation for the
opportunity to be involved with Immigration and Customs Enforcement El Paso
Center in the accreditation process.
Officer in Charge b6,b7c was informed that the team would be at the facility for
all shifts and wou
o review all programs and talk with as many staff and
offenders as time would allow and that the end of each day the team would inform
the warden of our findings and plans for the next day.
OIC
entry

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escorted the team to the Multi-Purpose Room where the formal
was held. The following persons were in attendance:
, Field Officer Director
, Officer in Charge
Health/Safety Officer
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Assistant Field Office Director
, Assistant Field Office Director
, Chief
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, Health Services Administrator
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Assistant Officer in Charge
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, Assistant Officer in Charge
Project Manager DECO Security
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aintenance supervisor
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, DECO Security Captain
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ood Supervisor
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, Training Officer
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, ACA Manager
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, ACA Team Member
IEA
ACA Team Member
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IEA
CA Team Member
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IEA
ACA Team Member
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It was explained that the goal of the visiting team was to be as helpful and nonintrusive as possible during the conduct of the audit. The chairperson emphasized
the goals of accreditation toward the efficiency and effectiveness of correctional
systems throughout the United States. The schedule was also discussed at this
time.
3.

Facility Tour
The team toured the facility from 8:30 a.m. to 2:30 p.m. and again from 2:15
p.m. to 3:45 p.m. The following persons accompanied the team on the tour and
responded to the team's questions concerning facility operations.
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4.

IOC
CA Manager
IEA
IEA
, IEA
, IEA
, Health and Safety Officer/IEA

Conditions of Confinement/Quality of Life
Security
The facility contracts with the DECO for security personnel that oversee the
detainees in the daily operations of the facility. There are 290 uniformed officers
4

and ten supervisors. The unformed staff works three to eight hour shifts and is
trained in accordance to the Immigration Service Agency policies and procedures.
Detainees are classified using Levels I-III and are dressed in specific colors for
security and identification purposes.
The facility has a well stored fire arm storage areas and equipment is maintained
and there is good documentation.
Environmental Conditions
Housing units are well organized and free of clutter. There are ample showers,
sinks and commodes. Each housing unit has a day room area for inmates to relax,
write letter, read and watch telephone. Lighting and noise levels are in acceptable
levels. Each housing unit is equipped with space for staff to conduct their duties
with restroom facilities that are separated from the offenders.
Sanitation
Sanitation at El Paso Processing Center is being maintained at a high level. The
facility has a system of control and accountability of the caustic that is to be
commented. Cleaning supplies are delivered to the different areas at a specific
time and are returned before the end of the day shift.
Fire Safety
The fire and safety regulations are being followed with the documentation of fire
drills and follow-up from the local fire departments. The facility is equipped with
fire alarms, fire extinguishers and posted fire exit signs throughout the facility.
The facility has good procedures in the handling and control of the cleaning
supplies and other toxic materials. At no time are detainees allowed to handle the
maintenance tools with out the immediate supervision of staff.
Food Service
The team sampled the lunch meals on two days of the audit. The food was found
it to be have the properly temperatures, was tasteful and was found to be more that
the daily requirement of calories. The agency philosophy is that most of the
detainees diets were lacking in the calories needed for good health. Thus the
detainees are given more food than is required. Normal daily calories are 2400
and the facility gives 3000 calories per day. The cost of a meal is $1.41. Sack
lunches are provided for detainees arriving after normal working hours. The
facility offers special meals to include medical, kosher and Muslim.
5

The facility has a dining room areas and detainees are allowed time to complete
their meals. The detainees and staff workers were clean and equipped with
required clothing and other equipment to perform their jobs. Temperatures for
the freezer and other storage areas were well maintained.
Medical Care
The facility has a seven bed infirmary and three isolation units. There is a full
time doctor, dentist, position for a social worker (currently vacant), and a host of
nursing staff. All psychological problems are referred to the Thompson General
Hospital located approximately five minutes from the facility. The medical staff
dispenses medication 24 hour per day and sick call is conducted five days a week.
The facility has a small waiting room and utilizes an outdoor recreation yard for
the detainees while they wait to be seen by the staff. The medication and
equipment was controlled and well documented. However, it was recommended
that the area that the medication carts were being stored needed to be placed
behind a locked door. The carts are locked, but they are stored in a room that has
no door.
Recreation
The facility has two full-time Recreation Specialists. Recreational opportunities
are available to the detainees in the form of yards, with weight/exercise equipment,
indoor and outdoor games, and televisions that are mounted in each housing unit.
The facility does not have a gymnasium, however, each housing unit and the
medical unit has yards for the detainee to exercise and participate in physical
fitness activities.
Religious Programming
Religious services are available to the detainee in their native language and are
provided by three religious staff members and a host of religious volunteers.
Offender Work Programs
Detainee workers are utilized on a voluntary basis. Detainees are given
opportunities to work in the food service area, law and leisure library, outside/
inside maintenance crews paint and wax the floors, and dorm laundry. The facility
has a “woman laundry” detail that cleans the facility. Other detainees are
encouraged to keep their living areas clean. Each working detainee is paid $1
(one dollar) a day that he or she can keep in their personal belongings. The money
is paid in cash. Worker detainees are dressed in specific colors for identification
purposes.
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Academic and Vocational Education
There is no educational or vocational programming at the El Paso Processing
center.
Social Services
Social Services are provided to the detainees by the Immigration Enforcement
personnel who assist the detainees in maintaining ties with their families and
country agencies. In services include, but is not limited to assisting the detainees
with help in obtain birth certificates, them to know rights and procedures,
visitation approval and translators services.
Visitation
Visitation is held seven days a week, during the evening hours. Detainees are
allowed contact visitation with families. Attorney and special visitation are
approved in advance. The facility has two visitation areas for the detainees to visit.
The facility has ample room equipped with vending machines, lockers for visitors’
property and an area for the children of the offenders. Visitation is conducted
indoor only.
Library Services
Library services are provided to the detainees seven days a week. The main library
has a small but an ample amount of books and periodical for the population. The
facility has one law clerk and one office clerk. The library is equipped with both
computers and typewriter for the detainees to use.
Laundry
Detainees are issued one set of clothing upon arrival to the unit. There is an
institutional laundry that cleans the clothing and each housing unit has a washer
and dryer for the use of the detainees per an approved schedule. The facility has
an ample supply of replacement clothing in case of emergencies.
F.

Examination of Records
Following the facility tour, the team proceeded to the Multi-Purpose Room to review
the accreditation files and evaluate compliance levels of the policies and procedures. The
facility has no notices of non-compliance with local, state, or federal laws or regulations.

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1.

Litigation
Over the last three years, the facility had no consent decrees, class action lawsuits
or adverse judgments.

2.

Significant Incidents/Outcome Measures
The facility has thirteen detainees- on- detainee assaults for this reporting period.
No weapons were uses. There was on detainee assault on staff and that was not a
direct assault. There were no escapes, suicides, or attempts. Based upon the
professional judgment and experience of the team the small numbers of incidents
represents a well ran facility in which the mission is being upheld and policy being
followed making the facility safe for both the staff and offenders.

3.

Departmental Visits
Team members revisited the following departments to review conditions relating to
departmental policy and operations:
Department Visited
Control room

**Person(s) Contacted
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Officers

SHU
Law Library
Messhall
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DOS
Deportations
OIC
Yard Maintenance
Armory
C-Unit
Recreation
Intake
Processing
Classification/DACS
Identification
Property Officer
Armed Post
Jail Run
Medical

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Rover
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,

4.

Shifts
a.

Day Shift
The team was present at the facility during the day shift from 7:55 a.m. to
4:00 p.m. The team was present and observed detainees in various activities
from being processed into the facility, in their living areas, on the many
recreational yards and in medical. The team was also present to observe a
court proceeding.

b.

Evening Shift
The team was present at the facility during the evening shift from 3:00 p.m.
to 4:30 p.m. The team observed the feeding of the evening meal, detainees
in the law/leisure library, and in the living areas playing their musical
instruments, and watching the community televisions. A shift change and
briefing was made and the team members spoke with the on-coming shift
concerning the ACA process and meanings.

c.

Night Shift
The team was present at the facility during the night shift from 7:00 a.m. to
8:00 a.m. The team was present during the change of shift and to talk with
the staff on the first shift as they completed their shift. Staff was eager to
share with the team how they felt about the facility, the new mission, and the
administration team.

5.

Status of Previously Non-compliant Standards/Plans of Action
The team reviewed the status of standards previously found non-compliant, for
which a waiver not granted, and found the following: This is the facility first audit
under the fourth edition standards. During the course of the audit, team members
met with both staff and offenders to verify observations and/or to clarify questions
concerning facility operations.

G.

Interviews
1.

Offender Interview
The team interviewed approximately 87 offenders. The team received few
complaints from the detainees and the ones that were heard had been addressed by
the approximate staff member. Most of the detainees appeared to be at eased in
the environment and in their interactions with the staff.
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2.

Staff Interviews
The team spoke with approximately 52 staff members. Most expressed how
pleased they are to be working at the facility especially with recent changes in the
mission, population and administration. This was noticed in both the ICE staff
and the contract staff as well.

H.

Exit Discussion
The exit interview was held at 11:00 a.m. in the Multi-Purpose Room with the Officer
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in Charge,
and 15 staff in attendance.
The following persons were also in attendance:
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Field Office Director
eputy Field Officer Director
Assistant Field Director
Asst. OIC
, Assistant OIC
Project Manager DECO Security

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COMMISSION ON ACCREDITATION FOR CORRECTIONS
AND THE
AMERICAN CORRECTIONAL ASSOCIATION

COMPLIANCE TALLY

Manual Type

Adult Local Detention Facilities, fourth edition

Supplement

2006 Standards Supplement

Facility/Program
Audit Dates
Auditor(s)

El Paso Service Processing Center
October 16-18, 2006
Chairperson;

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and

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MANDATORY

NON-MANDATORY

Number of Standards in Manual

61

322

Number Not Applicable

0

37

Number Applicable

61

285

Number Non-Compliance

0

1

Number in Compliance

61

284

Percentage (%) of Compliance

100%

99.6%

•

Number of Standards minus Number of Not Applicable equals Number Applicable

•

Number Applicable minus Number Non-Compliance equals Number Compliance

•

Number Compliance divided by Number Applicable equals Percentage of Compliance

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COMMISSION ON ACCREDITATION FOR CORRECTIONS
Department of Homeland Security
El Paso Service Processing Center
El Paso, Texas
October 16-18, 2006
Visiting Committee Findings
Non-Mandatory Standards
Non-Compliance
Standard # 4ALDF-2A-35
INMATES NOT SUITABLE FOR HOUSING IN MULTIPLE OCCUPANCY
CELLS ARE HOUSED IN SINGLE OCCUPANCY CELLS. NO LESS THAN
TEN PERCENT OF THE RATED CAPACITY OF THE FACILITY IS
AVAILABLE FOR SINGLE OCCUPANCY.
FINDINGS
Inmates not suitable for housing in multiple occupancy cells are housed in single
occupancy cells are housed in single occupancy cells. No less than ten percent of the rated
capacity of the facility is available for single occupancy.
The EP/ICE does not meet rated capacity. The total population is 759 with seven single
cell units.
AGENCY RESPONSE
Plan of action
Congress has allocated funding for the drafting and design of a new 203 single cell secure
dorm. The drafting and design plans have been completed and approved for a 203 bed
single cell secure dorm. We are currently pending additional congressional allocations
which will include funding for the 203 bed single cell unit.
AUDITOR RESPONSE
The visiting committee does not find the plan of action acceptable.
12

COMMISSION ON ACCREDITATION FOR CORRECTIONS
Department of Homeland Security
El Paso Service Processing Center
El Paso, Texas
October 16-18, 2006
Visiting Committee Findings
Mandatory Standards
Not Applicable
Standard #4-ALDF-2A-36
INMATES PARTICIPATING IN WORK OR EDUCATIONAL RELEASE
PROGRAMS ARE SEPARATED FROM INMATES IN THE GENERAL
POPULATION.
FINDINGS
Inmates participating in work or educational release programs are separated from inmates
in the general population.
Standard #4-ALDF-2A-38
IF YOUTHFUL OFFENDERS ARE HOUSED IN THE FACILITY, THEY ARE
HOUSED IN A SPECIALIZED UNIT FOR YOUTHFUL OFFENDERS
EXCEPT WHEN:
• VIOLENT, PREDATORY YOUTHFUL OFFENDER POSES AN UNDUE
RISK OF HARM TO OTHERS WITHIN THE SPECIALIZED UNIT, OR
• A QUALIFIED MEDICAL OR MENTAL-HEALTH SPECIALIST
DOCUMENTS THAT THE YOUTHFUL OFFENDER WOULD BENEFIT
FROM PLACEMENT OUTSIDE THE UNIT
A WRITTEN STATEMENT IS PREPARED DESCRIBING THE SPECIFIC
REASONS FOR HOUSING A YOUTHFUL OFFENDER OUTSIDE THE
SPECIALIZED UNIT AND A CASE-MANAGEMENT PLAN SPECIFYING
WHAT BEHAVIORS NEED TO BE MODIFIED AND HOW THE
YOUTHFUL OFFENDER MAY RETURN TO THE UNIT. THE
STATEMENT OF REASONS AND CASE-MANAGEMENT PLAN MUST
BE APPROVED BY THE FACILITY ADMINISTRATOR OR HIS/HER

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DESIGNEE. CASES ARE REVIEWED AT LEAST QUARTERLY BY THE
CASE MANAGER, THE ADMINISTRATOR OR HIS OR HER DESIGNEE,
AND THE YOUTHFUL OFFENDER TO DETERMINE WHETHER A
YOUTHFUL OFFENDER SHOULD BE RETURNED TO THE
SPECIALIZED UNIT.
FINDINGS
The EP/ICE facility does not house youthful offenders.
Standard #4-ALDF-2A-39
DIRECT SUPERVISION IS EMPLOYED IN THE SPECIALIZED UNIT TO
ENSURE THE SAFETY AND SECURITY OF YOUTHFUL OFFENDERS.
FINDINGS
The EP/ICE unit does not house youthful offenders.
Standard #4-ALDF-2A-40
CLASSIFICATION PLANS FOR YOUTHFUL OFFENDERS DETERMINE
THE LEVEL OF RISK AND PROGRAM NEEDS DEVELOPMENTALLY
APPROPRIATE FOR ADOLESCENTS. CLASSIFICATION PLANS INCLUDE
CONSIDERATION OF PHYSICAL, MENTAL, SOCIAL, AND EDUCATIONAL
MATURITY OF THE YOUTHFUL OFFENDER.
FINDINGS
The EP/ICE unit does not house youthful offenders.
Standard #4-ALDF-2A-41
ADEQUATE PROGRAM SPACE IS PROVIDED TO MEET THE PHYSICAL,
SOCIAL, AND EMOTIONAL NEEDS OF YOUTHFUL OFFENDERS AND
ALLOWS FOR THEIR PERSONAL INTERACTIONS AND GROUPORIENTED ACTIVITIES.
FINDINGS
The EP/ICE unit does not house youthful offenders.

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Standard #4-ALDF-2A-42
YOUTHFUL OFFENDERS IN THE SPECIALIZED UNIT FOR YOUTHFUL
INMATES HAVE NO MORE THAN INCIDENTAL SIGHT OR SOUND
CONTACT WITH ADULT INMATES FROM OUTSIDE THE UNIT IN
LIVING, PROGRAM, DINING, OR OTHER COMMON AREAS OF THE
FACILITY. ANY OTHER SIGHT OR SOUND CONTACT IS MINIMIZED,
BRIEF, AND IN CONFORMANCE WITH APPLICABLE LEGAL
REQUIREMENTS.
FINDINGS
The EP/ICE unit does not house youthful offenders.
Standard #4-ALDF-2A-43
PROGRAM PERSONNEL WHO WORK WITH YOUTHFUL OFFENDERS
ARE TRAINED IN THE DEVELOPMENTAL, SAFETY, AND OTHER
SPECIFIC NEEDS OF YOUTHFUL OFFENDERS.
WRITTEN JOB
DESCRIPTIONS AND QUALIFICATIONS REQUIRE TRAINING FOR STAFF
WHO ARE RESPONSIBLE FOR PROGRAMMING OF YOUTHFUL
OFFENDERS IN THE SPECIALIZED UNIT BEING ASSIGNED TO WORK
WITH YOUTHFUL OFFENDERS. TRAINING INCLUDES, BUT IS NOT
LIMITED TO THE FOLLOWING AREAS:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

ADOLESCENT DEVELOPMENT
EDUCATIONAL PROGRAMMING
CULTURAL AWARENESS
CRISIS PREVENTION AND INTERVENTION
LEGAL ISSUES
HOUSING AND PHYSICAL PLANT
POLICIES AND PROCEDURES
MANAGEMENT OF, PROGRAMMING FOR, SEX OFFENDERS
SUBSTANCE-ABUSE SERVICES
COGNITIVE-BEHAVIOR INTERVENTION, INCLUDING ANGER
MANAGEMENT, SOCIAL-SKILLS TRAINING PROBLEM SOLVING
RESISTING PEER PRESSURE
SUICIDE PREVENTION
NUTRITION
MENTAL-HEALTH ISSUES
GENDER-SPECIFIC ISSUES
CASE-MANAGEMENT PLANNING AND IMPLEMENTATION

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FINDINGS
EP/ICE does not house youthful offenders.
Standard #4-ALDF-4A-14
WHEN REQUIRED BY STATUTE, FOOD PRODUCTS THAT ARE GROWN
OR PRODUCED WITHIN THE SYSTEM ARE INSPECTED AND APPROVED
BY THE APPROPRIATE GOVERNMENT AGENCY; THERE IS A
DISTRIBUTION SYSTEM THAT ENSURES PROMPT DELIVERY OF
FOODSTUFFS TO FACILITY KITCHENS.
FINDINGS
El Paso Processing Center does not produce or grow foodstuff to be used in the kitchen.
Standard #4-ALDF-2C-02
WHEN A CANINE-UNIT IS OPERATED BY THE FACILITY:
•
•
•
•
•
•

•

THERE IS A MISSION STATEMENT, INCLUDING GOALS AND
OBJECTIVES
THE CIRCUMSTANCES IN WHICH CANINE UNITS MAY BE USED
ARE CLEARLY DEFINED
EMERGENCY PLANS FOR CANINE USE ARE INTEGRATED INTO
THE OVERALL EMERGENCY PLANS OF THE FACILITY
THERE ARE CRITERIA FOR SELECTION, TRAINING, AND CARING
FOR ANIMALS
THERE ARE CRITERIA FOR THE SELECTING, TRAINING, AND
EVALUATING PHYSICAL FITNESS OF HANDLERS
THERE IS AN APPROVED SANITATION PLAN THAT COVERS
INSPECTION,
HOUSING,
TRANSPORTATION
AND
DAILY
GROOMING FOR THE ANIMALS
THERE ARE DAILY AND CURRENT RECORDS ON TRAINING CARE
OF DOGS, AND SIGNIFICANT EVENTS.

FINDINGS
The El Paso Processing Center does not have a canine unit.
STANDARD #4-ALDF-4C-02
WHEN MEDICAL CO-PAYMENT FEES ARE IMPOSED, THE PROGRAM
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ENSURES THAT, AT A MINIMUM:
•

•

ALL INMATES ARE ADVISED, IN WRITING, AT THE TIME OF
ADMISSION TO THE FACILITY OF THE GUIDELINES OF THE COPAYMENT PROGRAM
CO-PAYMENT FEES ARE WAIVED WHEN APPOINTMENTS OR
SERVICES,
INCLUDING
FOLLOW-UP
APPOINTMENTS,
ARE
INITIATED BY MEDICAL STAFF

FINDINGS
The institution does not charge medical co payments or fees.
Standard #4-ALDF-4C-39
WHEN INMATES HAVE NONPRESCRIPTION MEDICATIONS AVAILABLE
OUTSIDE OF HEALTH SERVICES, THE ITEMS, AND ACCESS, ARE
APPROVED JOINTLY BY THE FACILITY ADMINISTRATOR AND THE
HEALTH AUTHORITY.
THE ITEMS AND ACCESS ARE REVIEWED
ANNUALLY BY THE HEALTH AUTHORITY AND ADMINISTRATOR.
FINDINGS
Per policy, detainees are not allowed to have prescription medication outside of health
services unit.
Standard #4-ALDF-4D-11
UNLESS PROHIBITED BY STATE LAW, INMATES, UNDER STAFF
SUPERVISION, MAY PERFORM FAMILIAL DUTIES COMMENSURATE
WITH THEIR LEVEL OF TRAINING. THESE DUTIES MAY INCLUDE THE
FOLLOWING:
•
•
•
•

•
•
•

PEER SUPPORT AND EDUCATION
HOSPICE ACTIVITIES
ASSISTING IMPAIRED INMATES ON A ONE-ON-ONE BASIS WITH
ACTIVITIES OF DAILY LIVING
SERVING AS SUICIDE COMPANION IF QUALIFIED AND TRAINED
THROUGH A FORMAL PROGRAM THAT IS PART OF A SUICIDE
PREVENTION PLAN
INMATES ARE NOT TO BE USED FOR THE FOLLOWING DUTIES:
PERFORMING DIRECT PATIENT CARE SERVICES
SCHEDULING HEALTH CARE APPOINTMENTS
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•

DETERMINING
ACCESS
TO
SURGICAL
INSTRUMENTS,
SYRINGES, NEEDLES, MEDICATIONS, OR HEALTH RECORDS

FINDINGS
Operating diagnostic or therapeutic equipment except under direct supervision, by
specially trained staff, in a vocational training program.
Detainees are not used in the delivery of medical services.
Standard #4-ALDF-5A-05
THERE IS A TREATMENT PHILOSOPHY WITHIN THE CONTEXT OF THE
TOTAL CORRECTIONAL SYSTEM AS WELL AS GOALS AND
MEASURABLE OBJECTIVES. THESE DOCUMENTS ARE REVIEWED AT
LEAST ANNUALLY AND UPDATED AS NEEDED.
FINDINGS
The EP/ICE unit does not have Therapeutic treatment program.
Standard #4-ALDF-5A-06
THERE IS AN APPROPRIATE RANGE OF PRIMARY TREATMENT
SERVICES FOR ALCOHOL AND OTHER SUBSTANCE-ABUSING
INMATES THAT INCLUDE, AT A MINIMUM, THE FOLLOWING:
•
INMATE DIAGNOSIS
•
IDENTIFIED PROBLEM AREAS
•
INDIVIDUAL TREATMENT OBJECTIVES
•
TREATMENT GOALS
•
COUNSELING NEEDS
•
DRUG EDUCATION PLAN
•
RELAPSE PREVENTION AND MANAGEMENT
•
CULTURALLY
SENSITIVE
TREATMENT
OBJECTIVES,
AS
APPROPRIATE
•
THE PROVISION OF SELF-HELP GROUPS AS AN ADJUNCT TO
TREATMENT
•
PRERELEASE AND TRANSITIONAL SERVICES
•
COORDINATING EFFORTS WITH COMMUNITY SUPERVISION
AND TREATMENT STAFF DURING THE PRERELEASE PHASE TO
ENSURE A CONTINUUM OF SUPERVISION AND TREATMENT

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FINDINGS
ICE/EPC does not have a drug treatment program.
Standard #4-ALDF-5A-07
THE FACILITY USES A COORDINATED STAFF APPROACH TO DELIVER
TREATMENT SERVICE. THIS APPROACH TO SERVICE DELIVERY IS
DOCUMENTED IN TREATMENT PLANNING CONFERENCES AND IN
INDIVIDUAL TREATMENT FILES.
FINDINGS
ICE/EPC des not have a drug treatment program.
Standard #4-ALDF-5A-08
THERE ARE INCENTIVES FOR TARGETED TREATMENT PROGRAMS TO
INCREASE AND MAINTAIN THE INMATE’S MOTIVATION FOR
TREATMENT.
FINDINGS
ICE/EPC does not have a drug treatment program.
Standard #4-ALDF-5A-09
INMATES HAVE ACCESS TO EDUCATIONAL PROGRAMS AND, WHEN
AVAILABLE, TO VOCATIONAL COUNSELING AND VOCATIONAL
TRAINING. EDUCATIONAL AND VOCATIONAL PROGRAMS ADDRESS
THE NEEDS OF THE INMATE POPULATION.
FINDINGS
ICE/EPA does not have educational or vocational programming.
Standard #4-ALDF-5A-10
IN FACILITIES OFFERING ACADEMIC AD VOCATIONAL TRAINING
PROGRAMS, CLASSROOMS ARE DESIGNED IN CONSULTATION WITH
SCHOOL
AUTHORITIES.
(RENOVATION,
ADDITION,
NEW
CONSTRUCTION ONLY).

19

FINDINGS
ICE/EPC does not offer educational or vocational programming.
Standard #4-ALDF-5B-14
WHEN THE FACILITY IS DESIGNATED TO OPERATE ANY TYPE OF
PRETRIAL INTERVENTION SERVICE OR OTHER RELEASE PROGRAMS
ITS AUTHORITY AND RESPONSIBILITY ARE STATED BY STATUTE OR
ADMINISTRATIVE REGULATION.
FINDINGS
ICE/EPC does not offer pretrial intervention services.
Standard #4-ALDF-5B-15
WHEN A PRETRIAL INTERVENTION PROGRAM, DIVERSION PROGRAM,
PRETRIAL RELEASE PROGRAM, OR SUPERVISED RELEASE PROGRAM
IS CONDUCTED IN THE FACILITY, SUFFICIENT STAFF, SPACE, AND
EQUIPMENT ARE PROVIDED TO SERVICE THE PROGRAM.
FINDINGS
ICE/EPC does not offer pretrial intervention programming.
Standard #4-ALDF-5B-16
WHERE TEMPORARY RELEASE PROGRAMS EXIST, THE PROGRAMS
HAVE THE FOLLOWING ELEMENTS:
•
•
•
•
•

WRITTEN OPERATIONAL PROCEDURES
CAREFUL SCREENING AND SELECTION PROCEDURES
WRITTEN RULES OF INMATE CONDUCT
A SYSTEM FOR EVALUATING PROGRAM EFFECTIVENESS
EFFORTS TO OBTAIN COMMUNITY COOPERATION
SUPPORT.

FINDINGS
ICE/EPC des not have a temporary release program.

20

AND

Standard #4-ALDF-5B-17
WHERE WORK RELEASE AND/OR EDUCATIONAL RELEASE ARE
AUTHORIZED, THE FACILITY ADMINISTRATOR HAS AUTHORITY TO
APPROVE OR DISAPPROVE PARTICIPATION FOR EACH INMATE.
FINDINGS
EP/ICE does not provide programs related to work release or educational release.
Standard #4-ALDF-5C-07
THE FACILITY REQUIRES ALL SENTENCED INMATES TO WORK IF
THEY ARE NOT ASSIGNED TO PROGRAMS.
FINDINGS
EP/ICE does not require any detainee to perform any work programs.
Standard #4-ALDF-5C-08
PRETRIAL AND UNSENTENCED INMATES ARE NOT REQUIRED TO
WORK EXCEPT TO DO PERSONAL HOUSEKEEPING AND TO CLEAN
THEIR HOUSING AREA. INMATES ARE ALLOWED TO VOLUNTEER FOR
WORK ASSIGNMENTS.
FINDINGS
EP/ICE does not house pretrial or un-sentenced inmates.
Standard #4-ALDF-5C-09
WHERE STATUTE PERMITS, INMATES ARE ASSIGNED TO PUBLIC
WORKS AND COMMUNITY SERVICE PROJECTS.
FINDINGS
Detainees are not allowed to participate in community service projects.
Standard #4-ALDF-5C-13
WHERE AN INDUSTRIES PROGRAM EXISTS, ITS ESTABLISHMENT IS
AUTHORIZED AND AREAS OF AUTHORITY, RESPONSIBILITY, AND
21

ACCOUNTABILITY ARE DELINEATED.
FINDINGS
The facility does not have industry program.
Standard #4-ALDF-5C-14
THE NUMBER OF INMATES ASSIGNED TO INDUSTRIES’ OPERATIONS
MEETS THE REALISTIC WORKLOAD NEEDS OF EACH OPERATING
UNIT.
FINDINGS
EP/ICE does not have an industry program.
Standard #4-ALDF-5C-15
THERE IS A COMPREHENSIVE QUALITY CONTROL PROCESS.
FINDINGS
EP/ICE does not have an industry program.
Standard #4-ALDF-5C-16
A COST ACCOUNTING SYSTEM FOR EACH INDUSTRY UNIT IS
DESIGNED, IMPLEMENTED, AND MAINTAINED IN ACCORDANCE WITH
GENERALLY ACCEPTED ACCOUNTING PRINCIPLES.
FINDINGS
EP/ICE does not have an industry program.
Standard #4-ALDF-5C-25
AN INMATE COMMISSARY OR CANTEEN IS AVAILABLE FROM WHICH
INMATES CAN PURCHASE APPROVED ITEMS THAT ARE NOT
FURNISHED BY THE FACILITY. THE COMMISSARY’S /CANTEEN’S
OPERATIONS ARE STRICTLY CONTROLLED USING STANDARD
ACCOUNTING PROCEDURES. EXCESS REVENUES DERIVED FROM THE
OPERATION OF THE COMMISSARY OR CANTEEN IS USED FOR THE
BENEFIT OF INMATES.

22

FINDINGS
EP/ICE does not have a canteen operation.
Standard #4-ALDF-5C-26
SPACE IS PROVIDED FOR AN INMATE COMMISSARY/CANTEEN, OR
PROVISIONS ARE MADE FOR A COMMISSARY SERVICE.
FINDINGS
EP/ICE does not have a canteen operation.
Standard #4-ALDF-6D-01
THE FACILITY PROVIDES SERVICES AND OPPORTUNITIES THAT
ENCOURAGE INMATES TO TAKE RESPONSIBILITY FOR THEIR
ACTIONS.
OPPORTUNITIES ARE BASED UPON VICTIMS AND
COMMUNITY INPUT AND ARE FASHIONED IN A WAY THAT SEEKS TO
AMELIORATE THE HARM DONE.
FINDINGS
EP/ICE does not provide detainees responsibility programs.
Standard #4-ALDF-7D-16
PROCEDURES GOVERN THE OPERATION OF ANY FUND ESTABLISHED
FOR INMATES. ANY INTEREST EARNED ON MONIES, OTHER THAN
OPERATION FUNDS, ACCRUES TO THE BENEFIT OF THE INMATES.
FINDINGS
EP/ICE does not govern the operation of any fund established for detainees.
Standard #4-ALDF-7D-18
THE CONDUCT OF RESEARCH COMPLIES WITH STATE AND FEDERAL
GUIDELINES FOR THE USE AND DISSEMINATION OF RESEARCH
FINDINGS AND WITH ACCEPTED PROFESSIONAL AND SCIENTIFIC
ETHICS. THE FACILITY ADMINISTRATOR REVIEWS ALL RESEARCH
PROJECTS AND APPROVES THEM BEFORE IMPLEMENTATION TO
ENSURE CONFORMANCE WITH POLICIES OF THE PARENT AGENCY.
23

INMATE PARTICIPATION IN NON-MEDICAL, NON-PHARMACEUTICAL,
AND NON-COSMETIC RESEARCH PROGRAM IS VOLUNTARY.
FINDINGS
EP/ICE does not conduct research projects on detainees.
Standard #4-ALDF-7E-02
THE FACILITY MAINTAINS A CURRENT, CONFIDENTIAL PERSONNEL
RECORD ON EACH EMPLOYEE. INFORMATION OBTAINED AS A PART
OF A REQUIRED MEDICAL EXAMINATION OR INQUIRY REGARDING
THE MEDICAL CONDITION OR HISTORY OF APPLICANTS AND
EMPLOYEE IS COLLECTED AND MAINTAINED ON SEPARATED FORMS
AND IN SEPARATE MEDICAL FILES AND TREATED AS A CONFIDENTIAL
MEDICAL RECORD.
FINDINGS
EP/ICE does not excess to confidential personnel records.
Standard #4-ALDF-7F-03
THE FACILITY ACTIVELY IDENTIFIES AND IMPLEMENTS ACTIVITIES
THAT CONTRIBUTE TO THE COMMUNITY.
FINDINGS
EP/ICE does not have any community projects.
Standard #4-ALDF-7F-07
IF VOLUNTEERS ARE USED IN THE DELIVERY OF HEALTH CARE,
THERE IS A DOCUMENTED SYSTEM FOR SELECTION, TRAINING,
STAFF SUPERVISION, FACILITY ORIENTATION AND DEFINITION OF
TASKS, RESPONSIBILITY AND AUTHORITY THAT IS APPROVED BY THE
HEALTH AUTHORITY. VOLUNTEERS MAY ONLY PERFORM DUTIES
CONSISTENT
WITH
THEIR
CREDENTIALS
AND
TRAINING.
VOLUNTEERS AGREE IN WRITING TO ABIDE BY ALL FACILITY
POLICIES, INCLUDING THOSE RELATING TO THE SECURITY AND
CONFIDENTIALITY OF INFORMATION.

24

FINDINGS
EP/ICE does not provide a health care volunteer program.

25

Significant Incident Summary
This summary is required to be provided to the chair of your audit team upon their arrival. The information contained on this form will also be summarized in the
narrative portion of the visiting committee report and will be incorporated into the final report. It should contain data for the last 12 months; indicate those months
in the boxes provided. Please type the data. If you have questions on how to complete the form, please contact your regional manager.
Facility

El Paso Service Processing Center, El Paso - Texas

Year

November 2005-October 2006
Months

11/05

12/05

01/06

02/06

03/06

04/06

05/06

06/06

07/06

08/06

09/06

10/06

P

P

P

P

P

P

P

P

N/A

N/A

N/A

S

0

0

0

0

0

0

0

0

0

0

0

0

4

4

1

1

2

3

3

1

0

0

0

1

N/A

N/A

N/A

N/A

N/A

P

N/A

N/A

N/A

N/A

N/A

N/A

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Number of Times
Chemical Agents Used

0

0

0

0

0

0

0

0

0

0

0

0

Number of Times Special
Reaction Team Used

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Indicate type (chair, bed,
board, etc.)

0

0

0

0

0

0

0

0

0

0

0

0

Offender Medical Referrals
as a Result of Injuries
Sustained

#’s should reflect
incidents on this form,
not rec or other source

1

1

0

1

2

2

2

3

0

0

0

0

Escapes

# Attempted

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

1

1

1

1

2

1

2

0

0

0

0

1

1

0

1

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Incidents
Assault:
Offenders/
Offenders*

Indicate types (sexual**,
physical, etc.)
# With Weapon
# Without Weapon

Assault:
Offender/
Staff

Indicate types (sexual**,
physical, etc.)
# With Weapon
# Without Weapon

Number of Forced
Moves Used***

(Cell extraction or other
forced relocation of
offenders)

Disturbances****

Four/Five Point
Restraints

Number

# Actual
Substantiated
Grievances
(resolved in favor of
offender)
Deaths

Reason (medical, food,
religious, etc.)
Number
Reason (violent, illness,
suicide, natural)
Number

*Any physical contact that involves two or more offenders
**Oral, anal or vaginal copulation involving at least two parties
***Routine transportation of offenders is not considered Aforced@
****Any incident that involves four or more offenders. Includes gang fights, organized multiple hunger strikes,
work stoppages, hostage situations, major fires, or other large scale incidents

26

ALDF Outcome Measure Worksheet
El Paso Service Processing Center, Texas
October 16-18, 2006
STANDARD

4C

OUTCOME
MEASURE

NUMERATOR
DENOMINATOR

VALUE

CALCULATE
D OUTCOME
MEASURE

Inmates maintain good health. Inmates have unimpeded
access to a continuum of health care services so that their
health care needs, including prevention and health
education, are met in a timely and efficient manner.
(1) Number of inmates with a positive tuberculin skin test on
13
admission in the past 12 months.
divided by The number of admissions in the past 12 months.
17,183
(2) Number of inmates diagnosed with active tuberculosis in the
2
past 12 months.
divided by The average daily population in the past 12 months.
805
(3) Number of conversions to a positive tuberculin skin test in the
0
past 12 months.
divided by The number of tuberculin skin tests given in the past 12
0
months.
(4) Number of inmates with a positive tuberculin skin test who
0
complete prophylaxis treatment for tuberculosis in the past 12
months.
divided by The number of inmates with a positive tuberculin skin test on
0
prophylaxis treatment for tuberculosis in the past 12 months.
(5) Number of Hepatitis C positive inmates in the past 12 months.
0
divided by The average daily population in the past 12 months.
805
(6) Number of HIV positive inmates in the past 12 months.
10
divided by The average daily population in the past 12 months.
805
(7) Number of HIV positive inmates who are being treated with
10
highly active antiretroviral treatment in the past 12 months.
divided by The number of known HIV positive inmates in the past 12
10
months.
(8) Number of inmates diagnosed with an Axis I (excluding sole
383
diagnosis of substance abuse) in the past 12 months.
divided by The average daily population in the past 12 months.
805
(9) Number of inmate suicide attempts in the past 12 months.
0
divided by The average daily population in the past 12 months.
805
(10) Number of inmate suicides in the past 12 months.
0
divided by The average daily population in the past 12 months.
805
(11) Number of inmate deaths due to homicide in the past 12
0
months.
divided by The average daily population in the past 12 months.
805
(12) Number of inmate deaths due to injuries in the past 12 months.
0
divided by The average daily population in the past 12 months.
805

27

.0007

.002

0

0

0
.01

1

.47

0

0

0

0

(13) Number of medically expected inmate deaths in the past 12
months.
divided by The average daily population in the past 12 months.
(14) Number of medically unexpected inmate deaths in the past 12
months.
divided by The average daily population in the past 12 months.
(15) Number of inmate admissions to the infirmary (where available)
in the past 12 months.
divided by The average daily population in the past 12 months.
(16) Number of inmate admissions to off-site hospitals in the past 12
months.
divided by The average daily population in the past 12 months.
(17) Number of inmates transported off-site (via an ambulance or
correctional vehicle) for treatment of emergency health
conditions in the past 12 months.
divided by The average daily population in the past 12 months.
(18) Number of inmate specialty consults completed in the past 12
months.
divided by The number of specialty consults (on-site or off-site) ordered by
primary health care provider (MD, NP, PA) in the past 12
months.
(19) Number of inmate grievances about access to health care
services found in favor of the inmate in the past 12 months.
divided by The number of inmate grievances about access to healthcare
services in the past 12 months.
(20) Number of inmate grievances related to the quality of health
care found in favor of inmates in the past 12 months.
divided by The number of inmate grievances related to the quality of
health care in the past 12 months.
(21) Number of inmates’ lawsuits about access to healthcare
services found in favor of inmates in the past 12 months.
divided by The number of inmate’s lawsuits about access to healthcare
services in the past 12 months.
(22) Number of individual sick call encounters in the past 12 months.
divided by The average daily population in the past 12 months.
(23) Number of physician visits in the past 12 months.
divided by The average daily population in the past 12 months.
(24) Number of individualized dental treatment plans in the past 12
months.
divided by The average daily population in the past 12 months.
(25) Number of hypertensive inmates enrolled in a chronic care
clinic in the past 12 months.
divided by The average daily population in the past 12 months.
(26) Number of diabetic inmates enrolled in a chronic care clinic in
the past 12 months.
divided by The average daily population in the past 12 months.
(27) Number of incidents involving pharmaceuticals as contraband
in the past 12 months.
divided by The average daily population in the past 12 months.
(28) Number of cardiac diets received by inmates with cardiac
disease in the past 12 months.
divided by The number of cardiac diets prescribed in the past 12 months.

28

0
805

0

0
805

0

216
805

.26

19
805

.02

41

.05

805
272
272

1

0
5

0

0
0

0

0
0

0

5,603
805

6.9

2,114
805

2.6

0
805

0

170
805

.21

51
805

.06

94
805

.11

0
0

0

(29) Number of hypertensive diets received by inmates with
hypertension in the past 12 months.
divided by The number of hypertensive diets prescribed in the past 12
months.
(30) Number of diabetic diets received by inmates with diabetes in
the past 12 months.
divided by The number of diabetic diets prescribed in the past 12 months.
(31) Number of renal diets received by inmates with renal disease in
the past 12 months.
divided by The number of renal diets prescribed in the past 12 months.
(32) Number of needle-stick injuries in the past 12 months.
divided by The number of employees in the past 12 months.
(33) Number of pharmacy dispensing errors in the past 12 months.

4D

170
170

1

51
51

1

1
1

1

0
30

0

6
divided by The number of prescriptions dispensed by the pharmacy in the 12,132
past 12 months.
(34) Number of nursing medication administration errors in the past
96
12 months.
divided by The number of medications administered in the past 12 months. 40,102
Health services are provided in a professionally acceptable
manner. Staff are qualified, adequately trained, and
demonstrate competency in their assigned duties.
(1) Number of staff with lapsed licensure and/or certification in the
past 12 months.
divided by The number of licensed or certified staff in the past 12 months.
(2) Number of new employees in the past 12 months who
completed orientation training prior to undertaking job
assignments.
divided by The number of new employees in the past 12 months.
(3) Number of employees who completed in-service training
requirements in the past 12 months.
divided by The number of employees eligible in the past 12 months.

.0004

.002

0
26

0

4

0.8

5
5
5

1

1
1

1

2
10

0.2

0
4

0

0

0

(4) Number of MD staff who left employment in the past 12 months.
divided by The number of authorized MD staff positions in the past 12
months.
(5) Number of RN staff who left employment in the past 12 months.
divided by The number of authorized RN staff positions in the past 12
months.
(6) Number of LPN staff who left employment in the past 12
months.
divided by The number of authorized LPN staff positions in the past 12
months.
(7) Number of medical records staff who left employment in the
past 12 months.
divided by The number of authorized medical records staff positions in the
past 12 months.
(8) Number of ancillary staff who left employment in the past 12
months.
divided by The number of authorized ancillary staff positions in the past 12

29

3
0
805

0

months.
(9) Number of alleged sexual misconduct incidents between
volunteers and/or contract personnel and detainees in the past
12 months.
divided by Average daily population in the past 12 months
(10) Number of confirmed sexual misconduct incidents between
staff and detainees in the past 12 months.
divided by Average daily population in the past 12 months
(11) Number of confirmed sexual misconduct incidents between
volunteers and/or contract personnel and detainees in the past
12 months.
divided by Average daily population in the past 12 months
(12) Number of detainees identified as high risk with a history of
sexually assault behavior in the past 12 months.
divided by Average daily population in the past 12 months
(13) Number of detainees identified as at risk for sexual victimization
in the past 12 months.
divided by

30

0

0

805
0
805

0

0

0

805
0
805

0

8
805

.009