U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
St. Paul Field Office
Hall County Department of Corrections
Grand Island, Nebraska

May 6–8, 2014

COMPLIANCE INSPECTION
HALL COUNTY DEPARTMENT OF CORRECTIONS
ST. PAUL FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................1
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations ...............................................................................................................6
ICE 2000 NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................7
Detainee Classification System............................................................................................8
Detainee Grievance Procedures ...........................................................................................9
Food Service ......................................................................................................................11
Funds and Personal Property .............................................................................................13
Medical Care ......................................................................................................................14
Sexual Abuse and Assault Prevention and Intervention ....................................................16
Special Management Unit – Disciplinary Segregation ......................................................17
Staff-Detainee Communication .........................................................................................18
Telephone Access ..............................................................................................................21
Use of Force .......................................................................................................................23

INSPECTION PROCESS
The U.S. Immigration and Customs Enforcement (ICE), Office of Professional
Responsibility (OPR), Office of Detention Oversight (ODO) conducts broad-based compliance
inspections to determine a detention facility’s overall compliance with the applicable ICE
National Detention Standards (NDS) or Performance-Based National Detention
Standards (PBNDS), and ICE policies. ODO bases its compliance inspections around specific
detention standards, also referred to as core standards, which directly affect detainee health,
safety, and well-being. Inspections may also be based on allegations or issues of high priority or
interest to ICE executive management.
Prior to an inspection, ODO reviews information from various sources, including the Joint Intake
Center (JIC), Enforcement and Removal Operations (ERO), detention facility management, and
other program offices within the U.S. Department of Homeland Security (DHS). Immediately
following an inspection, ODO hosts a closeout briefing at which all identified deficiencies are
discussed in person with both facility and ERO field office management. Within days, ODO
provides ERO a preliminary findings report, and later, a final report, to assist in developing
corrective actions to resolve identified deficiencies.

REPORT ORGANIZATION
ODO’s compliance inspection reports provide executive ICE and ERO leadership with an
independent assessment of the overall state of ICE detention facilities. They assist leadership in
ensuring and enhancing the safety, health, and well-being of detainees and allow ICE to make
decisions on the most appropriate actions for individual detention facilities nationwide.
ODO defines a deficiency as a violation of written policy that can be specifically linked to ICE
detention standards, ICE policies, or operational procedures. Deficiencies in this report are
highlighted in bold and coded using unique identifiers. Recommendations for corrective actions
are made where appropriate. The report also highlights ICE’s priority components, when
applicable. Priority components have been identified for the 2008 and 2011 PBNDS; priority
components have not yet been identified for the NDS. Priority components, which replaced the
system of mandatory components, are designed to better reflect detention standards that ICE
considers of critical importance. These components have been selected from across a range of
detention standards based on their importance to factors such as health and safety, facility
security, detainee rights, and quality of life in detention. Deficient priority components will be
footnoted, when applicable. Comments and questions regarding this report should be forwarded
to the Deputy Division Director, OPR ODO.

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INSPECTION TEAM MEMBERS

(b)(6), (b)(7)c

Management Program Analyst (Team Lead)
Special Agent
Special Agent
Inspections and Compliance Specialist
Contractor
Contractor
Contractor

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ODO
ODO
ODO
ODO
Creative Corrections
Creative Corrections
Creative Corrections

Hall County Department of Corrections
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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Hall County Department of Corrections (HCDC)
in Grand Island, Nebraska, from May 6 to 8, 2014. HCDC, which opened in 2008, is owned by
the County of Hall and operated by the Hall County Department of Corrections. ERO began
housing detainees at HCDC in December 2008 under an intergovernmental service agreement
with the County of Hall. Male and female detainees of all security classification levels (Levels I
through III) are detained at HCDC for periods in excess of 72 hours. The inspection evaluated
HCDC’s compliance with the
Capacity and Population Statistics
Quantity
2000 NDS and the 2011 Sexual
Total Bed Capacity
321
Abuse and Assault Prevention and
Intervention (SAAPI) standard.
ICE Detainee Bed Capacity
75
Average Daily Population

154

The ERO Field Office Director
Average Daily ICE Population
13
(FOD) in St. Paul, Minnesota, is
Average ICE Detainee Length of Stay (Days)
22
responsible for ensuring facility
compliance with the 2000 NDS,
Male Detainee Population (as of 05/06/2014)
34
2011 SAAPI PBNDS1 and ICE
Female Detainee Population (as of 05/06/2014)
0
policies. An Assistant Field Office
Director (AFOD) and a Supervisory Detention and Deportation Officer (SDDO) from the ERO
St. Paul Field Office oversee daily ICE operations at HCDC. No Detention Service Manager is
assigned to HCDC.
The Chief Administrator is the highest-ranking official at HCDC and is responsible for oversight
(b)(7)e
of daily operations.
staff members supported HCDC management at the time of the
inspection. Aramark Correctional Services operates the food service and Advanced Correctional
Healthcare provides medical care at the facility. HCDC holds no accreditations.
In September 2012, ODO conducted an inspection of HCDC under the NDS. ODO reviewed 16
standards and found HCDC compliant with ten standards. ODO found a total of nine
deficiencies in the remaining six standards.
During this inspection, ODO reviewed 16 NDS and the 2011 SAAPI standard, and found HCDC
compliant with six standards. ODO found a total of 20 deficiencies in the following ten
standards: Detainee Classification System (1 deficiency), Detainee Grievance Procedures (3),
Food Service (4), Funds and Personal Property (1), Medical Care (1), Sexual Abuse and Assault
Prevention and Intervention (1), Special Management Unit – Disciplinary Segregation (1), StaffDetainee Communication (4), Telephone Access (3), and Use of Force (1). ODO made two
recommendations during this inspection.
This report details all deficiencies and refers to the specific relevant sections of the 2000 NDS.
ERO will be provided a copy of this report to assist in developing corrective actions to resolve
all identified deficiencies. ODO discussed these deficiencies with HCDC and ERO personnel
during the inspection and at a closeout briefing conducted on May 8, 2014.
1

HCDC signed a contract modification with ICE on December 19, 2012, agreeing to implement the 2011SAAPI
standard.

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Upon the admission to HCDC, detainees receive medical, mental health, suicide, and sexual
abuse and assault screenings. All incoming detainees receive pat-down searches; strip
searches are not performed unless reasonable suspicion is established in accordance with ICE
and facility policy. HCDC staff classifies detainees using information provided by ERO.
Funds and personal property are counted and stored. Detainees receive clothing, towels,
bedding and personal hygiene items. All detainees are issued an ICE National Detainee
Handbook and facility handbook in either English or Spanish and are shown an orientation
video. ODO found five instances in which detainee identification was stored with property
and not provided to ERO.
HCDC has one law library located in a designated room near the detainee housing units. The
library is well lit, reasonably isolated from noise, and has a sufficient number of tables and
chairs. One desktop computer equipped with LexisNexis, a typewriter, and supplies are
available to support legal research and case preparation. Detainees are afforded access a
minimum of five hours weekly, and may request additional time if needed.
Detainees at HCDC may submit informal, formal and emergency grievances via kiosks located
in all housing units. HCDC staff was unable to provide ODO a 12-month history of grievances,
due to detainee and inmate grievance records being commingled. Four detainee grievances were
identified for a three-month period and involved the following topics: contraband (2), shower
water (1), and commissary funds (1). Deficient areas for detainee grievances procedures
includes: 1) HCDC staff failing to record the outcome of oral/informal grievances and placing
documentation in detention files; 2) staff failing to maintain any grievance documentation in
detention files; and 3) the facility handbook failing to notify detainees of the opportunity to file
informal grievances.
Sanitation of the facility was very good at the time of the inspection. Inventories of hazardous
substances used in the facility were current and accurate. Fire drills are conducted on a monthly
basis in each area of the facility and emergency keys are tested. Exit/evacuation diagrams in
both English and Spanish were present in the housing units and throughout the facility. Sharps
inventories in the medical department are conducted on each shift. The facility’s dedicated
barber shop operation meets the requirements of the standard.
Aramark Correctional Services manages food service operations. Kitchen staff consists of
civilian and inmate workers. Civilian staff does not undergo pre-employment medical
examinations; however, medical clearances are provided for all inmates. HCDC has a satellite
feeding system. Food delivery carts do not have locking mechanisms. ODO verified the
temperatures of a meal during the inspection and found they were not within the required range.
Also, sack meals do not contain all the required items.
Detainees receive health appraisals conducted by the nurse practitioner within 14 days of arrival.
The health appraisals include hands-on physical examinations and dental screenings and are
completed within the 14-day requirement. Privacy is not maintained during patient encounters.
First, local policy requires presence of a correctional officer in examination rooms during health

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care visits.2 Second, nursing staff conducts intake screenings in the presence of detention staff,
other personnel, inmates and detainees.
HCDC signed a contract modification with ICE on December 19, 2012, agreeing to implement
the 2011 SAAPI standard. Detainees are informed of the SAAPI program through the detainee
handbook, a PREA orientation video, and by PREA postings throughout the facility. Staff and
volunteers are required to attend pre-service and annual training on the SAAPI program. Facility
policies and procedures do not include a requirement that staff announce their presence when
entering detainee’s living areas of the opposite gender.
No detainees were assigned to administrative or disciplinary special management units (SMU) at
the time of the inspection. According to HCDC staff, nine administrative3 and two disciplinary
segregation placements occurred during the 12 months preceding the inspection. Segregation
orders were issued and required status reviews were conducted in each instance. The SMU log
showed detainees assigned to disciplinary segregation were denied social visitation privileges.
HCDC policy encourages and requires informal, direct and written questions, requests, or
concerns to ERO and facility staff be submitted via a kiosk. Supervisory HCDC staff visits the
detainee housing units daily, while non-supervisory ERO staff visits weekly. Between
November 2013 and May 2014, detainees submitted 131 requests to ICE. Requests are
submitted and responded to via the kiosk; however, the log maintained by HCDC staff does not
contain all of the information required by the NDS. Also, the facility handbook lacks
information and procedures for submitting written questions, requests, or concerns to ICE staff.
ERO’s visitation schedules are not posted in the detainee housing units.
According to the medical site manager, who is a registered nurse, no detainee suicide attempts or
suicide watch placements occurred in the 12 months preceding the inspection. HCDC’s policy
on suicide prevention and intervention covers training, identification, intervention, housing and
hospitalization of at-risk detainees. Detainees identified as at-risk are immediately referred to
the medical unit for further evaluation and housed and monitored in accordance with the
standard. The contract physician, with consultation by a mental health practitioner, is solely
responsible for the release of detainees from suicide watch. HCDC has two padded cells used
for suicide watch. Staff training curriculum covers all elements required by the standard.
The telephone availability ratio at HCDC for each housing unit is approximately three detainees
per telephone. ODO found ERO inspects the phones weekly, but HCDC does not inspect the
telephones regularly. All calls are limited to 15 minutes. The procedure for obtaining an
unmonitored call to a court, legal representative, or for the purposes of obtaining legal
representation is not posted in the housing units. The facility offers a TTY if needed.
According to facility staff, three use-of-force incidents involving ICE detainees occurred in the
12 months preceding the inspection. Written documentation and video recordings confirmed
compliance with the standard, except for two instances where there was no documentation of the
medical services provided in two of the three incidents.
2
3

This is a repeat deficiency from ODO’s June 2011 and September 2012 inspections.
Four of the nine placements involved in the same detainee.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 16 randomly-selected male detainees of various classification regarding
conditions of detention at HCDC. No female detainees were housed at HCDC at the time of the
inspection. All detainees interviewed had been housed at the facility from one week to six
months. Interview participation was voluntary. None of the detainees reported having witnessed
or experienced any abuse, discrimination or mistreatment while at HCDC.
All detainees interviewed received the ICE National Detainee Handbook, facility handbook and
hygiene items. Hygiene items are replenished at no cost. None of the detainees expressed
complaints about facility services or expressed dissatisfaction with food service or medical care.
All agreed they have access to the grievance system, law library, recreation, religious services,
visitation, and interpretation services. Detainees stated ERO staff visit the housing units at least
once weekly and interact with them.

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ICE 2000 NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 NDS and one 2011 PBNDS, and found HCDC fully compliant with
the following seven standards:
1.
2.
3.
4.
5.
6.
7.

Access to Legal Materials
Admission and Release
Detainee Handbook4
Environmental Health and Safety
Special Management Unit – Administrative Segregation
Suicide Prevention and Intervention
Telephone Access

As the standards above were compliant at the time of the inspection, a synopsis for these
standards is not included in this report.
ODO found deficiencies in the following ten standards:
1. Detainee Classification System
2. Detainee Grievance Procedures
3. Food Service
4. Funds and Personal Property
5. Medical Care
6. Sexual Abuse Assault Prevention and Intervention (2011 PBNDS)
7. Special Management Unit – Disciplinary Segregation
8. Staff Detainee Communication
9. Telephone Access
10. Use of Force
Findings for these standards are presented in the remainder of this report.

4

The Detainee Handbook standard was found compliant; however, deficiencies related to the detainee handbook are
provided under Deficiencies SDC-3 and DGP-3.

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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System standard at HCDC to determine if there is a
formal classification process for managing and separating detainees based on verifiable and
documented data, in accordance with the ICE NDS. ODO toured the booking area and
classification department, interviewed staff, and reviewed classification documentation and local
policy.
Newly-arrived detainees are classified by HCDC staff using information provided by ERO.
ERO provides HCDC staff the information and forms necessary for appropriate classification.
HCDC staff collects and verifies additional information that may affect a detainee’s housing
assignment. HCDC’s booking department creates a detention file and detainees are assigned to
housing units based on their classification level. ODO reviewed 20 detainee classification files
and found none contained the first-line supervisor review and approval required for each
classification (Deficiency DCS-1). Supervisory review assures classification levels are
appropriately and objectively assigned. Documentation was not signed by a supervisor.
The facility’s policy and handbook contain the required information and procedures. Procedures
are in place to reclassify detainees if necessary.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE NDS, Detainee Classification System section (III)(A)(3), the FOD
must ensure “the first-line supervisor will review and approve each detainee’s classification.”

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedure standard at HCDC to determine if a process to
submit formal or emergency grievances exists, and responses are provided in a timely manner,
without fear of reprisal. In addition, the review was conducted to determine if detainees have an
opportunity to appeal responses, and if accurate records are maintained, in accordance with the
ICE NDS. ODO reviewed detention files, logbooks, policies, and the detainee handbook, and
interviewed staff.
HCDC provides kiosks in all the housing units for both detainees and inmates in general
population to electronically submit general and sick call requests, grievances, and commissary
orders. To file a grievance, detainees select the appropriate option and input a description of
their grievance using a keyboard. Grievances may be sent either to the facility or directly to ICE.
Detainees may obtain assistance from others in preparing grievances. The kiosk routes the
grievance directly to the appropriate department, based upon the detainee’s selection. Medical
grievances are automatically routed directly to the medical unit to ensure confidentiality. All
grievances and responses are maintained electronically. Responses are provided to detainees
within 72 hours. Detainees are individually responsible for routinely checking the kiosk for
responses to their grievances. Detainees in SMU do not have access to kiosks; instead, they
submit grievances on paper forms.
HCDC staff was unable to provide ODO a 12-month history of grievances, due to detainee and
inmate grievance records being commingled. During the inspection, both inmates and detainees
were commingled in all housing units and accessed the same kiosks. ODO’s log review was
limited to the previous three months due to these restrictions, as well as aggregate volume. Four
detainee grievances were identified and involved the following topics: contraband (2), shower
water (1), and commissary funds (1). None of the grievances appeared to involve staff
misconduct. Grievances are received by the grievance coordinator, who responds or forwards
the grievance as appropriate. Responses for these four grievances were timely and appropriate.
HCDC’s grievance policies and procedures comply with the NDS, with the exception of three
areas. First, staff does not document or record the results of oral/informal grievances and
maintain a report in detention files (Deficiency DGP-1). Second, copies of detainee grievances
are not maintained in detention files. ODO reviewed 18 active and ten inactive hard copy
detention files and confirmed copies are not maintained in accordance with the standard
(Deficiency DGP-2). Third, the facility handbook fails to notify detainees of the opportunity to
file informal grievances (Deficiency DGP-3).
ODO recommends ERO work with HCDC to:




maintain a grievance log specifically for detainees,
track the timeliness of grievances responses, and
develop a method for annotating when detainees receive or check for responses to their
grievances in the kiosk (R-1).

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STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(1), the FOD
must ensure, “If an oral grievance is resolved to the detainee’s satisfaction at any level of review,
the staff member need not provide the detainee written confirmation of the outcome, however the
staff member will document the results for the record and place his/her report in the detainee’s
detention file.”
DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must
ensure, “A copy of the grievance will remain in the detainee’s detention file for at least three
years.”
DEFICIENCY DGP-3
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(G)(1), the FOD
must ensure, “The grievance section of the detainee handbook will provide notice of the
following:
1. The opportunity to file a grievance, both informal and formal.”

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at HCDC to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE NDS. ODO
interviewed staff, inspected storage areas, observed meal preparation and service, and reviewed
policy and relevant documentation.
Aramark Correctional Services manages food service operations. The department is staffed by a
food service director and a kitchen supervisor, supported by a crew of(b)(7)ecounty inmates. No
ICE detainees are assigned to work in food service.
Medical clearance documentation for all inmate workers was available; however, staff did not
undergo any pre-employment medical examination (Deficiency FS-2). Though required by the
NDS, Aramark management informed ODO medical examinations for their employees are not
required by local health department regulations. ODO observed staff and inmate workers wore
uniforms, gloves, hairnets and beard nets for facial hair.
ODO confirmed the master cycle menu was certified by a registered dietitian based on a
complete nutritional analysis. Although no detainees were receiving medical or religious diets
during the inspection, ODO verified procedures for approval and issuance of special diets met
the requirements of the NDS.
No knives are used in the kitchen at HCDC and other utensils are properly controlled. The food
service manager conducts inspections of the kitchen area weekly. The food service operation is
also inspected by the Central District Health Department (CDHD) semi-annually, with the last
inspection occurring in December 2013. ODO observed the sanitation in the food service area
was very good.
HCDC has a satellite meal operation. ODO observed the preparation and service of the noon
meal on May 7, 2014. Food service staff took temperatures of food items as the trays were being
prepared using a laser digital food thermometer. Hot items (macaroni, ham casserole and cooked
carrots) were 161 and 152 degrees Fahrenheit, respectively, and coleslaw was 41degrees
Fahrenheit. The trays were loaded on carts with no locking mechanism or other security features
(Deficiency FS-2). The carts were transported to the housing unit under the constant supervision
of a correctional officer. By the time the trays were issued, the temperatures of the hot foods had
dropped slightly below the required temperatures (Deficiency FS-3).
ODO inspected the sack meals provided to detainees being transported and found they contained
only one sandwich and did not include a fruit item (Deficiency FS-4). All other required items
were present.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE NDS, Food Service, section (III)(H)(3)(a)(b), the FOD must ensure,
a. “All food service personnel (both staff and detainee) shall receive a pre-employment
medical examination. The purpose of this examination is to exclude those who have
a communicable disease in any transmissible stage or condition. Detainees who
have been absent from work for any length of time for reasons of communicable
illness (including diarrhea) shall be referred to Health Services for a determination as
to fitness for duty prior to resuming work.
b. The food service workers' examination shall be conducted in sufficient detail
to determine absence of:
1.
2.
3.
4.

Acute or chronic inflammatory condition of the respiratory system.
Acute or chronic infectious skin disease.
Communicable disease.
Acute or chronic intestinal infection.”

DEFICIENCY FS-1
In accordance with ICE NDS, Food Service, section (III)(H)(3)(a)(b), the FOD must ensure,
a. “All food service personnel (both staff and detainee) shall receive a pre-employment
medical examination. The purpose of this examination is to exclude those who have a
communicable disease in any transmissible stage or condition. Detainees who have
been absent from work for any length of time for reasons of communicable illness
(including diarrhea) shall be referred to Health Services for a determination as to
fitness for duty prior to resuming work.
b. The food service workers' examination shall be conducted in sufficient detail
to determine absence of:
1.
2.
3.
4.

Acute or chronic inflammatory condition of the respiratory system.
Acute or chronic infectious skin disease.
Communicable disease.
Acute or chronic intestinal infection.”

DEFICIENCY FS-2
In accordance with the ICE NDS, Food Service, section (III)(C)(2)(g), the FOD must ensure,
“Food will be delivered from one place to another in covered containers. These may be
individual containers, such as pots with lids, or larger conveyances that can move objects in bulk,
such as enclosed, satellite-feeding carts. Food carts must have locking devices. All food safety
provisions (sanitation, safe-handling, storage, etc.) apply without exception to food in transit.
Soiled equipment and utensils must be transported to the appropriate.”

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DEFICIENCY FS-3
In accordance with the ICE NDS, Food Service, section (III)(G)(1), the FOD must ensure,
“Foods shall be kept hot enough or cold enough to destroy or arrest the growth of infectious
organisms. The FSA shall ensure that staff understand the special handling required by
potentially hazardous foods, e.g., meat, cream, or egg dishes. Staff must understand the critical
importance of time and temperature in delivering safe food… Foods in the potentially hazardous
category should remain under refrigeration until cooking time and, after cooking, maintained at
or above 140 degrees F.”
DEFICIENCY FS-4
In accordance with ICE NDS, Food Service, section (III)(G)(6)(c)(1), the FOD must ensure,
“…each sack shall contain at least two sandwiches per meal, of which at least one will be meat
(non-pork). Commercial bread or rolls may be preferable because they include preservatives.
To ensure freshness, fresh, facility-made bread may be used only if made on the day of lunch
preparation. Sandwiches should be individually wrapped or bagged in a secure fashion, to
prevent the food from deteriorating. Meats, cheeses, etc., should be freshly sliced the day of
sandwich preparation. Leftover cooked meats shall not be used after 24 hours. In addition, each
sack shall include: 1.) One piece of fresh fruit or properly packaged canned fruit (paper cup with
lid), complete with a plastic spoon.”

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at HCDC to determine if controls are
in place to inventory, document, store, and safeguard detainees’ personal property, in accordance
with the ICE NDS. ODO toured the facility; reviewed local policies, the detainee handbook, and
detention files; interviewed staff; and inspected areas where detainee property and valuables are
stored.
HCDC has written policies for safeguarding detainee funds and personal property. Property is
inventoried and logged during the intake process and documented on a personal property form.
Clothing is placed in hanging bags and stored in a secure, well-organized clean room. Valuables
are placed in plastic, zippered bags secured with numbered zip ties. The bags are stored in a
secure area. ODO inspected five property forms and associated bags and valuables and
confirmed all were secure and in their assigned location.
Detainees do not keep money in their possession. Domestic currency is placed in sealed
envelopes and deposited into the detainee’s commissary account the following business day.
Foreign currency is inventoried and secured in a locked cabinet and returned to the detainee upon
release or removal. ODO found identity documents are held in detainee property bags and not
forwarded to ICE ERO for proper placement in detainee’s A-file (Deficiency F&PP-1). Identity
documents (alien resident card, national consular card, social security card, etc.) were found
inside three property bags during the inspection. HCDC staff initiated corrective action during
the inspection.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE NDS, Funds and Personal Property section (III)(B)(3), the FOD must
ensure the “identity documents, such as passports, birth certificates, etc., will be held in the
detainee’s A-file. Upon request, staff will provide the detainee with a copy of the document,
certified by an ICE official to be a true and correct copy.”

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at HCDC to determine if detainees have access to
healthcare and emergency services to meet their health needs in a timely manner, in accordance
with the ICE NDS. ODO toured the facility and medical clinic, observed intake screening,
interviewed staff, verified all healthcare staff credentials, and reviewed the medical policies,
procedures, and detainee medical records.
Advanced Correctional Healthcare (ACH) provides health care at HCDC. HCDC holds no
accreditations; however, ACH policies reference adherence to State of Nebraska and National
Commission on Correctional Health Care standards. Administrative oversight of clinic
operations is provided by the site manager, who is a registered nurse. Medical coverage is
provided 24 hours a day, seven days a week by (b)(7)e licensed practical nurses (LPN) and (b)(7)e asneeded LPNs. In addition, a contract physician, nurse practitioner, and (b)(7)emental health
professionals are on site eight hours weekly and on call 24 hours a day, seven days weekly. The
physician is the designated clinical medical authority. ODO confirmed all ACH staff and
contract providers’ licenses and credentials were current and primary source-verified.
Island View Dental of Grand Island provides dental services on site as needed. Healthcare and
emergency services unavailable at the facility are provided at St. Francis Hospital located five to
ten minutes from the facility.
HCDC’s medical unit consists of a waiting room with six chairs, accessible to a toilet and sink;
three examination rooms; the site manager’s office; three storage rooms for equipment, supplies
and biohazard waste; two Americans with Disabilities Act-compliant restrooms for staff and
detainees; a linen room; four negative pressure observation cells with a shower; nursing station;
and a dental suit with a one chair operatory and equipment room. The clinic is adequately sized
and equipped.
ODO found privacy is not maintained during patient encounters (Deficiency MC-1). Local
policy HCDC 6A-09, Privacy of Care, requires the presence of a correctional officer in
examination rooms during health care visits, a practice directly observed by ODO. 5 Further,
nursing staff was observed conducting intake screenings while standing at the counter in the
booking area in front of detention staff and other personnel, inmates, and detainees. In addition
to violating detainee privacy, conducting intake screenings in this area may interfere with the
integrity of the screening process. Detainees may be uncomfortable disclosing medical
information in the presence of non-medical personnel and therefore, may be deterred from
answering questions truthfully. ODO discussed this issue with the Chief Administrator, who was
aware of the deficiency, but cited non-correctional staff safety and protection as his primary
concerns.
Nursing staff conduct medical and mental health screenings on each detainee upon arrival.
Tuberculosis (TB) screening is conducted by purified protein derivative (PPD) skin test, and
5

This deficiency was cited during ODO’s June 2011 and September 2012 inspections.

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chest X-rays are performed by mobile radiology service, Mobile-X, for detainees with a positive
result or past positive PPD. Results are received within three to four hours. Based on a review
of 20 detainee medical records, intake screenings and TB testing are completed in accordance
with the NDS, and signed consent for treatment statements are obtained.
Detainees receive health appraisals conducted by the nurse practitioner within 14 days of arrival.
ODO’s medical record review confirmed the health appraisals included hands-on physical
examinations and dental screenings and all were completed within the 14-day requirement.
Among the 20 records reviewed by ODO, only one documented a chronic condition. ODO
verified that a detainee who was hypertensive, received medications and regular provider follow
up. The medical record review identified no detainees who were sent to the emergency room or
for outside consultations.
Detainees access health care via an electronic kiosk present in each pod. The kiosk services are
available in English, Spanish and other languages. Detainees in the SMU complete hard-copy
request forms, which are picked up by nursing staff three times daily. ODO’s review of 40 sick
call requests found all were triaged upon receipt and detainees were seen the day of the request
or in less than 48 hours. In conducting sick call, nurses follow nursing protocols approved by the
clinical medical authority. HCDC utilizes the Language Link telephonic interpretation service
when needed. Detainees are not charged for medical services.
Diamond Pharmacy provides pharmacy services under contract. Orders are sent by way of fax
before 4 p.m., and the patient-specific medication arrives in blister packs the next morning. Any
medication needed on an immediate basis is filled by the local pharmacy. Nursing staff
distribute medications twice daily by way of a medication cart. The medication cart was well
organized and secure. ODO’s review of five detainee medication administration records found
the documentation was clear and complete.
During inspection of the facility, ODO observed first aid kits in each pod, the SMU, the control
center and administration area. Automated external defibrillators (AED) were available in the
control center, the health services unit, and administration. A review of(b)(7)erandomly-selected
training records for medical and correctional staff confirmed all had current certification in first
aid, cardio pulmonary resuscitation, and AED use. In addition, officers were trained in
medical/mental health emergencies, infectious and communicable diseases, hunger strikes, and
recognition of acute manifestation of certain chronic illnesses, including seizures, intoxication
and withdrawal, drug toxicity and adverse reaction to medication.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(B), the FOD must ensure
“Adequate space and equipment will be furnished in all facilities so that all detainees may be
provided basic health examinations and treatment in private.”

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SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION
(SAAPI)
ODO reviewed the Sexual Abuse and Assault Prevention and Intervention standard at HCDC to
determine if the facility acts to prevent sexual abuse and assaults on detainees, provides prompt
and effective intervention and treatment for victims of sexual abuse and assault, and controls,
disciplines, and prosecutes the perpetrators, in accordance with ICE 2011 PBNDS. ODO
reviewed policy and procedures, the detainee handbook, staff training records, interviewed staff
and detainees; and inspected informational postings throughout the facility.
On December 19, 2012, HCDC signed a contract with ICE to incorporate and comply with the
ICE 2011 Performance-Based National Detention Standard on Sexual Abuse and Assault
Prevention and Intervention (SAAPI). HCDC has a zero tolerance policy for any form of sexual
abuse or assault. The facility’s training sergeant is the SAAPI coordinator. All staff, including
volunteers, is required to attend pre-service and annual training on the SAAPI program,
completion of which was verified by review of(b)(7)etraining records. ODO’s review of the
training curriculum confirmed it is comprehensive and inclusive of all required elements in the
standard. ODO interviewed the training sergeant, who appeared knowledgeable of the SAAPI
program and the handling of any reports or observations concerning possible sexual abuse or
assault.
HCDC policy and procedure use a multi-disciplinary team approach when responding to sexual
abuse and assault. The team includes a medical practitioner, a mental health practitioner,
security staff and an investigator from the assigned investigative entity, as well as representatives
from outside entities.
Detainees are screened during the intake process for sexual abuse victimization history, as well
as for predatory history to identify potential sexual aggressors. Any information obtained during
intake screening relating to history of victimization or predatory sexual behavior is referred to
the SAAPI coordinator for review follow-up and/or referral to the medical/mental health staff.
Detainees receive information of the SAAPI program by way of the facility handbook, during a
PREA orientation video, and by postings throughout the facility. The postings are in English and
Spanish, and include toll-free telephone numbers for reporting incidents.
ODO found HCDC’s policies and procedures do not include a requirement that staff announce
their presence when entering detainee’s living areas of the opposite gender (Deficiency SAAPI1).

STANDARD/POLICY REQUIREMENT FOR DEFICIENT FINDINGS
DEFICIENCY SAAPI-1
In accordance with ICE 2011 PBNDS, Sexual Abuse and Assault Prevention and Intervention,
section (II)(14), the FOD must ensure “facility policies and procedures will include a
requirement that staff of the opposite gender will announce their presence upon entering detainee
living areas.”

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SPECIAL MANAGEMENT UNIT (SMU) – DISCIPLINARY
SEGREGATION
ODO reviewed the Special Management Unit (SMU) – Disciplinary Segregation standard at
HCDC to determine if the facility has procedures in place to temporarily segregate detainees for
disciplinary reasons, in accordance with the ICE NDS. ODO toured the SMU, interviewed
HCDC and ERO staff, and reviewed policies and electronic log books.
HCDC’s SMU for male detainees assigned to disciplinary segregation has six single cells in a
bottom tier and six cells on a top tier. The SMU for female detainees is used for both
administrative and disciplinary segregation and has five two-person cells. Inspection of the units
found they were clean, well lit, and temperature-appropriate.
No detainees were assigned to disciplinary segregation at the time of the review. According to
HCDC staff, two detainees were placed on disciplinary segregation status in the 12 months
preceding the inspection, one of whom received this sanction on four separate occasions. The
maximum term served was ten days, though one sanction was served consecutively for a total of
20 days. Segregation orders were issued and required status reviews were conducted in each
instance. The facility’s electronic SMU log confirmed the detainees assigned to disciplinary
segregation were afforded recreation, medical care, telephones, and access to legal visitation and
materials in accordance with the NDS. However, they are denied social visitation privileges
(Deficiency SMU DS -1). Per policy, social visits are restricted for detainees housed in
disciplinary segregation regardless of the reason for placement on such status.
HCDC’s policy also states detainees will be provided with razors to shave once weekly, prior to
a court appearance or upon written request, which is not the case. A deficiency is not cited
because ODO found no occasion in which a detainee requested and was denied the opportunity
to shave up to three times weekly as required by the NDS. However, ODO recommends the
facility revise its policy to allow access to razors three times weekly, without written request (R2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU DS-1
In accordance with the ICE NDS, Special Management Unit - Disciplinary Segregation, section
(III)(D)(17) , the FOD must ensure “The facility shall follow the ‘Visitation’ standard in setting
rules for detainees in disciplinary segregation. As a rule, a detainee retains visiting privileges
while in disciplinary segregation. The determining factor if the reason for which the detainee is
being disciplined.”
In accordance with the ICE NDS, Visitation, section (III)(H)(5), the FOD must ensure
“Detainees ordinarily retain visiting privileges while in administrative or disciplinary segregation
status.”

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at HCDC to determine if procedures
are in place to allow formal and informal contact between detainees and key ICE and facility
personnel; and if ICE detainees are able to submit written requests to ICE personnel and receive
timely responses, in accordance with the ICE NDS. ODO interviewed staff and detainees, and
reviewed ERO logbooks and the Facility Liaison Visit Checklists.
The ERO St. Paul Field Office has policies and procedures for staff-detainee communication.
No ERO staff members are permanently assigned at the facility. ODO reviewed a log and
interviewed HCDC staff to confirm regular unannounced visits by ERO.
Based on interviews with detainees and HCDC staff, Deportation Officers (DO) and Immigration
Enforcement Agents (IEA) conduct regular scheduled weekly visits on Thursdays between 8
a.m. and 12 p.m.6 ERO visits are recorded on Facility Liaison Visit Checklists as required by the
June 15, 2007 policy memo titled “Change Notice, National Detention Standards, and Model
Protocol.” No visitation schedules were posted in any of the detainee living areas or other areas
detainees access (Deficiency SDC-1).
Detainees are able to submit written questions, requests, or concerns to ERO and facility staff via
a kiosk in each housing unit. Requests may be submitted in English, Spanish and other
languages. HCDC staff informed ODO personnel that detainee requests addressed to ERO
through the kiosk cannot be seen or reviewed by HCDC staff. Procedures are in place allowing
detainees to obtain assistance from others in preparing requests on the kiosk. ERO staff retrieves
the requests electronically on a daily basis and provide responses to detainees within 72 hours of
receipt. ODO reviewed 131 detainee requests filed via the kiosk between November 1, 2013 and
May 5, 2014. The majority of the requests (over 90 percent) pertained to immigration and
removal proceedings.
HCDC maintains an electronic request log. The log lacks two required elements: A-number and
nationality (Deficiency-2). ODO also found detainee requests are not maintained in detention
files (Deficiency SDC-3). ODO reviewed 15 active and 15 archived detention files, and none
contained detainee requests. Facility and ERO staff admitted detainee requests are not
maintained in hard copy detention files. According to the NDS, the completed requests are
required to be filed in each detainee’s detention file and maintained for at least three years.
The facility handbook does not contain information that states the detainee has the opportunity to
submit written questions, requests, or concerns to ERO staff and the procedures for doing so
(Deficiency SDC-4). The DHS Office of Inspector General Hotline posters are displayed in the
housing units.

6

The facility initiated corrective action during the inspection by posting the ERO schedule in the detainee living
areas.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE NDS, Staff Detainee Communication, section (III)(2)(b), the FOD
must ensure “Written schedules shall be developed and posted in the detainee living areas and
other areas with detainee access.”
DEFICIENCY SDC-2
In accordance with the ICE NDS, Staff Detainee Communication, section (III)(2), the FOD must
ensure: “All requests shall be recorded in a logbook specifically designed for that purpose. The
log, at a minimum, shall contain:
The date the detainee request was received;’
Detainee’s name;
A-number;
Nationality;
Officer logging the request;
The date that the request, with staff response and action, is returned shall be recorded;
and
g. Any other site-specific pertinent information.
a.
b.
c.
d.
e.
f.

In IGSA’s, the date the request was forwarded to ICE and the date it was returned shall also be
recorded.”
DEFICIENCY SDC-3
In accordance with the ICE NDS, Staff Detainee Communication, section (III)(2), the FOD must
ensure: “All completed Detainee Requests will be filed in the detainee’s detention file and will
remain in the detainee’s detention file for at least three years.”
DEFICIENCY SDC-4
In accordance with the ICE NDS, Staff Detainee Communication, section (III)(3), the FOD must
ensure: “The facility shall provide each detainee, upon admittance, a copy of the detainee
handbook or equivalent. The handbook shall state that the detainee has the opportunity to submit
written questions, requests, or concerns to ICE staff and the procedures for doing so, including
the availability of assistance in preparing the request.”

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at HCDC to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and
others in the community, in accordance with the ICE NDS. ODO interviewed facility staff and
detainees; reviewed policy, procedures, and the detainee handbook; and conducted functionality
tests on the telephones located in detainee housing units.
ODO verified detainees have reasonable and equitable access to telephones at HCDC. ODO
confirmed the telephone listings for pro bono services, the DHS Office of Inspector General,
consulates, and embassies were located in each housing unit. The facility also provides a TTY
device if needed.
HCDC staff does not inspect the telephones regularly (Deficiency TA-1). ERO staff inspects
telephones weekly and ODO verified serviceability checks by reviewing ERO logbooks and
serviceability worksheets. ODO conducted operational checks of telephones in all detainee
housing units and found them to be in good working order.
Detainees may make unmonitored telephone calls to attorneys or legal representatives after
submitting a request form or notifying a housing unit officer. HCDC does not restrict the
number of calls a detainee places to legal representatives; however calls are limited to 15
minutes (Deficiency TA-2). Detainees can continue legal calls at the first available opportunity.
The procedure for obtaining an unmonitored call to a court, legal representative, or for the
purposes of obtaining legal representation are not posted in the housing units (Deficiency TA-3).
Detainees may submit, via the kiosk, requests to make legal calls in an area that affords privacy.
Notifications that calls are subject to monitoring are posted near the telephones, and on a
recorded phone message. The facility handbook also notifies detainees that telephone calls are
being recorded.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE NDS, Telephone Access, section (III)(D), the FOD must ensure “the
facility shall maintain detainee telephones in proper working order. Appropriate facility staff
shall inspect the telephones regularly.”
DEFICIENCY TA-2
In accordance with the ICE NDS, Telephone Access, section (III)(F), the FOD must ensure “the
facility shall not restrict the number of calls a detainee places to his/her legal representatives, nor
limit the duration of such calls by rule or automatic cut-off, unless necessary for security
purposes or to maintain orderly and fair access to telephones. If time limits are necessary for
such calls, they shall be no shorter than 20 minutes.”
DEFICIENCY TA-3
In accordance with the ICE NDS, Telephone Access, section (III)(K)(2), the FOD must ensure
“the facility shall have a written policy on the monitoring of detainee telephone calls. If
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telephone calls are monitored, the facility shall notify detainees in the detainee handbook or
equivalent provided upon admission. It shall also place a notice at each monitored telephone
stating:
2. The procedure for obtaining an unmonitored call to a court, legal representative, or
for the purposes of obtaining legal representation.”

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USE OF FORCE (UOF)
ODO reviewed the Use of Force standard at HCDC to determine if necessary use of force is
utilized only after all reasonable efforts have been exhausted to gain control of a subject, while
protecting and ensuring the safety of detainees, staff and others, preventing serious property
damage, and ensuring the security and orderly operation of the facility, in accordance with ICE
NDS. ODO interviewed staff and reviewed policy, use of force documentation, and training
records.
The facility’s use-of-force policy addresses confrontation avoidance and differentiates between
immediate and calculated force. Oleoresin capsicum (OC) spray is HCDC’s only intermediate
use of force device, and a restraint chair is used instead of four-point restraints. ODO’s review
of(b)(7)erandomly-selected staff training records confirmed completion of training in confrontation
avoidance, use of force, application of restraints, reporting procedures, communication
techniques, cultural diversity, dealing with the mentally ill, and cell extraction. In addition, the
officers had current OC spray certification.
Three use-of-force incidents involving detainees occurred at the facility in the 12 months
preceding the inspection. All three were immediate use-of-force incidents, two involving use of
OC spray and subsequent placement in the restraint chair. A review of written documentation by
security staff and video recordings confirmed substantial compliance with the standard, including
the presence of nursing staff during the detainee’s placement in the restraint chair and
completion of assessments thereafter. However, there was no documentation of the medical
services provided in two of the three incidents (Deficiency UOF-1). The facility has a medical
assessment form on which nurses are required to document the starting and ending time of
restraint chair placement, 15-minute checks, any injuries noted, vital signs, and patient actions.
Medical staff was able to produce this form in only one case. After-action reviews were
completed in accordance with the standard in all three cases, and ERO was notified.
Though there were no calculated use-of-force incidents, ODO confirmed protective gear for useof-force team members is available, and the facility’s policy addresses all requirements of the
NDS.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF-1
In accordance with the ICE NDS, UOF section (III)(G)(2), the FOD must ensure “After any use
of force or forcible application of restraints, medical personnel shall examine the detainee,
immediately treating any injuries. The medical services provided shall be documented. Medical
staff shall immediately examine any staff member involved in a use-of-force incident who
reports any injury and, if necessary, provide initial emergency treatment.”

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