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
Chicago Field Office
Tri-County Justice and Detention Center
Ullin, Illinois

June 26 – 28, 2012

FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law
enforcement, management, and employee information. It has been written for the express use of the
Department of Homeland Security to identify and correct management and operational deficiencies. In
reference to ICE Policy 17006.1, issued 09/22/05; any disclosure, dissemination, or reproduction of this
document, or any segments thereof, is prohibited without the approval of the Assistant Director, Office of
Professional Responsibility.

COMPLIANCE INSPECTION
TRI-COUNTY JUSTICE AND DETENTION CENTER
CHICAGO FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................5
Inspection Team Members ...................................................................................................5
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................6
Detainee Relations ...............................................................................................................6
ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................7
Disciplinary System .............................................................................................................8
Environmental Health and Safety ........................................................................................9
Food Service ......................................................................................................................10
Funds and Personal Property .............................................................................................12
Grievance System ..............................................................................................................13
Medical Care ......................................................................................................................15
Recreation ..........................................................................................................................18
Special Management Units ................................................................................................19
Telephone Access ..............................................................................................................20
Use of Force and Restraints ...............................................................................................21

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the Tri-County Justice and Detention Center
(TCJDC) in Ullin, Illinois, from June 26-28, 2012. TCJDC, which opened in 1998, is owned by
Pulaski County and operated by Paladin Eastside Psychological Services, Inc. (Paladin). U.S.
Immigration and Customs Enforcement (ICE), Office of Enforcement and Removal Operations
(ERO) began housing detainees at TCJDC in 2004 under an Intergovernmental Service
Agreement (IGSA) between the U.S. Marshals Service (USMS) and TCJDC. In December
2010, Pulaski County entered into a new IGSA with ICE to house male and female ICE
detainees of all security classification levels (Level I – lowest threat; Level II – medium threat;
Level III – highest threat) for periods in excess of 72 hours. TCJDC has a total capacity of 275,
with a maximum accommodation for ICE detainees of 234. At the time of the CI, the facility
housed 210 male ICE detainees. The average daily detainee population is 202. The average
length of stay is 20 days. Additional bed space at TCJDC is reserved for prisoners received from
area law enforcement jurisdictions. Paladin provides both medical care and food services. The
facility holds no accreditations.
The ICE ERO Field Office Director, Chicago, Illinois (FOD Chicago), is responsible for
ensuring facility compliance with ICE policies and the ICE Performance Based National
Detention Standards (PBNDS). ICE has no personnel stationed at the facility. An Assistant
Field Office Director (AFOD) located at the FOD Chicago office has responsibility over all
detention facilities in the FOD Chicago area of responsibility, which includes TCJDC. Weekly
scheduled and unscheduled visits are conducted by an ICE Immigration Enforcement Agent
(IEA) stationed at the ERO office in St. Louis, Missouri. An ERO Detention Service Manager
(DSM) assigned to TCJDC visits the facility two to three times each month to monitor facility
compliance with the PBNDS.
The Warden is the highest ranking official at TCJDC and is responsible for oversight of daily
operations. In addition to the Warden, supervisory staff at TCJDC includes (b)(7)eCaptain, (b)(7)e
Lieutenants, (b)(7)e Sergeants, and (b)(7)eTransportation Supervisor. TCJDC non-supervisory staff is
composed of(b)(7)eCorrections Officers. Paladin medical staff consists of a Health Services
Administrator (HSA) (b)(7)eregistered nurse (RN),(b)(7)e licensed practical nurses (LPN), and a
certified medical technician (CMT). Contracted personnel include a physician, a psychiatrist, a
dentist, and an advanced nurse practitioner (ANP). Paladin food service staff consists of (b)(7)e
full-time personnel:(b)(7)eFood Service Manager and (b)(7)e cook supervisors.
In June 2010, ODO conducted a Quality Assurance Review (QAR) at TCJDC pursuant to the
ICE National Detention Standards (NDS). ODO determined TCJDC to be in full compliance
with eight of the 29 standards reviewed. The remaining 21 standards accounted for 39
deficiencies.
In December 2010, TCJDC transitioned from the NDS to the PBNDS.
In April 2011, ODO conducted a Follow-up Inspection of the 39 deficiencies identified during
the June 2010 QAR. ODO identified 13 repeat deficiencies.
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In February 2012, ERO Detention Standards Compliance Unit (DSCU) contractor, Nakamoto
Group, Inc., conducted an Annual Review of the PBNDS at TCJDC. The facility was found to
be in compliance with 39 of the 40 standards reviewed. The Annual Review team determined
TCJDC did not meet the Medical Care standard due to non-compliance with one mandatory
component of this standard. Observation of actual practice by medical staff revealed no daily
inventory of needles and syringes was being conducted, no perpetual inventory of needles and
syringes was being maintained, and no inventory of needles and syringes placed and kept in the
medication cart was being kept. These deficiencies were corrected prior to completion of the
February 2012 ERO Annual Review.
During this CI, ODO reviewed 17 PBNDS. Seven standards were fully compliant, while 20
deficiencies were found in the following ten standards: Disciplinary System (1 deficiency),
Environmental Health and Safety (1), Food Service (2), Funds and Personal Property (2),
Grievance System (3) Medical Care (2), Recreation (1), Special Management Units (2),
Telephone Access (1), and Use of Force and Restraints (5).
This report details all deficiencies and refers to specific, relevant sections of the PBNDS. ERO
will be provided a copy of the report to assist in developing corrective actions to resolve the 20
identified deficiencies. These deficiencies were discussed with TCJDC personnel on-site during
the inspection, as well as during the closeout briefing conducted on June 28, 2012.
Overall, ODO found TCJDC orderly, well-managed, and in compliance with the standards
reviewed. Many of the deficiencies identified were administrative in nature, with minimal
impact to life-safety issues, as well as the overall operational readiness and security of the
facility. Deficiencies requiring immediate attention were identified in the areas of Recreation
and Use of Force and Restraints. Specifically, the facility’s exercise areas do not have a variety
of equipment as specified by the PBNDS. Interviews with TCJDC management staff confirmed
after-action reviews are not conducted following use of force incidents. Details of these
deficiencies are described in the corresponding standards contained in this report.
ICE detainees are classified by ICE prior to arrival at TCJDC. During the admission process, all
detainees receive and sign for an ICE National Detainee Handbook and a facility-specific
handbook, which are available in both English and Spanish. Excess and prohibited property is
properly inventoried and stored. Detainees are allowed a minimal amount of personal items to
keep in their possession and are given bins for storage of these items in the housing unit;
however, in two housing units, ODO observed detainees did not have a designated storage area
for their personal property. After being alerted to this issue, TCJDC management, issued storage
bins to the affected detainees.
Medical services are provided under contract by Paladin. Medical care is well-managed, and the
clinic is adequately staffed. The HSA is an RN, and is designated as the clinical medical
authority. The HSA is on-site 40 hours per week and is on-call during non-business hours. The
ANP is the clinical provider responsible for making clinical decisions, developing treatment
plans, and managing the health care needs of detainees. The contract physician, who is available
for consultation purposes and reviews orders from the ANP, is on-site six to eight hours per
month to see detainees referred by the ANP and to review chronic care management. Nursing
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coverage is provided 24 hours a day, seven days a week. ODO confirmed a language service is
used for non-English speaking detainees.
TCJDC has a memorandum of understanding (MOU) with Union County Hospital (UCH) for
inpatient services beyond the scope of the services offered by TCJDC. The MOU also covers
out-patient services such as laboratory tests and radiology. Pharmacy services are provided by a
contract pharmacy whose pharmacist provides quarterly monitoring of pharmacy services and
the pharmaceutical practices of providers.
The ODO inspection confirmed all chemicals, flammables, and combustible materials are stored
and issued as required. Material Safety Data Sheets are maintained in the safety office and are
reviewed semi-annually. Throughout the facility, sanitation is maintained at an acceptable level;
however, inspection of the detainee housing units revealed no trash receptacles were available
for discarding trash. Instead, plastic garbage bags are provided. ODO observed these plastic
bags under detainee bunks and hanging from stair rails.
The food service area is well-managed and was observed to be clean and orderly. Detainees are
fed via a satellite system involving preparation of meals in the food service area and delivery to
housing units on thermal trays. All menus are certified by a registered dietitian. Religious and
medically-prescribed meals are provided and properly documented; however, the facility did not
have a special menu for the ten federal holidays.
Detainees have the opportunity to file informal and formal grievances, and to appeal grievance
decisions. Grievance forms are available within the housing units. TCJDC staff attempts to
resolve all grievances at the lowest level possible. Detainees are free to bypass the informal
grievance process and proceed directly to the formal grievance process.
ICE staff conducts regular scheduled, unscheduled, and unannounced visits on a weekly basis at
TCJDC to monitor facility and detainee living conditions, address detainee concerns, and allow
for informal interaction with detainees. ERO supervisory visits occur on a weekly basis, and
ODO confirmed through staff interviews and facility visitation logbooks that the FOD and
AFOD visit the facility at least once per year. The most recent visit occurred in January 2012.
All ICE visits are documented in the facility’s visitor logbook and separately by ERO. ICE
visitation schedules are posted in the housing units. ODO verified detainees are able to submit
written requests and questions to ICE using request forms available within the housing units;
responses to written requests were timely.
ODO observed the Special Management Unit to be sanitary, well-lit, and well-ventilated. At the
time of the CI, there were no detainees in administrative or disciplinary segregation.
ODO confirmed there were four use-of-force incidents involving ICE detainees during the
twelve months preceding the ODO inspection. Because documentation does not categorize force
incidents as immediate or calculated, ODO reviewed reports and identified one immediate use of
force incident and three calculated use of force cell extractions. Medical personnel were not
contacted in advance of any of the three calculated force incidents, as required by the PBNDS.
An immediate use of force situation is created when a detainee's behavior constitutes a serious
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and immediate threat to self, staff, another detainee, property, or the security and orderly
operation of the facility. In that situation, staff may respond without a supervisor's direction or
presence. A calculated use of force occurs when a detainee is in a location where there is no
immediate threat to the detainee or others. Based on interviews and inspection, ODO determined
procedures are not in place to assure audiovisual recording equipment is routinely inspected and
tested to assure operability. No use-of-force packets contained documentation of after-action
reviews to assess the reasonableness of force and its application, to include viewings of
audiovisual recordings. Interviews with the Captain and Warden confirmed after-action reviews
are not conducted
Although detainees receive adequate daily outdoor recreation, exercise and recreational
equipment is limited. Exercise equipment in the indoor recreation area consisted of a basketball
goal and a basketball. Prior to completion of the CI, two soccer balls and two basketballs were
purchased. Detainees have access to religious programs, telephones, a law library, and are
provided adequate visitation opportunities.

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INSPECTION PROCESS
ODO inspections evaluate the welfare, safety, and living conditions of detainees. ODO primarily
focuses on areas of noncompliance with the NDS or the PBNDS, as applicable. The PBNDS
apply to TCJDC. In addition, ODO may focus its inspection based on detention management
information provided by ERO Headquarters (HQ) and ERO field offices, and on issues of high
priority or interest to ICE executive management.
ODO reviewed the processes employed at TCJDC to determine compliance with current policies
and detention standards. Prior to the inspection, ODO collected and analyzed relevant
allegations and detainee information from multiple ICE databases, including the Joint Integrity
Case Management System (JICMS), the ENFORCE Alien Booking Module (EABM), and the
ENFORCE Alien Removal Module (EARM). ODO also gathered facility facts and inspectionrelated information from ERO HQ staff to prepare for the site visit at TCJDC.

REPORT ORGANIZATION
This report documents inspection results, serves as an official record, and is intended to provide
ICE and detention facility management with a comprehensive evaluation of compliance with
policies and detention standards. It summarizes those PBNDS that ODO found deficient in at
least one aspect of the standard. ODO reports convey information to best enable prompt
corrective actions and to assist in the ongoing process of incorporating best practices in
nationwide detention facility operations.
OPR classifies program issues into one of two categories: deficiencies and areas of concern.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
PBNDS, ICE policy, or operational procedure. OPR defines an area of concern as something
that may lead to or risk a violation of the PBNDS, ICE policy, or operational procedure. When
possible, the report includes contextual and quantitative information relevant to the cited
standard. Deficiencies are highlighted in bold throughout the report and are encoded
sequentially according to a detention standard designator.
Comments and questions regarding the report findings should be forwarded to the Deputy
Division Director, OPR, ODO.

INSPECTION TEAM MEMBERS

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

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Special Agent (Team Leader)
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

5

ODO, Chicago
ODO, Houston
ODO, Houston
Creative Corrections
Creative Corrections
Creative Corrections

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the Warden, the Captain, a Lieutenant, and (b)(7)eSupervisory Detention and
Deportation Officers (SDDO). During the interviews, all personnel stated the working
relationship between TCJDC and ICE is excellent, and morale is high.
The Warden and the Captain stated the staffing level at TCJDC is sufficient to handle the current
ICE detainee population. The Warden and the Captain stated they observe ICE staff visiting the
housing units and communicating with detainees to address their questions and concerns at least
once a week.
Each SDDO stated TCJDC staff accommodates ICE. ICE staff stated the FOD Chicago has
implemented a process, including a schedule, to ensure regular weekly visits by ICE officers and
weekly supervisory-level visits to TCJDC.

DETAINEE RELATIONS
ODO interviewed 18 randomly selected detainees to assess the overall living and detention
conditions at TCJDC. All detainees stated they were treated with dignity and respect by
TCJDC staff. ODO received no complaints concerning access to the law library, issuance and
replenishment of clothing and hygiene supplies, sending and receiving mail, visitation
privileges, access to religious services, food service, or the grievance process. There were no
complaints regarding the quality of medical services or facility sanitation.
Each detainee stated outdoor recreation is offered seven days a week, weather permitting. Six
detainees noted a lack of equipment and recreational choices. All detainees stated they
received a facility-specific detainee handbook, as well as the ICE National Detainee Handbook.
Five detainees did not know the identity of their assigned Deportation Officer (DO); however,
four of the five stated they knew how to contact their DO. ODO verified that DO names and
telephone numbers, as well as an ICE visitation schedule, are posted in the housing units. All
detainees stated ICE staff visit their respective housing units a minimum of one time each
week. Each detainee stated requests to ICE are responded to in a timely manner and requests
made to facility staff are handled immediately.

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ICE PERFORMANCE BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 17 PBNDS and found TCJDC fully compliant with the following seven
standards:
Admission and Release
Classification System
Detainee Handbook
Law Libraries and Legal Materials
Personal Hygiene
Staff-Detainee Communication
Suicide Prevention and Intervention
As these standards were compliant at the time of the review, a synopsis for these standards was
not prepared for this report.
ODO found deficiencies in the following ten standards:
Disciplinary System
Environmental Health and Safety
Food Service
Funds and Personal Property
Grievance System
Medical Care
Recreation
Special Management Units
Telephone Access
Use of Force and Restraints
Findings for each of these standards are presented in the remainder of this report.

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DISCIPLINARY SYSTEM (DS)
ODO reviewed the Disciplinary System standard at TCJDC to determine if sanctions imposed on
detainees who violate facility rules are appropriate, and if the discipline process includes due
process requirements, in accordance with the ICE PBNDS. ODO interviewed staff, reviewed
policies and the detainee handbook, and examined disciplinary files.
The disciplinary system at TCJDC includes progressive levels of review and appeal procedures.
Prohibited acts are divided into four severity categories: greatest, high, moderate, and low. ODO
verified the detainee handbook describes rules of conduct, the disciplinary system, and detainee
rights and responsibilities. An interview with the Discipline Hearing Officer confirmed the
facility’s disciplinary policy reflects current practices and compliance with procedural
requirements of the PBNDS; however, the disciplinary policy was last reviewed on December
18, 2010 (Deficiency DS-1). Annual review of policy, procedures and rules ensures procedures
are accurately codified in policy, and this analysis can determine whether changes are necessary.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DS-1
In accordance with the ICE PBNDS, Disciplinary System, section (V)(A)(2), the FOD must
ensure each facility holding ICE/DRO detainees in custody shall have a detainee disciplinary
system with progressive levels of reviews, appeals, procedures, and documentation procedures.
Written disciplinary policy and procedures shall clearly define detainee rights and
responsibilities. The policy, procedures and rules shall be reviewed at least annually.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at TCJDC to determine if the
facility maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances, in accordance with the ICE PBNDS. ODO toured the
facility, interviewed staff, and reviewed policies and documentation of inspections, hazardous
chemical management, pest control, generator testing, and fire prevention and control
procedures.
The ODO inspection confirmed all chemical, flammable, and combustible materials are stored
and issued as required. Hazardous substances are strictly controlled, and a master index of
chemicals and Material Safety Data Sheets are maintained in the safety office and reviewed
semi-annually. Documentation confirms monthly fire drills are conducted on each shift, and
include drawing and testing emergency keys for operability. Weekly and monthly safety
inspections are conducted for all areas of the facility. Pest control invoices and reports for water
testing are current. Barbering services are conducted in a designated area, and hair care
sanitation regulations are posted. The facility’s emergency generators are tested on a quarterly
basis by an external service company. Internal testing of the facility’s emergency generators is
conducted every week for 60 minutes, which exceeds the PBNDS requirement for bi-weekly
testing.
Sanitation is at an acceptable level throughout the facility; however, inspection of detainee
housing units found no waste containers available for discarded trash (Deficiency EH&S-1).
ODO observed plastic garbage bags underneath detainee bunks and hanging from stair rails.
Non-combustible, non-porous waste containers help prevent pest infestation, contain fires, and
support overall sanitation in the units. ODO notes this deficiency was also identified during the
annual Fire Marshal inspection conducted on December 21, 2011, by the Office of the Illinois
State Fire Marshal, Fire Prevention Division. The Safety Manager stated the Warden is aware of
the issue, but has not announced how it will be addressed.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE PBNDS, Environmental Health and Safety, section (V)(C)(6), the
FOD must ensure waste containers shall be non-porous and lined with plastic bags and the liner
shall be changed daily.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at TCJDC to determine if detainees are provided a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE PBNDS. ODO
interviewed food service staff, reviewed documentation, observed food preparation and serving,
and inspected food and chemical storage areas.
The food service department is staffed by (b)(7)e CJDC employees: (b)(7)eFood Service Manager
and (b)(7)e Cook Supervisors. (b)(7)e
CE detainee volunteer workers are assigned to food
service. ODO verified food service staff and detainee workers receive medical clearances and
are properly trained in food service operations. TCJDC has a satellite system of meal service
involving food preparation in the kitchen and delivery to housing units on trays via carts. Staff
members conduct food temperature checks on the serving line and during tray make-up. ODO
confirmed food temperatures met the requirements of the standard. Food service staff and
detainee workers wear hair restraints and beard guards. ODO found the food served was
acceptable and portions were adequate.
Southern Seven Health Department found TCJDC fully compliant with Illinois food service
regulations during its annual inspection. The Southern Seven Health Department is the Public
Health Authority for seven Illinois counties, including Pulaski (where TCJDC is located). ODO
confirmed all areas of the food service department were clean and well organized. Pest control
inspections and treatments are conducted on a monthly basis by an outside contractor. Cleaning
schedules are posted in all areas of the food service department. ODO verified the food service
area is inspected on a weekly basis by food service staff and on a monthly basis by the Safety
Manager. However, the food service policy does not address inspections of the food service area
(Deficiency FS-1). During the inspection, ODO recommended revision of the policy to address
inspections of the food service area. TCJDC management stated the food service policy would
be amended to include food service area inspections.
TCJDC uses the first-in-first-out stock rotation method to assure freshness of food items. A fiveweek menu cycle is in place for rotation of meals. ODO verified that a registered dietician
completes a nutritional analysis and a statement of nutritional adequacy for all menus. Records
of substitutions are recorded on a Menu Substitution Log Sheet, which is reviewed by the Food
Service Manager. Procedures are in place to ensure special diets are provided to detainees, and
documentation of approval and removal from special diets is maintained. ODO confirmed the
facility does not have a special menu for any of the ten federal holidays (Deficiency FS-2).

STANDARD/ POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE PBNDS, Food Service, section (V)(J)(13), the FOD must ensure the
facility shall implement written procedures requiring administrative, medical, and/or dietary
personnel to conduct the weekly inspections of all food service areas, including dining, storage,
equipment, and food-preparation areas.

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DEFICIENCY FS-2
In accordance with the ICE PBNDS, Food Service, section (V)(G)(2), the FOD must ensure
Common Fare is intended to accommodate detainees whose religious dietary needs cannot be
met on the mainline. The Common Fare menu is based on a 14-day cycle, with special menus
for the 10 Federal holidays. The menus must be certified as exceeding minimum daily
nutritional requirements and meeting daily allowances (RDAs). Beverages shall be selected
from the regular menu.

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at TCJDC to determine if controls are
in place to inventory, receipt, store, and safeguard detainees’ personal property, in accordance
with the ICE PBNDS. ODO reviewed policies, procedures, and the facility detainee handbook;
interviewed staff; and inspected areas where property is secured.
The property storage area at TCJDC is clean and organized. It is located in the admission and
release area behind a locked door, and is only accessible to supervisory staff and the Warden.
The area is staffed 24 hours a day. All detainee property bags are clearly marked documenting
the name and Alien Number of each detainee. Any abandoned property is turned over to ICE.
TCJDC conducts quarterly audits of the personal property and documents the audits on a local
established property form.
The TCJDC detainee handbook does not provide notice to detainees of facility policies and
procedures for requesting an ICE-certified copy of identity documents placed in their Alien Files,
the rules for mailing property not allowed in their possession, or the procedure for claiming
property upon release (Deficiency F&PP-1). Although storage bins are provided to detainees
for storage of personal property, ODO observed TCJDC did not provide storage bins or a
designated storage area for the personal property of detainees held in housing units D and E
(Deficiency F&PP-2). After being informed of this issue, TCJDC management stated this was
an oversight on their part and immediately instructed facility staff to issue storage bins to the
affected detainees.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(C), the FOD must
ensure the detainee handbook or equivalent shall notify the detainees of facility policies and
procedures concerning personal property, including [among others]:




That, upon request, they shall be provided a ICE/DRO-certified copy of any identity
document (passport, birth certificate, etc.) placed in their A-files;
The rules for storing or mailing property not allowed in their possession;
The procedure for claiming property upon release, transfer, or removal.

DEFICIENCY F&PP-2
In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(E)(4), the FOD
must ensure, for each housing area, the facility administrator shall designate a storage area for
storing detainee personal property.

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at TCJDC 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 PBNDS. ODO interviewed staff and reviewed policies, grievance logs, detention files, and
the facility’s local handbook.
Review of the grievance process at TCJDC showed there were no systemic problems with regard
to the facility responding to and processing grievances. Grievances are appropriately logged, to
include the date the grievance was received, the nature of the grievance, and the date a response
was provided. A total of 35 grievances were filed from January through June 2012. All
grievances were acted upon in a timely manner. ODO reviewed 20 randomly-selected detainee
detention files and confirmed copies of these grievances were placed in detainee detention files.
All grievances are maintained by the designated Grievance Officer and documented in a
logbook. Grievances regarding food service and medical care are forwarded to those respective
departments.
Upon admission to TCJDC, detainees are provided a facility handbook, as well as the National
Detainee Handbook. Review of the facility detainee handbook determined the handbook does
not contain instructions for filing emergency grievances, does not provide procedures for
contacting ICE to appeal facility decisions, and does not state that detainees will not be subjected
to retaliation for filing a grievance or contacting the Office of Inspector General (OIG)
(Deficiency GS-1). ODO noted that the facility policy manual contains these requirements and
is provided to staff for reference and review.
ODO reviewed TCJDC policy regarding documentation of informal oral grievances. At the time
of review, facility personnel stated there is no system available for documenting such grievances.
ODO advised staff that informal oral grievances must be logged, and documentation referencing
the grievances must be placed in the detainees’ detention files (Deficiency GS-2).
The facility policy manual states, if a grievance is not resolved to the satisfaction of the detainee,
staff shall note in detail the reasons on the grievance form and shall refer the written grievance to
the next level within 15 working days of receipt. ODO advised facility staff, grievances that are
not resolved should be referred to the next level of supervision within 5 working days of receipt
(Deficiency GS-3).
Nineteen of the total of 35 grievances filed from January 2012 through June 2012 were general
in nature and included a variety of issues, such as complaints regarding phone cards, receipt of
mail, and problems with the television remote. Eleven grievances were related to food service,
and five were minor complaints against staff not involving alleged misconduct. No grievances
were appealed during this period. ODO confirmed there were no medical grievances filed by
ICE detainees within the specified time period.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE PBNDS, Grievance System, section (V)(B), the FOD must ensure
the facility shall provide each detainee, upon admittance, a copy of the Detainee Handbook /
local supplement, in which the grievance section provides notice of [among others]:




The process for filing emergency grievances.
The procedures for contacting ICE/DRO to appeal a decision in a CDF or IGSA facility.
The policy prohibiting staff from harassing, disciplining, punishing, or otherwise
retaliating against any detainee for filing a grievance or contacting the Inspector General.

DEFICIENCY GS-2
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(1), the FOD must ensure,
if an oral grievance is resolved, the employee need not provide the detainee written confirmation
of the outcome but shall document the result for the record in the detainee’s Detention File and
in any logs or data systems the facility has established to track such actions.
DEFICIENCY GS-3
In accordance with the ICE PBNDS, Grievance System, section (V)(C)(3)(2)(e), the FOD must
ensure, if the grievance cannot be resolved to the satisfaction of the detainee, the supervisor shall
so annotate in detail the reasons on the grievance form and refer the written grievance to the next
level of supervision in his or her chain of command or to the appropriate department head within
five working days of receipt.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at TCJDC to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE PBNDS. ODO toured the clinic, observed sick call, reviewed policies and procedures,
examined 36 medical records, verified medical staff credentials, and interviewed medical clinic,
facility, and training staff.
Medical services are provided under contract with Paladin. The HSA is an RN whose position
description designates her as the clinical medical authority. The HSA is on-site 40 hours per
week, and is on-call during non-business hours. A part-time ANP is the clinical provider
responsible for making clinical decisions, developing treatment plans, and managing detainees’
health care needs. A physician is available for consultation purposes and reviews orders from
the ANP, which are brought to him in his community office. In addition, the physician is on-site
six to eight hours per month to see detainees referred to him by the ANP and review chronic care
management. Nursing coverage is provided 24 hours a day by an additional RN and (b)(7)eLPNs.
A CMA is responsible for medication administration. Review of the CMA’s personnel file
confirmed certification in medication administration and routine evaluation of her performance
by the HSA. Dental care is provided by a contract dentist who also trains nursing staff in dental
assessment. All medical staff credentials, professional and prescriptive licenses, and
cardiopulmonary resuscitation (CPR) certifications are current and verified. Review of(b)(7)e
custody staff training records confirmed current certification in CPR, first aid, and use of the
Automated External Defibrillator (AED). ODO confirmed a language service is used for nonEnglish speaking detainees.
TCJDC has an MOU with UCH for inpatient services beyond the scope of the services available
at TCJDC. In addition, the MOU covers out-patient services, such as laboratory tests and
radiology. Pharmacy services are provided by a contract pharmacy whose pharmacist provides
quarterly monitoring of pharmacy services and the pharmaceutical practices of providers.
Pharmaceuticals are stored in a double-locked room with solid walls extending from floor to
ceiling. Current Drug Enforcement Administration (DEA) licenses are noted for all providers.
ODO verified the stock and working inventories of needles and syringes are current.
ICE Health Service Corps (IHSC) forms are used to document medical and mental health intake
screenings and physical examinations (PE). ODO verified that in all 36 medical records
reviewed, medical and mental health intake screenings were conducted by nursing staff when
detainees arrive at TCJDC. Testing for tuberculosis (TB) was completed by way of a Purified
Protein Derivative (PPD) skin test. Detainees with a history of positive PPD tests are isolated
pending completion of a chest X-ray to rule out the presence of active TB. Detainees with active
TB are transferred to UCH for housing and treatment, because TCJDC does not have a negative
pressure room for isolation.
An RN performs each PE. ODO verified every RN has documented training in conducting a PE,
and every PE is hands-on, in conformance with the PBNDS and IHSC performance improvement
criteria. The record review found one PE conducted 18 days after a detainee’s arrival at the
facility, which is outside the 14 day PBNDS requirement (Deficiency MC-1).
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Access to medical services is explained to detainees during the intake screening process and is
also described in the detainee handbook. Detainees access medical services by completing sick
call request forms printed in English and Spanish, and placing them in locked boxes in the
housing units. Nurses retrieve and triage the requests, and hold sick call within 24 to 48 hours.
Contact is made with the ANP for consultation purposes, if necessary. TCJDC management
stated the ANP and HSA are currently formulating a set of nursing protocols to support the
efficiency of the sick call process.
TCJDC management holds quarterly administrative meetings with facility department heads and
medical staff; however, review of meeting agendas found three of the five minimum topics
required by the PBNDS were not included. Discussions of health environment factors that may
need improvement, review and discussion of communicable disease and infectious control
activities, and changes affected since the previous meeting are not among the topics of
discussion (Deficiency MC-2). Inter-disciplinary discussion of the issues identified in the
standard supports effective delivery of health care services.
ODO notes the facility’s policy on management of communicable and infectious diseases does
not address notification of Varicella diagnoses to the ICE Headquarters Epidemiology Unit.
Though there have been no Varicella cases at TCJDC, ODO recommends modification of the
policy to support compliance with the standard in the event of any future diagnosis of Varicella.
ODO further notes that at the time of the review, TCJDC did not have a Clinical Laboratory
Improvement Amendments (CLIA) waiver for laboratory tests performed at the facility. The
CLIA are established federal regulatory standards governing clinical laboratory testing, defined
as any test on specimens derived from humans for the purpose of providing information for the
diagnosis, prevention, or treatment of disease, and assessment of health. A CLIA waiver is
required for any test performed in a correctional facility, including urine test by dipstick, and
glucose monitoring using a glucometer. During the review, TCJDC management submitted an
electronic request for a CLIA waiver.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE PBNDS, Medical Care, section (V)(J), the FOD must ensure each
facility’s health care provider shall conduct a health appraisal including a physical examination
on each detainee within 14 days of the detainee’s arrival unless more immediate attention is
required due to an acute or identifiable chronic condition, in accordance with the most recent
ACA Adult Local Detention Facility standards for Health Appraisals. If there is documentation
of one within the previous 90 days, the facility health care provider upon review may determine
that a new appraisal is not required.
DEFICIENCY MC–2
In accordance with the ICE PBNDS, Medical Care, section (V)(X)(1), the FOD must ensure the
administrative health authority shall convene a meeting at least quarterly and include other
facility and medical staff as appropriate. The meeting agenda shall include, at a minimum:


An account of the effectiveness of the facility health care program;

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




Discussions of health environment factors that may need improvement;
Review and discussion of communicable disease and infectious control activities;
Changes effected since the previous meetings; and,
Recommended corrective actions, as necessary.

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RECREATION (R)
ODO reviewed the Recreation standard at TCJDC to determine if detainees are provided access
to recreational programs and activities within the constraints of a safe and secure environment, in
accordance with the ICE PBNDS. ODO interviewed detainees and staff, toured the indoor and
outdoor recreation areas, and examined recreation logs and files.
Detainees have daily opportunities to participate in leisure-time activities, such as reading,
watching television, and playing board games in housing unit dayrooms. Weather-permitting,
detainees may participate in outdoor recreation for one hour each day. The outdoor recreation
area consists of a fenced in area with unencumbered space, to include an open recreation area
and a wide L-shaped walkway.
ODO observed the outdoor recreation area while in use by one housing unit holding 54
detainees. The only outdoor recreation equipment provided to detainees was a soccer ball.
Inspection of the indoor recreation area found natural light and fresh air is available through a
large, fenced opening in the upper portion of the outside wall. This opening is controlled by a
large garage-type door, which is opened when the area is in use. A basketball goal and a
basketball were the only exercise equipment provided to detainees in the indoor recreation area
(Deficiency R-1). Prior to completion of the review, TCJDC management purchased two soccer
balls and two basketballs for use by detainees.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY R-1
In accordance with the ICE PBNDS, Recreation, section (V)(D)(2), the FOD must ensure
exercise areas shall offer a variety of equipment. Weight training, if offered, must be limited to
fixed equipment. Free weights are prohibited.

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SPECIAL MANAGEMENT UNITS (SMU)
ODO reviewed the Special Management Units standard at TCJDC to determine if the facility has
procedures in place to temporarily segregate detainees for disciplinary and administrative
reasons, in accordance with the ICE PBNDS. ODO toured the SMU, interviewed staff, and
reviewed policies, logs and other pertinent documentation.
The SMU is located within the main housing unit and is monitored through a window from the
unit’s control center. Inspection of the SMU confirmed it is well-lit, adequately ventilated, and
maintained in a sanitary condition. The SMU at TCJDC consists of eight double cells, with one
secure shower for the entire unit. During the ODO review there were no ICE detainees in SMU.
TCJDC management stated that detainees are rarely placed in segregation, and no detainees had
been placed in either administrative or disciplinary segregation within recent memory; therefore,
no records were available to review.
Review of facility policy found it does not address guidelines concerning the property detainees
may retain while in the SMU (Deficiency SMU-1). In addition, TCJDC does not have a policy
addressing retention of religious items while in the SMU (Deficiency SMU-2). Addressing these
matters in policy will assure clarity and help to avoid confusion on the part of detainees and staff.
ODO verified facility policy addresses all other requirements of the standard. To support full
compliance, ODO recommends revision of facility policy to include guidelines for personal
property and religious items. Additionally, though not required by the PBNDS to be in writing,
ODO recommends that daily visits to the SMU by the Facility Administrator, which are required,
be written into the suggested policy revision.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SMU-1
In accordance with the ICE PBNDS, Special Management Units, section (V)(B)(5), the FOD
must ensure each facility shall issue guidelines in accordance with this Standard concerning the
property detainees may retain in each type of segregation. Generally, detainees in Disciplinary
Segregation shall be subject to more stringent personal property restrictions and control than
those in Administrative Segregation, given the non-punitive nature of Administrative
Segregation.
DEFICIENCY SMU-2
In accordance with the ICE PBNDS, Special Management Units, section (V)(B)(15) the FOD
must ensure detainees in SMUs shall be allowed visits by members of the clergy, upon request,
unless the supervisor determines such a visit presents a safety or security risk, or would interfere
with the orderly operation of the facility. Violent and uncooperative detainees may be
temporarily denied access to religious guidance. Staff shall advise the clergy member of the
detainee’s present state of behavior before he or she agrees to visit the detainee. Each facility
will develop procedures to allow detainees to retain religious items within their possession
consistent with good security practices (e.g., religious wearing apparel, religious headwear,
prayer rugs, beads, prayer rocks, medallions).

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at TCJDC 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 PBNDS. ODO toured TCJDC, interviewed
detainees, and reviewed work requests for telephone maintenance.
ODO found detainees have reasonable and equitable access to telephones at TCJDC. The
telephone availability ratio is approximately 15 detainees per telephone. Detainees are given
emergency messages and allowed to return emergency telephone calls without delay.
Review of the TCJDC Detainee Telephone Log confirmed facility personnel conduct daily
inspections of telephones. Additionally, ODO reviewed ICE Telephone Serviceability
Worksheets from January 2012 through June 2012 and confirmed weekly telephone inspections
by ICE staff. ODO reviewed maintenance requests for telephone repairs and the work orders for
those repairs. ODO checked the operability of telephones in detainee housing areas, and found
them to be in good working order. Pre-programmed numbers for OIG, foreign consulates, and
pro bono legal services are fully functional.
Procedures for telephone use and obtaining an unmonitored call are addressed in the facility
handbook and posted in each housing unit. Additionally, detainees are notified calls are subject
to monitoring by way of a pre-recorded message provided in English and Spanish before calls
are connected. Facility policy addresses detainee telephone locations, hours of use, emergency
use of telephones, pro bono listings, and procedures for indigent detainees; however, local policy
does not address the monitoring of detainee telephone calls or procedures for obtaining an
unmonitored call (Deficiency TA-1). If detainees wish to make a telephone call to a legal
representative, detainees are escorted either to the Officer’s Station or visitation conference
rooms where the telephones are not monitored. Detainees are supervised through a glass
window when making unmonitored calls, which allows for privacy.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE PBNDS, Telephone Access, section (V)(B), the FOD must ensure
each facility shall have a written policy on the monitoring of detainee telephone calls.

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USE OF FORCE AND RESTRAINTS (UOF)
ODO reviewed the Use of Force and Restraints standard at TCJDC to determine if necessary use
of force is used 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 the ICE PBNDS. ODO interviewed staff and reviewed local policy, training records, use of
force documentation, and the use of force log.
TCJDC management stated there were four use-of-force incidents involving ICE detainees
during the 12 months preceding the ODO inspection. Because documentation does not
categorize force incidents as immediate or calculated, ODO reviewed reports and identified one
immediate use of force incident and three calculated use of force cell extractions. An immediate
use of force situation is created when a detainee's behavior constitutes a serious and immediate
threat to self, staff, another detainee, property, or the security and orderly operation of the
facility. In that situation, staff may respond without a supervisor's direction or presence. A
calculated use of force occurs when a detainee is in a location where there is no immediate threat
to the detainee or others. Medical personnel were not contacted in advance of any of the three
calculated force incidents (Deficiency UOF&R-1). Video diskettes were taped or binderclipped to documentation for two of three calculated force incidents; however, both diskettes
were corrupt and could not be viewed to assess the appropriateness of force used, or compliance
with video recording procedures. No diskette or other audiovisual recording was available for
the third calculated force incident (Deficiency UOF&R-2). Based on interviews and inspection,
ODO determined procedures are not in place to assure audiovisual recording equipment is
routinely inspected and tested to assure operability. In addition, procedures are not in place to
catalog recordings or to assure the availability of audiovisual recordings for supervisory or ICE
review, if necessary (Deficiency UOF-3).
Overall, ODO found the use of force packets disorganized and without a consistent format.
Documentation of all four incidents reflected that detainees were medically examined following
the use of force encounters; however, forms were not consistently completed. In all four cases,
the Medical Evaluation Anatomical Body Forms were blank, including two where minor injuries
to the detainees and staff were noted in other documentation.
No use of force packets contained documentation of an after-action review to assess the
reasonableness of force and its application, to include viewing of audiovisual recordings.
Interviews of the Warden and Captain confirmed after-action reviews are not conducted
(Deficiency UOF&R-4). TCJDC management stated ICE was notified of the incidents by way
of incident reports only.
TCJDC designates the supervisory staff authorized to carry and use oleoresin capsicum (OC)
spray. Review of training files confirmed current certification. TCJDC management stated that
all TCJDC officers are trained in use of force. The facility produced a video recording of a
training session conducted in February 2012; however, no attendance roster was available, and
review of training records for(b)(7)e fficers confirmed none included documentation of completion
of the training. ODO viewed the training session video recording and found it covered cell
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extraction procedures only. It did not cover all elements of the use of force team technique
required by the standard, including confrontation avoidance, professionalism, and debriefing
(Deficiency UOF&R-5). No lesson plan was available for ODO review. This deficiency was
also identified during the June 2010 ODO inspection.
The PBNDS stresses confrontation avoidance prior to use of force. In addition, it distinguishes
between immediate and calculated force situations, the former requiring spontaneous force to
prevent a detainee from harming self or others; the latter allowing assessment and possible
resolution without resorting to force because no immediate threat is posed. Review of the
TCJDC use of force policy confirmed it does not address confrontation avoidance. In addition,
ODO found it distinguishes between immediate and calculated force, but does not address the
PBNDS requirements relating thereto. The policy outlines procedures for calculated use of force
in the form of a cell extraction, which is the planned and coordinated removal of a non-compliant
detainee from a cell or other isolated area by a trained team following the use of force team
technique. The policy does not address health services staff involvement prior to and following
use of force incidents, audiovisual recordings, or after-action reviews. The policy also does not
address documentary requirements for immediate use of force incidents.
Comprehensive use of force policies and training programs are critical to the safety of detainees
and staff. Thorough documentation and review of uses of force support accountability. ODO
recommends TCJDC take immediate steps to correct the deficiencies cited under the Use of
Force PBNDS, revise its use of force policy, and improve staff documentation of use of force
incidents.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF&R-1
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(I)(1), the FOD
must ensure, before authorizing the calculated use of force, the ranking detention official, a
designated health professional, and others as appropriate shall assess the situation. Taking into
account the detainee's history and the circumstances of the immediate situation, they shall
determine the appropriateness of using force.
DEFICIENCY UOF&R-2
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(I)(2), the FOD
must ensure, while ICE/DRO requires that all use-of-force incidents be documented and
forwarded to ICE/DRO for review, for calculated use of force, it is required that the entire
incident be audio visually recorded. The facility administrator or designee is responsible to
insure that use of force incidents are audio visually recorded. Staff will be trained in the
operation of audiovisual recording equipment. There will be a sufficient number of cameras
appropriately located and maintained in the facility. The audiovisual record and accompanying
documentation shall be included in the investigation package for the After-Action Review.
DEFICIENCY UOF&R-3
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(K), the FOD must
ensure staff shall store and maintain audiovisual recording equipment under the same conditions
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as “restricted” tools. The equipment must be kept in a secure location elsewhere in the facility.
Since audiovisual recording equipment must often be readily available, each facility
administrator shall designate and incorporate in one or more post orders responsibility for:




Maintaining cameras and other audiovisual equipment;
regularly scheduled and documented testing to ensure all parts, including batteries, are in
working order; and
keeping back-up supplies on hand (batteries, tapes or other recording media, lens cleaners,
etc.).

Each audiovisual record shall be catalogued and preserved until no longer needed, but shall be
kept no less than 30 months after its last documented use. In the event of litigation, the facility
shall retain the relevant audiovisual record a minimum of six months after the litigation has
concluded or been resolved. The audiovisual records may be catalogued electronically or on 3"
x 5" index cards, provided that the data can be searched by date and detainee name. A log shall
document audiovisual record usage. Use-of-force audiovisual records shall be available for
supervisory, Field Office and Headquarters incident reviews and may also be used for training.
Release of use-of-force audiovisual recordings to the news media may occur only if authorized
by the Director of Detention and Removal Operations, in accordance with ICE/DRO procedures
and rules of accountability.
DEFICIENCY UOF&R-4
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(P)(1), the FOD
must ensure all facilities shall have ICE/DRO-approved written procedures for After-Action
Review of use-of-force incidents (immediate or calculated) and applications of restraints. The
primary purpose of an After-Action Review is to assess the reasonableness of the actions taken
and determine whether the force used was proportional to the detainee's actions. IGSAs shall
model their incident review process after ICE/DRO’s process and submit it to ICE/DRO for
DRO review and approval. The process must meet or exceed the requirements of ICE/DRO’s
process.
DEFICIENCY UOF&R-5
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(I)(3)(b), the FOD
must ensure, when a detainee must be forcibly moved and/or restrained during a calculated use
of force, staff shall use the use-of-force team technique to prevent or diminish injury to staff and
(b)(7)e
detainees and exposure to communicable disease. The technique usually involves
trained staff members clothed in protective gear, including helmet with face shield, jumpsuit,
stab-resistant vest, gloves, and forearm protectors. Team members enter the detainee's area
together and have coordinated responsibility for achieving immediate control of the detainee.
The use-of-force team technique training shall include the technique, its application,
confrontation-avoidance, professionalism, and debriefing.

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