DHS OIG, OIG-23-26, Results of an Unannounced Inspection of Northwest ICE Processing Center in Tacoma, Washington * (2023)

ults of an nnounced ection of Res Una Insp Northwest ICE Processing Center in Tacoma, Washington May 22, 2023 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Washington, DC 20528 / www.oig.dhs.gov May 22, 2023 MEMORANDUM FOR: Tae D. Johnson Acting Director U.S. Immigration and Customs Enforcement FROM: SUBJECT: Joseph V. Cuffari, Ph.D. Inspector General Results of an Unannounced Inspection of Northwest ICE Processing Center in Tacoma, Washington Attached for your action is our final report, Results of an Unannounced Inspection of Northwest ICE Processing Center in Tacoma, Washington. We incorporated the formal comments provided by your office. The report contains eight recommendations aimed at improving care of detainees at Northwest ICE Processing Center. Your office concurred with seven recommendations and did not concur with one recommendation.

We consider three recommendations resolved and closed, four recommendations resolved and open, and one recommendation unresolved and open. Once your office has fully implemented the remaining recommendations, please submit a formal closeout letter to us within 30 days so that we may close the recommendations. The memorandum should be accompanied by evidence of completion of agreed-upon corrective actions. Please send your response or closure request to [email protected].

Consistent with our responsibility under the Inspector General Act, we will provide copies of our report to congressional committees with oversight and appropriation responsibility over the Department of Homeland Security. We will post the report on our website for public dissemination. Please call me with any questions, or your staff may contact Thomas Kait, Deputy Inspector General for Inspections and Evaluations at (202) 981-6000. Attachment DHS OIG HIGHLIGHTS Results of an Unannounced Inspection of Northwest ICE Processing Center in Tacoma, Washington May 22, 2023 What We Found Why We Did This Inspection In accordance with the Consolidated Appropriations Act, 2022, we conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards.

From August 30 to September 1, 2022, we conducted an in- person inspection of the Northwest facility in Tacoma, Washington, to evaluate compliance with ICE detention standards and COVID-19 requirements. What We Recommend We made eight recommendations to improve ICE’s oversight of detention facility management and operations at Northwest. For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at [email protected] During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Northwest ICE Processing Center (Northwest) in Tacoma, Washington, we found that the facility complied with standards for intake and classification; facility conditions, including housing and hygiene; detainee access to law library and legal services; recreation; segregation; use of force; and providing timely responses to detainee requests. Northwest also complied with COVID-19 protocols and requirements set forth by a Federal court order.

However, Northwest did not always provide timely responses to detainee grievances and did not always respond to detainee requests and grievances in a language understood by the detainee. Further, Northwest had an incomplete food inventory control system and did not always practice sound food storage practices. Our medical contractors found more than 30 percent of the facility’s medical staff positions were vacant, preventative screening practices were not consistently applied, and the facility was not immediately able to locate the emergency delivery kit. In addition, Northwest has discontinued use of its detainee voluntary work program.

Finally, ICE paid for unused bedspace because Northwest’s detainee population did not meet the guaranteed minimum outlined in the facility’s operating contract. ICE Response ICE concurred with seven recommendations and did not concur with one recommendation. We consider three recommendations resolved and closed, four recommendations resolved and open, and one recommendation unresolved and open. www.oig.dhs.gov OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Table of Contents Background .................................................................................................... 3 Results of Inspection .......................................................................................

4 Northwest Complied with Multiple Standards ........................................ 4 Northwest Took Measures to Prevent the Spread of COVID-19 and Complied with Requirements Set Forth by a Federal Court Order ........... 6 Northwest Did Not Always Provide Timely Responses to Grievances ....... 7 Northwest and ICE Did Not Always Respond to Detainee Requests and Grievances in a Language Understood by the Detainee ....................

8 Northwest Did Not Always Practice Sound Storage and Inventory Practices for Food Products.................................................................... 9 Northwest Provided Compliant Medical Care to Detainees but Had Medical Staff Vacancies, Inconsistent Preventative Screening Practices, and Could Not Immediately Locate the Emergency Delivery Kit ....................................................................................................... 12 Northwest Discontinued Use of the Detainee Voluntary Work Program............................................................................................... 13 ICE Housed Less Than Half the Guaranteed Minimum Population at Northwest and Paid More Than $40 Million for Unused Bed Space for 1 Year.............................................................................................

14 Recommendations ......................................................................................... 15 Management Comments and OIG Analysis .................................................... 16 Appendixes Appendix A: Objective, Scope, and Methodology ................................. 23 Appendix B: ICE Comments to the Draft Report ..................................

25 Appendix C: Office of Inspections and Evaluations Major Contributors to This Report .................................................................. 33 Appendix D: Report Distribution ......................................................... 34 www.oig.dhs.gov 1 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Abbreviations CBP ERO FSA ICE PBNDS PRR Northwest U.S. Customs and Border Protection Enforcement and Removal Operations food service administrator U.S. Immigration and Customs Enforcement Performance-Based National Detention Standards Pandemic Response Requirements Northwest ICE Processing Center www.oig.dhs.gov 2 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Background U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 130 facilities nationwide, and the conditions and practices at those facilities can vary greatly. ICE must comply with Federal detention standards and establish an environment that protects the health, safety, and rights of detainees.

As mandated by Congress,1 we conduct unannounced inspections of ICE detention facilities to ensure compliance with the Performance-Based National Detention Standards 2011 (PBNDS 2011). Our program of unannounced inspections of ICE detention facilities has identified and helped correct violations of these detention standards at facilities across the country. From August 30 through September 1, 2022, we conducted an unannounced, in- person inspection of Northwest ICE Processing Center (Northwest) in Tacoma, Washington, and identified concerns regarding detainee care and treatment. ICE Enforcement and Removal Operations (ERO) oversees the detention facilities it manages in conjunction with private contractors or state or local governments.

Northwest is operated by the GEO Group, Inc., and began housing detainees in 2004. Between September 1, 2021, and August 31, 2022 (the year prior to our inspection), Northwest had an average daily population of 374 detainees, with a maximum capacity of 1,575. Under the facility’s contract, ICE pays Northwest nearly $5 million a month to house ICE detainees. The contract also requires Northwest to comply with the PBNDS 2011, as revised in December 2016.

According to ICE, the PBNDS 2011 establishes consistent conditions of detention, program operations, and management expectations within ICE’s detention system. These standards set requirements in areas such as: • environmental health and safety, including cleanliness, sanitation, security, detainee searches, segregation, and disciplinary systems; • detainee care, e.g., food service, medical care, and personal hygiene; • activities, including visitation and recreation; and • grievance systems. ICE houses both male and female detainees at Northwest in 20 traditional housing pods, a segregation unit, and a medical unit. At the start of our inspection, Northwest had a total of 326 ICE detainees — 311 detainees in 1 Consolidated Appropriations Act, 2022, Pub.

L. No. 117-103, Division F; Department of Homeland Security Appropriations Act, 2022, H.R. Rep. No. 117-87 (2021). www.oig.dhs.gov 3 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security traditional housing pods, 9 detainees in segregation, and 6 detainees in the medical unit. Our onsite inspection team included contracted medical experts to review Northwest’s compliance with applicable medical standards of care,2 and we have incorporated their assessments in our findings. During our inspection, we conducted a walk-through of Northwest facilities, including detainee housing pods, medical units, and indoor and outdoor recreation areas.

We also requested and reviewed documents and files and interviewed ICE personnel, Northwest officials, and detainees. Results of Inspection We found that Northwest complied with standards for intake and classification; facility conditions, including housing and hygiene; detainee access to law library and legal services; recreation; segregation; use of force; and providing timely responses to detainee requests. Northwest also complied with COVID- 19 protocols and requirements set forth by a Federal court order. However, Northwest did not always provide timely responses to detainee grievances and did not always respond to detainee requests and grievances in a language understood by the detainee.

Further, Northwest had an incomplete food inventory control system, and we found violations of food safety and storage standards. Our medical contractors found room for improvement regarding Northwest’s medical staff vacancies, preventative screening practices, and immediate availability of an emergency delivery kit. In addition, Northwest has discontinued use of its detainee voluntary work program. Finally, ICE paid for unused bedspace because Northwest’s detainee population did not meet the guaranteed minimum outlined in the facility’s operating contract.

Northwest Complied with Multiple Standards We found that Northwest complied with the PBNDS 2011 standards for intake and classification; facility conditions, including housing and hygiene; detainee access to law library and legal services; recreation; segregation; use of force; and providing timely responses to detainee requests. Our findings are summarized below. Intake and Classification. The standards require that detainees be classified,3 screened, and oriented to the facility to ensure safety, security, and 2 In addition to the PBNDS 2011, our medical contractors used the National Commission on Correctional Health Care’s 2018 Standards for Health Services in Jails.

3 PBNDS 2011, Section 2.1, Custody Classification System (revised Dec. 2016). www.oig.dhs.gov 4 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security good order.4 The piece of the intake process we observed for new detainees was compliant with admission regulations. We also reviewed 32 detainee files and found that all were classified correctly and within 12 hours of admission, as required.5 Facility Conditions, Housing, and Hygiene. The standards require facilities to provide adequate bathing and toilet facilities as well as clean clothing, bedding, towels, and personal hygiene items.6 We inspected eight of the traditional detainee housing pods, including both open floor plans and individual cells, and found that bathing and toilet facilities were generally well maintained, and the facility supplied appropriate and clean clothing, bedding, towels, and hygiene items.

We observed that two of seven showers did not function properly in pod F4. Despite the two non-functioning showers, the pod met the required ratio of operable showers to detainees. We also found that water from showers frequently collected in walking areas, posing a danger for slips or falls, but the facility took safety precautions during our inspection by adding slip hazard warning signs and “spill blocker” mats. Detainee Access to Law Library and Legal Services.

The standards require facilities to ensure detainees have access to courts, counsel, legal rights groups, legal materials, legal telephone calls, and the law library.7 Northwest met these requirements. Legal rights groups visit the facility weekly to give in- person legal rights presentations, and we observed signup sheets for the legal orientation program in the housing units. Recreation. The standards require that all detainees in the general population have access to recreational and exercise programs and activities for 4 hours a day, 7 days a week, at a reasonable time of day.8 Northwest met these requirements and posted recreation schedules in all housing units.

Northwest also provided a variety of exercise and sports equipment for its indoor and outdoor recreation areas, as well as access to televisions with gaming consoles, board games, and leisure reading materials in multiple languages. Segregation. The standards allow for certain detainees to be segregated from the general population in special management units.9 This includes administrative segregation for detainees who require protective custody and 4 PBNDS 2011, Section 2.1, Admission and Release (revised Dec. 2016).

5 PBNDS 2011, Section 2.1, Admission and Release (revised Dec. 2016). Each newly admitted detainee shall be kept separated from the general population until health, housing, and custody classification is completed but not longer than 12 hours. 6 PBNDS 2011, Section 4.5, Personal Hygiene (revised Dec.

2016). 7 PBNDS 2011, Section 6.3, Law Libraries and Legal Material (revised Dec. 2016). 8 PBNDS 2011, Section 5.4, Recreation (revised Dec.

2016). 9 PBNDS 2011, Section 2.12, Special Management Units (revised Dec. 2016). www.oig.dhs.gov 5 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security disciplinary segregation for detainees separated from the general population for disciplinary reasons. Detainees in segregation must receive daily medical visits, welfare checks, and status reviews to determine whether to continue with placement in segregation.

During our visit, Northwest housed nine detainees in special management units — eight in administrative segregation and one in disciplinary segregation. We found the facility complied with the standards for segregation. Use of Force. The standards authorize staff to use necessary and reasonable force to protect people, to minimize injury, to prevent escape or serious property damage, or to maintain the security and orderly operation of the facility.10 Restraint devices can be used to prevent escape, for medical reasons, or to prevent self-injury, injury to others, or property damage.

Northwest reported five use of force incidents in the 6 months prior to our inspection (February 1, 2022, to August 31, 2022). All five uses of force appeared appropriate and authorized based on the facility’s video footage and written incident reports. When restraints were used, it was done so in compliance with standards. Northwest employees involved in use of force incidents submitted reports documenting the incidents in a timely manner.

Incident reports were also submitted to the field office director within 2 working days, as required. Timely Responses to Detainee Requests. The standards require facilities to log and track requests received from detainees and respond to them within 3 business days.11 We found that detainees received timely and substantive responses to requests sent to both facility staff and ICE, regardless of whether they submitted requests using paper forms or electronic tablets. Northwest Took Measures to Prevent the Spread of COVID-19 and Complied with Requirements Set Forth by a Federal Court Order ICE’s Pandemic Response Requirements sets forth expectations for detention facilities’ management of COVID-19 and requires facilities to have a COVID-19 mitigation plan that protects employees, detainees, and others from exposure to the virus.

Additionally, on August 23, 2021, the U.S. District Court for the Western District of Washington in Seattle granted a motion for a temporary restraining order against Northwest requiring ICE to test detainees for COVID- 19 prior to their transfer to Northwest and “to take all reasonable measures to ensure there is no cross-exposure between COVID-19 positive detainees and 10 PBNDS 2011, Section 2.15, Use of Force and Restraints (revised Dec. 2016). 11 PBNDS 2011, Section 2.13, Staff-Detainee Communication (revised Dec. 2016). www.oig.dhs.gov 6 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security COVID-19 negative detainees during transport.”12 The order further prohibits Northwest from admitting any detainee who “was not transferred in compliance with this order.”13 In order to comply with the requirements of this order, ICE transfers detainees released from U.S. Customs and Border Protection (CBP) custody at the southern border to another ICE facility for COVID-19 testing before they are transferred to Northwest.

According to the assistant health services administrator, upon arrival at Northwest, all detainees are screened by ICE Health Service Corps staff for signs and symptoms of COVID-19, including a temperature check. We observed this to be true when we witnessed a group of detainees entering the facility and going through the procedures as described by the assistant health services administrator. Due to the temporary restraining order, most Northwest detainees are transferred from other ICE detention facilities, where they are tested before their transfer to Northwest. As such, Northwest only tests arriving detainees who show signs and symptoms of COVID-19, using a polymerase chain reaction COVID-19 test.

Any detainee who arrives with signs or symptoms of COVID-19 is placed in a “rule-out” housing unit. If the detainee tests positive for COVID-19, he or she is admitted to the Northwest infirmary. If a detainee in a “rule-out” unit tests negative, he or she will still remain in that unit for 10 days. All other arriving detainees are placed in one of Northwest’s New Intake Monitoring System housing pods for intake quarantine.

After 10 days in quarantine, detainees in the “rule-out” units and those in the New Intake Monitoring System pods are tested for COVID-19 using a rapid COVID-19 test. ICE Health Service Corps also administers rapid tests to detainees being released or transferred. Northwest Did Not Always Provide Timely Responses to Grievances The PBNDS 2011 requires facilities to log and track grievances filed by detainees and to respond to grievances within 5 days.14 In the housing units we visited, detainees could submit grievances to facility staff via either paper forms or electronic tablets. Northwest uses a system called Geo Track to track electronic and paper grievances.

We reviewed 251 grievances submitted from March 1, 2022, through August 31, 2022, and found that 15 did not receive a response, reducing our sample to 236 grievances.15 Of those, Northwest did 12 Mot. for Temporary Restraining Order, Juarez v. Asher, 556 F. Supp. 3d 1181 (W.D. Wash. Aug. 23, 2021).

13 Id. at 1192. 14 PBNDS 2011, Section 6.2, Grievance System (revised Dec. 2016). 15 When a detainee files several grievances for the same issue, the reviewing official will respond to the original submission and reject the duplicates or mark them as a nuisance. www.oig.dhs.gov 7 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security not provide timely responses in 44 instances, or about 19 percent of the time.

Specifically, 23 of the responses took 11 days or longer, with the longest response time at 45 days. Figure 1 shows the response timeframes for the 236 grievances that received responses. Figure 1. Northwest’s Responses to Grievances Were Not Always Timely Total 236 grievances Each = 10 grievances Within 5 days 6–10 days 11–20 days 21 or more days 192 responses (81%) 21 responses (9%) 21 responses (9%) 2 responses (1%) Source: Department of Homeland Security Office of Inspector General analysis of data provided by Northwest Northwest and ICE Did Not Always Respond to Detainee Requests and Grievances in a Language Understood by the Detainee Detainees can submit requests and grievances to facility and ICE staff.

The PBNDS 2011 requires facilities to make language assistance available for any of these communications for detainees with limited English proficiency,16 but both Northwest and ICE staff did not always provide responses in a language the detainee could understand. 16 PBNDS 2011, Section 2.13, Staff-Detainee Communication (revised Dec. 2016); and PBNDS 2011, Section 6.2, Grievance System (revised Dec. 2016). www.oig.dhs.gov 8 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security We reviewed a random sample of 100 requests submitted by detainees using the electronic tablet system between March 1, 2022, and August 31, 2022.

Of the 50 requests submitted to the facility, only 5 responses were in the same language as the request. Of the 50 requests submitted to ICE, none of the responses were in the same language as the request. 0% Number of ICE responses in our sample in which the response was in the same language as the request. Similarly, we reviewed all 60 detainee grievances submitted electronically to the facility in languages other than English between March 1, 2022, and August 31, 2022.

Northwest staff did not respond in the language used by the detainee 52 percent of the time. The facility and ICE cannot ensure the detainee will understand the response if it is not written in the language used by the detainee. Northwest Did Not Always Practice Sound Storage and Inventory Practices for Food Products The PBNDS 2011 requires sound safety and sanitation practices for food products and services.17 Food service areas must be regularly inspected on schedules determined by the food service administrator (FSA) and applicable policy requirements. Based on our inspection of Northwest’s food storage areas, we determined that the facility did not meet these standards and did not have an appropriate inventory control system in place to identify, track, and remove old18 food products.

Northwest’s Inventory Inspection Practices Were Not Effective The PBNDS 2011 states, “Since control and location of subsistence supplies are site-specific, each FSA shall establish procedures for storing, receiving and inventorying food.”19 During our tour, the FSA at Northwest explained that part of her team’s daily inventory responsibility was to identify and track best- by, packed, or production dates of food products. The facility administrator also later provided us with the shelf-life reference guide he said Northwest uses to determine how long food should be kept in its inventory. The guide includes the shelf life for opened and unopened produce, dry goods, refrigerated and frozen items, and baked items. Once a food item is identified for removal from inventory, the facility administrator said the item is placed on a list of items to 17 PBNDS 2011, Section 4.1, Food Service (revised Dec.

2016). 18 Past the manufacturers’ recommended shelf-life guidance used by the facility. 19 PBNDS 2011, Section 4.1, Food Service (revised Dec. 2016). www.oig.dhs.gov 9 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security remove from the inventory system.

Despite Northwest’s food service staff having a process for identifying and removing food products from inventory, we found at least 13 products with best-by, packed, or production dates as far back as 2019. According to the manufacturer’s best-by dates and Northwest’s shelf-life reference guide, these items should have been removed from Northwest’s inventory, but they remained in the food storage areas for use, in some instances, years after their best-by date. For example, we found boxes of canned pears that were dated September 201920 by the manufacturer (see Figures 2 and 3), as well as boxes containing frozen turkey breasts with a “pack date” of September 2019. According to the manufacturer’s storage instructions and shelf-life reference guide Northwest provided us on site, frozen turkey breasts and industrial-sized cans of pears dated September 2019 should have been discarded by September and March 2021, respectively.

However, we observed those items in the storage areas during our facility tour in August 2022. The FSA also explained that another part of her inspection process was to ensure staff mark the date of receipt on food product boxes when the items arrive at the facility. We observed the month and day written on many boxes in Northwest’s food storage area, but staff did not mark the year of receipt. In other instances, we noted that there was no date of receipt at all.

As not every Northwest food product is received and consumed during the same year, this may cause confusion when Northwest’s staff inspect their inventory. During our initial tour of the facility, we brought food items of concern to the attention of the FSA, including the previously mentioned frozen turkey breasts and cans of pears. She said that she sent a list of approximately 20 food items we identified to the GEO Group, Inc., so it could determine whether the products should be discarded. When we returned to inspect the food storage areas on the last day of our inspection (3 days later), the only item Northwest had discarded was a 50-pound bag of grits with a best-by date of September 2020.

20 It was unclear from the packaging of this product whether the “09 14 2019” date on the can was a production or expiration date. www.oig.dhs.gov 10 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Figure 2 Figure 3 Figures 2 and 3. Stacks of Boxes of Pears with “11/9” and “11/7” Marked on the Side (Figure 2, with markings circled in red) and the Top of an Industrial-Sized Can of Pears with a Manufacturer Date of September 14, 2019 (Figure 3), Both Observed on August 30, 2022 Source: DHS OIG photos Northwest Did Not Always Follow Safe Food Storage Practices We found several boxes of frozen, fully cooked meat patties, chicken fritters, meatballs, and butter slices, with no visible best-by or production date, open and exposed to the air (see Figures 4–6). We also found a box of chicken on the floor of one of Northwest’s freezers, but the standards require all food products to be stored at least 6 inches above the floor to facilitate pest-control measures.21 Northwest’s storage of these products did not conform with sound safety and sanitation practices, which are meant to protect detainees from potential illness. 21 PBNDS 2011, Section 4.1, Food Service (revised Dec.

2016). www.oig.dhs.gov 11 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Figure 4 Figure 5 Figure 6 Figures 4–6. An Open Box with Frozen Meat Labeled “Country Fried Patty” (Figure 4), an Open Box with Frozen Meat Labeled “Baked Italian Style Meatballs” (Figure 5), and an Open Box with Individual Slices of Butter (Figure 6), All Observed on August 30, 2022 Source: DHS OIG photos Northwest Provided Compliant Medical Care to Detainees but Had Medical Staff Vacancies, Inconsistent Preventative Screening Practices, and Could Not Immediately Locate the Emergency Delivery Kit In addition to the PBNDS 2011, which requires that detainees have access to appropriate and necessary medical, dental, and mental health care (including emergency services),22 our medical contractors examined compliance with some standards in the National Commission on Correctional Health Care’s 2018 Standards for Health Services in Jails. The medical experts concluded that the medical facility was well run overall, but they found room for improvement regarding medical staff vacancies, screening and preventative services, and the need for an emergency delivery kit. Medical Staff Vacancies Could Cause a Decrease in Care The PBNDS 2011 requires facilities to provide medical staff and sufficient support personnel to meet the standards.23 Our contracted medical staff found that Northwest had 89 medical positions, 27 of which were vacant at the time 22 PBNDS 2011, Section 4.3, Medical Care (revised Dec.

2016). 23 PBNDS 2011, Section 4.3, Medical Care (revised Dec. 2016). www.oig.dhs.gov 12 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security of our inspection (more than 30 percent). The detainee population at the time of our inspection was only 31 percent of the facility’s maximum capacity, making a future increase in population possible.

Providing adequate medical care to detainees is an important part of their overall wellbeing while in ICE custody and has proved to be an ongoing challenge at facilities across the country.24 It is critical that the facility provides the appropriate number of medical staff to ensure medical care standards are met. Screening and Preventative Services Were Not Provided Consistently The PBNDS 2011 also requires that detainees have access to a continuum of health care services, including screening, prevention, health education, diagnosis, and treatment.25 In addition, guidelines exist for screening and preventative services, such as mammograms and colon screenings. However, our medical contractors found through health record reviews and interviews with medical staff that the guidelines were not consistently used by all medical staff. In addition, the current practice of the facility is to use registered nurses to complete annual exams, rather than a physician.

Staff Could Not Locate the Emergency Delivery Kit Finally, the PBNDS 2011 requires that pregnant detainees have access to prenatal and specialized care.26 Based on the standards, the medical contractors concluded that this care should include the facility having an emergency delivery kit for birth at the facility, but the facility could not locate the kit during our inspection. Facility staff members notified us that they located the emergency delivery kit shortly after we completed our onsite inspection and provided photographic evidence of the kit. Northwest Discontinued Use of the Detainee Voluntary Work Program The PBNDS 2011 allows facilities to provide detainees with the opportunity to work and earn money while confined, subject to the number of work opportunities available and within the constraints of the safety, security, and good order of the facility.27 24 OIG-22-03, Many Factors Hinder ICE’s Ability to Maintain Adequate Medical Staffing at Detention Facilities, Oct. 29, 2021.

25 PBNDS 2011, Section 4.3, Medical Care (revised Dec. 2016). 26 PBNDS 2011, Section 4.4, Medical Care (Women) (revised Dec. 2016).

27 PBNDS 2011, Section 5.8, Voluntary Work Program (revised Dec. 2016). www.oig.dhs.gov 13 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Northwest discontinued its voluntary work program in October 2021 because of an August 2021 court ruling requiring the facility to pay detainees minimum wage.28 The facility elected to not pay detainees minimum wage and instead use a combination of third-party contractors, local janitors, and temporary duty janitorial staff to do the work previously done by detainees in the work program. Most notably during our site visit, the kitchen duties were performed by existing facility staff and cleaning services were provided by local janitorial staff. The facility administrator noted the facility’s cleanliness declined immediately after Northwest discontinued the voluntary work program.

Specifically, the GEO Group, Inc., hired a third-party contractor to clean the facility in November 2021 but terminated the contractor in February 2022 because it was not performing as expected. Between February and July 2022, the GEO Group, Inc., transported janitors to the facility from other locations on temporary duty to clean the facility. Since July 2022, the GEO Group, Inc., has hired local janitors to clean the facility. As noted previously in this report, during our inspection, we observed that the facility overall was clean and complied with requirements to provide detainees with clean and adequate facilities.

ICE Housed Less Than Half the Guaranteed Minimum Population at Northwest and Paid More Than $40 Million for Unused Bed Space for 1 Year ICE’s contract with Northwest required ICE to pay for space for a guaranteed minimum of 1,181 detainees. As of October 2021, the daily rate was $138.86 per detainee. We found Northwest’s detained population was, on average, only 31 percent of its guaranteed minimum from October 2021 through August 2022 (see Figure 7). 28 Nwauzor et al. v. GEO Grp.

Inc., No. 3:17-CV-05769, 2021 WL 9374966 (W.D. Wash. Oct. 29, 2021). www.oig.dhs.gov 14 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Figure 7. Average Monthly Detainee Population Compared with the Contracted Guaranteed Minimum at Northwest during FY 2022 (October 2021 through August 2022) Guaranteed Minimum Actual Number of Detainees Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 418 461 441 390 308 291 271 343 395 385 347 1181 1181 1181 1181 1181 1181 1181 1181 1181 1181 1181 Source: DHS OIG analysis of data provided by Northwest Northwest staff explained that the previously mentioned August 2021 court ruling regarding COVID-19 protocols has also prevented the facility from accepting detainees directly from CBP custody and, therefore, reduced the number of detainees that could be housed at Northwest.

Northwest staff also said that vendors at local airports refuse to work with ICE, compelling ICE to fly detainees into an airport 3.5 hours away for transport to the facility. We determined ICE paid more than $40 million for unused bed space under the guaranteed minimum for the 1-year period prior to our inspection. Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Seattle Field Office, responsible for Northwest, to: Recommendation 1: Ensure responses to grievances occur within 5 days. Recommendation 2: Ensure responses to requests and grievances are in a language understood by the detainee. www.oig.dhs.gov 15 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Recommendation 3: Update the facility’s food service policy to ensure the food service department’s pre-existing weekly mandatory inspections include checking that products are used before their “best-by” or expiration dates, in accordance with the shelf-life reference guide used by the facility.

Recommendation 4: Adopt the practice of writing complete dates of receipt (month, day, and year) on packaging. Recommendation 5: Ensure food products are protected from exposure to contaminates and stored 6 inches above the floor. Recommendation 6: Ensure the guidelines for medical screening and preventative services are followed by all staff and annual exams are conducted by an appropriate medical provider. Recommendation 7: Review and update ICE’s contract with the facility by better identifying housing requirements and determining an appropriate guaranteed minimum.

We recommend the Executive Associate Director of Enforcement and Removal Operations direct ICE Health Service Corps to: Recommendation 8: Ensure the facility has a plan to fill medical vacancies. Management Comments and OIG Analysis ICE concurred with seven recommendations and did not concur with one recommendation. Appendix B contains ICE’s management comments in their entirety. We also received technical comments on the draft report and made revisions as appropriate.

We consider three recommendations resolved and closed, four recommendations resolved and open, and one recommendation unresolved and open. A summary of ICE’s response to our recommendations and our analysis follows. Recommendation 1: Ensure responses to grievances occur within 5 days. ICE Response to Recommendation 1: Concur.

In January 2023, the ERO Seattle Field Office Assistant Director adjusted the workloads of the enforcement and removal assistants to assist in screening grievances Supervisory detention and deportation officers hold regular meetings with staff and provide general reminders about answering grievances on a timely basis. www.oig.dhs.gov 16 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Also, in October 2022, the ERO Seattle Field Office transitioned to allowing staff to telework once a week, and working on grievances is a requirement during a telework day. The contractor provides annual grievance refresher training to all employees, and the grievance coordinator mentors employees regarding grievance procedures, as needed, during daily reviews of grievances. The grievance coordinator will monitor staff responses daily and report any issues to the responsible department head to ensure staff responses to grievances comply with the ICE grievance process. In addition, on December 21, 2022, a training video for the grievance system was disseminated to all detention facility staff responsible for responding to detainee communications.

The video provided information on the system’s functionality as well as how to use the system to better facilitate the grievance process. All staff completed the training by January 11, 2023. On April 18, 2023, ICE provided OIG documentation corroborating these efforts under a separate cover. ICE requests that OIG consider this recommendation resolved and closed as implemented.

OIG Analysis: ICE provided us a log of 85 detainee grievances submitted to the facility (81 grievances) and to ICE (4 grievances) from February 2, 2023, through April 5, 2023. The log shows improvement in responding to detainee grievances within 5 calendar days (from 81 percent shown in our report finding to 87 percent in the updated log), which is responsive to our recommendation. However, we continued to see some grievances received a response after the 5- day requirement, and the log did not show any response at all for some grievances. We consider this recommendation resolved and open based on the documented progress.

We urge the facility and ICE to continue improving timely responses to all detainee grievances and will close this recommendation when we receive evidence that responses to all detainee grievances are timely. Recommendation 2: Ensure responses to requests and grievances are in a language understood by the detainee. ICE Response to Recommendation 2: Concur. The system Northwest uses for grievances submitted via tablets has a built-in “quick edit” function that automatically translates text into multiple languages and can provide a grievance response in a language the detainee can understand.

Northwest will leverage other commercially available translation services to review and respond to paper grievances written in a language other than English. In December 2022, Northwest also disseminated a training video provided by the vendor to demonstrate the use of the system to better facilitate the www.oig.dhs.gov 17 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security grievance process. The grievance coordinator shared the training with all staff responsible for responding to detainee communications. All applicable staff completed the training by January 11, 2023.

On April 6, 2023, Northwest began tracking the language of grievances submitted on paper, as well as the language in which the responses are sent to the detainees. On April 18, 2023, ICE provided OIG documentation corroborating these efforts under a separate cover. ICE requests that OIG consider this recommendation resolved and closed as implemented. OIG Analysis: ICE provided us a log of 85 detainee grievances submitted to the facility (81 grievances) and to ICE (4 grievances) from February 2, 2023, through April 5, 2023.

Only one detainee grievance was submitted to ICE in a language other than English, and there was no logged response from ICE. The facility received 34 grievances in a language other than English. Of those 33 grievances, only 15 responses (44 percent) were in a language understood by the detainee. We acknowledge ICE and the facility’s efforts to increase awareness of the translation functions available by providing additional training to staff, but more needs to be done to ensure responses are provided to detainees in a language they understand.

We consider this recommendation resolved and open. We will close this recommendation when we receive evidence that detainee grievance responses, from both ICE and the facility, are being provided in a language understood by the detainee. Recommendation 3: Update the facility’s food service policy to ensure the food service department’s pre-existing weekly mandatory inspections include checking that products are used before their “best-by” or expiration dates, in accordance with the shelf-life reference guide used by the facility. ICE Response to Recommendation 3: Concur.

Northwest reviewed the inventory control process and safe storage practices. The review revealed that, during the OIG visit, the 20 food items of concern were placed on a pallet and disposed of after reviewing the “pack date” and “best by” dates. The inventory removal process was shared with OIG following the audit. Moving forward, as part of ongoing facility operations, Northwest’s food storage service team and Business Management Department will continue to conduct food service inventory audits to validate expiration dates to ensure food items are used in a timely and safe manner.

During these audits, any food item requiring disposal will be removed from inventory and appropriately thrown away. www.oig.dhs.gov 18 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security OIG noted in its draft report that it found many items had no visible “best used by” or expiration date. The Food and Drug Administration codes do not require these markings as they are unrelated to food safety, and there are many variations of the terms among different manufacturers. On April 18, 2023, ICE provided OIG documentation corroborating these efforts under a separate cover. ICE requests that OIG consider this recommendation resolved and closed as implemented.

OIG Analysis: We did not receive documentation specifically supporting the food service inventory audits. We are pleased to hear the items we identified as expired during our site visit were eventually discarded. We consider this recommendation resolved and open based on Northwest’s efforts to continue improving its inventory practices. We will close this recommendation when the facility provides evidence that it updated the facility’s food service policy to ensure the food service department’s pre-existing weekly mandatory inspections include checking that products are used before their “best-by” or expiration dates.

Recommendation 4: Adopt the practice of writing complete dates of receipt (month, day, and year) on packaging. ICE Response to Recommendation 4: Concur. Northwest uses a “first in, first out” inventory system that includes marking the date on food product using a month/day/year format. ERO notes for context that it receives shipments that contain the same food items with different pack dates and may receive later shipments with an earlier pack date.

To adjust for this issue, the staff carefully organizes products by “first in” and “first out” by the product’s packing date. This process ensures all food is used in a timely and safe manner. Facility records indicate the frozen turkey breasts were ordered as a special product and served for Thanksgiving in 2019. As a result of the OIG inspection, the canned pears and frozen turkey breasts were discarded.

Northwest is committed to food safety, and a thorough review of food items did not identify any items that were served past industry standard guidelines. On April 18, 2023, ICE provided OIG documentation corroborating these efforts under a separate cover. ICE requests that OIG consider this recommendation resolved and closed as implemented. OIG Analysis: Northwest provided documentation to show that products are now being labeled with a complete date of receipt (month, day, and year), which www.oig.dhs.gov 19 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security is responsive to our recommendation.

We consider this recommendation resolved and closed. Recommendation 5: Ensure food products are protected from exposure to contaminates and stored 6 inches above the floor. ICE Response to Recommendation 5: Concur. OIG noted in its draft report that a sealed and unbroken box of chicken had fallen off the storage system in the freezer and that there were open boxes of pre-packaged, fully cooked food items, identified in Figures 4–6.

These issues were immediately corrected by facility staff. The food items were restacked and resealed. The storage system maintains food items 6 inches off the floor. Food records indicate these items were all within their shelf-life periods.

The food service staff will continue to monitor the storage system to ensure food items are stacked properly and will adhere to proper storage requirements to ensure all food products are protected from contamination. On April 18, 2023, ICE provided OIG documentation corroborating these efforts under a separate cover. ICE requests that OIG consider this recommendation resolved and closed as implemented. OIG Analysis: The facility provided documentation to show that products are being stored at least 6 inches above the floor, which is responsive to our recommendation.

We consider this recommendation resolved and closed. Recommendation 6: Ensure the guidelines for medical screening and preventative services are followed by all staff and annual exams are conducted by an appropriate medical provider. ICE Response to Recommendation 6: Concur. ICE Health Service Corps and Northwest convened to review and discuss the existing medical screening and preventative services policy to determine updates needed.

Because the ICE Health Service Corps policy permitted nurses to do some annual physical exams but prohibited them from ordering preventative health products (mammogram, colonoscopy, pap, etc.), it needed to be updated to require medical professionals (MDs, DOs, APPs) to perform the annual physical exam. The formal request to update the clinical protocol so that nurses will no longer be automatically assigned annual physical exams was submitted and completed on September 22, 2022. The nursing staff was notified by their onsite leadership of the process change. In addition, because national guidelines for medical screening and preventative services did not exist for ICE Health Service Corps, local annual preventative screening guidelines were developed to ensure standardization in practice.

On www.oig.dhs.gov 20 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security September 23, 2022, Northwest’s annual preventative guidelines were finalized and disseminated to staff. The guidelines were also printed and placed on the wall within each provider’s office. On September 24, 2022, the medical records team reassigned all previously scheduled annual physical exams to providers instead of nurses. On September 30, 2022, nurses were provided with education on the preventative health guidelines.

On April 18, 2023, ICE provided OIG documentation corroborating these efforts under a separate cover. ICE requests that OIG consider this recommendation resolved and closed as implemented. OIG Analysis: Northwest provided its preventative health guidelines and updated guidance on providers performing annual exams, which is responsive to our recommendation. Based on these documents and guidance, we consider this recommendation resolved and closed.

Recommendation 7: Review and update ICE’s contract with the facility by better identifying housing requirements and determining an appropriate guaranteed minimum. ICE Response to Recommendation 7: Non-concur. The population size at Northwest was affected by the temporary restraining order granted in August 2021 by the U.S. District Court for the Western District of Washington in Seattle, as described in the report. The temporary restraining order requires ICE to test detainees for COVID-19 prior to their transfer to Northwest and enjoins ICE from admitting any detainees to Northwest who were not transferred, regardless of mode of transportation, in compliance with the order.

The order has reduced the number of detainees housed at Northwest. Along with the limitations due to the temporary restraining order, COVID-19 preventative measures limited the Northwest’s ability to meet the guaranteed minimum. From April 2020 through November 2022, ICE’s Pandemic Response Requirements (PRR) contained the requirement to limit detainee populations to 75 percent of capacity. Since then, the PRR eliminated the 75 percent population target and transitioned to a facility status system mirroring the local community’s transmission rates.

Northwest’s capacity is 1,575 detainees, and 75 percent of its capacity is 1,181. While the population during the period covered in OIG’s review was under the guaranteed minimum, this was largely due to the PRR requirement and the temporary restraining order. The use of a contract with a guaranteed minimum allows both ICE and its service provider to balance between ICE’s operational requirements and recurring or fixed costs that are not directly affected by the number of detainees present at Northwest. Additionally, a www.oig.dhs.gov 21 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security contract that provides ICE with the exclusive use of a facility provides flexibility and reduced per diem costs once the fixed or recurring costs are met.

On April 18, 2023, ICE provided OIG documentation corroborating these efforts under a separate cover. ICE requests that OIG consider this recommendation resolved and closed as implemented. OIG Analysis: On April 10, 2023, President Biden signed into law a congressional joint resolution29 that terminates the national emergency related to the COVID-19 pandemic, eliminating many of the barriers Northwest has in filling detention beds. We understand the need to balance the requirements of both ICE and the contract service provider.

However, OIG is concerned with the extent to which ICE is paying for unused bedspace and ICE’s stewardship of taxpayer money. We continue to recommend that ICE review and update its contract with the facility by better identifying housing requirements and determining an appropriate guaranteed minimum. Especially given that the average daily population for the 2 fiscal years preceding the temporary restraining order was only 552 detainees. We consider this recommendation unresolved and open.

We will close this recommendation when ICE shows that it has analyzed the historical needs of Northwest and adjusts the guaranteed minimum accordingly. Recommendation 8: Ensure the facility has a plan to fill medical vacancies. ICE Response to Recommendation 8: Concur. ICE Health Service Corps has allocated 15 Federal clinical positions at Northwest, six of which are filled.

In November 2022, and February through April 2023, multiple job announcements were posted on USA Jobs to fill the remaining nine vacancies. Upon receipt of selection certificates from ICE Office of Human Capital, ICE Health Service Corps staff will conduct interviews, background checks, etc., to complete the hiring process, as appropriate. Estimated completion date: September 29, 2023. OIG Analysis: Based on ICE Health Service Corps’ efforts to hire additional medical staff, we consider this recommendation resolved and open.

We will close this recommendation once ICE Health Service Corps provides an updated staffing plan to show the filled vacancies. 29 https://www.whitehouse.gov/briefing-room/legislation/2023/04/10/bill-signed-h-j-res-7/ www.oig.dhs.gov 22 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix A Objective, Scope, and Methodology The Department of Homeland Security Office of Inspector General was established by the Homeland Security Act of 2002 (Pub. L. No. 107-296) by amendment to the Inspector General Act of 1978. We initiated this inspection at Congress’ direction.

We analyze various factors to determine which facilities to inspect. We review OIG Hotline complaints and prior inspection reports, and past and future inspection schedules. We also consider requests, input, and information from Congress, the DHS Office of Civil Rights and Civil Liberties, nongovernmental organizations, and media outlets to determine which facilities may pose the greatest risks to the health and safety of detainees. Finally, to ensure we review facilities with both large and small detainee populations in geographically diverse locations, we consider facility type (e.g., service processing centers, contract detention facilities, and intergovernmental service agreement facilities) and applicable PBNDS.

We generally limited our scope to the PBNDS 2011 for health, safety, medical care, mental health care, grievances, classification, searches, use of segregation, use of force, and staff training. However, as noted in this report, our medical contractors also used the National Commission on Correctional Health Care’s 2018 Standards for Health Services in Jails when reviewing medical related policies and procedures at the facility. Finally, we conducted a limited review of facility compliance with COVID-19 requirements. Prior to our inspection, we reviewed relevant background information, including: • OIG Hotline complaints • • • ICE PBNDS 2011 ICE Office of Detention Oversight reports and other inspection reports Information from nongovernmental organizations We conducted our unannounced in-person inspection of Northwest from August 30 through September 1, 2022.

During the inspection we: • Conducted an in-person walk-through of the facility. We viewed areas used by detainees, including intake processing areas; medical facilities; residential areas, including sleeping, showering, and toilet facilities; legal services areas, including law libraries; and recreational facilities. www.oig.dhs.gov 23 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security • Reviewed the facility’s compliance with key health, safety, and welfare requirements of the PBNDS 2011 for classification, segregation, voluntary work program, access to legal services, access to medical care and mental health care, and medical and nonmedical grievances. • Reviewed the facility’s response to the COVID-19 pandemic. • • Interviewed ICE and detention facility staff members, including key ICE operational and detention facility oversight staff and detention facility medical, segregation, classification, grievance, and compliance officers. Interviewed detainees held at the detention facility to evaluate compliance with PBNDS 2011 grievance procedures and grievance resolution. • Reviewed documentary evidence, including medical files, and grievance and communication logs and files. We contracted with a team of qualified medical professionals to conduct a comprehensive evaluation of detainee medical care at the Northwest facility.

We incorporated information provided by the medical contractors in our findings. We conducted this review under the authority of the Inspector General Act of 1978, as amended, and according to the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. Access to DHS Information During this inspection, DHS provided timely responses to the information we requested and did not delay or deny DHS OIG’s access to DHS information. www.oig.dhs.gov 24 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix B ICE Comments on the Draft Report www.oig.dhs.gov 25 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 26 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 27 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 28 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 29 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 30 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 31 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 32 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix C Office of Inspections and Evaluations Major Contributors to This Report John Shiffer, Chief Inspector Gwen Schrade, Lead Inspector Adam Brown, Senior Inspector Ian Stumpf, Senior Inspector Mitchell Trump, Senior Inspector Brett Cheney, Inspector Lisa Knight, Communications Analyst Brittany Scott, Independent Referencer www.oig.dhs.gov 33 OIG-23-26 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix D Report Distribution Department of Homeland Security Secretary Deputy Secretary Chief of Staff Deputy Chiefs of Staff General Counsel Executive Secretary Director, GAO/OIG Liaison Office Under Secretary, Office of Strategy, Policy, and Plans Assistant Secretary for Office of Public Affairs Assistant Secretary for Office of Legislative Affairs ICE Audit Liaison Office of Management and Budget Chief, Homeland Security Branch DHS OIG Budget Examiner Congress Congressional Oversight and Appropriations Committees www.oig.dhs.gov 34 OIG-23-26 Additional Information and Copies To view this and any of our other reports, please visit our website at: www.oig.dhs.gov. For further information or questions, please contact Office of Inspector General Public Affairs at: [email protected].

Follow us on Twitter at: @dhsoig. OIG Hotline To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click on the red "Hotline" box. If you cannot access our website, call our hotline at (800) 323-8603, or write to us at: Department of Homeland Security Office of Inspector General, Mail Stop 0305 Attention: Hotline 245 Murray Drive, SW Washington, DC 20528-0305