DHS OIG, OIG-23-51, Results of an Unannounced Inspection of ICE's Caroline Detention Facility in Bowling Green, Virginia (2023)

Results of an Unannounced Inspection of ICE’s Caroline Detention Facility in Bowling Green, Virginia September 15, 2023 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Washington, DC 20528 / www.oig.dhs.gov September 15, 2023 MEMORANDUM FOR: Patrick J. Lechleitner Senior Official Performing the Duties of the Director U.S. Immigration and Customs Enforcement FROM: Joseph V. Cuffari, Ph.D. Inspector General Signed by GLENN E Digitally signed by SKLAR Glenn Sklar Principal Deputy Inspector General GLENN E SKLAR Date: 2023.09.15 23:35:14 -04'00' SUBJECT: Results of an Unannounced Inspection of ICE’s Caroline Detention Facility in Bowling Green, Virginia Attached for your action is our final report, Results of an Unannounced Inspection of ICE’s Caroline Detention Facility in Bowling Green, Virginia. We incorporated the formal comments provided by your office. The report contains eight recommendations aimed at improving care of detainees at ICE’s Caroline Dentetion Facility. Your office concurred with two recommendations and did not concur with six.

We consider four recommendations unresolved and open and four recommendations resolved and open. Once your office has fully implemented all 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 contact 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 ICE’s Caroline Detention Facility in Bowling Green, Virginia September 15, 2023 What We Found Why We Did This Inspection In accordance with the Consolidated Appropriations Act, 2023, we conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards.

In January 2023, we conducted an in-person inspection of the Caroline facility in Bowling Green, Virginia, to evaluate compliance with ICE detention standards. What We Recommend We made eight recommendations to improve ICE’s oversight of detention facility management and operations at Caroline. During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Caroline Detention Facility (Caroline) in Bowling Green, Virginia, we found that Caroline complied with standards for classification, segregation, use of force, recreation, and facility conditions. We also found that Caroline complied with most standards for medical care, but the absence of a dentist caused delays in advanced dental care, and outdated guidance for chronic care was concerning.

Further, Caroline did not follow standards related to the voluntary work program. Regarding detainee grievances, although Caroline provided appropriate responses in a language understood by the detainee, we found the facility did not always provide timely responses and did not keep an accurate log of detainee grievances. Regarding detainee requests, we found that Caroline staff did not record requests in detainee files. Further, ICE deportation officer visits to the housing units were not frequent or consistent, and daily activity schedules were not posted in all housing units, as required.

In addition, Caroline did not consistently display lists of legal providers or visitation hours in the housing areas and common spaces. Finally, Caroline did not always meet cleanliness standards for food preparation. ICE Response ICE concurred with two recommendations and did not concur with six. We consider four recommendations unresolved and open, and four recommendations resolved and open.

For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at [email protected] www.oig.dhs.gov OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Table of Contents Background .................................................................................................... 1 Results of Inspection ....................................................................................... 2 Caroline Complied with Standards for Classification, Segregation, Use of Force, Recreation, and Facility Conditions ................................... 2 Caroline’s Medical Department Complied with Most, but Not All Requirements ........................................................................................

4 Caroline Did Not Comply with Voluntary Work Program Requirements ........................................................................................ 5 Caroline Did Not Comply with All Standards for Grievances ................... 5 ICE and Caroline Did Not Comply with Standards for Staff-Detainee Communication ..................................................................................... 6 Caroline Did Not Consistently Display the List of Legal Providers or Visitation Hours for Detainees ...............................................................

8 Caroline Did Not Always Meet Cleanliness Standards for Food Preparation ............................................................................................ 8 Recommendations ......................................................................................... 10 Management Comments and OIG Analysis .................................................... 11 Appendixes Appendix A: Objective, Scope, and Methodology .................................

19 Appendix B: ICE Comments to the Draft Report ................................... 21 Appendix C: Office of Inspections and Evaluations Major Contributors to This Report ................................................................. 29 Appendix D: Report Distribution .......................................................... 30 www.oig.dhs.gov OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Abbreviations Caroline ERO ICE PBNDS 2011 Caroline Detention Facility Enforcement and Removal Operations U.S. Immigration and Customs Enforcement Performance-Based National Detention Standards 2011 www.oig.dhs.gov OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Background U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 120 facilities nationwide, and the conditions and practices at those facilities can vary greatly.

Facilities are required to comply with detention standards established by ICE to provide a clean and safe environment and protect 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 has identified and helped correct violations of detention standards at facilities across the country. From January 24 through January 26, 2023, we conducted an unannounced, in-person inspection of Caroline Detention Facility (Caroline) in Bowling Green, Virginia, 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. Operated by Caroline County, Caroline began housing detainees in 2018. Between January 24, 2022, and January 23, 2023 (the year prior to our inspection), Caroline had an average daily population of 172 detainees, with a maximum capacity of 336. Under the agreement with ICE, Caroline receives approximately $850,000 a month to house ICE detainees.

ICE’s intergovernmental service agreement requires Caroline 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. At the start of our onsite inspection, Caroline housed a total of 192 adult male ICE detainees and no female detainees.

Our onsite team included contracted medical experts to review Caroline’s compliance with applicable medical 1 Consolidated Appropriations Act, 2023, Pub. L. No. 117-328, and Department of Homeland Security Appropriations Act, 2023, H.R. Rep. No. 117-396 (2022). www.oig.dhs.gov 1 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security standards of care,2 and we have incorporated their assessments in our findings. During our inspection, we conducted a walk-through of Caroline facilities, including detainee housing units, medical units, and indoor and outdoor recreation areas.

We also requested and reviewed documents and files and interviewed ICE personnel, Caroline officials, and detainees. Results of Inspection We found that Caroline complied with standards for classification, segregation, use of force, recreation, and facility conditions. We also found that Caroline complied with most standards for medical care, but the absence of a dentist caused delays in advanced dental care, and outdated guidance for chronic care was concerning. Further, Caroline did not follow standards related to the voluntary work program.

Regarding detainee grievances, although Caroline provided appropriate responses in a language understood by the detainee, we found the facility did not always provide timely responses and did not keep an accurate log of detainee grievances. Regarding detainee requests, we found that Caroline staff did not record requests in detainee files. Further, ICE deportation officer visits to the housing units were not frequent or consistent, and daily activity schedules were not posted in all housing units, as required. In addition, Caroline did not consistently display lists of legal providers or visitation hours in the housing areas and common spaces.

Finally, Caroline did not always meet cleanliness standards for food preparation. Caroline Complied with Standards for Classification, Segregation, Use of Force, Recreation, and Facility Conditions According to the PBNDS 2011, facilities are required to classify and house detainees according to risk level, and the initial classification process and housing assignment should be completed within 12 hours of a detainee’s admission to a facility.3 We reviewed a sample of 15 detainee files and found Caroline complied with the standards for classification. The PBNDS 2011 also governs the use of administrative and disciplinary segregation. Caroline complied with standards requiring administratively segregated detainees to receive access to recreation, legal calls, laundry services, mail, legal materials, the law library, and the commissary.4 An 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 2.2, Custody Classification System (revised Dec. 2016). 4 PBNDS 2011, Section 2.12, Special Management Units (revised Dec. 2016). www.oig.dhs.gov 2 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security interview with a detainee currently in administrative segregation confirmed his access to these resources.

Caroline also complied with standards requiring that detainees in disciplinary segregation receive daily assessments from health care personnel and that the segregation not last longer than 30 days.5 We reviewed nine records of detainees in administrative or disciplinary segregation that showed completion of daily medical assessments and segregation durations all less than 30 days. We also interviewed four detainees in disciplinary segregation, who confirmed they see health care professionals daily. Finally, we inspected conditions inside segregation units and interviewed one detention officer to further support these assessments of compliance. The PBNDS 2011 requires facility staff to use physical force only when necessary and reasonable and requires appropriate documentation of any use of force incident, including submission of a written report by the end of the officer’s shift.6 Caroline reported one use of force incident in the 6 months prior to our inspection (between June 23, 2022, and January 23, 2023).

Through reviewing video footage and reports of the incident, we found the facility staff complied with the standards. In addition, the PBNDS 2011 requires that detainees have access to both indoor and outdoor recreation areas.7 We saw these areas available at Caroline and corroborated our observations through detainee interviews. Finally, the PBNDS 2011 requires facilities to maintain high standards of cleanliness and sanitation, including having an adequate number of toilets, washbasins, and showers, as well as regular issuance of clean clothing, linens, and personal hygiene items.8 Through observations and interviews, we determined that Caroline complied with the standards for facility conditions. We observed that Caroline was generally clean in appearance and detainees had an adequate supply of and access to clean, size-appropriate clothing and linens.

We tested washbasins to ensure they were operable and tested the showers in the housing units to ensure that the water temperature was safe. We also collected and tested9 drinking water samples for contaminants and found no abnormal results. Through general observation we concluded that the housing units had adequate lighting and were well-ventilated, and there were no lingering odors or moisture buildup on any surfaces. 5 Id. 6 PBNDS 2011, Section 2.15, Use of Force and Restraints (revised Dec.

2016). 7 PBNDS 2011, Section 5.4, Recreation (revised Dec. 2016). 8 PBNDS 2011, Section 1.2, Environmental Health and Safety (revised Dec.

2016). 9 We used a commercially available, off-the-shelf test kit that tests drinking water for 50 contaminants. We collected a sample from a sink in the facility that supplies drinking water and sent it to a U.S. Environmental Protection Agency-certified laboratory for analysis. www.oig.dhs.gov 3 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Caroline’s Medical Department Complied with Most, but Not All Requirements In general, Caroline provided medical care in a timely and appropriate manner, as required.10 Our contracted medical professionals found Caroline complied with medical standards for program administration, emergency care, health care records and screening, sick calls, special needs, pharmacy management, and medical grievances. However, the absence of a dentist caused delayed dental care for advanced procedures, and outdated guidance for chronic care was concerning.

Caroline Did Not Comply with Standards for Timely Advanced Dental Care Caroline had been without a dentist since May 2022 and was not able to provide routine or emergency dental treatment, as required by the PBNDS 2011.11 Existing medical staff could perform some minor dental procedures but not more advanced dental services. Dental issues that could only be addressed by a dentist, such as a tooth abscess or broken tooth, required the scheduling of an appointment with an outside dental provider. While the PBNDS 2011 allows this process, onsite medical staff said it affected the timeliness of more advanced dental care. Without the necessary dental staff, detainees waited an extended length of time between diagnosis and appropriate care and treatment.

ICE Did Not Always Use the Most Current Guidance for Chronic Care The PBNDS 2011 requires facilities to provide detainees with appropriate and necessary medical care.12 ICE Health Service Corps, the medical providers at Caroline, used the Federal Bureau of Prisons’ treatment guidance for chronic illnesses. However, this guidance is outdated, and our contracted medical professionals noted that alternate, updated guidance is available13 that would better align with medical community standards and be more accurate for treating chronic illnesses. For example, the Bureau of Prisons guidance regarding proper lipid levels for people with diabetes is outdated. Some provider staff at Caroline followed the outdated guidance, while others used more updated treatment approaches.

The use of outdated guidance by some 10 PBNDS 2011, Section 4.3, Medical Care (revised Dec. 2016). 11 Id. 12 National Commission on Correctional Health Care, Standards for Health Services in Jails, 2018, and PBNDS 2011, Section 4.3, Medical Care (revised Dec. 2016).

13 More current, nationally recognized standards can be found on the websites of specialty medical organizations such as the American Diabetes Association and the American Academy of Family Physicians. www.oig.dhs.gov 4 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security provider staff may mean that the facility is providing less than appropriate and necessary care for detainees. Caroline Did Not Comply with Voluntary Work Program Requirements The PBNDS 2011 requires that detainees who participate in the voluntary work program work no more than 8 hours daily and 40 hours weekly.14 We reviewed 3 months of voluntary work program records and found that Caroline did not enforce these requirements. Specifically, we determined that eight kitchen volunteers worked hours that exceeded the 40-hour work week limit. One detainee worked more than 65 hours in 1 week and as long as 14 hours in a single day.

Another detainee averaged 56 hours of work per week during a 6- week period (until the detainee left the facility). Additionally, detainees we interviewed identified concerns with the facility’s voluntary work program. For example, regarding job assignments in the kitchen, one detainee told us his recreation time was canceled because it was scheduled at the same time as his kitchen shift. Another detainee told us that the kitchen was understaffed and often needed additional help.

As a result, the facility sometimes required detainees to work more hours than the prescribed maximum, in violation of the standards. Caroline Did Not Comply with All Standards for Grievances The PBNDS 2011 requires facilities to have a procedure for detainees to file grievances and receive a timely response in a language they can understand.15 We reviewed a sample of 72 out of 215 grievances submitted by detainees between July 1, 2022, and December 31, 2022, and found all but 1 grievance received an appropriate response from facility staff. We also found that facility staff responded to detainee grievances in a language understood by the detainee for all the grievances in our sample. However, the facility did not always provide timely responses and did not keep an accurate log of detainee grievances.

Caroline Did Not Always Provide Timely Responses to Detainee Grievances The PBNDS 2011 requires facilities to respond to detainee grievances within 5 days.16 Of the 215 total grievances submitted between July 1, 2022, and December 31, 2022, facility staff did not respond within the required 5-day timeframe in 57 instances (26.5 percent). For all 57, staff responded within 14 PBNDS 2011, Section 5.8, Voluntary Work Program (revised Dec. 2016). 15 PBNDS 2011, Section 6.2, Grievance System (revised Dec.

2016). 16 Id. www.oig.dhs.gov 5 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security 7 days. Timely responses to detainee grievances are needed to help protect detainees’ rights and ensure they are treated fairly. Caroline Did Not Maintain an Accurate Log of Grievances The PBNDS 2011 requires facilities to track or log all detainee grievances.7 Caroline did not have an electronic means for detainees to submit grievances; instead, staff collected handwritten grievances from detainees and manually entered them into an electronic log.

Facilities are not required to have an electronic submission process, but manually inputting data in a spreadsheet increases the opportunity for error. We reviewed a sample of 72 grievances and found that 20 (28 percent) contained discrepancies between the dates written on the paper grievance forms and the dates entered in the electronic log. These errors make it difficult to rely on the log as an accurate record of grievances or to determine the facility’s compliance with standards. ICE and Caroline Did Not Comply with Standards for Staff- Detainee Communication The PBNDS 2011 encourages and requires direct and written contact among staff and detainees.17 We determined ICE and facility staff did not fully comply with the standards for staff-detainee communication practices.

Specifically, Caroline staff did not record requests made by detainees in detention files, ICE deportation officer visits to the housing units were not frequent or consistent, and daily activity schedules were not posted in all housing units, as required. Caroline Did Not Properly Record Detainee Requests The PBNDS 2011 establishes procedures for detainees to send written requests to facility staff and requires that documentation for all completed requests be maintained in the detainee’s detention file.18 For a sample of 15 requests from separate detainees recorded in the request logbook, we checked each detainee’s file and found that none of the requests had been documented in the respective detainee detention file, as required. 0% Percentage of detainee requests in our sample that were documented in the detainee’s detention file. 17 PBNDS 2011, Section 2.13, Staff-Detainee Communication (revised Dec.

2016). 18 Id. www.oig.dhs.gov 6 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE Did Not Provide Routine Contact with Deportation Officers The PBNDS 2011 requires that detainees have frequent opportunities for informal contact with ICE staff.19 We observed posted weekly sign-up sheets in the Caroline housing units for detainees to meet with their assigned deportation officers. However, in our analysis of ICE visitation logs to the housing units from July 2022 through January 2023, we found spans of up to 30 days between logged ICE visits to the housing facilities — not weekly as the sign-up sheets seemed to indicate. In interviews and informal conversations during our housing unit tour, detainees expressed frustration that, even though they added their names to the weekly sign-up sheets, ICE personnel did not routinely visit the housing units.

One detainee told us he knew who his ICE deportation officer was but did not get a response most of the time when submitting a paper request form to meet. Multiple detainees made similar complaints during our initial facility walk-through as well. Another detainee we interviewed said ICE officials did not visit housing units weekly as intended, his deportation officer changed constantly, and sometimes it took as long as a month to receive any type of response to his requests. Caroline Did Not Comply with Posted Detainee Activity Schedule Requirements The PBNDS 2011 requires recreation schedules to be provided to detainees or posted in the facility.20 The PBNDS 2011 also requires a minimum number of scheduled hours per week for activities like recreation and access to the law library.

However, while touring the facility, we did not observe posted schedules. We noted this observation to Caroline staff, and by the last day of our inspection, schedules had been posted in each housing unit. Although new schedules were posted throughout the facility, they were not compliant with PBNDS requirements and some housing units had fewer than the prescribed number of hours for recreation or law library access. 21 For example, one housing unit had recreation scheduled during pill call, meal delivery, facility counts, and religious services, resulting in 35 scheduled minutes of recreation time per day.

Another housing unit had law library hours scheduled during facility counts and religious services, resulting in 30 minutes of law library time per day or 3.5 hours per week.22 19 Id. 20 PBNDS 2011 Section 5.4, Recreation (revised Dec. 2016). 21 PBNDS 2011 requires detainees in the Special Management Unit for disciplinary reasons to be offered at least 1 hour of exercise opportunities per day, 5 days per week, and all detainees to have at least 5 hours of access to the law library per week. See Section 5.4, Recreation and Section 6.3, Law Libraries and Legal Material.

22 Per PBNDS, law library hours of operation shall generally be scheduled between official counts, meals, and other official detention functions. See Section 6.3, Law Libraries and Legal Materials. www.oig.dhs.gov 7 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Caroline Did Not Consistently Display the List of Legal Providers or Visitation Hours for Detainees The PBNDS 2011 requires facilities to prominently post a current list of free legal service providers in detainee housing units and other appropriate areas, along with the hours and rules for legal visitation. 23 However, during our initial walk-through, we observed that the required listings of pro bono legal providers and visitation hours were not posted in housing units or in the visitation area. We identified postings to contact a local pro bono organization in the housing units, but it was not the list of legal providers that ICE maintains and gives to facilities for posting.

We asked staff members where the visitation rules and hours were located, and they said that this information was in the detainee handbooks, but they could not confirm whether it was posted in the housing units. We reviewed a facility handbook given to detainees and confirmed that it listed visitation hours. However, the handbook also said that specific visitation hours vary depending on a detainee’s housing unit and that the specific hours should be posted in living areas. Facility staff took steps to correct these issues while we were onsite by posting lists of both legal providers and visitation hours in the detainee housing units.

Caroline Did Not Always Meet Cleanliness Standards for Food Preparation The PBNDS 2011 requires detainees assigned to the food service department to have a neat and clean appearance, and detainees with facial hair must wear beard guards when working in the food preparation or serving areas.24 During our kitchen tour, we observed that detainees were not properly covering their facial hair, risking contamination to food products. We pointed this out to Caroline staff, and before the completion of the kitchen tour, detainees had properly covered their facial hair. 23 PBNDS 2011 Section 5.7, Visitation (revised Dec. 2016).

24 PBNDS 2011, Section 4.1, Food Service (revised Dec. 2016). www.oig.dhs.gov 8 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security The PBNDS 2011 requires food to be protected from sources of contamination. At Caroline, we found moldy cabbage and carrots in the refrigerator, as shown in Figure 1 (only cabbage pictured). The PBNDS 2011 also requires each food service administrator to establish procedures for storing, receiving, and inventorying food.25 We identified labeling inconsistencies throughout the food storage areas, including food boxes marked with multiple dates but without clear labels for the meaning of the dates, as well as items without dates or labels.

For example, we observed a container of salad dressing with no date marked. When we asked the kitchen staff how they determined whether something was expired, they said that they “just knew” or they looked on the box. Caroline did not have a procedure to ensure consistent markings on food boxes, which would help prevent the expiration and contamination of food items. Figure 1.

Moldy Cabbage in Refrigerator, Observed on January 24, 2023 Source: DHS OIG photo 25 Id. www.oig.dhs.gov 9 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Washington Field Office, responsible for Caroline, to: Recommendation 1: Ensure timely dental care for advanced procedures is provided to detainees. Recommendation 2: Assess whether a sufficient pool of interested voluntary work program participants exists to accomplish facility needs, without detainees working more than 8 hours per day and 40 hours per week, and ensure participants work according to a schedule that does not interfere with required activities. Recommendation 3: Ensure that all detainee grievances receive responses within the required 5 days and the grievances log is accurate. Recommendation 4: Ensure detainee detention files include all submitted requests.

Recommendation 5: Ensure ICE personnel provide frequent opportunities for informal contact with detainees by adhering to the weekly visitation schedule posted in the housing units and by recording their visits in the appropriate logs. Recommendation 6: Ensure the posting of all required information, including: • updated lists of pro bono legal representatives in all housing units, as well as the visitation hours and rules in housing units and visitation areas, and • unit-specific schedules in all detainee housing units, including required privileges with dedicated times that do not overlap the times of other required activities. Recommendation 7: Ensure compliance with standards for kitchen cleanliness and inventory control, including that: • kitchen workers with facial hair wear beard guards when working in the • food preparation or serving areas, inventory control processes are in place to discard spoiled or expired food, and • a standard operating procedure exists for clearly labeling food expiration dates. www.oig.dhs.gov 10 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security We recommend the Executive Associate Director of Enforcement and Removal Operations direct ICE Health Service Corps to: Recommendation 8: Ensure the Caroline facility medical staff are using the most current treatment guidance for chronic illnesses. Management Comments and OIG Analysis ICE provided comments to our draft report and concurred with two of our eight recommendations and did not concur with six.

Appendix B contains ICE’s management comments in their entirety. We also received technical comments on the draft report and took them into consideration when finalizing our report. Although ICE non-concurred with six recommendations, the actions ICE took associated with two of the six address the intent of the recommendation, further underscoring the dissonance of ICE’s non-concurrence. We consider four recommendations unresolved and open, and four recommendations resolved and open.

As our office strives for continual improvement, we take ICE’s non-concurrence of our recommendations seriously and appreciate its active participation in our long-standing collaborative and interactive report review process. However, we note that ICE did not raise its concerns during the report review process in this particular review. ICE had multiple opportunities to discuss the basis for our recommendations during various stages of our standard report review process – which included a Notice of Findings and Recommendations preview document, the opportunity to provide technical comments to the draft report, and a formal exit conference – but ICE chose not to. To the contrary, ICE noted “no technical comments or concerns” on several areas of the Notice of Findings and Recommendations even though the eight recommendations essentially remained the same throughout the review process.

ICE and facility staff did not discuss their concerns with us during the drafting process for this report and only chose to convey their non-concurrences after the exit conference and at the final stage of the process. We stand by the recommendations made in this report to protect the health and safety of detainees in ICE’s care, and we remain committed to ensuring implementation of these recommendations at Caroline and within ICE. A summary of ICE’s response to our recommendations and our analysis follows. Recommendation 1: Ensure timely dental care for advanced procedures is provided to detainees. www.oig.dhs.gov 11 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE Response to Recommendation 1: Non-concur.

While ICE ERO agrees that timely dental care is a critical element of detention, ICE disagrees with OIG’s application of “timely care” as always having onsite dentists available. ICE ERO currently ensures that dental care is a top priority by leveraging multiple off-site care centers. Specifically, Caroline medical staff address emergent and urgent dental conditions by stabilizing detainees with antibiotics and pain medication as clinically necessary. Should follow-up dental procedures be needed, Caroline enters a referral for dental care and schedules the patient with one of three available off-site providers.

This practice of using multiple off-site dentists for patient referral is valuable, as it increases the access to timely dental care and appointment availability while ICE ERO continues to work to fill the dentist vacancy. On February 24, 2023, ICE Health Service Corps’ Eastern Regional Dental Consultant posted a dental vacancy on the ICE Health Service Corps Listserv and Max.gov websites; the position is advertised and will remain open until filled. In the interim, ICE Health Service Corps continues to support Caroline dental needs with multiple dentists on Temporary Duty to ensure care is compliant with National Commission on Correctional Health Care accreditation standards. Finally, the ICE Health Service Corps’ Eastern Regional Dental Consultant regularly collaborates with the Caroline Health Service Administrator in working with Caroline clinical staff to ensure proper dental training is occurring on an annual basis to identify those who need appropriate dental services.

ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: OIG appreciates ICE ERO’s stance that timely dental care is a critical element of detention and the efforts to fill the dental vacancy. However, our medical contractors, in discussion with ICE Health Service Corps facility staff, determined that timely dental care for advanced services is negatively affected by the lack of a dental provider on-site. Although ICE non-concurred with the recommendation, the actions taken address the intent of the recommendation.

We consider this recommendation resolved and open until the facility provides documentary evidence showing an improved waiting period for advanced dental needs or that the advertised dental vacancy is filled. Recommendation 2: Assess whether a sufficient pool of interested voluntary work program participants exists to accomplish facility needs, without detainees working more than 8 hours per day and 40 hours per week, and ensure participants work according to a schedule that does not interfere with required activities. www.oig.dhs.gov 12 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE Response to Recommendation 2: Non-concur. Caroline makes every effort to ensure participants work no more than 8 hours per day or 40 hours per week, in accordance with a schedule that does not interfere with required activities. Moreover, due to the limited number of cleared volunteers, the facility may experience a temporary shortage of available volunteer workers when volunteers are released from the facility or transferred.

This may necessitate longer shifts. However, Caroline and the newly formed ICE Compliance, Inspections, and Training Unit monitors schedules closely and asserts that volunteers working more than 40 hours is not a normal practice and is avoided, when possible, but may be necessary for brief periods. Further, as of May 2023, ICE ERO and ICE Health Service Corps took a number of actions to address staffing shortages, including but not limited to: 1) creating volunteer worker schedules for Caroline food service personnel; 2) allowing non-violent, medium-high detainees to work in the kitchen; 3) ensuring the ICE Health Service Corps medical section responsible for conducting clearances performs expedited clearances of volunteer kitchen workers; and 4) ICE ERO Compliance, Inspections, and Training Unit personnel identifying potential volunteer kitchen workers during intake and forwarding eligible names to medical for a medical clearance. ICE requests that the OIG consider this recommendation resolved and closed.

OIG Analysis: The OIG is concerned by ICE’s response to this recommendation. PBNDS 2011 clearly states that detainees are not permitted to work more than 8 hours per day and more than 40 hours per week, yet ICE openly disregards this standard in its response by confirming that staffing shortages may “necessitate longer shifts” from detainees in the voluntary work program. Additionally, the voluntary work program is designed to provide detainees opportunities to work and earn money while confined, not to augment facility staffing shortages. This recommendation remains unresolved and open until the facility and ICE demonstrate understanding and implementation of the standard and ensure detainees work no more than 8 hours per day and 40 hours per week.

Recommendation 3: Ensure that all detainee grievances receive responses within the required 5 days and the grievances log is accurate. ICE Response to Recommendation 3: Non-concur. ICE ERO agrees that grievances are to be addressed within 5 days of receipt. However, ERO disagrees with the implied notion that grievance responses are not addressed www.oig.dhs.gov 13 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security within the required 5 days.

Moreover, the current manual grievance form includes “collected by” and “collected date” fields, and the 5-day time requirement starts as of the “collected by” date and not when it is received by the ICE grievance officer. Further, the electronic log of these forms includes the date collected, date received by the grievance officer, and the date returned to the noncitizen, and ERO notes that numerous noncitizens “hold” grievances for several days prior to submission, which ERO cannot prevent noncitizens from doing. This practice results in inconsistencies with grievance response times. In addition, ERO notes several instances in which noncitizens also documented the wrong date on the form.

As of February 2023, ICE’s practices ensure that grievances are addressed within 5 days of receipt, and that: 1) the grievance officer logs the actual date the detainee writes the grievance as the date submitted, even if the date is incorrectly written by the detainee; 2) the date the grievance officer uses for the 5-day response time is determined by the date recorded by the mail clerk when collecting grievances from the grievance box; and 3) a facility captain is assigned the monthly review of grievance logs to ensure compliance. As of August 14, 2023, the ICE contracted phone service provider will be installing its electronic tablet system at Caroline allowing for direct email communication with ICE Deportation Officers regarding case status, grievances, and general information requests. This will allow precise tracking of grievances, therefore eliminating any discrepancy with the 5-day response requirements. ICE requests that the OIG consider this recommendation resolved and closed, as implemented.

OIG Analysis: The OIG used the “date received” when calculating the facility’s response time to grievances, therefore eliminating discrepancies due to detainees incorrectly dating grievances or withholding grievances for extended lengths of time. Using the information provided by the facility, we reiterate our conclusion that the facility did not respond to detainee grievances within the 5- day response requirement in 57 occurrences. Although ICE non-concurred with the recommendation, the actions taken address the intent of the recommendation. Using an electronic system, as the facility indicates it has done, should eliminate the facility’s difficulty in determining grievance collection dates.

We consider this recommendation www.oig.dhs.gov 14 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security resolved and open. We will close this recommendation when ICE provides three months of evidence that the facility is responding to detainee grievances within the 5-day response requirement. Recommendation 4: Ensure detainee detention files include all submitted requests. ICE Response to Recommendation 4: Concur.

As of March 2023, detention files follow the appropriate record keeping schedule and include all submitted requests. Specifically, ERO National Detention Standards Officers, now the Compliance Inspection and Tasking Unit, took action to ensure that: 1) Caroline stores all requests submitted by the detainee within their corresponding detention file, and 2) detention files are stored in accordance with a record schedule pursuant to National Archives and Records Administration guidance. ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: We consider this recommendation resolved and open.

We will close this recommendation when ICE provides documentary evidence that detainee requests are stored in the detainee’s detention file. Recommendation 5: Ensure ICE personnel provide frequent opportunities for informal contact with detainees by adhering to the weekly visitation schedule posted in the housing units and by recording their visits in the appropriate logs. ICE Response to Recommendation 5: Non-concur. As of July 2023, ERO maintains a cadre of personnel onsite at Caroline that continuously provide detained noncitizens with ongoing communication capabilities.

ERO disagrees with the implied notion that opportunities for frequent informal contact with detainees is not occurring. Specifically, ERO is complying and notes that noncitizens can: 1) sign up to speak with ERO staff (case officers) using Caroline’s “weekly sign-up sheets” for in-person visitations; 2) submit a request using the ERO staff detainee communication request process; and, 3) speak directly with ERO staff during daily and weekly housing visits. Detainees are also provided daily opportunities for informal contact with ERO personnel, and ERO monitors, responds to, and logs all detainee requests. For www.oig.dhs.gov 15 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security example, ERO personnel walk through every housing unit during their scheduled visitation days to ensure any noncitizen who did not utilize the “sign-up sheet” can speak with ERO staff.

The ERO Custody Resource Coordinator is also available throughout the week to speak with noncitizens and direct or address any questions or concerns. ERO staff will continue to ensure noncitizens have formal and informal contact opportunities throughout their detention or stay at Caroline, as appropriate. ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: OIG reviewed the ICE visitation logs at Caroline and noted instances of up to 30 days between logged ICE visits.

If ICE is visiting as frequently as indicated in its response to this recommendation, their visits should be documented in the visitation logs. We consider this recommendation unresolved and open. We will close this recommendation when ICE provides documentary evidence that they are visiting the housing units as frequently as indicated in their response. Recommendation 6: Ensure the posting of all required information, including: • updated lists of pro bono legal representatives in all housing units, as well as the visitation hours and rules in housing units and visitation areas; and • unit-specific schedules in all detainee housing units, including required privileges with dedicated times that do not overlap the times of other required activities.

ICE Response to Recommendation 6: Non-concur. As of April 2023, ERO works with Caroline staff to ensure required postings are available in each housing unit and common area. ERO disagrees with the implied notion that postings of all required information are not followed. ERO has taken appropriate steps in ensuring postings are available as required.

For example, wall mounted displays are used to house all postings, reducing the risk of damage, and required information is posted, as appropriate, within all detainee housing units. Postings include unit-specific schedules of required privileges, with dedicated times, that are not to overlap with other activities. However, due to noncitizen movements and facility activities, postings sometimes fall off or are destroyed, and ERO placed a greater emphasis on replacing damaged postings going forward, by assigning a facility captain to conduct a monthly review of all housing unit postings. On May 2023, ERO also established the Compliance, Inspections, and Training Unit which has an exclusive focus on ensuring local facilities meet ICE’s industry-high standards, to include daily and weekly reviews of postings. www.oig.dhs.gov 16 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE requests that the OIG consider this recommendation resolved and closed, as implemented.

OIG Analysis: OIG commends the facility for adjusting to the challenges of continuously displaying legal and visitation information. However, the detainee activity schedules the facility provided to the OIG shows several overlaps in the schedules of required privileges and other activities. For example, facility count and meal service overlaps with religious service and recreation overlaps with visitation. These overlaps force detainees to choose between required privileges, or interrupt participation in religious activities when detainees are required to participate in facility counts.

We consider this recommendation unresolved and open. We will close this recommendation when ICE provides documentary evidence that legal and visitation information is displayed according to standards and unit-specific schedules in detainee housing units include required privileges with dedicated times that do not overlap the times of other required activities. Recommendation 7: Ensure compliance with standards for kitchen cleanliness and inventory control, including that: • kitchen workers with facial hair wear beard guards when working in the • food preparation or serving areas, inventory control processes are in place to discard spoiled or expired food, and • a standard operating procedure exists for clearly labeling food expiration dates. ICE Response to Recommendation 7: Concur.

On March 1, 2023, the Caroline food service director and kitchen officer were directed to enforce hair covers in the kitchen, and staff responsible for weekly kitchen inspections were directed to observe for, and document, non-compliance. The Caroline inspection team consists of the Food Service Director, Facility Captain, and Life/Health Safety Inspector. Persons who fail to comply with kitchen controls and standards are removed from the kitchen. Further, as of March 2023, a weekly kitchen inspection includes, but is not limited to, a review of food storage to ensure stored food is appropriately labeled and that the Kitchen Officer is conducting a daily inspection of stored food for labeling and rotation.

Persons who fail to uphold these standards are removed from the kitchen. ICE requests that the OIG consider this recommendation resolved and closed, as implemented. www.oig.dhs.gov 17 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security OIG Analysis: ICE’s response meets the intent of this recommendation. We consider this recommendation resolved and open. We will close this recommendation when ICE provides documentary evidence of the weekly kitchen inspections showing a review of compliance for facial hair covering and inventory control of expired food, and procedures for labeling food expiration dates.

We recommend the Executive Associate Director of Enforcement and Removal Operations direct ICE Health Service Corps to: Recommendation 8: Ensure the Caroline facility medical staff are using the most current treatment guidance for chronic illnesses. ICE Response to Recommendation 8: Non-concur. ERO affirms the ICE Health Service Corps chronic care treatment approach is in line with the Chronic Care Guidelines, which are reviewed and approved annually by the ICE Health Service Corps Medical Director. ERO disagrees with the implied notion that ICE Health Service Corps medical staff are not following current treatment guidance or appropriate medical guidelines.

When a new policy is implemented, all ICE Health Service Corps staff are made aware via email. Clinical staff then make the proper adjustments to ensure compliance with ICE Health Service Corps policies. Each February, the ICE Health Service Corps Assistant Director also annually reviews and approves treatment guidance. Documentation corroborating these efforts was provided to OIG on August 3, 2023.

ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: As stated in the report, ICE Health Service Corps relies on outdated guidance for chronic care and some provider staff at Caroline followed this outdated guidance, while others used more updated treatment approaches. Providers should not have to choose between following outdated ICE guidance or providing patients with the most updated treatment approach. The documentation ICE refers to in their response is a single page Note To The Record which states that ICE reserves the right to update the ICE Health Service Corps Policy and Procedures Manual and that the policies and documents have been reviewed by the ICE Health Service Corps Assistant Director.

It does not support any changes discussed in ICE’s response to this recommendation. We consider this recommendation unresolved and open. We will close this recommendation once ICE updates its chronic care guidance to reflect the most current treatment approaches. www.oig.dhs.gov 18 OIG-23-51 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.

DHS OIG initiated this inspection at Congress’ direction.26 DHS OIG analyzes various factors to determine which facilities to inspect. We review OIG Hotline complaints and prior inspection reports, and past and future inspection schedules of other ICE and DHS inspection organizations. 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. 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 Caroline from January 24-26, 2023. 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; 26 Department of Homeland Security Appropriations Act, 2023, H.R. Rep. No. 117-396, Custody Operations Reporting. www.oig.dhs.gov 19 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security residential areas, including sleeping, showering, and toilet facilities; legal services areas, including law libraries; and recreational facilities. • 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. 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, detainee files, and grievance and communication logs and files. • Collected drinking water samples for testing by a laboratory certified by the U.S. Environmental Protection Agency.

We contracted with a team of qualified medical professionals to conduct a comprehensive evaluation of detainee medical care at the Caroline facility. We incorporated information provided by the medical contractors in our findings. We conducted work for this report between January and July 2023 pursuant to the Inspector General Act of 1978, 5 U.S.C. §§ 401-424, and in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.

DHS OIG

Access to DHS Information During this inspection, DHS provided timely responses to our requests for information and did not deny or delay access to the information we requested. www.oig.dhs.gov 20 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix B ICE Comments on the Draft Report www.oig.dhs.gov 21 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 22 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 23 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 24 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 25 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 26 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 27 OIG-23-51 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 28 OIG-23-51 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 Brett Cheney, Senior Inspector Benjamin Diamond, Senior Inspector Becky McLain, Senior Inspector Joshua Bradley, Inspector Natalia Segermeister, Attorney Advisor Anthony Crawford, Independent Referencer www.oig.dhs.gov 29 OIG-23-51 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, U.S. Government Accountability Office/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 30 OIG-23-51 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