DHS OIG, OIG-24-29, Results of an Unannounced Inspection of ICE's Denver Contract Detention Facility in Aurora, Colorado (2024)

OIG-24-29 FINAL REPORT Results of an Unannounced Inspection of ICE's Denver Contract Detention Facility in Aurora, Colorado June 12, 2024 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Washington, DC 20528 | www.oig.dhs.gov June 12, 2024 MEMORANDUM FOR: Patrick J. Lechleitner Senior Official Performing the Duties of the Director U.S. Immigration and Customs Enforcement FROM: SUBJECT: Joseph V. Cuffari, Ph.D. Inspector General JOSEPH CUFFARI Digitally signed by JOSEPH V CUFFARI Date: 2024.06.12 13:27:53 -04'00' Results of an Unannounced Inspection of ICE’s Denver Contract Detention Facility in Aurora, Colorado Attached for your action is our final report, Results of an Unannounced Inspection of ICE’s Denver Contract Detention Facility in Aurora, Colorado. We incorporated the formal comments provided by your office. The report contains fourteen recommendations aimed at improving care of detainees at Denver. Your office concurred with all fourteen recommendations.

Based on information provided in your response to the draft report, we consider recommendations 1, 2, 4, 5, 6, 7, 8, and 13 resolved and open. We consider recommendations 3, 9, 10, 11, 12, and 14 resolved and closed. Once your office has fully implemented the 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 at (202) 981-6000.

Attachment OIG Project No. 24-002-ISP-ICE DHS OIG HIGHLIGHTS Results of an Unannounced Inspection of ICE’s Denver Contract Detention Facility in Aurora, Colorado June 12, 2024 Why We Did This Inspection In accordance with the Department of Homeland Security Appropriations Act, 2023, H.R. Rep. No. 117-396 (2022), we conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards. From October 17–19, 2023, we conducted an in-person, unannounced inspection of ICE’s Denver Contract Detention Facility in Aurora, Colorado, to evaluate its compliance with ICE detention standards. What We Recommend We made 14 recommendations to improve ICE’s oversight of detention facility management and operations at Denver.

For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at: [email protected]. What We Found During our unannounced inspection of U.S Immigration and Customs Enforcement’s (ICE) Denver Contract Detention Facility (Denver) in Aurora, Colorado, we found that Denver’s staff complied with Performance-Based National Detention Standards 2011, revised in December 2016, for recreation, use of force, library, and the voluntary work program. However, facility and ICE staff did not comply with standards related to staff-detainee communication and grievance practices. In addition, ICE did not maintain proper documentation of detainee grievances and a current log of paper requests and grievances, nor did they provide timely and appropriate responses to all requests.

Facility staff did not provide detainees consistent information regarding ingredients of food items, such as menu items labeled beef that did not contain beef. They also did not distribute pillows to all incoming detainees, provide equal access to barber services, clarify proper procedures for securely saving legal information on communal computers, and conduct medical screenings prior to assigning classification ratings. Moreover, some detainees experienced delays in receiving specialty medical care from outside providers. Finally, one detainee in prolonged segregation was not provided the required orders documenting her transition from disciplinary segregation into administrative segregation.

ICE Response ICE concurred with all 14 report recommendations. We consider six recommendations resolved and closed, and eight recommendations resolved and open. www.oig.dhs.gov OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Table of Contents Background .......................................................................................................................................... 3 Results of Inspection ............................................................................................................................ 2 Facility Staff Complied with Inspection Standards for Recreation, Use of Force, Library, and the Voluntary Work Program ............................................................................................

4 The Facility Provided Inconsistent Communication to Detainees Regarding Requests and Grievances ......................................................................................................................... 4 ICE Staff Did Not Comply with All Staff-Detainee Communication Practices ....................... 5 Facility and ICE Staff Did Not Adhere to All Grievance Standards ......................................... 7 Facility Staff Did Not Consistently Describe Food Menu Ingredients ....................................

8 Intake Staff Did Not Distribute Pillows with Other Standard Issue Items ............................. 9 Facility Staff Were Not Offering Barber Services to All Detainees ........................................ 10 Facility Staff Did Not Ensure Detainees Used Secure Means to Save Legal Information .... 11 Facility Staff Were Not Always Conducting Required Intake Medical Screening Prior to Classification ..........................................................................................................................

11 Facility’s Medical Scheduling and Documentation Needs Improvement ........................... 12 Facility Staff Did Not Always Adequately Document Prolonged Segregation .................... 13 Recommendations ............................................................................................................................. 15 Management Comments and OIG Analysis .......................................................................................

16 Appendix A: ......................................................................................................................................... 21 Objective, Scope, and Methodology ................................................................................................. 21 DHS OIG’s Access to DHS Information ................................................................................... 22 Appendix B: ICE’s Comments on the Draft Report ............................................................................

23 Appendix C: Report Distribution ........................................................................................................ 31 Abbreviations Denver ERO ICE GEO Group PBNDS 2011 USB Denver Contract Detention Facility Enforcement and Removal Operations U.S. Immigration and Customs Enforcement The GEO Group, Inc. Performance-Based National Detention Standards 2011 universal serial bus www.oig.dhs.gov OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Background U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 110 facilities nationwide, and the conditions and practices at those facilities can vary greatly. ICE must comply with detention standards and establish an environment that protects the health, safety, and rights of detainees. Contracts and agreements with facilities that hold ICE detainees must adhere to applicable detention standards, including the Performance-Based National Detention Standards 2011, as revised in December 2016 (PBNDS 2011).

As mandated by Congress,1 we continue to conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards. ICE houses detainees at the Denver Contract Detention Facility2 (Denver) in Aurora, Colorado. Denver is comprised of one large building, referred to as ‘North’ and one smaller building, referred to as the ‘Annex’ (see Figure 1). Figure 1.

Aerial View of the Denver Contract Detention Facility Source: The GEO Group, Inc. website image, February 7, 2024 The two buildings are connected via an outdoor covered walkway. The Annex building is further divided into the East Annex and West Annex. Denver houses male detainees in both the North and Annex buildings, while housing female and transgender detainees in separate housing units 1 Department of Homeland Security Appropriations Bill, 2023, H.R. Rep. No. 117-396 (2022).

2 ICE refers to this facility as the Denver Contract Detention Facility, while facility staff, including medical, refer to the facility as the Aurora ICE Processing Center. www.oig.dhs.gov OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security within the Annex building.3 At the start of our on-site inspection, October 17, 2023, Denver housed 873 detainees. ICE contracts with The GEO Group, Inc. (GEO Group) to provide immigration detention, transportation, security, and medical services at Denver.4 In addition to GEO Group (facility staff), ICE also assigns deportation officers and other employees (ICE staff) to provide an on-site presence at Denver. The Office of Inspector General inspection team included inspectors and contracted medical professionals. We toured and inspected areas of the facility including general housing units, kitchen, law library, special management unit,5 recreation facilities, barber shops, and the medical unit.

During our inspection, we also collected and analyzed documentation related to detainee requests and grievances, detention files, and special management unit records. The contracted medical professionals’ inspection included a visual inspection of all areas where medical staff provide health services, document and health record reviews, and interviews with key health services team members. Results of Inspection During our unannounced inspection of Denver, we found that facility staff complied with PBNDS 2011 for recreation, library, use of force, and the voluntary work program. However, we inspected multiple areas of detention management that did not fully comply with standards, including staff-detainee communication, grievance system, food standards, personal hygiene, law library and legal materials, medical care, and special management unit (see Table 1).

3 The only exception is that Denver houses all special management unit detainees (regardless of gender) in the North building. 4 GEO Group also provides services at Cheyenne Mountain Center, also in the Denver area of responsibility for ICE Enforcement and Removal Operations. 5 Segregation is the process of separating certain detainees from the general population for disciplinary or administrative reasons. www.oig.dhs.gov 2 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Table 1. Summary of Findings from Unannounced Inspection of ICE’s Denver Facility in Aurora, Colorado Standard Staff-Detainee Communication Grievance System Food Service Personal Hygiene Law Libraries and Legal Material Medical Care Special Management Unit Non-Compliance ICE Staff Did Not Comply with All Staff-Detainee Communication Practices • ICE staff did not respond to some requests within the applicable timeframe and did not consistently maintain a detainee request log for paper requests.

Facility and ICE Staff Did Not Adhere to All Grievance Standards • • Facility staff did not maintain consistent records on alleged harassment or address alleged retaliation, nor did they always respond timely or properly document detainee grievances. ICE staff did not log paper grievances. Facility Staff Did Not Consistently Describe Food Menu Ingredients • Menus contained unclear ingredient descriptions. Intake Staff Did Not Distribute Pillows with Other Standard Issue Items • Staff were not distributing pillows to detainees during intake.

Facility Staff Did Not Offer Barber Services to All Detainees • The facility did not offer barber services to female and transgender detainees in the Annex section. Facility Staff Did Not Ensure Detainees Used Secure Means to Save Legal Information • Some detainees saved their personal information to a computer’s desktop and were unaware they could save their legal work to a secure, individual universal serial bus (USB) drive. Facility Staff Were Not Always Conducting Required Intake Medical Screening Prior to Classification Facility’s Medical Scheduling and Documentation Needs Improvement • Detainees did not receive timely specialty care. Facility Staff Did Not Always Adequately Document Prolonged Segregation • The facility did not document the transition of one detainee from disciplinary segregation to administrative segregation.

Source: DHS OIG analysis of key findings www.oig.dhs.gov 3 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Facility Staff Complied with Inspection Standards for Recreation, Use of Force, Library, and the Voluntary Work Program PBNDS 2011 requires that detainees have access to both indoor and outdoor recreation.6 The inspection team observed the facility’s adherence to this standard and confirmed it through detainee interviews. Indoor facilities had recreational equipment for detainees’ use. The facility also had an outdoor space with a variety of ways for detainees to exercise, including recreation equipment and a sports field. For use of force incidents, PBNDS 2011 requires appropriate levels of force and restraint to protect the people involved in these incidents and that staff involved submit reports documenting these incidents within 2 business days of the incident.7 The facility reported nine use of force incidents between April 17, 2023, and October 17, 2023.

Through reviewing video footage and documented reports of the incidents, we found the facility staff complied with these standards. In addition, PBNDS 2011 requires the facility to make available to detainees reading materials in English and Spanish and we observed reading materials in these languages in the facility’s library.8 Detention standards also require facilities to provide detainees with the opportunity to participate in voluntary work assignments to earn money while confined.9 Based on our review of policies, procedures, records, and observations, we found Denver complied with this standard. Denver provided program information and position-specific training for detainees who chose to participate in the program. In addition, they paid detainees for their hours worked and work schedules did not exceed 8 hours per day or 40 hours per week as required.

The Facility Provided Inconsistent Communication to Detainees Regarding Requests and Grievances PBNDS 2011 requires facilities to provide information to detainees on the facility’s request and grievance processes.10 Detainees may submit requests and grievances electronically through a tablet or via paper forms available in the housing units. We reviewed PBNDS 2011, the ICE National Detainee Handbook, the facility’s supplemental handbook, and observed pertinent forms and drop boxes while touring the facility. We determined the handbooks, forms, and drop boxes all used different terminology when referencing the grievance and request processes. For example, the terminology used to refer to a detainee’s right to submit a request to the facility is referred to as “request” in all communication except on the paper forms available in the housing units, where the facility labeled requests as a “kite.” In addition, we observed forms in the 6 PBNDS 2011 (Revised 2016), Section 5.4, Recreation, Section (II).

7 PBNDS 2011 (Revised 2016), Section 2.15, Use of Force and Restraints, Section (II). 8 PBNDS 2011 (Revised 2016), Section 5.4, Recreation, Section (V) (F). 9 PBNDS 2011 (Revised 2016), Standard 5.8, Voluntary Work Program, Section (I). 10 PBNDS 2011 (Revised 2016), Standard 6.1, Detainee Handbook, Section (V)(B). www.oig.dhs.gov 4 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security housing units titled “ICE Grievance Request,” which combines terminology for two different processes.

Further, the housing units only had paper grievance forms for submission to ICE, but not to the facility. This inconsistent terminology and unavailable forms could make it difficult for detainees to understand how and where to submit forms to the facility and ICE. ICE Staff Did Not Comply with All Staff-Detainee Communication Practices PBNDS 2011 establishes procedures for contact among staff and detainees, including written communication, and observation of living conditions.11 These procedures require ICE and facility staff to respond to detainee requests in a timely and appropriate manner, as well as maintain a historical log of all requests. We reviewed all detainee requests to facility staff between May and September 2023.

These requests included topic areas related to mail, religious requests, legal requests, and case management. We found that while facility staff generally responded to detainee requests in a timely manner with appropriate responses, ICE staff did not always provide timely and appropriate responses to all written requests, and they had not logged paper requests since May 2023. ICE Staff Did Not Respond to Some Requests within the Applicable Timeframe and Did Not Consistently Maintain a Detainee Request Log for Paper Requests PBNDS 2011 establishes procedures for detainees to submit requests to ICE and requires ICE staff to respond within 3 business days of receipt.12 According to ICE’s log of electronic requests, detainees electronically submitted 7,110 requests to ICE from April 1, 2023, through October 11, 2023. Of the 7,110 electronic requests, ICE did not respond to 1,819 requests (approximately 25 percent) within the required 3 business days.

ICE’s responses ranged from 1 to 12 days late with an average response time of 6 days. Without timely responses from ICE, detainees may face undue delays in resolving important questions or concerns, such as those related to their immigration cases or detention conditions. Additionally, during our on-site inspection, ICE provided two stacks of paper requests submitted by detainees. We manually reviewed several hundred of these requests and found ICE staff did not respond to many of these within the required 3 business days.

Further, while PBNDS 2011 requires ICE to log all detainee requests for record keeping and file maintenance,13 at the time of our onsite inspection in October 2023, ICE had not logged paper detainee requests since May 2023. Onsite ICE personnel acknowledged the deficiency and suggested staff vacancies caused the noncompliance. 11 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section (I). 12 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section (V)(B)(1).

13 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section (V)(B)(2). www.oig.dhs.gov 5 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security ICE Generally Complied with Providing Appropriate Responses to Detainee Requests PBNDS 2011 requires that detainees have frequent informal interaction with ICE and facility staff.14 Written interactions should include an appropriate response to detainee requests in a language the detainees can understand. As previously noted, we reviewed 7,110 electronic detainee requests to ICE, and of those 7,110, we found ICE staff generally provided appropriate responses and responded to detainees in a language the detainee could understand. However, we found some ICE staff responded to paper requests in a language different from the original request. This may result in the detainee not being able to understand the response.

In addition, we noted responses from one deportation officer were disrespectful and unprofessional. Table 2 provides examples of these responses. ICE identified and addressed the issue with this officer prior to our inspection and the officer was no longer employed at the facility by the time of our inspection. Table 2.

ICE Officer’s Responses to Detainees’ Requests at Denver Detainees’ Submissions ICE Officer Response [OIG Note–translated from Spanish to English] “Good morning, I want to know when I will be deported since I have children to support and my mother is sick. I am going to be detained for 3 months, it is not fair and I have all my legal documents, please.” [OIG Note–translated from Spanish to English] “I'm afraid of airplanes. Only once have I gotten on a plane and I feel pressure in my head and my ears seem to block. I'm afraid that I’m in very bad pain since the trip to Venezuela is long or something will happen to me if I can. be expelled or go to waste I want to know.” [OIG Note–translated from Spanish to English] “Good afternoon, I don't have a passport, just enter with your identity card.

How much longer does the process of finding the document to travel take? Help me? thank you.” Source: ICE Detainee Requests [Response provided in English] “Not fair? You enter the United States illegally and claim being mistreated because you are held in custody? People that commit crimes go to jail.

If you continue to commit crimes, you will continue to go to jail. Any other questions about your situation? You are wasting our time that we could be spending on doing our jobs.” [Response provided in English] “Oh...We didn't know you were scared of airplanes. In that case you will still be deported from the United States.” [Response provided in English] “It takes as long as it takes.

We are not a travel service. You are on our schedule. Not the other way around.” 14 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section (II)(1). www.oig.dhs.gov 6 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Facility and ICE Staff Did Not Adhere to All Grievance Standards PBNDS 2011 requires facilities housing detainees to have a grievance submission system that protects detainees’ rights and ensures staff treat all detainees fairly.15 Facility staff did not adhere to all required standards of the grievance program, specifically regarding their response to an alleged retaliation, and their absence of timely and properly documented responses to grievances. Further, ICE staff was not logging detainees’ paper grievances, as required.

Facility Staff Did Not Maintain Consistent Records on Alleged Harassment or Address Alleged Retaliation PBNDS 2011 requires staff to offer immediate protection to any detainee who alleges sexual abuse, such as separation from the assailant, and to immediately report alleged incidents to appropriate personnel.16 While reviewing the facility’s grievance logs, we found two reported grievances of sexual abuse among detainees between April 1 and September 30, 2023.17 Facility documents for one of these grievances, filed on August 4, 2023, show one detainee was charged with “making sexual proposals or threats” to another detainee and given 23 days of disciplinary segregation. While the facility separated the two detainees, staff’s documentation did not clearly show the date of separation. For example, a Segregation Order from August 30, 2023, gives two different dates (August 8, 2023, and August 16, 2023) for the start of disciplinary segregation, while an Administrative Segregation Order stated the assailant was placed in segregation pending a disciplinary hearing on August 16, 2023. Due to the conflicting dates on the segregation orders, we could not determine whether facility staff immediately separated the victim and assailant.

The standards also require all staff to report to the appropriate officials any retaliation against detainees who reported or participated in an investigation about sexual abuse and to employ protection measures against continued retaliation.18 Following the initial allegation of sexual abuse, the individual who filed the grievance referenced above subsequently alleged another detainee verbally harassed them because of their original grievance of sexual abuse. However, through our review of the allegation we found staff prematurely rejected the detainee’s harassment allegation without further investigation; did not offer immediate protection and/or separation to the detainee from the alleged retaliator; and advised the detainee to file a medical grievance instead, though the grievance did not involve the facility’s medical department. These 15 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (I). 16 PBNDS 2011 (Revised 2016), Standard 2.11, Sexual Abuse and Assault Prevention and Intervention, Section (II).

17 The first grievance we reviewed was handled appropriately by facility staff and we found no violations of PBNDS 2011. 18 PBNDS 2011 (Revised 2016), Standard 2.11, Sexual Abuse and Assault Prevention and Intervention, Section (V) (K). www.oig.dhs.gov 7 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security actions confirm staff did not follow standards related to appropriate responses to alleged harassment. Facility Staff Did Not Always Respond Timely or Properly Document Detainee Grievances PBNDS 2011 requires staff to respond to detainee grievances within 5 days of receipt.19 We reviewed 201 grievance forms or associated log entries for both medical and non-medical grievances filed between April 1, 2023, and September 30, 2023. We found issues with 18 grievance responses (8 percent), such as late replies, inconsistent dates, or missing information.

The average time for facility staff to respond to detainees for these 18 grievances was 13 days. In one example, staff did not provide the detainee with any written outcomes or updates until they completed their investigation into the grievance 26 days later, leaving the detainee without a documented response during the investigation. Half of the late responses we identified had documented reasons for being delayed, such as ongoing investigations, which staff acknowledged can take beyond 5 days to complete. In addition to grievances with late responses, we found log entries for five medical grievances had staff responses dated earlier than the detainees’ filing dates.

ICE Did Not Log Detainee Grievances Submitted on Paper Forms PBNDS 2011 requires each facility to have a procedure to log all ICE detainee grievances separately.20 These standards also state that ICE may review grievances at a facility to evaluate compliance with grievance standards and procedures. Detainees can submit grievances to ICE through paper forms available in the detainee housing units. However, we found ICE staff did not track or log the paper grievances they received from detainees. We reviewed 14 grievance forms detainees submitted to ICE between April 1 and September 30, 2023 and found none of the grievance forms had an associated log number.

ICE provided 13 of the grievances we reviewed, while the inspection team found a 14th grievance in a random file during our inspection. ICE confirmed they do not have a grievance log to document detainee grievances; instead, they store scanned copies of grievances to ICE on an internal shared drive. Because ICE does not maintain a log of detainee grievances for tracking paper forms or conducting compliance reviews, we could not confirm the completeness of ICE grievances or responses at the facility. Facility Staff Did Not Consistently Describe Food Menu Ingredients During our detainee interviews, detainees voiced concerns about the facility’s food menu.

Many submitted complaints or grievances, and even declined meals due to unclear information about the contents of specific menu items.21 For instance, facility staff consistently informed detainees 19 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (V)(C)(3). 20 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (V)(A). 21 PBNDS 2011 (Revised 2016), Standard 4.1, Food Service, Section (V)(G). www.oig.dhs.gov 8 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security that the kitchen does not serve beef. However, items such as “Beef and Bean Burrito” and “Hamburger Patty,” which generally contain beef, were listed on the menu (see Figure 2).

Figure 2. Menu items that may generally contain beef, observed on October 17, 2023 Source: DHS OIG Photos (Highlights in photo were made by DHS OIG) Other examples of confusing menu items that supposedly did not contain beef include “Salisbury Steak” and “Beef Meatloaf.” The facility’s kitchen manager said the meat and beef listed on the menu were “a mesh of chicken and turkey.” Because these menu items do not have additional descriptions, detainees could assume the items highlighted in Figure 2, as well as “Salisbury Steak” and “Beef Meatloaf” actually contain beef. Staff said they have communicated this information to the detainees, but detainee interviews indicated they remained concerned about menu ingredients. Kitchen staff told the inspection team the facility avoids serving beef due to cost; the exception being the “Meat and Vegetable Stew,” which does contain beef.

However, while observing the contents of items in the facility’s freezer, our team identified another menu item that explicitly listed beef as an ingredient. Further, facility staff also indicated the kitchen does not serve pork. Yet menu items such as “T-Ham” (explained as Turkey Ham) or “Turkey Salami” could confuse detainees who may think these items contain pork. Intake Staff Did Not Distribute Pillows with Other Standard Issue Items PBNDS 2011 states that a pillow is part of the standard issue bedding items given to detainees upon arrival.22 When touring the facility, we noticed the West Annex had mattresses with built-in 22 PBNDS 2011 (Revised 2016), Standard 4.5, Personal Hygiene, Section V(G)(1). www.oig.dhs.gov 9 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security pillows (see Figure 3), while the East Annex had standard mattresses with no built-in pillows.

Some detainees with standard mattresses in the East Annex did not have pillows (see Figure 4) and created their own pillows with extra blankets and sheets. Staff showed us the items detainees receive at intake and a pillow was not included. When asked why a pillow was not issued, intake staff stated they did not know where they would house each detainee or whether the detainee’s mattress would have a built-in pillow or not. Therefore, intake staff chose not to issue pillows to anyone housed in the Annex building.

Staff further explained that if a detainee did not receive a pillow during intake, it was the detainee’s responsibility to request a pillow from the officers in their housing unit. However, PBNDS 2011 states it is the facility’s responsibility to provide a pillow to the detainee during the intake process. Figure 3. Mattress with built-in pillow Figure 4.

Mattress with pillows made from blankets Source: DHS OIG photo Source: DHS OIG photo Facility Staff Were Not Offering Barber Services to All Detainees PBNDS 2011 states that detainees are allowed freedom in personal grooming, and they shall be provided hair care services in a manner and environment that promotes sanitation and safety.23 The standards further specify equal access to benefits and programs for all detainees housed at a detention facility, regardless of religion, disability, etc. Through interviews with detainees, we 23 PBNDS 2011 (Revised 2016), Standard 4.5 Personal Hygiene, Section (V)(F). www.oig.dhs.gov 10 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security found the facility offered male detainees in the North and Annex sections barber services, but they did not offer barber services to female and transgender detainees in the Annex section. For example, one female detainee we interviewed said she had been at the facility for 1 year and facility staff had never offered her barber services, so she resorted to using fingernail clippers to cut her hair. Further, we asked a group of approximately 16 female detainees in one housing unit who had been at the facility between 3 and 12 months whether they had ever been offered barber services; they collectively responded, “No.” When we followed up to ask if they would sign up for barber services if they were offered, they all responded, “Yes.” We also found facility leadership did not know the process for detainees to sign up for barber services, nor did they know how many barber areas were operational. The facility staff’s failure to offer barber services to all detainees, regardless of gender, does not comply with the requirement for equal access to these services.

Facility Staff Did Not Ensure Detainees Used Secure Means to Save Legal Information PBNDS 2011 states that detainees “shall be provided with a means of saving any legal work in a secure and private electronic format that is password protected, so they may return at a later date to access previously saved legal work products.”24 The facility has two law libraries – a main one equipped with eight working computers serving the North building of the facility and a second smaller library equipped with two computers serving the Annex building. The North building’s law library complied with standards for saving legal work. However, the smaller library in the Annex did not. We found some detainees in the Annex saved their personal legal documents to an individual USB device while others saved their legal documents to the desktop of the communal computers, which facility staff and other detainees can access.

In the documents saved to the desktop of the communal computers, we found personally identifiable information and sensitive legal documentation. The facility maintains a supply of USBs for detainees to save their personal information. However, staff had not communicated this to detainees. Three of seven detainees we interviewed indicated they did not have a USB to save legal work.

Facility Staff Were Not Always Conducting Required Intake Medical Screening Prior to Classification PBDNS 2011 requires that after completing the in-processing health screening form, the classification officer assigned to intake processing shall complete a custody classification worksheet or equivalent.25 We found the intake staff complied with completing the classification worksheet, but they could not guarantee that medical staff were always conducting the required 24 PBNDS 2011 (Revised 2016), Standard 6.3, Law Libraries and Legal Material, Section (I). 25 PBNDS 2011 (revised 2016), Standard 2.2 Custody Classification System, Section (V)(D). www.oig.dhs.gov 11 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security health screening prior to a detainee’s classification assignment. Intake and classification staff stated the facility receives an abnormally large influx of detainees at one time. During these large intakes, detainees undergo intake processing, including classification assignments and medical health screenings, in different orders, depending on which intake station is available.

If facility staff classify a detainee prior to the health screening, they cannot ensure all health conditions are considered before making the classification and housing assignments. Facility’s Medical Scheduling and Documentation Needs Improvement PBNDS 2011 requires that detainees have access to appropriate and necessary medical care, including specialty health care.26 GEO Group manages all aspects of the health care process at Denver and partners with community providers for some specialty care needs. Facility staff complied with most reviewed PBNDS 2011 standards and National Commission on Correctional Health Care’s 2018 Standards for Health Services in Jails related to medical care, including program administration, emergency care, health care records, sick call, chronic care, pharmacy management, medical diets, and privacy. However, facility staff said the lack of specialty care providers in Aurora delayed detainees’ access to timely specialty care.

Detainees Did Not Receive Timely Specialty Care PBNDS 2011 requires that detainees shall be able to request health services daily and shall receive timely follow-up.27 Our medical contractors noted delays in detainees’ receipt of specialty care, such as optometry and podiatry. Specifically, the facility staff said a general absence of specialty care providers in Aurora delayed detainees’ timely receipt of care. For example, facility medical staff stated there are two local hospitals that could provide detainee care. Yet one of the two facilities prefers not to provide services to the detainee population, which forces the facility to depend on the services of the other hospital.

Facility medical staff confirmed for the 2 months preceding our site visit — August and September 2023 — staff scheduled 47 specialty appointments for detainees and as of our site visit, 31 of those appointments had not yet occurred. Delayed access to specialty care could lead to negative health effects. 26 PBNDS 2011 (revised 2016), Standard 4.3 Medical Care, Section (I). 27 PBNDS 2011 (revised 2016), Standard 4.3 Medical Care, Section (II)(4). www.oig.dhs.gov 12 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Facility Staff Did Not Always Adequately Document Prolonged Segregation PBNDS 2011 allows facilities to segregate detainees from the general population in special management units for administrative or disciplinary reasons.28 Table 3 describes the differences between administrative and disciplinary segregation.

Table 3. Types of Segregation in Special Management Units Administrative Segregation Disciplinary Segregation Non-punitive – at the detainee’s request or as needed to protect the detainee from harm Disciplinary – after the detainee is found guilty of a prohibited act or rule violation Detainees are held until their safety, and the safety of others, is no longer a concern.29 Detainees are held for no more than 30 days per incident, except in extraordinary circumstances. Detainees typically receive the same privileges available to the general population. Detainees are allowed at least 2 hours of recreation time outside of their cells, 7 days a week.

Detainees are subject to more stringent personal property control, including limitations on reading material, television viewing, and restricted commissary or vending machine purchases. Detainees are allowed at least 1 hour of recreation time outside of their cells, 5 days a week. Detainees can receive time out of their cells for showers, phone calls, use of the law library, visitation, and religious services. Detainees can receive time out of their cells for showers, phone calls, use of the law library, visitation, and religious services.

Source: PBNDS 2011, Section 2.12, Special Management Units At the time of our onsite inspection, Denver had four males and one female in administrative segregation, and one female in disciplinary segregation. We reviewed the segregation files related to these six detainees and determined the facility appropriately documented detainee privileges, visitation from facility leadership, and completed segregation file reviews on appropriate intervals. 28 PBNDS 2011 (Revised 2016), Standard 2.12, Special Management Unit, Section (I). This facility uses the term Restricted Housing Unit interchangeably with Special Management Unit.

This report will use the PBNDS language of Special Management Unit. 29 If a detainee has been segregated for his/her own protection, but not at the detainee’s request, approval by a facility administrator is required to authorize continued detention. www.oig.dhs.gov 13 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security However, the facility did not document the transition of one detainee from disciplinary segregation to administrative segregation. PBNDS 2011 states that the facility must complete an administrative segregation order prior to a detainee’s placement in administrative segregation and immediately provide the order to the detainee. We found that facility staff transferred one female detainee from disciplinary segregation to administrative segregation but did not provide her with the required administration segregation orders.

This detainee was aware of the privileges she should receive in administrative segregation and confirmed during her interview with inspectors that she was receiving those privileges. However, the only documentation showing she should receive the same privileges in administrative segregation as detainees in general population was an informal facility memorandum. www.oig.dhs.gov 14 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations, responsible for Denver, direct the Denver Field Office to: Recommendation 1: Ensure consistent language in various publications when communicating to detainees about the grievance and request processes. Recommendation 2. Ensure responses to detainee requests are timely, and in a language understood by the detainee.

Recommendation 3. Ensure ICE staff maintains an updated log of detainee requests. Recommendation 4: Maintain complete and consistent records on sexual harassment allegations and continue training staff on Sexual Abuse and Assault Prevention and Intervention complaint processes. Recommendation 5: Provide responses to grievances within 5 working days, even if it’s to update the detainees that a grievance response will likely be late due to an investigation.

Recommendation 6: Ensure facility grievance logs are accurate. Recommendation 7: Ensure ICE staff maintain an updated log of detainee grievances to ICE. Recommendation 8: Ensure facility staff is communicating clear and accurate information to detainees regarding menu ingredients. Recommendation 9: Provide all detainees with the required supplies at intake, including pillows.

Recommendation 10: Ensure facility staff offer all detainees barber services. Recommendation 11: Ensure the facility consistently communicates and provides detainees with a secure way to save legal work. Recommendation 12: Ensure intake staff is completing the medical health screening form prior to classifying a detainee and assigning a housing unit. Recommendation 13: Establish and implement a plan to reduce wait times for specialty care appointments. www.oig.dhs.gov 15 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Recommendation 14: Ensure consistent documentation and communication to detainees about the reason for transitions from disciplinary to administrative segregation, and the duration of such subsequent segregation.

Management Comments and OIG Analysis ICE provided written comments in response to the draft report and concurred with all 14 recommendations. Appendix B contains ICE’s management comments in their entirety (ICE under separate cover provided and we processed its technical comments) on the draft report. We consider recommendations 1, 2, 4, 5, 6, 7, 8, and 13 resolved and open. We consider recommendations 3, 9, 10, 11, 12, and 14 resolved and closed.

A summary of ICE’s response and our analysis follows. ICE Response to Recommendation 1: Concur. In February 2024, Denver revised the language in the local detainee handbook, forms, and drop boxes to ensure consistency in the grievance and request process terminology. Furthermore, Denver posted the updated language in all housing units and the updated language was also added to all local detainee handbooks and provided in the languages covered.

OIG Analysis: ICE provided documentation of the updated language used to reference the detainee request and grievance process. We consider this responsive to this recommendation which is resolved and open. We will close this recommendation when ICE provides evidence of the revised language in the local detainee handbook. ICE Response to Recommendation 2: Concur.

In January 2024, ICE Enforcement and Removal Operations (ERO) increased the number of ERO personnel at the facility to increase accountability, oversight, and to address increases in detainee requests. Specifically, ICE ERO added Supervisory Detention and Deportations Officers and senior Deportation Officers to increase oversight in detained case management and reduce the response time on detainee requests. Further, ICE will use translation services when necessary to provide effective communication to the detainee. OIG Analysis: ICE provided request response data from January 2023 through March 2024.

However, the data shows an average response time greater than the required 3 business days. We consider this responsive to the recommendation which is resolved and open. We will close this recommendation when ICE provides updated data to show an average request response time of 3 business days or less and evidence that they are using the translation services when appropriate. www.oig.dhs.gov 16 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security ICE Response to Recommendation 3: Concur. ICE ERO implemented staff training and increased the number of on-site officers, enforcement removal assistants, and supervisors to ensure accurate maintenance of an updated log of detainee requests.

Specifically, the Denver request log is fully updated, and enforcement removal assistants will update the log daily. OIG Analysis: ICE provided request response data from January 2023 through March 2024. The data appears updated and complete. We consider this responsive to the recommendation which is resolved and closed.

ICE Response to Recommendation 4: Concur. Denver reviewed its processes and procedures and took corrective actions to address complaint, grievance adjudication, and response requirements for sexual abuse and assault prevention and intervention by providing training to staff on the importance of maintaining complete and consistent Sexual Abuse and Assault Prevention and Intervention records and an overview of related procedures. OIG Analysis: We consider these efforts responsive to this recommendation which is resolved and open. We will close this recommendation when ICE provides evidence of the Sexual Assault Prevention and Intervention training and overview of the process.

ICE Response to Recommendation 5: Concur. Historically, detainee grievances were maintained by ICE ERO as a paper copy or electronic scan of the grievance. In November 2023, ICE ERO created an electronic log to ensure accurate tracking and accountability for grievance receipt and response timeliness. The electronic log tracks the date the appeal was filed, and the date of the decision is made.

OIG Analysis: ICE provided documentation of four grievances submitted in March 2024 and tracked on the electronic log. We consider these actions responsive to the recommendation which is resolved and open. We will close this recommendation when ICE provides two additional months of electronically tracked grievances. ICE Response to Recommendation 6: Concur.

In March 2024, Denver took corrective actions to ensure facility grievance logs are accurate and address grievance standards by instructing staff to complete responses to detainee grievances within 5 days of receipt. OIG Analysis: ICE provided documentation of four grievances submitted in March 2024 and tracked on the electronic log. We consider these actions responsive to the recommendation which is resolved and open. We will close this recommendation when ICE provides two additional months of electronically tracked grievances.

ICE Response to Recommendation 7: Concur. Historically, detainee grievances were maintained by ICE ERO as a paper copy or electronic scan of the grievance. In November 2023, ICE ERO created an electronic log to ensure accurate tracking and accountability for grievance receipt www.oig.dhs.gov 17 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security and response timeliness. The electronic log tracks the date the appeal was filed, and the date of the decision is made.

OIG Analysis: ICE provided documentation of four grievances submitted in March 2024 and tracked on the electronic log. We consider these actions responsive to the recommendation which is resolved and open. We will close this recommendation when ICE provides two additional months of electronically tracked grievances. ICE Response to Recommendation 8: Concur.

In March 2024, Denver initiated corrective actions with its corporate food service department to make changes to its posted menu to clarity the menu items. Some examples include: • “Turkey Bacon" will now be labeled as “Turkey Breakfast Strip.” • “Turkey Ham” or “T-Ham” will now be labeled as “Turkey Deli Meat.” • “Breakfast Sausage” will now be labeled as “Chicken Breakfast Meat.” • “Chicken Dinner Sausage,” “Dinner Sausage,” or “Chicken Hot Dogs” will now be labeled as “Chicken Lunch or Dinner Meat,” depending on the meal being served. Denver also posted a notice, in multiple languages, to all detainees detailing these upcoming description changes and reiterates that Denver is a pork free facility. The estimated completion date for action needed to close this recommendation is June 28, 2024.

OIG Analysis: ICE provided an example of the notice explaining the food description changes that was presented in multiple languages. We consider this responsive to the recommendation which is resolved and open. We will close this recommendation when ICE provides notification that they have fully implemented the food description changes, which they estimate to be June 2024. ICE Response to Recommendation 9: Concur.

In March 2024, Denver issued a memorandum directing intake staff and housing officers to ensure that all detainees assigned to the north annex are provided with the required supplies at intake, including a pillow. OIG Analysis: ICE provided a copy of the memorandum directing a pillow to be included in the supplies provided to detainees in the north annex and a picture of where the pillows are located for distribution. We consider this responsive to the recommendation which is resolved and closed. ICE Response to Recommendation 10: Concur.

In October 2023, Denver constructed a salon for female and transgender detainees in the south annex, and in March 2024, the new salon opened and was operational. Currently, all housing units have posted schedules for barbers and salon services. www.oig.dhs.gov 18 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security OIG Analysis: ICE provided documentation showing the barber and salon service schedule for all housing units, including the annex buildings. This is responsive to the recommendation which is resolved and closed. ICE Response to Recommendation 11: Concur.

In March 2024, Denver ensured that library staff maintain a log of all thumb drives issued to detainees, which is secured in a locked cabinet, checked out by security staff, and returned after each use. In addition, updated signs in multiple languages were created and posted for residents instructing them to save their documents to their issued thumb drives and not on the computer. Denver is also collaborating with the local IT manager to develop an automatic nightly clearing method for the computers. OIG Analysis: ICE provided an example log of thumb drives assigned to detainees, the updated sign informing detainees of their information saving options, and examples of coordination with the director of information systems regarding the law library thumb drives.

We consider this responsive to the recommendation which is resolved and closed. ICE Response to Recommendation 12: Concur. In February 2024, the Denver Health Services Administrator provided formal refresher training to all medical staff. The training focused on coordinating and sequencing intake medical screenings with security.

In March 2024, ICE provided documentation of these actions and requests this recommendation be resolved and closed. OIG Analysis: ICE provided a copy of the sign in sheet and agenda from the formal refresher training to all medical staff. They also provided an example of four classification worksheets documenting Denver staff conducted the initial health screening prior to assigning the classification and housing assignment. This is responsive to the recommendation which is resolved and closed.

ICE Response to Recommendation 13: Concur. Denver continues to work with local medical providers to obtain and schedule specialty care appointments, and the medical scheduler will document the efforts in obtaining appointments for all required specialty services. Denver is also working closely with ICE’s Health Service Corps to augment access to specialty care. Any pending specialty service appointments that reach 40-days without the patient being seen will be brought to the attention of field medical staff for their assistance and the Denver contractor will consider the use of telemedicine to increase the availability of specialty care appointments.

ICE will document the reduction in wait time to ensure any appointments that reach 40 days without the patient being seen will be brought to the attention of field medical staff. The estimated completion date for action needed to close this recommendation is September 30, 2024. www.oig.dhs.gov 19 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security OIG Analysis: Denver provided provider recruitment information and a log of detainee specialty appointment requests, approvals, schedules, and notes. The average days between request and appointment was 50 days. Of concern is four of the specialty appointments had to be rescheduled because of “no transportation.” The facility should ensure that detainees are able to keep these difficult-to-schedule appointments by planning ahead for transportation.

We consider this responsive to the recommendation which is resolved and open. We will close this recommendation when we receive documentation showing any appointments that reach 40- days without the patient being seen will be brought to the attention of field medical staff. ICE Response to Recommendation 14: Concur. ICE reiterated that they documented the reasons for the transition between the types of segregation, to include a signed copy of a noncitizens’ administrative order transitioning them from disciplinary to administrative segregation.

OIG Analysis: ICE provided documentation that shows the detainee signed several orders assigning her to disciplinary and then administrative segregation. We consider this responsive to the recommendation which is resolved and closed. www.oig.dhs.gov 20 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. 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. As mandated by Congress,30 we continue to conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards.

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 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 limit our scope to the PBNDS 2011 for health, safety, medical care, mental health care, grievances, classification, 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; and information from nongovernmental organizations. We conducted our unannounced in-person inspection of Denver from October 17 through October 19, 2023.

During the inspection, we: • Conducted an in-person walk-through of the facility. We inspected 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. 30 Department of Homeland Security Appropriations Act, 2023, H.R. Rep. No. 117-396 (2022). www.oig.dhs.gov 21 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. 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.

Interviewed ICE and detention facility staff members, including key ICE operational and detention facility oversight staff and detention facility medical, 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. We contracted with a team of qualified medical professionals to conduct a comprehensive evaluation of detainee medical care at the Golden State facility. We incorporated information provided by the medical contractors in our findings.

We conducted this inspection under the authority of the Inspector General Act of 1978, 5 United States Code §§ 401–424, and according to the Quality Standards for Inspections and Evaluations, issued by the Council of the Inspectors General on Integrity and Efficiency. DHS OIG’s Access to DHS Information During this inspection, ICE provided timely responses to our requests for information and did not delay or deny access to information we requested. www.oig.dhs.gov 22 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix B: ICE’s Comments on the Draft Report www.oig.dhs.gov 23 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 24 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 25 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 26 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 27 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 28 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 29 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 30 OIG-24-29 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix C: 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 DHS ICE Liaison Office of Management and Budget Chief, Homeland Security Branch DHS OIG Budget Examiner Congress Congressional Oversight and Appropriations Committees www.oig.dhs.gov 31 OIG-24-29 To view this and any other DHS OIG reports, Please visit our website: www.oig.dhs.gov Additional Information For further information or questions, please contact the DHS OIG Office of Public Affairs via email: [email protected] DHS OIG Hotline To report fraud, waste, abuse, or criminal misconduct involving U.S. Department of Homeland Security programs, personnel, and funds, please visit: www.oig.dhs.gov/hotline If you cannot access our website, please contact the hotline by phone or mail: Call: 1-800-323-8603 U.S. Mail: Department of Homeland Security Office of Inspector General, Mail Stop 0305 Attention: Hotline 245 Murray Drive SW Washington, DC 20528-0305