ICE NDS 2019, Standard 4.3

STANDARD 4.3 MEDICAL CARE I. POLICY All detainees shall have access to appropriate medical, dental, and mental health care, including emergency services. Each medical facility will strive for accreditation with National Commission on Correctional Health Care. II.

STANDARDS AND PROCEDURES A.

General Every facility shall directly or contractually provide its detainee population with the following: 1. Initial medical, mental health and dental screening; 2. Medically necessary and appropriate medical, dental and mental health care and pharmaceutical services at no cost to the detainee; 3. Comprehensive, routine and preventive health care, as medically indicated; 4.

Emergency care; 5. Specialty health care; 6. Timely responses to medical complaints; 7. Hospitalization as needed within the local community; and 8.

Staff or professional language services necessary to allow for meaningful access for detainees with limited English proficiency (LEP), and effective communication for detainees with disabilities, during any medical or mental health appointment, sick call, treatment, or consultation. The health care program and the medical facilities will be under the direction of a Health Services Administrator (HSA) and/or Clinical Medical Authority (CMA). When the HSA is not a physician, final clinical judgment shall rest with the facility’s designated CMA. Facilities will employ sufficient medical staff to perform basic exams and treatments for all detainees.

The HSA will negotiate and keep current arrangements with nearby medical facilities or health care providers to provide required health care not available within the 4.3 Medical Care 112 National Detention Standards Revised 2019 facility. These arrangements will include appropriate custodial officers to transport and remain with the detainee for the duration of any off-site treatment or hospital admission. B. Facilities Adequate space and equipment will be furnished so that all detainees are provided basic health examination, treatment, and communication in private. Medical records will be kept separately from detainee records and stored in a securely locked area.

All pharmaceuticals will be stored in a secure area and temperature controlled to ensure no alteration in potency. C. Health Care Staff Health care staff shall have a valid professional licensure and/or certification for the jurisdiction in which they practice and will perform duties within the scope of their clinical license. The following terms apply to health care staff referred to throughout this standard. 1.

Health Care Practitioner: Defined as an individual who is licensed, certified, or credentialed by a state, territory, or other appropriate body to provide health care services within the scope and skills of the respective health care profession. 2. Mental Health Provider: Psychiatrist, clinical or counseling psychologist, physician, psychiatric nurse, clinical social worker, or any other mental health professional who, by virtue of their education, credentials, and experience, are permitted by law to evaluate and care for the mental health needs of patients. D. Medical Screening (New Arrivals) As soon as possible, but no later than 12 hours after arrival, all detainees shall receive, by a health care practitioner or a specially trained detention officer, an initial medical, dental and mental health screening and be asked for information regarding any known acute, emergent, or pertinent past or chronic medical conditions, including history of mental illness, particularly prior suicide attempts or current suicidal/homicidal ideation or intent, and any disabilities or impairments affecting major life activities.

Any detainee responding in the affirmative shall be sent for evaluation to a qualified, licensed health care practitioner as quickly as possible, but no later than two working days. Detainees who appear upon arrival to raise urgent medical or mental health concerns shall receive priority in the intake screening process. For intra-system transfers, a health care practitioner will review each incoming detainee’s health record or health summary within 12 hours of arrival, to ensure continuity of care. Facilities shall have policies and procedures to ensure documentation of the initial health screening and assessment.

4.3 Medical Care 113 National Detention Standards Revised 2019 1. Tuberculosis All new arrivals shall receive tuberculosis (TB) screening in accordance with the most current Centers for Disease Control and Prevention (CDC) guidelines, including, but not limited to, CDC Guidelines for Correctional Facilities, prior to being placed in general population. For detainees who have been in continuous law enforcement custody, symptom screening plus documented TB screening within one year of arrival may be accepted for intake screening purposes. Detainees with symptoms suggestive of pulmonary TB disease and/or with suspected or confirmed TB disease based on historical, clinical and/or laboratory findings will be housed in an airborne infection isolation room with negative pressure ventilation and promptly evaluated for TB disease.

Detainees with suspected pulmonary TB disease will remain in airborne infection isolation until determined by a health care practitioner to be noncontagious in accordance with CDC guidelines. All detainees with suspected or confirmed TB disease shall be evaluated for human immunodeficiency virus (HIV), and all detainees with HIV shall be evaluated for TB disease, which includes a chest x- ray. The CMA will consult with the local or state TB program on all aspects of health and public health care for detainees with suspected or confirmed TB disease, including testing, treatment, release from isolation, placement in general population, and public health actions. 2.

Infectious and Communicable Diseases The facility will have written plans that address the management of infectious and communicable diseases, including, but not limited to, testing, isolation, prevention, and education. This also includes reporting and collaboration with local or state health departments in accordance with state and local laws and recommendations. E. Comprehensive Health Assessment The facility will conduct and document a comprehensive health assessment, including a physical examination and mental health screening, on each detainee within 14 days of the detainee’s arrival at the facility. Health assessments shall be performed by a physician, physician assistant, nurse practitioner, registered nurse (RN) (with documented initial and annual training provided by a physician), or other health care practitioner, as permitted by law.

When a physical examination is not conducted by a provider, it must be reviewed by a provider. If there is documented evidence of a comprehensive health assessment within the previous 90 days, the health care practitioner may determine that a new assessment is not required. F. Substance Dependence and Detoxification During the initial screening, all detainees shall be evaluated for their use of or dependence on mood and mind-altering substances including alcohol, opiates, hypnotics, and sedatives. 4.3 Medical Care 114 National Detention Standards Revised 2019 Detainees reporting the use of such substances shall be evaluated for their degree of reliance and potential for withdrawal.

The CMA shall establish guidelines for evaluation and treatment of new arrivals who require detoxification. If females are housed at the facility, guidelines will specifically address the treatment of pregnant women who are chemically dependent. Treatment and supportive measures shall be provided to permit withdrawal with minimal discomfort. Where a detainee requires hospitalization, a physician’s order will be obtained and ICE/ERO shall be notified.

Detainees experiencing severe or life-threatening alcohol or drug withdrawal shall be immediately transferred to an emergency department for evaluation. Once evaluated, the detainee will be treated on-site if the facility is qualified to provide treatment and monitoring for withdrawal or transferred to an appropriate facility. G. Translation, Interpretation, and Language Access for Detainees with Limited English Proficiency Facilities shall provide appropriate interpretation and language services for LEP detainees related to medical and mental health care. When appropriate staff interpretation is not available, facilities will make use of professional interpretation services.

Detainees shall not be used for interpretation services during any medical or mental health service. Interpretation and translation services by other detainees shall only be used in an emergency medical situation. H. Dental Treatment An initial dental screening exam shall be performed within 14 days of the detainee’s arrival. If no on-site dentist is available, the initial dental screening may be performed by a physician, physician assistant, nurse practitioner, or registered nurse.

Such non-dental clinicians shall be trained annually on how to conduct the exam by a dentist. Detainees shall be afforded only authorized dental treatment, defined as follows: 1. Emergency dental treatment shall be provided for immediate relief of pain, trauma, and acute oral infection. 2.

Routine dental treatment may be provided to detainees for whom dental treatment is inaccessible for prolonged periods because of detention for over six months. Routine dental treatment includes amalgam and composite restorations, prophylaxis, root canals, extractions, x-rays, the repair and adjustment of prosthetic appliances, and other procedures required to maintain the detainee’s health. I. Sick Call The facility will have regularly scheduled times, in accordance with facility policy, when medical personnel are available to see detainees who have requested medical services, commonly known as sick call. 4.3 Medical Care 115 National Detention Standards Revised 2019 The facility will have a mechanism that allows detainees the opportunity to privately request health care services (including mental health and dental services) provided by a physician or other health care practitioner in a clinical setting.

If necessary, detainees shall be provided assistance in filling out the request, especially detainees with a disability, or who are illiterate or LEP. The facility shall have procedures to ensure that all request slips are received and triaged by the medical staff within 24 hours of receipt of the request. Request slips shall be provided in English and Spanish, at a minimum. A health care practitioner will review the request and determine when the detainee will be seen based on the acuity of the problem and within a reasonable period of time.

All detainees, including those in Special Management Units, regardless of classification, will have access to sick call. J. 24-Hour Emergency Medical and Mental Health Treatment The facility will have a written plan for the delivery of 24-hour emergency medical and mental health care when no medical personnel are on duty at the facility, or when immediate outside medical attention is otherwise required. K. First Aid and Medical Emergencies The CMA will determine the availability and placement of first aid kits. Detention staff and health care staff will be trained to respond to health-related emergencies within a 4-minute response time.

This training will be provided by a responsible medical authority in cooperation with the facility and will include the following: a. The recognition of signs of potential health emergencies and the required response; b. The administration of first aid and cardiopulmonary resuscitation (CPR); c. The recognition of signs and symptoms of mental illness; and d. The facility’s established plan and procedures for providing emergency medical care including, when required, the safe and secure transfer of detainees for appropriate hospital or other medical services. If a detainee requires emergency medical care, the first responding officer will immediately take steps to contact a health care practitioner through established procedures. 4.3 Medical Care 116 National Detention Standards Revised 2019 L. Delivery of Medication Medication will be distributed according to the specific instructions and procedures established by the health care provider. Health care providers and officers shall keep written records of all medication given to (or refused by) detainees.

Medication will not be delivered or administered by detainees. In facilities that are medically staffed 24 hours a day, a health care practitioner will distribute medication. In facilities that are not medically staffed 24 hours a day, medication may be distributed, consistent with state law and/or regulations, by detention officers who have received proper training, but only when medication must be delivered at a specific time when medical staff is not on duty. Distribution of medication by non-medical staff will be according to the specific instructions and procedures established by the CMA.

M. Special Needs The facility will notify ICE/ERO of any detainee who requires close medical supervision, including chronic and convalescent care. The facility shall develop a written treatment plan, including access to health care and other treatment, and coordination with non- medical personnel as necessary. The facility will notify ICE/ERO of any self-identified transgender detainees and coordinate care with ICE/ERO based on medical needs. N. Bloodborne Pathogens See also Standard 1.1 “Environmental Health and Safety” for additional information.

Information regarding infectious diseases shall be communicated on a regular basis to non- medical and medical staff, as well as detainees. Detainees exposed to potentially infectious bodily fluids (e.g., through needle sticks or bites) shall be afforded immediate medical assistance, and the incident shall be reported as soon as possible to the clinical director or designee and documented in the detainee’s medical file. All detainees shall be assumed to be infectious for bloodborne pathogens, and standard precautions are to be used at all times when caring for all detainees. The facility shall establish a written plan to address exposure to bloodborne pathogens and post-exposure intervention, including prophylactic administration of medication, as appropriate and according to facility policies; the management of hepatitis A, B, and C; and the management of HIV infection, including reporting.

1. Hepatitis A detainee may request hepatitis testing at any time. 4.3 Medical Care 117 National Detention Standards Revised 2019 2. HIV A detainee may request HIV testing at any time.

Facilities shall develop a written plan to ensure the highest degree of confidentiality regarding HIV status. Staff training shall emphasize the need for confidentiality, and procedures shall be established to limit access to health records to only authorized individuals and only when necessary. The accurate diagnosis and medical management of HIV infection among detainees is important. An HIV diagnosis may be made only by a qualified health care practitioner, based on a medical history, current clinical evaluation of signs and symptoms, and laboratory studies.

3. Clinical Evaluation and Management Medical personnel shall provide all detainees diagnosed with HIV or acquired immunodeficiency syndrome (AIDS) appropriate medical care consistent with national recommendations and guidelines disseminated through the U.S. Department of Health and Human Services agencies, including the CDC, and the Infectious Diseases Society of America. Medical and pharmacy personnel shall ensure that all Food and Drug Administration (FDA) approved medications currently approved for the treatment of HIV/AIDS are accessible. Medical and pharmacy personnel shall develop and implement distribution procedures to ensure timely and confidential access to medications.

Any detainee with confirmed or suspected TB disease shall also be evaluated for possible HIV infection, and any detainee with HIV shall be evaluated for TB disease. Medical and pharmacy personnel shall ensure the facility maintains access to adequate supplies of FDA-approved medications for the treatment of HIV/AIDS to ensure that newly admitted detainees are able to continue with their treatment without interruption. Upon release, detainees currently receiving anti-HIV therapy and other drugs shall receive up to a 30-day supply of their medications as medically appropriate. When current symptoms suggest HIV infection, the following procedures shall be implemented. a. Clinical evaluation shall determine the medical need for isolation, but HIV infection cannot be the sole reason for isolation.

Segregation of HIV-positive detainees is not necessary for public health purposes. Detainees with HIV shall not be separated from the general population, either pending a test result or after a test report, unless clinical evaluation reveals a medical need for isolation. b. Following a clinical evaluation, if a detainee manifests symptoms requiring treatment beyond the facility’s capability, a qualified health care practitioner shall recommend the detainee’s transfer to a local hospital or other appropriate facility 4.3 Medical Care 118 National Detention Standards Revised 2019 for further medical testing, final diagnosis, and acute treatment, as needed, and consistent with local and national standards. c. New HIV-positive diagnoses must be reported to government bodies according to state and local laws and requirements; the HSA is responsible for ensuring that all applicable state requirements are met. O. Informed Consent The facility health care practitioner will obtain specific signed and dated consent forms from all detainees before any medical examination or treatment, except in emergency circumstances. Prior to the administration of psychotropic medications, a separate documented informed consent, that includes a description of the medications side effects, shall be obtained.

As a rule, medical treatment shall not be administered against the detainee’s will. If a detainee refuses treatment, ICE/ERO will be consulted in determining whether forced treatment will be administered, unless the situation is an emergency. In emergency situations or those that place other detainees or staff at risk of exposure to infectious agents, the facility shall take appropriate emergency measures and notify ICE/ERO as soon as possible. If the detainee refuses to consent to treatment, medical staff will explain the medical risks to the detainee of declining treatment and make reasonable efforts to convince the detainee to voluntarily accept treatment in a language or manner that the detainee understands.

Medical staff will document their treatment efforts and the refusal of treatment in the detainee’s medical record. A detainee refusing examination or treatment may be segregated from the general population when recommended by the medical staff. Forced treatment is prohibited unless there is a valid court order authorizing involuntary medical treatment. P. Confidentiality and Release of Medical Records All medical personnel, and in particular those who have access to medical records, shall protect the privacy of detainees’ medical information to the maximum extent possible while permitting the exchange of health information required to fulfill program responsibilities and to provide for the well-being of detainees.

Detainees and their representatives shall be allowed to request and receive medical records pursuant to facility policy, which shall be communicated to the detainee in the facility handbook. Detainees and their representatives may also request medical records through the detainee’s designated ICE officer or the ICE Freedom of Information Act (FOIA) process as described in the National Detainee Handbook. Detainees who indicate that they wish to obtain copies of their medical records shall be provided with any appropriate forms. The facility will provide the detainee with assistance 4.3 Medical Care 119 National Detention Standards Revised 2019 in making the written request (if needed) and will assist in transmitting the request to the appropriate office or person.

Following the release of health information, the written authorization shall be retained in the health record, and a copy placed in the detainee’s detention file or maintained in a retrievable electronic format.

Q. Transfer and Release of Detainees 1.

Medical/Psychiatric Alert When a health care practitioner determines that a detainee’s medical or psychiatric condition requires either clearance by the medical staff prior to release or transfer to another facility, or requires medical escort during removal or transfer, the facility shall notify ICE/ERO in writing. 2. Notification of Transfers, Releases, and Removals Medical personnel will be given advance notice prior to the release, transfer, or removal of a detainee, so that they may provide for any medical needs associated with the transfer or release. 3.

Transfer of Medical Information a. When a detainee is transferred to another detention facility, the sending facility shall ensure that a medical transfer summary accompanies the detainee. Upon request of the receiving facility, the sending facility shall transmit a copy of the full medical record within five business days or sooner if determined by the receiving facility to be a medically urgent matter. b. Upon removal or release from ICE/ERO custody, the detainee shall be provided medication (in quantities specified below), referrals to community-based providers as medically appropriate, and a detailed medical care summary. This summary should include instructions that the detainee can understand and health history that would be meaningful to future medical providers. The summary shall include, at a minimum, the following items: 1) Patient identification; 2) Tuberculosis (TB) screening results (including results date) and current TB status if TB disease is suspected or confirmed; 3) Current mental, dental, and physical health status, including all significant health issues, and highlighting any potential unstable issues or conditions which require urgent follow-up; 4.3 Medical Care 120 National Detention Standards Revised 2019 4) Current medications, with instructions for dose, frequency, etc., with specific instructions for medications that must be administered en route; 5) Any past hospitalizations or major surgical procedures; 6) Recent test results, as appropriate; 7) Known allergies; 8) Any pending medical or mental health evaluations, tests, procedures, or treatments for a serious medical condition scheduled for the detainee at the sending facility.

In the case of patients with communicable disease and/or other serious medical needs, detainees being released from ICE/ERO custody are given a list of community resources, at a minimum; 9) Copies of any relevant documents as appropriate; 10) Printed instructions on how to obtain the complete medical record; and 11) The name and contact information of the transferring medical official. 4. Medications The facility shall ensure that, at a minimum, a seven-day supply of medication (or, in the case of TB medications, 15 days; and in the case of HIV/AIDS medications, 30 days) accompanies the detainee upon transfer from the facility, as ordered by the prescribing authority. Upon removal or release from ICE custody, the detainee shall receive up to a 30-day supply of medication as ordered by the prescribing authority and a medical care summary.

If a detainee is on prescribed narcotics, the clinical health authority shall make a determination regarding continuation, based on assessment of the detainee. R. Medical Experimentation and Research Detainees shall not be used in any medical, pharmaceutical, or cosmetic experiments or research. This will not preclude an individual detainee from receiving a medical treatment or procedure not generally available, but determined medically necessary by the CMA, such as medications and clinical trials. The administration of such investigational therapies shall follow relevant FDA or other national protocols and will be administered only with written consent from the detainee, which should be retained in the detainee’s medical record.

The facility shall notify ICE/ERO of all such situations. 4.3 Medical Care 121 National Detention Standards Revised 2019 S. Mental Health Program 1. Details The facility shall have a mental health program, approved by the appropriate medical authority, that provides: a. Assistance with intake screening for mental health concerns; b. Referral as needed for evaluation, diagnosis, treatment and monitoring of mental illness by a qualified mental health care provider; c. Sufficient capacity to provide crisis intervention and management of acute mental health episodes; d. Transfer to licensed mental health facilities of detainees whose mental health needs exceed the capabilities of the facility; and e. Professional consultation for and assistance with the suicide prevention program. 2.

Referrals and Treatment Based on the intake screening, the comprehensive health assessment, medical documentation, or subsequent observations by detention staff or medical personnel, a detainee may be referred for mental health treatment or evaluation. Any detainee referred for mental health treatment shall be triaged for any emergency needs and receive an evaluation by a qualified mental health provider no later than seven days after the referral. The provider shall develop an overall treatment/management plan. If the detainee’s mental illness or developmental or intellectual disability needs exceed the treatment capability of the facility, a referral for an outside mental health facility shall be initiated and the facility shall notify ICE/ERO in a timely manner.

Any detainee prescribed psychiatric medications must be regularly evaluated by a duly licensed and appropriate medical professional to ensure proper treatment and dosage. 3. Involuntary Administration of Psychotropic Medication Involuntary administration of psychotropic medication to detainees shall comply with established guidelines and applicable laws, and shall be performed only pursuant to the specific, written, and detailed authorization of a physician. Absent a declared medical emergency, before psychotropic medication is involuntarily administered, the HSA shall contact ICE/ERO to facilitate a request for a court order.

4. Serious Mental Illness The following non-exhaustive categories of conditions should be considered to constitute a serious mental illness: 4.3 Medical Care 122 National Detention Standards Revised 2019 a. conditions that a qualified medical provider has determined to meet the criteria for a “serious mental disorder or condition” pursuant to applicable ICE policies, including: 1) A mental disorder that is causing serious limitations in communication, memory, or general mental and/or (e.g., communicating, conducting activities of daily life, social skills); or a severe medical condition(s) (e.g., traumatic brain injury or dementia) that is significantly impairing mental function; or functioning intellectual 2) One or more of the following active psychiatric symptoms and/or behaviors: severe disorganization, active hallucinations or delusions, mania, catatonia, severe depressive symptoms, suicidal ideation and/or behavior, marked anxiety or impulsivity; or 3) Significant symptoms of one of the following: i. Psychosis or Psychotic Disorder; ii. Bipolar Disorder; iii. Schizophrenia or Schizoaffective Disorder; iv.

Major Depressive Disorder with Psychotic Features; v. Dementia and/or a Neurocognitive Disorder; or vi. Intellectual Development Disorder (moderate, severe, or profound); 4) Any ongoing or recurrent conditions that have required a recent or prolonged hospitalization, typically for greater than 14 days, or a recent and prolonged stay in the medical clinic of a detention or correctional facility, typically for greater than 30 days; 5) Any condition that would preclude the detainee from being housed, typically for greater than 30 days, in a non-restrictive setting (such as a general population housing unit, as opposed to a special management unit or a medical clinic); and 6) Any other mental illness determined to be serious by IHSC. T. Referrals for Sexual Abuse Victims or Abusers If any security or medical intake screening or classification assessment indicates that a detainee has experienced prior sexual victimization or perpetrated sexual abuse, staff shall, as appropriate, ensure that the detainee is immediately referred to a qualified medical 4.3 Medical Care 123 National Detention Standards Revised 2019 practitioner or mental health provider for a medical and/or mental health evaluation and follow-up as appropriate. When a referral for medical follow-up is initiated, the detainee shall receive a health evaluation no later than two working days from the date of assessment.

When a referral for mental health follow-up is initiated, the detainee shall receive a mental health evaluation no later than 72 hours after the referral. For the purposes of this section, a “qualified medical practitioner” or “qualified mental health practitioner” means a health or mental health professional, respectively, who in addition to being qualified to evaluate and care for patients within the scope of his or her professional practice, has successfully completed specialized training for treating sexual abuse victims. U. Women’s Medical Care Female detainees shall receive routine, age appropriate gynecological and obstetrical health care, consistent with recognized community and clinical guidelines for women’s health services. 1.

Initial Assessment All initial health assessments of female detainees shall be conducted by a qualified health care practitioner. In addition to the criteria listed on the health assessment form, the evaluation shall inquire about and perform the following: a. Pregnancy test for detainees aged 18-56 and deliver to the detainee and document the results; b. If the detainee is currently nursing (breastfeeding); c. Use of contraception; d. Reproductive history (number of pregnancies, number of live births, number of spontaneous/elective abortions, pregnancy complications, etc.); e. Menstrual cycle; f. History of breast and gynecological problems; g. Family history of breast and gynecological problems; and h. Any history of physical or sexual victimization and when the incident occurred. 4.3 Medical Care 124 National Detention Standards Revised 2019 A pelvic and breast examination, pap test, baseline mammography and sexually transmitted disease (STD) testing shall be offered and provided as deemed appropriate or necessary by a health care practitioner. 2.

Preventive Services Contraception Upon request, appropriately trained medical personnel within their scope of practice shall provide detainees with non-directive (impartial) advice and consultation about family planning and contraception, and where medically appropriate, prescribe and dispense medical contraception. 3. Pregnancy Upon confirmation by health care practitioner that a detainee is pregnant, the detainee shall be provided close medical supervision. Pregnant detainees shall have access to prenatal and specialized care, and comprehensive counseling on topics including, but not limited to, nutrition, exercise, complications of pregnancy, prenatal vitamins, labor and delivery, postpartum care, lactation, family planning, abortion services and parenting skills.

The facility administrator shall ensure that ICE/ERO is notified as soon as practicable of any pregnant detainee, but no later than 72 hours after such determination. A health care practitioner will identify any special needs (e.g., diet, housing, and other accommodations such as the provision of additional pillows) and inform all necessary security staff and facility authorities. If a pregnant detainee has been identified as high risk, the detainee shall be referred to a physician specializing in high risk pregnancies. All chemically dependent pregnant detainees (e.g., detainees dependent on substances including alcohol, sedatives/hypnotics, anxiolytics, and opioids) are considered high risk and referred to qualified physician capable of addressing their needs immediately. a. Abortion Access In the event continued detention is necessary and appropriate, and consistent with the practice of ICE/ERO’s federal partners, if the life of the mother would be endangered by carrying a fetus to term, or in the case of rape or incest, ICE/ERO will assume the costs associated with a female detainee’s decision to terminate a pregnancy.

1) In this instance, or in a situation where a female detainee opts to fund the termination of her pregnancy, ICE/ERO will arrange for transportation at no cost to the detainee for the medical appointment and, if requested by the detainee, for access to religious counseling, and non-directive (impartial) 4.3 Medical Care 125 National Detention Standards Revised 2019 medical resources and social counseling, to include outside social services or women’s community resources groups. 2) If a detainee requests to terminate her pregnancy, it will be documented in the detainee’s medical records. The detainee’s statement should be signed personally by the detainee and include clear language of the detainee’s intent. 4.3 Medical Care 126 National Detention Standards Revised 2019