DHS OIG, OIG-25-24, Results of an Unannounced Inspection of ICE's Buffalo Federal Detention Facility in Batavia, New York (2025)

OIG-25-24 FINAL REPORT June 3, 2025 Results of an Unannounced Inspection of ICE's Buffalo Federal Detention Facility in Batavia, New York OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Washington, DC 20528 | www.oig.dhs.gov June 3, 2025 MEMORANDUM FOR: Todd M. Lyons Acting Director FROM: SUBJECT: U.S. Immigration and Customs Enforcement Joseph V. Cuffari, Ph.D. Inspector General JOSEPH V CUFFARI Digitally signed by JOSEPH V CUFFARI Date: 2025.06.03 08:36:52 -04'00' Results of an Unannounced Inspection of ICE’s Buffalo Federal Detention Facility in Batavia, New York Attached for your action is our final report, Results of an Unannounced Inspection of ICE’s Buffalo Federal Detention Facility in Batavia, New York. We incorporated the formal comments provided by your office. The report contains 10 recommendations aimed at improving care of detainees at Buffalo. Your office concurred with all 10 recommendations.

Based on information provided in your response to the draft report, we consider recommendations 1 through 6, 9, and 10 resolved and open. We consider recommendations 7 and 8 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 Buffalo Federal Detention Facility in Batavia, New York June 3, 2025 Why We Did This Inspection In accordance with the Department of Homeland Security Appropriations Act, 2024 (Pub. L. 118-47), we conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards. From September 10 to 12, 2024, we conducted an in- person, unannounced inspection of Buffalo to evaluate its compliance with these standards. What We Recommend We made 10 recommendations to improve ICE’s oversight of detention facility management and operations at Buffalo.

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) Buffalo Federal Detention Facility (Buffalo) in Batavia, New York, we found that Buffalo’s staff generally complied with Performance-Based National Detention Standards 2011, as revised in December 2016, for facility conditions, kitchen standards, legal access, medical care, recreation (general population only), and the voluntary work program. However, facility and ICE staff did not fully comply with standards related to the use of force, staff-detainee communication, detainee grievances, recreation in the Special Management Unit (SMU), classification, admission and release, and medical unit staffing. • • We found one instance of an inappropriate use of force and two instances where facility staff should have used calculated rather than immediate force. ICE did not always provide timely responses to detainee requests.

Facility staff did not maintain an accurate or complete log for paper requests, nor did they always provide responses to detainee grievances within the required 5 days or capture all response dates in the grievance log. Likewise, the Grievance Appeal Board did not always conduct reviews within 5 days of each appeal. • Buffalo facility staff did not provide detainees in the SMU with exercise equipment in the outdoor space, prevent detainees of different classification levels from comingling in the same holding area, ensure detainees could hear or view captions for the orientation video, or ensure detainees’ identification wristbands were legible and always worn. • Vacant dentist and physician positions caused delays in care. ICE’s Response ICE concurred with all 10 report recommendations. We consider two recommendations resolved and closed, and eight recommendations resolved and open. www.oig.dhs.gov OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Table of Contents Background ..........................................................................................................................................

1 Results of Inspection ............................................................................................................................ 2 Facility Staff Generally Complied with Standards for Cleanliness and Sanitation, Food Service, Legal Access, Medical Care, Recreation (General Population), and the Voluntary Work Program .......................................................................................................................... 3 Facility Staff Did Not Comply with All Elements of the Use of Force Standard ..................... 4 ICE Staff Did Not Comply with All Staff-Detainee Communication Practices .......................

6 Facility Staff Did Not Comply with All Grievance Standard Requirements ........................... 7 Facility Staff Did Not Provide Detainees in the SMU Outdoor Recreation Equipment ......... 7 Buffalo Allowed Low and High Custody Detainees to Comingle in Common Areas ............. 8 Facility Staff Did Not Comply with All Admission Requirements ...........................................

9 The Facility Had Several Medical Staffing Vacancies ............................................................ 11 Recommendations ............................................................................................................................. 11 Management Comments and OIG Analysis ....................................................................................... 12 Appendix A: Objective, Scope, and Methodology .............................................................................

15 DHS OIG’s Access to DHS Information ................................................................................... 16 Appendix B: ICE Comments on the Draft Report .............................................................................. 17 Appendix C: Report Distribution ........................................................................................................ 24 Abbreviations Buffalo Federal Detention Facility U.S. Immigration and Customs Enforcement Buffalo ICE PBNDS 2011 Performance-Based National Detention Standards 2011 SMU Special Management Unit www.oig.dhs.gov OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Background U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 107 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. Facilities that house ICE detainees must adhere to applicable detention standards, which include the Performance-Based National Detention Standards 2011 (PBNDS 2011), as revised in 2016. As mandated by Congress,1 the Department of Homeland Security Office of Inspector General conducts unannounced inspections of ICE detention facilities to ensure compliance with detention standards. ICE houses detainees at the Buffalo Federal Detention Facility (Buffalo) in Batavia, New York.

ICE owns the facility and provides on-site management. At the start of our inspection, Buffalo housed 535 male detainees classified as low to high custody.2 ICE contracts with Akima Global Services (facility staff) to provide security and food services at the facility, East Company and Chenega to provide janitorial services, and Jesuit Refugee Service USA to provide religious services. ICE Health Service Corps provides medical services. Our team of inspectors and contracted medical professionals toured and inspected areas of the facility, including the general housing units, kitchen, law library, Special Management Unit (SMU),3 recreation facilities, and medical unit.

We also collected and analyzed documentation related to detainee requests and grievances, detention files, and SMU records. The contracted medical professionals’ inspection included a visual inspection of all areas where medical staff provide health services, reviews of relevant documents and health records, and interviews with key health services team members. 1 Joint Explanatory Statement Accompanying H.R. 2882, Further Consolidated Appropriations Act, 2024, Div. C, Department of Homeland Security Appropriations Act, 2024 (Pub.

L. 118-47).

2 PBNDS 2011 (Revised 2016) requires ICE to use a classification process for managing and separating detainees by threat risk and special vulnerabilities or special management concerns that is based on verifiable and documented data. For example, detainees classified as low may have no or only minor criminal histories, or nonviolent felony charges. This classification may not include any detainee arrested or convicted of physical violence, or with a history of assaultive behavior. In contrast, a detainee classified as medium-high or high has a history of violent or assaultive charges, convictions, institutional misconduct, or gang affiliation.

3 The Special Management Unit (SMU), also referred to as segregation, is used to separate certain detainees from the general population for disciplinary or administrative reasons. Each detainee in SMU shall receive (or be offered) access to exercise opportunities and equipment outside the living area and outdoors, usually for 1 hour a day. www.oig.dhs.gov 1 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Results of Inspection During our unannounced inspection of Buffalo, we found that facility staff generally complied with inspected PBNDS 2011 standards for facility conditions, kitchen standards, legal access, medical care, recreation (general population), and the voluntary work program. Table 1 summarizes areas where facility and ICE staff did not fully comply with PBNDS 2011, which could negatively affect the health, safety, and rights of detainees. Table 1.

Areas of non-Compliance: ICE’s Buffalo Federal Detention Facility in Batavia, New York Standard Use of Force Staff-Detainee Communication Non-Compliance Facility Staff Did Not Comply with All Elements of the Use of Force Standard • One incident involved a detention officer’s inappropriate use of force. • Facility staff in two incidents inappropriately used immediate force instead of calculated force. ICE Staff Did Not Comply with All Staff-Detainee Communication Practices ICE did not always respond to detainee requests within the required 3 business days. • • Facility staff did not maintain an accurate log for paper requests; the log they maintained did not contain all required information. Facility Staff Did Not Comply with All Grievance Standard Requirements • Facility staff did not always respond to detainee grievances within the required 5 days. Grievance System • The facility’s grievance log did not always capture the facility’s response date. • The Grievance Appeal Board did not always conduct a review within 5 days of the appeals.

Facility Staff Did Not Provide Detainees in the SMU with Outdoor Recreation Equipment • The designated space for SMU recreation did not contain exercise Recreation (SMU) equipment. Classification Buffalo Allowed Low Custody and High Custody Detainees to Comingle in Common Areas • In one instance, facility staff allowed comingling of detainees classified as low or medium-low in a locked holding area with a detainee classified as high or medium-high. www.oig.dhs.gov 2 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Admission and Release Facility Staff Did Not Comply with All Admission and Release Requirements • Facility staff did not ensure detainees could hear or view captions for the orientation video. • Facility staff did not ensure detainee identification wristbands were legible and always worn. The Facility Had Several Medical Staffing Vacancies • The facility does not employ an on-site, full-time dentist or Staffing Vacancies in the Medical Unit physician. Source: DHS OIG analysis of key findings Facility Staff Generally Complied with Standards for Cleanliness and Sanitation, Food Service, Legal Access, Medical Care, Recreation (General Population), and the Voluntary Work Program Cleanliness and Sanitation: PBNDS 2011 expects facilities to maintain high standards of cleanliness and sanitation.4 It specifies washbasin and toilet ratios5 and regular issuance of clean clothing, linens, and personal hygiene items.6 Through observation, we determined that Buffalo generally complied with these standards.

We observed a compliant ratio of washbasins and toilets, clean laundered linens and items of clothing available in storage, and cases of new toiletry items, which staff issued upon detainee arrival. Food Service: Facility staff also complied with the PBNDS 2011 standard on food service, which ensures facilities provide detainees a nutritionally balanced diet that is prepared and presented in a sanitary and hygienic food service operation.7 We observed a clean kitchen and properly secured kitchen knives. Buffalo’s food menu consisted of at least two hot meals a day, and a registered dietician approved the religious diets. Legal Access: PBNDS 2011 also requires facilities to provide detainees with a properly equipped law library with legal materials and equipment.8 Buffalo complied with this standard by affording detainees access to a law library with legal materials, such as lists of local free legal service providers, legal articles and books, and equipment to print and photocopy documents.

Medical Care: PBNDS 2011 requires that detainees have access to appropriate and necessary medical, dental, and mental health care, including emergency services.9 Our medical contractors 4 PBNDS 2011 (Revised 2016), Standard 1.2, Environmental Health and Safety, Section I. 5 PBNDS 2011 (Revised 2016), Standard 4.5, Personal Hygiene, Section V. 6 Id. 7 PBNDS 2011 (Revised 2016), Standard 4.1, Food Service, Section I. 8 PBNDS 2011 (Revised 2016), Standard 6.3, Law Libraries and Legal Materials, Section V.A. 9 PBNDS 2011 (Revised 2016), Standard 4.3, Medical Care, Section I. www.oig.dhs.gov 3 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security conducted a visual inspection of all areas where ICE Health Service Corps staff provide services. They also reviewed a sample of health records and interviewed key health services team members. They found Buffalo medical staff managed a well-organized health care program and provided well documented, timely, and appropriate care. Although the care provided by facility medical staff complied with standards, staffing shortages caused delays in dental and off-site specialty care (see “The Facility had Several Medical Staffing Vacancies”).

Recreation: PBNDS 2011 also requires that detainees have access to exercise opportunities and equipment.10 Buffalo complied with these requirements for detainees in the general population housing units by providing books, musical instruments, televisions, and equipment for indoor exercise. Additionally, Buffalo offered detainees in the general population minimally restricted access to outdoor recreation areas/basketball courts during daylight hours. Voluntary Work Program: Buffalo complied with standards for the voluntary work program. PBNDS 2011 outlines standards for facilities to provide detainees with the opportunity to participate in voluntary work assignments to earn money.11 Based on our review of policies, procedures, records, and observations, Buffalo complied with this standard.

The facility provided program information and training to detainees who chose to participate in the voluntary work program. Detainees received payment for their hours worked and their work schedules did not exceed 8 hours per day or 40 hours per week per PBNDS 2011 requirements. Facility Staff Did Not Comply with All Elements of the Use of Force Standard PBNDS 2011 states, “[S]taff shall use only the degree of force necessary to gain control of detainees and, under specified conditions, may use physical restraints to gain control of a dangerous detainee.”12 It also prohibits staff from “[s]triking a detainee when grasping or pushing him/her would achieve the desired result […] unless both necessary and reasonable in the circumstances.”13 Based on our review of video footage and written documentation, eight use of force incidents occurred in the 6 months14 before our on-site visit. In one incident, a detention officer inappropriately used force on a detainee.

The security camera video showed officers successfully move the detainee from his cell to a shower cell by pushing and grasping him, in compliance with PBNDS 2011. However, the video then showed a detention officer strike the detainee’s back with his foot after the detainee had entered the shower cell. We consider the officer striking the detainee in the back as inappropriate use of force. 10 PBNDS 2011 (Revised 2016), Standard 5.4, Recreation, Section II.

11 PBNDS 2011 (Revised 2016), Standard 5.8, Voluntary Work Program, Section I. 12 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section I. 13 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section V.E. 14 March 2024 to September 2024. www.oig.dhs.gov 4 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security In addition, PBNDS 2011 divides use of force incidents into two categories: immediate and calculated. An immediate use of force situation occurs when a detainee’s behavior constitutes a serious and immediate threat to self or others.15 Calculated use of force is preferred to immediate use of force in most cases and appropriate if a detainee is in a location where there is no immediate threat to the detainee or others (for example, a locked cell), even if the detainee is verbalizing threats or brandishing a weapon.16 Per PBNDS 2011, calculated use of force is preferred because it affords staff time to strategize and resolve situations in the least confrontational manner, assists to de-escalate the situation, and requires an audio and visual recording of the incident.17 PBNDS 2011 also instructs team members and others participating in a calculated use of force operation to wear protective gear and designate an audiovisual camera operator who must record the entire use of force team operation, unedited, until the detainee is in restraints. The precautions required in a calculated use of force response are preferable in most cases because they likely minimize harm to both detainees and staff. Of the eight use of force incidents reviewed, the facility categorized seven as immediate uses of force and one as a calculated use of force.

Based on our review of the evidence, immediate use of force did not appear appropriate in two incidents. • • In one incident, an unspecified individual(s) tasked lieutenants with relocating eight detainees, who declared a hunger strike, from their current cells to different cells for medical observation. Security camera video and written incident reports showed one detainee refused orders to exit his cell, so the officers opened and entered his cell, forcibly placed the detainee on the floor, and applied hand restraints. The detainee, who was alone in his locked cell at the time of the incident, did not demonstrate a serious or immediate threat to himself or others. Because this detainee did not pose a threat to himself or others, officers should have followed calculated use of force procedures, including using protective gear and designating an audiovisual camera operator to record the operation.

In the second immediate use of force incident, officers used force to remove a detainee’s hand restraints. During this incident, officers sprayed the detainee with oleoresin capsicum spray (pepper spray)18 and pinned the detainee to his bunk to remove the detainee’s hand restraints. This use of force began after the detainee refused orders to come to his cell door so officers could remove his hand restraints. Since this detainee did not appear to pose a threat to himself or others, officers should have followed calculated use of force procedures, including using protective gear and designating an audiovisual camera operator to record the operation.

15 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section V.H. 16 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section V.I. 17 Id. 18 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section V.4.a. www.oig.dhs.gov 5 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security In both incidents, the facility’s written reports did not indicate the detainees posed a threat of harm to self or others. In addition, for both incidents, using calculated force instead of immediate force would have required a staff member to record (audio and video) the entire use of force team operation. However, because the officers used immediate force, we had to rely on stationary security cameras mounted in the facility with no audio capability and minimal visibility of the cell interiors to review the incidents. ICE Staff Did Not Comply with All Staff-Detainee Communication Practices PBNDS 2011 establishes procedures for contact between staff and detainees, including communication and supervisory observation of living conditions.19 These procedures require facility and ICE staff to respond to detainee requests within 3 business days of receipt.20 We reviewed all electronic requests detainees made to facility staff and ICE from May through August 2024.

These requests related to recreation, food service, religion, property, and case management. We reviewed a sample of the responses to these requests and found that facility staff generally responded within the standard time and in an appropriate manner. Although ICE staff responded appropriately to a sample of electronic detainee request responses we reviewed, they did not always provide timely responses to all requests. According to ICE’s log of electronic requests, detainees submitted 4,137 requests to ICE between May and August 2024.

Of the 4,137 electronic requests, ICE did not respond to 808 requests (20 percent) within the required 3 business days. Without timely responses from ICE, detainees may face undue delays in resolving important questions or concerns. In addition to submitting requests through the electronic tablets, detainees may also submit paper requests to facility staff. Per PBNDS 2011, facility staff must record all requests in a paper or electronic logbook.21 The facility provided a log of 77 paper requests that detainees had submitted between May and August 2024.

During our review of this log, we found facility staff did not record all required information, such as the date the facility responded to the detainees’ requests. As a result, we could not determine whether facility staff responded to the detainees within the required 3 business days. 19 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section I. 20 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section V.B.1. 21 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section V.B.2. www.oig.dhs.gov 6 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Facility Staff Did Not Comply with All Grievance Standard Requirements PBNDS 2011 requires facilities housing detainees to have a grievance submission system that protects detainees’ rights and ensures staff treat all detainees fairly.22 It also states that staff should respond to grievances within 5 days of receipt.23 Based on our review of the 368 electronically submitted grievances from March through August 2024, facility staff generally complied with this requirement.

In addition, the facility staff’s electronic responses were appropriate in the sample we reviewed. PBNDS 2011 also requires the facility to maintain a log of all grievances (submitted both electronically and by paper). The log must contain the date filed, name of detainee submitting the grievance, nature of the grievance, date decision was provided to the detainee, and the outcome of adjudication.24 Facility staff provided pictures of the paper grievance log showing approximately 136 grievances submitted between January and November 2024. However, the log was incomplete and did not include the nature of the grievance.

Therefore, we could not assess whether the facility’s response to each grievance was appropriate. We also found facility staff did not provide responses within 5 days in 14 of 136 submissions (10 percent). Finally, detainees appealed the facility’s original response to grievances 29 times from January through November 2024. In 12 of the 29 appeals (41 percent), the Grievance Appeal Board did not provide a response within 5 days.

In 7 of the 29 appeals (24 percent), after the detainee appealed the Grievance Appeal Board decision, facility management did not conduct a review and provide a response within 5 days, as PBNDS 2011 requires.25 Without timely responses from ICE, detainees may face undue delays in resolving important questions or concerns. Facility Staff Did Not Provide Detainees in the SMU Outdoor Recreation Equipment PBNDS 2011 states, each detainee in the SMU “shall receive (or be offered) access to exercise opportunities and equipment outside the living area and outdoors.”26 During our inspection of the SMU, we observed a dayroom for indoor recreation equipped with a television and a computer. However, Buffalo’s SMU outdoor space did not comply with the PBNDS 2011 recreation standard requirement for providing detainees outdoor exercise equipment. The designated space for outdoor SMU recreation consisted of a fenced-in area without exercise equipment, as seen in Figure 1.

22 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section I. 23 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section V.C.3.b. 24 Id. 25 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section V.C.3.b.2.b. and V.C.3.b.3.b. 26 PBNDS 2011 (Revised 2016), Standard 5.4, Recreation, Section II.4. www.oig.dhs.gov 7 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Figure 1. SMU Outdoor Recreation Area, Observed on September 11, 2024 Source: DHS OIG Photo Buffalo Allowed Low and High Custody Detainees to Comingle in Common Areas PBNDS 2011 requires facilities to classify and house detainees according to risk level.27 Facility staff should also complete the initial classification process and housing assignment within 12 hours of a detainee’s admission.28 Our review of 20 detainee files confirmed Buffalo staff complied with these standards. PBNDS 2011 further states that low custody detainees may not comingle with high custody detainees.29 We observed detainees classified as low (based on blue colored uniform) comingled with a detainee classified as high (based on red colored uniform) in the facility’s visitation area (see Figure 2). These detainees were in a locked room while awaiting visitation, and facility staff were not present inside the room.

PBNDS states that “[g]rouping detainees with comparable histories together and isolating those at each classification level from all others reduces non- criminal and nonviolent detainees’ exposure to physical and psychological danger.”30 Facilities should avoid comingling as it increases these risks. 27 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System, Section V and V.F. 28 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System, Section V.D. 29 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System, Section V.F.1. 30 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System, Section V.F. www.oig.dhs.gov 8 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Figure 2. Comingling of Detainees of Different Classification Levels, Observed on September 10, 2024 Source: DHS OIG Photo Facility Staff Did Not Comply with All Admission Requirements PBNDS 2011 “protects the community, detainees, staff, volunteers, and contractors by ensuring secure and orderly operations when detainees are admitted to or released from a facility.”31 Buffalo did not fully comply with requirements to provide detainees an orientation video in a language or manner detainees can understand, nor did Buffalo ensure staff could identify detainees by their facility-issued wristbands.

Facility Staff Did Not Ensure Detainees Could Understand the Orientation Video PBNDS 2011 orientation standards require the facility administrator to produce an orientation video and to screen it for every detainee. The standard specifically states the video should be “[…] in a language or manner that detainees can understand.”32 While observing an orientation video screening in the intake holding area with a single detainee present, we could not hear the video’s content and the screen did not show subtitled text. Therefore, the detainee viewing the video could neither hear nor read the video’s content. When we mentioned the lack of volume to facility staff, they adjusted the volume to an audible level.

Detainees must understand the orientation video (either audibly or through subtitles) to learn about facility operations and 31 PBNDS 2011 (Revised 2016), Standard 2.1, Admission and Release, Section I. 32 PBNDS 2011 (Revised 2016), Standard 2.1, Admission and Release, Section V.F. www.oig.dhs.gov 9 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security departments, standards of conduct, disciplinary procedures, typical detention-case timelines, and the availability of legal services. Facility Staff Did Not Ensure Detainees Wore Identification Wristbands at All Times Upon admission to Buffalo, facility staff issue each detainee a color-coded identification wristband that shows their name, alien registration number, classification level, housing pod, and bunk number.33 PBNDS 2011 states, “The wristband must remain on his/her wrist until removed by an officer.”34 We observed multiple detainees in the housing pods not wearing their wristbands (see Figure 3). Figure 3. Detainee Not Wearing Identification Wristband, Observed on September 10, 2024 Source: DHS OIG Photo In other instances, we saw wristbands that were faded in color and damaged to the point where they were unreadable.

Facility staff noted it is common for detainees to not wear their wristbands. Detainees’ wristbands should correctly identify them and their classification level and ensure that detainees are not comingled. Detainees’ removal of the wristband is a violation of standards and creates security risks for the detainee population and the facility staff. 33 Per PBNDS 2011 (Revised 2016), Standard 2.1, Admission and Release, Section V.E.i., the wristband should feature “if applicable, the detainee’s information including but not limited to the following: name and A-number; housing and bunk assignment; and the Form I-77 [Baggage Check] number.” 34 PBNDS 2011 (Revised 2016), Standard 2.1, Admission and Release, Section V.E.j. www.oig.dhs.gov 10 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security The Facility Had Several Medical Staffing Vacancies Buffalo medical staff managed a well-organized health care program and provided well documented, timely, and appropriate care.

However, staffing shortages caused delays in dental and off-site specialty care. PBNDS 2011 requires all facilities to provide medical staff and sufficient support personnel to meet the medical standards. The Medical Care standard further states that a staffing plan, which identifies the positions needed to perform the required services, shall be reviewed at least annually.35 Buffalo had medical staffing vacancies, including a permanent dentist and physician position. Without a permanent dentist at the facility, the ICE regional dentist must provide care at the facility.

The regional dentist visits approximately every 3 to 4 months. When general dentistry needs arise between the regional dentist’s visits, facility medical staff must schedule off-site dental care for detainees. The absence of a dentist at the facility on a regular basis created delays in dental care — as of September 10, 2024, there were 21 detainees scheduled for general dentistry with a wait of up to 5 months. Because of the vacant physician position, medical staff had to schedule off-site referrals for detainees’ medical needs, including specialty appointments.

As of September 10, 2024, the facility’s medical scheduler reported a backlog of 150 specialty appointments scheduled through February 2025. Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations for the Buffalo Field Office, direct Buffalo to: Recommendation 1. Ensure all facility staff respond appropriately during use of force incidents and applying adequate de-escalation techniques. Recommendation 2.

Ensure facility staff assess all response techniques prior to addressing noncompliance from a detainee when the situation does not require immediate force. Recommendation 3. Ensure ICE staff respond to all detainee requests within the required 3 business days. Recommendation 4.

Ensure facility staff respond to all detainee grievances and appeals within the required 5 days. Recommendation 5. Ensure facility staff maintain a complete log of all grievances, to include paper submissions. Recommendation 6.

Provide outdoor recreation equipment for detainees housed in the SMU. 35 PBNDS 2011 (Revised 2016), Standard 4.3, Medical Care, Section V.B. www.oig.dhs.gov 11 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Recommendation 7. Prevent the comingling of detainees of different classification levels in any area of the facility. Recommendation 8.

Ensure detainees can hear or read the contents of the orientation video in a language they understand. Recommendation 9. Ensure detainees always wear identification wristbands and that any unreadable wristbands are immediately replaced with new ones. Recommendation 10.

Ensure the facility fills medical staffing vacancies, to include a permanent dentist and physician, as soon as possible. Management Comments and OIG Analysis ICE provided written comments in response to the draft report and concurred with all 10 recommendations. Appendix B contains ICE’s management comments to the draft report in their entirety. ICE provided no technical comments on the draft report and affirmed there were no sensitivity concerns.

We consider recommendations 7 and 8 resolved and closed. We consider recommendations 1 through 6, 9, and 10 resolved and open. A summary of ICE’s response and our analysis follows. ICE Response to Recommendation 1: Concur.

The facility has updated its Use of Force policy and provides annual refresher training on de-escalation tactics. OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open. ICE provided the facility’s updated Use of Force policy, the annual training curriculum (including de-escalation techniques), and an example sign-in-sheet from the annual training. The refresher training sign-in-sheet ICE provided is dated 2024.

We will close this recommendation when ICE provides the most recent sign-in-sheet for this training. ICE Response to Recommendation 2: Concur. The facility has updated its Use of Force policy, which now requires video recording when de-escalation techniques include verbal commands by a supervisor. They also noted the facility provides annual refresher training on de-escalation tactics.

OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open. ICE provided the facility’s updated Use of Force policy, the annual training curriculum (including de-escalation techniques), and an example sign-in-sheet from the annual training. www.oig.dhs.gov 12 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security The refresher training sign-in-sheet ICE provided is dated 2024. We will close this recommendation when ICE provides the most recent sign-in-sheet for this training. ICE Response to Recommendation 3: Concur.

The facility issued a memorandum to staff requiring a daily check of the request system to identify any outstanding requests, grievances, or messages. OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open. ICE provided a copy of the memorandum from the facility to staff. We will close this recommendation when ICE provides evidence that the facility is responding to detainee requests within 3 business days.

ICE Response to Recommendation 4: Concur. The facility issued a memorandum to staff requiring a daily check of the request system to identify any outstanding requests, grievances, or messages. OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open. ICE provided a copy of the memorandum from the facility to staff.

We will close this recommendation when ICE provides evidence that the facility is responding to detainee grievances and appeals within 5 days. ICE Response to Recommendation 5: Concur. The facility has implemented a process requiring staff to maintain a written log of all paper grievances. OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open.

We will close this recommendation when ICE provides evidence of the policy and a current log of paper and electronic grievances. ICE Response to Recommendation 6: Concur. The facility provides handballs, basketballs, and soccer balls during recreation time to detainees in the SMU, if requested. OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open.

We will close this recommendation when ICE provides evidence that the facility provides this equipment for detainees in the SMU. ICE Response to Recommendation 7: Concur. The facility issued a memorandum to staff instructing no comingling of detainees of different classification levels anywhere in the facility. OIG Analysis: We consider this responsive to the recommendation, which is resolved and closed.

ICE provided a copy of the memorandum, which satisfies the full intent of the recommendation. www.oig.dhs.gov 13 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security ICE Response to Recommendation 8: Concur. The facility purchased speakers for the intake processing area where the orientation video is played. OIG Analysis: We consider this responsive to the recommendation, which is resolved and closed. ICE provided pictures of the installed speakers, which satisfies the full intent of the recommendation.

ICE Response to Recommendation 9: Concur. The facility’s Handbook requires detainees to wear their wristbands at all times and staff to send detainees for replacement wristbands when their current wristbands become unreadable. OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open. ICE provided a copy of the memorandum from the facility to staff, which discusses the Facility Handbook requirements and the posted Housing Unit Guidelines.

We will close this recommendation when ICE provides a copy of the posted Housing Unit Guidelines. ICE Response to Recommendation 10: Concur. The facility is actively recruiting for a physician and dentist, and in September 2024, awarded a contract to provide additional medical staffing. ICE estimates completion of this recommendation on March 31, 2026.

OIG Analysis: We consider this partially responsive to the recommendation, which is resolved and open. ICE provided a contract with a medical provider to reduce medical staffing vacancies. We will close this recommendation when ICE provides evidence that Buffalo has filled the physician and dentist vacancies. www.oig.dhs.gov 14 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix A: Objective, Scope, and Methodology The Homeland Security Act of 2002 (Pub. L. No. 107−296) by amendment to the Inspector General Act of 1978 established the DHS OIG.

As mandated by Congress,36 we 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, 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. Our objective was to determine whether Buffalo complied with select standards outlined in PBNDS 2011 and the National Commission on Correctional Health Care’s Standards for Health Services in Jails (2018). 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, 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.

Before our inspection, we reviewed relevant background information for Buffalo, including: • OIG Hotline complaints; • PBNDS 2011; • • ICE Office of Detention Oversight reports and other inspection reports; and information from nongovernmental organizations. 36 Joint Explanatory Statement Accompanying H.R. 2882, Further Consolidated Appropriations Act, 2024, Div. C, Department of Homeland Security Appropriations Act, 2024 (Pub. L. 118-47). www.oig.dhs.gov 15 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security From September 10 to 12, 2024, we conducted an unannounced, in-person inspection of Buffalo.

During our inspection, we: • • • • • inspected areas detainees used; reviewed the facility’s compliance with key health, safety, and welfare requirements; interviewed ICE and detention facility staff; interviewed detainees; and reviewed documentary evidence, including medical files (reviewed by medical contractors), grievances, and communication logs and files. We conducted this inspection under the authority of the Inspector General Act of 1978, 5 U.S.C. §§ 401–424, and according to the Quality Standards for Inspection and Evaluation, 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 16 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix B: ICE Comments on the Draft Report www.oig.dhs.gov 17 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 18 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 19 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 20 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 21 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 22 OIG-25-24 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 23 OIG-25-24 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 24 OIG-25-24 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