DHS OIG, OIG-24-21, Results of an Unannounced Inspection of ICE's Krome North Service Processing Center in Miami, Florida (2024)

OIG-24-21 FINAL REPORT April 16, 2024 Results of an Unannounced Inspection of ICE's Krome North Service Processing Center in Miami, Florida OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Washington, DC 20528 | www.oig.dhs.gov April 16, 2024 MEMORANDUM FOR: Patrick J. Lechleitner Senior Official Performing the Duties of the Director U.S. Immigration and Customs and Enforcement FROM: SUBJECT: Joseph V. Cuffari, Ph.D. Inspector General J OSEPH V C UFFARI Results of an Unannounced Inspection of ICE's Krome North Service Processing Center in Miami, Florida Digitally signed by JOSEPH V CUFFARI Date: 2024.04.16 10:24:40 -07'00' Attached for your action is our final report, Results of an Unannounced Inspection of ICE's Krome North Service Processing Center in Miami, Florida. We incorporated the formal comments provided by your office. The report contains eight recommendations aimed at improving care of detainees at Krome North Service Processing Center. Your office concurred with seven recommendations and did not concur with one.

Based on information provided in your response to the draft report, we consider recommendations 2 and 6 resolved and open, recommendations 1 and 7 are resolved and closed, recommendation 8 is open and unresolved. 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 for the Office of Inspections and Evaluations, at (202) 981-6000. Attachment OIG Project No. 23-001-ISP-ICE(d) DHS OIG HIGHLIGHTS Results of an Unannounced Inspection of ICE’s Krome North Service Processing Center in Miami, Florida April 16, 2024 What We Found Why We Did This Inspection In accordance with the Consolidated Appropriations Act, 2023, we conduct unannounced inspections of U.S. Immigration and Customs Enforcement (ICE) detention facilities to ensure compliance with detention standards.

From June 13 to 15, 2023, we conducted an in-person, unannounced inspection of Krome in Miami, Florida, to evaluate their compliance with ICE detention standards. What We Recommend During our unannounced inspection of Krome North Service Processing Center (Krome) in Miami, Florida, we found that Krome’s staff complied with Performance-Based National Detention Standards 2011, as revised in December 2016, for classification, voluntary work program, recreation, facility conditions, and non-medical grievances. However, they did not comply with use of force standards for several incidents. Additionally, while Krome’s medical staff generally provided care in a timely and appropriate manner and complied with standards for program administration, peer review, pharmacy management, initial and periodic health assessments, emergency care, special needs, and specialty care, our contracted medical professionals found several areas of concern related to sick calls, staffing vacancies, and submission of medical grievances.

The process for detainees to submit medical grievances was unclear and contradictory. Additionally, the facility did not always provide detainees with writing instruments or paper grievance forms, and one version of Krome’s paper grievance form imposed non-compliant reporting standards. Further, Krome’s medical staff did not always respond to grievances or place copies of medical grievances in detainees’ medical files or maintain an accurate log of medical grievances. We made eight recommendations to improve ICE’s oversight of detention facility management and operations at Krome.

Lastly, Krome’s staff did not comply with all standards for access to legal resources or special management units, facility intake forms did not accurately account for items assigned to detainees, and facility staff did not place copies of electronic requests into detainees’ records. For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at: DHS- [email protected]. ICE Response ICE concurred with seven recommendations and did not concur with one. We consider one recommendation unresolved and open, five recommendations resolved and open, and two recommendations resolved and closed. www.oig.dhs.gov OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Table of Contents Background ..........................................................................................................................................

1 Results of Inspection ............................................................................................................................ 2 Krome’s Staff Complied with Standards for Classification, Voluntary Work Program, Recreation, and Facility Conditions ........................................................................................ 2 Krome’s Staff Did Not Comply with Use of Force Standards for Several Incidents .............. 3 Krome’s Medical Staff Did Not Comply with All Medical Care Standards ..............................

4 Krome’s Medical Grievance Practices Did Not Meet PBNDS 2011 Standards ....................... 5 Krome’s Staff Did Not Consistently Provide Detainees Access to Legal Resources .............. 7 Krome’s Staff Did Not Adequately Maintain Special Management Unit Activity Logs .......... 8 Krome’s Staff Required Detainees to Sign for Items Before Receipt .....................................

8 Krome’s Staff Did Not Place Electronic Requests into Detainee Records ............................. 9 Recommendations ............................................................................................................................... 9 Management Comments and OIG Analysis ....................................................................................... 10 Appendix A: Objective, Scope, and Methodology .............................................................................

14 DHS OIG’s Access to DHS Information ................................................................................... 15 Appendix B: ICE Comments on the Draft Report .............................................................................. 16 Appendix C: Office of Inspections and Evaluations Major Contributors to this Report .................. 23 Appendix D: Report Distribution .......................................................................................................

24 Abbreviations ERO HSA ICE Krome OC PBNDS 2011 SMU Enforcement and Removal Operations Health Services Administrator U.S. Immigration and Customs Enforcement Krome North Service Processing Center oleoresin capsicum Performance-Based National Detention Standards 2011 Special Management Unit www.oig.dhs.gov OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Background U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 120 facilities nationwide, and the conditions and practices at those facilities can vary greatly. ICE Enforcement and Removal Operations (ERO) oversees the detention facilities it manages with private contractors or state or local governments. Facilities must comply with ICE detention standards to provide a clean and safe environment and protect the health, safety, and rights of detainees. As mandated by Congress,1 we conduct unannounced inspections of ICE detention facilities to ensure compliance with the Performance Based Detention Standards 2011, as revised in 2016 (PBNDS 2011).

PBNDS 2011 establishes consistent conditions of detention, program operations, and management expectations within ICE’s detention system. These standards set requirements in areas such as: • environmental health and safety, including cleanliness, sanitation, security, detainee searches, segregation, and disciplinary systems; • detainee care, e.g., food service, medical care, and personal hygiene; • activities, including visitation and recreation; and • grievance systems. Our program of unannounced inspections of ICE detention facilities has identified and helped correct violations of these detention standards at facilities across the country. From June 13 to June 15, 2023, we conducted an in-person, unannounced inspection of Krome North Service Processing Center (Krome) in Miami, Florida, and identified concerns regarding detainee care and treatment that we present in this report.

Krome is owned by ICE and operated by ICE officers and contract employees. In May 2018, ICE contracted with Akima Global Services, LLC, to provide detention and transportation services to Krome. The contract requires Akima Global Services, LLC to comply with PBNDS 2011. At the start of our onsite inspection, Krome housed 615 adult male ICE detainees and no adult female detainees.2 Our onsite inspection team included contracted medical experts who reviewed Krome’s compliance with applicable medical standards of care;3 we incorporated their assessment into our findings.

During our onsite inspection, we conducted a walk-through of Krome facilities, including detainee housing units and indoor and outdoor recreation areas. We also requested and reviewed documents and files and interviewed ICE personnel, Krome officials, and detainees. 1 Department of Homeland Security Appropriations Act, 2023, H.R. Rep. No. 117-396 (2022).

2 The population at ICE detention centers can vary due to continuous arrival and departure of detainees. 3 In addition to the PBNDS 2011 standards, our medical contractors also determine compliance with certain standards from the National Commission on Correctional Health Care 2018 Standards for Health Services in Jails. www.oig.dhs.gov 1 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Results of Inspection We found that Krome’s staff complied with standards for classification, voluntary work program, recreation, facility conditions, and nonmedical grievances. However, they did not comply with use of force standards for several incidents. Additionally, though Krome’s medical staff generally provided care in a timely and appropriate manner and complied with standards for program administration, peer review, pharmacy management, initial and periodic health assessments, emergency care, special needs, and specialty care, our contracted medical professionals found several areas of concern related to sick calls, staffing vacancies, and medical grievances.

The process for detainees to submit medical grievances was unclear, the facility did not always provide detainees with writing instruments or paper grievance forms, and one version of Krome’s paper grievance form imposed noncompliant reporting standards. Further, Krome’s medical staff did not always respond to grievances or place copies of medical grievances in detainees’ medical files or maintain an accurate log of medical grievances. Lastly, Krome’s staff did not comply with all standards for access to legal resources or special management units (SMUs), facility intake forms did not accurately account for items assigned to detainees, and facility staff did not place copies of electronic requests into detainees’ records. Krome’s Staff Complied with Standards for Classification, Voluntary Work Program, Recreation, and Facility Conditions PBNDS 2011 requires facilities to classify and house detainees according to risk level.

Officers should also complete the initial classification process and housing assignment within 12 hours of a detainee’s admission.4 Our review of a random sample of 30 detainee files confirmed Krome’s staff complied with these standards. Further, based on our review of policies, procedures, records, and observations, we found Krome complied with PBNDS 2011 voluntary work program standards, which require facilities to provide detainees with opportunities to participate in voluntary work assignments and earn money while confined.5 The facility’s staff provided program information and position-specific training for detainees who chose to participate in the program. Additionally, the facility paid detainees for their hours worked, and work schedules did not exceed 8 hours per day or 40 hours per week, as required.6 4 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System. 5 PBNDS 2011 (Revised 2016), Standard 5.8, Voluntary Work Program, Section (I).

6 Id. www.oig.dhs.gov 2 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security PBNDS 2011 requires that detainees have access to both indoor and outdoor recreation areas.7 Krome met these requirements and posted recreation schedules in all housing units. During our facility tour we observed outdoor basketball and volleyball courts. Inside, we observed books and exercise equipment. PBNDS 2011 also requires facilities to maintain high standards of cleanliness and sanitation,8 including having an adequate number of toilets, washbasins, and showers, as well as regular issuance of clean clothing, linens, and personal hygiene items.9 Through observations, we determined Krome complied with these standards for facility conditions.

We generally observed clean conditions throughout the facility but did observe one dirty shower in Krome’s intake area. Staff explained that detainees’ frequent use of the intake showers makes it more difficult to keep these showers clean. We tested washbasins to ensure they worked properly and showers to ensure the water temperature was appropriate. Through observation, we concluded the housing units were well lit, ventilated, and without lingering odors.

Krome detainees also had access to an adequate supply of clean, size-appropriate clothing and linens. Krome’s Staff Did Not Comply with Use of Force Standards for Several Incidents PBNDS 2011 states, “staff 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.”10 PBNDS 2011 also prohibits certain techniques and practices including choke holds, use of restraints as punishment, and applying force against detainees offering no resistance.11 While on site, we reviewed video footage and documentation from a random selection of 5 of 44 use of force incidents reported by the facility in the 6-month period prior to our site visit. We found four of five incidents involved what appeared to be an inappropriate use of force. The videos we reviewed for the five incidents showed the following: • • Incident 1: A detention officer deployed oleoresin capsicum (OC) spray12 against a detainee who was being held down by multiple officers.

Incident 2: Two detention officers deployed OC spray against a detainee offering no resistance while alone inside an SMU cell. The officers deployed their canisters of OC 7 PBNDS 2011 (Revised 2016), Standard 5.4, Recreation (II). 8 PBNDS 2011 (Revised 2016), Standard 1.2, Environmental Health and Safety (I). 9 PBNDS 2011 (Revised 2016), Standard 4.5, Personal Hygiene, (V)(E)(1-3); (V)(A).

10 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section (I). 11 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section (V)(E). 12 Also known as pepper spray, OC spray is a chemical compound that irritates the eyes to cause tears, pain, and temporary blindness. www.oig.dhs.gov 3 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security • • • spray through a slot in the door while standing outside the cell. The officers were not under threat, and the detainee was not a threat to himself or others.

Incident 3: A detention officer appeared to use a chokehold on a detainee while trying to restrain him. A second detention officer deployed OC spray. Incident 4: A detention officer deployed OC spray on a detainee before attempting de- escalation and conflict avoidance. The facility’s own after-action report also identified these issues.

Incident 5: A detainee tried to leave the cafeteria with a prohibited item and refused to comply with a pat-down search. The detainee walked away, and detention officers pursued and restrained the detainee. The detention officers used force after attempts at de-escalation and the amount of force used appeared appropriate for this incident. The video footage demonstrates that in four of the five incidents reviewed, facility staff did not use de-escalation or conflict avoidance techniques before using force.

The facility’s internal review of all use of force incidents during the same 6-month period identified 10 incidents requiring remedial training in use of force tactics for the officers involved. As of June 15, 2023, only four of the officers had received the remedial training. Additionally, we interviewed three mental health providers who said the detention officers need immediate retraining on de- escalation methods and management of mental health episodes. One ICE officer stated staff could use additional de-escalation training.

Finally, we reviewed the training records for a random selection of five Krome detention officers and found three of five were not up to date on use of force training. Krome’s Medical Staff Did Not Comply with All Medical Care Standards In general, Krome’s medical staff provided care in a timely and appropriate manner.13 Our contracted medical professionals found Krome’s medical staff complied with standards for program administration, peer review, pharmacy management, initial and periodic health assessments, emergency care, special needs, specialty care, and behavioral health services. However, they found several areas of concern related to sick calls, staffing vacancies, and medical grievances. Krome’s Medical Staff Did Not Address Sick Calls in a Timely Manner Our medical professionals reviewed five randomly selected detainee health records and found sick calls were not occurring within the 48- to 72-hour requirement (2 to 3 days) in the facility’s sick-call policy.

Our review of the five records showed a sick-call response time of 5 to 7 days. The health services administrator (HSA) reported the facility had a plan to begin an “open sick 13 PBNDS 2011 (Revised Dec. 2016), Section 4.3, Medical Care. www.oig.dhs.gov 4 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security call” process, where medical care providers will treat detainees on the same day they sign up for a sick call. Krome Had Several Medical Staffing Vacancies Krome had several medical staffing vacancies, including a dentist and two medical records technicians.

The dental vacancy delayed detainees’ receipt of annual dental exams, while the medical records technician vacancies contributed to a backlog in medical records scanning. At the time of our site visit, the facility had been without a permanent dentist since January 2023. In March 2023, ICE sent a temporary dentist to see all patients on the dental-service list. Though this measure briefly eliminated the backlog of annual dental exams and other dental services, it did not provide a permanent solution.

By the time of our site visit in June, the backlog had increased yet again. Without a permanent dentist or more frequent visits from a temporary dentist, detainees will experience delays in dental exams and other dental services. During our site visit, two of four medical records technician positions were vacant, causing a backlog of around 2,000 medical documents that staff needed to scan into individual detainee health records. The backlog in medical records scanning could affect medical staff’s care decisions.

Krome’s Medical Grievance Practices Did Not Meet PBNDS 2011 Standards In general, Krome’s staff complied with PBNDS 2011 standards for nonmedical grievances, but they did not comply with standards for medical grievances. For example, the process for detainees to submit medical grievances was unclear and contradictory, the facility did not always provide detainees with writing instruments or paper grievance forms, and one version of Krome’s paper grievance form imposed noncompliant reporting standards. Additionally, Krome’s medical staff did not always respond to medical grievances or place copies of grievances in detainees’ medical files; nor did they maintain an accurate log for medical grievances, as required. Krome’s Process for Submitting Medical Grievance Forms Was Unclear and Contradictory, Forms were not Always Available, and One Version Imposed Noncompliant Reporting Standards PBNDS 2011 standards require that staff inform detainees of the facility’s grievance system and provide detainees with grievance forms if requested; these standards also prohibit staff from limiting when a detainee may submit a formal grievance.14 During our site visit, we found Krome’s process for submitting medical grievances was unclear.

14 PBNDS 2011 (revised 2016), Standard 6.2, Grievance System, Section (II)(1); (V)(C)(3). www.oig.dhs.gov 5 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security The ICE grievance officer and HSA both stated detainees should submit medical grievances using a paper grievance form because, they believe, electronic submission of medical grievances does not protect detainees’ medical information. Instead, we found that only 8 of 68 (12 percent) of medical grievances medical staff logged from January 2023 through April 2023 were submitted using paper forms. If a detainee does submit an electronic medical grievance, the ICE grievance officer must forward it to the HSA in an email, then respond to the detainee in the electronic Talton tablet that the detainee should use paper forms to submit future medial grievances. We asked Krome’s HSA how detainees would know they should not submit medical grievances via the electronic Talton system in the first place, and they provided us two memoranda from March 2022 and June 2023.

Neither explicitly states detainees should not submit medical grievances electronically. In addition, the detainee handbook contains no mention of submitting medical grievances using the paper form. During our facility tour, we found the facility did not always provide detainees with paper grievance forms or writing instruments. Of the seven housing units we toured, two did not have any grievance forms available, and three did not have any writing instruments.

When we requested the forms and writing instruments, staff said they did not have any. Two different housing unit officers we spoke to said grievances were typically submitted on the tablets; one said they “don’t allow” submission of paper grievances because the detainees are supposed to use the tablets. This discrepancy may create confusion among detainees and contribute to their continued submission of medical grievances electronically, contrary to the HSA’s preferred method. We also found noncompliant reporting standards for one version of Krome’s paper grievance forms.

As required by ICE’s standards, Krome’s own grievance policy states, “the facility may not impose a time limit on when a detainee may submit a formal grievance.” Despite this guidance, bold text at the top of one of two versions of Krome’s15 paper grievance forms states, “[a] grievance must be filed within 5 days of original incident or issue.” This guidance contradicts Krome’s own policy and may lead detainees to believe they cannot report incidents or concerns after 5 days. Krome’s Medical Staff Did Not Always Respond to Medical Grievances or Place Them in Detainee Medical Files PBNDS 2011 requires that the facility’s administrative health authority receive all medical grievances within 24 hours or the next business day, with a response from medical staff within 5 working days, where practicable.16 We reviewed 70 electronically submitted medical grievances 15 Krome has two grievance forms in circulation, one revised in August 2016 and one revised in 2011. The 2011 form that imposes the 5-day reporting timeframe is used for medical and non-medical grievances at Krome. 16 PBNDS 2011 (revised 2016), Standard 6.2, Grievance System, Section (V)(A)(4). www.oig.dhs.gov 6 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security submitted from March 1 through May 31, 2023 and found the ICE grievance officer forwarded 51 (73 percent) to Krome’s medical department within 24 hours.

ICE grievance officers did not forward the remaining 19 (27 percent) within 24 hours, preventing Krome’s medical department from receiving them within the required timeframe. Additionally, Krome’s medical staff did not place paper and electronic medical grievances in detainee medical files as required by PBNDS 2011. Krome maintains a waiver,17 granted by the Acting ICE Director in August 2021, that exempts it from the requirement to place copies of electronic grievances in detainee detention files.18 The waiver approval presumes medical staff are responding to all medical grievances using Talton’s electronic system; but as previously noted, Krome’s medical staff does not use this method. Therefore, this waiver does not apply to medical grievances.

Krome’s Medical Staff Did Not Maintain an Accurate Medical Grievance Log PBNDS 2011 requires that facilities maintain accurate records for medical grievances, including their resolution, in a grievance log and medical file.19 As part of our inspection, we reviewed Krome’s grievance logs from January 1, 2023, to June 15, 2023, but found Krome had not updated its logs since April 25, 2023. Of the 68 grievances listed in the medical grievance log during this period, only 13 (19 percent) had a documented outcome (i.e., resolution or disposition) and only 45 (66 percent) had a response date, which did not allow us to accurately calculate the overall timeliness rate when responding to medical grievances. Additionally, while detainees had submitted 35 electronic medical grievances in Talton’s system from April 26 to June 14, 2023, Krome did not place any of these in the medical grievance log. Krome’s Staff Did Not Consistently Provide Detainees Access to Legal Resources PBDNS 2011 protects detainees’ legal rights by ensuring their access to courts, counsel, and comprehensive legal materials.20 PBNDS 2011 further states detainees, “shall be provided with a means of saving any legal work in a secure and private electronic format, password protected, so they may return at a later date to access previously saved legal work products.”21 We found some detainees were saving their legal documents to the desktop of the computers in the law library, leaving these documents easily accessible to other detainees and staff.

We also 17 This waiver does not appear on ICE’s public-facing Facility Inspections website (https://www.ice.gov/detain/facility-inspections), which houses an Inspection Waivers Master File and appears to have been last updated in 2022. 18 This waiver does not exempt facility staff from placing copies of paper grievances into detainee detention or medical files. 19 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (II)(7); (V)(D). 20 PBNDS 2011 (Revised 2016), Standard 6.3, Law Libraries and Legal Material, Section (I).

21 PBNDS 2011 (Revised 2016), Standard 6.3, Law Libraries and Legal Material, Section (V)(D). www.oig.dhs.gov 7 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security found personally identifiable information and sensitive legal documentation saved to the law library computer desktop, creating significant privacy and safety concerns. For example, we identified a legal document saved on one desktop that outlined a detainee’s asylum claim and their fear of persecution because of their sexual orientation. Another document had personally identifiable information including mother’s maiden name, names of children, and home addresses. We also learned ICE personnel occasionally scrub and delete files saved to the desktop, including detainees’ legal work.

When we asked detainees about this practice, they stated they were either unaware of a secure means to save their work, or facility staff told them to save their documents to the desktop. PBNDS 2011 further states detainees shall be able to have confidential contact with attorneys and their authorized representatives in person, on the telephone and through correspondence.22 Pro bono attorneys shared concerns about the facility’s procedures for attorneys to meet confidentially with the detainees they represent. For example, local attorneys stated their meetings with detainees were not confidential because detainees sometimes called them from the public phones in their housing units, and guards sometimes interrupted in-person meetings. Krome’s Staff Did Not Adequately Maintain Special Management Unit Activity Logs According to PBNDS 2011, a permanent log shall be maintained in the SMU to record all activities concerning SMU detainees.23 Specifically, the standard states, “the facility medical officer shall sign each individual’s record when he or she visits a detainee in the SMU.”24 Our observation of the SMU activity logs found medical staff did not sign or initial the activity log following the daily health check for each detainee.

Krome’s staff initialed all other activities on the log. But because Krome staff did not initial the daily health check, we could not ensure they were completing the required medical checks, which poses a possible threat to detainees’ health. Krome’s Staff Required Detainees to Sign for Items Before Receipt During our observation of the detainee intake process, we noted a detainee signed a standard form titled “Uniform and Linen Issue” before receiving the items listed on the form, and the form did not accurately list the items ultimately issued to the detainee. For example, the personal hygiene section of the form indicated the detainee received “5 item[s]” of “shampoo” but the detainee only received two small plastic sleeves of shampoo.

Requiring a detainee to sign documentation that states they have received items before receiving them exposes the 22 PBNDS 2011 (Revised 2016), Standard 6.3, Law Libraries and Legal Material, Section (II)(7). 23 PBNDS 2011 (Revised 2016), Standard 2.12, Special Management Unit, Section (V)(D)(1). 24 PBNDS 2011 (Revised 2016), Standard 2.12, Special Management Unit, Section (V)(D)(3)(b). www.oig.dhs.gov 8 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security detainees to undue risk, such as being held accountable for property they did not receive in addition to not receiving critical hygiene supplies. Krome’s Staff Did Not Place Electronic Requests into Detainee Records PBNDS 2011 requires the facility and ICE to keep a log of all detainee requests, and they must maintain documentation for all completed requests in the detainee’s detention file.25 Facility staff produced a waiver documenting an exception to maintaining electronic grievances in detainee detention files, but this waiver did not cover electronic requests.

Facility staff believed this waiver covered both grievances and requests; therefore, these staff were not placing electronic requests in detainee files. Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Miami Field Office, responsible for Krome to: Recommendation 1: Ensure facility staff are up to date on annual training for use of force, intermediate force weapons, de-escalation, and mental health assistance. Recommendation 2: Provide additional training on de-escalation techniques and mental health assistance. Recommendation 3: Comply with PBNDS 2011 standards by: a) providing documentation for the new open sick call system and reduction in wait times; b) continuing efforts to fill vacant positions; c) ensuring that urgent dental needs are met in a timely manner; and d) devising and executing a plan to eliminate the medical documentation scanning backlog.

Recommendation 4: Comply with PBNDS 2011 standards by: a) ensuring Krome’s medical department responds to medical grievances within the required time; b) ensuring copies of all paper medical grievances are placed in detainee medical records; c) ensuring all medical grievances are tracked and logged appropriately; d) updating the facility grievance policy to include expectations related to the submission of medical grievances. If the expectation is for detainees to only submit 25 PBNDS 2011 (Revised 2016), Section 2.13, Staff Detainee Communication, Section (V)(B)(2). www.oig.dhs.gov 9 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security medical grievances through the paper grievance forms, Krome should update the facility’s detainee handbook; e) removing the grievance form, revised in 2011, from circulation at Krome and ensuring the facility does not impose a time limit on when a detainee may submit a formal grievance; and f) maintaining an adequate supply of paper grievance forms and writing instruments in housing units. Recommendation 5: Ensure compliance with standards for legal resources by: a) ensuring the facility consistently provides detainees with a means of saving any legal work in a secure and private electronic format; and b) implementing procedures to facilitate more reliable and confidential communication and visitation between attorneys and detainees. Recommendation 6: Ensure medical staff and housing officers initial the SMU activity log after daily check-ins are complete.

Recommendation 7: Ensure detainees sign the “Uniform and Linen Issue” form after they receive their items and that items listed on the form are accurate. Recommendation 8: Ensure that electronic and paper detainee requests are placed in detention files. Management Comments and OIG Analysis ICE provided written comments in response to the draft report and concurred with seven of eight recommendations. Appendix B contains ICE’s management comments in their entirety.

We also received technical comments from ICE on the draft report; we revised the report as appropriate. We consider recommendations 2 through 6 resolved and open. Recommendations 1 and 7 are resolved and closed, and recommendation 8 is unresolved and open. A summary of ICE’s response and our analysis follows.

ICE Response to Recommendation 1: Concur. On June 30, 2023, Krome staff conducted a review of personnel training to ensure all staff currently working at Krome were up to date on their use of force, intermediate force weapons, de-escalation, and mental health assistance trainings. OIG Analysis: We consider these actions responsive to the recommendation. The facility provided documents showing completed trainings for Krome personnel.

We consider this recommendation resolved and closed. www.oig.dhs.gov 10 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security ICE Response to Recommendation 2: Concur. As of March 2024, all Krome staff who might have been involved in a use of force incident were retrained in de-escalation techniques and mental health assistance. OIG Analysis: We consider these actions partially responsive to the recommendation. The facility provided documents showing Krome personnel completed standard training.

We will close this recommendation once we verify facility staff received additional training on de-escalation and mental health assistance beyond the requirement. We consider this recommendation resolved and open. ICE Response to Recommendation 3: Concur. The HSA at Krome informed detainees and medical personnel of a new, open sick-call system in a “Sick Call Clinic Process” memorandum, dated August 1, 2023, which states medical care providers will treat detainees on the same day they sign up for a sick call.

Krome staff are also working to ensure detainees receive timely dental care by contracting with off-site dental care centers, as well as hiring an onsite dentist on September 22, 2023 (pending onboarding). ICE ERO will send the OIG documentation corroborating completion of these actions and others under a separate cover. The estimated completion date for action needed to close this recommendation is April 30, 2024. OIG Analysis: We consider these actions partially responsive to the recommendation.

The facility provided documentation for the new sick-call process and described its efforts to fill vacant positions and ensure it is meeting detainees’ urgent dental needs. We will close this recommendation when the facility provides documentation showing reduced wait times for dental appointments and a decrease in the medical documentation-scanning backlog. We consider this recommendation resolved and open. ICE Response to Recommendation 4: Concur.

On July 21, 2023, ICE Health Service Corps designated additional staff to assist the grievance officer, when needed. On August 1, 2023, Krome staff updated and shared their policies and procedures regarding the expectations related to submitting medical grievances with staff and detainees. The estimated completion date for action needed to close this recommendation is April 30, 2024. OIG Analysis: We consider these actions partially responsive to part d) of the recommendation.

We will close this recommendation once the facility provides documentation supporting closure of parts a), b), c), e), and f). We consider this recommendation resolved and open. ICE Response to Recommendation 5: Concur. Krome staff posted notification throughout the law library advising detainees that the public-access computers are viewable to all users.

Krome staff have also taken measures to increase the privacy of communications between detainees and their attorneys. On January 16, 2024, virtual attorney visitation booths became fully www.oig.dhs.gov 11 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security operational. The estimated completion date for action needed to close this recommendation is April 30, 2024. OIG Analysis: We consider these actions partially responsive to the recommendation.

The recommendation will remain resolved and open until the facility provides documentation that the virtual-attorney visitation booths are fully operational. We consider this recommendation resolved and open. ICE Response to Recommendation 6: Concur. ICE Health Service Corps staff directed nursing staff leadership on June 10, 2021, to reinforce the procedure for initialing the SMU activity log after daily check-ins are complete.

ICE ERO will send the OIG documentation corroborating the completion of this action under a separate cover. The estimated completion date for action needed to close this recommendation is April 30, 2024. OIG Analysis: We consider these actions partially responsive to the recommendation. The action referenced in ICE’s response to recommendation 6 occurred in June 2021, 2 years before our inspection.

Recommendation 6 is resolved and open until ICE provides documentation that it has ensured medical staff, and housing officers are initialing the SMU activity log after completing the daily check-ins. We consider this recommendation resolved and open. ICE Response to Recommendation 7: Concur. On October 21, 2023, Krome staff took measures to ensure detainees receive all items listed on the “Uniform and Linen Issue” form by requiring itemization at the time of issuance with verification and signature.

Krome staff also updated the “Uniform and Linen Issue” form to reflect current items received and the manner of distribution. OIG Analysis: We consider these actions responsive to the recommendation. ICE provided the updated “Uniform and Linen Issue” form. The form includes a note that says, “Officers must ensure to give items to detainees before having the detainee sign this form.” We consider this recommendation resolved and closed.

ICE Response to Recommendation 8: Non-concur. ICE contends an ICE Assistant Director’s Broadcast, titled “Krome Service Processing Center-Waiver Request for Visitation Standard,” regarded permissible use of the electronic system as an approved storage mechanism. Further, as discussed with the OIG team during this inspection, the facility had added notification in all detention files to reflect the extension of detention files to include the electronic record-keeping system. OIG Analysis: Facility staff produced a waiver documenting an exception to maintaining electronic grievances in detainee detention files and an ICE Assistant Director’s Broadcast titled “Krome Service Processing Center-Waiver Request for Visitation Standard,” but neither the waiver nor the broadcast cover electronic requests.

We will close this recommendation when ICE www.oig.dhs.gov 12 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security begins placing copies of electronic requests in detainee files or updates its grievance waiver to include requests. We consider this recommendation unresolved and open. www.oig.dhs.gov 13 OIG-24-21 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. DHS OIG initiated this inspection at Congress’ direction.

DHS OIG analyzes various factors to determine which facilities to inspect. We review OIG Hotline complaints and prior inspection reports, and past and future inspection schedules of other ICE and DHS inspection organizations. We also consider requests, input, and information from Congress, the DHS Office for 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 of the PBNDS 2011 requirements to health, safety, medical care, mental health care, grievances, classification, searches, use of segregation, use of force, and staff training. As noted in this report, our medical contractors also used the National Commission on Correctional Health Care 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: • • • 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 Krome from June 13 to June 15, 2023.

During the inspection, we: • Conducted an in-person walk-through of the facility. We observed 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. • 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. www.oig.dhs.gov 14 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security • • Interviewed ICE and detention facility staff members, including key ICE operational and detention facility oversight staff and detention facility medical, segregation, classification, grievance, and compliance officers. Interviewed detainees held at the detention facility to evaluate compliance with PBNDS 2011 grievance procedures and grievance resolution. • Reviewed documentary evidence, including medical files, detainee files, and grievance and communication logs and files. For our review of requests, we selected 60 requests out of the 9,061 by reviewing the request log and arbitrarily selecting one request at an interval of every few hundred.

We contracted with a team of qualified medical professionals to conduct a comprehensive evaluation of detainee medical care at the Krome facility, and we incorporated information provided by the medical contractors in our findings. We conducted fieldwork for this report between June and August 2023 pursuant to the Inspector General Act of 1978, 5 U.S.C. §§ 401-424, and in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. DHS OIG’s Access to DHS Information During this inspection, ICE provided timely responses to our requests for information and did not deny or delay access to the information we requested. www.oig.dhs.gov 15 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix B: ICE Comments on the Draft Report www.oig.dhs.gov 16 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 17 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 18 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 19 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 20 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 21 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 22 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix C: Office of Inspections and Evaluations Major Contributors to this Report John Shiffer, Chief Inspector Adam Brown, Lead Inspector Gwen Schrade, Lead Inspector Benjamin Diamond, Senior Inspector Becky McLain, Senior Inspector Joshua Bradley, Inspector Jason De Los Santos, Attorney Advisor Dorie Chang, Communications Analyst Donna Ruth, Independent Referencer www.oig.dhs.gov 23 OIG-24-21 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix D: Report Distribution Department of Homeland Security Secretary Deputy Secretary Chief of Staff Deputy Chiefs of Staff General Counsel Executive Secretary Director, GAO/OIG Liaison Office Under Secretary, Office of Strategy, Policy, and Plans Assistant Secretary for Office of Public Affairs Assistant Secretary for Office of Legislative Affairs ICE Audit Liaison Office of Management and Budget Chief, Homeland Security Branch DHS OIG Budget Examiner Congress Congressional Oversight and Appropriations Committees www.oig.dhs.gov 24 OIG-24-21 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