DHS OIG, OIG-23-38, Results of an Unannounced Inspection of ICE's Stewart Detention Center in Lumpkin, Georgia (2023)

Results of an Unannounced Inspection of ICE’s Stewart Detention Center in Lumpkin, Georgia July 27, 2023 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Washington, DC 20528 / www.oig.dhs.gov July 27, 2023 MEMORANDUM FOR: Patrick J. Lechleitner Senior Official Performing the Duties of the Director U.S. Immigration and Customs Enforcement FROM: SUBJECT: Joseph V. Cuffari, Ph.D. Inspector General Results of an Unannounced Inspection of ICE’s Stewart Detention Center in Lumpkin, Georgia Attached for your action is our final report, Results of an Unannounced Inspection of ICE’s Stewart Detention Center in Lumpkin Georgia. We incorporated the formal comments provided by your office. The report contains nine recommendations aimed at improving care of detainees at ICE’s Stewart Detention Center. Your office concurred with all nine recommendations and we consider all nine resolved and open.

Once your office has fully implemented all recommendations, please submit a formal closeout letter to us within 30 days so that we may close the recommendations. The memorandum should be accompanied by evidence of completion of agreed- upon corrective actions. Please send your response or closure request to [email protected]. Consistent with our responsibility under the Inspector General Act, we will provide copies of our report to congressional committees with oversight and appropriation responsibility over the Department of Homeland Security.

We will post the report on our website for public dissemination. Please contact me with any questions, or your staff may contact Thomas Kait, Deputy Inspector General for Inspections and Evaluations at (202) 981-6000. Attachment DHS OIG HIGHLIGHTS Results of an Unannounced Inspection of ICE’s Stewart Detention Center in Lumpkin, Georgia July 27, 2023 What We Found Why We Did This Inspection In accordance with the Consolidated Appropriations Act, 2022, we conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards. In November 2022, we conducted an in-person inspection of the Stewart facility in Lumpkin, Georgia, to evaluate compliance with ICE detention standards.

What We Recommend We made nine recommendations to improve ICE’s oversight of detention facility management and operations at Stewart. During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Stewart Detention Center (Stewart) in Lumpkin, Georgia, we found that Stewart complied with standards for the voluntary work program, law libraries and legal materials, and facility conditions. However, Stewart did not meet all standards for special management units, custody classification, grievances, staff-detainee communication, and medical care, compromising the health, safety, and rights of detainees. Specifically, Stewart inappropriately and repeatedly disciplined detainees who should have been placed in administrative segregation.

We also observed issues with classification, including commingling of high and low custody detainees. The grievance and staff- detainee communication programs at Stewart were both deficient. For example, ICE did not always visit detainee housing units according to the schedule provided to detainees. We also found that the Stewart medical unit was not appropriately conducting “sick call” for routine medical requests and was not complying with some medical care standards.

Finally, ICE paid for unused bedspace because its population did not meet the guaranteed minimum outlined in the contract with Stewart. ICE Response ICE concurred with all nine recommendations, and we consider them resolved and open. For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at [email protected] www.oig.dhs.gov OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Table of Contents Background .................................................................................................... 3 Results of Inspection .......................................................................................

4 Stewart Complied with Standards for the Voluntary Work Program, Law Libraries, and Legal Materials ......................................................... 5 Stewart Generally Complied with Standards for Facility Conditions........ 5 Stewart Inappropriately Disciplined Detainees Who Refused to Leave the Special Management Unit ................................................................ 6 Stewart Allowed Low Custody and High Custody Detainees to Commingle in Common Areas ................................................................

7 Stewart Classified and Housed Some Detainees before Conducting an Initial Health Screening .................................................................... 8 Grievance Practices at Stewart Were Deficient ........................................ 9 Staff-Detainee Communication Practices at Stewart Were Deficient ...... 13 Stewart Did Not Appropriately Conduct “Sick Call” for Routine Medical Requests and Did Not Comply with Some Medical Care Standards ............................................................................................

17 ICE’s “Guaranteed Minimum” Contract with Stewart Caused ICE to Pay for Unused Bed Space ................................................................... 18 Recommendations ......................................................................................... 19 Management Comments and OIG Analysis .................................................... 21 Appendixes Appendix A: Objective, Scope, and Methodology .................................

27 Appendix B: ICE Comments to the Draft Report ................................... 29 Appendix C: Office of Inspections and Evaluations Major Contributors to This Report ............................................. 35 Appendix D: Report Distribution .......................................................... 36 www.oig.dhs.gov 1 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Abbreviations ERO ECD ICE PBNDS 2011 Stewart Enforcement and Removal Operations estimated completion date U.S. Immigration and Customs Enforcement Performance-Based National Detention Standards 2011 Stewart Detention Center www.oig.dhs.gov 2 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Background U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 120 facilities nationwide, and the conditions and practices at those facilities can vary greatly.

ICE must comply with Federal detention standards and establish an environment that protects the health, safety, and rights of detainees. As mandated by Congress,1 we conduct unannounced inspections of ICE detention facilities to ensure compliance with the Performance-Based National Detention Standards 2011 (PBNDS 2011). Our program of unannounced inspections of ICE detention facilities has identified and helped correct violations of these detention standards at facilities across the country. From November 8 through November 10, 2022, we conducted an unannounced, in- person inspection of Stewart Detention Center (Stewart) in Lumpkin, Georgia, and identified concerns regarding detainee care and treatment that we present in this report.

Prior to our inspection of Stewart, DHS OIG received allegations about alleged sexual misconduct at the facility. Those allegations were referred to our Office of Investigations for appropriate action. ICE Enforcement and Removal Operations (ERO) oversees the detention facilities it manages in conjunction with private contractors or state or local governments. Operated by CoreCivic, Stewart began housing detainees in 2006.

Between November 10, 2021, and November 9, 2022, Stewart had an average daily population of 1,088 detainees, with a maximum capacity of 1,966. Based on the contract with ICE, Stewart County receives nearly $3.3 million a month to house ICE detainees. ICE’s intergovernmental service agreement2 requires Stewart to comply with the PBNDS 2011, as revised in December 2016. According to ICE, the PBNDS 2011 establishes consistent conditions of detention, program operations, and management expectations within ICE’s detention system.

These standards set requirements in areas such as: • environmental health and safety, including cleanliness, sanitation, security, detainee searches, segregation, and disciplinary systems; • detainee care, e.g., food service, medical care, and personal hygiene; • activities, including visitation and recreation; and 1 Consolidated Appropriations Act, 2022, Pub. L. No. 117-103, Division F; Department of Homeland Security Appropriations Act, 2022, H.R. Rep. No. 117-87 (2021). 2 The parties in the agreement include ICE and the service provider, Stewart County, Georgia.

The county subcontracts with CoreCivic to operate the facility. www.oig.dhs.gov 3 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security • grievance systems. At the start of our onsite inspection, Stewart housed a total of 1,382 detainees, including 1,188 male and 194 female detainees. Our onsite team included medical experts we contracted with to review Stewart’s compliance with applicable medical standards of care, and we have incorporated their assessments in our findings. During our inspection, we conducted a walk- through of Stewart facilities, including detainee housing units, medical units, and indoor and outdoor recreation areas.

We also requested and reviewed documents and files and interviewed ICE personnel, Stewart officials, and detainees. Results of Inspection We found that Stewart complied with standards for the voluntary work program, law libraries and legal materials, and facility conditions. However, Stewart did not meet all standards for special management units, custody classification, grievances, staff-detainee communication, and medical care, compromising the health, safety, and rights of detainees. Specifically, Stewart inappropriately disciplined detainees who should have been placed in administrative segregation.

We also observed commingling of high and low custody detainees and found that Stewart classified and housed some detainees before completing an initial health screening, as required. The grievance and staff-detainee communication programs at Stewart were both deficient. For grievances, staff responses were not always timely or appropriate, staff without a need to know had access to detainee grievances, and staff did not ensure grievance responses were in a language detainees could understand. Similarly for staff-detainee communication, Stewart and ICE staff did not always respond to detainee requests in a timely manner, or at all.

Further, ICE did not always visit detainee housing units according to the schedule provided to detainees. Finally, Stewart did not maintain a tracking log for any paper requests and did not ensure communications were in a language detainees could understand. We also found that the Stewart medical unit was not appropriately conducting “sick call” for routine medical requests and was not complying with some medical care standards. Finally, ICE paid for unused bedspace because its population did not meet the guaranteed minimum outlined in the contract with Stewart. www.oig.dhs.gov 4 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Stewart Complied with Standards for the Voluntary Work Program, Law Libraries, and Legal Materials The PBNDS 2011 requires facilities to provide detainees with the opportunity to participate in voluntary work assignments.3 Based on our review of policies, procedures, and payment records, we found that Stewart complied with this standard.

Stewart provided program information, including position safety standards, and position-specific training for detainees who chose to participate. Detainees received payment after completing their work shifts, which did not exceed 8 hours per day or 40 hours per week, as required. Detainees we spoke to said that they were not forced to participate in the work program. Our review did not identify any complaints from detainees about discrimination regarding voluntary work program participation.

One detainee at Stewart experienced an on-the-job injury in 2022. Stewart medical staff determined the necessary treatment, administered first aid, and completed an accident/notification report for facility administrator review, in accordance with the PBNDS 2011. In addition, the PBNDS 2011 requires facilities to provide detainees a properly equipped law library as well as legal materials and equipment to facilitate the preparation of documents.4 Standards also require facilities to provide a way for detainees to save any legal work in a secure and private electronic format that is password protected. Stewart had three law libraries for detainees and three mobile carts detainees could use to do legal work in housing units.

The law libraries had functional computers with CD drives and up-to-date legal software installed. Detainees could save their legal work on CDs provided by the facility or on a secure external drive purchased from the commissary. Stewart Generally Complied with Standards for Facility Conditions The PBNDS 2011 requires “maintaining high facility standards of cleanliness and sanitation,” including having an adequate number of toilets, washbasins, and showers, as well as regular issuance of clean clothing, linens, and personal hygiene items.5 We inspected seven housing units and observed mostly clean and sanitary conditions. However, we found an inoperable shower and toilet in one housing unit and an inoperable shower in another housing unit.

Consequently, one housing unit did not have the required number of toilets (per the toilet-to-detainee ratio established in standards) to ensure that each 3 PBNDS 2011, Section 5.8, Voluntary Work Program (revised Dec. 2016). 4 PBNDS 2011, Section 6.3, Law Libraries and Legal Material (revised Dec. 2016).

5 PBNDS 2011, Section 1.2, Environmental Health and Safety (revised Dec. 2016). www.oig.dhs.gov 5 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security detainee was able to maintain acceptable personal hygiene practices. Stewart provided work orders after our facility inspection showing the toilet was fixed on the day of our walk-through. Additionally, we found that Stewart regularly provided clean clothing, linen, and hygiene items.

We observed that clothing and linen appeared to be laundered and in good condition. Detainees in housing units did not have complaints or concerns about access to personal hygiene items or laundry when questioned, and facility staff ensured the facility had sufficient clothing and linen in inventory to meet detainees’ needs. Stewart Inappropriately Disciplined Detainees Who Refused to Leave the Special Management Unit The PBNDS 2011 allows facilities to segregate detainees from the general population in special management units for administrative or disciplinary reasons.6 Table 1 describes the differences between administrative and disciplinary segregation. Table 1.

Types of Segregation in Special Management Units Administrative Segregation Disciplinary Segregation Non-punitive – at the detainee’s request or as needed to protect the detainee from harm Disciplinary – after the detainee is found guilty of a prohibited act or rule violation Detainees are held until their safety, and the safety of others, is no longer a concern.7 Detainees are held for no more than 30 days per incident, except in extraordinary circumstances. Detainees typically receive the same privileges available to the general population. Detainees are subject to more stringent personal property control, including limitations on reading material, television viewing, and restricted commissary or vending machine purchases. Detainees are allowed at least 2 hours of recreation time outside of their cells, 7 days a week.

Detainees are allowed at least 1 hour of recreation time outside of their cells, 5 days a week. 6 PBNDS 2011, Section 2.12, Special Management Units (revised Dec. 2016). 7 If a detainee has been segregated for his/her own protection, but not at the detainee’s request, approval by a facility administrator is required to authorize continued detention. www.oig.dhs.gov 6 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Administrative Segregation Disciplinary Segregation Detainees can receive time out of their cells for showers, phone calls, use of the law library, visitation, and religious services.

Detainees can receive time out of their cells for showers, phone calls, use of the law library, visitation, and religious services. Source: PBNDS 2011, Section 2.12, Special Management Units At Stewart, the facility ordered two detainees in segregation to return to the general population. Both detainees refused to return to the general population, but the facility did not document a reason for their refusal. Per the PBNDS 2011, the detainees should be placed in administrative segregation if they refuse to return to general population and do not provide a reason.8 Instead, the facility staff disciplined the detainees for “Refus[al] to Obey (Refuse[d] Housing)” in violation of standards.

Specifically, after the detainees refused to return to the general population, facility staff placed them in administrative segregation pending the outcome of a disciplinary hearing. Once found guilty of refusing housing, the facility placed the detainees into disciplinary segregation. Stewart Allowed Low Custody and High Custody Detainees to Commingle in Common Areas The PBNDS 2011 prohibits the commingling of detainees classified as low custody with detainees classified as high custody and requires detainees be given color-coded uniforms, wristbands, or other means to easily identify their classification level on sight.9 Color-coding helps prevent detainees of different levels being housed together or commingled in common areas of the facility. Accordingly, Stewart uses a color-coded uniform system to identify classification levels: navy blue and beige for low and medium-low risk detainees (low custody) respectively, and orange and red for medium-high and high-risk detainees (high custody) respectively.

We observed and confirmed through interviews with ICE officials that commingling of low or medium-low risk detainees with medium-high or high risk detainees occurred at Stewart. We observed three instances of commingling of low custody detainees and high custody detainees. In one instance, we observed 11 detainees of both high and low custody levels sitting together in a conference room during departure preparations. As seen in Figure 1, a low custody detainee was seated next to a high custody detainee in an office area.

When we asked facility staff why the 8 PBNDS 2011, Section 2.12, Special Management Units (revised Dec. 2016). 9 PBNDS 2011, Section 2.2, Custody Classification System (revised Dec. 2016). www.oig.dhs.gov 7 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security two detainees were seated together, they said the detainees were waiting to see medical staff.

Figure 1. High Custody and Low Custody Detainees Commingling, Observed on November 11, 2022 Source: DHS Office of Inspector General photo An ICE official said commingling is a recurring issue frequently observed during movement activities when detainees are escorted through the halls to get meals or travel to recreation. Another ICE official said that commingling also occurs when detainees are boarding the bus for transport. The ICE official explained that facility staff will perform a correction on the spot if made aware that commingling is occurring.

The ICE official also noted that Stewart takes greater care in separating female and male detainees during movement and will clear hallways to facilitate gender segregation. Stewart Classified and Housed Some Detainees before Conducting an Initial Health Screening The PBNDS 2011 requires facilities to medically screen each newly arrived detainee within 12 hours of arrival at a detention facility and to complete an ICE Health Service Corps Intake Screening Form or equivalent prior to placing the detainee in a housing unit.10 Stewart policy also requires that each 10 PBNDS 2011, Section 4.3, Medical Care (revised Dec. 2016). www.oig.dhs.gov 8 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security detainee entering the facility receive an initial medical screening by the clinical staff. We reviewed 20 detainee files and found that 11 detainees were classified and housed before they received their health screening.11 When we asked how the facility ensures timely health screenings prior to detainee placement in a housing unit, the classification official said they could not confirm this occurred.

Grievance Practices at Stewart Were Deficient Detainees can submit electronic or paper grievances to facility staff. We determined Stewart was not meeting standards for the grievance system. Stewart staff did not always provide timely or appropriate responses to grievances and did not consistently file grievances in detainees’ detention files. Further, some security staff had access to sensitive medical grievances without a need to know.

Additionally, Stewart did not provide meaningful access for detainees with limited English proficiency to submit grievances electronically, as parts of the grievance submission menu were only available in English. Also, staff infrequently responded to grievances in a language detainees could understand and did not use the “translate to” feature available to them in the electronic grievance system. Finally, a portion of the facility’s policy for submitting formal grievances was unclear. Stewart Did Not Always Provide Timely or Appropriate Responses to Detainee Grievances The PBNDS 2011 requires facilities to respond to detainee medical grievances within 5 working days and nonmedical grievances within 5 calendar days of receipt.12 Standards also require that each detainee’s grievances and responses be placed in the detainee’s detention file.

We reviewed detainee grievances submitted during the 6 months prior to our site visit (May 9, 2022, through November 4, 2022) and determined responses from facility staff were not always timely, and in some cases, staff did not respond at all. Additionally, Stewart staff did not consistently place grievances and responses into detainee detention files as required. 11 PBNDS 2011, Section 4.3, Medical Care requires that medical information is taken into consideration prior to a detainee’s housing assignment to account for medical conditions that would affect the housing assignment, such as communicable diseases and mental illness. 12 PBNDS 2011, Section 6.2, Grievance System (revised Dec.

2016). www.oig.dhs.gov 9 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security For medical grievances,13 we determined that medical staff only responded to 10 of 82 grievances (12 percent) that detainees submitted electronically. Of those 10 responses, only 4 responses were provided within the required 5 working days. Further, the medical department had not logged or tracked paper medical grievances received for at least 1 month and could not determine how many or what type of medical grievances had been filed by detainees. When Stewart medical staff did log paper medical grievances, the log did not accurately reflect the type of grievances submitted and how medical staff had resolved the grievance.

We also found that medical grievance appeals were reviewed and addressed by the same staff member who reviewed and completed the initial grievance. This violates the PBNDS 2011 requirement that the review be performed at a level higher and exclude the same staff involved in rendering the initial grievance decision. The percentage of electronic medical grievances Stewart responded to in a 6-month period. 12% For nonmedical grievances submitted electronically, Stewart’s grievance officer responded within the required 5 days 77 percent of the time (95 of 124 grievances).

For nonmedical grievances submitted on paper, the grievance officer responded to detainees within the 5-day requirement 95 percent of the time (123 of 129 grievances). We determined that Stewart staff did not always provide adequate responses to detainee grievances. In one instance, a detainee complained that an officer treated detainees like animals, yelled at them, and removed her towel from the door when she used the bathroom. As shown in Figure 2, the grievance officer responded, “This complaint is merely an opinion of how detainee [redacted] feels about Officer [redacted].

This complaint do [sic] not personally affect the detainee in a negative manner. Grievance was returned.” 13 Specifically, electronic grievances detainees submitted to Stewart’s Dental Services, Medical Services, or Mental Health Services. www.oig.dhs.gov 10 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Figure 2. Stewart Grievance Officer’s October 2022 Response to a Detainee’s Complaint about an Officer’s Behavior Source: DHS OIG photo of a paper grievance response. The standards require that each grievance receive appropriate review.

Based on the grievance officer’s response, we concluded that this grievance, and others, did not receive appropriate review. The grievance officer could have investigated this allegation by reviewing video footage and speaking with the detainee who submitted the complaint, other detainees who may have been witnesses, and the officer named in the complaint, but did not do so. Moreover, of the 18 paper grievance files we reviewed,14 we found that three grievances lodged against the grievance officer, by two different detainees, were responded to and closed by the grievance officer herself. According to the paper grievance log, Stewart had at least four other individuals who have assisted in responding to grievances who could have responded to avoid a conflict of interest.

Lastly, we randomly reviewed 14 detention files of detainees who had submitted grievances and found that Stewart staff had only placed copies of the grievances in 6 of 14 of the files (43 percent). Stewart Security Personnel Had Access to Detainee Dental and Mental Health Grievances The PBNDS 2011 requires that formal written grievances regarding medical care be submitted directly to medical personnel designated to receive and respond to medical grievances.15 We received a roster of personnel with access to detainee grievances and determined that 12 Stewart security personnel, such as unit managers and shift supervisors, were included among those with access to all detainee grievances submitted for dental and mental health services. Allowing nonmedical staff access to sensitive detainee medical information risks detainee health information being read or disclosed by individuals without a need to know. 14 We randomly selected these grievance files from the grievance officer’s filing cabinet while at Stewart to read the full details of the grievances and verify that information contained in the paper grievance log was recorded accurately.

15 PBNDS 2011, Section 6.2, Grievance System (revised Dec. 2016). www.oig.dhs.gov 11 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security The Electronic Grievance Menu Was Only Available in English, and Stewart Did Not Respond to Grievances in a Language Detainees Could Understand The PBNDS 2011 requires that all written materials, including facility grievance procedures, provided to detainees generally be translated into Spanish and that information and directions are provided to detainees in a language or manner they can understand.16 Although the main menu of electronic tablets17 used by detainees offered options in English, French, and Spanish, submenu options were only available in English. For example, when a detainee selected the Spanish option for grievances, “Las Quejas,” the subcategories for where to send the communication (e.g., Law Library) all appeared in English, which may lead to detainees submitting requests to the wrong recipient. During our review period, detainees submitted 36 electronic medical grievances in a language other than English.

Stewart medical staff only responded to eight grievances, all in English. Detainees also submitted 29 nonmedical electronic grievances in a language other than English, and Stewart staff responded to all but one in English (the other one received no response). When we asked the grievance officer whether she translated her responses to detainees, she said she did not need to because the detainee tablets had the functionality for detainees to translate staff responses. On the contrary, the tablets used by detainees could only translate the status of a grievance (e.g., closed or open), but not Stewart staff’s free-form responses.

The tablet service provider confirmed that the tablet translation function available to detainees only translates grievance form fields and not facility staff free-form responses to detainees.18 The service provider also confirmed that Stewart’s grievance system has the functionality for staff to translate their free-form responses to detainees if staff save the translation before returning a response to detainees. However, Stewart staff were not using this feature. Although 11 Stewart staff, including the grievance officer, attended training on April 25, 2022, and received instruction on how to use the feature to translate their responses to detainees, none did so in practice. 16 Id. 17 Electronic tablets were available to detainees in all of the housing units at Stewart.

Each detainee had an electronic account and could use the tablets to electronically submit grievances and requests to facility and ICE staff. 18 The service provider’s instruction guide reads, “Detainee can translate a fully completed request or grievance.” The service provider confirmed to us that this feature does not translate staff responses on detainee tablets, which we also confirmed at Stewart by testing this feature on the tablets. www.oig.dhs.gov 12 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Stewart’s Grievance Policy and Detainee Handbook Do Not Fully Comply with ICE Detention Standards The PBNDS 2011 grievance standard allows detainees to file a formal grievance at any time, and during, after, or in lieu of making an informal complaint.19 Stewart’s grievance policy20 contradicts that standard by stating the following: • • • “At any time the informal resolution process has not provided successful resolution of the complaint or in the event of an emergency grievance, inmates/residents may use the formal grievance process.” (emphasis added) “With the exception of emergency grievances, inmates/residents are required to utilize the informal resolution process concerning questions, disputes, or complaints prior to the submission of a formal grievance.” (emphasis added) “At Stewart Detention Center, in the event a detainee decides to bypass the informal resolution process, the detainee will have seven (7) calendar days from the date of the alleged incidient to file a formal grievance.” (emphasis added) Further contradicting the standard, Stewart’s local detainee handbook supplement includes the following: • • “However, all detainees have access to formal grievance procedures any time the informal process has not provided successful resolution of the complaint.” (emphasis added) “You must document on the [formal] grievance form that an informal resolution was attempted and with whom.” (emphasis added) Staff-Detainee Communication Practices at Stewart Were Deficient Detainees can submit requests to facility and ICE staff. We determined that Stewart did not meet standards for staff-detainee communication practices. Stewart and ICE responses to detainee requests were not consistently provided within the required 3-day timeframe, and in some cases, Stewart staff did not respond to detainee requests at all.

One facility program had not responded to electronic detainee requests for at least 2 years. ICE staff did not always visit housing units as scheduled and did not collect or receive ICE paper requests in enough time to ensure they could respond within the required timeframe. 19 PBNDS 2011, Section 6.2, Grievance System (revised Dec. 2016).

20 Stewart policy 14-5, Inmate/Resident Grievance Procedures. www.oig.dhs.gov 13 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Stewart did not log or track any paper detainee requests as required. Also, Stewart did not provide meaningful access for detainees with limited English proficiency to submit requests electronically, as the submenu in the system for submitting electronic requests was only available in English. Staff infrequently responded to requests in a language detainees could understand and did not use the available “translate to” feature in the electronic request system. Stewart and ICE Staff Did Not Always Respond, or Provide Timely Responses, to Detainee Requests The PBNDS 2011 requires staff to respond to detainee requests within 3 business days of receipt.21 We analyzed detainee requests to Stewart and ICE for the 6 months prior to our site visit (May 9, 2022, through November 4, 2022)22 and determined staff did not always respond to detainees.

When Stewart and ICE staff did respond to detainee requests, they did not always do so within the required 3-day timeframe. Specifically, we found that 42 percent of Stewart programs (11 of 26) to which detainees submitted requests had not responded to any detainee requests.23 One Stewart staff member told us they had been responsible for 1 of the 11 programs for approximately the past 2 years but had never received or responded to an electronic detainee request.24 Stewart staff later confirmed this individual had access to the electronic system to receive and respond to detainee requests. Of the 2,557 Stewart detainee requests we analyzed, Stewart staff responded to 1,803 (71 percent). Only 1,104 responses (43 percent) were within the required 3 business days.25 Additionally, we analyzed 7,387 electronic and paper detainee requests to ICE for the same time period and determined ICE 21 PBNDS 2011, Section 2.13, Staff-Detainee Communication (revised Dec.

2016). 22 Data provided by ICE for paper requests, which were manually logged, began on July 18, 2022. 23 The programs that did not respond to any requests were Law Library, Legal Requests, Recreation and Library, Food Service, Inmate Accounts, ADO [Administrative Duty Officer] Staff, Job Requests and Job Coordinator, Release of Protected Health Information, Phone Issues, Notary Requests, and Maintenance. 24 During the 6 months preceding our site visit, detainees submitted 86 requests to this program that went unanswered.

25 This is an issue the ICE detention standards compliance officer brought to Stewart’s attention on numerous occasions since at least July 2022. For example, the detention standards compliance officer’s weekly reports from Oct. 7, 2022, and Nov. 4, 2022, stated he reviewed 15 detainee requests for compliance and in both reports he determined 12 of 15 requests (80 percent) had not received responses within 3 business days. www.oig.dhs.gov 14 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security responded to 7,158 requests (97 percent) and was timely 65 percent26 of the time (4,784 requests), as shown in Figure 3, below.

Figure 3. Stewart and ICE* Detainee Request Data from May 9, 2022, to November 4, 2022 Stewart Request Data ICE Request Data Response Timeliness 43% Response Timeliness 65% Response Rate 71% Response Rate 97% Source: DHS OIG analysis of ICE and Stewart request data * ICE paper request data was from July 18, 2022, to November 4, 2022. Other issues with ICE paper requests that could affect the response timeliness are mentioned in the next section. ICE Did Not Always Visit Detainee Housing Units as Scheduled and Did Not Collect Detainee Paper Requests in a Timely Manner The PBNDS 2011 requires that detainees not be restricted from having frequent, informal access to and interaction with ICE staff in a language detainees can understand.27 The standards also require facilities to display information in the detainee housing units regarding when ICE staff is available to be contacted by detainees.

At Stewart, detainees were restricted from having frequent, informal access to ICE staff despite four or five ERO deportation officers being assigned to each housing unit.28 After numerous detainees in multiple housing units told us that ICE infrequently visited their housing pods (the living areas in housing units), we reviewed the ICE visit logbooks from Stewart’s seven housing units. We determined ICE did not always provide frequent, informal access to ICE staff or do so in accordance with the schedule posted in the detainee housing pods. For one housing unit, ICE staff did not log visiting for 22 consecutive days between September 10, 2022, and October 3, 2022. In many instances, ICE 26 Based on our review of a random sampling of 40 ICE paper requests, we determined it took ICE upwards of 14 business days to collect some detainees’ requests.

As such, ICE’s response timeliness may have actually been less than 65 percent. Due to time constraints, we could not manually review all 544 ICE paper requests. 27 PBNDS 2011, Section 2.13, Staff-Detainee Communication (revised Dec. 2016).

28 The ERO visitation schedule posted in detainee housing pods listed a total of 30 deportation officers and six supervisors scheduled to visit detainees on-site. www.oig.dhs.gov 15 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security staff spent less than 5 minutes in housing units, which can include up to six housing pods, on the scheduled visit days (Tuesdays or Thursdays). It is unlikely ICE staff would be able to visit all housing pods in a housing unit and answer detainee questions within that period of time. During both our one-on- one interviews with detainees and our tours of multiple housing units, numerous detainees said that ICE rarely visited their housing pods, with one detainee remarking that the one time ICE staff visited, they “left after 2 minutes” and did not answer questions the detainees had about their cases. Additionally, of the 40 ICE paper requests we reviewed,29 we determined ICE staff took between 3 and 14 business days to collect or receive 25 of these requests from the housing units.

ICE’s paper request log shows that ICE responded to all 40 of these requests within 1 business day of receipt, therefore seemingly meeting requirements for timely response. However, because days elapsed between detainees submitting their paper request forms and ICE staff collecting or receiving the forms, we cannot conclude that ICE met the intent of the standard that requires responses to detainee requests within 3 business days of receipt. Further, the PBNDS 2011 specifies that facilities without onsite ICE staff must forward paper requests to ICE within 2 business days.30 Although the PBNDS 2011 does not dictate how long it should take ICE to collect requests at facilities with an onsite ICE presence, based on that standard, ICE is taking an unreasonable amount of time to collect or receive detainees’ paper requests at Stewart. As such, the amount of time ICE staff at Stewart takes to respond to detainees’ paper requests is longer than the paper request log may indicate.

Stewart Did Not Track Detainee Paper Requests The PBNDS 2011 requires facilities to keep a log of all detainee requests.31 When we asked Stewart leadership and staff to provide the log(s) of detainees’ paper requests, they responded that staff did not log paper requests but did place the requests in the detainee files. Stewart leadership added that no other inspection entity had ever told them they were required to keep a paper request log. We were unable to determine anything about detainee paper requests submitted to Stewart staff, including how many paper requests had been submitted, how often Stewart responded to detainees’ paper requests, whether they responded within the required 3-day timeframe, and the appropriateness of staff responses. 29 We randomly selected 40 ICE detainee paper requests from ICE’s 2022 request/ correspondence log to review.

30 PBNDS 2011, Section 2.13, Staff-Detainee Communication (revised Dec. 2016). 31 Id. www.oig.dhs.gov 16 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security The Electronic Request Menu Was Only Available in English, and Stewart and ICE Staff Did Not Respond to Requests in a Language Detainees Could Understand The PBNDS 2011 requires all written materials provided to detainees to generally be translated into Spanish and that detainees have frequent opportunities for informal communications with key facility staff members in a language they can understand.32 Although the main menu of the electronic tablets used by detainees offered options in English, French, and Spanish, submenu options were only available in English. For example, when a detainee selected the Spanish option for requests, “Peticiones,” the subcategories for where to send the communication (e.g., Law Library) all appeared in English, which may have led to detainees submitting requests to the wrong recipient.

In our analysis of a judmental sample of non-English electronic requests, Stewart staff only responded to detainees in the language of the request 21 percent of the time,33 while ICE staff only responded to non-English requests in the language of their request 28 percent of the time. The tablet service provider also confirmed that the tablet request program can translate Stewart staff’s free-form responses to languages detainees would understand, if staff activate that feature before returning a response to detainees. Similar to their responses to grievances, Stewart staff was not using this feature when responding to detainee requests. Some but not all ICE deportation officers at Stewart consistently used the program’s translation functionality to respond to detainee requests in a language they understood.

Stewart Did Not Appropriately Conduct “Sick Call” for Routine Medical Requests and Did Not Comply with Some Medical Care Standards The PBNDS 2011 requires facilities to have a sick call procedure that allows detainees the unrestricted opportunity to freely request health care services (including dental and mental health services) provided by a physician or other qualified medical staff in a clinical setting.34 Our medical contractors determined this was not occurring at Stewart and found that the sick call system at Stewart was not functioning properly. Although the sick call was occurring 7 days per week as required, medical staff reported delays in receiving sick call requests from the lockboxes in the hallways and housing 32 Id. 33 To assess Stewart and ICE’s translation compliance, we reviewed the first 50 non-English requests for every subcategory (e.g., Law Library, ICE Bonds) and determined how many responses were provided in the language of the request. 34 PBNDS 2011, Section 4.3, Medical Care (revised Dec. 2016). www.oig.dhs.gov 17 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security units.

Medical staff rely on facility staff to bring the lockboxes to the medical unit each morning but said this does not always occur — sometimes they arrive late in the day and sometimes not at all — resulting in a lack of access to medical care for detainees. Our medical experts determined facility staff took no proactive action to ensure the medical unit received sick call requests in a timely manner. Standards also require facilities to maintain a permanent record of all sick call requests. Stewart did not maintain a log of sick call requests, making it impossible to properly track and ensure completion of the requests.

Detainees we interviewed reported difficulties in obtaining sick call services, and our medical experts found corroborating evidence in medical records. A random review of electronic sick call requests showed that detainees were only seen 50 percent of the time.35 Our medical contractors identified additional issues with the medical care program at Stewart, specifically: • Stewart had an established peer review program for provider staff, but not for nursing staff, which is required to maintain accreditation from the National Commission on Correctional Health Care. • Staffing shortages have affected the timely delivery of mental health services, delaying comprehensive mental health evaluations for detainees by approximately 1 month. ICE’s “Guaranteed Minimum” Contract with Stewart Caused ICE to Pay for Unused Bed Space The contract with Stewart requires ICE to pay the facility for a guaranteed minimum of 1,600 detainees at a fixed, daily rate of $67.86 per bed. The cost to house detainees at or below the guaranteed minimum is $108,576 per day, resulting in a total annualized cost of $39.6 million.

We analyzed 12 months of population counts at Stewart, from November 2021 through November 2022, and found that detainee populations were consistently below the contractual guaranteed minimum amount of 1,600 detainees,36 with an average detainee 35 We could not determine the percentage of time medical staff assessed detainees in response to paper requests they submitted, as medical staff did not log the requests or document whether and how they were handled. 36 Stewart has a capacity of 1,966 detainees. Between April 2020 and June 2022, ICE temporarily recommended facilities make efforts to reduce detainee population to 75 percent of capacity, or 1,474 detainees for Stewart. (See ICE ERO’s COVID-19 Pandemic Response Requirements, Version 9.0, Jun.

13, 2022.) www.oig.dhs.gov 18 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security population of 1,088 for all 12 months (see Figure 4). As a result, ICE paid $12.6 million for unused bed space in a 1-year timeframe, or nearly a third of the total guaranteed minimum expenditures. Figure 4. ICE Detainee Population at Stewart from November 10, 2021, to November 9, 2022 Source: DHS OIG analysis of data provided by Stewart Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Atlanta Field Office, responsible for Stewart, to: Recommendation 1: Document in special management unit records the reason detainees refuse to return to general population to ensure facility staff do not use disciplinary segregation as a punitive measure for detainees who require protection.

Recommendation 2: Ensure health screenings are conducted within the first 12 hours after a detainee arrives at the facility, before classifying or determining housing assignment. www.oig.dhs.gov 19 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Recommendation 3: Ensure low custody detainees are not commingled with medium, medium-high, or high custody detainees at any time or place in the facility. Recommendation 4: Comply with the PBNDS 2011 grievance standard by: a. responding to detainee grievances within the required timeframes; b. designating alternative staff who are responsible for responding to grievances, when necessary, to ensure the subject of a grievance is not the same as the person responding to the grievance; c. conducting training for the facility grievance officer and other officials responsible for responding to grievances on what constitutes an appropriate grievance response; d. ensuring detainees can submit medical grievances directly to medical staff and no other staff can access detainee electronic medical grievance information; and e. ensuring responses to grievances are in a language detainees can understand. Recommendation 5: Comply with the PBNDS 2011 staff-detainee communication standard by: a. responding to detainee requests within the required timeframes; b. ensuring detainees have frequent opportunities for informal contact with ICE ERO field office staff, including by requiring ICE ERO to post and adhere to a visitation schedule; c. ensuring responses to detainees are in a language they can understand; d. establishing a request tracking system for paper requests to ensure timely responses, with a complete request log; and e. maintaining copies of each completed detainee request in detainees’ detention files. Recommendation 6: Establish and enforce a sick call procedure that allows detainees the unrestricted opportunity to freely request health care services (including dental and mental health services) provided by a physician or other qualified medical staff in a clinical setting by ensuring medical staff receives all detainee sick call requests in a timely manner.

Recommendation 7: Establish a log to maintain a permanent record of all sick call requests, including but not limited to the detainee’s name, A number, a brief description of the complaint, and how the issue was resolved. www.oig.dhs.gov 20 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Recommendation 8: Establish and implement a peer review program for nursing staff, and onboard needed mental health staff to contribute to timely medical care. Recommendation 9: Review and update ICE’s contract with Stewart by better identifying housing requirements and determining whether guaranteed minimums are necessary. Management Comments and OIG Analysis ICE concurred with all nine recommendations. Appendix B contains ICE’s management comments in their entirety.

We also received technical comments on the draft report and took them into consideration when finalizing our report. We consider all nine recommendations resolved and open. A summary of ICE’s response to our recommendations and our analysis follows. Recommendation 1: Document in special management unit records the reason detainees refuse to return to general population to ensure facility staff do not use disciplinary segregation as a punitive measure for detainees who require protection.

ICE Response to Recommendation 1: Concur. The “Performance-Based National Detention Standards 2011” (PBNDS 2011) state that a detainee may be placed in “protective custody” status in administrative segregation at the detainee’s request or by staff as needed to protect the detainee from harm, and that in situations in which a detainee released from disciplinary segregation and the detainee refuses to return to general population, the detainee should be placed in administrative segregation. It is important to clarify that detainees at Stewart never requested protective custody and denied fear of harm in returning to general population. In fact, both detainees referenced in the OIG’s draft report simply refused to return to a general population housing unit, stating they just wanted to live alone.

Ultimately, the disciplinary hearing panel found that both detainees were guilty of disobeying the order to return to general population, and both were placed in disciplinary segregation, in accordance with PBNDS 2011. Stewart, moving forward, will be sure to document the reasons detainees refuse to return to general population to prevent the possibility that facility staff use disciplinary segregation as a punitive measure for detainees and that they are placed in administrative www.oig.dhs.gov 21 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security segregation in accordance with PBNDS 2011. Estimated Completion Date (ECD): October 31, 2023. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open.

We will close this recommendation when ICE provides evidence showing that Stewart is documenting the reasons detainees refuse to return general population. Recommendation 2: Ensure health screenings are conducted within the first 12 hours after a detainee arrives at the facility, before classifying or determining housing assignment. ICE Response to Recommendation 2: Concur. Once a detainee arrives at Stewart, the health screening will take place within the first 4 hours during initial intake, which will then be followed by classification.

On February 23, 2023, CoreCivic trained the Intake Sergeants on how to conduct classification screenings to ensure compliance with the detention standards, as well as completing the custody classification worksheet. Once the classification worksheet is completed during the initial intake, the Stewart classification department evaluates all classification for ICE detainees. Once classification is completed, the Classification Supervisor verifies all classifications for accuracy. ECD: September 29, 2023.

OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when ICE provides evidence showing that health screenings are conducted prior to classifying or determining housing assignment. Recommendation 3: Ensure low custody detainees are not commingled with medium, medium-high, or high custody detainees at any time or place in the facility. ICE Response to Recommendation 3: Concur.

On November 17, 2022, Stewart implemented a corrective plan to ensure that there will be no comingling amongst the low custody, medium custody, medium-high custody, and high custody detainees. Prior to releasing any detainee from a unit pod, the housing control officer ensures that if the detainee is a “Level 3,” communication is made with the pod officer or unit team to find out the reason the detainee is exiting the pod. All “levels” of detainees will be escorted by facility staff and guards. Further, the detainee will be escorted by a member of the unit team or officer if the detainee needs to be taken to another area outside the unit, or the escort will be provided before the detainee is released if in another “out” location.

ICE ERO, in tandem with CoreCivic, will also create www.oig.dhs.gov 22 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security a new memorandum to notify all unit controls and central control that Level 3 detainees will not be in the hall without an escort, and to instruct central control to monitor cameras, gates, and doors to ensure that there are not any Level 3 detainees in the hallway without an escort. ECD: September 29, 2023. OIG Analysis: We consider these actions partially responsive to the recommendation, which is resolved and open. ICE’s response did not address how detainees in waiting areas, like medical, will be separated.

We will close this recommendation when ICE provides evidence of the corrective plan, including in waiting areas. Recommendation 4: Comply with the PBNDS 2011 grievance standard by: a. responding to detainee grievances within the required timeframes; b. designating alternative staff who are responsible for responding to grievances, when necessary, to ensure the subject of a grievance is not the same as the person responding to the grievance; c. conducting training for the facility grievance officer and other officials responsible for responding to grievances on what constitutes an appropriate grievance response; d. ensuring detainees can submit medical grievances directly to medical staff and no other staff can access detainee electronic medical grievance information; and e. ensuring responses to grievances are in a language detainees can understand. ICE Response to Recommendation 4: Concur. On December 7, 2022, ERO Atlanta Field Office management provided staff, including supervisory detention and deportation officers, with additional docket training to ensure detainee correspondences are returned within the three business days/72- hour window, in accordance with PBNDS 2011.

On December 7, 2022, ERO Atlanta Field Office implemented a tracking process for all paper requests, to include grievances, and developed a procedure for monitoring staff electronic responses. CoreCivic continues to work with Talton to enhance staff’s knowledge of the system and to ensure all staff members have appropriate access to the system. The Talton system currently ensures that the only personnel who can view and/or respond to detainee medical grievances are medical personnel. CoreCivic will assign a grievance officer that will maintain and respond to detainee grievances and to ensure that all grievances are returned to detainees in a language that they can understand.

The facility will also assign a training officer to maintain training records and dates. ECD: October 31, 2023. www.oig.dhs.gov 23 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when ICE provides evidence showing that each grievance in the recommendation has been addressed. Recommendation 5: Comply with the PBNDS 2011 staff-detainee communication standard by: a. responding to detainee requests within the required timeframes; b. ensuring detainees have frequent opportunities for informal contact with ICE ERO field office staff, including by requiring ICE ERO to post and adhere to a visitation schedule; c. ensuring responses to detainees are in a language they can understand; d. establishing a request tracking system for paper requests to ensure timely responses, with a complete request log; and e. maintaining copies of each completed detainee request in detainees’ detention files.

ICE Response to Recommendation 5: Concur. On March 7 and 8, 2023, Talton provided training on detainee visitation to ERO Atlanta staff and CoreCivic staff. On December 7, 2022, ERO Atlanta management provided staff with additional docket training instructing deportation officers to ensure they are making bi-weekly visits to the facility, and that the supervisory detention and deportation officers ensure the visits are completed by personally visiting the facility three times weekly so that detainees will have informal contact with ICE ERO Field Office staff.

ICE ERO

Atlanta is currently updating a standard operating procedure, “Staff Detainee Communication,” in furtherance of this effort. ERO Atlanta also has a tracking system in place for paper requests, in which three copies are made of the paper detainee paper request. According to this process, the first copy goes to the unit manager for filing, the second copy goes into the detainee detention file, and the third copy is given to the detainee. Currently, Talton has advised ERO that the translation feature only works if the detainee translates the form to their language of origin.

Once the detainee translates the form and sends to the designated personnel, the designated personnel can choose the quick edit option to translate their response back to the detainee in their language of origin. ERO Atlanta will reinforce the Talton instructions for requesting translations to staff by having CoreCivic ensure that staff is trained and updated. ECD: September 29, 2023. www.oig.dhs.gov 24 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when ICE provides evidence showing that all aspects of the recommendation have been addressed.

Recommendation 6: Establish and enforce a sick call procedure that allows detainees the unrestricted opportunity to freely request health care services (including dental and mental health services) provided by a physician or other qualified medical staff in a clinical setting by ensuring medical staff receives all detainee sick call requests in a timely manner. ICE Response to Recommendation 6: Concur. On November 10, 2022, Stewart established a procedure to ensure medical staff receive all detainee sick call requests in a timely manner, on the same date. Facility leadership met with medical personnel weekly to discuss this standard to ensure continued compliance.

ERO Atlanta will provide the OIG with documentation validating that the procedure was established at Stewart. ECD: July 31, 2023. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when ICE provides documentation showing that all procedures have been implemented.

Recommendation 7: Establish a log to maintain a permanent record of all sick call requests, including but not limited to the detainee’s name, A number, a brief description of the complaint, and how the issue was resolved. ICE Response to Recommendation 7: Concur. On November 10, 2022, Stewart medical implemented a process to ensure that all medical sick call requests received are logged and documented, and this log is currently in use. ERO Atlanta will have Stewart provide documentation to the OIG validating that the log maintains a permanent record of all sick call requests.

ECD: July 31, 2023. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when ICE provides documentation showing that Stewart is maintaining a complete medical sick call log. Recommendation 8: Establish and implement a peer review program for nursing staff, and onboard needed mental health staff to contribute to timely medical care. www.oig.dhs.gov 25 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE Response to Recommendation 8: Concur.

Stewart implemented a peer review program for nursing staff and completed a review for all nurses in November of 2022. ERO Atlanta will have Stewart provide documentation to the OIG validating that this peer review program for nursing staff was established. ECD: July 31, 2023. OIG Analysis: We consider these actions partially responsive to the recommendation, which is resolved and open.

ICE did not address the onboarding of mental health staff. We will close this recommendation when ICE provides documentation showing that the nursing peer review program has been implemented, and when ICE provides additional information about how it will address its mental health staffing needs. Recommendation 9: Review and update ICE’s contract with Stewart by better identifying housing requirements and determining whether guaranteed minimums are necessary. ICE Response to Recommendation 9: Concur.

At the time in which the OIG conducted this inspection, ERO Atlanta followed the ICE ERO “COVID-19 Pandemic Response Requirements, Version 8.0” dated April 4, 2022, which sets forth expectations and assists ICE detention facility operators with sustaining detention operations, while mitigating risk to the safety and well- being of detainees, staff, contractors, visitors, and stakeholders due to COVID- 19. On November 1, 2022, the ICE ERO Coronavirus Disease 2019 (COVID-19) Pandemic Response Requirements, Version 8.0 were superseded by Version 10.0 and instructed facilities to make efforts to reduce the population to approximately 75 percent of capacity, with the understanding that, in some instances, the physical layout of some facilities may permit exceeding 75 percent capacity while still following Centers for Disease Control and Prevention (CDC) guidance. In such cases, facilities could do so, so long as they continued to abide by Centers for Disease Control and Prevention guidance. As of May 11, 2023, COVID-19 restrictions were lifted, and ICE facilities are currently allowed to resume pre-pandemic levels.

As a result, Stewart is currently in the process of moving its capacity back to pre-pandemic levels and working toward meeting its guaranteed minimum by the end of the fiscal year. ECD: September 29, 2023. OIG Analysis: We consider these actions partially responsive to the recommendation, which is resolved and open. We will close this recommendation when ICE provides documentation showing facility capacity is at the guaranteed minimum. www.oig.dhs.gov 26 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix A Objective, Scope, and Methodology The Department of Homeland Security Office of Inspector General was established by the Homeland Security Act of 2002 (Pub.

L. No. 107-296) by amendment to the Inspector General Act of 1978. DHS OIG initiated this inspection at Congress’ direction. 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.

We also consider requests, input, and information from Congress, the DHS Office of Civil Rights and Civil Liberties, nongovernmental organizations, and media outlets to determine which facilities may pose the greatest risks to the health and safety of detainees. Finally, to ensure we review facilities with both large and small detainee populations in geographically diverse locations, we consider facility type (e.g., service processing centers, contract detention facilities, and intergovernmental service agreement facilities) and applicable PBNDS. We generally limited our scope to the PBNDS 2011 for health, safety, medical care, mental health care, grievances, classification, searches, use of segregation, use of force, and staff training. However, as noted in this report, our medical contractors also used the National Commission on Correctional Health Care’s 2018 Standards for Health Services in Jails when reviewing medical related policies and procedures at the facility.

Prior to our inspection, we reviewed relevant background information, including: • OIG Hotline complaints • • • ICE PBNDS 2011 ICE Office of Detention Oversight reports and other inspection reports Information from nongovernmental organizations We conducted our unannounced in-person inspection of Stewart from November 8 through November 10, 2022. During the inspection, we: • Conducted an in-person walk-through of the facility. We viewed areas used by detainees, including intake processing areas; medical facilities; residential areas, including sleeping, showering, and toilet facilities; legal services areas, including law libraries; and recreational facilities. www.oig.dhs.gov 27 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security • Reviewed the facility’s compliance with key health, safety, and welfare requirements of the PBNDS 2011 for classification, segregation, voluntary work program, access to legal services, access to medical care and mental health care, and medical and nonmedical grievances. • • Interviewed ICE and detention facility staff members, including key ICE operational and detention facility oversight staff and detention facility medical, 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, and grievance and communication logs and files.

We contracted with a team of qualified medical professionals to conduct a comprehensive evaluation of detainee medical care at the Stewart facility. We incorporated information provided by the medical contractors in our findings. We conducted this review under the authority of the Inspector General Act of 1978, as amended, 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, DHS provided timely responses to our requests for information and did not deny or delay access to the information we requested. www.oig.dhs.gov 28 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix B ICE Comments on the Draft Report www.oig.dhs.gov 29 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 30 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 31 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 32 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 33 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 34 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix C Office of Inspections and Evaluations Major Contributors to This Report John Shiffer, Chief Inspector Jennifer Berry, Lead Inspector Benjamin Diamond, Senior Inspector Brittany Scott, Senior Inspector Mitchell Trump, Senior Inspector Brett Cheney, Inspector Natalia Segermeister, Attorney Advisor Lisa Knight, Communications Analyst Donna Ruth, Independent Referencer www.oig.dhs.gov 35 OIG-23-38 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix D Report Distribution Department of Homeland Security Secretary Deputy Secretary Chief of Staff Deputy Chiefs of Staff General Counsel Executive Secretary Director, 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 36 OIG-23-38 Additional Information and Copies To view this and any of our other reports, please visit our website at: www.oig.dhs.gov.

For further information or questions, please contact Office of Inspector General Public Affairs at: [email protected]. Follow us on Twitter at: @dhsoig. OIG Hotline To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click on the red "Hotline" box. If you cannot access our website, call our hotline at (800) 323-8603, or write to us at: Department of Homeland Security Office of Inspector General, Mail Stop 0305 Attention: Hotline 245 Murray Drive, SW Washington, DC 20528-0305