DHS OIG, OIG-22-14, Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center (2022)

Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center January 3, 2022 OIG-22-14 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Washington, DC 20528 / www.oig.dhs.gov January 3, 2022 MEMORANDUM FOR: Tae D. Johnson Acting Director U.S. Immigrations and Customs Enforcement FROM: SUBJECT: Joseph V. Cuffari, Ph.D. Inspector General JOSEPH V CUFFARI Digitally signed by JOSEPH V CUFFARI Date: 2022.01.03 15:09:13 -05'00' Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center Attached for your information is our final report, Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center. We incorporated the formal comments provided by U.S. Immigrations and Customs Enforcement in the final report. The report contains five recommendations aimed at improving ICE’s oversight of medical care and facility operations at Irwin County Detention Center(cid:3) (cid:44)(cid:38)(cid:39)(cid:38)(cid:12)(cid:17) Your office concurred with one recommendation but (cid:71)(cid:76)(cid:71)(cid:3)(cid:81)(cid:82)(cid:87)(cid:3)(cid:70)(cid:82)(cid:81)(cid:70)(cid:88)(cid:85)(cid:3) (cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:73)(cid:82)(cid:88)(cid:85)(cid:3)(cid:85)(cid:72)(cid:70)(cid:82)(cid:80)(cid:80)(cid:72)(cid:81)(cid:71)(cid:68)(cid:87)(cid:76)(cid:82)(cid:81)(cid:86)(cid:3)(cid:68)(cid:86)(cid:3)(cid:76)(cid:87)(cid:3)(cid:81)(cid:82)(cid:3)(cid:79)(cid:82)(cid:81)(cid:74)(cid:72)(cid:85)(cid:3)(cid:75)(cid:82)(cid:88)(cid:86)(cid:72)(cid:86)(cid:3)(cid:71)(cid:72)(cid:87)(cid:68)(cid:76)(cid:81)(cid:72)(cid:72)(cid:86)(cid:3)(cid:68)(cid:87)(cid:3)(cid:44)(cid:38)(cid:39)(cid:38)(cid:3)(cid:68)(cid:81)(cid:71)(cid:3)(cid:76)(cid:87)(cid:86)(cid:3) (cid:70)(cid:82)(cid:81)(cid:87)(cid:85)(cid:68)(cid:70)(cid:87)(cid:3)(cid:90)(cid:76)(cid:87)(cid:75)(cid:3)(cid:44)(cid:38)(cid:39)(cid:38)(cid:3)(cid:72)(cid:81)(cid:71)(cid:72)(cid:71)(cid:3)(cid:82)(cid:81)(cid:3)(cid:50)(cid:70)(cid:87)(cid:82)(cid:69)(cid:72)(cid:85)(cid:3)(cid:26)(cid:15)(cid:3)(cid:21)(cid:19)(cid:21)(cid:20)(cid:17)(cid:3)(cid:3)Based on information provided in the response to the draft report, we consider one recommendation open and resolved(cid:17)(cid:3)(cid:3)We have administratively closed four recommendations that cannot be implemented due to the termination of the I(cid:38)(cid:39)(cid:38) contract. Once your office has fully implemented the recommendation, please submit a formal closeout letter to us within 30 days so that we may close the recommendation.

The memorandum should be accompanied by evidence of completion of agreed- upon corrective actions and of the disposition of any monetary amounts. 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 call 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 Medical Processes and Communication Protocols Need Improvement at Irwin County Detention Center January (cid:22)(cid:15) 2022 Why We Did This Inspection In September 2020, DHS OIG received complaints concerning medical care, response to COVID-19 protocols, retaliation against employees and detainees, and specific allegations about detainees referred for gynecological procedures at ICDC. We sought to determine whether ICDC provided detainees adequate medical care and adhered to COVID-19 protections. This inspection did not review the gynecological procedure approval process for detainees at ICDC, which has been referred to our Office of Investigations.

What We Recommend We made five recommendations to improve ICE’s oversight of medical care and facility operations at ICDC. For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at [email protected] What We Found We determined Irwin County Detention Center (ICDC) in Ocilla, Georgia, generally met U.S. Immigration and Customs Enforcement (ICE) detention standards, which specify that detainees have access to appropriate and necessary medical, dental, and mental health care. However, our contract medical team’s evaluation of ICDC’s medical processes found the facility’s chronic care, continuity of care, and medical policies and procedures to be inadequate. The medical team identified additional concerns in seven other areas: health assessments, medication administration, sick call, health records, program administration, emergency care, and women’s health.

We initiated a separate audit which will focus on how surgical procedures are authorized and approved for detainees across ICE detention facilities. Similar to our findings on the ICE detention standards, the facility generally complied with Centers for Disease Control and Prevention and ICE COVID-19 guidance, but ICDC and ICE management did not adequately or consistently keep facility employees, ICE staff, and detainees informed of COVID-19 protocols and guidance. We also found that detainees’ communication with, and access to, their ICE deportation officers were limited. Further, some ICE officers stated they were not comfortable expressing concerns with detention conditions.

ICE Response ICE did not concur with four recommendations as it no longer houses detainees at ICDC and its contract with ICDC ended on October 7, 2021, but concurred with one recommendation directed at enhancing communication among Atlanta Field Office. We have administratively closed four recommendations and consider one recommendation resolved and open. www.oig.dhs.gov OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Table of Contents Introduction.................................................................................................... 3 Background .................................................................................................... 3 Results of Inspection.......................................................................................

6 Medical Care Provided to Detainees Generally Met Standards, but Improvements Were Warranted .............................................................. 7 ICDC Generally Complied with CDC and ICE COVID-19 Guidance, but Faced Challenges Implementing Protocols............................................ 12 Communication about COVID-19 to ICE Officers, Facility Staff, and Detainees Was Inconsistent ................................................................. 17 Detainees’ Access to ICE Deportation Officers Was Limited during the COVID-19 Pandemic ............................................................................

19 Detainees and ICDC Staff Were Generally Comfortable Lodging Concerns, but Some ICE Officers Were Hesitant to Voice Their Concerns ............................................................................................. 21 Recommendations......................................................................................... 22 Management Comments and OIG Analysis .................................................... 23 Appendixes Appendix A: Objective, Scope, and Methodology .................................

26 Appendix B: ICE Comments to the Draft Report ................................... 27 Appendix C: NCCHC Resources, Inc., Irwin County Detention Center Inspection Report ................................................................................ 32 Appendix D: Office of Inspections and Evaluations Major Contributors to This Report .................................................................. 64 Appendix E: Report Distribution ..........................................................

65 Abbreviations ADP CDC COVID-19 coronavirus disease 2019 average daily population Centers for Disease Control and Prevention www.oig.dhs.gov OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security DOJ DRF ERO EUA FDA HIPAA ICDC ICE IGSA IHSC LPN NCCHC NSAID PBNDS PPE PRR TDY U.S.C. Department of Justice Detainee Request Form Enforcement and Removal Operations Emergency Use Authorization Food and Drug Administration Health Insurance Portability and Accountability Act Irwin County Detention Center U.S. Immigration and Customs Enforcement intergovernmental services agreement ICE Health Service Corps licensed practical nurse National Commission on Correctional Health Care non-steroidal anti-inflammatory drug Performance-Based National Detention Standards personal protective equipment Pandemic Response Requirements temporary duty United States Code www.oig.dhs.gov OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Introduction In September 2020, Project South, an advocacy group, filed a complaint with Department of Homeland Security Office of Inspector General concerning the Irwin County Detention Center (ICDC) in Ocilla, Georgia, which houses U.S. Immigration and Customs Enforcement (ICE) detainees. We started our review in October 2020. The complaint included allegations from ICE detainees and a licensed practical nurse previously employed by ICDC about inappropriate medical care, inadequate response to coronavirus disease 2019 (COVID-19), and retaliation against employees and detainees.1 It also included specific allegations about the rate at which intrusive gynecological procedures were performed on ICE detainees in ICDC custody. In response to this complaint, numerous hotline complaints DHS OIG recieved,2 and congressional requests, we sought to determine whether ICDC provided adequate medical care to detainees and whether COVID-19 protections were in place and adequate.

This inspection did not review the gynecological procedure approval process for detainees at ICDC, which has been referred to our Office of Investigations. We also initiated a separate audit which will focus on how surgical procedures are authorized and approved for detainees across ICE detention facilities. Background ICE apprehends, detains, and removes noncitizens who are in the United States unlawfully. ICE Enforcement and Removal Operations (ERO) oversees the detention of noncitizens in approximately 150 detention facilities in conjunction with private contractors or state or local governments.

ICDC is owned by LaSalle Corrections and operates under an intergovernmental service agreement (IGSA) as an ICE detention facility.3 As of February 2021, ICDC held 236 male and 9 female immigration detainees. In addition to ICE detainees, the facility houses Federal prisoners for the U.S. Marshals Service and Irwin County inmates. In May 2021, Secretary Mayorkas announced DHS 1 Allegations regarding reprisal or retaliation against employees were referred to another DHS OIG office. 2 Between FY 2017 and FY 2020, the DHS OIG Hotline received 795 complaints referencing ICDC.

Many Hotline complaints originated from detainees in the facility, family members of detainees within the facility, and those who had previously been detained at ICDC. 3 ICE uses DHS authority under the Immigration and Nationality Act to enter into IGSAs with state or local entities (e.g., a county sheriff or a city government). These entities, in turn, may contract with a private company to provide detention services, or provide the services using local law enforcement entities (such as a local jail that holds local criminal populations and ICE detainees). The Immigration and Nationality Act, as amended, grants ICE the authority to enter into an agreement with a state or locality to provide necessary clothing, medical care, requisite guard hire; and the housing, care, and security for detained individuals.

See 8 United States Code (U.S.C.) § 1103(a)(11)(A). www.oig.dhs.gov 3 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security plans to discontinue the use of ICDC as soon as possible and transfer all detainees whose continued detention is necessary. ICE terminated the contract with LaSalle Corrections effective October 7, 2021, and as of September 3, 2021, ICE no longer housed(cid:3)detainees at ICDC. ICDC is required to follow the 2011 ICE Performance-Based National Detention Standards (PBNDS).4 According to ICE, the PBNDS reflect ICE's ongoing effort to tailor the conditions of immigration detention to its unique purpose while maintaining a safe and secure detention environment for staff and detainees. ICE detention standards require that all facilities provide detainees with access to appropriate and necessary medical, dental, and mental health care, including emergency services.

These standards also require facilities to have written plans that address the management of infectious and communicable diseases, including, but not limited to, education, prevention, testing, and isolation. ICE Health Service Corps (IHSC) provides direct on-site medical services in at least 20 facilities that house ICE detainees for more than 72 hours. At all other detention facilities, including ICDC, local government staff or private contractors deliver on-site care while IHSC provides general oversight of those facilities’ medical services.5 ICE ERO also provides on-site management of detention operations in an effort to ensure a safe and secure detention environment for staff and detainees. At the time of our review, the ICE staff at ICDC included a detention standards compliance officer from ICE ERO Custody Management, as well as an ERO supervisory detention and deportation officer, and three deportation officers, some on permanent and some on temporary bases.6 On March 11, 2020, the World Health Organization declared the outbreak of the infectious and communicable COVID-19 a pandemic.

In March 2020, ERO decided to reduce the population of all detention facilities to 75 percent capacity or less, to allow for greater social distancing.7 When we initiated this 4 ICDC followed the 2008 PBNDS until June 15, 2020. 5 IHSC does not directly provide or direct the medical care in approximately 148 non-IHSC- staffed detention facilities. IHSC oversees those facilities’ compliance with national detention standards and coordinates medical referrals through the Field Medical Coordinator Program. In addition, IHSC oversees the financial authorization and payment for off-site specialty and emergency care services for detainees in ICE custody.

6 In lieu of assigning all deportation officers at ICDC on a permanent basis, some ICE officers have temporary duty (TDY) assignments to ICDC, which can be voluntary or mandatory, with an average detail length of 60 days. 7 Since March 1, 2020, ICE ERO has decreased its detainee population by more than 7,000 individuals. In March 2020, ERO evaluated its detainee population and released more than www.oig.dhs.gov 4 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security review in October 2020, ICDC had an average daily population (ADP) of 406, compared with 878 detainees in October 2019, a 54 percent reduction. Although ICE reduced the ICDC ADP and the facility enhanced COVID-19 sanitation protocols, we were not able to determine if these actions had a direct effect in mitigating the spread of COVID-19 in the facility.

Table 1 shows the reduced ADP at ICDC from October 2019 to March 2021. Table 1. ICDC Average Detainee Population (ADP), October 2019 to May 2021 Month October 2019 November 2019 December 2019 January 2020 February 2020 March 2020 April 2020 May 2020 June 2020 July 2020 August 2020 September 2020 October 2020 November 2020 December 2020 January 2021 February 2021 March 2021 April 2021 May 2021 Female ADP 344 324 296 292 297 277 189 140 127 119 113 100 85 71 50 24 9 5 1 0 Total ADP 878 819 758 745 717 631 583 534 479 510 482 436 406 369 369 320 245 185 113 271 Male ADP 533 495 462 453 420 354 395 393 352 391 369 336 321 298 319 296 236 180 111 271 Source: ICE Integrated Decision Support. Note: Due to rounding, the total ADP may not equal the sum of the male and female ADP for each month.

In response to the pandemic, the Centers for Disease Control and Prevention (CDC) issued its Interim Guidance on Management of Coronavirus Disease 2019 900 individuals who might be at higher risk for severe illness as a result of COVID-19, after evaluating their immigration history, criminal record, potential threat to public safety, flight risk, and national security concerns. ERO continues to assess other potentially vulnerable populations currently in ICE custody and all new arrestees. Additionally, ERO has fewer new detainees coming from U.S. Customs and Border Protection, resulting from Title 42 restrictions. See https://www.ice.gov/coronavirus and 42 U.S.C. § 265, 268 (b). www.oig.dhs.gov 5 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (COVID-19) in Correctional and Detention Facilities, to “ensure continuation of essential public services and protection of the health and safety of incarcerated and detained persons, staff, and visitors.”8 The CDC frequently updated this guidance on its website between March 2020 and June 2021 as more information about COVID-19 became available.

Based on CDC guidance, ICE provided Pandemic Response Requirements (PRR) to help facility operators “sustain detention operations while mitigating risk to the safety and well-being of detainees, staff, contractors, visitors, and stakeholders due to COVID-19.”9 ICE first issued the PRRs in April 2020 and subsequently released five updated versions as COVID-19 protocols evolved. The objective of our review was to determine whether ICDC provided adequate medical care to detainees and whether COVID-19 protections were in place and adequate.10 We conducted our work remotely, given the inherent risks associated with on-site inspections during the COVID-19 pandemic.11 We interviewed ICE personnel, ICDC officials, and detainees by telephone. We also viewed surveillance video from common and housing areas. To assess medical care, we utilized medical experts from the National Commission on Correctional Health Care (NCCHC) Resources, Inc.12 to conduct a virtual tour of the ICDC medical unit and medical records review.

Results of Inspection We determined ICDC generally met ICE detention standards, which specify that detainees have access to appropriate and necessary medical, dental, and mental health care. However, the NCCHC Resources medical team’s evaluation of ICDC’s medical processes found the facility’s chronic care, continuity of care, and medical policies and procedures to be inadequate. The medical team identified additional concerns in seven other areas: health assessments, medication administration, sick call, health records, program administration, emergency care, and women’s health. Similar to our findings on the ICE detention standards, the facility generally complied with CDC and ICE COVID- 19 guidance, but ICDC and ICE management did not adequately or 8 https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance- correctional-detention.html.

9 ERO, COVID-19 Pandemic Response Requirements (Version 1.0, April 10, 2020). 10 DHS OIG is also conducting a separate, in-depth evaluation of ICE’s handling of COVID-19 in its detention facilities. 11 At the time of this review, COVID-19 vaccines were not widely available. 12 NCCHC Resources, Inc. works to strengthen the mission of its parent company (NCCHC), to improve the quality of health care in prisons, jails, and juvenile detention and confinement facilities.

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Resources was created to manage the increasing demand for correctional health care technical assistance and other consulting work through the provision of high- quality consulting services. https://www.ncchc.org/work www.oig.dhs.gov 6 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security consistently keep facility employees, ICE staff, and detainees informed of COVID-19 protocols and guidance. We also found that detainees’ communication with, and access to, their ICE deportation officers were limited. Further, some ICE officers stated they were not comfortable expressing concerns about detention conditions during the pandemic. Medical Care Provided to Detainees Generally Met Standards, but Improvements Are Necessary We determined ICDC adhered to ICE 2011 PBNDS, which specify that detainees have access to appropriate and necessary medical, dental, and mental health care.13 Our contracted medical team assessed the adequacy of medical processes and policies and the appropriateness of any actions taken to address medical concerns.14 NCCHC Resources’ full report evaluating the 36 defined medical care processes is included as Appendix C. Of those 36 processes, NCCHC Resources determined 3 — chronic care, continuity of care, and policies and procedures — were inadequate.15 The medical team identified additional concerns in seven other areas: health assessments, medication administration, sick call, health records, program administration, emergency care, and women’s health.16 These results should be considered in the context that medical care in fiscal year 2020 was provided to a detainee population in ICDC that was significantly less than normal, due to the COVID-19 pandemic.

ICDC Medical Unit Needs to Improve Chronic Care Program Organization, Continuity of Care, and Policies and Procedures The contract medical team reviewed 37 medical files with chronic care diagnoses. The team determined that care for chronic conditions, such as hypertension, hyperlipidemia, diabetes, asthma, and menstrual disorders, appeared adequate, but that the chronic care program itself was inadequate.17 Of the 37 medical files reviewed, the NCCHC Resources physician identified 13 ICE, Performance-Based National Detention Standards, 2011, § 4.3, Medical Care (Revised Dec. 2016) (“PBNDS 2011”). 14 NCCHC Resources’ review included 195 medical records of detainees with stays at ICDC of 180 days or longer between FY 2017 and FY 2020, as well as the provision of care for 37 detainees who had chronic care conditions.

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Resources also reviewed 5 medical records resulting from our interviews with ICDC detainees. 15 See Appendix C, Policies and Procedures, pp. 38–39; Chronic Care, pp. 44–45; and Continuity of Care, pp.

45–46. 16 See Appendix C, Health Assessments, pp. 40–41; Pharmacy Management/Medication Management, pp. 49–50; Sick Call/Nursing Protocols, pp.

43–44; Health Records, p. 38; Program Administration, p. 37; Emergency Care, p. 48; and Women’s Health, pp. 46–47. 17 See PBNDS 2011, § 4.3, Medical Care, W. Special Needs and Close Medical Supervision. www.oig.dhs.gov 7 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security issues in 15 files related to chronic care management.18 Our contract medical team found the medical unit did not have consistent guidance or provider- developed guidelines for chronic care; rather, ICDC medical staff reported using several different guidance documents for care. The contract medical team also found provider staff were not monitoring and documenting the current status or condition of detainees with chronic conditions.

In addition, the contract medical team identified records where providers acknowledged laboratory results, but did not include interpretation of those results, actions taken regarding those results, and proof of sharing the results with the detainee. The NCCHC Resources physician identified issues regarding the continuity of care process19 in 12 of the 37 detainee medical files reviewed.20 In nine of the cases, the physician highlighted issues with both continuity of care and chronic care. These issues included multiple medical files missing care plans,21 records without planned chronic care visits,22 missing laboratory results,23 and improper medications.24 We also found issues in medical records, including unexplained orders, grievance responses, improper referrals, and timeliness concerns.25 The contract medical team deemed ICDC’s policies and procedures process inadequate because ICDC had not established facility-specific policies and procedures. Instead, it relied on overarching policies and procedures established by the facility contractor, LaSalle Corrections.

For example, we found the terminal illness policy references Louisiana state laws, even though ICDC is located in the state of Georgia.26 Additionally, a detainee medical restraint and seclusion policy exists despite ICDC reporting that the facility does not use either method in the ICDC medical facility. Without clear written policies and procedures specific to the facility, ICDC staff do not have adequate guidance. As a result of the lack of facility specific policies, the facility was also found to be delinquent on annual reviews of facility-specific policies and 18 For chronic care issues, see cases 1, 4, 8–9, and 13–20 in Appendix C. 19 PBNDS 2011, § 4.3, Medical Care, Z. Continuity of Care. Continuity of care requires the facility Health Service Administrator to ensure a plan is developed that provides for continuity of medical care in the event of a change in detention placement or status.

20 For continuity of care issues, see cases 2–4, 6, 8, 10–17, and 19–20 in Appendix C. 21 Appendix C, cases 6, 10–12, and 14–15. 22 Appendix C, cases 2, 4, 11, and 13. 23 Appendix C, cases 1, 9–10, 12, and 19–20. 24 Appendix C, cases 3, 5, 7–8, 11, 16, 18, and 20.

25 Appendix C, see case 20 for unexplained order, case 4 for issues with grievances, case 3 for improper referrals, and case 17 for timeliness concerns. 26 It appears ICDC’s terminal illness policy referenced Louisiana state laws because ICDC was using a policy from another LaSalle detention facility located in Louisiana. www.oig.dhs.gov 8 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security procedures, which are necessary to ensure appropriate updates are made when said policies and procedures are in place. ICDC Needs to Improve Health Assessments, Medication Administration, Sick Call, Health Records, Program Administration, Emergency Care, and Women’s Health Health Assessments The contract medical team reviewed 195 detainee intake records and found that care was timely and complete, with only 3 records indicating minor issues that were not reflections of an inefficient intake program.27 Overall, ICDC’s compliance with standards in this area was adequate, but there is room for improvement. For example, we found ICDC does not have defined health assessment criteria to provide consistent and adequate periodic health assessments.28 We also identified 7 records indicating the health assessment occurred after the required 14-day timeframe, and 15 records missing health assessment documentation.

Additionally, the NCCHC Resources physician found one case where a detainee reported at intake a history of asthma with previous inhaler use, but the initial health assessment of the detainee, days later, did not acknowledge that health history.29 Medication Administration Process The 2011 PBNDS require prescriptions and medications to be ordered, dispensed, and administered in a timely manner and as prescribed by a licensed health care professional.30 Although the pharmacy and the medication management processes were found to be adequate, some issues in medication administration exist. For example, our medical contractors found it “almost impossible to provide an accurate assessment of medication administration practices based on the documentation provided in the health record.”31 To complete the medication assessment review, the medical team 27 PBNDS 2011, § 2.1, Admission and Release. Intake occurs within 12 hours of a detainee’s arrival at the facility and prior to placement in the general population. A more in-depth initial health care assessment occurs after intake, approximately 14 days after a detainee’s arrival at the facility.

PBNDS 2011, § 4.3, Medical Care. Each detainee shall receive a comprehensive health assessment, including a physical examination and mental health screening, by a qualified, licensed health care professional no later than 14 days after entering into ICE custody or arrival at facility. 28 See Appendix C. 29 Asthma is a chronic care condition that requires continuous and ongoing care. See Appendix C, case 4.

30 PBNDS 2011, § 4.3, Medical Care. 31 Appendix C, report p. 16. www.oig.dhs.gov 9 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security needed the original order, documentation of first dose, and the medication administration record, which were missing from the health records provided from ICDC. To determine the quality of medication services, the contracted medical team reviewed 37 chronic care health records. Of the 37 records, 22 indicated detainees were seen by a provider, received their medication promptly, and were found to have properly taken the medication.

The remaining 15 records showed detainees’ general lack of compliance taking medication. Nursing staff documented detainees who did not show up for pill call, but the records did not have detainee signatures demonstrating refusal of the medication.32 Additionally, only some detainees received provider’s education on the importance of medication administration. During our interviews, a detainee reported difficulty receiving medication, and we referred the case to the NCCHC Resources physician for review.33 This record revealed the detainee did not show up for medication pass34 to receive the prescribed medication for most of July and part of August 2020. The medical staff did not adhere to the facility policy requiring provider medication counseling after 3 days of missed medication.

The detainee was not seen by a provider until August 9, 2020. Sick Call and General Nursing Protocols The NCCHC Resources team found co-related issues in the areas of sick call and nursing protocols.35 They reviewed 195 health records with 236 sick call visits. The team determined that care provided during 8 of the 236 visits could have had been more appropriate. The team also found issues with nursing protocols that allow the nursing staff to provide over-the-counter medications without checking the current medications the detainee is prescribed.

For example, the nursing protocols allow nurses and licensed practical nurses (LPN) to administer appropriate amounts of ibuprofen to detainees, resulting in some detainees receiving ibuprofen while already on other non-steroidal anti- inflammatory drugs (NSAID), which the NCCHC Resources team determined 32 PBNDS 2011, § 4.3, Medical Care. ICE requires facilities to maintain written records of all prescribed medication given to or refused by detainees. 33 Appendix C, case B. 34 Medication pass is the administering of prescribed drugs by nurses or aides to a group of patients or residents, in accordance with state and federal standards. 35 2011 PBNDS, § 4.3, Medical Care, S. Sick Call.

Facilities are required to have sick-call procedures that allow detainees unrestricted opportunity to freely request health care services and that ensure sick-call requests are received and triaged by appropriate medical personnel within 24 hours of the detainees’ requests. At ICDC, detainees are able to make sick-call requests using electronic tablets or by submitting paper requests into a confidential lockbox. www.oig.dhs.gov 10 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security was inappropriate.36 An ICDC provider specifically stated in one medical record that the detainee was not to be prescribed NSAIDs. However, the detainee was prescribed an NSAID 3 days later during a sick-call visit by a different provider. The current facility-established nursing protocols would not identify this medication administration as inappropriate.37 During our interviews on February 24, 2021, one detainee reported being referred to a provider during a sick-call visit but was restricted from seeing a provider due to being under a quarantine.

We referred this case to the NCCHC Resources physician who reviewed the medical record and found the detainee had been referred to a provider on February 12, 2021, but there was no documentation indicating a provider had ever seen the detainee.38 On-site medical staff assured the team that quarantine does not limit a detainee’s ability to be seen by a provider. However, staff could not supply documentation showing a provider saw the detainee. Health Records During the health records review, the contracted medical team was unable to determine if a Health Insurance Portability and Accountability Act (HIPAA) program was in place and properly applied. No evidence of HIPAA training was provided to the medical team for evaluation, despite the team’s request.

Overall Program Administration The program administration review found ICDC’s medical unit had not developed a continuous quality improvement program. The purpose of a continuous quality improvement program is to improve health care by identifying problems, implementing and monitoring corrective action, and studying the improvement program’s effectiveness. ICDC did not provide documentation showing any organized approach to evaluate the delivery of health care services. 36 Appendix C cases 3, 5, and 18.

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Resources defines nursing protocols as written instructions or guidelines that specify the steps to be taken to evaluate a patient’s health status and provide intervention. These protocols include acceptable first-aid procedures and care of ailments that would ordinarily be treated with over-the-counter medication or through self-care. 37 Appendix C, case 18. 38 Appendix C, case A. www.oig.dhs.gov 11 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Emergency Care During the emergency care review, despite NCCHC Resources’ request, the medical unit was unable to provide emergency response drill documentation, making it unclear whether the drills were being conducted.

Lack of emergency preparation, such as conducting drills, could hinder proper response to emergency situations at ICDC. Women’s Health Based on its medical records review, the NCCHC Resources team determined women’s health care to be appropriate.39 However, off-site specialty provider care information was not consistently returned to the ICDC medical unit. Proper health assessments, medication administration, sick-call procedures, and general nursing protocols are necessary to ensure that sufficient care is provided to detainees. Appropriate documentation, procedures for health records, and off-site documentation related to women’s health care ensure adequate care is provided to each individual detainee.

Continuous quality improvement protocols ensure responsiveness to detainee needs. Additionally, having emergency response plans ensures personnel and detainee safety while in the medical unit. ICDC Generally Complied with CDC and ICE COVID-19 Guidance, but Has Faced Challenges Implementing Protocols The Project South complaint letter described allegations regarding the lack of COVID-19 protections at ICDC. Specifically, the complaint alleged the facility: (cid:120) did not implement social distancing; (cid:120) did not provide sufficient face masks for detainees and allowed employees to enter the facility without wearing personal protective equipment (PPE); (cid:120) allowed detainees with COVID-19 to transfer into the facility, and (cid:120) transferred detainees with COVID-19 out of the facility; failed to test detainees for COVID-19 who exhibited symptoms such as coughing or fever; and (cid:120) allowed employees with COVID-19 symptoms to report to work.

39 The NCCHC Resources team did not evaluate the specific allegations of inappropriate gynecological care, as those have been referred to our Office of Investigations. www.oig.dhs.gov 12 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security We discussed these issues with detainees and staff, and reviewed records and video footage from the facility to determine whether we could substantiate these allegations. ICDC generally complied with guidance, but we identified issues with social distancing, wearing of PPE, and routine testing for COVID- 19. Our findings for each of the allegations follow. Allegation: ICDC Did Not Implement Social Distancing The team found that ICDC did not adequately implement and enforce social distancing protocols.

CDC guidance recommends prevention practices for detainees and staff in detention facilities to include implementing social distancing strategies and wearing face masks to help reduce the risk of transmission and severe disease from COVID-19.40 ICE’s PRR provide additional social distancing measures for detention facilities to implement, if practicable, such as housing detainees in individual rooms, rearranging beds in housing areas to maintain 6 feet of separation, and having detainees sleep “head-to-foot” in shared sleeping quarters. We found ICDC staff and detainees did not always observe or enforce these protocols. In our interviews, female detainees expressed concerns about being moved to a dorm where they had difficulty social distancing. ICDC’s ADP of female detainees decreased from 100 in September 2020 (when the complaint was sent) to 9 in February 2021, with all females consolidated into two dorms.

Detainees described these dorms as double-wide trailers with the beds very close together (2 feet apart), minimizing their ability to be 6 feet apart from each other. The security camera footage from one of these dorms corroborated the bunk beds had very little space between them. We also noted that female detainees in the dorm did not wear masks or practice social distancing with each other while in the common areas of the dorm. During our review of ICDC security footage from cameras throughout the facility, we observed instances of detainees and staff members near each other while not wearing masks.

Staff told us detainees are required to wear masks outside dormitory areas and are encouraged to wear masks and practice social distancing within the dorms, but detainees often choose not to do so within the dorms. The September 2020 ICE guidance makes no distinction between the need for mask-wearing inside or outside dormitory areas. The facility risks additional COVID-19 spread by not ensuring detainees practice social distancing and wear masks within the dormitory area and housing units. 40 CDC, Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities Guidance for Correctional & Detention Facilities (July 2020). www.oig.dhs.gov 13 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Allegation: ICDC Did Not Provide Sufficient Face Masks for Detainees and Allowed Employees to Enter the Facility without Wearing PPE The team confirmed that ICDC encountered problems obtaining and distributing masks to detainees and staff at the beginning of the COVID-19 pandemic.

As of April 2020, ICE PRR guidance recommended detainees and staff wear cloth masks to help slow the spread of COVID-19. ICE updated the PRR guidance in July 2020 to require facilities to provide cloth masks to detainees at no charge, which the facility did beginning in May 2020. However, we heard in numerous interviews that confusion at the beginning of the pandemic made for a late and inconsistent implementation of mask distribution and wearing. For example, an ICDC officer said that, at the beginning of the pandemic, employees were instructed by management not to wear masks.

ICE officers also confirmed that, at the beginning of the pandemic, the facility had limited numbers of masks and gloves available for ICDC officers and detainees, but ICE provided masks and gloves for ICE personnel. ICDC management acknowledged that its mask roll-out was slow, which it attributed to confusion over guidance. Most detainees and staff we interviewed told us the staff wore their masks consistently. Staff also said they were required to wear masks and PPE or would face disciplinary action.

Our review found that ICDC did not consistently ensure staff appropriately wore masks. We reviewed surveillance video footage from February 22, 2021, and March 10, 2021, and observed facility staff not wearing masks or practicing social distancing (see Figures 1 and 2). Figures 1 and 2. ICDC staff not wearing masks and not practicing social distancing on February 21, 2021.

Source: Video surveillance footage provided by ICDC. www.oig.dhs.gov 14 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security In addition, most ICDC staff we interviewed said they were comfortable reporting to work with the COVID-19 protocols that were in place. Those who expressed a degree of discomfort listed the following as potential concerns: (cid:120) possibility of contact with asymptomatic detainees; (cid:120) uncertainty of PPE protection when in direct contact with COVID-19 positive detainees; lack of consistency enforcing facility entrance protocols; and lack of COVID-19 testing for facility staff. (cid:120) (cid:120) Allegation: ICDC Allowed Detainees with COVID-19 to Transfer into the Facility, and Transferred Detainees with COVID-19 out of the Facility The team found that ICE transferred a small number of COVID-19 positive detainees in and out of ICDC during the COVID-19 pandemic. This was in line with ICE guidance as an operational requirement.

ICE PRR guidance allows for the limited transfer, where possible, of ICE detainees to and from other jurisdictions and facilities. The transfers may occur, if necessary, for medical evaluation, medical isolation/quarantine, clinical care, extenuating security concerns, to facilitate release or removal, or to prevent overcrowding. According to ICE, between March 2020 and March 2021, one detainee transferred out of ICDC to another facility, and two detainees transferred into ICDC from another facility, while positive for COVID-19. Other detainees were repatriated or released, including two detainees who were released after testing positive for COVID-19.

As of October 2020, CDC guidance did not require detainees to be COVID-19 negative before transfer or release. We interviewed ICDC intake officers and reviewed ICE PRR and ICDC intake policies and procedures and determined that ICDC adhered to proper procedures when transferring detainees with a positive COVID-19 test. Allegation: ICDC Failed to Test Detainees for COVID-19 Who Exhibited Symptoms Such as Coughing or Fever We found that, although ICDC has implemented testing and other procedures to slow the spread of COVID-19, it did not routinely test asymptomatic detainees. CDC guidance states that detainees exhibiting COVID-19 symptoms should be separated from other detainees and get tested.

The guidance does not dictate testing of asymptomatic detainees. However, it suggests facilities consider strategies for testing asymptomatic detainees without known exposure to COVID-19 for early identification of COVID-19 in the facility. As of July 2021, ICDC reported 146 detainees with confirmed COVID-19 infections, and no detainee deaths in the facility were attributed to COVID-19. www.oig.dhs.gov 15 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security According to testing records we reviewed, ICDC tested a detainee for COVID-19 for the first time on March 31, 2020. During April and May 2020, ICDC tested a total of 57 detainees.

We were not able to determine the reason for testing these detainees because ICDC did not track the reason for testing. However, ICDC staff members told us that all detainees are tested upon intake and whenever they present COVID-19 symptoms. In August 2020, ICDC tested 499 detainees; 461 of the detainees were tested on August 18 during a facility-wide test. All 12 detainees we interviewed in February 2021 indicated they had been tested for COVID-19 at least once while detained at ICDC.

Instead of testing asymptomatic detainees, the facility used a cohorting approach.41 ICDC staff used the “cohort” term to refer to dorms that house detainees during quarantine.42 Interviewees consistently stated that when a detainee tested positive for COVID-19, the detainee was put in medical isolation,43 and the rest of the dorm residents were quarantined together and monitored for symptoms. The neighboring dorms were also monitored for COVID-19 symptoms. Allegation: ICDC Allowed Symptomatic Employees to Work We were not able to confirm this allegation as the ICDC policy requires employees and visitors to self-report COVID-19 symptoms. As of October 2020, CDC guidance required symptomatic staff to self-quarantine.

To ensure continuity of operations, staff could continue to work following potential exposure if they remained asymptomatic and additional precautions were implemented to protect them and others. In order to enter the facility, employees and visitors must have completed a COVID-19 questionnaire and had their temperature taken by an automated temperature scanner.44 One staff member described witnessing officers at the main entrance not taking seriously their responsibility to perform temperature self-screenings and not paying attention when the reader identified an abnormal temperature. All of the other staff members we spoke with said employees with symptoms were not allowed to work. Several staff we spoke with had either contracted COVID-19 41 ICE ERO’s PRR defines cohort as a group of persons with a similar condition grouped or housed together for observation over a period of time.

42 Quarantine is the separation of a person or group of people reasonably believed to have been exposed to a communicable disease but not yet symptomatic, from others who have not been exposed, to prevent the possible spread of the communicable disease. 43 Isolation is the separation of a person or group of people known or reasonably believed to be infected with a communicable disease and potentially infectious from others to prevent the spread of the communicable disease. 44 ICDC COVID-19 Employee/Visitor/Attorney/Contractor Screening Form. www.oig.dhs.gov 16 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security or had close contact with a family member with COVID-19 and were familiar with the protocols for self-identifying and not reporting to work. Communication about COVID-19 to ICE Officers, Facility Staff, and Detainees Was Inconsistent Our review of ICDC’s response to COVID-19 identified issues with communication to ICE officers, facility staff, and detainees.

First, staff and detainees reported not receiving consistent information regarding positive COVID-19 cases within the facility. Additionally, confusion existed among staff and detainees regarding access to PPE. Lastly, detainees reported not being informed of their cohort or quarantine status, their COVID-19 test results, or facility COVID-19 protocols. Positive Cases of COVID-19 Were Not Appropriately Communicated to ICE Officers, Facility Staff, and Detainees At the time of our review, CDC guidelines stated facilities should provide clear information to detainees and staff about the presence of COVID-19 in the facility and the protections in place.

However, opinions varied among ICE, ICDC staff, and the detainees regarding the quality and extent of COVID-19 communication. Specifically, on-site ICE officers, ICDC staff, and detainees complained about poor communication and a lack of transparency about suspected and confirmed cases in the facility. One ICE officer described not hearing about confirmed cases at the facility from ICE management or facility staff prior to arriving for a TDY assignment. Another ICE officer said the ICE field office would send ICE staff electronic notifications regarding potential exposures to detainees with COVID-19, stating there were no exposures to staff, but the officer did not believe ICE was asking the on-site ICE staff if they had contact with those detainees, to confirm no exposure had occurred.

Facility staff also expressed concerns about the lack of communication regarding positive COVID-19 cases in the facility. One ICDC officer described an instance when officers and a supervisor on-duty unknowingly entered a dorm that was housing detainees with confirmed COVID-19 cases. During our interviews with 12 detainees, we heard similar concerns over insufficient COVID-19 communication. Detainees reported learning about COVID-19 protections, such as needing to wear PPE and social distance, from a variety of external sources such as other facilities, news stations, or family and friends.

Only five detainees said they received some instruction from the facility through staff or posters on the walls; two detainees claimed they never received any instruction. One detainee described facility staff communication with detainees as “poor,” explaining that, while their previous facility provided www.oig.dhs.gov 17 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security direct communication from the warden regarding the COVID-19 pandemic, ICDC did not. ICDC Staff Were Aware of COVID-19 Protocols, but Access to Respirator Masks Varied We found that ICDC had adequate policies related to COVID-19 protocols and maintained an adequate supply of PPE, including face masks, gowns, and gloves. These COVID-19 policies included intake procedures for detainees entering the facility, employee screening procedures, facility sanitation procedures, and general infectious disease protocols.

ICDC staff we spoke to understood that masks and gloves were required in the facility and that KN95 or N95 masks and gowns were required in dorms with confirmed COVID-19 cases. Staff we spoke to reported receiving hands-on training for the use of masks and gloves from facility medical staff, supervisors, or prior employers. However, ICDC officers from various units in the facility gave inconsistent answers about the availability of, and the protocols for, obtaining and using KN95 and N95 masks.45 For example, one ICDC officer said it was possible to get a new respirator mask whenever one was needed. Another said ICDC officers were issued a KN95 mask every 30 days and described replacing one as a “hassle.” Yet another officer said respiratory masks were issued every 3 days.

Despite hands-on training and an adequate supply of all types of protective masks and gloves, confusion remained among staff about their use and availability. ICDC Did Not Consistently Ensure Detainees Were Notified of COVID-19 Quarantine, Cohorting, or Testing Status and Facility COVID-19 Protocols We found detainees were not receiving results of their COVID-19 testing, and some feared reporting COVID-19 symptoms. ICDC conducted facility-wide COVID-19 testing in August 2020, but nine detainees we spoke with said they were never provided the results of their test. We also found detainees were not being informed of their quarantine or cohorting status.

Of the 12 detainees we interviewed, 11 described being cohorted for COVID-19 quarantine either upon arrival or sometime during their stay at ICDC. However, only six of these 45 In April 2020 the Food and Drug Administration (FDA) approved an Emergency Use Authorization (EUA) for use of KN95 respirator masks by health care personnel. KN95 masks do not meet the National Institute for Occupational Safety and Health (NIOSH) standards for approval as a level of respiratory protection. In June 2021, the FDA revoked the EUA. www.oig.dhs.gov 18 OIG-22-(cid:20)(cid:23) (cid:97) OFFICE OF INSPECTOR GENERAL Department of Homeland Security detainees were informed of their quarantine status, while five of the detainees reported not having the situation explained to them.46 The lack of communication caused additional issues among detainees, including fear of reporting symptoms.

A detainee described an incident where dorm residents witnessed another detainee report COVID-19 symptoms and get removed from the dorm without explanation. After the incident, the detainee explained that some detainees experienced possible COVID-19 symptoms but refused to report the symptoms out of fear of segregation.47 Detainees’ Access to ICE Deportation Officers Was Limited during the COVID-19 Pandemic According to PBNDS, security, safety, and orderly operation of a detention facility relies on a system that encourages and requires informal, direct, and written contact among staff and detainees, as well as informal supervisory observation of living and working conditions. Although the PBNDS are very specific as to how ICE should interact with detainees, compliance with those provisions was limited at ICDC due to COVID-19 travel restrictions and the apparent reluctance of ICE officers to visit detainee dorms. The 2011 PBNDS require ICE officers to respond to detainee questions and requests in 3 to 5 business days, depending on the location of the ICE ERO officer.48 Detainees’ requests normally include questions regarding immigration case information, medical care, facility conditions, and assistance locating family.

In March 2020, ICE ERO notified detention centers and field offices that detainees may experience increased feelings of fear and confusion during the pandemic and should have frequent opportunities for interaction with ERO field office staff.49 ICDC is located approximately 185 miles from the 46 Most detainees who were not aware of their cohort or quarantine status described living conditions such as being placed in single cells, having meals brought to them, having their temperatures checked daily, or being put into medical isolation. All descriptions matched the ICDC incoming detainee procedures that required detainees to cohort prior to entering general population. 47 Segregation is the process of separating certain detainees from the general population for administrative or disciplinary reasons. Disciplinary segregation is a punitive form of separation from the general population imposed after a finding by a disciplinary hearing panel that the detainee is guilty of a serious prohibited act or rule violation.

Administrative Segregation is a nonpunitive status in which detainees are separated from the general population to ensure the safety of detainees and others, the protection of property, or the security or good order of the facility. PBNDS 2011, § 2.12 Special Management Units. 48 PBNDS 2011, § 2.13, Staff-Detainee Communication. 49 ICE Memorandum on Coronavirus Disease 2019 (COVID-19) Action Plan, Revision 1 (March 27, 2020). www.oig.dhs.gov 19 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Atlanta ERO Field Office where the detainees’ deportation officers normally work.

Deportation officers we interviewed stated they had primarily performed their duties by telework and had not visited ICDC during the COVID-19 pandemic due to travel restrictions. At the time of our review, three ICE officers were assigned to the facility, and up to three additional officers were detailed on a rotational basis. Detailed officers we interviewed told us they perform a variety of duties to oversee detainee detention, with one officer designated to collect and provide responses to Detainee Request Forms (DRF). The detailed officer responsible for DRFs normally collects them from the locked collection boxes located in each dorm.

The officer records all requests in a logbook and determines whether the request can be answered locally. Many requests are for immigration case information, which then are referred to the assigned deportation officer in the Atlanta Field Office. Two of the detainees we interviewed stated that ICE officers do not check the collection boxes on a regular basis and that DRFs were not readily available in the dorm. Additionally, an ICE officer that was TDY to ICDC stated that one of the assigned ICE officers refused to go to the detainee dorms during the COVID-19 pandemic.

The 2011 PBNDS require the ICE ERO officer receiving the request to normally respond in person or in writing as soon as possible and practicable, but no later than within 3 business days of receipt, for facilities with ICE ERO staff on-site, which is the case with ICDC.50 We reviewed 3,593 requests in the ICDC Detainee Communication Log submitted between January and October 2020, and found that 284 did not receive a response within the 3-day period. An ICE officer detailed to ICDC believed the 3-day response time was not being met because of a mandate for field office staff to telework, which seemed to create delays. The 2011 PBNDS also require each detention center’s local supplement to the detainee handbook to include contact information for the ICE ERO field office and the scheduled hours and days that ICE ERO staff is available to be contacted by detainees at the facility.51 The local detainee handbook supplement must also include procedures to submit written questions, requests, or concerns to ICE ERO staff, and to ensure the availability of assistance to prepare such requests. Of 12 detainees we interviewed, 7 complained about not being able to get in touch with their assigned deportation officers.

One detainee who has been at ICDC since September 2020 reported not knowing the name of the assigned ICE deportation officer and claimed to 50 PBNDS 2011, § 2.13, Staff-Detainee Communication. 51 PBNDS 2011, § 6.1. Detainee Handbook. www.oig.dhs.gov 20 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security have never spoken to him or her. Another detainee at ICDC since May 2020 also reported “never once” being able to communicate with an ICE deportation officer about his/her immigration case, resulting in almost 10 months without questions or requests being addressed.

We reviewed the Lasalle Corrections Southeast Inmate/Detainee Handbooks dated February and December 2020, respectively, and found that neither version had contact information or the scheduled hours and days that ICE ERO staff is available to be contacted by detainees at the facility. Detainees and ICDC Staff Were Generally Comfortable Lodging Concerns, but Some ICE Officers Were Hesitant to Voice Their Concerns The Project South complaint letter described retaliation against staff for reporting concerns about detention conditions at ICDC. We asked ICE and ICDC staff about fear of retaliation for raising concerns about facility operations. We also asked detainees to share any concerns about how they are treated at the facility.

We found that most of the ICDC staff we interviewed did not report fear of retaliation; most said they were comfortable bringing their concerns to either their supervisors or directly to the warden. Several of the staff members reported their voices were not always acknowledged or concerns were not always addressed, and that communication from management could be better. Several ICE officers were hesitant to speak up about conditions at ICDC, specifically regarding COVID-19 protocols. Some did not feel comfortable voicing concerns about the facility conditions.

One ICE officer alleged that a systemic issue existed within ICE leadership in the Atlanta Field Office that is not willing to hear complaints or concerns about detention facilities. The officer further noted that fellow officers were disinclined to complain about ICDC because of the opportunity to receive additional money while TDY to ICDC. The officer also believes there is reluctance to use other means to voice concerns, such as filing an OIG Hotline complaint, due to the impression that one’s identity would be compromised as the calls are recorded. When asked whether detainees had complaints about how they were treated by ICDC officers, detainees we interviewed had a range of opinions, describing some officers as “good,” but others as “rude,” “bossy,” and “kind of crazy.” None of the detainees we interviewed described experiencing physical abuse.

However, some detainees expressed discomfort with the way some facility officers communicated with them, using rude language such as “shut your mouth.” Detainees we spoke with did not provide any specific allegations toward officers or staff and had not filed complaints alleging verbal abuse. One www.oig.dhs.gov 21 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE officer we interviewed recalled, in visits over the course of several years, staff being “very nasty” and “very unprofessional” in the way they addressed detainees and hearing comments from facility and medical staff about detainees that were “degrading and harsh.” Between FY 2017 and FY 2020, detainees at ICDC filed 970 non-medical grievances. In addition, the DHS OIG Hotline received 795 complaints referencing ICDC. Many Hotline complaints originated from detainees in the facility, family members of detainees within the facility, and those who had previously been detained at ICDC.

We found that detainees knew how to file grievances and complaints and did so regularly. When asked about any concerns they had, none referenced being afraid of complaining about facility conditions. However, one detainee explained to us that detainees were afraid to disclose possible COVID-19 symptoms for fear of being sent to isolation or the “hole” as the detainee put it. The detainee said other detainees had symptoms like lack of taste and smell or body aches or a high temperature but did not want to disclose them and tried to hide their symptoms.

Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Atlanta Enforcement and Removal Field Office responsible for Irwin County Detention Center to: Recommendation 1: Ensure IHSC coordinates with ICDC medical unit to update processes and documentation for chronic care cases and develop a continuous quality improvement program. Recommendation 2: Ensure IHSC conducts training with ICDC medical unit about medication administration and health records documentation. Recommendation 3: Coordinate with ICDC management staff to develop a communication plan to keep detainees informed during a pandemic or other emergency situations, and to include related policy and protocols, potential exposures, quarantine/isolation status, and testing procedures. Recommendation 4: Develop a plan to enhance communication among Atlanta Field Office staff, permanent on-site ICE staff, and ICE detailed staff to ensure awareness of pandemic-related policy, protocols, and conditions.

Recommendation 5: Coordinate with ICDC management staff to review and update the ICDC Detainee Handbook to ensure it contains current contact www.oig.dhs.gov 22 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security information for the ICE ERO Atlanta Field Office and the scheduled hours and days that ICE ERO staff are available to detainees. Management Comments and OIG Analysis ICE concurred with one recommendation but did not concur with four recommendations, as it no longer houses detainees at ICDC and its contract with ICDC ended on October 7, 2021. Appendix B contains ICE’s management comments in their entirety. We also received technical comments to the draft report and revised the report as appropriate.

We have administratively closed four recommendations; recommendation 4 is resolved and open. A summary of ICE’s response and our analysis follows. ICE Comments to Recommendation 1: Non-Concur. Because ICE no longer uses ICDC, ICE is required to not concur with this recommendation for procedural reasons, while acknowledging the importance of maintaining appropriate conditions at its detention facilities.

As of September 3, 2021, ICE no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on October 7, 2021. Therefore, ICE cannot implement this recommendation. Should detainees again be housed at ICDC at some point in the future, ICE will ensure that all applicable detention standards are followed, as appropriate. OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on October 7, 2021, and that ICE cannot reasonably implement this recommendation, which we have administratively closed.

However, we reserve the option to reopen the recommendation should ICE reinstate a contract to house ICE detainees at ICDC. ICE Comments to Recommendation 2: Non-Concur. Because ICE no longer uses ICDC, ICE is required to not concur with this recommendation for procedural reasons, while acknowledging the importance of maintaining appropriate conditions at its detention facilities. As of September 3, 2021, ICE no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on October 7, 2021.

Therefore, ICE cannot implement this recommendation. Should detainees again be housed at ICDC at some point in the future, ICE will ensure that all applicable detention standards are followed, as appropriate. OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on October 7, 2021, and that ICE cannot reasonably implement this recommendation, which we have administratively closed. However, we reserve the option to reopen the recommendation should ICE reinstate a contract to house ICE detainees at ICDC. www.oig.dhs.gov 23 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE Comments to Recommendation 3: Non-Concur.

Because ICE no longer uses ICDC, ICE is required to not concur with this recommendation for procedural reasons, while acknowledging the importance of maintaining appropriate conditions at its detention facilities. As of September 3, 2021, ICE no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on October 7, 2021. Therefore, ICE cannot implement this recommendation. Should detainees again be housed at ICDC at some point in the future, ICE will ensure that all applicable detention standards are followed, as appropriate.

OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on October 7, 2021, and that ICE cannot reasonably implement this recommendation, which we have administratively closed. However, we reserve the option to reopen the recommendation should ICE reinstate a contract to house ICE detainees at ICDC. ICE Comments to Recommendation 4: Concur. ICE acknowledges the importance of strong communication practices to fully implement ICE’s policies and protocols that protect employees and people detained by ICE from COVID- 19.

To address this recommendation, the Atlanta Field Office will supplement, reinforce, and enhance a communications plan and leadership will directly engage in enhancements to that plan. To address the need for fulsome communication, the Field Office Director conducts: (1) quarterly “town-halls” for all employees; (2) daily meetings with his staff and Deputy Field Office Directors; and (3) weekly meetings with the Assistant Field Office Directors throughout the area of responsibility. In turn, Assistant Field Office Directors regularly meet with their supervisory staff, as do supervisory staff with their employees. In addition, the Atlanta Field Office has a full-time staff devoted to messaging and sending communications throughout the Field Office, through which all broadcast messages and policies from ICE Headquarters or Field Office leadership are sent to ensure all communication is disseminated to the appropriate parties.

All employees have access to all the broadcast messages and intranet and internet information, and supervisors ensure that all messaging is understood by the employees. Accordingly, on-site facility staff’s responsibility was to ensure that the facility remained compliant with ICE policies and procedures, including compliance with all COVID-19-related protocols. Further, ICE broadcast messages are distributed to all supervisors with COVID-19 decision trees, in accordance with the current communication plan, to assist management with making educated decisions regarding potential or confirmed exposures. www.oig.dhs.gov 24 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security ICE also distributes each new release of the PRR to all ICE employees and shares these updates with all contractors operating ICE facilities. On March 24, 2020, prior to the first PRR, ICE ERO followed established communications guidance to issue a broadcast message to all employees titled “CDC Interim Guidance on Management of COVID-19 for Correctional and Detention Facilities,” and similar broadcast messages and guidance are available to all employees on the ICE intranet under the link “COVID-19 Coronavirus - Updates & Guidance.” In addition to reinforcing the communications practices that the Atlanta Field Office already has in place, the Field Office Director will conduct mandatory bi- weekly meetings with individual detention facilities’ responsible ERO management, senior contract management, IHSC, OPLA, and the COR and/or Detention Standards Manager.

At these meetings, the Field Office Director will personally message select PRR requirements and confirm that relevant stakeholders understand and are implementing those requirements. Moreover, these meetings will allow for an open discussion of all concerns at the facility with full stakeholder participation. OIG Analysis: We consider these actions responsive to the intent of the recommendation, which is resolved and open. We will close this recommendation when we receive documentation showing the Atlanta Field Office implemented the stated enhancements to the communications plan to include evidence of the mandatory bi-weekly meetings with individual detention facilities’ ICE personnel.

ICE Comments to Recommendation 5: Non-Concur. Because ICE no longer uses ICDC, ICE is required to not concur with this recommendation for procedural reasons, while acknowledging the importance of maintaining appropriate conditions at its detention facilities. As of September 3, 2021, ICE no longer houses detainees at ICDC, and ICE’s contract with ICDC ended on October 7, 2021. Therefore, ICE cannot implement this recommendation.

Should detainees again be housed at ICDC at some point in the future, ICE will ensure that all applicable detention standards are followed, as appropriate. OIG Analysis: We acknowledge that ICE’s contract with ICDC terminated on October 7, 2021, and that ICE cannot reasonably implement this recommendation, which we have administratively closed. However, we reserve the option to reopen the recommendation should ICE reinstate a contract to house ICE detainees at ICDC. www.oig.dhs.gov 25 OIG-22-(cid:20)(cid:23) 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.

We initiated this review in response to complaints requesting OIG investigate the health and welfare of detainees at ICDC. We conducted the review remotely, given the travel restrictions and inherent risks associated with on- site inspections during the COVID-19 pandemic. We focused on elements of applicable standards that could be observed and evaluated remotely. We conducted our fieldwork between October 2020 and May 2021.

During this period, we reviewed ICE 2011 PBNDS guidance, ICDC surveillance camera footage, CDC and ICE COVID-19 guidance, and ICDC’s medical, grievance, and complaint logs. We reviewed DHS OIG Hotline complaints from FY 2017 through FY 2020, totaling 795 allegations specific to ICDC. We excluded hotline allegations related to the ongoing OIG investigation (25 allegations) from our review. Additionally, we interviewed 12 detainees in ICDC custody; 26 ICDC staff members, including the warden, deputy warden, and corrections officers; 12 ICE officers assigned or detailed to ICDC; and 6 ICE staff assigned to the Atlanta Field Office.

We utilized a contracted medical team from NCCHC Resources, Inc., to conduct medical record review and a virtual site tour of the ICDC medical unit. The contracted medical team consisted of one physician and two registered nurses. The medical team reviewed a total of 200 detainee records, including 195 randomly selected records for detainees at ICDC for 180 days or longer between FY 2017 and FY 2020, with 5 more added as a result of OIG concerns during detainee interviews. The nursing staff reviewed 158 records, focusing on completeness, timeliness, and proper actions, while the physician focused on 37 chronic care detainees that were identified.

We incorporated information provided by the medical team into our findings and include the full report in Appendix C. We conducted this inspection 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. www.oig.dhs.gov 26 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix B ICE Comments to the Draft Report www.oig.dhs.gov 27 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 28 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 29 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 30 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 31 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix C NCCHC Resources, Inc., Irwin County Detention Center Inspection Report www.oig.dhs.gov 32 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 33 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 34 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 35 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 36 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 37 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 38 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 39 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 40 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 41 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 42 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 43 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 44 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 45 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 46 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 47 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 48 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 49 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 50 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 51 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 52 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 53 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 54 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 55 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 56 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 57 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 58 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 59 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 60 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 61 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 62 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security www.oig.dhs.gov 63 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix D Office of Inspections and Evaluations Major Contributors to This Report Tatyana Martell, Chief Inspector Kimberley Lake de Pulla, Supervisory Lead Inspector Stephen Farrell, Senior Inspector Erika Algeo, Senior Inspector Rebecca Blaskey, Attorney Advisor Jean Choi, Attorney Advisor Stephanie Christian, Independent Referencer www.oig.dhs.gov 64 OIG-22-(cid:20)(cid:23) OFFICE OF INSPECTOR GENERAL Department of Homeland Security Appendix E 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 for Office of Strategy, Policy and Plans Assistant Secretary for Office of Public Affairs Assistant Secretary for Office of Legislative Affairs ICE Liaison Office of Management and Budget Chief, Homeland Security Branch DHS OIG Budget Examiner Congress Congressional Oversight and Appropriations Committees www.oig.dhs.gov 65 OIG-22-(cid:20)(cid:23) 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" tab.

If you cannot access our website, call our hotline at (800) 323-8603, fax our hotline at (202) 254-4297, 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