DHS OIG, OIG-21-32, Violations of ICE Detention Standards at Pulaski County Jail (2021)

Violations of ICE Detention Standards at Pulaski County Jail April 29, 2021 OIG-21-32 DHS OIG HIGHLIGHTS Violations of ICE Detention Standards at Pulaski County Jail (cid:3) April 29, 2021 What We Found Why We Did This Inspection In accordance with the Consolidated Appropriations Act, 2020, we conduct unannounced inspections of U.S. Immigration and Customs Enforcement (ICE) detention facilities to ensure compliance with detention standards. Between November 2020 and January 2021, we conducted a remote inspection of the Pulaski County Jail (Pulaski) to evaluate compliance with ICE detention standards and COVID- 19 requirements. What We Recommend We made five recommendations to improve ICE’s oversight of detention facility management and operations at Pulaski. For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at [email protected] (cid:3) During our unannounced inspection of Pulaski County Jail in Ullin, Illinois, we identified violations of ICE detention standards that threatened the health, safety, and rights of detainees.

In addressing COVID-19, Pulaski did not consistently enforce precautions including use of facial coverings and social distancing, which may have contributed to repeated COVID-19 transmissions at the facility. Pulaski did not meet standards for classification, medical care, segregation, or detainee communication. We found that the facility was not providing a color-coded visual identification system based on the criminal history of detainees, causing inadvertent comingling of a detainee with significant criminal history with detainees who had no criminal history. The facility generally provided sufficient medical care, but did not provide emergency dental services and the medical unit did not have procedures in place for chronic care follow-up.

We also found that the facility was not consistently providing required oversight for detainees in segregation by conducting routine wellness checks. Finally, we found deficiencies in staff communication practices with detainees. Specifically, ICE did not specify times for staff to visit detainees and could not provide documentation that it completed facility visits with detainees during the pandemic. We did find that Pulaski generally complied with the ICE detention standard for grievances.

ICE Response ICE concurred with all five recommendations. We included a copy of ICE’s response in Appendix B. www.oig.dhs.gov OIG-21-32 OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Table of Contents (cid:3) Introduction.................................................................................................... 2 Background .................................................................................................... 2 Results of Inspection.......................................................................................

3 Pulaski Complied with Standards on Grievances.................................... 4 Pulaski Took Some Measures to Prevent the Spread of COVID-19, but Found Some Guidelines Difficult to Enforce ........................................... 4 Improper Identification of Detainee Criminal History Led to Commingling ............................................................................................................. 6 Pulaski Medical Unit Generally Provided Sufficient Care but Needs to Improve Chronic Care Protocols .............................................................

7 Pulaski Medical Unit Does Not Have Emergency or Timely Dental Services ................................................................................................. 8 Welfare Checks for Detainees in Segregation Were Insufficient ............... 8 Detainee Communications Practices Were Deficient ............................... 9 Recommendations.........................................................................................

10 Appendixes Appendix A: Objective, Scope, and Methodology ................................. 15 Appendix B: ICE Comments to the Draft Report ................................... 17 Appendix C: Office of Special Reviews and Evaluations Major Contributors to This Report ................................................................. 24 Appendix D: Report Distribution.........................................................

25 Abbreviations COVID-19 Coronavirus Disease 2019 DO DSM ERO ICE IHSC PBNDS Pulaski Deportation Officer Detention Services Manager Enforcement Removal Operations U.S. Immigration and Customs Enforcement ICE Health Service Corps Performance-Based National Detention Standards Pulaski County Jail www.oig.dhs.gov OIG-21-32 (cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Introduction U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 200 facilities nationwide, but the conditions and practices at those facilities can vary greatly. Although treatment and care of detainees at facilities can be challenging, complying with detention standards and establishing an environment that protects the health, safety, and rights of detainees are vital to effective detention. Our program of unannounced inspections of ICE detention facilities has identified and helped correct 2011 Performance-Based National Detention Standards (2011 PBNDS) violations at facilities across the country. From November 2020 to January 2021, we conducted an unannounced remote inspection of the Pulaski County Jail (Pulaski) in Ullin, Illinois, and identified concerns regarding detainee care and treatment.

Background ICE apprehends, detains, and removes aliens who are in the United States unlawfully. ICE Enforcement and Removal Operations (ERO) oversees the detention facilities that it manages in conjunction with private contractors or state or local governments. Owned and operated by Pulaski County, Pulaski began housing detainees in 1998 and as of September 2020, had an average daily population of 107 detainees and a maximum capacity of 216. ICE’s intergovernmental service agreement with Pulaski requires the facility to comply with 2011 PBNDS, as revised in December 2016.

According to ICE, the 2011 PBNDS establish consistent conditions of confinement, program operations, and management expectations within ICE’s detention system. These standards set requirements for areas such as: (cid:120) environmental health and safety, including cleanliness, sanitation, security, detainee searches, segregation,1 and disciplinary systems; (cid:120) detainee care, e.g., food service, medical care, and personal hygiene; (cid:3) 1 ICE, Performance-Based National Detention Standards, 2011, Section 2.12, Special Management Units (Revised Dec. 2016). Segregation is the process of separating certain detainees from the general population for administrative or disciplinary reasons.

Detainees in segregation at Pulaski are placed in individual cells. Detainees in disciplinary segregation can be held for no more than 30 days per incident, except in extraordinary circumstances. Detainees in disciplinary segregation are allowed out of their cells for 1 hour of recreation time at least 5 days a week. Detainees in administrative segregation are separated from the general population to ensure the safety of all detainees and can be held in segregation until their safety, and the safety of others, is no longer a concern.

Detainees in administrative segregation are allowed out of their cells for up to 2 hours of recreation time at least 7 days a week. Detainees in both disciplinary and administrative segregation are also allowed time out of their cells for showers, phone calls, law library, visitation, and religious services. www.oig.dhs.gov 2 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:120) activities, including visitation and recreation; and (cid:120) grievance systems. As mandated by Congress,2 we conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards. From November 2020 to January 2021, we made an unannounced, remote inspection of Pulaski to determine whether Pulaski complied with ICE’s 2011 PBNDS.

We also conducted a limited review of the facility’s COVID-19 pandemic preparedness measures and its response to outbreaks of COVID-19 across the detainee population.3 We incorporated information provided by the Office of Inspector General’s (OIG) contracted medical experts into our findings. At the start of the inspection, Pulaski housed 113 ICE detainees in different housing units within the facility. During our virtual inspection, we directed a livestream video walk-through of the facility where we inspected Pulaski facilities including detainee housing units, a kitchen, medical units, and indoor and outdoor recreation areas. We viewed surveillance video from areas within the facility including housing units and of specific use of force incidents involving detainees.

We also interviewed ICE personnel, Pulaski officials, and detainees by telephone and video conferencing. Results of Inspection During our unannounced inspection of Pulaski County Jail, we identified violations of ICE detention standards that threatened the health, safety, and rights of detainees. In addressing COVID-19, Pulaski did not consistently enforce precautions including use of facial coverings and social distancing, which may have contributed to repeated COVID-19 transmissions at the facility. Pulaski did not meet standards for classification, medical care, segregation, or detainee communication.

We found that the facility was not providing a color-coded visual identification system based on the criminal history of detainees causing inadvertent commingling of a detainee with significant criminal history with detainees who had no criminal history. The facility generally provided sufficient medical care, but did not provide emergency dental services and the medical unit did not have procedures in place for chronic care follow-up. We also found that the facility was not consistently providing required oversight for detainees in segregation by conducting routine wellness checks. Finally, we found deficiencies in staff (cid:3) 2 Consolidated Appropriations Act, 2020, Pub.

L. No. 116-93, Division D, Department of Homeland Security Appropriations Act, 2020; H.R. Rep. No. 116-180, at 17 (2020); S. Rep. No. 116-125, at 23 (2020). 3 OIG is also conducting a separate, in-depth evaluation of ICE’s handling of COVID-19 in its detention facilities. www.oig.dhs.gov 3 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) communication practices with detainees.

Specifically, ICE did not specify times for staff to visit detainees and could not provide documentation that it completed facility visits with detainees during the pandemic. We did find that Pulaski generally complied with the ICE detention standard for grievances. Pulaski Complied with Standards on Grievances The 2011 PBNDS establishes procedures for detainees to file grievances regarding any aspect of their detention.4 Our review of Pulaski policies, guidance, and grievance records indicated Pulaski complied with the detainee grievance standard. Analysis of detainee grievances from May to November of 2020 showed that Pulaski provided timely written responses to address all detainee grievances.

Pulaski Took Some Measures to Prevent the Spread of COVID- 19, but Found Some Guidelines Difficult to Enforce We conducted a limited review of Pulaski’s response to COVID-19 and identified areas for improvement. Between February 2020 and February 2021, Pulaski has had 111 cases of COVID-19. Although Pulaski took some measures to prevent spread of the virus, such as serving meals in detainee housing areas, restricting visitation and services, and providing detainees hand sanitizer and masks, officials found it difficult to ensure detainees wore masks and practiced social distancing in housing areas. Pulaski Restricted Services and Social Activities in Response to COVID-19 In March 2020, ICE directed Pulaski to restrict several activities in response to the COVID-19 pandemic.5 This included halting in-person social visitation, although still allowing visits from legal representatives.

In response, the facility provided each detainee with 520 free telephone minutes per month to compensate for the lost visitation. The facility suspended dining hall and library services and, instead, delivered meals to detainees in the housing units. In September and October 2020, ICE released additional pandemic response requirements6 for detention facilities and, as of January 2021, the restrictions on detainee activities due to the pandemic remained in place. (cid:3) 4 2011 PBNDS, Section 6.2, Grievance System (Revised Dec.

2016). 5 U.S. ICE Memorandum on Coronavirus Disease 2019 (COVID-19) Action Plan, Revision 1, Mar. 27, 2020. 6 U.S. ICE ERO COVID-19 Pandemic Response Requirements (Version 4.0), Sept.

4, 2020; U.S. ICE ERO COVID Pandemic Response Requirements (Version 5.0), Oct. 27, 2020. www.oig.dhs.gov 4 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Pulaski Did Not Consistently Ensure Detainees Wore Facial Coverings or Practiced Social Distancing The ICE guidance from March 2020 also required Pulaski to assess inventories of personal protective equipment, including masks. We examined facility purchase orders and other records and spoke to Pulaski and ICE staff who told us the facility currently issues each detainee an N-95 type mask upon arrival and a replacement once per week or upon request. Detainees also have access to an abundant supply of disposable, surgical-style facial coverings.

Facility staff stated that they encouraged detainees to wear masks and socially distance, but found it difficult to consistently enforce. They reported also providing oral reminders and posting signs on wearing masks. ICE guidance from September 2020 specifies, “Cloth face coverings should be worn by detainees and staff to help slow the spread of COVID-19.”(cid:3) We reviewed facility surveillance video footage from November and December 2020 and frequently observed detainees gathered in groups, not wearing masks or practicing social distancing (see Figure 1) and detainees and staff in close proximity not wearing or improperly wearing masks (see Figure 2). Figure 1.

Pulaski detainees not wearing masks and not practicing social distancing on December 6, 2020. Source: Video surveillance footage provided by Pulaski staff www.oig.dhs.gov 5 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Figure 2. Pulaski detainees not wearing a mask in close proximity to Pulaski staff improperly wearing a mask on November 27, 2020. Source: Video surveillance footage provided by Pulaski staff During our November 2020 livestream walkthrough across multiple housing units and each of our video surveillance footage reviews from inside the facility, we observed numerous detainees in close proximity throughout the facility not wearing masks.

Staff told us detainees are required to wear masks outside housing areas, and although they encourage detainees to wear their masks and practice social distancing within housing areas, there are often times when detainees choose not to wear their masks or practice social distancing. The September 2020 ICE guidance makes no distinction between the need for mask-wearing inside or outside housing areas. Improper Identification of Detainee Criminal History Led to Commingling According to the 2011 PBNDS,7 facilities must classify detainees according to risk level to assign housing with others of similar background and criminal or 7 2011 PBNDS, Section 2.2, Custody Classification System (Revised Dec. 2016).

(cid:3) www.oig.dhs.gov 6 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) civil history, and ensure separation of high custody and low custody detainees. The standards require that detainees be given color-coded uniforms, wristbands, or other means to easily identify their classification level. ICE standards8 state “A system of color-coding permits staff to identify a detainee’s classification on sight, thereby eliminating confusion, preventing potentially serious miscommunication, and facilitating consistent treatment of detainees.” Color-coded uniforms or wristbands help to ensure that detainees of different levels are not inadvertently housed together or commingled in common areas of the facility. However, Pulaski policies and guidance on classification do not require color- coded uniforms or wristbands to identify detainee classification level, and our visual inspection of the facility revealed that it does not provide them.

Pulaski issues a gray uniform and a pink undershirt to all detainees and provides ID cards as the sole means of detainee classification identification level. Although Pulaski required detainees to carry the ID card with them at all times, the cards are not easily visible to staff to ensure detainees with different classifications are not commingled. During our review, we identified an incident in which a detainee classified as high for having significant criminal history was inadvertently placed in a housing unit with detainees classified as low for having no criminal history. It was not until another detainee, who was aware of the detainee’s classification, brought it to the attention of a guard that the detainee was moved to a housing unit with other high level detainees.

Improper classification puts detainees and staff at risk, but can be mitigated through the use of a color-coded visual identification system. Pulaski Medical Unit Generally Provided Sufficient Medical Care but Needs to Improve Chronic Care Protocols We found that Pulaski met the 2011 PBNDS standards of medical care9 for those areas that we evaluated. We found that access to and quality of medical care was sufficient to meet the general needs of the detainee population. The facility has 24-hour nursing coverage, on-call physician coverage, and an on- call mental health provider.

Sick call is provided daily, and patients receive medical appointments in a timely manner. We reviewed 16 detainee health records and found that facility health services personnel addressed patient medical needs, typically within 12 to 24 hours. In cases where the facility could not handle the patient’s medical needs, the facility made appropriate 8 2011 PBNDS, Section 2.2, Custody Classification System (Revised Dec. 2016).

9 2011 PBNDS, Section 4.3, Medical Care (Revised Dec. 2016). (cid:3) www.oig.dhs.gov 7 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) referrals to specialty care providers. A qualified mental health professional addressed mental health needs on site, and a psychiatrist was available for consultation as needed.

The facility provides medications via pharmacy services with a doctor’s prescription. The pharmacy services are timely, and the medical unit has a back-up pharmacy services plan. However, while general medical needs were met, we found that the facility could improve its care for patients with chronic care needs. Specifically, Pulaski does not have chronic care protocols or guidelines in place for the medical provider to follow.

Health record reviews showed that the provider did not initiate statin therapy (drugs used to lower cholesterol levels in the blood) for diabetic patients requiring such treatment. The records also showed no evidence that asthmatic patients received the necessary tests to ensure that asthma was well controlled. Chronic care protocols are necessary to ensure that sufficient care is provided for patients with specialized medical needs. Pulaski’s Medical Unit Does Not Have Emergency or Timely Dental Services 2011 PBNDS specifies that detainees have access to appropriate and necessary dental care, including emergency services.10 We found that routine dental cases at Pulaski were backlogged because dental services in the community were shut down multiple times during the COVID-19 pandemic.

As a result, five detainees requiring annual dental services waited to receive routine dental screening. We also found that the Pulaski medical unit does not have emergency dental services. A dentist provides regular dental services outside of the facility during a 2-hour window (approximately 3 to 5 patients) each week, but there is no access to dental services outside this window. We also found that trained personnel were not conducting initial dental screenings.

Initial dental screenings are completed by nursing staff who are normally provided dental assessment training. However, training sessions were put on hold in March 2020 because of COVID-19, preventing staff from receiving the necessary training for dental assessments. As a result, the medical staff may not be able to identify dental issues until they become severe. Welfare Checks for Detainees in Segregation Were Insufficient ICE’s 2011 PBNDS requires facility staff to observe detainees in segregation for a welfare check once every 30 minutes and record results in the segregation 10 2011 PBNDS, Section 4.3, Medical Care (Revised Dec.

2016). (cid:3) www.oig.dhs.gov 8 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) housing record.11 At Pulaski, facility staff automatically record the welfare checks by placing a handheld electronic device on each cell door in the segregation unit. We reviewed 6 days of welfare check logs and determined facility staff did not conduct timely welfare checks 12 percent of the time. Further, video surveillance footage from the segregation unit revealed instances of facility staff recording welfare checks with the electronic device but neglecting to look in the cell to observe the detainee.

We reviewed footage of eight welfare checks conducted during a 3-day period. On six of eight occasions facility staff did not observe some or all of the detainees in segregation. Facilities must demonstrate they are properly conducting welfare checks every 30 minutes to prevent suicide and identify detainees who need medical assistance. Detainee Communication Practices Were Deficient ICE’s 2011 PBNDS requires ICE staff to visit detainees at the facility and post a schedule with the days and hours ICE will visit.12 The ICE visitation schedule must be posted in housing units and be included in the detainee handbook.

Although ICE posted notification in each housing unit stating visits would occur on Wednesdays from 9 AM to 2 PM, the poster did not specify exact times the visits would occur in each housing unit so detainees could ensure they did not miss the opportunity to visit with their Deportation Officer (DO). Also, ICE suspended scheduled in-person visits due to the COVID-19 pandemic, and from April 6 to August 16, 2020, performed its weekly visits remotely. Although ICE documented that remote visits occurred, officers did not document specific communications with detainees. It was also unclear if detainees knew how to contact their ICE DO by phone during the time ICE restricted in-person visits.

Further, the detainee handbook does not specify times ICE visits would occur in each housing unit as required by 2011 PBNDS. Detainees need to know what specific times they can contact their DO so they can plan their days accordingly and not risk missing their DO because they attended activities such as recreation or religious services. Neglecting to properly inform detainees of DO visits violates 2011 PBNDS for staff-detainee communication. 11 2011 PBNDS, Section 2.12, Special Management Units (Revised Dec.

2016). 12 2011 PBNDS, Section 2.13, Staff-Detainee Communication (Revised Dec. 2016). (cid:3) www.oig.dhs.gov 9 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Recommendations We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Chicago Enforcement and Removal Field Office responsible for Pulaski to: Recommendation 1: Ensure Pulaski implements a color-coded visual identification system to easily identify detainees based on their classification levels.

(cid:3) Recommendation 2: Ensure Pulaski meets ICE’s COVID-19 requirements for wearing masks and social distancing. Recommendation 3: Ensure Pulaski staff complete and record the results of visual welfare checks for detainees in segregation once every 30 minutes. Recommendation 4: Ensure the Pulaski Medical Unit develops chronic care guidelines, and provides routine and emergency dental care. Recommendation 5: Ensure detainees have consistent and appropriate access to ICE ERO deportation officers and include identifying time, duration, and location of ICE facility visits.

(cid:3) Management Comments and OIG Analysis ICE concurred with all 5 recommendations. ICE described corrective actions to address the issues identified in this report. Appendix B contains ICE management comments in their entirety. We also received technical comments to the draft report and revised the report as appropriate.

We consider two recommendations resolved and closed, and three recommendations resolved and open. A summary of ICE’s response and our analysis follows. ICE Comments to Recommendation 1: Concur. 2011 PBNDS section 2.2 - Custody Classification System states, “Upon completion of the classification process, at facilities where applicable, staff shall assign individual detainees color-coded uniforms, wristbands, or other means of custody identification.

A system of color-coding permits staff to identify a detainee’s classification on sight, thereby eliminating confusion, preventing potentially serious miscommunication, and facilitating consistent treatment of detainee.” To comply with this requirement, Pulaski currently provides a color-coded identification card to each detainee to differentiate classification levels. In addition, Pulaski recently purchased color-coded wristbands to differentiate each of the four classifications and, once received, will distribute the www.oig.dhs.gov 10 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) wristbands to all ICE detainees. Estimated Completion Date (ECD): June 30, 2021. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open.

We will close this recommendation when we receive documentation showing the implementation of the color-coded wristbands to visibly differentiate each of the four classification levels. ICE Comments to Recommendation 2: Concur. As stated in ICE ERO’s PRR, the objectives of ICE’s safety measures, such as wearing masks and social distancing, include protecting detainees and staff from exposure to the virus. As discussed with the OIG after receiving the draft report, ICE already took multiple steps, to the extent reasonably possible, to ensure detainee and staff safety.

Pulaski continues to constantly remind detainees verbally and visually with posters to wear personal protective equipment and socially distance. In addition, Pulaski recently implemented an ongoing vaccination program. In alignment with PRR requirements, Pulaski worked with the Southern Seven Health Department in Illinois, the state’s COVID-19 vaccine resource, to offer the vaccine to all detainees. On March 10, 2021, for example, 35 detainees opted to receive the Janssen/Johnson & Johnson one-time vaccine.

The vaccine is also offered to all new intake detainees, and re-offered to detainees every two to four weeks depending on the demand and availability. As discussed with the OIG during the course of this audit, the implementation of Pulaski’s ongoing vaccination program achieves the intent of the recommendation, which is to protect the health and safety of detainees and staff. ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and closed.

ICE provided documentation that the facility initiated vaccination plans to address COVID-19 transmission within the Pulaski facility. In addition, Pulaski continues to constantly remind detainees verbally and visually with posters to wear personal protective equipment and socially distance. This corrective action addresses the intent of the recommendation to reduce transmission of COVID-19. Pulaski has offered and continues to offer detainees the opportunity to obtain vaccines to reduce detainees transmitting and contracting COVID-19.

ICE Comments to Recommendation 3: Concur. ICE ERO will provide Pulaski staff with remedial training on how a Housing Unit Officer will www.oig.dhs.gov 11 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) personally observe all Special Management detainee/offenders at least every 30 minutes. In addition, each staff member will be provided the opportunity to ask questions and receive clarification. Furthermore, on March 23, 2021, ICE ERO assigned a dedicated ICE ERO Detention Services Manager (DSM) to the Pulaski County Jail.

The DSM will assist with monitoring welfare checks and provide training to remind officers the proper technique in checking cells as well as timely checks. ECD: June 30, 2021. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when we receive documentation showing remedial training was provided to Pulaski staff on checks for segregated detainees.

ICE should also provide documentation of oversight checks provided by the DSM showing that welfare checks are being performed as required. ICE Comments to Recommendation 4: Concur. The Pulaski Medical Unit already has existing chronic care guidelines that are based on community standards of care, National Commission on Correctional Health Care, and American Correction Association guidelines. On October 13, 2020, ICE Health Service Corps (IHSC) performed a full inspection of both chronic care guidelines related to the 2011 PBNDS standards, as well as quality of care measures, and identified that peak flow measurements were not obtained on detainees with asthma per their existing asthma clinical guideline.

All other 2011 PBNDS standards and quality of care measures related to chronic care disease management were found highly compliant at the time of IHSC’s inspection. A corrective action plan to address the findings of the IHSC inspection was implemented and approved on December 20, 2020. On April 9, 2021, IHSC approved another corrective action plan in response to this OIG draft report, which will implement a Continuous Quality Improvement component to audit all charts of asthmatic detainees to ensure peak flow is maintained. Further, ICE’s Office of Detention Oversight will conduct an inspection scheduled for April 12 through16, 2021.

IHSC will determine if additional recommendations or a follow-up audit are warranted based on Office of Detention Oversight’s and IHSC’s monitored Continuous Quality Improvement findings. It is also important to note that all 2011 PBNDS standards and quality of care outcomes were highly compliant at IHSC’s inspection in October 2020. Detainees currently have access to emergency medical services, as 2011 PBNDS does not define the emergency services as required by the dentist. Detainees with dental complaints are evaluated after hours by nursing staff and can be sent to the emergency room if necessary.

Outside of the dentist’s work hours, a medical doctor evaluates and treats any dental issues pending a referral to the dentist, as appropriate. The Pulaski www.oig.dhs.gov 12 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Medical Unit also procured an additional dental provider and are conducting administrative processes to bring onboard this provider. ECD: September 30, 2021. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open.

We will close this recommendation when we receive documentation showing that the Pulaski facility has completed procurement of an additional dental provider and covers emergency dental needs for detainees. ICE should also provide the Office of Detention Oversight inspection of the facility’s medical department with any corrective action plan addressing medical related findings. ICE Comments to Recommendation 5: Concur. 2011 PBNDS section on Staff-Detainee Communication states, “The local supplement to the detainee handbook shall 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.

The same information shall be posted in the living areas (or “pods”) of the facilities.” There are no on-site ICE officials at the Pulaski County Detention Center due to the remote location of the facility. To offset this limitation, ICE ERO provides a posting in each housing unit and the facility detainee handbook, showing that an ICE officer will visit the facility on Wednesdays from 9 a.m. to 2 p.m. Therefore, the pod posting includes the scheduled hours and days per the standard. Furthermore, when ICE officers arrive at a unit, the Custodial officer announces that ICE officers are in the housing unit to ensure that all detainees have the opportunity to speak with the visiting officer. Setting specific scheduled times in each individual housing unit could prevent thorough visits, as strict time requirements may prevent officers from completely addressing all concerns or questions before having to leave for the next housing unit.

As of March 23, 2021, ICE ERO assigned a dedicated DSM to Pulaski, who will assist with visiting detainees and addressing any issues or concerns regarding the facility. ERO staff will also be on-site to answer any questions the detainees may have. In addition to the visits by ICE officers, the detainees have other options for communicating with their ICE Deportation Officer. Each pod has a posting of assigned Deportation Officers and their telephone numbers so detainees can contact their respective officers.

Detainees can also complete an ICE request form that is sent to their assigned Deportation Officer and which requires a response within 3 business days. www.oig.dhs.gov 13 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and closed. ICE provided documentation showing that it hired a DSM at Pulaski to provide daily on-site oversight at the facility including ongoing daily communication with detainees. This addresses the intent of the recommendation which was intended to improve communication between ICE and detainees. www.oig.dhs.gov 14 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Appendix A Objective, Scope, and Methodology The Department of Homeland Security Office of Inspector General (OIG) was established by the Homeland Security Act of 2002 (Public Law 107-296) by amendment to the Inspector General Act of 1978.

DHS OIG initiated this inspection at Congress’ direction. Prior to conducting an unannounced inspection, we review and analyze concerns raised by immigrant rights groups and complaints to the DHS OIG Hotline about conditions for aliens in ICE custody. We generally limited our scope to the 2011 PBNDS for health, safety, medical care, mental health care, grievances, classification and searches, use of segregation, use of force, language access, and staff training. We also conducted a limited review of facility compliance with COVID-19 requirements.

We conducted the inspection remotely, given the inherent risks associated with on-site inspections during the COVID-19 pandemic. We focused on elements of these standards that could be observed and evaluated remotely. Prior to our inspection, we reviewed relevant background information, including: (cid:120) OIG Hotline complaints (cid:120) (cid:120) (cid:120) (cid:120) ICE 2011 PBNDS ICE Office of Detention Oversight reports Information from nongovernmental organizations Information provided in congressional requests We conducted our unannounced remote inspection of Pulaski from November 16, 2020, to January 5, 2021. During the visit we: (cid:120) Directed the locations within the facility we would observe during a live video walkthrough.

We viewed areas used by detainees including intake processing areas; medical facilities; kitchens and dining facilities; residential areas, including sleeping, showering, and toilet facilities; legal services areas, including law libraries and immigration proceedings; and recreational facilities. (cid:120) Reviewed select video surveillance footage of detainee housing areas and use of force incidents from November to December 2020. (cid:120) Reviewed facility’s compliance with key health, safety, and welfare requirements of the 2011 PBNDS for classification and searches, www.oig.dhs.gov 15 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) segregation, access to medical care and mental health care, and medical and nonmedical grievances. (cid:120) Reviewed the facility’s pandemic response to COVID-19, including (cid:120) (cid:120) standards modified and whether ICE was notified and approved any changes that affected facility compliance with applicable standards.

Interviewed ICE and detention facility staff members, including key ICE operational and detention facility oversight staff, detention facility medical, segregation, classification, grievance, and compliance officers. Interviewed detainees held at the detention facility to evaluate compliance with 2011 PBNDS grievance procedures and grievance resolution. (cid:120) 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 Pulaski facility.

We incorporated information provided by the medical contractors into 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. www.oig.dhs.gov 16 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Appendix B ICE Comments to the Draft Report www.oig.dhs.gov 17 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) www.oig.dhs.gov 18 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) www.oig.dhs.gov 19 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) www.oig.dhs.gov 20 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) www.oig.dhs.gov 21 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) www.oig.dhs.gov 22 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) www.oig.dhs.gov 23 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Appendix C Office of Special Reviews and Evaluations Major Contributors to This Report John D. Shiffer, Chief Inspector Stephanie Christian, Supervisory Lead Inspector Jennifer Berry, Senior Inspector Brittany Scott, Senior Inspector Ian Stumpf, Senior Inspector Steven Staats, Independent Referencer www.oig.dhs.gov 24 (cid:3) OIG-21-32(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) 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 Assistant Secretary for Office of Policy 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 (cid:3) (cid:3) (cid:3) www.oig.dhs.gov 25 (cid:3) OIG-21-32(cid:3) 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 (cid:3) 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