[Senate Hearing 117-537]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 117-537
 
             MEDICAL MISTREATMENT OF WOMEN IN ICE DETENTION

=======================================================================

                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS


                             SECOND SESSION

                               ----------                              

                           NOVEMBER 15, 2022

                               ----------                              

        Available via the World Wide Web: http://www.govinfo.gov

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs
        
        
        
        
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              U.S. GOVERNMENT PUBLISHING OFFICE 
 50-238PDF             WASHINGTON : 2023
 
      

       

             MEDICAL MISTREATMENT OF WOMEN IN ICE DETENTION

=======================================================================

                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS


                             SECOND SESSION

                               __________

                           NOVEMBER 15, 2022

                               __________

        Available via the World Wide Web: http://www.govinfo.gov

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs

        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                   GARY C. PETERS, Michigan, Chairman
THOMAS R. CARPER, Delaware           ROB PORTMAN, Ohio
MAGGIE HASSAN, New Hampshire         RON JOHNSON, Wisconsin
KYRSTEN SINEMA, Arizona              RAND PAUL, Kentucky
JACKY ROSEN, Nevada                  JAMES LANKFORD, Oklahoma
ALEX PADILLA, California             MITT ROMNEY, Utah
JON OSSOFF, Georgia                  RICK SCOTT, Florida
                                     JOSH HAWLEY, Missouri

                   David M. Weinberg, Staff Director
                    Zachary I. Schram, Chief Counsel
                Pamela Thiessen, Minority Staff Director
                     Laura W. Kilbride, Chief Clerk
                    Ashley A. Howard, Hearing Clerk


                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                     JON OSSOFF, Georgia, Chairman
THOMAS R. CARPER, Delaware           RON JOHNSON, Wisconsin
MAGGIE HASSAN, New Hampshire         RAND PAUL, Kentucky
ALEX PADILLA, California             JAMES LANKFORD, Oklahoma
                                     RICK SCOTT, Florida

                  Douglas S. Pasternak, Staff Director
                     Caitlin Warner, Chief Counsel
                 Brian Downey, Minority Staff Director
                  Kyle Brosnan, Minority Chief Counsel
                      Kate Kielceski, Chief Clerk
                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Ossoff...............................................     1
    Senator Hassan...............................................    12
    Senator Padilla..............................................    24
Prepared statements:
    Senator Ossoff...............................................    33
    Senator Johnson..............................................    36

                               WITNESSES
                       Tuesday, November 15, 2022

Karina Cisneros Preciado, Former Detainee at Irwin County 
  Detention Center...............................................     4
Margaret G. Mueller MD., Associate Professor, Obstetrics and 
  Gynecology, Northwestern Medicine..............................     5
Peter H. Cherouny MD., Professor Emeritus of Obstetrics, 
  Gynecology, and Reproductuve Sciences, University of Vermont 
  College of Medicine............................................     7
Stewart D. Smith DHSc, Assistant Director, U.S. Immigration and 
  Customs Enforcement Health Service Corps, U.S. Department of 
  Homeland Security..............................................    16
Pamela Hearn MD., Medical Director, LaSalle Corrections..........    18
Hon. Joseph V. Cuffari, Ph.D., Inspector General, U.S. Department 
  of Homeland Security Office of Inspector General...............    19

                     Alphabetical List of Witnesses

Cherouny, Peter H. MD.:
    Testimony....................................................     7
    Prepared statement...........................................    43
Cuffari, Hon. Joseph V. Ph.D.:
    Testimony....................................................    19
    Prepared statement...........................................    63
Hearn, Pamela MD.:
    Testimony....................................................    18
    Prepared statement...........................................    56
Mueller, Margaret G. MD.:
    Testimony....................................................     5
    Prepared statement...........................................    39
Cisneros Preciado, Karina:
    Testimony....................................................     4
    Prepared statement...........................................    38
Smith, Stewart D. DHSc:
    Testimony....................................................    16
    Prepared statement...........................................    47

                                APPENDIX

Staff Report.....................................................    74
Senator Ossoff chart--Dr. Amin Procedures........................   182
Government Accountability Project Statement for the Record.......   183
Documents from Daniela Meza Medina
    Statement for the Record.....................................   195
    Signed Declaration...........................................   198
    Administrative Complaint Letter..............................   206
Southern Poverty Law Center Statement for the Record.............   224
Three Documents from the Center for Reproductive Rights
    UN Communication Regarding ICDC Medical Neglect and Abuse....   226
    Pregnant Immigrants and Asylum Seekers During COVID-19.......   250
    UN Special Procedures Urgent Communication to the United 
      States Government..........................................   259


             MEDICAL MISTREATMENT OF WOMEN IN ICE DETENTION

                              ----------                              


                       TUESDAY, NOVEMBER 15, 2022

                                   U.S. Senate,    
              Permanent Subcommittee on Investigations,    
                    of the Committee on Homeland Security  
                                  and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 2:30 p.m., via 
Webex and in room 342, Dirksen Senate Office Building, Hon. Jon 
Ossoff, Chairman of the Subcommittee, presiding.
    Present: Senators Ossoff, Hassan, and Padilla.

             OPENING STATEMENT OF SENATOR OSSOFF\1\

    Senator Ossoff. The Permanent Subcommittee on 
Investigations (PSI) will come to order.
---------------------------------------------------------------------------
    \1\ The prepared statement of Senator Ossoff appears in the 
Appendix on page 33.
---------------------------------------------------------------------------
    Before we begin this hearing, guests and viewers should be 
advised that this hearing will discuss the medical abuse of 
women in the custody of the U.S. Government and that the 
subject matter is deeply distressing and highly sensitive.
    Eighteen months ago, I launched a PSI investigation focused 
on the medical treatment of women detained by the Department of 
Homeland Security (DHS). This investigation has been bipartisan 
from start to finish, and I would like to thank Ranking Member 
Johnson and his staff for their contributions.
    Our findings are deeply disturbing.
    It is the bipartisan finding of the Subcommittee that 
female detainees in Georgia were subjected by a DHS-contracted 
doctor to excessive, invasive, and often unnecessary 
gynecological surgeries and procedures, with repeated failures 
to obtain informed medical consent.
    This is an extraordinarily disturbing finding, and in my 
view represents a catastrophic failure by the Federal 
Government to respect basic human rights.
    Among the serious abuses this Subcommittee has investigated 
during the last 2 years, subjecting female detainees to non-
consensual and unnecessary gynecological surgeries is one of 
the most nightmarish and disgraceful.
    The Subcommittee has been thorough, interviewing more than 
70 witnesses and reviewing more than 540,000 pages of records, 
and I want to thank and commend the staff who have worked on 
this for the last year and a half.
    The Subcommittee engaged medical experts, including Dr. 
Peter Cherouny, Obstetrician and Gynecologist (OB/GYN), who 
previously conducted medical reviews of other matters for the 
U.S. Department of Health and Human Services (HHS) inspector 
general (IG), and who independently reviewed more than 16,000 
pages of medical records obtained by the Subcommittee.
    The Subcommittee also consulted Dr. Margaret Mueller, OB/
GYN, who has also reviewed extensive medical records related to 
the investigation. Both Dr. Cherouny and Dr. Mueller will 
testify today, and I thank you both for your service to the 
Subcommittee and to the U.S. Senate.
    These medical experts reviewed the clinical conduct of Dr. 
Mahendra Amin, an OB/GYN doctor contracted by the Department of 
Homeland Security, who has subjected female detainees to 
aggressive and unethical gynecological care, quickly scheduled 
surgeries when non-surgical options were available, performed 
unnecessary injections and treatments, and often proceeded 
without informed consent.
    In addition to this expert review of medical records, the 
Subcommittee analyzed relevant data secured from U.S. 
Immigration and Customs Enforcement (ICE), and the results of 
our analysis were shocking. For example, from 2017 to 2020, Dr. 
Amin accounted for just 6.5 percent of all offsite 
OB/GYN visits for all ICE detainees nationwide. Yet during the 
same period, this single doctor, according to ICE statistics, 
performed 82 percent of all dilation and curettage (D&C) 
surgeries, 93 percent of all contraceptive injections, and 94 
percent of all laparoscopic surgeries to remove lesions 
performed on the entire ICE detainee population nationwide.
    Let me reiterate those statistics: one doctor, 6.5 percent 
of OB/GYN visits; 82 percent of D&C surgeries, 93 percent of 
contraceptive injections, 94 percent of laparoscopic surgeries 
to remove lesions, performed on the entire nationwide ICE 
detainee population.
    The Subcommittee sought an interview with Dr. Amin during 
this investigation, and when he declined, we issued a subpoena. 
Dr. Amin invoked his Fifth Amendment right not to testify and 
has not spoken with the Subcommittee.
    We will also be joined today by an extraordinarily 
courageous woman, Karina Cisneros Preciado. Karina was born in 
Mexico and brought to the United States as an 8-year-old child. 
She began working at 15, and by 18 was married to a spouse who 
physically abused her.
    After she called the police to her home during an incident 
of domestic abuse, Karina was arrested, and although all 
charges against her were dropped, she wound up detained at 
Irwin County Detention Center (ICDC) in Ocilla, Georgia, 
because of her immigration status. Just 4 months earlier, 
Karina had given birth to her 4-month-old daughter, who was 
still breastfeeding at the time. Now forcibly separated from 
her infant daughter, Karina had not yet received her postpartum 
exam, and sought care while in detention. Karina was sent to 
Dr. Amin.
    As we will hear, her encounter with Dr. Amin left her 
deeply disturbed, and it may only be because some allegations 
of medical abuse became public at this time that Karina was 
spared further abuse.
    On behalf of the U.S. Senate, Karina, I thank you for your 
decision to join us today and your service to the country.
    Today we will also question Dr. Stewart Smith, who leads 
the ICE Health Service Corps (IHSC) and is responsible for all 
medical care provided to all ICE detainees; Dr. Joseph Cuffari, 
the DHS Inspector General; and Dr. Pamela Hearn, Medical 
Director for LaSalle Corrections.
    Among the essential questions we will ask today, why are 
doctors who treat detainees not properly vetted by the 
Department of Homeland Security, when such a vet would have 
revealed in this case that the doctor in question had been 
previously sued by the Department of Justice (DOJ) and the 
State of Georgia for performing excessive and unnecessary 
procedures, had been dropped by a major insurer for excessive 
malpractice claims, and was not board certified?
    What due diligence did the Department of Homeland Security 
perform in signing off on each of these procedures, because 
indeed they did sign off on these procedures? Why was the 
inexplicably high number of surgeries performed by a single 
physician not a red flag that attracted greater scrutiny?
    What responsibility is borne by the private detention 
center operator for mistreatment of detainees housed in their 
facilities when that mistreatment occurs at an offsite medical 
facility?
    All of these, and more, will be the subject of vigorous 
questioning today.
    Senator Johnson will be joining us later in the hearing, 
and at this time I ask unanimous consent (UC) to enter his 
opening statement into the record.\1\
---------------------------------------------------------------------------
    \1\ The prepared statement of Senator Johnson appears in the 
Appendix on page 36.
---------------------------------------------------------------------------
    Senator Ossoff. We will now call our first panel of 
witnesses for this afternoon's hearing.
    Ms. Karina Cisneros Preciado was formerly detained at the 
Irwin County Detention Center in Ocilla, Georgia.
    Dr. Peter Cherouny is a medical expert the Subcommittee 
engaged to conduct a review of medical records of patients 
treated by Dr. Amin, who were detained at Irwin County 
Detention Center in Ocilla, Georgia. He will be testifying 
remotely.
    Dr. Margaret Mueller is a medical expert and physician who 
was part of an independent medical review team that conducted a 
review of medical records for detainees treated by Dr. Amin.
    I appreciate all of you for being with us today and look 
forward to your testimony.
    The rules and customs of the Subcommittee require all 
witnesses to be sworn in, so at this time I would ask you to 
please stand and raise your right hand.
    Do you swear that the testimony you are about to give 
before this Subcommittee will be the truth, the whole truth, 
and nothing but the truth, so help you, God?
    Ms. Cisneros Preciado. I do.
    Dr. Mueller. I do.
    Dr. Cherouny. I do.
    Senator Ossoff. Let the record reflect the witnesses 
answered in the affirmative. You may take your seats.
    We will be using a timing system today. We ask that you try 
to limit your opening statements to around 5 minutes, but if 
you need a bit more time it is not a problem. Just let me know.
    Ms. Cisneros Preciado, thank you again for joining us, and 
if you are ready we will hear from you first.

 TESTIMONY OF KARINA CISNEROS PRECIADO,\1\ FORMER DETAINEE AT 
                 IRWIN COUNTY DETENTION CENTER

    Ms. Cisneros Preciado. Good afternoon and thank you for the 
opportunity to share my story with you today. My name is Karina 
Cisneros Preciado. I was brought to the United States when I 
was 8 years old. I am now a 23-year-old mother of two. I have a 
1-year-old and a 2-year-old.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Cisneros Preciado appears in the 
Appendix on page 38.
---------------------------------------------------------------------------
    When my daughter was 4 months old I called the police to 
stop ongoing abuse from her father. This led to me being 
arrested, and even though the charges were dropped I still 
ended up at ICDC for almost 7 months, away from my daughter, 
away from my family.
    At ICDC I became 72176 instead of Karina. At ICDC, I went 
through hell. This place was extremely filthy. The showers were 
moldy. The water cooler where we drank water from, there was 
mold in the spout. We were given dirty and used underwear to 
wear.
    At ICDC I sought help, medical help, because I had not had 
my postpartum checkup from my daughter. After several requests 
I finally got an appointment to see a doctor. The nurse told me 
I was going to get a Pap smear. When the day came they 
handcuffed me and put a chain around my waist, all the way down 
to my ankles.
    When we arrived at the clinic we were taken in one by one 
by an escort and the rest stayed in the car with another 
officer. In the clinic, they took my blood pressure, my 
temperature, my weight with my handcuffs still on. Once in the 
room they took my handcuffs off so I could get undressed.
    When Dr. Amin came in he did not acknowledge me. He did not 
say a word. He just sat in front of me and started prepping for 
the procedure, which he did not explain. Then he said, ``Open 
your legs,'' and continued with, ``It is going to be cold,'' 
and inserted a white tube inside of me. He wiggled it around, 
roughly. It was extremely uncomfortable.
    As I was about to look at the monitor that was next to me 
he immediately pulled it out and he told me that I had a cyst 
on my left ovary and that I was going to get a Depo shot for 
it, and if the cyst did not dissolve in 4 weeks I was going to 
have to come back for surgery. Then he asked the nurse how many 
more, and he just walked off.
    I got dressed and they put the handcuffs back on, and 
another nurse came in and she gave me the shot on my arm and 
made me sign a paper, which I did not have a chance to read it 
or hold it. I was wearing handcuffs. I just signed it.
    Back in the van the other woman asked me if I had gotten 
the shots and I have babies as well. I did not know what it 
was. It was not explained to me. That is when I learned it was 
birth control, and if I would have known I would have said 
something, as the women in my family had very bad experiences 
from birth control.
    When we came back to ICDC I learned the story of many other 
women that Dr. Amin had told the same thing. They all had cysts 
on their ovaries, we all got shots, and some of them even got 
surgeries. I thank God that the news came out, because he did 
not get to do anything else to me.
    The reason I am telling this story is because this should 
not happen to anyone anymore. We are not animals. We are human. 
We are not just a number.
    Thank you for your time.
    Senator Ossoff. Thank you, Ms. Cisneros Preciado.
    Dr. Mueller, we will hear from you now, please.

 TESTIMONY OF MARGARET G. MUELLER, MD,\1\ ASSOCIATE PROFESSOR, 
        OBSTETRICS AND GYNECOLOGY, NORTHWESTERN MEDICINE

    Dr. Mueller. Good afternoon, Chairman Ossoff, Senators, and 
staff as well as guests.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Mueller appears in the appendix 
on page 39.
---------------------------------------------------------------------------
    The first thing I want to do is take this opportunity to 
praise Karina for her courage and bravery for coming today. 
Although difficult to hear and heartbreaking, it certainly 
gives voice to the medical records that I reviewed and my 
colleagues reviewed as well.
    My name is Margaret Mueller. I am a physician and I hold 
specialty board certification in OB/GYN and subspecialty board 
certification in Female Pelvic Medicine and Reconstructive 
Surgery. I have a faculty appointment at Northwestern 
University Feinberg School of Medicine where I serve as the 
Program Director for the Female Pelvic Medicine and 
Reconstructive Surgery Fellowship.
    As mentioned, I was part of an independent medical review 
team made up of nine other board-OB/GYNs and two nurse 
practitioners. In 2020, we reviewed the medical records of 19 
women who alleged medical abuse and mistreatment while in 
detention at Irwin County Detention Center. Since that summary 
was prepared and published, I have reviewed additional medical 
records that make it clear that this pattern of mistreatment 
and abuse was not limited to those 19 women.
    Our findings identified a disturbing pattern of overly 
aggressive gynecologic care, many times involving unnecessary 
diagnostic procedures, and in some cases, unnecessary or 
inappropriate surgical procedures. Often, significant steps in 
the appropriate evaluation and management of common gynecologic 
conditions were completely omitted, leading to these 
unindicated and unnecessary procedures. Our review, more 
concerningly, identified a serious failure by the facility-
assigned gynecologist, Dr. Amin, to obtain meaningful informed 
consent from the women who he was treating.
    The unindicated and under-consented procedures included 
transvaginal ultrasounds, which is a procedure in which a woman 
is undressed from the waist down and a medical professional 
inserts a wand or probe into the vagina to image the 
reproductive female organs--the uterus, cervix, the fallopian 
tubes, and ovaries; Pap smears, again a procedure in which a 
women is undressed from the waist down and a medical 
professional inserts a speculum into the vagina, and a brush is 
used to exfoliate the cervical cells to send to the 
pathologist; a LEAP procedure, a procedure which typically is 
performed in the office, however under Dr. Amin's care this was 
performed in the operating room under anesthesia, where again a 
speculum is inserted into the vagina and electric cautery is 
used to burn or remove or cauterize a significant portion of a 
woman's cervix.
    Dilation and curettage, which you have heard about, a 
surgical procedure which is performed again in an operating 
room, under anesthesia, where a speculum is inserted into the 
vagina, and instruments are used to sequentially dilate or open 
a woman's cervix, obtaining access to the endometrial cavity or 
inside of the uterus. Once that is done, a separate instrument 
is used to scrape the inside or lining of the endometrial 
cavity to provide a pathologic specimen.
    Finally, laparoscopy, a surgical procedure in the operating 
room, under general anesthesia, where one or more small 
incisions is made in the abdomen, a camera is introduced, and 
different instruments are used to either remove or repair 
tissue or organs.
    Additionally, in several cases, women actually had 
incorrect procedures performed by Dr. Amin. These incorrect 
procedures resulted in (1) a woman being inadequately treated 
for a cervical cancer, and (2) a reproductive-age woman 
undergoing unnecessary removal of a significant portion of her 
cervix, as examples. Due to these incorrect procedures, both 
women can expect to require further and future procedures and 
monitoring, none of which would have been necessary had the 
appropriate procedures been done in the first place.
    All of these procedures involve risks. Those risks are 
those that are directly attributed to the procedure, for 
example, an injury to a bowel or a portion of the intestines at 
the time of a laparoscopic procedure, and those that are 
downstream consequences--preterm birth or preterm labor 
following a LEAP procedure, or infertility and fertility 
implications following a dilation and curettage.
    These unnecessary medical procedures were performed without 
an adequate consent, which means more than just placing a 
signed consent form in a chart, but a documentation of an 
appropriate discussion of less-invasive options that might be 
appropriate for the management for a patient, thus signifying a 
meaningful shared decisionmaking discussion between a patient 
and her physician. This lack of adequate informed consent was 
apparent from the medical records, but corroborated further by 
the stories like you heard from Karina, where really it was 
identified that there was a total absence of shared 
decisionmaking in the process between the patient and the 
physician.
    An informed consent discussion should explore (1) the 
patient's symptoms and degree of bother from those symptoms; 
(2) the full range of treatment options available for a 
specific condition, ranging from least invasive, for example, 
observation if appropriate, to most invasive, as an example, 
surgery; and then finally, the risks, the benefits, and the 
alternative of all of those proposed management strategies.
    Importantly, if a patient has no symptoms or has no bother 
by her symptoms, or if a particular surgery is unindicated, 
then the intervention exposes the patient to unwarranted risks 
without any medical benefit.
    Finally, many of these concerns are magnified by the 
vulnerable nature of these women. As you have heard, many of 
these women identify as trauma survivors. Several report a 
history of either rape, sexual abuse, or sexual assault. All 
were incarcerated and unable to choose a medical professional 
with whom they felt comfortable.
    In that setting, these women were forced to relinquish 
their autonomy and their decision to participate in their own 
medical care. Autonomy is one of the four pillars of medical 
ethics and represents a patient's right to make decisions 
regarding her health care, without the medical provider trying 
to unduly influence her decision.
    More simply stated, it is the right to refuse or choose 
medical care without the fear of retaliation. By nature of 
their incarceration, these women did not have a choice in what 
providers they saw. Some were retaliated against when they 
asked for a second opinion or refused surgery with Dr. Amin. 
This further compounds the concerning pattern of care that we 
identified.
    The manner in which these women were treated as they were 
subject to aggressive, unnecessary, unindicated, and incorrect 
procedures and surgeries, often without any benefit, and 
usually without informed consent, is unacceptable by any 
standard. This cannot be allowed to happen again.
    Thank you very much for your investigation and your time 
today. I look forward to your questions.
    Senator Ossoff. Thank you, Dr. Mueller, for your testimony.
    Dr. Cherouny, we will hear from you now, and Dr. Cherouny 
will be joining us remotely.

 TESTIMONY OF PETER H. CHEROUNY, MD,\1\ PROFESSOR EMERITUS OF 
 OBSTETRICS, GYNECOLOGY, AND REPRODUCTIVE SCIENCES, UNIVERSITY 
                 OF VERMONT COLLEGE OF MEDICINE

    Dr. Cherouny. Chairman Ossoff, Members of the Permanent 
Subcommittee on Investigations, all other interested parties 
and staff, good afternoon.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Cherouny appears in the Appendix 
on page 43.
---------------------------------------------------------------------------
    My name is Peter Cherouny, as you heard. I am currently 
Professor Emeritus at the University of Vermont in the 
Department of Obstetrics, Gynecology, and Reproductive 
Sciences. I did send in a CV, and you have heard some about 
that.
    Particularly, I have extensive experience in quality 
assessment and improvement in medical care, and I have 
previously been involved with reviews within the United States 
government, as you have heard, as well as internationally, 
including the obstetric care review that was mentioned within 
the Indian Health Care Service a few years ago.
    I will try not to be repetitive, as most of what, if not 
everything Dr. Mueller said, was accurate in my review, but I 
am coming from the quality side. I was asked to review the 
obstetric and gynecologic care of the immigrants within the 
United States Immigration and Customs Enforcement custody at 
the Irwin County Detention Center. The medical records included 
those from the detention center, from Irwin County Hospital, 
and the provider of record, Dr. Amin.
    Of note, I will mention that I was not involved in the 
selection of the patients' records for review and I do not have 
knowledge of the provider's accessibility to the patients from 
the detention center.
    As time is limited I will move on to the summary of my 
findings. The main point of concern, as you have already heard, 
in the provided care is the use of in-hospital surgical 
procedures for assessment of patient complaints regarding 
things such as irregular menstrual bleeding, also known as 
menorrhagia, metrorrhagia, dysmenorrhea, or pain; in-hospital 
dilatation of the cervix and curettage of the uterus, commonly 
called D&C and exploratory laparoscopic procedures of the 
pelvis and abdomen, as you have heard, placing a lighted camera 
into the abdomen to look at the pelvis and evaluate what is 
going on. These have largely been replaced by advancing imaging 
techniques and outpatient medical treatment options in order to 
establish diagnoses and proceed with definitive patient care.
    The provider does use some of these diagnostic tools but 
often incorrectly and without adequate documentation to be 
useful.
    Two examples of these would be the use of Depo Provera 
shots, as you have heard, progesterone hormonal shots for the 
management of regular menstrual bleeding without allowing 
sufficient time for a therapeutic effect of this intervention. 
Also vaginal ultrasound, for which the provider does not follow 
guidelines for either performance or documentation, proposed by 
our professional organizations such as the American Institute 
of Ultrasound in Medicine.
    During the surgeries, the provider often performs resection 
or removal of benign lesions, such as ovarian cysts and 
fibroids of the uterus, which have not been shown to be 
contributory to the patient's complaints. On a few occasions he 
aspirates ovarian cysts, which is not a recommended treatment.
    Of additional concern, the provider's Pap smear management 
is outside of guidelines, and provider's colposcopic skills and 
documentation, as well as cervical conization skills, as you 
heard from Dr. Mueller, appear limited for several patients. 
These are essential steps within the abnormal Pap smear care 
flow. Colposcopy is essentially using a magnifying glass to 
better visualize abnormalities which have previously been 
reported on a Pap smear, and cervical conization, again as you 
have heard, is surgical removal of a cone-shaped piece of 
tissue from the cervix to get pathologic evaluation of the 
abnormality suspected from the Pap smear and colposcopic 
impression.
    Of importance, there are patients within this review where 
no follow-up is documented, where the treatment resulted in no 
answer. That is, the way the surgery on the cervix was 
performed resulted in no useful tissue for a pathologic 
evaluation or diagnosis that could guide further care, and that 
is the whole point of the procedure within the diagnostic and 
care algorithm of Pap smears.
    Other concerns I can expand on if you like during 
questioning, regarding treatment of vaginal infections, 
intrauterine device management, treatment of condyloma 
acuminata, also known as venereal warts, diagnosis of 
endometriosis and adenomyosis, and documentation of both 
options for care and consent are noted.
    Thank you for the opportunity to help in the quality 
assessment and improvement of care for this population
    Senator Ossoff. Thank you, Dr. Cherouny, for your 
testimony, and thanks again to both Dr. Cherouny and Dr. 
Mueller for the many hours of work that you invested in helping 
the Subcommittee understand the records that we secured.
    We will now turn to a first round of questions for our 
first panel of witnesses, and I will be asking the first 
questions. Ms. Cisneros Preciado, we will begin with you. I 
want to begin by again thanking you for your testimony and your 
presence here. It is deeply appreciated. It took courage, and I 
am grateful that you are here and sharing what you have been 
through with the American people and the U.S. Congress.
    Ms. Cisneros Preciado. Thank you for having me.
    Senator Ossoff. I want to review a little bit about your 
story and how you came to be detained at Irwin County Detention 
Center in Ocilla, Georgia. It is my understanding that you were 
brought to the United States when you were a child. Is that 
right?
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. How old were you?
    Ms. Cisneros Preciado. I was 8 years old.
    Senator Ossoff. Eight years old.
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. Have you ever known a home other than the 
United States?
    Ms. Cisneros Preciado. No.
    Senator Ossoff. You currently live in Florida. Is that 
correct?
    Ms. Cisneros Preciado. Yes, sir.
    Senator Ossoff. You are the mother of two children?
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. How old are they?
    Ms. Cisneros Preciado. I have a boy, he is one, and my 
daughter, she is two.
    Senator Ossoff. Before you were detained at ICDC had you 
ever had any kind of trouble with the law?
    Ms. Cisneros Preciado. No. Never.
    Senator Ossoff. You were in an abusive spousal 
relationship. Correct?
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. You called the police during an incident?
    Ms. Cisneros Preciado. I did.
    Senator Ossoff. But rather than arresting your partner you 
were arrested. Is that right?
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. The charges were dropped.
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. But you wound up at Irwin County Detention 
Center.
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. Tell us a little bit more about your 
experience there, please.
    Ms. Cisneros Preciado. Irwin is the worst place I have ever 
been in my life. Like I said, I went from being Karina, a 
mother, to being 72176. They did not care about what we felt. 
They did not care about our names. They did not care about any 
of that.
    Senator Ossoff. You had just given birth to your daughter. 
Is that right?
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. That was about 3 months beforehand?
    Ms. Cisneros Preciado. Yes. My daughter was 4 months.
    Senator Ossoff. I think you mentioned in a statement you 
had submitted that you were still breastfeeding your infant 
daughter.
    Ms. Cisneros Preciado. Yes. I was trying to breastfeed her.
    Senator Ossoff. You were taken from her.
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. How long were you detained at Irwin County 
Detention Center?
    Ms. Cisneros Preciado. Almost 7 months.
    Senator Ossoff. Seven months away from your newborn 
daughter.
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. What was it like when you were reunited 
with your daughter after you were released?
    Ms. Cisneros Preciado. It was a mixture of feelings because 
when I left her she was just a baby. When I came to see her she 
was already walking. She did not know who I was. She knew my 
mother as her mother. She was scared of me. She would not come 
to me. It was hard, but it was the best moment because I got to 
see her again after so long, after crying for her every night. 
After wishing a lot of times that I just did not wake up 
anymore if I was not going to wake up next to her, I finally 
got to see her. It is extremely hard for me to be here because 
I left her. I left her again. Although it is for the better for 
the both of us, she is away from me right now and it is really 
hard for me.
    Senator Ossoff. Take your time.
    Ms. Cisneros Preciado. Sorry.
    Senator Ossoff. No problem.
    Now when you arrived at Irwin County Detention Center you 
had not yet had your postpartum exam. Is that correct?
    Ms. Cisneros Preciado. Correct.
    Senator Ossoff. You requested medical attention.
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. After some difficulty you wound up, as you 
said, in Dr. Amin's office.
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. How did that experience make you feel?
    Ms. Cisneros Preciado. It made me feel like I had no 
control over my body. Before this experience I had suffered 
from sexual assault before, as a child, so this experience with 
Dr. Amin made me feel the same thing I felt. It made me feel 
like I had no control over my body. I had no say, no vote, no 
nothing. When he did not explain the procedure and he was doing 
a vaginal ultrasound--because I knew it was a vaginal 
ultrasound because I had that done before--I did not think I 
could ask any questions, as the nurse had told me I was getting 
a Pap smear. I did not ask any questions. I thought I could 
not. He made me feel miserable.
    Senator Ossoff. During that appointment, Ms. Cisneros 
Preciado, did Dr. Amin address any of your concerns, allow you 
to ask any questions, or explain what he was doing?
    Ms. Cisneros Preciado. No.
    Senator Ossoff. He prescribed an injection in addition to 
conducting a transvaginal ultrasound. Is that correct?
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff. Do you know what the injection was?
    Ms. Cisneros Preciado. I did not know. He did not explain 
what it was. I learned after, in the car, when one of the other 
women told me what it was.
    Senator Ossoff. As you mentioned in your opening statement 
you heard from other women that other women had experienced a 
similar pattern of treatment----
    Ms. Cisneros Preciado. Yes.
    Senator Ossoff [continuing]. From Dr. Amin.
    Did anyone ask for your consent to receive that shot? Did 
you sign any documents?
    Ms. Cisneros Preciado. They did not ask anything, and I 
signed a paper but I did not know what it was. They told me, 
``Sign here,'' and like I said, I did not have a voice, so I 
just signed.
    Senator Ossoff. Thank you, Ms. Cisneros Preciado.
    Dr. Mueller, you reviewed extensive medical records, as has 
the Subcommittee. One of the things I think is important to 
make clear is that the experience that Ms. Cisneros Preciado 
just related to us is by no means unique. In fact, it is 
consistent with a pattern that we see in the care that was 
provided by this physician to women who were incarcerated, to 
women who were powerless.
    Can you talk a little bit about how what Ms. Cisneros 
Preciado just described conforms with the broader pattern that 
you saw in the medical records, and then reflect for a moment, 
as a practitioner, on the particular sensitivity required when 
treating people who are incarcerated. At that point I will 
yield to my colleague, Senator Hassan, for her questions.
    Dr. Mueller. Absolutely. After Karina spoke I mentioned 
that really she does give voice to the medical records. As you 
mentioned, this was repeated over and over and over again. 
Almost all of the women who came to see him for either a 
gynecologic concern or something unrelated received a Depo shot 
for unclear indications, received Pap smears when they did not 
need a Pap smear, were managed incorrectly or inappropriately 
following that.
    Again, I am a medical expert. My role is to review the 
medical records. But it was such a concerning pattern that it 
gave you pause, and I am starting to understand perhaps why 
this was happening.
    Karina also mentioned, and gave further insight, now that 
you can all experience this, that this is a very vulnerable 
population. This is not like your mother or your sister you 
gets to go on Yelp and look to see who has the best reviews or 
see a provider for the first time and see if she feels 
comfortable in the hands of that provider who is going to be 
taking care and guiding her through choices and medical 
management, et cetera. This is not a provider that many of 
these women would have ever wanted to go back to.
    Clearly he did not take this seriously. He was not 
operating from a standpoint of providing trauma-informed care, 
realizing that this is a vulnerable population, taking a 
history that would indicate that a woman has been a survivor or 
victim of a sexual assault. This is basic, standard medical 
school equivalent to just performing a basic history and 
physical, which without that you actually, again, to the point 
of informed consent, cannot have a meaningful informed consent 
because you have no understanding of the risks that you might 
be exposing a patient to and their medical history.
    Senator Ossoff. Thank you, Dr. Mueller. Senator Hassan.

              OPENING STATEMENT OF SENATOR HASSAN

    Senator Hassan. Thank you, Chair Ossoff, and I want to 
thank you and Ranking Member Johnson for holding this hearing 
and for the investigation.
    To Ms. Cisneros Preciado, thank you for coming forward. It 
is extraordinarily difficult to do what you are doing and to 
share such personal information. I hope you will take some 
solace in knowing that it is by sharing information in the way 
you are sharing it that we are able to move forward and change. 
Your courage is really remarkable, and you are making a 
difference for others. I hope that gives you a little bit more 
solace today. This is difficult, I know.
    It was very disturbing to hear and to read your testimony, 
on a number of levels obviously. But I was very concerned that 
you did not have a chance to ask any questions when you were 
seen by Dr. Amin, and that you did not feel that you could say 
no to what he planned to do.
    I want to follow up on Senator Ossoff's questions. Just to 
be clear, did Dr. Amin ever ask questions about your medical 
history or whether you had any previous cysts?
    Ms. Cisneros Preciado. No.
    Senator Hassan. Did he explain or provide any other 
treatment options for the cyst he reported, or did he provide 
any chance for you to discuss your treatment options?
    Ms. Cisneros Preciado. No, he did not.
    Senator Hassan. OK. Thank you.
    I have a question for both Dr. Mueller and Dr. Cherouny. 
Dr. Mueller's testimony says, and this is a quote, ``If a 
patient has no symptoms, is not bothered by her symptoms, or if 
a particular surgery or intervention is not indicated, then 
that intervention exposes the patient to unwarranted risk 
without any benefit.''
    The Subcommittee found that the ICDC doctor performed an 
unexpectedly large number of invasive procedures on women from 
its facility. Ninety percent of four types of invasive 
procedures performed on all ICE detainees were performed by Dr. 
Amin, despite the fact that ICDC housed just 4 percent of the 
national female detainee population.
    Starting with you, Dr. Mueller, what is your best 
assessment for why a doctor would perform such an extreme 
number of invasive procedures on these women?
    Dr. Mueller. Thank you, Senator, for that question. Of 
course, as a medical expert I can review the medical records 
and tell you if this was beneath the standard of care, what is 
typically done, et cetera. It is difficult for me to be able to 
comment on the motivation behind that type of medical care, but 
I do think that you shed light onto potential motivation. I 
think that potential motivations could include billing, et 
cetera.
    Again, my role as a medical expert is to comment on the 
medical records, but just as a person I would surmise that.
    Senator Hassan. Yes, and I understand your role, but it is 
also generally true, in my experience, that reimbursements are 
more clear and sometimes better for actual procedures as 
opposed to consultations. Is that an assessment or a statement 
you generally agree with?
    Dr. Mueller. Typically, depending on the contract set up. 
Certainly if this is something that if there is some 
reimbursement incentive for the amount of procedures then yes, 
that would be motivation.
    Senator Hassan. Thank you. Dr. Cherouny, the same question 
to you. Do you have an assessment of why a doctor would perform 
such an extreme number of invasive procedures on these women?
    Dr. Cherouny. Senator, thank you for the question as well. 
Coming from the quality aspect it is important that I outline 
that when we look at quality improvement and assessment we do 
not include punishment, if you will, associated with that, and 
that is very important, so that you get good quality 
information you need to get adequate quality assessment and 
improvement.
    Anywhere from just simply lack of knowledge or an ease of a 
way to move forward are reasons. Certainly using what would 
have been a somewhat standard medicine 30 years ago perhaps 
with what we have today and the dramatic improvement in both 
medical care--in other words, not surgical care--as well as the 
advancement of medical imaging, medical imaging has really 
helped to draw a better assessment of surgical necessity, which 
really I cannot say was used in this case because the 
physician's skill around vaginal ultrasound, which was 
predominantly what he used, sometimes at the hospital, but most 
times in his office, showed a lack of documentation that was 
hard to say it was successful and it helped with the care of 
the patient other than finding benign lesions for which he used 
those as indications for surgery, which I would also say is 
outside the current quality demands of gynecologic care.
    Senator Hassan. Thank you.
    I have one additional question and it is to Dr. Mueller. 
Your testimony stated, Doctor, that you and the medical review 
team found a disturbing pattern of overly aggressive medical 
care, sometimes involving unnecessary procedures. Your 
testimony also noted that some women presented with symptoms 
that were not appropriately evaluated, diagnosed, or managed, 
despite the patient undergoing invasive surgical procedures. 
Your testimony further explains the general requirements for 
informed consent.
    Could you elaborate on what information should be shared 
with the patient? What requirement or expectation is there 
regarding possible language barriers as well?
    Dr. Mueller. Yes, thank you, Senator. You bring up a great 
point. Yes, in order to have a meaningful informed consent 
discussion to adequately reflect shared decisionmaking between 
a patient and her physician you would need to take away any 
barriers, language being one of them. In any of those informed 
consent discussions there should have been an interpreter 
present or utilized.
    It is very important to understand that consent is not a 
signed piece of paper. Consent is a discussion between the 
physician and the patient. Again, you would need to know the 
patient's background, medical history, allergies, et cetera, 
prior to having informed consent, the symptoms or the bother, 
and then explain to the patient and document the range of 
treatment options, and explicitly what those risks are in that 
setting.
    Senator Hassan. Based on that testimony it seems to me, and 
based on the report, that the women detained at the ICDC have 
received a far lower level of care than they should have 
received. Based on your testimony, the work of the medical 
review team, and this Subcommittee's investigation, it appears 
as though many, if not most patients seen by Dr. Amin have 
little to no discussion of their conditions or alternative 
treatment options.
    Were not these women entitled to a higher level of care 
than they received, including at least a reasonable discussion 
of their conditions and possible treatment options?
    Dr. Mueller. Absolutely. I find this to be a grave 
miscarriage of justice that these women were exposed to this 
type of treatment.
    Senator Hassan. I appreciate that. I regret the 
circumstances that bring us here today but I am very grateful 
for your testimony and all of the witnesses. Thank you, and 
thank you, Mr. Chair.
    Senator Ossoff. Thank you, Senator Hassan.
    Dr. Cherouny, I would like to turn to you to discuss the 
potential long-term consequences of surgery and other 
gynecological procedures that are not medically indicated on 
these women. I want to remind everybody again, who have tuned 
in here, we are talking about dozens of cases that the experts 
here have reviewed in which incarcerated women were subjected 
to unnecessary, often non-consensual, and extremely invasive 
gynecological procedures and surgeries. This is one of the most 
outrageous things that this Subcommittee has investigated in 
the last 2 years.
    Dr. Cherouny, I think that it would be helpful if you could 
discuss for a moment what the long-term risks, the long-term 
impacts on health, physical and mental health, can be from that 
kind of mistreatment.
    Dr. Cherouny. Thank you again. Let us take a small step 
back and say again, since a large number of these procedures 
have been changed to the point where we can do outpatient 
evaluation to find the appropriate diagnostic issues with a 
given patient, what was used here was the D&C, as we heard, the 
dilatation of the cervix and the curettage of the uterus, and 
endoscopic, laparoscopic evaluation in the abdomen as an 
invasive procedure, and in the vast majority of times 
identified benign issues which did not require intervention or 
were certainly not evaluated closely enough to find out of that 
was the cause of the patient's complaint.
    When that happens, there are a number of things that occur, 
and Dr. Mueller has already touched on some of them. 
Consequences related to any surgery would include short-term 
infection, bleeding, et cetera, as well as longer-term scarring 
formation. Scarring around the female reproductive organs can 
result in things such as infertility, adhesions, which are 
internal scarring which can cause persistent, long-term pain. 
These are all consequences that are not insignificant, and 
which is why medicine has tried to minimize the necessity for 
these procedures over the course of decades, to get to the 
point where we can identify the individuals who require the 
surgery and where the risk-benefit ratio is optimized for them. 
Then their potential benefits were not the potential risks 
associated with the procedure.
    Again, the vast majority of these patients, risk-benefit, 
No. 1, it is hard to even evaluate much less come to a 
conclusion that the patient is going to overall benefit from 
one of these procedures.
    Senator Ossoff. Thank you, Dr. Cherouny, and thank you 
again for your service.
    Ms. Cisneros Preciado, I would like to offer you the 
opportunity, if you have anything you would like to add, 
anything you would like the Senate and the American people to 
hear. The floor is yours.
    Ms. Cisneros Preciado. Yes. I would like to add that 
because of this incident with what happened with Dr. Amin, to 
this day I am extremely scared to go to any doctor, for myself 
and for my kids. It was extremely traumatic, and I do not know 
if I could ever get over it. I am scared to take my kids to the 
doctor. I scared to take them out. It was horrible.
    The reason I am sharing my story is because I do not want 
this to happen to any other women or any other person. They 
should not have to be separated from their family. They should 
not have to be scared to go to the doctor when we are supposed 
to be able to trust them. Thank you.
    Senator Ossoff. Thank you, Ms. Cisneros Preciado.
    That concludes the first witness panel at today's hearing. 
We will now take a brief recess and welcome the second panel to 
the witness table. Thank you all, Dr. Mueller, Ms. Cisneros 
Preciado, and Dr. Cherouny, for your attendance today.
    [Recess.]
    We will now call our second panel of witnesses for this 
afternoon's hearing.
    Dr. Stewart Smith serves as the Assistant Director of the 
U.S. Immigration and Customs Enforcement Health Service Corps.
    Dr. Pamela Hearn serves as the Medical Director for LaSalle 
Corrections.
    The Honorable Joseph Cuffari serves as the Inspector 
General for the Department of Homeland Security Office of 
Inspector General.
    It is the custom of this Subcommittee to swear in all 
witnesses, so at this time I would ask you please stand and 
raise your right hands.
    Do you swear that the testimony you are about to give 
before this Subcommittee is the truth, the whole truth, and 
nothing but the truth, so help you, God?
    Mr. Smith. I do.
    Dr. Hearn. I do.
    Mr. Cuffari. I do.
    Senator Ossoff. You may take your seats. Let the record 
note all witnesses answered in the affirmative.
    We will be using a timing system today. Your written 
testimonies will be printed in the record in their entireties, 
and we ask that you limit your oral testimonies to 
approximately 5 minutes for your openers.
    Dr. Smith, we will hear from you first, and you may begin.

  TESTIMONY OF STEWART D. SMITH, DHSC,\1\ ASSISTANT DIRECTOR, 
U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT HEALTH SERVICE CORPS, 
              U.S. DEPARTMENT OF HOMELAND SECURITY

    Dr. Smith. Chairman Ossoff, Ranking Member Johnson, and 
distinguished Members of the Subcommittee, thank you for the 
opportunity to appear before you today.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Smith appears in the Appendix on 
page 47.
---------------------------------------------------------------------------
    IHSC is committed to providing quality health care services 
in accordance with nationally recognized detention standards. 
The IHSC workforce consists of approximately 1,700 health care 
provider positions, comprised of Federal civil servants, U.S. 
Public Health Service (PHS) Commissioned Corps officers, and 
contractors. These positions represent a wide array of health 
care professionals throughout the United States, including 
physicians, advanced practice providers, registered nurses, 
psychiatrists, psychologists, social workers, pharmacists, 
dentists, and health care administrators.
    IHSC provides direct medical care or oversight of offsite 
medical care to a diverse and fluid population. Each facility 
housing ICE detainees is staffed by medical care professionals 
24 hours a day, 7 days a week for direct patient access.
    In fiscal year (FY) 2022, IHSC provided direct care to over 
118,000 detained non-citizens housed at 19 IHSC staff 
facilities throughout the Nation. In addition, IHSC oversaw 
compliance with detention standards for health care for over 
120,000 detained non-citizens housed in 163 non-IHSC staff 
facilities.
    ICE's detained population presents unique health care 
challenges, and IHSC staff work diligently to improve health 
care and resiliency through prevention and evidence-based 
disease treatment. In many instances, the care detainees 
receive while in ICE custody is the first professional medical 
care they have ever received. Consequently, it is common for 
initial health care screenings to identify chronic and serious 
health conditions which were previously undiagnosed.
    To fulfill our mission of delivering high-quality health 
care to all those in our custody, detainees receive a 
comprehensive medical, dental, and mental health intake 
screening within 12 hours upon arrival at the facility. 
Furthermore, they receive a comprehensive health assessment, 
including physical examination and mental health screening by a 
qualified, licensed health care professional within 14 days. 
Detained non-citizens identified as high risk during the intake 
process are triaged for a higher level of care immediately.
    ICE embraces national detention standards that are 
recognized for detention and health care delivery, and ICE's 
integrated health care delivery program undergoes extraordinary 
scrutiny. ICE conducts regular reviews, internal audits, and 
onsite assessments, and when needed, implements corrective 
action plans.
    ICE detention facilities are also subject to multiple 
levels of independent oversight inspections by the DHS Office 
of Inspector General, the ICE Office of Detention Oversight, 
the DHS Office for Civil Rights and Civil Liberties, and the 
DHS Office of the Immigration Detention Ombudsman.
    In September 2020, ICE learned of allegations of forced 
medical procedures performed by an offsite provider serving the 
Irwin County Detention Center through a whistleblower 
complaint. ICE and IHSC take these allegations and all 
allegations of medical mistreatment seriously.
    In October 2020, following the whistleblower complaint, ICE 
took immediate steps to discontinue sending patients in our 
custody to this offsite provider and to pursue alternate 
providers to serve the women in custody at ICDC.
    On November 25, 2020, ICE ceased intake of female detained 
non-citizens at ICDC, and on September 17, 2021, ICE ceased 
operations at ICDC altogether.
    While offsite community-based providers are not contracted 
to provide services with ICE or the detention facility, they 
are licensed medical professionals vetted by State and county 
licensing boards. IHSC is improving its oversight of offsite 
providers by establishing national care guidelines and 
instituting the utilization review process, an initiative 
started well before the allegations came to light.
    ICE is firmly committed to ensuring all those in its 
custody receive appropriate medical care and are treated with 
respect and dignity. ICE is also committed to fully cooperating 
and complying with all requests for information about these 
allegations from oversight bodies, including Congress.
    ICE and IHSC continue to fully participate in all 
investigations of the allegations of medical mistreatment at 
ICDC.
    Thank you again for the opportunity to speak with you 
today, and I look forward to your questions.
    Senator Ossoff. Thank you, Dr. Smith.
    Dr. Hearn, you may offer your opening statement.

  TESTIMONY OF PAMELA HEARN, MD,\1\ MEDICAL DIRECTOR, LaSALLE 
                          CORRECTIONS

    Dr. Hearn. Chairman Ossoff, Ranking Member Johnson, and 
Members of the Subcommittee, thank you for arranging this 
hearing and for the opportunity to provide testimony concerning 
allegations of detainee mistreatment.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Hearn appears in the Appendix on 
page 56.
---------------------------------------------------------------------------
    My name is Dr. Pamela Hearn. I serve as the Medical 
Director for LaSalle Corrections, and have overseen medical 
care at the Irwin County Detention Center in Georgia since 
January 2020. I am responsible for the medical operations and 
deployment of health resources to support a number of medical 
facilities, including the Irwin County Detention Center's 
medical department.
    Also, I am actively involved in performance improvement 
initiatives for the patients we serve. I communicate with ICE 
to establish clinical policy, procedures, and protocols, and 
analyze audit results to ensure patient care meets the expected 
standards.
    Today I seek to clarify who LaSalle is and its limited role 
in the provision of outside medical services.
    LaSalle was founded in 1997, to address overcrowding and 
underfunding in State-run detention facilities. LaSalle 
currently manages 15 facilities in 4 States. LaSalle partners 
with local municipalities to provide facility management and 
operational services, while also providing employment 
opportunities and economic stability to these areas.
    LaSalle is led by a corporate management team. Each member 
has extensive professional experience in detention 
administration, criminal justice, and public service. Guided by 
this leadership, LaSalle demonstrates a deep understanding and 
ongoing commitment to the health and well-being of those 
entrusted to our care.
    LaSalle is committed to operating its facilities and 
programs with the highest levels of decency and humanity, while 
providing safe, secure, and humane surroundings for our staff 
and those in our custody. LaSalle does this in all the 
communities we serve, including Irwin County, Georgia.
    It is LaSalle's policy to ensure that all detainees have 
access to appropriate medical care by onsite, qualified 
personnel who are licensed, registered, or certified, with 
applicable State and Federal requirements.
    LaSalle provided onsite health care services to patients in 
accordance with the stringent standards set forth by ICE, known 
as the 2011 Performance-Based National Detention Standards 2008 
(PBNDS). Frequent independent audits verified Irwin County 
Detention Center met or exceeded these standards. In addition, 
IHSC provided consistent guidance in the form of interim 
reference sheets and the pandemic response requirements. Again, 
independent reviews substantiate the fact that LaSalle and 
Irwin County met or exceeded standards.
    At no point was LaSalle involved in the vetting or 
monitoring of outside providers or the provision of translation 
services on behalf of patients, nor could we have done so under 
the regulations governing our involvement at Irwin County 
Detention Center. Rather, the IHSC credentialing department was 
responsible for vetting and approving all outside medical 
providers, and ICE was to monitor and pay for the same.
    LaSalle's limited role respecting outside medical care was 
to ensure that outside medical providers were available and to 
provide transportation of the patient to and from those 
providers. At all times, LaSalle partners with the Federal 
Government and their agencies to provide excellent medical care 
and exceed the relevant ICE standards.
    Senator Ossoff. Thank you, Dr. Hearn.
    Inspector General Cuffari, you may now offer your opening 
statement.

TESTIMONY OF THE HONORABLE JOSEPH V. CUFFARI, PHD,\1\ INSPECTOR 
    GENERAL, U.S. DEPARTMENT OF HOMELAND SECURITY OFFICE OF 
                       INSPECTOR GENERAL

    Mr. Cuffari. Chairman Ossoff, Ranking Member Johnson, and 
Members of the Subcommittee, thank you for the opportunity to 
discuss the oversight work of DHS IG. Our mission is to provide 
independent and objective oversight of DHS. This is a 
responsibility that I and the dedicated career professionals on 
my team take seriously.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Cuffari appears in the Appendix 
on page 63.
---------------------------------------------------------------------------
    It is an honor to appear before you today to discuss our 
oversight of medical care in ICE detention facilities. I am 
profoundly grateful for the continued bipartisan support we 
have received from Congress. This support has included year-
over-year increases in our appropriations during my tenure.
    As I promised the Homeland Security and Governmental 
Affairs Committee (HSGAC) in my confirmation hearing, I have 
used the expanded investment in our work to augment our 
detention oversight with contract medical professionals. 
Between fiscal years 2020 and 2022, our office conducted 12 
inspections of ICE detention facilities. In 9 of those 
inspections, a team of medical professionals, typically a nurse 
and a doctor, reviewed detainee medical files, medical staffing 
levels, training curriculum, and medical protocols to determine 
whether the medical care provided to detainees complied with 
Federal detention standards and with Coronavirus Disease 2019 
(COVID-19) protocols.
    In 7 of the 11 reports we issued from fiscal year 2020 to 
2022, we found deficiencies in detainee medical care. In total, 
we made 69 recommendations, 20 of which are aimed at improving 
detainee medical care.
    In September 2020, we received a complaint about the Irwin 
County Detention Center. We referred the criminal allegations 
of forced medical procedures to our Office of Investigations 
and the whistleblower retaliation complaint to our 
Whistleblower Protection Unit.
    We also initiated an inspection of the Irwin County 
Detention Center in October 2020. I personally visited that 
facility in June 2021.
    Following our established protocol, we interviewed ICE 
personnel, Irwin officials, and detainees. We also reviewed 
video surveillance of housing and common areas. Our medical 
experts conducted a virtual tour of the medical unit and 
reviewed medical records.
    Our inspection determined that Irwin generally met ICE 
detention standards. However, our medical team found the 
facility's chronic care, continuity of care, and medical 
policies and procedures to be inadequate. Our medical team 
found the quality of women's health care to be adequate based 
on records reviewed, but noted that offsite providers did not 
consistently share information with the facility.
    The facility generally complied with COVID-19 guidelines 
but faced challenges implementing those protocols. We also 
found that detainees' communication with and access to ICE 
deportation officers was limited.
    We published our report in January 2022, and made five 
recommendations to improve the facility's medical care and 
operations. ICE concurred with one recommendation and 
implemented corrective actions. ICE did not concur with the 
other four recommendations since, in May 2021, Secretary 
Mayorkas announced DHS's plans to discontinue the use of the 
facility. By September 2021, ICE no longer housed detainees at 
Irwin.
    In addition to our inspections of individual detention 
facilities, at my direction DHS IG has undertaken systemic 
reviews of longstanding issues in detention. For example, in 
October 2021, we issued for the first time ever a 5-year review 
of the use of administrative and disciplinary segregation in 
detention. This is the practice of holding individuals in 
isolation.
    In a separate review on medical vacancies across all 
detention facilities, we determined that ICE faces challenges 
recruiting, hiring, and retaining medical staff. Earlier this 
year we launched a separate system-wide audit across all DHS 
detention facilities to ascertain the vigor of the approval 
process for invasive surgical procedures.
    Whether it is through individual inspections or broad 
systemic reviews, our recommendations continue to demonstrate 
to the Department, Congress, and the public our commitment to 
quality oversight.
    Mr. Chairman, this concludes my testimony. I am happy to 
answer any questions you or the other Members of the 
Subcommittee may have.
    Senator Ossoff. Thank you, Inspector General Cuffari. Thank 
you to all of our panel two witnesses, for your opening 
statements. We will now proceed to questions.
    Dr. Smith, I would like to begin with you. You lead the ICE 
Health Service Corps. Its fiscal year 2020 annual report 
states, ``The IHSC assistant director is responsible for all 
administrative and operational elements of the IHSC health care 
system and consequently all activities related to the health 
care of individuals in ICE custody.'' This is you, correct?
    Mr. Smith. That is correct, sir.
    Senator Ossoff. You are responsible for overseeing the 
whole IHSC system and any activities related to the health care 
of individuals in ICE custody. Correct? That is from your 2020 
annual report.
    Mr. Smith. That is correct.
    Senator Ossoff. In addition to your job description, ICE 
and IHSC are legally required, and your own manual and 
guidelines require, that individuals under your custody must be 
provided with adequate medical care. Correct?
    Mr. Smith. That is correct.
    Senator Ossoff. IHSC is responsible for ensuring the 
adequacy of this care for all detainees in ICE custody, not 
merely those at ICE-administered facilities. Correct?
    Mr. Smith. We do not monitor the direct patient care 
activities on an ongoing daily basis----
    Senator Ossoff. That is not my question. My question is 
that you are responsible--this is the quote from the annual 
report--you are responsible personally for all administrative 
and operational elements of the IHSC health care system, and 
that includes the provision of health care to detainees at 
privately administered facilities. Correct?
    Mr. Smith. Correct.
    Senator Ossoff. Now it is my understanding that IHSC 
employees, who are called field medical coordinators, and 
regional clinical directors, approve referrals to offsite 
providers, and the regional clinical directors approve the 
performance of surgical procedures by those offsite providers, 
such as Dr. Amin in Georgia. Is that correct?
    Mr. Smith. That is correct.
    Senator Ossoff. Those regional clinical directors report up 
the chain, at which you are at the top. Correct?
    Mr. Smith. Correct.
    Senator Ossoff. They approve every surgical procedure that 
is referred to an offsite provider. Is that correct?
    Mr. Smith. That is correct.
    Senator Ossoff. I want to give you an opportunity to 
respond to some of the specifics, some of the facts of this 
matter, Dr. Smith. Your opening statement was quite broad. 
These are bipartisan findings of the U.S. Senate's preeminent 
investigative subcommittee that women ICE detainees were 
subject consistently to unnecessary, invasive, and often non-
consensual gynecological surgical procedures. What is your 
response?
    Mr. Smith. Thank you for that question, Senator. Receiving 
the documented informed consent is a core principle of medical 
care, given throughout the country. It is a core tenet of what 
is to occur. Documenting informed consent ensures that people 
understand the procedures they are going to go through and that 
they sign off on those and agree that they will go through 
those.
    IHSC relies on those offsite providers to obtain informed 
consent as they would do for any patient that receives care in 
the U.S. health system.
    Senator Ossoff. Hold on a second. If I might, are you 
saying you rely on those offsite providers. But you personally, 
as we have established, and it is from IHSC documents, are 
responsible for all administrative and operational elements of 
the IHSC health care system, and consequently all activities 
related to the health care of individuals in ICE custody. That 
is from your agency.
    What I am trying to understand, Dr. Smith, is this has been 
a bipartisan, 18-month, U.S. Senate investigation, and the 
bipartisan conclusions of our investigation are that women 
whose care you are responsible for were subjected to 
unnecessary, invasive gynecological procedures, including in at 
least dozens of cases, gynecological surgeries that were not 
clinically indicated that carried substantial risks to the 
long-term health of those women who were incarcerated at the 
time.
    You are not shocked that this happened under your watch?
    Mr. Smith. It is very troubling to hear the testimony given 
earlier. Obviously, we take the care of all detainees in ICE 
custody very seriously. I want to be clear that we do not have 
our own IHSC staff at these contracted facilities. They are 
contracted to provide that care. Our role is to provide that 
oversight through different audits so that we are assured that 
they comply with the detention standards of care.
    Our field medical coordinators, when they conduct their 
audits, they look for those different standards of care to make 
sure they are complying with them, and they do a quality 
assurance audit to make sure that the types of care that is 
being provided is in concert with those standards.
    Senator Ossoff. Let us talk about that oversight, Dr. 
Smith. Were you aware, was IHSC aware, for example, that Dr. 
Amin, whom you contracted to provide care to detainees for whom 
you were responsible, had previously been sued by the 
Department of Justice and the State of Georgia for performing 
unnecessary and excessive medical procedures?
    Mr. Smith. When we became aware----
    Senator Ossoff. When did you become aware?
    Mr. Smith. We became aware through the whistleblower 
allegation process.
    Senator Ossoff. Right. My question is were you aware at the 
time that you engaged his services that he had been sued by the 
Federal Government and the State of Georgia for doing what it 
appears he did again working for you?
    Mr. Smith. No, we were not.
    Senator Ossoff. You were not aware. Were you aware, from 
2017 to 2020--that is the relevant period here--that despite 
only seeing 6.5 percent of all OB/GYN patients, he was 
performing 95 percent of all laparoscopies and dilation and 
curettage surgeries? These are intrusive gynecological 
surgeries. Were you aware of that?
    Mr. Smith. We became aware after the allegations were 
filed.
    Senator Ossoff. You were not aware at the time?
    Mr. Smith. No.
    Senator Ossoff. Do you vet the doctors you hire?
    Mr. Smith. We do not vet them----
    Senator Ossoff. You do not vet them?
    Mr. Smith. Let me finish if I may, sir. These providers are 
not contracted directly with ICE. They are not an employee of 
ICE. They are referred offsite. Since these allegations, and 
actually before, we have been sending out different types of 
letters of agreement with them that they will abide by the 
different standards of care, and that they will provide the 
informed consent. We now have that as part of our process.
    But even if these things were to show up in a national 
practitioner database as a red flag, it does not necessarily 
mean that they are not going to be licensed, if they are 
licensed in the State and they have been provided credentialing 
and privileging in the different facilities, and we have not 
received any specific complaints on the physicians, we will 
evaluate it further. In this particular case, in Dr. Amin's 
case, he was the only provider in the area that was willing to 
see these patients. However, we were not aware of all the 
particulars until the whistleblower allegation.
    Senator Ossoff. Did you maintain any process for detecting 
whether or not providers working for DHS, working for IHSC, 
were preforming extraordinarily high numbers of certain 
procedures, which can be a classic signature, for example, of 
fraudulent billing?
    Mr. Smith. The process we had in place at the time was 
through the claims process where we can actually see those 
claims when they come in. If there is an overbilling that is 
occurring, we can catch that. Oftentimes, because of the way 
the system was currently set up, we would not see those until 
well after the fact. These providers have up to a year to 
submit their claims for processing, and at the time that was 
the only process we had in place to see if there were these 
overbilling or de-bundling of services to overcharge, and that 
sort of thing.
    Senator Ossoff. Let us return to the vetting. What I heard 
you say, effectively, is that you do not vet, and even if you 
had vetted it would not catch this kind of thing. Is that your 
testimony?
    Mr. Smith. I am saying that based on the lack of any 
derogatory information that was in a national practitioner 
database, specifically as to the type of care, which we were 
not performing extensively at that time, we were starting to, 
we did not have the ability to see that information other than 
through a claims process.
    Senator Ossoff. We found that information quite swiftly. We 
found that the relevant provider had been sued by the Federal 
Government and the State government for excessive and 
unnecessary billing practices. We found that he had been 
dropped by a major insurer for excessive malpractice claims. We 
found that he was not board certified. Those, I think, would 
have at least been warning signs to watch a little more 
carefully, and then during the relevant period he is 
performing, again, 90-plus percent of all of these 
gynecological surgeries nationwide, despite seeing only 6 
percent of 
OB/GYN patients in the country.
    Mr. Smith. Right, and all of these procedures that were 
referred offsite were vetted through our regional clinical 
directors for appropriateness. Again, since then we have 
expanded our ability----
    Senator Ossoff. Yes. I am sorry but let me ask about that. 
They were vetted by all of your regional coordinators for 
appropriateness.
    Mr. Smith. Correct.
    Senator Ossoff. How can that be when we have heard from 
medical experts who have reviewed thousands and thousands of 
pages of records, and it is the bipartisan finding of the 
Subcommittee that they were not appropriate? In fact, it is not 
only that they were not appropriate, they were dangerous, they 
were wrong, they were not clinically indicated, and they were 
poorly executed. Women had parts of the cervixes removed. They 
underwent transvaginal ultrasounds with Pap smears with no 
clinical indication for it. They underwent laparoscopic surgery 
when there was no need. They had their uterine lining and 
endometria removed, in part, without clinical indication. You 
are saying that all of that was vetted and approved by your 
employees?
    Mr. Smith. What I am suggesting is when these referrals 
from the clinic came to our regional clinical directors to 
approve an offsite referral to see an OB/GYN physician or a 
specialist, they approved that. They had no way of knowing 
exactly what was going to happen subsequent to that referral.
    Now since then we have some Milliman Guidelines that we are 
then tooling our clinical directors so that when they see that 
here is the procedure that is going to be performed offsite we 
have an evidence-based protocol that we can actually take a 
look at. The clinical director looks at that offsite referral 
as far as the referral being appropriate and says either yes, 
we agree that it should be referred offsite to a specialist for 
further evaluation. What that evaluation may entail, we do know 
until after the fact.
    Senator Ossoff. We will return in just a moment. I am going 
to yield now to my colleague, Senator Padilla.

              OPENING STATEMENT OF SENATOR PADILLA

    Senator Padilla. Thank you, Mr. Chair. Mr. Smith, I 
understand you have received a lot of questions so far today, 
and I have some as well but I will give you a minute to catch 
your breath, and address my first question to Dr. Cuffari.
    In your written testimony you mentioned that following the 
complaints at Irwin County Detention Center you launched a 
system-wide audit across all DHS detention facilities. During 
this audit did you find examples in other ICE detention 
facilities of women being subjected to invasive medical 
procedures without their consent?
    Mr. Cuffari. Thank you for that question, Senator. Good to 
see you, and I look forward to visiting with you. I know our 
staff is coordinating a visit.
    That review is currently ongoing and I would be certainly 
happy to share it with you as soon as the review has been 
completed.
    Senator Padilla. Has there been any evidence you have come 
across thus far, even though the review is not completed?
    Mr. Cuffari. Nothing that would warrant our immediate 
notification to the Committee.
    Senator Padilla. OK. You also mentioned in your testimony 
that facilities face challenges in the recruitment, the hiring, 
and the retention of medical staff.
    What ideas do you offer this Committee on how ICE can 
improve practices so that medical care is more consistent 
across detention centers?
    Mr. Cuffari. I believe in our review, Senator, we found 
that recruitment and retention to be a significant problem. We 
made a number of recommendations already to the Department to 
shore that up, to strengthen their recruitment and retention 
efforts, and we look forward to receiving word back from the 
Department on exactly what their process is and how to 
strengthen it.
    Senator Padilla. OK. Eventually that comes to a question of 
budget and resources, in which this Committee and the Senate 
and the Congress as a whole needs to be involved, so please 
keep us posted.
    Mr. Cuffari. Yes, sir.
    Senator Padilla. Mr. Smith, in July of last year, ICE 
issued a new policy on pregnant, postpartum, and nursing 
individuals. This policy states that such individuals cannot be 
detained unless their release is prohibited by law or 
exceptional circumstances exist. There is also a requirement 
that ICE Health Services Corps must maintain information on all 
detainees who are pregnant, postpartum, and nursing, and report 
this information to the ICE enforcement and removal operations.
    Since your office is charged with collecting this 
information, can you tell us whether the number of pregnant, 
postpartum, and nursing women in ICE detention has dropped 
since the policy went into effect a year ago?
    Mr. Smith. Yes, sir, it has.
    Senator Padilla. OK, and we will look forward to the 
underlying data behind that response.
    Follow-up is what procedures are in place for ICE officers 
to ascertain whether an individual fits this criterion? For 
example, are they asking individuals to take a pregnancy test 
or asking if they are nursing at the time of arrest?
    Mr. Smith. Yes, we have a female health services directive 
that outlines all the different unique care we provide to the 
female population. They are screened for pregnancy, as part of 
the intake process, and----
    Senator Padilla. Being more specific, screened as in tested 
or questioned?
    Mr. Smith. Urine test, OK, so we can have confirmation 
whether they are or not.
    This directive also addresses elective abortions, 
contraception, emergency contraception, restrictive housing of 
female, pregnant, postpartum, breastfeeding, and all of those 
types of things. Unless there is a compelling reason outside of 
what we would have to detain this person, our recommendation is 
always to release.
    Senator Padilla. I am glad you bring up the question of 
care beyond the test. As you know, in July of this year, 
following the Dobbs decision by the Supreme Court, it was 
reported that an internal ICE memo was going to be sent from 
the director to Enforcement and Removal Operations (ERO), 
reiterating that pregnant women detained in ICE custody have 
access to full reproductive health care, and that it may be 
necessary to transfer detainees to another area of 
responsibility to ensure such access.
    ICE's own 2011 standards state that women have the right to 
access abortion and that ICE will fund the cost if the mother 
was raped or if carrying the fetus would be detrimental to her 
health. Women can also request an abortion in other situations 
if they cover the cost.
    What is ICE doing to ensure that individuals in ICE 
detention are informed about their right to an abortion?
    Mr. Smith. As part of the intake process we do explain this 
to all the women in our custody if they are found to be 
pregnant. We explain the termination of pregnancy that, as you 
mentioned, ICE does pay. We provide counseling, clinical staff 
schedule and coordinate any transfer for a woman that decides 
that she wants to take that route. If the particular State that 
they are in does not allow that, based upon that Dobbs ruling, 
we recommend transport to a State that would allow that.
    We at ICE and IHSC support that, and we make sure that 
those that would do the transfer are aware of that, and we give 
our recommendation.
    Senator Padilla. OK. Last question. How many individuals 
have been transferred to other facilities to ensure they can 
receive an abortion if they need or choose, and can you tell us 
which States they have been transferred from or to? Do you keep 
that level of data?
    Mr. Smith. I will take that as a get-back. I do not have 
with me today.
    Senator Padilla. OK. Please, at your earliest opportunity.
    Thank you, Mr. Chair.
    Senator Ossoff. Thank you, Senator Padilla.
    Picking up where we left off, please, Dr. Smith, we have 
established that you personally are responsible for, and I 
quote from again your agency's documents, ``all activities 
related to the health care of individuals in ICE custody.''
    Let me reiterate our bipartisan findings. Excessive, 
invasive, and often unnecessary gynecological procedures. 
Repeated failures to secure informed consent. ICE did not 
conduct thorough oversight of offsite medical providers and 
procedures.
    Do you take responsibility?
    Mr. Smith. Yes, sir. Ultimately, I do. I am the responsible 
party to make sure that the right processes and procedures are 
in place to monitor these things, and if we see things not 
going in the proper direction, to take the proper course of 
action to fix those.
    Senator Ossoff. Why did your agency fail?
    Mr. Smith. Again, I believe that we provide the policies, 
the procedures, and we make sure that our clinicians understand 
what those procedures are, and we do not have direct knowledge 
at the time of some of these procedures happening. We are 
working on putting systems in place to do that through the 
Milliman Care Guidelines, to give our clinical directors and 
those that approve these procedures a template that they can 
use, based on evidence-based standards, so they can be more 
informed on whether to approve an offsite procedure or not, 
based on those standards.
    Senator Ossoff. I understand you are taking those steps 
now, Dr. Smith. My question is why did your agency fail? How 
did you allow this to happen? How did you allow dozens, if not 
hundreds of women to be subjected to unnecessary gynecological 
surgery? How did that happen?
    Mr. Smith. We were not aware of these complaints. We were 
not aware of them until we received the whistleblower 
complaint. We did not have access to that information.
    Senator Ossoff. Why were you not aware? Why were you not 
aware that one doctor was performing 9/10th of gynecological 
procedures but only seeing 6 percent of patients?
    Mr. Smith. We did not have the proper systems in place to 
detect that information. We started putting that process in 
place, though, and those systems in place well in advance of 
this. We just have not got those completely implemented at this 
point.
    Senator Ossoff. What would you say to the women who went 
through this?
    Mr. Smith. It is disheartening.
    Senator Ossoff. It is disheartening.
    Mr. Smith [continuing]. And it is very disturbing. Any 
responsibility that we have we take very seriously. We want to 
fix this system so it does not happen again.
    Senator Ossoff. Dr. Smith, you have full responsibility. We 
have established that. This is worse than disheartening.
    Mr. Smith. Yes, sir.
    Senator Ossoff. It is hard for me to think of anything 
worse, really, Dr. Smith, than the Federal Government 
subjecting incarcerated women to needless gynecological 
surgery. It is one of the most appalling things this 
Subcommittee has seen in the last 2 years.
    Dr. Hearn, I understand that you want to clarify, and you 
sought to do so in your opening statement, where you believe 
the lines of responsibility between the Federal Government and 
LaSalle, the contractor, are. I would like to give you an 
opportunity to do that, please.
    Dr. Hearn. We provide onsite care, primary care, and any 
care that is deemed more advanced is referred to an outside 
specialist. This specialist must be approved by IHSC in order 
for us to schedule an appointment.
    Senator Ossoff. Let me start there, Dr. Hearn. I appreciate 
that. The specialist must be approved by IHSC. Dr. Smith, how, 
during the period of 2017 to 2020, did you go about approving 
those specialists? What was the process?
    Mr. Smith. The process was that these specialists were 
referred--these patients were referred offsite, and we made 
sure we had a letter of understanding in place with them that 
they would accept the proper Medicare rates, would be the first 
thing, and if they were credentialed or licensed in the 
facility they would perform in or in the State then they were 
deemed as competent enough to provide those services.
    Senator Ossoff. The only due diligence was to see if there 
was a valid medical license in that jurisdiction. That was the 
extent of your vetting.
    Mr. Smith. If they had any adverse things that were 
outstanding as far as direct patient care complaints through 
the national practitioner database, which we began to implement 
during that time.
    Senator Ossoff. For this provider, in 2005, a major medical 
insurer drops him because of excessive malpractice claims. In 
2013, the Federal Government initiates an investigation of 
alleged billing fraud. One year later, you hire him. DOJ, the 
State of Georgia, and the doctor settle in 2015, and then for 5 
years, with apparently no vetting and no oversight, he is 
treating the patients for whom you have responsibility, agency-
level responsibility, and as we have established, personal 
responsibility.
    Did you have a chance Dr. Smith, to hear the first panel? 
Did you listen to the testimony from our first panel of 
witnesses?
    Mr. Smith. Yes, I did.
    Senator Ossoff. Dr. Cherouny stated to the Subcommittee 
that it appeared this doctor was operating with no oversight at 
all. Is that accurate?
    Mr. Smith. Again, the only type of oversight that we had in 
place for an offsite provider at the time was going to be 
through the medical claims process. We did not have any 
utilization management, utilization review. Part of our 
modernization program is to put those things in place so we can 
detect those types of things before they happen, and we are in 
the process of doing that.
    Senator Ossoff. Thank you, Dr. Smith.
    Dr. Hearn, forgive my interruption, but you had begun to 
explain how responsibility is shared between LaSalle and the 
Federal Government. You noted that IHSC makes determinations 
with respect to who the offsite providers are and approves the 
referrals. Is that correct?
    Dr. Hearn. That is correct.
    Senator Ossoff. OK. Please tell me more about the balance 
of responsibilities between LaSalle and the Federal Government.
    Dr. Hearn. Once a provider onsite determined a specialty 
appointment was indicated, the request was presented through a 
MedPAR authorization to IHSC, and once the MedPAR was approved 
through IHSC then the mechanism existed where the approval was 
transmitted to the unit and the unit then scheduled the 
appointment with the approved outside provider.
    Senator Ossoff. Thank you, Dr. Hearn. Again turning to you, 
Dr. Smith, describe the approval process whereby your agency 
approves the surgeries and other procedures requested through 
the referral from the private operator?
    Mr. Smith. All those referrals, surgical referrals, are 
referred to our regional clinical director, and they review 
those.
    Senator Ossoff. What does that review consist of?
    Mr. Smith. That review consists of taking a look at what 
that patient is being referred for. At the time we did not have 
the specific evidence-based guidelines in place so they were 
using their best judgment on those things, as a clinician.
    Since that time we have----
    Senator Ossoff. These are doctors who are making these 
determinations?
    Mr. Smith. Yes, they are.
    Senator Ossoff. So they are using their best judgment. What 
does that mean? What criteria are they accountable to? What 
guidance did you give them? What is the policy?
    Mr. Smith. The guidance is, if they were being referred 
offsite because the clinic did not have the expertise to 
provide that, obviously the right thing to do is not to keep 
them at the clinic and try to provide care for them there. We 
needed to get them offsite. They would make sure that yes, they 
are going offsite to a provider that has those types of 
qualifications. Dr. Amin was that provider that was willing to 
see our female patient population.
    Senator Ossoff. Are these individuals, these physicians 
making these determinations as part of your agency, are they 
specialists in a relevant field or are they generalists? What 
are their specialties, typically?
    Mr. Smith. They have specialty--internal medicine, family 
medicine, those types of things, which have a certain degree of 
OB specialty, I might say, knowledge, enough knowledge to know 
that when they are being referred to an OB physician that that 
is the right place for them to go to be seen for their offsite 
care.
    Senator Ossoff. Do these physicians look at the nature of 
the complaint and assess whether or not the treatment that is 
being requested is clinical indicated?
    Mr. Smith. To the best of their knowledge, with the 
information they have at the time, yes, but----
    Senator Ossoff. So how did it happen that repeatedly, as 
you heard from the medical experts, the underlying condition 
was treated with a course of treatment that was not appropriate 
for the underlying condition?
    Mr. Smith. I have no way of specifically knowing what they 
knew at that time when they referred them.
    Senator Ossoff. Have you asked them?
    Mr. Smith. We have asked them.
    Senator Ossoff. What did they say?
    Mr. Smith. They said based upon the information they had 
through the referral process that they thought it was the 
appropriate thing to refer them offsite to a higher level of 
specialty care.
    Senator Ossoff. Dr. Hearn, I believe, in your testimony, 
you stated that when these allegations became public that you 
undertook a review. Is that correct?
    Dr. Hearn. That is correct.
    Senator Ossoff. Why did you do that?
    Dr. Hearn. The allegations were extremely concerning to 
LaSalle and to myself, so we immediately began an internal 
review at that time.
    Senator Ossoff. You began the review because they were 
concerning. They certainly were concerning. Were you advised by 
corporate leadership to undertake that review? What was the 
decisionmaking process to launch that review?
    Dr. Hearn. The discussion between myself and the Chief 
Executive Officer (CEO) concerning the allegations led us to 
launch a review.
    Senator Ossoff. How long did that review take?
    Dr. Hearn. That review started the day after my discussion 
with the CEO, and it has continued throughout until this very 
day.
    Senator Ossoff. That is a little bit different from what we 
heard from the company previously. We understood, and we can 
refer to the relevant part of the interview, there was a 3-day 
review. What does that 3-day review refer to?
    Dr. Hearn. The three-day review was an onsite review of 
documents at the facility, discussions with the medical 
leadership, and discussions with the unit leadership.
    Senator Ossoff. What did you find?
    Dr. Hearn. I reviewed medical charts, and I had a 
discussion with the leadership, and at that----
    Senator Ossoff. OK. Forgive me. You reviewed medical charts 
and had a discussion with leadership. Here is what I am trying 
to understand. It took a team of professional investigators 
from both political parties here in the Senate 18 months and 
consultation with a significant number of outside medical 
experts to go through tens of thousands of pages of medical 
records in order for us to arrive at these conclusions. How 
could a 3-day review have possibly been sufficient for LaSalle 
to draw any firm conclusions about what happened here?
    Dr. Hearn. My review involved the process of referral, the 
process of referral at the unit, the appropriateness of the 
referral, and the approval process in which the referrals were 
approved.
    Senator Ossoff. OK. Let us talk about that referral 
process. As we have heard from our medical experts, there was a 
consistent pattern, a course of treatment that this provider 
consistently undertook, and generally speaking, it began with 
imaging or examination procedures that were not clinically 
indicated by the underlying complaint. Then a statement by the 
physician that the first intervention would be a Depo Provera 
shot, a contraceptive injection.
    Then on the basis of, for example, imaging, a transvaginal 
ultrasound that may have been performed, a determination that 
there were cysts present, and a statement by the physician that 
if it did not resolve in a number of weeks they might proceed 
to some surgical intervention, and in many cases the doctor did 
cut these patients, laparoscopically, dilation and curettage, a 
range of other procedures.
    You said that when you make that referral are you 
assessing? Are your medical professionals assessing whether the 
course of treatment that is proposed by the offsite provider is 
clinically appropriate, given the underlying complaint?
    Dr. Hearn. The medical provider is reliant on the expertise 
of the specialist.
    Senator Ossoff. I need you to be a little more specific. 
The medical provider meaning your employee onsite.
    Dr. Hearn. The onsite medical provider is dependent upon 
the expertise of the outside medical provider.
    Senator Ossoff. Do they accept the outside provider's 
recommendation without any review, without any question?
    Dr. Hearn. There is a review of the medical documents 
received from the outside provider, but the documents are very 
limited oftentimes.
    Senator Ossoff. Why do LaSalle personnel undertake that 
review? Why do the clinicians onsite at your facilities review 
the underlying documentation submitted by the specialist to 
determine whether or not the procedure is appropriate? Why do 
you do that?
    Dr. Hearn. The onsite providers do not have the clinical 
expertise or the knowledge of the specialist referral, but the 
onsite provider is reviewing the records regarding the 
treatment that has been recommended by the outside clinician in 
order to request IHSC approval for the requested treatment.
    Senator Ossoff. Say that last part again. You are looking 
to see what?
    Dr. Hearn. You are looking to review the treatment that was 
recommended by the outside provider, and then the request for 
treatment is submitted to an approval process with IHSC. Any 
follow-up appointments are approved by IHSC.
    Senator Ossoff. Right. I am not getting clarity on whether 
or not your personnel onsite, the clinicians onsite at LaSalle 
facilities, are making a determination about the propriety of 
the proposed course of treatment. Are they just rubber-stamping 
it or are they looking at the record, looking at the complaint 
that has been diagnosed, and making an assessment as to whether 
it is the appropriate course of treatment?
    Dr. Hearn. Onsite are not making an assessment.
    Senator Ossoff. What are they doing? They are just 
referring it to IHSC.
    Dr. Hearn. Yes.
    Senator Ossoff. They do not exercise any discretion and 
they approve or refer 100 percent.
    Dr. Hearn. They are referring all recommendations to IHSC.
    Senator Ossoff. Your testimony is that it is entirely the 
responsibility of IHSC to assess the propriety of the proposed 
intervention.
    Dr. Hearn. Any referral, follow-up appointment, or 
procedure is approved by IHSC.
    Senator Ossoff. You said that your review was ongoing to 
this day. What steps have you taken subsequent to those initial 
3 days, and why have you taken them?
    Dr. Hearn. With the subpoenas that were issued, I 
personally reviewed page after page of medical records that 
were on paper, until September 2017. Afterwards LaSalle 
utilized electronic health records, and we pulled electronic 
health records to comply with the request from the subpoenas.
    Senator Ossoff. For clarity, Dr. Hearn, what you mean when 
you say the review has continued to this day is that you have 
complied with this Subcommittee's and perhaps other agencies' 
processes for securing information, but you have not undertaken 
any additional review yourself of the underlying records or the 
propriety of the treatment provided by Dr. Amin. Is that 
correct?
    Dr. Hearn. During my document production there was some 
review that goes along with document production as well.
    Senator Ossoff. I see. In the course of providing us and 
other potential agencies with those documents you looked at 
them, is what you are saying.
    Dr. Hearn. Yes.
    Senator Ossoff. OK.
    Dr. Hearn. Not every document, but some were reviewed.
    Senator Ossoff. I hear you.
    Inspector General Cuffari, I know that the Office of the 
Inspector General is currently engaged in its own review of 
this matter. When can we expect you to complete that?
    Mr. Cuffari. Senator, in an open setting I would be remiss 
because we are touching on other agencies within the Executive 
Branch that have equities in the matter you are asking about, 
and I do not have a timeline to give you in an open setting.
    Senator Ossoff. What steps can the Office of the Inspector 
General take to ensure that these grotesque failures and abuses 
never happen again?
    Mr. Cuffari. To continue our vigorous and objective 
oversight of the Department of Homeland Security and ICE 
detention, to include U.S. Customs and Border Protection (CBP) 
detention as well.
    Senator Ossoff. Thank you, Inspector General Cuffari.
    Mr. Cuffari. Yes, sir.
    Senator Ossoff. This will conclude the questioning for 
today's hearing. The record will remain open for 15 days for 
submissions.
    I just have to say, this is such an appalling case. I am 
repeating myself, but as I said earlier, I cannot think of much 
of anything worse than this, unnecessary surgeries performed on 
prisoners. Give me a break. It is an abject failure, Dr. Smith. 
It is a disgrace to the Federal Government.
    What we have heard today is that there was no real vetting. 
Your assessment appears to be that if you had undertaken 
vetting you would not have found anything. That suggests that 
you are not thinking creatively enough about how to vet these 
providers, because there were red flags that should have at 
least provided the basis for more careful monitoring of this 
physician. That basically there were no processes in place, no 
due diligence, no review, and no way to monitor for red flags. 
The data was warning you, but you were not looking at it, and a 
lot of people got hurt.
    We will have follow-up questions, Dr. Smith and Dr. Hearn, 
and Inspector General Cuffari, I look forward to the conclusion 
of your ongoing work related to this matter.
    Mr. Cuffari. Yes, sir.
    Senator Ossoff. I thank you all for your presence today. I, 
without objection, will introduce this full report into the 
record\1\ and adjourn the hearing.
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    \1\ The Staff report appears in the Appendix on page 74.
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    [Whereupon, at 4:34 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

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