Alien Detention Standards: Observations on the Adherence to ICE's
Medical Standards in Detention Facilities (04-JUN-08,		 
GAO-08-869T).							 
                                                                 
In fiscal year 2007, Department of Homeland Security's (DHS) U.S.
Immigration and Customs Enforcement (ICE) detained over 311,000  
aliens, with an average daily population of over 30,000 and an	 
average length of stay of about 37 days in one of approximately  
300 facilities. The care and treatment of aliens while in	 
detention is a significant challenge to ICE, as concerns continue
to be raised by members of Congress and advocacy groups about the
treatment of the growing number of aliens while in ICE's custody.
This testimony focuses on (1) the extent to which 23 facilities  
complied with medical care standards, (2) deficiencies found	 
during ICE's annual compliance inspection reviews, and (3) the	 
types of complaints filed by alien detainees about detention	 
conditions. This testimony is based on GAO's July 2007 report	 
evaluating, among other things, the extent to which 23 facilities
complied with aspects of eight of ICE's 38 National Detention	 
Standards. This report did not address quality of care issues.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-869T					        
    ACCNO:   A82261						        
  TITLE:     Alien Detention Standards: Observations on the Adherence 
to ICE's Medical Standards in Detention Facilities		 
     DATE:   06/04/2008 
  SUBJECT:   Accountability					 
	     Aliens						 
	     Correctional facilities				 
	     Detention facilities				 
	     Facility management				 
	     Health care facilities				 
	     Health care personnel				 
	     Health care policies				 
	     Health care programs				 
	     Health care reform 				 
	     Health care services				 
	     Health policy					 
	     Inspection 					 
	     Internal controls					 
	     Mental health					 
	     Mental health care services			 
	     Noncompliance					 
	     Standards						 
	     Standards evaluation				 
	     Standards (health care)				 

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**                                                              **
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GAO-08-869T

This is the accessible text file for GAO report number GAO-08-869T 
entitled 'Alien Detention Standards: Observations on the Adherence to 
ICE's Medical Standards in Detention Facilities' which was released on 
June 4, 2008.

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Testimony before the Subcommittee on Immigration, Citizenship, 
Refugees, Border Security and International Law, Committee on the 
Judiciary, House of Representatives: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 2:00 p.m. EDT:
Wednesday, June 4, 2008: 

Alien Detention Standards: 

Observations on the Adherence to ICE's Medical Standards in Detention 
Facilities: 

Statement of Richard M. Stana: 
Director, Homeland Security and Justice Issues: 

GAO-08-869T: 

GAO Highlights: 

Highlights of GAO-08-869T, a testimony to the Subcommittee on 
Immigration, Citizenship, Refugees, Border Security and International 
Law, Committee on the Judiciary, House of Representatives. 

Why GAO Did This Study: 

In fiscal year 2007, Department of Homeland Securityï¿½s (DHS) U.S. 
Immigration and Customs Enforcement (ICE) detained over 311,000 aliens, 
with an average daily population of over 30,000 and an average length 
of stay of about 37 days in one of approximately 300 facilities. The 
care and treatment of aliens while in detention is a significant 
challenge to ICE, as concerns continue to be raised by members of 
Congress and advocacy groups about the treatment of the growing number 
of aliens while in ICEï¿½s custody. This testimony focuses on (1) the 
extent to which 23 facilities complied with medical care standards, (2) 
deficiencies found during ICEï¿½s annual compliance inspection reviews, 
and (3) the types of complaints filed by alien detainees about 
detention conditions. This testimony is based on GAOï¿½s July 2007 report 
evaluating, among other things, the extent to which 23 facilities 
complied with aspects of eight of ICEï¿½s 38 National Detention 
Standards. This report did not address quality of care issues. 

What GAO Found: 

At the time of its visits, GAO observed instances of noncompliance with 
ICEï¿½s medical care standards at 3 of the 23 facilities visited. These 
instances related to staff not administering a mandatory 14-day 
physical exam to approximately 260 detainees, not administering medical 
screenings immediately upon admission, and first aid kits not being 
available as required. However, these instances did not show a 
pervasive or persistent pattern of noncompliance across all 23 
facilities. Officials at some facilities told GAO that meeting the 
specialized medical and mental health needs of detainees had been 
challenging, citing difficulties they had experienced in obtaining ICE 
approval for outside nonroutine medical and mental health care. On the 
other hand, GAO observed instances where detainees were receiving 
specialized care at the facilities visited. 

At the time of its study, GAO reviewed the most recently available ICE 
annual inspection reports for 20 of the 23 detention facilities that it 
visited; these reports showed that ICE reviewers had identified a total 
of 59 instances of noncompliance with National Detention Standards, 4 
of which involved medical care. One facility had sick call request 
forms that were available only in English whereas the population was 
largely Spanish speaking. Another did not maintain alien medical 
records on-site. One facilityï¿½s staff failed to obtain informed consent 
from the detainee when prescribing psychiatric medication. Finally, 
another facility did not have medical staff on-site to screen detainees 
arriving after 5 p.m. and did not have a properly locked medical 
cabinet. GAO did not determine whether these instances of noncompliance 
were subsequently corrected as required. 

The types of grievances at the facilities GAO visited typically 
included the lack of timely response to requests for medical treatment, 
missing property, high commissary prices, poor food quality and 
insufficient food quantity, high telephone costs, problems with 
telephones, and questions concerning detention case management issues. 
ICEï¿½s detainee grievance standard states that facilities shall 
establish and implement procedures for informal and formal resolution 
of detainee grievances. Four of the 23 facilities GAO visited did not 
comply with all aspects of ICEï¿½s detainee grievance standards. For 
example, one facility did not properly log all grievances that GAO 
found in their facility files. Detainee complaints may also be filed 
with several governmental and nongovernmental organizations. The 
primary way for detainees to file complaints is to contact the DHS 
Office of Inspector General (OIG). About 11 percent of detainee 
complaints to the OIG between 2005 and 2006 involved medical treatment 
issues. However, we found that the OIG complaint hotline 1-800 number 
was blocked or otherwise restricted at 12 of the facilities we tested. 
OIG investigates the most serious complaints and refers the remainder 
to other DHS components. GAO could not determine the number of cases 
referred to ICEï¿½s Detention Removal Office and concluded that ICEï¿½s 
detainee complaint database was not sufficiently reliable. 

What GAO Recommends: 

While this testimony contains no new recommendations, GAO made 
recommendations to DHS to, among other things, establish improved 
internal control procedures to help ensure that detainee complaints are 
properly documented and their disposition recorded. DHS agreed with 
GAOï¿½s recommendations and is making progress implementing them. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-869T]. For more 
information, contact Richard M. Stana at (202) 512-8777 or 
[email protected]. 

[End of section] 

Chairman Lofgren, Mr. King, and members of the Subcommittee: 

Thank you for inviting me here today to discuss our observations on the 
adherence to medical standards in alien detention facilities. According 
to the Department of Homeland Security's (DHS) U.S. Immigration and 
Customs Enforcement (ICE) officials, they maintain custody of one of 
the most highly transient and diverse populations of any correctional 
or detention system in the world. In fiscal year 2007, ICE detained 
over 311,000 aliens, with an average daily population of over 30,000 
and an average length of stay of about 37 days (50 percent stay 18 days 
or less). This diverse population includes individuals from different 
countries; with varying medical conditions and security risks (criminal 
and noncriminal); and includes males, females, and families of every 
age group. 

The care and treatment of aliens while in detention is a significant 
challenge to ICE, as concerns continue to be raised by members of 
Congress and advocacy groups about the treatment of the growing number 
of aliens while in ICE's custody. ICE has 38 National Detention 
Standards to help ensure that alien detainees are housed under 
appropriate conditions of confinement. These standards relate to a 
range of detainee services, including medical services. ICE policy is 
to conduct annual compliance inspection reviews of all adult, juvenile, 
and family detention facilities to check compliance with these 
standards. In doing so, ICE inspection staff are to review each 
detention facility's compliance with about 300 factors that are related 
to these standards (e.g., whether under the medical care standard the 
facility established a policy and procedures for responding to a 
detainee hunger strike). In addition to being required to comply with 
ICE's National Detention Standards, some ICE detention facilities are 
accredited by The Joint Commission, the predominant standards-setting 
and accrediting body in health care, and the National Commission on 
Correctional Health Care (NCCHC), which offers a health services 
accreditation program to determine whether correctional institutions 
meet its standards in their provision of health services. 

From May 2006 through May 2007 we conducted a review to determine the 
extent to which selected facilities complied with aspects of 8 of the 
38 standards, whether similar deficiencies were disclosed by ICE's 
annual compliance inspection review process, and the nature and 
disposition of complaints filed by aliens in detention facilities. We 
selected these eight National Detention Standards to review on the 
basis of interviews with officials from the United Nations High 
Commissioner for Refugees (UNHCR), the American Bar Association, and 
DHS Office of the Inspector General (OIG). These eight standards we 
reviewed were telephone access, medical care, hold room procedures, use 
of force, food services, recreation, access to legal materials, and 
detainee grievance procedures. During the course of our review we 
visited 23 detention facilities under ICE oversight--18 of 330 adult, 2 
of 19 juvenile, and all 3 family detention facilities. Because we did 
not randomly select our detention facilities, the results of our field 
observations from these facilities cannot be generalized to the full 
universe of detention facilities nationwide. However, these 
observations provided us with an overview of compliance with detention 
standards at different sizes and types of facilities in various 
locations across the country. We reviewed policies, procedures, 
documents, and inspection and grievance reports pertaining to detainee 
conditions of confinement, and interviewed facility and ICE staff 
responsible for compliance with the eight standards that we reviewed. 
In addition, we interviewed some individual detainees concerning their 
treatment at detention facilities, particularly with respect to the 
eight standards, but did not independently assess the merits of 
detainee complaints. 

My statement today is based on our results regarding medical care 
standards that we reported in July 2007[Footnote 1] and addresses the 
extent to which the 23 facilities complied with ICE's medical care 
standards, deficiencies found during ICE's annual compliance 
inspections of these facilities, and the types of complaints filed by 
alien detainees about detention conditions. With respect to ICE medical 
care standards, we ascertained whether (1) a range of medical and 
mental health services specified in ICE's standards were available, (2) 
detainees received initial medical screening upon admission and a more 
complete physical exam within 14 days of admission,[Footnote 2] (3) 
detainees had the opportunity to request medical services, (4) 
specialized medical and mental health services could be arranged, (5) 
procedures and facilities for suicide prevention were available, and 
(6) a plan for 24-hour emergency care was available. We did not 
systematically review individual detainee medical cases or ICE 
decisions on the type or extent of nonroutine treatment that is 
medically necessary, nor did we otherwise investigate quality of care. 

Some Instances of Noncompliance with Medical Care Standards Occurred: 

At the time of our visits, we observed instances of noncompliance with 
ICE's medical care standards at 3 of the 23 facilities we visited. 
However, these instances did not show a pervasive or persistent pattern 
of noncompliance across the facilities like we those identified with 
the telephone system.[Footnote 3] Detention facilities that we visited 
ranged from those with small clinics with contract staff to facilities 
with on-site medical staff, diagnostic equipment such as X-ray 
machines, and dental equipment. Medical service providers include 
general medical, dental, and mental health care providers that are 
licensed by state and local authorities. Some medical services are 
provided by the U.S. Public Health Service (PHS), while other medical 
service providers may work on a contractual basis. 

At the San Diego Correctional Facility in California, an adult 
detention facility, ICE reviewers that we accompanied cited PHS staff 
for failing to administer the mandatory 14-day physical exam to 
approximately 260 detainees. PHS staff said the problem at San Diego 
was due to inadequate training on the medical records system and 
technical errors in the records system. At the Casa de San Juan Family 
Shelter in California, we found that the facility staff did not 
administer medical screenings immediately upon admission, as required 
in ICE medical care standards. At the Cowlitz County Juvenile Detention 
Center in Washington state, we found that no medical screening was 
performed at admission and first aid kits were not available, as 
required. 

Officials at some facilities told us that meeting the specialized 
medical and mental health needs of detainees can be challenging. Some 
also cited difficulties they had experienced in obtaining ICE approval 
for outside nonroutine medical and mental health care as also 
presenting problems in caring for detainees. On the other hand, we 
observed instances where detainees were receiving specialized medical 
care at the facilities we visited. For example, at the Krome facility 
in Florida we observed one detainee sleeping with the assistance of 
special breathing equipment (C-PAP machine) to address what we were 
told was a sleep apnea condition. At the Hampton Roads Regional jail in 
Virginia we observed a detainee receiving treatment from a kidney 
dialysis machine. Again, assessing the quality of care and ICE's 
decision--making process for approval of nonroutine medical procedures 
were outside the scope of our review. 

ICE Compliance Inspections Also Show Some Instances of Noncompliance 
With Medical Standards: 

We reviewed the most recently available ICE annual inspection reports 
for 20 of the 23 detention facilities that we visited. With the 
exception of the San Diego facility in California, the reports covered 
a different time period than that of our review.[Footnote 4] The 20 
inspection reports showed that ICE reviewers had identified a total of 
59 instances of noncompliance, 4 of which involved medical care. 
According to ICE policy, all adult, juvenile, and family detention 
facilities are required to be inspected at 12-month intervals to 
determine that they are in compliance with detention standards and to 
take corrective actions if necessary. As of November 30, 2006, 
according to ICE data, ICE had reviewed approximately 90 percent of 
detention facilities within the prescribed 12-month interval. 
Subsequent to each annual inspection, a compliance rating report is to 
be prepared and sent to the Director of the Office of Detention and 
Removal or his representative within 14 days. The Director of the 
Office of Detention and Removal has 21 days to transmit the report to 
the field office directors and affected suboffices. Facilities receive 
one of five final ratings in their compliance report--superior, good, 
acceptable, deficient, or at risk.[Footnote 5] ICE officials reported 
that as of June 1, 2007, 16 facilities were rated "superior," 60 
facilities were rated "good," 190 facilities were rated "acceptable," 4 
facilities were rated "deficient," and no facilities were rated "at 
risk." ICE officials stated that this information reflects completed 
reviews, and some reviews are currently in process and pending 
completion. Therefore, ICE could not provide information on the most 
current ratings for some facilities. 

Four inspection reports disclosed instances of noncompliance with 
medical care standards. The Wakulla County Sheriffs Office in Florida 
had sick call request forms that were available only in English whereas 
the population was largely Spanish speaking. The Cowlitz County 
Juvenile Detention Facility in Washington state did not maintain the 
alien juvenile medical records on-site. The San Diego Correctional 
facility staff, in addition to the deficiencies noted earlier in this 
statement, failed to obtain informed consent from the detainee when 
prescribing psychiatric medication. Finally, the Broward Transitional 
Center in Florida did not have medical staff on-site to screen 
detainees arriving after 5 p.m. and did not have a properly locked 
medical cabinet. We did not determine whether these deficiencies were 
subsequently addressed as required. 

Alien Detainee Complaints Included Concerns About Medical Care: 

Our review of available grievance data obtained from facilities and 
discussions with facility management showed that the types of 
grievances at the facilities we visited typically included the lack of 
timely response to requests for medical treatment, missing property, 
high commissary prices, poor quality or insufficient quantity of food, 
high telephone costs, problems with telephones, and questions 
concerning detention case management issues. ICE's detainee grievance 
standard states that facilities shall establish and implement 
procedures for informal and formal resolution of detainee grievances. 
Four of the 23 facilities we visited did not comply with all aspects of 
ICE's detainee grievance standards. Specifically, Casa de San Juan 
Family Shelter in San Diego did not provide a handbook to those aliens 
in its facility, the Cowlitz County Juvenile Detention Center in 
Washington state did not include grievance procedures in its handbook, 
Wakulla County Sheriff's Office in Florida did not have a log, and the 
Elizabeth Detention Center in New Jersey did not record all grievances 
that we observed in their facility files. 

The primary mechanism for detainees to file external complaints is 
directly with the OIG, either in writing or by phone using the DHS OIG 
complaint hotline. Detainees may also file complaints with the DHS 
Office for Civil Rights and Civil Liberties (CRCL), which has statutory 
responsibility for investigating complaints alleging violations of 
civil rights and civil liberties. In addition, detainees may file 
complaints through the Joint Intake Center (JIC), which is operated 
continuously by both ICE and U.S. Customs and Border Protection (CBP) 
personnel, and is responsible for receiving, classifying, and routing 
all misconduct allegations involving ICE and CBP employees, including 
those pertaining to detainee treatment. ICE officials told us that if 
the JIC were to receive an allegation from a detainee, it would be 
referred to the OIG. OIG may investigate the complaint or refer it to 
CRCL or DHS components such as the ICE Office of Professional 
Responsibility (OPR) for review and possible action. In turn, CRCL or 
OPR may retain the complaint or refer it to other DHS offices, 
including ICE Office of Detention and Removal (DRO), for possible 
action. Further, detainees may also file complaints with 
nongovernmental organizations such as ABA and UNHCR. These external 
organizations said they generally forward detainee complaints to DHS 
components for review and possible action. 

The following discussion highlights the detainee complaints related to 
medical care issues where such information is available. We did not 
independently assess the merits of detainee complaints. 

* Of the approximately 1,700 detainee complaints in the OIG database 
that were filed in fiscal years 2003 through 2006, OIG investigated 173 
and referred the others to other DHS components. Our review of 
approximately 750 detainee complaints in the OIG database from fiscal 
years 2005 through 2006 showed that about 11 percent involved issues 
relating to medical treatment, such as a detainees alleging that they 
were denied access to specialized medical care.[Footnote 6] 

* OPR stated that in fiscal years 2003 through 2006, they had received 
409 allegations concerning the treatment of detainees. Seven of these 
allegations were found to be substantiated,[Footnote 7] 26 
unfounded,[Footnote 8] and 65 unsubstantiated.[Footnote 9] Four of the 
seven substantiated cases involved employee misconduct, resulting in 
four terminations. According to OPR officials, three cases were still 
being adjudicated and the nature of the allegations was not provided. 
Additionally, 200 of the allegations were classified by OPR as either 
information only to facility management, requiring no further action, 
or were referred to facility management for action, requiring a 
response. 

* CRCL also receives complaints referred from the OIG, nongovernmental 
organizations, and members of the public. Officials stated that from 
the period March 2003 to August 2006 they received 46 complaints 
related to the treatment of detainees, although the nature of the 
complaints was not identified. Of these 46 complaints, 14 were closed, 
11 were referred to ICE OPR, 12 were retained for investigation, and 9 
were pending decision about disposition. 

* We could not determine the number of cases referred to DRO or their 
disposition. On the basis of a limited review of DRO's complaints 
database and discussions with ICE officials knowledgeable about the 
database, we concluded that DRO's complaint database was not 
sufficiently reliable for audit purposes. We recommended that ICE 
develop a formal tracking system to ensure that all detainee complaints 
referred to DRO are reviewed and the disposition, including any 
corrective action, is recorded for later examination. 

* We reviewed 37 detention monitoring reports compiled by UNHCR from 
the period 1993 to 2006. These reports were based on UNHCR's site 
visits and its discussions with ICE officials, facility staff, and 
detainee interviews, especially with asylum seekers. Eighteen of the 37 
UNHCR reports cited concerns related to medical care, such as detainee 
allegations that jail staff were unresponsive to requests for medical 
assistance and UNHCR's concern about the shortage of mental health 
staff. 

* While American Bar Association officials informed us that they do not 
keep statistics regarding complaints, they compiled a list for us of 
common detainee complaints received through correspondence. This list 
indicated that of the 1,032 complaints it received from January 2003 to 
February 2007, 39 involved medical access issues such as a detainee 
alleging denial of necessary medication and regular visits with a 
psychiatrist, allegations of delays in processing sick call requests, 
and allegations of a facility not providing prescribed medications. 

Madam Chairman, this concludes my prepared remarks. I would be happy to 
answer any questions you or the members of the subcommittee have. 

Contacts and Acknowledgments: 

For further information on this testimony, please contact Richard M. 
Stana at (202) 512-8777 or by e-mail at [email protected]. Contact points 
for our Offices of Congressional Relations and Public Affairs may be 
found on the last page of this statement. 

In addition to the contact named above, William Crocker III, Assistant 
Director; Minty Abraham; Frances Cook; Robert Lowthian; and Vickie 
Miller made key contributions to this statement. 

[End of section] 

Footnotes: 

[1] GAO, Alien Detention Standards: Telephone Access Problems Were 
Pervasive at Detention Facilities; Other Deficiencies Did Not Show a 
Pattern of Noncompliance, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-875] (Washington, D.C.: 
July 6, 2007). 

[2] ICE standards state that detainees are to receive an initial 
medical screening immediately upon admission and a more complete 
medical assessment within 14 days. The policy also states that a health 
care specialist shall determine needed medical treatment. 

[3] The most persistent and pervasive problem we found was with the 
detention facility telephone systems. Many facilities used an ICE 
contractor-provided telephone system, known as the "pro bono telephone 
system," to satisfy the standard that requires the facilities to 
provide a means for detainees to make calls to certain entities at no 
charge to themselves or the recipient. At 16 of the 17 facilities we 
visited that used this system, we had significant problems making 
connections to consulates, pro bono legal providers, and the DHS OIG 
complaint hotline. 

[4] Our review was done from May 2006 to May 2007, whereas the ICE 
inspection reports were done at various times during 2004, 2005 and 
2006. 

[5] According to Detention Management Control Program policies and 
procedures, a superior rating means that the facility is performing all 
of its functions in an exceptional manner, has excellent internal 
controls, and exceeds expectations. A good rating means that a facility 
is performing all of its functions, and there are few deficient 
procedures, but internal controls are not limited by these 
deficiencies. An acceptable rating means that detention functions are 
being adequately performed. Although deficiencies may exist, they do 
not detract from the acceptable accomplishment of the vital functions. 
Deficient ratings mean that one or more detention functions are not 
being performed at an acceptable level. Internal controls are weak, 
thus allowing for serious deficiencies in one or more program areas. At-
risk ratings mean the detention operations are impaired to the point 
that they are not presently accomplishing their overall mission. That 
is, internal controls are not sufficient to reasonably ensure 
acceptable performance can be expected in the future. 

[6] In connection with the persistent and pervasive telephone problems 
we found, the OIG complaint hotline telephone number was blocked or 
otherwise restricted at 12 of the 23 facilities that we visited. 
Therefore, while some detainees at these facilities may have filed 
written complaints with the OIG, the number of reported allegations may 
not reflect the universe of detainee complaints. 

[7] OPR defines "substantiated allegation" as an allegation for which 
the evidence would cause a reasonable person to conclude that the 
alleged act of misconduct is likely to have occurred. 

[8] An allegation is unfounded in OPR's definition when the evidence 
would cause a reasonable person to conclude that the subject employee 
did not commit the alleged misconduct, or that, in fact, no misconduct 
occurred. 

[9] An allegation is unsubstantiated in OPR's definition when the 
evidence is not sufficient for a reasonable person to determine whether 
the subject employee committed the alleged misconduct. 

[End of section] 

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