Alien Detention Standards
Observations on the Adherence to ICE's Medical Standards in Detention Facilities Gao ID: GAO-08-869T June 4, 2008In 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.
At the time of its visits, GAO observed instances of noncompliance with ICE's 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 facility's 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. 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 GAO visited did not comply with all aspects of ICE's 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 ICE's Detention Removal Office and concluded that ICE's detainee complaint database was not sufficiently reliable.
GAO-08-869T, Alien Detention Standards: Observations on the Adherence to ICE's Medical Standards in Detention Facilities
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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 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.
What GAO Found:
At the time of its visits, GAO observed instances of noncompliance with
ICE‘s 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 facility‘s 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.
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 GAO visited did not
comply with all aspects of ICE‘s 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 ICE‘s Detention Removal Office and concluded that ICE‘s
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
GAO‘s 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
stanar@gao.gov.
[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 stanar@gao.gov. 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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