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ICE Detention Standards Compliance Audit - Frederick County Detention Center, Frederick, MD, ICE, 2013

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U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
Baltimore Field Office
Frederick County Detention Center
Frederick, Maryland

February 20 – 22, 2013

COMPLIANCE INSPECTION
FREDERICK COUNTY DETENTION CENTER
BALTIMORE FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................5
Inspection Team Members ...................................................................................................5
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................6
Detainee Relations ...............................................................................................................6
ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................8
Access to Legal Material .....................................................................................................9
Admission and Release ......................................................................................................11
Detainee Grievance Procedures .........................................................................................13
Environmental Health and Safety ......................................................................................14
Food Service ......................................................................................................................16
Hold Rooms in Detention Facilities ..................................................................................18
Medical Care ......................................................................................................................19
Telephone Access ..............................................................................................................23

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the Frederick County Detention Center (FCDC) in
Frederick, Maryland, from February 20 to 22, 2013. Opened in October 1984, the
107,636 square-foot facility is owned by the County of Frederick and operated by the Frederick
County Sheriff’s Department. In July 2007, U.S. Immigration and Customs Enforcement (ICE)
began housing ICE detainees at FCDC. ICE contracts with FCDC through an intergovernmental
service agreement to house male and female detainees for over 72 hours. Among the facility’s
405 beds, 56 are currently designated for male ICE detainees and six for female ICE detainees.
During the CI, FCDC housed 40 male ICE detainees, 26 Level I (lowest threat) and 12 Level II
(medium threat). There were no female ICE detainees held at FCDC at the time of the CI. The
average daily detainee population in fiscal year 2012 was 48 males and three females, with an
average length of stay of 94 days. The Office of Enforcement and Removal Operations (ERO) in
Baltimore, Maryland, is currently preparing to house detainees of higher classification levels at
FCDC as part of compliance with ICE’s prosecutorial discretion memorandum. FCDC is
accredited by the Maryland Commission on Correctional Standards through 2015, and the
National Commission on Correctional Health Care (NCCHC) through 2013.
RO personnel in the Baltimore field office are responsible for overseeing FCDC’s
compliance with the ICE National Detention Standards (NDS) and ICE policies. ERO personnel
include: an Assistant Field Office Director, (b)(7)e Supervisory Detention and Deportation Officers,
a Supervisory Immigration Enforcement Agent, a Deportation Officer, and an Immigration
Enforcement Agent. No Detention Services Managers are assigned to FCDC, but there is an
Immigration Health Service Corps representative assigned the Baltimore field office.

(b)(7)e

FCDC’s Warden is responsible for oversight of daily operations, and is supported by
(b)(7)e security and support personnel.
In July 2012, the ERO Detention Standards Compliance Unit contractor, the Nakamoto Group,
Inc., conducted an annual review of the ICE NDS at FCDC. FCDC received an overall
recommended rating of “Acceptable,” and was found compliant with all 38 standards reviewed.
During this CI, ODO reviewed 21 ICE NDS. Thirteen standards were fully compliant. ODO
identified 20 deficiencies in the following eight standards: Access to Legal
Material (3 deficiencies), Admission and Release (1), Detainee Grievance Procedures (2),
Environmental Health and Safety (4), Food Service (3), Hold Rooms in Detention Facilities (2),
Medical Care (2), and Telephone Access (3).
This report details all deficiencies identified by ODO and refers to the specific, relevant sections
of the ICE NDS. ERO will be provided a copy of this report to assist in developing corrective
actions to resolve all identified deficiencies. These deficiencies were discussed with ERO
management and FCDC personnel on-site during the inspection, as well as during the closeout
briefing conducted on February 22, 2013.

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The grievance system at FCDC provides for both formal and informal grievances. FCDC
personnel encourage detainees to resolve their grievances at the lowest level possible. Detainees
are provided with information on informal and formal grievance procedures by way of FCDC’s
detainee handbook and orientation video. The information is provided in both the Spanish and
English languages. According to FCDC’s Grievance Coordinator, three formal grievances were
filed in 2012. ODO found FCDC is not maintaining a grievance log and is not maintaining
detainee files with the required grievance information. FCDC’s Grievance Coordinator
implemented a log of ICE grievances during the CI.
Detainees are notified of the disciplinary process during orientation and by way of the detainee
handbook. FCDC’s detainee handbook addresses prohibited acts and sanctions, disciplinary and
appeal procedures, and detainee rights. Graduated severity scales for prohibited acts and
disciplinary consequences are in place, and minor violations are informally settled whenever
possible. Reports are prepared by the staff member observing the incident, and investigated by a
supervisor within 24 hours. Hearings are conducted in a timely manner, and appeal rights and
procedures are explained to detainees.
ODO was informed there have been no detainee hunger strikes or detainee suicides at FCDC.
Review of FCDC policy confirmed procedures are in place to identify and address the health
care needs of a detainee on a hunger strike, including referral to the medical department and
housing in the observation area of the medical unit. Daily monitoring by nursing staff and
evaluation by both the physician and psychiatrist are required, as is notification of ICE. A
review of training files for all(b)(7)emedical staff and ten randomly selected correctional officers
confirmed completion of training in hunger strike protocols at the time of employment and on an
annual basis.
ODO toured the medical clinic and medical observation housing, reviewed policies and
procedures, examined 20 active medical records of ICE detainees, verified medical personnel
credentials, inspected personnel training files, and observed operations including sick call and
medication administration rounds. In addition, ODO interviewed personnel, including the Health
Services Administrator, the FCDC Commander of Special Operations, and several nurses. ODO
found medical personnel are not effectively communicating with detainees of limited English
proficiency during medical interactions.
FCDC management stated there have been no reported incidents of sexual misconduct in the last
36 months. Sexual conduct between personnel and detainees, volunteers or contract personnel
and detainees, regardless of consensual status, is strictly prohibited. Substantiated allegations of
sexual assault involving personnel result in administrative and possible criminal disciplinary
sanctions. FCDC personnel are trained in the facility’s sexual assault procedures during
orientation, and receive annual refresher training. Detainees confirmed during group interviews
they received sexual assault literature upon admission into FCDC. According to FCDC
personnel, the sexual assault literature is available in seven languages, including English,
Spanish, French, German, Russian, Italian and Yoruba. This information is also included in the
ICE National Detainee Handbook and the local FCDC detainee handbook. Detainees are
required to sign an acknowledgement form indicating they are aware of and received the
information concerning sexual misconduct with inmates. The signed acknowledgement forms
are kept in each detainee’s detention file.
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ODO determined FCDC’s special management unit policies address all procedural requirements
of the ICE NDS, including completion of a written order by a supervisor and issuance of a copy
of the order to the detainee, and reviews within timeframes required by the ICE NDS. Review of
FCDC policy regarding disciplinary segregation confirmed all requirements of the ICE NDS are
addressed, including the requirement that detainees be issued a copy of the hearing officer’s
decision imposing a disciplinary segregation term.
There were no detainees on administrative or disciplinary segregation status at the time of the CI.
Based on review of available documentation, no detainees had been assigned to administrative or
disciplinary segregation in the past three months. FCDC personnel could not recall any instances
when detainees were placed in administrative or disciplinary segregation; therefore, ODO was
unable to review case-specific records.
Both the administrative and disciplinary units consisted of five double-occupancy cells. ODO
found the cells were well ventilated, adequately lit, appropriately heated, and appeared in good
sanitary condition. Detainees in disciplinary segregation are afforded the same general
privileges as those in administrative segregation, with regard to exchange of clothing and linens,
meals, hygiene, and legal materials.
ODO found detainees are afforded opportunities to communicate with FCDC and ICE personnel
on a daily and weekly basis. Detainees have opportunities to engage with FCDC personnel from
inside the housing blocks between the hours of 6:00 am and 11:00 pm daily. Detainees also have
opportunities to engage with ICE personnel from inside the housing block. Logbooks verify ICE
personnel visit once weekly, on average. Both FCDC and ICE personnel offer detainees two
separate and distinct processes for filing requests and informal grievances. FCDC handles all
facility-specific requests in-house, and carbon copies of request forms are maintained in
unofficial detainee files; logbooks are not maintained. ICE-specific requests are resolved either
on-site during weekly visits or during future visits. Original forms are maintained at the field
office and logged into an electronic file. Carbon copies are not provided to detainees by ICE.
ODO was informed there have been no detainee deaths at FCDC. FCDC policy addresses
procedures for detainees to establish a health care proxy/advance directive for their health care in
accordance with Maryland law, and requires notification of ICE if a detainee signs a Living Will,
an Advance Directive or a Do Not Resuscitate Order. The policy addresses terminal illness, Do
Not Resuscitate, and death notification procedures, and the release of remains. FCDC policy
also requires the medical provider to conduct a mortality review within 30 days of a detainee
death. FCDC does not have an infirmary; therefore, seriously and terminally ill or injured
detainees are transferred to an appropriate facility arranged through ICE.
ODO was informed there have been no use-of-force incidents involving ICE detainees in the past
year. FCDC’s use of force policy is comprehensive and addresses all requirements of the ICE
NDS, including the use of force team technique, video-recording of calculated force incidents,
post-incident medical examination of detainees, after-action reviews, and notification of ICE.
Confrontation avoidance is emphasized in policy and in the facility’s use of force training
curriculum. FCDC’s less-than-lethal munitions consist of Oleo Capsicum (OC) spray, X26
tasers, and the Less Lethal projectile and beanbag launcher systems. Facility policy prohibits use
of tasers on detainees. Review of 15 randomly selected staff training files confirmed completion
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of initial and annual use of force training, and current certification in OC spray. ODO confirmed
protective gear and video cameras are available in the event calculated force is used.

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INSPECTION PROCESS
ODO inspections evaluate the welfare, safety, and living conditions of detainees. ODO primarily
focuses on areas of noncompliance with the ICE NDS or the ICE Performance-Based National
Detention Standards, as applicable. The ICE NDS apply to FCDC. In addition, ODO may focus
its inspection based on detention management information provided by ERO Headquarters and
ERO field offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at FCDC to determine compliance with current policies
and detention standards. Prior to the inspection, ODO collected and analyzed relevant
allegations and detainee information from multiple ICE databases, including the Joint Integrity
Case Management System, the ENFORCE Alien Booking Module, and the ENFORCE Alien
Removal Module. ODO also gathered facility facts and inspection-related information from
ERO Headquarters staff to prepare for the site visit at FCDC.

REPORT ORGANIZATION
This report documents inspection results, serves as an official record, and is intended to provide
ICE and detention facility management with a comprehensive evaluation of compliance with
policies and detention standards. It summarizes those ICE NDS that ODO found deficient in at
least one aspect of the standard. ODO reports convey information to best enable prompt
corrective actions and to assist in the on-going process of incorporating best practices in
nationwide detention facility operations.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
ICE NDS, ICE policy, or operational procedure. When possible, the report includes contextual
and quantitative information relevant to the cited standard. Deficiencies are highlighted in bold
throughout the report and are encoded sequentially according to a detention standard designator.
Comments and questions regarding the report findings should be forwarded to the Deputy
Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

(b)(6), (b)(7)c

Management & Program Analyst (Team Leader)
Section Chief
Contract Inspector
Contract Inspector
Contract Inspector
Contract Inspector

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ODO, Headquarters
ODO, Headquarters
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections

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As a group, these detainees complained about the lack of variety in meals, shower water
temperatures, low sink water pressures, and poor sink drainage. ODO verified a registered
dietician certifies the caloric and nutritional content of all meals. Food portions met all dietary
and nutritional requirements.
Individual detainees in the group had additional concerns including: lack of variety in recreation
equipment, strip searches during admission, difficulty in distinguishing between FCDC and ICE
officials, and confiscation of new commissary products during cell shakedowns. One detainee
alleged a “Chinese” officer used inappropriate and derogatory language with detainees.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 21 ICE NDS and found FCDC fully compliant with the following
13 standards:
Detainee Classification System
Detainee Handbook
Disciplinary Policy
Funds and Personal Property
Hunger Strikes
Recreation
Religious Practices
Special Management Unit – Administrative Segregation
Special Management Unit – Disciplinary Segregation
Staff-Detainee Communication
Suicide Prevention and Intervention
Terminal Illness, Advanced Directives, and Death
Use of Force
As these standards were compliant at the time of the review, a synopsis for these areas was not
prepared for this report.
ODO found deficiencies in the following eight standards:
Access to Legal Material
Admission and Release
Environmental Health and Safety
Food Service
Detainee Grievance Procedures
Hold Rooms in Detention Facilities
Medical Care
Telephone Access
Findings for each of these standards are presented in the remainder of this report.

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ACCESS TO LEGAL MATERIAL (ALM)
ODO reviewed the Access to Legal Material standard at FCDC to determine if detainees have
access to a law library, legal materials, courts, counsel, and document copying equipment to
facilitate the preparation of legal documents, in accordance with the ICE NDS.
FCDC’s detainee handbook states all detainees are afforded a minimum of five hours of legal
library time weekly and one hour of general library time weekly. ODO found documentary
evidence supporting this practice for male detainees, but for female detainees, the practice
described did not match FCDC’s written policy.
Male ICE detainees, who are all housed in K Block, have access to two computers equipped with
Lexis-Nexis software between the hours of 6:00 am and 11:00 pm daily. The computers are
located in a separate, well-lit room, reasonably isolated from noise. Male detainees can print
documents from inside the housing block. Male detainees also have access to a large library
within the facility. The library, an extension of the Frederick County Public Library system, is
equipped with paper, writing implements, printing and photocopying equipment, written legal
materials, and a third computer with Lexis-Nexis software. Male detainees are automatically
scheduled time at the library, and can receive additional time by request and appointment. Based
on a July 2012 schedule provided to ODO by the librarian, male detainees receive between five
and seven hours in the large library weekly.
Compared to male detainees, females are not afforded the same amount of library access in
practice. Female detainees, who are commingled with female inmates in the Y2 Block at FCDC,
do not have access to document processing equipment from inside their housing block.
Therefore, they are dependent upon access to the large library. According to the same July 2012
schedule provided to ODO by the librarian, females in the Y2 Block receive only one hour of
library access once biweekly (Deficiency ALM-1). The librarian confirmed this practice, stating
that due to the large size of the male population overall, it is difficult to schedule library time for
the smaller female population.
ODO tested all three ICE computers and two printers throughout the facility to ensure proper
operation, and to verify the existence of the latest version of Lexis-Nexis. ODO found all three
computers did not contain the latest version of Lexis-Nexis, which was brought to the attention
of ERO and FCDC personnel. ERO produced new Lexis-Nexis CDs during the CI, but none of
the computers were updated by the conclusion of ODO’s review (Deficiency ALM-2).
According to ERO Headquarters, the Baltimore field office verified receipt of the CDs on
February 11, 2013. The printer in K Block was found to be missing an ink cartridge
(Deficiency ALM-3). This issue was raised with FCDC personnel during the closeout briefing.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY ALM-1
In accordance with the ICE NDS, Access to Legal Material, section (III)(G), the FOD must
ensure the facility shall devise a flexible schedule to permit all detainees, regardless of housing
or classification, to use the law library on a regular basis. Each detainee shall be permitted to use
the law library for a minimum of five (5) hours per week.
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DEFICIENCY ALM- 2
In accordance with the ICE NDS, Access to Legal Material, section (III)(E), the FOD must
ensure the facility shall designate an employee with responsibility for updating legal materials,
inspecting them weekly, maintaining them in good condition, and replacing them promptly as
needed. The facility shall notify the designated contact person at INS Headquarters if anticipated
updates are not received or if subscriptions lapse.
DEFICIENCY ALM- 3
In accordance with the ICE NDS, Access to Legal Material, section (III)(B), the FOD must
ensure the facility shall designate an employee with responsibility to inspect the equipment at
least weekly and ensure that it is in good working order, and to stock sufficient supplies.

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ADMISSION AND RELEASE (AR)
ODO reviewed the Admission and Release standard at FCDC to determine if procedures are in
place to protect the health, safety, security, and welfare of each person during the admission and
release process, in accordance with the ICE NDS. ODO reviewed policies, procedures, and
detention files, observed the admission process, and interviewed personnel and detainees.
New arrivals are screened and interviewed by intake officers. Detainees are pat-down searched
upon admission, though policy states a strip search may be conducted if there is a reasonable
suspicion the detainee is in possession of contraband that would present a threat to the safety and
security of the facility. The intake process includes completion of medical questionnaires to
identify any health issues requiring immediate attention and emergency contact information
forms. Subsequent medical and mental health screening is conducted by nursing personnel. The
classification process is completed, funds and property are inventoried, jail clothing and basic
hygiene items are issued, and detainee handbooks with detailed information regarding facility
operations are provided to detainees. The intake process also includes an orientation conducted
by FCDC personnel.
Following completion of intake processing, detainees are housed in cells within the Holding Unit
pending completion of tuberculosis screening by way of chest x-ray. Review of documentation
confirmed this is generally completed within one day of arrival. Upon medical clearance,
detainees are transferred to the general population housing unit designated for ICE detainees.
ODO was advised by facility personnel that detainees are strip searched prior to transfer to the
general population housing unit; further, detainees are routinely strip searched when returning
from court (Deficiency AR-1). ODO was advised by facility personnel that safety and security
of the facility is the justification for conducting strip searches without specific reasonable
suspicion.
Upon transfer to general population housing, detainees are provided with two additional sets of
clothing, including undergarments and socks. They are also provided with additional personal
hygiene items. An orientation video-recording is played in the housing unit, and classification
personnel meet with detainees one-on-one to discuss classification and address questions or
concerns.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY AR-1
In accordance with Change Notice Admission and Release – National Detention Standard Strip
Search Policy, dated October 15, 2007, the FOD must ensure facilities are reminded that strip
searches, cavity searches, monitored changes of clothing, monitored showering, and other
required exposure of the private parts of a detainee’s body for the purpose of searching for
contraband are prohibited, absent reasonable suspicion of contraband possession. Facilities may
use less intrusive means to detect contraband, such as clothed pat searches, intake questioning, xrays, and metal detectors.

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If information developed during admission processing supports reasonable suspicion for a full
search, the information supporting that suspicion should be documented in detail on Form G1025, Record of Search.

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedures standard at FCDC to determine if a process to
submit formal or emergency grievances exists, and responses are provided in a timely manner,
without fear of reprisal. In addition, the review was conducted to determine if detainees have an
opportunity to appeal responses, and if accurate records are maintained, in accordance with the
ICE NDS. ODO interviewed personnel, and reviewed policy, the detainee handbook, and
grievance documentation.
Detainees are provided with information on informal and formal grievance procedures by way of
the detainee handbook and the facility’s orientation video. The information is provided in both
Spanish and English. FCDC has a designated Grievance Coordinator. The Grievance
Coordinator pro-actively and personally interacts with detainees in order to informally resolve
issues where possible. The Grievance Coordinator maintains grievance statistics; however, the
facility does not maintain a grievance log (Deficiency DGP-1). A log supports tracking of
grievances and outcomes, and analysis of grievance activity. An ICE detainee grievance log was
implemented by the Grievance Coordinator during the review to correct the deficiency.
According to the Grievance Coordinator, there were three formal grievances filed in 2012.
When ODO asked to review the three grievances, FCDC personnel only found two. ODO was
advised the third grievance was likely a record-keeping error and did not exist. The two
identified grievances were filed by the same detainee. In the first grievance, the detainee
complained that an officer did not provide him with a clean uniform. The second grievance was
a request to see the doctor. The detainee was released to ICE prior to disposition of both
grievances. It is noted that documentation reflects the detainee was seen by the physician the
day after his grievance was submitted. ODO reviewed the detainee’s electronic and hard-copy
files, and found the grievances were not included (Deficiency DGP-2). Copies of the grievances
were printed from the computer system and placed in the detainee’s file prior to completion of
ODO’s review.
According to both ERO and FCDC management and personnel, there have been no allegations of
personnel misconduct filed regarding a supervisor or higher-level official.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must
ensure each facility will devise a method for documenting detainee grievances. At a minimum,
the facility will maintain a Detainee Grievance Log.
DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(E), the FOD must
ensure a copy of the grievance will remain in the detainee’s detention file for at least three years.
The facility will maintain that record for a minimum of three years and subsequently, until the
detainee leaves ICE custody.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at FCDC to determine if the
facility maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances, in accordance with ICE NDS. ODO toured the facility,
interviewed personnel, and reviewed procedures and documentation of inspections, hazardous
chemical management, and fire prevention measures.
Male ICE detainees are housed in K Block, a two-tiered housing unit containing 23 two-bed
cells. Each cell is equipped with a commode/sink combination unit, and writing desk and stool
attached to the floor. The two bunks are attached to the wall, one above the other. There is a
large open dayroom and six individual shower stalls on the first floor of K Block. An outdoor
recreation area is located adjacent to the housing unit and is used only by ICE detainees.
ODO observed cells not in use were open, and had trash on the floor and bunks. ODO
recommended to FCDC management that cells be cleaned immediately when they become
vacant. ODO also observed two leaking shower heads and soap scum on the walls of all showers
in K Block. One shower had leaked to the point the metal walls had rusted in the lower corner,
and a towel was present to keep the water from flowing onto the floor outside the shower. Rust
causes metal to break down, allowing moisture to seep into the area between the shower and
wall. The presence of moisture promotes growth of mold and mildew, creating a health hazard.
Further, the presence of water on the floor creates a safety concern because it may cause slips
and falls.
FCDC has a designated Safety Officer. Documentation supports required weekly and monthly
inspections are conducted throughout the facility. Hazardous substances are listed in a master
index, which includes Material Safety Data Sheets and documentation of periodic review for
accuracy. Material Safety Data Sheets are also present in areas where substances are stored and
used. ODO’s inspection found chemicals, flammables, and combustible materials are stored and
issued as required by the NDS, with one exception. A gallon container of bleach was discovered
on the floor next to a washing machine in an inmate housing unit. Later, when inspecting the
inventory in the laundry storage area, ODO found the bleach had been returned and there was no
documentation it had ever been removed (Deficiency EH&S-1). The Safety Officer speculated
an officer on the night shift had taken the bleach from the storage area without signing it out, and
it was not signed back in when returned. Though not in the detainee housing area, the discovery
of the bleach points to inadequate control of hazardous substances by facility personnel. Proper
storage and control of hazardous substances is critical to preventing injury to detainees and
personnel. ODO recommends re-training of personnel having access to the chemical storage
area in proper control and accountability of chemicals.
The Safety Officer provided documentation of extensive weekly fire and safety inspections, as
well as required monthly inspections. The facility has prominently posted evacuation plans in
English and Spanish, with locations of emergency equipment and directional arrows for traffic
flow. Fire drills are conducted on a monthly basis; however, documentation reflects emergency
keys were checked out during only two of the last six month’s drills (Deficiency EH&S-2).
Testing of emergency keys and exit doors ensures operability and expeditious egress in the event
of an emergency.
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The emergency power generator is checked weekly; however, testing is completed only once a
month for 30 minutes, rather than bi-weekly for an hour as required by the NDS. In addition, the
generator is serviced by an external company twice a year rather than quarterly
(Deficiency EH&S-3). Emergency generators serve a vital life-safety function in the event of a
power outage; therefore, prescribed preventive maintenance and testing are essential.
FCDC has a contract with a local barber to provide barbering services twice a month. The room
used for barbering is equipped with a sink with hot and cold running water, and sanitation
regulations for barber operations are posted on the wall. ODO was informed the same room is
used twice a month for dental care (Deficiency EH&S-4). According to personnel, the contract
barber does not maintain any equipment at the facility, the barber chair is removed from the
room following barbering, and a dental chair and equipment is moved into the room for
scheduled dental services. ODO was informed the room is completely sanitized following each
use by the dentist and barber.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section, (III)(E)(4), the FOD
must ensure accountability. Inventory records for a hazardous substance must be kept current
before, during, and after each use.
DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4)(c), the
FOD must ensure emergency-key drills will be included in each fire drill, and timed. Emergency
keys will be drawn and used by the appropriate staff to unlock one set of emergency exit doors
not in daily use. NFPA recommends a limit of four and one-half minutes for drawing keys and
unlocking emergency doors.
DEFICIENCY EH&S-3
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(O), the FOD
must ensure the biweekly test of the emergency electrical generator will last one hour. During
that time, the oil, water, hoses and belts will be inspected for mechanical readiness to perform in
an emergency situation. The emergency generator will also receive quarterly testing and
servicing from an external generator-service company. Among other things, the technicians will
check starting battery voltage, generator voltage and amperage output.
DEFICIENCY EH&S-4
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(P)(1), the FOD
must ensure the [barber] operation will be located in a separate room not used for any other
purpose.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at FCDC to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with ICE NDS. ODO
interviewed personnel, inspected storage areas, observed meal preparation and service, and
reviewed policy and relevant documentation.
FCDC employees manage the facility’s food service operation. Food service personnel consist
of (b)(7)e Food Service Manager and (b)(7)e cook supervisors, supported by a crew of (b)(7)ecounty inmate
workers. No ICE detainees are assigned to work in food service. ODO verified all personnel
and inmate workers received medical clearances. All food service workers were observed
wearing clean uniforms, hairnets, gloves, and beard nets for facial hair. All visitors to the
kitchen were required to wear hair/beard nets. The food service operation was last inspected by
the Maryland Department of Health and Mental Hygiene in October 2012. One minor
compliance issue was noted and corrected during that inspection, and no follow-up was required.
Inspection of the kitchen confirmed knives and utensils were properly controlled. ODO verified
the menu was certified by a registered dietitian based on a complete nutritional analysis, and
religious and medical diets were provided in accordance with standard. At the time of the
inspection, one detainee was receiving a medical diet and one detainee was on an approved
religious diet.
FCDC has a satellite meal service operation involving preparation of meals in the kitchen and
delivery to the housing units on carts. ODO observed preparation of the noon meal trays on
Thursday, and accompanied the carts to the housing units. FCDC uses enclosed, heated carts to
transport trays from the kitchen to the housing units, cited by ODO as a best practice because
they ensure hot food items are maintained at appropriate temperatures. Food is placed on the
trays, then immediately loaded onto the pre-warmed carts. The carts are then transported to the
housing units under the direct supervision of an officer and plugged into an outlet upon arrival.
ODO sampled the noon meal on Wednesday during the inspection, and found the food items
were at appropriate temperatures, properly seasoned, and portions were as listed on the menu.
ODO observed sanitation of food surface and preparation areas was good, and workers were
observed following “clean as you go” procedures. However, ODO identified sanitation and
safety concerns in the walk-in freezer and dry storage area. Trash was observed on the floors of
both the freezer unit and dry storage area (Deficiency FS-1). In the dry storage area, boxes and
packaged food items were stored against the walls (Deficiency FS-2). Storage against walls
promotes insect and rodent infestation, and does not allow adequate pest control measures. Prior
to completion of the review, the food items were moved away from the walls, and trash had been
removed from the dry storage area. In the freezer, ODO observed a significant accumulation of
frozen condensation and ice on the blower unit, and on the floor beneath. Some condensation
had dripped and frozen on boxes of food items (Deficiency FS-3). Though ODO verified the
condensation did not come into contact with electrical parts, and the food items inside the boxes
were in sealed plastic bags, the presence of condensation signifies the freezer is not functioning
properly and needs repair. The Food Service Manager was present when this was discovered and
informed ODO that maintenance personnel had checked the freezer unit several times but had
not been able to resolve the problem. The Food Service Manager instructed personnel to make
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certain no boxes were stored near the leaking unit to prevent any potential contamination.
During a follow up inspection the next day, ODO found the boxes had been moved to prevent
condensation from dripping on them; however, trash remained on the floor, and the condensation
problem continued. ODO recommends all necessary steps be taken to ensure the matter is
addressed.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE NDS, Food Service, section (III)(H)(5)(c), the FOD must ensure all
facilities shall meet the following environmental standards [among others]: routinely cleaned
walls, floors, and ceilings in all areas.
DEFICIENCY FS-2
In accordance with the ICE NDS, Food Service, section (III)(J)(3)(e), the FOD must ensure the
following procedures apply when receiving or storing food [among others]: store food items at
least two inches from the walls and at least six inches above the floor. Wooden pallets may be
used to store canned goods and other non-absorbent containers, but not to store dairy products or
fresh produce.
DEFICIENCY FS-3
In accordance with the ICE NDS, Food Service, section (III)(D)(5), the FOD must ensure food
and ice will be protected from dust, insects and rodents, unclean utensils and work surfaces,
unnecessary handling, coughs and sneezes, flooding, drainage, overhead leakage, and other
sources of contamination. Protection will be continuous, whether the food is in storage, in
preparation/on display, or in transit.

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HOLD ROOMS IN DETENTION FACILITIES (HR)
ODO reviewed the Hold Rooms in Detention Facilities standard at FCDC to determine if
detainees placed temporarily in hold rooms, awaiting further processing, are in a safe, secure,
and comfortable environment, and not held confined in hold rooms for over 12 hours, in
accordance with the ICE NDS. ODO inspected the hold rooms, interviewed personnel, and
reviewed policy and documentation.
FCDC has one hold room used for detainees waiting processing. There were no detainees in the
hold room during the review. The room is in direct line of sight of the officer assigned to the
intake area, and meets the physical requirements of the NDS. The room does not have a
lavatory/toilet fixture; however, ODO was informed detainees are removed from the hold room
to use toilet facilities when necessary. A log is not maintained to record required custody
information, including 15-minute monitoring checks (Deficiency HR-1). FCDC does not require
officers to perform 15-minute checks (Deficiency HR-2). ODO was informed detainees are
removed from hold rooms within an hour; however, this could not be verified in the absence of a
log.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY HR-1
In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(2), the
FOD must ensure each facility shall maintain a detention log (manually or electronically) for
every detainee placed in a hold cell. The log records custodial information about new arrivals
(e.g., a "voluntary return" waiting for a scheduled transportation run); detainees awaiting legal
visitation; and detainees awaiting interviews with supervisory personnel or other officials.
The designated hold-room officer will enter specified information into the log immediately upon
the detainees' placement in a hold room. However, the log will not record information about
detainees in the hold room pending release, in-house medical services, or awaiting court.
DEFICIENCY HR-2
In accordance with the ICE NDS, Hold Rooms in Detention Facilities, section (III)(C)(4), the
FOD must ensure officers shall closely supervise the detention hold rooms through direct
supervision, which involves "irregular" visual monitoring every 15 minutes (each time recording
the time and officer's star number in the detention log). When the hold room is not in the
officer's direct line of sight, he/she shall maintain continuous auditory monitoring.
Any unusual behavior or complaints shall be noted under "comments." Officers shall keep under
constant surveillance any detainee exhibiting signs of hostility, depression, or other symptomatic
behavior. In such cases, they shall notify the shift supervisor

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is used for both dental services and barbering at separate times. A mobile dental chair and dental
operatory are moved into this room when the dentist is on-site twice a month. Dental equipment
and supplies are not in the room when used for barbering. ODO inspected the room the day after
barbering and while in use by the dentist. The room was clean and sanitary, and the dentist had
no concerns with sanitation measures.
Detainees receive medical intake screening on arrival at FCDC by correctional officers trained
by medical personnel. Medical personnel are notified immediately if the screening officer has
any concerns about the detainees’ medical or mental health status. Medical personnel then
complete a follow-up medical, mental health, and dental intake screening within four hours of
detainee arrival. Review of the forms used by officers and medical personnel confirmed they are
comprehensive, and address all necessary and appropriate health matters. Detainees sign a
statement on the medical intake screening form consenting to general medical treatment, and
specific consent forms are signed prior to invasive treatment, dental or surgical procedures, and
for psychotropic medications. Detainees are screened for tuberculosis by way of chest x-ray, and
are held in cells in the booking area until the chest x-ray result is obtained. After tuberculosis
clearance is obtained, the detainees are moved to a general population unit. ODO verified intake
screening procedures meet NDS requirements by review of 20 ICE detainee active medical files.
ODO verified the initial health appraisal involves a hands-on physical examination as described
in the applicable NCCHC standards. A review of 20 medical records confirmed physical
examinations are performed by either a physician or physician assistant within 14 days of arrival.
The health appraisal includes an examination of the oral cavity for dental caries or other
abnormalities. ODO verified completion of health appraisals by review of 20 ICE detainee
active medical files.
Detainees have daily access to medical services by way of a sick call sign-up sheet available in
each housing unit during the breakfast meal. Information entered on the sign-up sheet is limited
to the detainee's name, number, and signature, and does not include the nature of the request or
other medical information. The sign-up sheets are collected by nursing personnel after the
breakfast meal, and each detainee requesting medical services is seen for sick call the same day.
Upon arrival in the Health Services Department, the detainee completes the top half of a sick call
request form recording the medical concern, and is then seen by nursing personnel. ODO notes
the sick call slips are only printed in English and recommends that a Spanish-language version
be made available. Documentation in the medical record supported that 20 detainees requesting
healthcare services by way of the sick call sign-up system were evaluated by medical personnel
the same day. Treatment provided by nursing personnel is based on physician-approved nursing
protocols. Medications allowed by the protocols are over-the-counter medications, only. If
clinically indicated, detainees are referred to a provider and are seen on the next scheduled clinic
day.
Though there were no detainees on administrative or disciplinary segregation status at the time of
the review, ODO verified detainees in segregation have the same opportunity for daily sick call
as detainees in general population, and medical personnel are required to make daily rounds. A
Segregation Assessment Record form is maintained in the detainee’s medical record for each
detainee housed in either type of segregation.

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In four of 20 medical records reviewed, ODO found documentation by both medical and
correctional personnel indicating a language barrier between detainee and staff. The records
reviewed suggested the four detainees did not speak English or had difficulty understanding
English, and therefore were unable to communicate effectively with FCDC personnel. In one
case, a correctional officer who performed an intake health screening on a detainee noted in
writing that the detainee “doesn’t speak English;” yet, the correctional officer recorded “no” as
the answer for all 53 questions on the form. ODO found no documentation demonstrating an
attempt to provide language interpretation or translation assistance through other FCDC
personnel or a telephone interpretation service (Deficiency MC-1).
In the other three cases, detainee sick call forms were written in Spanish, and nursing personnel
documented a language barrier, but made no attempt to access language interpretation or
translation assistance (Deficiency MC-2). During an interview with two nurses, ODO found
there was confusion about whether a telephone interpretation or translation service was even
available.
FCDC’s Special Operations Commander informed ODO there are several certified interpreters
available on an as-needed basis, but it is unclear how frequently these personnel are used and
what languages they speak fluently. Further, ERO personnel reported FCDC has permission to
use the ICE national language line. Part of a Department of Homeland Security memorandum
addressing the ICE-contracted language line was posted in the Health Services Department;
however, the part of the memorandum providing instructions for use was unavailable. ODO
recommends educating and training all medical and correctional personnel in use of any
language interpretation and translation services.
Of the 20 medical records reviewed, only one documented a chronic medical condition. The
detainee’s history of Diabetes Mellitus Type 2 was identified at intake. He was immediately
referred to a provider, enrolled as a chronic care patient, and received appropriate care.
Medications at FCDC are stored in locked carts in the medical department. The certified
medication technician and nursing personnel make medication rounds to the housing units three
times a day. Correctional personnel stand with medical personnel during medication rounds, and
each detainee’s mouth is checked to ensure medication is swallowed. Medical personnel make
entries on the detainee’s Medical Administration Record when the medication is administered.
At the time of the ODO inspection there were no detainees receiving psychotropic medication,
and FCDC policy does not allow the use of forced psychotropic medication without valid court
order. Sharps, medical instruments, and bulk medications are inventoried by medical personnel
at every shift change.
Local policy requires the FCDC Commander of Operations to notify ICE officials in cases of
emergency hospitalization, serious illness or other significant medical issues while housed at
FCDC.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(D), the FOD must ensure, if
language difficulties prevent the health care provider/officer from sufficiently communicating
with the detainee for purposes of completing the medical screening, the officer shall obtain
translation assistance. Such assistance may be provided by another officer or by a professional
service, such as a telephone translation service. In some cases, other detainees may be used for
translation assistance if they are proficient and reliable and the detainee being medially screened
consents. If needed translation assistance cannot be obtained, medical personnel will be notified
or the screening form will be filled out to refer the detainee to medical personnel for immediate
attention.
DEFICIENCY MC-2
In accordance with the ICE NDS, Medical Care, section (III)(F), the FOD must ensure all
facilities must have a procedure in place to ensure that all request slips are received by the
medical facility in a timely manner. If necessary detainees will be provided with assistance in
filling out the request slip, especially detainees who are illiterate or non-English speaking.

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at FCDC to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and
others in the community, in accordance with the ICE NDS.
FCDC provides detainees general guidelines for use of its telephones. Detainees in the general
population are permitted 17 uninterrupted hours of telephone access between 6:00 am and
11:00 pm daily. During that time, detainees have the opportunity to make outgoing collect calls
to both domestic and international numbers. Pro-bono calls to ICE-approved entities are
permitted between the hours of 9:00 am and 6:00 pm daily. Detainees housed in special
management units are afforded telephone access for a minimum of one hour daily during
recreation, and based on their disciplinary charges. FCDC’s telephone access policies and
procedures are outlined in the detainee handbook.
ODO found the telephone ratio in each housing block was compliant with the standard. ODO
observed three telephones in the K Block, which houses up to 60 male detainees; one telephone
in Y2 Block, which houses up to ten female detainees; and one telephone in each special
management unit, which houses up to five detainees. The K Block telephones are located at the
back of the housing unit and offer a reasonable amount of privacy for legal calls; however, the
telephones in the Y2 Block and segregation offer little to no privacy.
ODO checked all telephones in the detainee housing blocks and found them to be in good
working order, with the exception of one telephone in the K Block that had a missing switch
hook. The missing piece did not affect one’s ability to make a call, but did affect one’s ability to
end a call. The NDS states the facility shall inspect the telephones regularly and maintain them
in working order. ERO personnel check the telephones during their weekly visits, while FCDC
management relies on detainees and inmates to notify the facility of service issues.
ODO was unable to verify the direct dial numbers, as FCDC’s telephone system operates on
voice recognition biometrics. In order to make a call, detainees are required to enter an “AR
number” and provide a voice sample, which is verified against the AR number and the
individual’s voice biometrics. ERO personnel indicated they are unable to ensure proper
operation of the telephones due to this technology.
ODO confirmed FCDC permits detainees to make free direct calls upon request. A logbook
confirmed detainees are provided free calls of up to ten minutes in length, not 20 minutes as
required by the ICE NDS (Deficiency TA-1). FCDC’s detainee handbook states free
“professional calls” are available via the facility’s informal grievance process. According to
FCDC management, free calls are primarily made from the ICE 287(g) office or a post telephone
located outside each housing unit.
During a review of 15 randomly-selected detention files, ODO found a number of requests from
detainees for free telephone calls. A closer look revealed these requests were being fulfilled
between four to 14 days after the initial request (Deficiency TA-2), not within 24 hours as
required by the ICE NDS. The sample reviewed by ODO reflected delays between handling by
the referring officer and the responding officer. When brought to the attention of FCDC
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management, management stated requests for free calls are fulfilled within five days in
accordance with the Detainee Grievance standard. FCDC management claimed The Nakamoto
Group, Inc. found no issues with their response times during the July 2012 inspection. When
ODO asked FCDC management how they decipher the purpose and urgency of call requests,
FCDC management implied detainees who repeatedly request free calls are abusing the system,
since all detainees have access to telephones in their housing blocks.
IC Solutions of San Antonio, Texas, is the current telephone carrier for FCDC. According to
FCDC management and the detainee handbook, IC Solutions records and monitors all calls made
from the housing blocks, regardless of nature. All calls made from the 287(g) office are also
recorded and monitored, with the exception of verified legal calls. FCDC’s local detainee
handbook states “all detainee housing unit telephone calls are recorded and archived”
(Deficiency TA-3). FCDC management stated the only exception to this practice in the housing
blocks is calls made to the ICE pro bono list and members of the Frederick Bar Association.

STANDARDS/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE NDS, Telephone Access, section (III)(F), the FOD must ensure the
facility shall not restrict the number of calls a detainee places to his/her legal representatives, nor
limit the duration of such calls by rule or automatic cut-off, unless necessary for security
purposes or to maintain orderly and fair access to telephones. If time limits are necessary for
such calls, they shall be no shorter than 20 minutes, and the detainee shall be allowed to continue
the call if desired, at the first available opportunity.
DEFICIENCY TA-2
In accordance with the ICE NDS, Telephone Access, section (III)(E), the FOD must ensure staff
will allow detainees to make such [direct and free] calls as soon as possible after the request,
factoring in the urgency expressed by the detainee. Generally, access will be granted within
eight (facility-established) waking hours of the detainee's request, excluding the hours between
lights-out and morning resumption of scheduled activities. The detainee will always be granted
access within 24 hours of his/her request.
DEFICIENCY TA-3
In accordance with the ICE NDS, Telephone Access, section (III)(K), the FOD must ensure a
detainee’s call to a court, a legal representative, or for the purposes of obtaining legal
representation will not be aurally monitored absent a court order. The OIC retains the discretion
to have other calls monitored for security purposes.

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