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Investigation

Confidential Report Warned ICE of “Inhumane” Use of Solitary Confinement

(Illustration: Leslie Garvey/POGO)

An Immigration and Customs Enforcement (ICE) detention center has kept an “alarming” number of detainees with serious mental illness confined in solitary, and many have been isolated for “shockingly” long periods, according to a previously confidential Department of Homeland Security review obtained through a Freedom of Information Act lawsuit by the Project On Government Oversight (POGO).

The review says the Adelanto, California, detention center’s reliance on solitary confinement to house detainees with mental illness—in one case, for a cumulative 904 days—is “both inhumane and in violation of” ICE policy.

Detainees in solitary are isolated from other people for up to 23 hours a day.

Matthew Albence, acting director of Immigration and Customs Enforcement, claims on a Fox & Friends segment that the Adelanto facility is “representative of all our detention centers,” calling them “humane” and “safe.”

The review details myriad and long-standing medical and mental health care failures at Adelanto, ICE’s second-largest adult detention center. Adelanto is run by the GEO Group, a private prison company that several former top ICE officials have gone to work for. In April 2018, the review was sent to current acting director Matthew Albence, who at the time was head of ICE’s Enforcement and Removal Operations division, the part of the agency that arrests, detains, and deports immigrants.

Albence has been a stalwart defender of his agency’s detention centers. This summer, during a Fox & Friends segment that also featured an arranged tour of Adelanto, Albence said the facility is “representative of all our detention centers,” calling them “humane” and “safe.”

The review paints a different picture. “Incompetent medical leadership,” according to the review, was the root cause of Adelanto’s failure to provide adequate care, and has “contributed to the inadequate detainee medical care that resulted in medical injuries, including bone deformities and detainee deaths, and continues to pose a risk to other detainees.”

The review is based on a November 2017 examination by three independent experts on correctional facilities and medical and mental health care on contract with the Office for Civil Rights and Civil Liberties (often referred to by its abbreviation, CRCL). Those experts, whose names are redacted, interviewed staff and detainees at Adelanto, examined extensive ICE and contractor records, and wrote assessments that make up the body of the review. In an earlier review, in December 2015, the office also had found many of the same problems.

The 2017 review was prompted in part by the deaths of three Adelanto detainees earlier that year, including a suicide in March using a bedsheet as a noose, and detainee complaints. More than six months after that suicide, the review found “tie-off's” that heightened the risk of suicide by hanging in solitary confinement cells.

A week after the independent experts’ on-site investigation, “due to the serious nature of certain health and safety-related findings,” the Office for Civil Rights and Civil Liberties notified ICE’s leadership of the problems and made informal recommendations for “immediate action.”

There are signs that ICE’s leaders did not make changes quickly enough once they had been warned of the dangers facing detainees. A week after the formal review and recommendations were sent to Albence in late April 2018, and months after the earlier notification, the Department of Homeland Security’s Office of Inspector General conducted a surprise inspection at Adelanto, finding “nooses” in detainees’ cells and continuing problems with care and use of solitary. The inspector general’s report was published in September 2018 and was widely covered by the press.

Regarding the continuing ease with which detainees could hang themselves more than a year after the March 2017 suicide, the inspector general’s office wrote that “ICE’s lack of response to address this matter at the Adelanto Center shows a disregard for detainee health and safety.”

While ICE didn’t respond to POGO’s detailed request for comment, a journalist for The Atlantic, with whom POGO shared the Office for Civil Rights and Civil Liberties review, wrote that an ICE spokesperson said the agency “disagreed with much of” the review even though the Office of Inspector General separately found many similar problems. Instead, the spokesperson held up the findings of an inspection company on contract with the agency. The company, whose approach has been criticized for frequently overlooking problems, had found that Adelanto met all of ICE’s standards. (See “Contractor Impunity at ICE” at the end of this article for more details.)

Among numerous unanswered questions, POGO had asked ICE why the inspection company’s findings should carry more weight than those of the inspector general and the Office for Civil Rights and Civil Liberties, and why ICE rejected many of the office’s findings.

“A last resort”?

The Office for Civil Rights and Civil Liberties’ review contains details about the use of solitary, officially called “segregation,” and problems with care beyond those in the inspector general report.

“Detainees with serious mental health disorders are routinely—and inappropriately—housed in administrative segregation at ACF [Adelanto Correctional Facility],” the review found. (Administrative segregation is solitary confinement for reasons other than punishment.) “Detainees with serious mental disorders should only be housed in administrative segregation as a last resort, as that environment is not conducive to improving mental health status.”

Adelanto “staff reported that 60% to 70% of detainees in administrative segregation had serious mental disorders.” And when the experts conducting the review visited Adelanto in November 2017, 26 of the 50 detainees held in solitary confinement cells as punishment, called disciplinary segregation, had serious mental illnesses.

A POGO investigation into ICE’s use of solitary published last month showed that Adelanto not only reported using solitary confinement far more than any other detention center, but that it appeared to confine a disproportionate number of detainees with mental illness. POGO’s analysis of 6,559 records of solitary placements covering January 2016 to May 2018, obtained through the Freedom of Information Act, found that Adelanto placed detainees in solitary 1,190 times (some detainees were confined in solitary more than once). Two Adelanto detainees with mental illness had been held continuously in solitary for more than a year. The detention center reported 112 overall instances of detainees being kept in solitary for 75 days or longer.

All told, the agency’s detention centers reported use of solitary confinement more than 4,000 times for more than 15 days, and nearly a quarter of those instances involved detainees with mental illness, the ICE data shows. A United Nations expert has recommendedbanning the use of solitary confinement beyond 15 days and banning it altogether when a person has a mental illness.

An ICE spokesperson has defended the agency’s use of solitary confinement by pointing to internal studies from 2012 and 2013 that found 1.1% of ICE’s population has been kept in solitary, versus the estimated 4.5% of incarcerated individuals in solitary in prisons nationwide. According to the data POGO obtained, those studies don’t reflect the agency’s recent practices: ICE detention centers reported about 42% more placements of detainees in solitary in 2017 than in 2014, even as states such as Texas and Colorado, as well as the federal Bureau of Prisons have curbed their use of restricted housing, which includes solitary confinement. The Bureau of Prisons, unlike ICE, proactively makes data available onlineon how restricted housing is used.

Also unlike prison, ICE detention is officially not meant to be punitive. Although ICE’s “civil detention” system is supposed to be different from the country’s prison systems, the use of solitary confinement is perhaps the starkest illustration of their similarities.

“I hate to be alone”

The Office for Civil Rights and Civil Liberties’ review provides some details on individual detainees kept in solitary at Adelanto, including four who were isolated cumulatively for more than a year. One was isolated for a cumulative 904 days.

“No detainee should be held in the [Special Management Unit] for this amount of time. Isolation alone can create physical safety concerns and can result in mental decompensation,” according to the review (“special management unit” is one name for restricted housing where detainees are isolated from the general population). “Continuous and prolonged segregation housing of the mentally ill,” the review states, had led “to inadequate mental health care, and increased the likelihood of poor mental health outcomes.”

One detainee who had been isolated for a total of 269 days was still without medication despite the presence of a “clear signal” in an electronic tracking system that he needed “robust psychiatric care.” Another who had been isolated for a cumulative 68 days had a “profound mental health history” including several stays at mental health treatment centers, yet was on “no standing antipsychotic medication … and he was suffering as a result.”

One detainee who was diagnosed with schizophrenia told the review team he “did not wish to be in segregation, and reported that his symptoms (namely auditory hallucinations) were worsening with so much time in isolation.”

The review notes that “it is common for psychotic symptoms, such as auditory hallucinations, to get worse when persons with schizophrenia are alone in isolation (i.e. voices often quiet when a person is engaged with others).”

The review team’s mental health expert recalled the detainee saying, “I hate to be alone.”

Many detainees with mental illness had requested to be separated from the general population and placed in solitary, according to the review. But this was due to a lack of alternatives. Adelanto staffers told the Office for Civil Rights and Civil Liberties experts that solitary “is ‘the best option’ available for some of” the detainees with mental illness “because of the absence of other options for appropriate mental health housing.” The review team recommendedthat Adelanto “develop a safe housing alternative with more intensive mental health services.”

In 2015, CRCL clearly informed Adelanto that clinical leadership was not competent and that problematic medical care was occurring as a result.

Office for Civil Rights and Civil Liberties (CRCL) review of Adelanto

This wasn’t the first time the office had raised issues regarding Adelanto’s use of solitary. “In 2015 CRCL recommended that long-term segregation housing of detainees with serious mental health conditions at ACF should cease. This was not corrected,” according to the review.

ICE’s use of solitary has also sparked bipartisan congressional concern. In a letter to ICE’s acting director Albence this July, Senators Chuck Grassley (R-IA) and Richard Blumenthal (D-CT) called detention centers’ reliance on solitary to hold vulnerable populations, such as detainees with mental illness, a “basic structural challenge for ICE.”

Another reason detainees were left to languish in solitary, according to the review: “Clinical staff did not consider themselves as responsible for the segregation and/or ongoing segregation of their patients.”

“Incompetent leadership”

The review cites hundreds of internal complaints at Adelanto in 2016 and 2017 related to medical and mental health care. Most of the complaints regarding “delays or denials of care” were confirmed, the review states, and were partly attributable to inadequate medical staffing.

“This large number of healthcare related grievances is not typical in a correctional setting, and is a key indicator that the healthcare needs of the detainee population is not being met,” the review states.

Adelanto’s problems with medical and mental health care fundamentally stemmed from poor medical leadership, according to the review.

“In 2015, CRCL clearly informed Adelanto that clinical leadership was not competent and that problematic medical care was occurring as a result. In 2017—two years since the 2015 onsite—the experts found no evidence that corrections were made to address this issue,” states the review.

The GEO Group, which runs Adelanto, provided healthcare at the detention center until February 2016, when it hired a medical subcontractor called Correct Care Solutions, recently rebranded as Wellpath. The head of Wellpath is a former GEO executive who worked simultaneously as a GEO consultant and as president of the healthcare company when GEO hired it to run healthcare at Adelanto.

But the change in the company providing care didn’t affect Adelanto’s top medical personnel. “That new contractor left the same incompetent leadership in place,” the review states.

At the time of publication, POGO was not able to identify who led Adelanto’s medical care.

The Office for Civil Rights and Civil Liberties’ experts recommended Adelanto replace those heading up the detention center’s medical care. “In the event that new leadership cannot be recruited immediately—as it is likely that it will take some time to put new leadership in place—at-risk detainees should be immediately removed from the facility and transferred to other facilities with well-functioning medical programs,” the review recommends.

At-risk detainees should be immediately removed from the facility and transferred to other facilities with well-functioning medical programs.

Office for Civil Rights and Civil Liberties review of Adelanto

The review contains nearly identical criticism of the mental health leadership at Adelanto.

Neither GEO nor Wellpath responded to POGO’s requests for comment.

Last month, a massive federal lawsuit was filed on behalf of 15 detainees—eight of whom were detained at Adelanto at the time of the filing—against ICE and the Department of Homeland Security, stating that the Office for Civil Rights and Civil Liberties “has no enforcement power, so ICE is free to disagree with CRCL recommendations or refuse to implement them.” The lawsuit names top Homeland Security officials, including acting ICE head Albence. The officials’ lax oversight of ICE detention centers, plaintiffs claim, has led to systemically poor medical and mental healthcare, deaths, and other adverse health and safety impacts.

Beyond his Fox & Friends interview, Albence has been vocal in his defense of contractors running many of ICE’s detention centers as well as the conditions in the facilities, including family detention centers that he said last year are “like a summer camp.” At a Senate hearing where he stood by that comparison, Albence refused to answer when asked if he would send his children to his agency’s detention centers.

“That question’s not applicable,” he said.

Katherine Hawkins contributed reporting and former POGO interns Vanessa Perry and Caterina Hyneman contributed research.

Adelanto illustrates problems, spanning across presidential administrations, with what’s been described as ICE’s “layered system for inspections” and the agency’s unwillingness to hold its contractors accountable. The agency’s use of an inspection company called the Nakamoto Group to examine the contractors that operate its detention centers has contributed to problems persisting at ICE, according to the Department of Homeland Security’s watchdog office.

Responding to a query regarding the Office for Civil Rights and Civil Liberties’ review of Adelanto, an ICE spokesperson pointed a journalist for The Atlantic to the results of Nakamoto’s preannounced inspection that occurred after the office’s review and the inspector general’s surprise inspection. In contrast to the office’s review and the inspector general’s findings, the company found Adelanto completely compliant with ICE’s standards, and called the inspector general’s work “erroneous” and “inflammatory.”

In a previous interview with POGO, Nakamoto Vice President Mark Saunders said the inspector general “took a housekeeping problem and made it a suicide issue” to “sell their product.” The “housekeeping problem” is a reference to the hanging bedsheets in detainees’ cells that Adelanto’s staff described as “nooses” to the inspector general team. A detainee had used a bedsheet to hang himself in 2017.

An examination by Disability Rights California, a nonprofit empowered by law to investigate conditions in facilities where people with disabilities are held, showed that some of Nakamoto’s conclusions were at odds with what the nonprofit found.

For example, according to the nonprofit’s report, Nakamoto’s finding that there were “no serious suicide attempts” at Adelanto in 2018 is “demonstrably false,” because it relies on the GEO Group’s narrow definition of suicide attempt “that is inconsistent with the definition used by the federal government.”

However, Disability Rights California quotes Adelanto facility records from 2018 saying a detainee was found “in the shower in fetal position, fully dressed, crying and holding left bleeding wrist,” and was subsequently hospitalized for five days. Medical records called it a “suicide attempt,” which the detainee confirmed.

A Department of Homeland Security advisory group and the inspector general have found flaws in Nakamoto’s approach to inspections of ICE detention centers. Nakamoto’s role at ICE has also come under congressional scrutiny in recent months.

“One of ICE’s performance goals is for all of its detention centers to pass inspection…[and] Nakamoto is well aware of the pressures to meet that target,” according to an NPR story this summer that cited a former agency official. ICE has claimed that 100% of its detention facilities have met agency standards since fiscal year 2013.

“Every negative report made about us has been factually refuted,” said Saunders, the Nakamoto vice president, in an email to POGO, while declining to provide details. “We have no agenda whatsoever but to do our work, and do it well.”

The agency’s Office of Detention Oversight also inspects detention centers. Unlike Nakamoto, the Office of Detention Oversight “uses effective methods and processes to thoroughly inspect facilities and identify deficiencies,” the inspector general wrote last year, though this office’s inspections are “too infrequent” (its last inspection of Adelanto was in 2014).

The Office of Detention Oversight’s most recent annual report on inspection findings states that in fiscal year 2017, it found “close to a threefold increase in the incidence of repeat deficiencies compared to the previous fiscal year.”

But even when ICE’s inspectors do find violations of standards, the inspector general wrote in January 2019, “ICE does not adequately hold detention facility contractors accountable.”

The watchdog found that between October 2015 and June 2018, ICE’s various inspectors had identified 14,003 deficiencies involving 106 contractor-run detention centers, but that “instead of holding facilities accountable through financial penalties, ICE frequently issued waivers to facilities with deficient conditions, seeking to exempt them from having to comply with certain detention standards.”

During that period, according to the inspector general, ICE only financially penalized “one facility as a result of a pattern of repeat deficiencies over a 3-year period, primarily related to health care and mental health standards.” The facility and the contractor operating it were not named.