When a government expert in mental health visited one of the largest immigration detention centers in the U.S. in 2017, she knew the conditions that detainees there sometimes face. A past inspection had found that staff often failed to obtain adequate mental health histories, leading to faulty diagnoses and, in some cases, treatment plans that were incorrect.
Upon arrival at the Immigration and Customs Enforcement processing center in Adelanto, Calif., a similar pattern emerged. One detainee she observed had a diagnosis of schizophrenia. When she asked an officer about him, she was told that the man "floods his cell, bangs his head."
She searched the man's medical chart for records from his recent stay at an inpatient psychiatric unit, but they appeared to be missing. He had been placed in what the government refers to as "segregation," a term known more commonly as solitary confinement.
Inside, the expert found, he was suffering from "active auditory hallucinations." Moreover, they appeared to worsening.
"I hate to be alone," he told the expert.
The detainee's case is detailed in a previously confidential report on the Adelanto facility obtained by NPR. Despite the report's findings — and repeated, scathing criticism of the facility from the federal government's own internal watchdogs — ICE decided at the end of 2019 to renew and expand a contract to keep the Adelanto facility open.
The report dates to late 2017, but attorneys and advocates say the problems identified in the report have persisted. ICE declined to respond to specific findings in the report.
Like many other detention centers, the Adelanto facility is operated by a for-profit company — in this case, the GEO Group. The U.S. government is GEO's single biggest customer, and the company has made nearly $1 billion in federal contracts over the past 12 months, according to government data.
The company's business has been threatened by a new California law that largely bans for-profit companies from operating prisons and immigration detention facilities in the state. Findings of inadequate care and treatment of detainees at the Adelanto facility and others were a driving force behind that law.
But by signing the new 15-year contract before the law could take effect, GEO and the Trump administration effectively circumvented the state of California until 2034. (GEO has also sued the state in federal court, arguing that the California law is unconstitutional.)
Advocates and attorneys for immigrants say the new contract — which also expands the Adelanto facility by more than 700 detention beds — demonstrates how ICE fails to hold contractors accountable for major problems in immigration detention centers.
Their concerns are echoed in the report obtained by NPR from the Department of Homeland Security's Office for Civil Rights and Civil Liberties, an internal oversight office.
Among the report's findings:
- The facility failed to meet ICE's own standards for using solitary confinement. One detainee, for instance, cumulatively spent nearly 2 1/2 years in solitary.
- Staff used pepper spray on immigrants held in detention but did not follow best practices when it came time to remove the spray from detainees — in some cases their efforts intensified the painful "burning effect."
- It was "more likely than not" that problems with medical care "contributed to medical injuries, including bone deformities and detainee deaths."
- And government experts were so alarmed that they recommended "immediately" transferring "at-risk" detainees to another facility to protect their health and safety.
The expert inspectors from the Department of Homeland Security found that, in several cases, ICE and GEO had been either unwilling or unable to fix problems despite repeated warnings over the years.
The report's findings provide a window into the types of challenges presented by the Trump administration's push to detain more immigrants who are awaiting asylum hearings or deportation proceedings. Under the president's hard-line immigration policies, the number of immigrants in detention has grown to all-time highs, with private companies like GEO playing a central role in that system. While defenders say the crackdown is needed to help stem what they call a crisis on the southern border, immigration advocates say the growing reliance on detention has stretched an already troubled system to the breaking point.
"These reports never see the light of day"
NPR has sought records regarding the facility for more than a year and obtained this report under the Freedom of Information Act. Sources familiar with the Office for Civil Rights and Civil Liberties say such reports almost always remain confidential.
"Normally, these reports never see the light of day," says Nick Schwellenbach, a senior investigator with the nonprofit watchdog group Project On Government Oversight, or POGO.
In September 2019, POGO released a version of the report after filing a public records lawsuit. But the government had more heavily redacted critical findings and recommendations.
"It's kind of confounding why they withheld some of this information [from us]," says Schwellenbach.
A representative for GEO said the company would "defer to ICE" on any response to the report.
Lori K. Haley, a spokesperson for ICE, also declined to comment on specific findings in the report.
In an email, Haley wrote, "The safety, rights and health of detainees in ICE's care are of paramount concern."
But, she noted, the agency "either did not concur or only partially concurred with roughly half their recommendations."
Haley declined to say which recommendations ICE agreed with and why, or what actions the agency took in response.
Lawyers, who regularly visit the facility and represent detainees there, say they have seen little evidence that ICE or GEO has followed through on the recommendations.
"I don't have reason to believe that many of these reports are being taken as seriously as they should by the facility or by ICE," says Pilar Gonzalez of the nonprofit Disability Rights California, which advocates for detainees at the facility.
Liz Jordan, an attorney with the Civil Rights Education and Enforcement Center, says the issues identified in the report have persisted.
"ICE does not demand any sort of accountability from the contractors or force any changes or improvements," says Jordan, who is representing current and former Adelanto detainees in a lawsuit.
"Instead, they get rewarded to keep on keeping on."
"No correction was made"
The Adelanto ICE Processing Center holds nearly 2,000 adult detainees, most of whom have no criminal record.
Unlike prison, immigration detention is not meant as punishment. The government holds people in detention while deciding their immigration status.
In November 2017, the authors of the report — three Department of Homeland Security experts in health care, corrections and mental health — traveled to Adelanto, Calif., to inspect the ICE detention facility after a series of complaints. The names of the experts are redacted in the report.
All three experts found major problems, but the most serious findings in the documents obtained by NPR come from the report on health care.
"Overall, the medical care at the Adelanto facility is inadequate" and does not meet federal standards, the report found, citing "incompetent clinical medical leadership."
The Office for Civil Rights and Civil Liberties had previously visited the facility in 2015 under the Obama administration and detailed "negligent" medical care at that time. But rather than seeing improvements in 2017, the experts found that medical care had gotten worse.
"No correction was made," the report states, noting that the number of complaints around detainee medical care had actually increased.
The medical expert cites multiple examples of poor medical care, including long delays in appointments for broken bones and a failure to provide needed antibiotics and other medications.
In at least one case, a detainee's death was "likely related" to failures by the facility's medical staff.
As a result, the expert recommended a drastic measure:
"At-risk detainees must be immediately removed from the facility (transferred to another facility with a well-functioning medical program)."
Given the problems at the facility, the expert defined "at-risk" as any detainee with a chronic medical problem like diabetes, as well as any detainee over 55 years old.
Attorneys for detainees told NPR that there's no indication that ICE or GEO actually followed this recommendation.
ICE declined to say whether it made changes to its medical staff in the wake of the report or transferred detainees.
Allegations of "verbal harassment" and "retaliation"
The allegations against the Adelanto facility went beyond medical care.
"Detainees suffer retaliation, verbal harassment and [are] treated with disrespect," the report found. Leadership "must hold facility staff accountable for substantiated abusive and disrespectful treatment of the detainees," the report went on, noting that this problem had not been addressed after previous inspections.
In another instance, detainees alleged even harsher measures.
In June 2017, a group of asylum-seekers from Central America went on hunger strike to protest conditions at the facility. When the group locked arms and refused to move, staff used pepper spray and physically removed them.
The corrections expert found that the use of pepper spray was "appropriate given the circumstances." But the expert saw a significant problem with the staff's subsequent actions.
Cold water is recommended to safely decontaminate pepper spray.
But, the corrections expert found, "The facility does not have any access to cold water. The facility only provides a mix of cold and hot water through a shower head." The expert warned that "warm water will exacerbate the burning effect of the OC pepper spray."
When the group of hunger strikers was placed in showers, they described "writhing" in pain as the water reactivated the spray. One detainee, Marvin Josue Grande Rodriguez, said that he fainted in the shower, because "the gas and the heat of the water ... It was far too much for me."
The report says the use of a hot shower was a "significant issue" and concluded that the facility "must provide access to a cold-water shower" in the future.
In response to a lawsuit filed by the group of hunger strikers, lawyers for GEO said that water "does reactivate the tingling sensation" from pepper spray but that it was "necessary to remove the spray" and was not intended to cause pain.
Because ICE and GEO declined to answer specific questions, it's unclear if they followed the recommendation on cold-water showers.
Attorneys for detainees told NPR that they were unsure whether any changes had been made.
But it is clear that the facility staff continue to use pepper spray. ICE statistics show that pepper spray has been used more than 25 times since the 2017 inspection.
An "inhumane" use of solitary confinement
Additionally, the government's experts found that the Adelanto facility was failing to meet federal standards for solitary confinement — known in ICE's bureaucratic language as "segregation."
Overall, the report found that GEO Group staff had "no current strategy" when it came to long-term use of solitary confinement and that people were suffering as a result.
In one case, inspectors found, a detainee was held in a "Special Management Unit," or SMU, for 426 days.
"No detainee should be held in the SMU for this amount of time," the report states. "Isolation alone can create physical safety concerns and can result in mental decompensation."
The expert inspectors were especially critical of the use of solitary confinement for immigrants with serious mental disorders. They found that about a third of the detainees held in solitary had a "serious mental illness."
Over the course of multiple stays, one detainee logged 904 days — or nearly 2 1/2 years — in solitary confinement, which the report calls "shockingly high."
The experts found that some detainees with serious mental illness were put in solitary confinement simply because it was the only available space where they could be closely watched. The report called that practice "inhumane."
"If strategies are not developed," the report warned, "the mental health and other long-term detainee cases will continue to decompensate, and the population of the SMU will continue to grow."
In response to NPR, an ICE spokesperson wrote that the agency "is compliant" with agency standards on the use of solitary confinement, citing a directive from 2013.
But again, critics of ICE say that is not true.
"You have these experts ... essentially screaming from the rooftops, 'You need to fix this problem!' " says Schwellenbach of POGO, which has also investigated the use of solitary confinement in ICE detention. "There's solutions that they're actually putting forward, but they're being ignored."
Ongoing oversight of immigration detention
The state of California has repeatedly clashed with the Trump administration over immigration policy.
The office of California Sen. Kamala Harris, a former Democratic presidential candidate and former state attorney general, reviewed the documents obtained by NPR.
"It is unconscionable to subject detained persons to inhumane conditions," Harris' office said in a statement, "including issues arising from insufficient medical care as well as prolonged isolation and detention at immigrant detention facilities."
Criticism of conditions at the Adelanto ICE Processing Center by Harris and others was one factor that led to the recent California law, largely banning the use of private contractors in prisons and immigration detention centers.
"State laws aimed at obstructing federal law enforcement are inappropriate and harmful," ICE's Haley wrote to NPR. "Policy makers who strive to make it more difficult to remove dangerous criminal aliens and aim to stop the cooperation of local officials and business partners, harm the very communities whose welfare they have sworn to protect."
In their lawsuit against the state, GEO argues that the law is a "transparent attempt by the State to shut down the Federal Government's detention efforts within California's borders" and "a direct assault on the supremacy of federal law."
California state legislator Rob Bonta, who championed the law, tweeted that the lawsuit was, "Exactly what you'd expect fr[om] a collapsing industry in its final death throes."
Read the full internal report: