Medical mismanagement and falsified records may have contributed to the deaths of immigrants held at for-profit detention centers that are run under contract with the federal government, according to a report released Thursday by the House Oversight and Reform Committee.

The report, based on a year-long investigation by Democratic committee staffers, recounts numerous examples of medical misdiagnoses, incomplete or incorrect treatment for chronic illnesses and “grossly negligent” responses to infectious diseases including hepatitis, tuberculosis, meningitis and HIV. It also notes severe delays in emergency response to strokes and heart attacks, negligent suicide watches and deficiencies in psychiatric care that led one detainee to self-mutilate.

The investigation focused on facilities under the authority of two Homeland Security agencies, Immigration and Customs Enforcement, and Customs and Border Protection.

“This staff report and the documents the Committee obtained explain how the Administration and its private prison contractors have let known problems fester into a full-blown crisis — a crisis that has become far worse during the coronavirus pandemic,” Committee Chairwoman Carolyn B. Maloney, D-N.Y., said in a statement. “This broken system needs fundamental reforms, including enhancing internal and external oversight, ending the use of private prison contractors, and significantly decreasing the number of immigrants detained in the first place — all choices the Administration could make right now.”

The investigation was launched last July by Maloney’s predecessor, the late Elijah E. Cummings of Maryland.

In addition to obtaining thousands of pages of internal staff complaints, assessments and whistleblower accounts, congressional staff conducted on-site inspections at 20 facilities in Arizona, California, Georgia, Louisiana and Texas. 

The report cites, for instance, falsification of records involving Jean Carlos Jimenez-Joseph, a 27-year-old Panamanian migrant who committed suicide in May 2017 at ICE’s Stewart Detention Center in Georgia after reporting hallucinations and suicidal thoughts. 

Jimenez-Joseph was a recipient of Deferred Action for Childhood Arrivals, an Obama-era program that allows undocumented immigrants who came to the country as children the ability to live and work in the United States. He was detained 69 days at the Georgia facility, which is run by private prison company CoreCivic, after being arrested for a misdemeanor in 2017.  

“In addition to leaving the unit unsupervised on seven occasions the night of Jimenez’s suicide, Officer [Redacted] falsely logged that he completed security rounds at 12:00 a.m. and 12:28 a.m., neither of which were corroborated by video surveillance footage,” according to an internal ICE review cited in the report.  

The House Oversight report also cites a review by Homeland Security’s Office for Civil Rights and Civil Liberties of the Adelanto detention center, a California facility run by the company GEO Group. That review reported that a “failure to hire an effective and qualified clinical leader contributed to the inadequate detainee medical care that resulted in medical injuries, including bone deformities and detainee deaths.”  

Medical care in ICE custody also has been under intense scrutiny during the pandemic, as the number of positive cases of COVID-19 has steadily climbed since March. The report notes that as of Sept. 23, more than 6,000 detainees and 45 employees at ICE detention centers nationwide have tested positive. This includes 16 facilities run by GEO Group and another 16 facilities run by CoreCivic. 

According to the report, employees at a CoreCivic facility in Mississippi tried to impede congressional inspection during a delegation visit after a detainee tried to flag down committee staff to complain about abuse and humiliation.

“Rather than permit him to speak, an ICE official threatened to end the tour immediately and cancel future site visits if Committee staff attempted to communicate with the detainees,” the report said.

Despite issues revealed through internal audits and reviews, since 2017 “the Trump Administration has awarded its two biggest detention contractors, CoreCivic and GEO Group, more than $5 billion in contracts to operate private detention facilities,” the report said. 

A separate report issued earlier this week by the House Homeland Security Committee found similar issues with medical care in ICE detention.

Stacey Daniels, public affairs director for ICE, told CQ Roll Call that the agency is “fully committed to the health and safety of those in our care and will review the committee’s report.”

“However, it is clear this one-sided review of our facilities was done to tarnish our agency’s reputation, as opposed to actually reviewing the care detainees receive while in our custody,” Daniels said.

She added that ICE has an “aggressive inspections program, which includes formal facility inspections, independent third-party compliance reviews, daily on-site compliance reviews and targeted site visits.”

ICE also pointed to a 2018 Office of Inspector General report that found that ICE’s Office of Detention Oversight “uses effective methods and processes to thoroughly inspect facilities and identify deficiencies.”

However, that same report noted that those inspections were “too infrequent to ensure the facilities implement all corrections” and that ICE “does not adequately follow up on identified deficiencies or systematically hold facilities accountable for correcting deficiencies.” In addition, the report found that the third-party inspections were “not consistently thorough.

CoreCivic spokeswoman Amanda Gilchrist told CQ Roll Call that the company is “committed to the safety and health of every individual in our care.”

“We take seriously our obligation to adhere to federal Performance Based National Detention Standards in our ICE-contracted facilities,” she said.

Gilchrist noted that prior to November 2018, CoreCivic did not provide medical services at Georgia’s Stewart center and attributed the responsibility of that care to ICE’s Health Service Corps. She said the congressional tour at the Adams County Correctional Center in Mississippi “was facilitated by our government partner.”

GEO spokesman Pablo Paez said the company denied the report’s “baseless allegations, which are part of another politically driven report that ignores more than three decades of providing high-quality services to those in our care.”

Paez noted the Adelanto center provides “safe and humane” residential and medical care and employs nearly 80 health services professionals, including seven mental health professionals.

The House Oversight report follows a whistleblower complaint filed to the Homeland Security inspector general alleging “jarring medical neglect” and mismanagement of the COVID-19 crisis at an ICE facility in Georgia. The complaint included comments from detainees and a nurse, Dawn Wooten, employed at the facility until July 2020, who alleged that hysterectomies were conducted on some women without proper consent. 

At his Senate nomination hearing Wednesday, acting Homeland Security Secretary Chad Wolf said the “dramatic allegations” in that complaint were being investigated by the department’s inspector general.

“But if there is a kernel of truth to any of that, you can guarantee that I will hold those accountable and will take very decisive action.”