Loyal Source has obtained CBP contracts worth at least $630 million since 2015, according to government records. Over the past nine months, the company has slowed the agency’s attempts to hire a different medical provider by filing protests about contract requirements, records show.

Loyal Source’s quality of care and staffing have been under scrutiny since the May 17 death of Anadith Danay Reyes Alvarez, who was infected with the flu while in CBP custody after crossing the Rio Grande into South Texas with her family. As the child’s symptoms worsened and her mother pleaded for urgent care, medical staff did not call a doctor and mishandled files showing Reyes Alvarez had a heart condition and sickle cell disease, according to a CBP timeline.

Federal court records also show the company is a defendant in a lawsuit filed by a Guatemalan mother alleging Loyal Source staff and U.S. authorities failed to provide proper medical care to her 14-month-old daughter after she contracted the flu in U.S. custody in 2019. The child spent months in intensive care and suffered long-term cognitive and physical impairment, according to the lawsuit.

Loyal Source did not respond to emails and calls, and the company has not spoken publicly about Reyes Alvarez’s death. Its website does not list a media or communications contact. Attorneys representing Loyal Source in the 2019 case did not respond to inquiries.

CBP’s current contract dispute with Loyal Source, which has not been previously reported, adds strain to the government’s chronic struggle to provide medical care for the hundreds of thousands of children crossing into the United States each year alone or with their families.

Loyal Source and two other companies filed protests about the selection process after CBP tried to hire one of their competitors last September. CBP amended its requirements in response, but Loyal Source filed additional protests.

The Government Accountability Office, the federal entity that arbitrates federal contracting disputes, denied Loyal Source’s protests in March, saying CBP “acted reasonably and within its discretion.”

CBP officials familiar with Loyal Source’s operations said the company’s staff has often been stretched thin, shuttling back and forth between border facilities to cover vacancies.

Many of the border communities where CBP operates are in rural areas with limited medical care, and providers in those areas say hiring and retaining doctors, nurses and other staff is a significant challenge. Large swings in the number of monthly border crossings can be a burden for government contractors who may not be able to hire quickly enough to keep pace.

The death of Reyes Alvarez has exposed deficiencies in CBP care that were largely glossed over during the pandemic, when most migrant families were quickly released from custody or expelled to Mexico in a matter of hours, according to experts familiar with migrant medical services.

Illegal crossings along the southern border rose 33 percent from June to July, from 99,539 to 132,652, according to the latest CBP enforcement data. Almost half of the migrants taken into CBP custody last month were parents with children arriving as part of a family group — the highest share since 2019.

Paul Wise, a Stanford University pediatrician appointed by the federal court system to monitor medical care for underage migrants, called the death of Reyes Alvarez “clearly preventable” in a July 18 report to the U.S. District Court in California that oversees the care of minors in U.S. immigration custody.

Wise wrote that the child’s death raises “profound concerns regarding not only the direct care she received but also the custodial and medical systems that failed to prevent (Reyes Alvarez’s) clinical deterioration and death.”

Wise did not respond to requests for comment.

Born in Panama to Honduran parents, Reyes Alvarez was diagnosed with influenza after being in U.S. custody five days and transferred to a Border Patrol station used as a medical isolation ward, according to CBP records and federal court filings.

An autopsy of Reyes Alvarez showed the child’s lungs had filled with fluid on the day she lost consciousness and died. Mabel Alvarez Benedicks, the girl’s mother, told reporters her daughter had cried and begged for her life as she grew sicker and Loyal Source medical staff refused more advanced care.

“Only after (Reyes Alvarez) lost consciousness and suffered an apparent cardiac arrest was an ambulance called,” Wise wrote in his report to the federal court system.

CBP responded to the child’s death by opening an investigation, barring several Loyal Source staff from border facilities and launching a review of CBP’s own medical care practices and record-keeping. In June, the Department of Homeland Security removed CBP’s top medical officer, David Tarantino, who was responsible for overseeing the Loyal Source contract.

“As CBP works to implement required improvements to our medical care policies and processes, including from the ongoing investigation into the tragic in-custody death of a child in Harlingen, we are bringing in additional senior leadership to drive action across the agency,” the agency said in June.

DHS acting chief medical officer Herbert O. Wolfe told CBP in a June 8 memo that the Border Patrol station where the girl and her family were held “lacked sufficient medical engagement and accountability to ensure safe, effective, humane and well-documented medical care.”

Wolfe’s memo to CBP acting commissioner Troy Miller described poor communication among staff, an ad hoc system for managing medical records and a lack of clear guidelines for seeking help from doctors. The Loyal Source-run medical ward had a list of on-call doctors and pediatricians that was “out of date” because it was used so rarely, according to Wolfe’s memo, a copy of which was obtained by The Washington Post.

Loyal Source has not responded publicly to Wolfe’s memo or Wise’s report.

CBP officials said they are closely monitoring the quality of Loyal Source medical services following Reyes Alvarez’s death. The agency said it is trying to help the company become more efficient in its hiring efforts and said Loyal Source has increased its staffing levels 50 percent over the past year.

“CBP has built 11 facilities over the past two years that include dedicated space for medical triage and management of basic care, as well as isolation areas for communicable diseases,” CBP spokesperson Erin Waters said in a statement. “Those facilities and others along the border have been bolstered by over 1,000 medical personnel who have been contracted as part of wrap-around services funded by Congress.”

CBP officials said they are prepared to replace Loyal Source with another provider if the company fails to fulfill its contractual obligations to properly staff U.S. facilities. In the meantime, the agency said it continues to seek a new long-term contract and evaluate providers’ bids.

Federal contracting records show that in September 2022, CBP tried to hire Vighter, a Texas-based medical provider, for a five-year, $1 billion contract scheduled to take effect in March. But that award was blocked when Loyal Source and two other companies filed their protests to the GAO.

CBP is still paying Loyal Source nearly $25 million per month to provide medical care at Border Patrol facilities because it has not awarded a new contract.

CBP did not say when it would award a new contract nor whether Vighter remained the front-runner. Vighter did not respond to a request for comment.

CBP said it will continue to rely on Loyal Source medical staff until a new contract is finalized, and the current arrangement with the company can be extended through December if necessary. Agency officials did not say if Loyal Source has been ruled out as a potential recipient for a new contract, but past performance would be taken into account when evaluating bids.

Mark Travasso, an infectious-disease specialist and pediatrician at the University of Maryland, said U.S. border authorities need to make sure children in U.S. custody are treated by medical personnel with pediatric expertise.

“Children require specialized care and equipment,” said Travasso, who has reviewed the medical records of two children who died in 2018 after being taken into CBP custody.

“Even if you’re having them be seen by adult care providers, it’s not appropriate personnel,” said Travasso in an interview. “If they’re taken care of by individuals without that expertise, it’s medical mismanagement.”

Court records show Loyal Source is a defendant in a $6 million lawsuit filed by Arlyn Roque, a Guatemalan mother whose family allegedly experienced a medical ordeal in CBP custody in 2019 similar to that of Reyes Alvarez.

Roque was 17 when she crossed into the United States near McAllen, Tex., in June 2019 with her 14-month-old daughter. After several days in Border Patrol custody, the infant began vomiting and running a fever, according to the lawsuit. Roque said her requests for emergency medical care were ignored by Loyal Source staff as the baby’s condition worsened.

After 10 days, the child was admitted to a hospital with “severe respiratory distress” and intubated, medical records show. The girl was transferred to a hospital in San Antonio for more advanced treatment five days later and placed on oxygen therapy. Two weeks later, she was flown to a medical center in New York City.

The child remained in long-term care for at least five months while undergoing rehabilitation and suffered physical and cognitive impairment, according to the lawsuit, which has not been previously reported.

Meagher & Meagher, a White Plains, N.Y., law firm representing Roque, did not respond to calls and emails. A person who answered the phone at the Roque’s last known address said the family no longer lived there.

CBP said it could not comment on pending litigation, but attorneys for the government have denied allegations of malpractice and negligence.

Loyal Source attorneys say the child had a fever when she arrived at CBP custody and received treatment from the company’s staff, according to court filings. Her condition improved, but when her fever and symptoms returned, she was transferred to a hospital, according to the Loyal Source attorneys. Their motion to move the trial from New York to Texas was granted last year.

Record numbers of migrant families crossed the U.S. southern border illegally in 2018 and 2019, putting hundreds of thousands of teens and children through crowded CBP facilities where infectious diseases can spread quickly. The deaths of seven minors during that period prompted Homeland Security officials to begin building a more robust system of medical care after relying for years primarily on Border Patrol agents with emergency medical training.

CBP policy directs agents to transfer families out of its facilities within 72 hours, but during periods of peak migration when the agency is overwhelmed, teens and children have been held far longer. Unlike U.S. Immigration and Customs Enforcement (ICE), which operates a nationwide network of jails and detention centers, CBP has not developed a modern system for managing the medical records and files, according to agency officials.

Miller said in a statement that his agency has undertaken significant steps to address shortcomings and “ensure that medically fragile individuals and family units receive the best possible care and spend the minimum amount of time possible in CBP custody.”

That goal sometimes clashes with the Biden administration’s determination to increase deportations of migrant families at a time when nearly half of illegal border crossings consist of parents with children. The 72-hour detention policy for families in CBP custody generally does not afford U.S. authorities enough time to process parents with children and prepare their deportation.

The Biden administration shut down the three family detention centers operated by ICE in 2021.

As the number of migrants crossing as part of a family group rises, the administration in recent weeks has been highlighting its deportation flights for families and expanding its use of climate-controlled tent facilities where conditions are more child-appropriate than the austere detention cells of traditional brick-and-mortar Border Patrol stations.

Loyal Source staff provide medical services at both types of facilities.

Researcher Magda Jean-Louis contributed to this report