Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 33 of 65

function and
and also
also take
take any
any actions
actions that
thatare
are appropriate
appropriate
function
regarding the
the allegation
allegation of
ofabusive
abusive actions
actions by
by correctional
correctional
regarding
staff on 12/05/10.
12/05/10.
staff
12. I reviewed
II reviewedthe
themedical
medicalrecord
recordofofaa28
28year
yearold
oldwoman
woman
12.

(MCJ #
# 719570)
719570) who
(MCJ
who died
diedin
in the
the Estrella
EstrellaJail
Jail on
on 12/07/10,
12/07/10,
after she
she collapsed
collapsed in
in aa shower
shower and
and was
was non-responsive
non-responsive
after
despite cardiopulmonary
resuscitation efforts.
efforts. She
She had
had
despite
cardiopulmonar resuscitation
been screened oni
oni2/01/
2/01/ 10,reported
reported having
having asthma and
and
been
on 12/01/10,
being on multiple medications.
She was
was noted
noted to
to have
have
being
medications. She
markedobesity.
obesity. AA "Pre-Booking
Medical
marked
"Pre-Booking Assessment
Assessment Medical
Clearance Report"
10 showed
showed normal
blood
Clearance
Report" dated
dated 12/01/
12/01/ 10
normal blood
pressure, pulse rate, respiratory
respiratory rate
rate and
and blood
blood oxygen
oxygen
levels.
12/02/10,she
she submitted
submitted aa request
request to
to be
be seen
seen
levels. On 12/02/10,
for severe
severe persistent
She was then seen
seen by a
a
persistent headaches.
headaches. She
nurse on 12/04/10
12/04/
12/04/10
10at
atwhich
whichtime
timesystolic
systolicblood
blood pressure
pressure
was moderately
mni
moderately elevated
elevated at
at 151
151 mm
mm Hg.
Hg. The nurses'
nurses'
assessment note indicates
indicates that the patient described her
I'sudden
headache
"same as
as
headache both
both as
as "sudden
"sudden onset"
onset" and the "same
as usual".
usual".
The
The nurse
nurse recommended
recommended aspirin
aspirin and
and because
because the
the patient
patient
said
been drinking the water
water in the
the jail, gave
gave
said she had not been
water
water and
and encouraged
encouraged her
her to
to drink
drink water
water as
as usual.
usuaL. On
On
12/06/
10, the patient submitted
submitted another request to be
12/06/10,
be seen
seen
for
forheadache.
headache. A
A nurse
nurse sent
sent aa written
written response
response
recommending administration of Tylenol
headache.
Tylenol for
for the headache.
recommending administration of

The
The
Thepatient's
patient's sudden
sudden death
death occurred
occurred later
later that
that day.
day. The
report
report of
of an
an autopsy
autopsy was
was not
not complete
complete as
as of
ofMarch
March 1,
1, 2001,
2001,

29
29

Case 2:77-cv-00479-NVW Document 1966

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butthe
thecause
causeof
ofdeath
deathaccording
according to
to the
the death
deathcertificate
certificatewas
was
but
subarachnoidhemorrhage
hemorrhage due
due to
to rupture
ruptureofofone
oneof
ofthe
the
subarachnoid
arteries supplying
supplying the
the brain.
brain. This
Thistype
typeof
ofcerebrovascular
cerebrovascular
arteries
catastrophe is
is rare
rare in
inaa young
young person
person and
and was
was likely
likely
catastrophe
unrelated to
to this
thispatient's
patient'sother
othermedical
medicalproblems
problen~s
problenlsof
ofobesity
obesity
unrelated
and asthma.
asthma. The
The patient's
patient'sheadache
headache symptoms
symptomsmay
mayhave
have
and
been associated
associated with
aneurysm (out-pouching);
(out-pouching);
been
with an arterial
arterial aneurysm
however, this
is speculative,
speculative, lacking
lacking full
full results
results of
of the
the
however,
this is
autopsy. The
Thesystolic
systolicblood
bloodpressure
pressure elevation
elevation was
was not
not
severe and
not likely
likely to
cerebral arterial
arterial
severe
and not
to have
have caused
caused aa cerebral
aneurysm or
The patient
patient apparently
apparently did not
aneurysm
or rupture.
rupture. The
of neck pain or stiffness
stiffness whieh
which is often
often present
complain of
with the
the onset
onset of a
a subarachnoid hemorrhage.
with
hemorrhage. Other
observations
of care are
observations regarding
regarding quality of
are not appropriate
without additional information, including the final
final autopsy
report.
It is
for CHS
to review
review its
its
report. It
is appropriate,
appropriate, however,
however, for
CHS to
nursing
protocol with
with
nursing protocol
with respect
respect to
to evaluation
evaluation of
of patients
patients with
sudden
sudden onset
onset of
of severe
severeheadache.
headache. II will
wil discuss
discuss this
this
recommendation
Dr. Alvarez
recommendation with
with Dr.
Alvarez and
and offer
offersuch
such advice
advice as
as
helpful.
may
helpfu1.
may be helpfuL.
Among
Amongthe
theother
other medical
medical records
records that
that were reviewed
reviewed and
and
critiqued
2011 by
byPlaintiffs'
Plaintiffs'Counsel,
Counsel, there
there are
are
critiqued in
in January
Januar 2011
numerous
numerous other
other examples
examples of
ofdeficiencies
deficienciesininquality
quality and
and
documentation
documentation of
ofcare.
care. II agree
agree with
withPlaintiffs
PlaintiffsCounsel
Counselthat
that

30
30

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 35 of 65

can logically
manyof
ofthese
these deficiencies
deficiencies can
logicallybe
be placed
placed into
intothe
the
many
categories:
following categories:
following

Delaysinincare
care and
andstabilzation
stabilization of
of incoming
incoming(Intake
(Intake
.• Delays
Center) patients,
patients,
Center)
Incompleteororincorrect
incorrect nursing
andlack
lack of
of
.• Incomplete
nursing assessments
assessments and
actual or
or timely
timely communications
communications from
from nurses
nurses to
to medical
medical
actual
practitioners.
practitioners.
errorsofofcommission,
Medicationerrors
commission,omission
omissionand
and and
and MAR
MAR
.• Medication
documentation.
It
important to
to note
note that
that the
the records
records summarized
summarized above
above
It is
is important

were drawn
from aa very
very selective
selective sampling
sampling methodology
methodology
were
drawn from
requested
Counsel. This sampling
sampling methodology
methodology
requested by
by Plaintiffs'
Plaintiffs' CounseL.
effectively
adverse events
effectively identifies adverse
events associated
associated with
with care of
complex
complex patients,
patients, most
most of whom
whom have
have multiple
multiple chronic
chronic serious
serious
medical
For example,
example, the
medical conditions.
conditions. For
the sample
sample includes
includes all
all
patients
patients who
who were
were transferred
transferred from
from CBS
CBS facilities
facilities to
to an outside
hospital
hospital or
or emergency
emergencydepartment
department during
during aa prior
prior four
four month
month
period.
Furthermore, from
from among
among a
a total of approximately 110
110
period. Furthermore,
medical
medical records
records made
madeavailable
availablefor
fortheir
their review,
review, Plaintiffs'
Plaintiffs'
Counsel
Counsel forwarded
forwarded to
to me
me aa list
list of
of thirty-five
thirty-five written
written
summaries.
do not
not know
know ifif Plaintiffs'
Plaintiffs' Counsel
Counsel reviewed
reviewed other
summaries. II do
other
records
recordsand
and ifif so,
so, whether
whether negative
negative or
or positive
positive observations
observations
were
weremade.
made. Because
Because of
ofthe
the sampling
sampling methodology
methodology used
used to
to
identify
identify these
these cases,
cases,ititisisnot
not possible
possibleto
toextrapolate
extrapolatethe
theresults
results
3131

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 36 of 65

of to
to aa random
random sample
sample of
of the
the larger
larger CHS
CHS patient
patient population
population or
or
of
even to
CHS
This
even
to the
the entire
entire CRS
CHS population
population with
with chronic
chronic illnesses.
ilnesses. This
ambiguity is
major question
will address
address in
in
ambiguity
is aa major
question that
that III wil
subsequentrecord
record reviews
reviews conducted
conductedin
inconcert
concertwith
withCHS
CHS as
as
subsequent
described in the
the Corrective
Corrective Action Plan
Plan detailed
detailed in
in Part
Part E
E of
of
this Sixth
this
Sixth Report.
Report.
Despite the
the highly
highly selective
selective sampling methodology used in
in
reviewed recently by Plaintiffs'
Plaintiffs' Counsel
Counsel
selecting the records reviewed
these records
records do
do reflect
reflect a higher than
me, these
than acceptable
acceptable
and me,
context of
of the
prevalence of quality of care
care deficiencies
deficiencies in
in the context
SAJ.

Plan
Part E
Action Plan
E -- Corrective Action
includes aa provision
3,
2009 includes
Judge
Judge Wake's
Wake'sOrder
OrderofofJanuary
Januar 3,2009
3,2009
experts to
for
for the Court's appointed medical and mental health experts
assist
assist CHS
CHS in
in preparation
preparation of aa Corrective
Corrective Action
Action Plan,
Plan, ifif
needed,
needed, to
to achieve
achieve compliance
compliancewith
with pertinent
pertinent requirement
requirement of
the
Because compliance
compliance with
7, and
of .
the SAJ.
SAJ. Because
withParagraphs
Paragraphs6,6,7,
and 88 of
CBS
the
been achieved,
the SAJ
SAJ has
has not
not been
achieved, and
and CHS
CHS has
has agreed
agreedthat
that
objectives,
further
further actions
actions are
are consistent
consistent with
with their
their needs
needs and
and objeetives,
CBS' executive
II have
have worked
worked closely
closely with
with CHS'
executive leaders
leaders to
to prepare
prepare
the
the Corrective
CorrectiveAction
ActionPlan
Planthat
that is
is detailed
detailed in
in the
the following
following
of this plan
largely
substance of
plan largely
section
sectionofofthis
thisreport.
report. The substance
were proposed
mirrors
mirrors the
the content
content of
of the
the ten
ten remedies
remedies that
that were
proposed in
in
32
32

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 37 of 65

my Expert's
Expert's Report
Reporton
onCompliance
Compliancewith
withMedical
MedicalProvisions
Provisions
my
of Second
Second Amended Judgment,
Judgment, dated
dated August
August 202010.
20 2010.
of

Based on current
circumstances, including
includingaa new
newCHS
CHS
Based
current circumstances,
leadership team,
team, II have
have made aa number of modifications
modifications and
and
leadership
additions in
in the
the content
contentand
andformat
formatof
ofmy
mypreviously
previouslyproposed
proposed
additions
remedies. For
For the
the most
most part,
part, II think
think these
these changes
changes are
are in
in line
line
remedies.
with the
and agreement
agreementof
of CHS
CHSleadership.
leadership..
with
the understanding
understanding and
with any
cate
As is usually the case with
any major health
health care
care organization
organization
As
committedto
to aa Continuous
Quality Improvement
(CQI)
committed
Continuous Quality
Improvement (CQI)
Program, further
this Corrective
Corrective Action
Program,
further adaptations within
within this
Plan may well be
and appropriate
appropriate going
going forward
be necessary
necessar and
over the
18 months.
over
the next 12 to 18
To
and Defendants
Defendants may
To the extent that Counsel for Plaintiffs and
disagree
CAP, II ask
disagree with
with any aspect
aspect of
of this
this CAP,
ask that
that they consider
the
the following
following points:
points:

•. II will
ofall
all
will be
be intensively
intensivelymonitoring
monitoring implementation
implementation of
aspects of this plan with the expectation that
positive
that positive
outcomes
be evident in terms of accessibility,
outcomes will
wil be

health care
care and
and aa
coordination and continuity of health
coordination and continuity of

reduction
reduction in potentially preventable
preventable adverse
adverse events
events
•. If
If specific
prove ineffective
ineffective or
specificaspects
aspects of
ofthe
the CAP
CAP prove
or

insufficient
insufficient to
to achieve
achieve needed
needed improvements
improvements in
in health
health
care
care quality,
quality, IIwill
wil propose
propose and
and support
support whatever
whatever changes
changes
are
are necessary.
necessar.

33
33

Case 2:77-cv-00479-NVW Document 1966

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willcontinue
continue
offertoto facilitate
facilitate regular
.• I I wil
totooffer
regular joint
joint meetings
meetings
with CHS
CHS leaders
leaders and
andPlaintiffs'
Plaintiffs'and
andDefendants'
Defendants'Counsel
Counsel
with

to discuss
discuss implementation
implementationof
ofthe
theCAP,
CAP, joint
jointreview
review and
and
to
discussion of
medical records,
records, policies
of medical
policies and
and procedures
procedures
discussion
and measures
measures that
thatmay
be useful
may be
useful in
in assessing
assessing
and
compliance.
compliance.
The Corrective Action Plan I propose
propose at
time has
has the
the
at this time
following components
components and
Many
and projected
projected timelines.
timelines. Many
respect
also be monitored and assessed
assessed with
with respect
components will
wil also
as part
part of
ofCHS'
CHS'
their implementation
implementationand
andoutcomes
outcomes as
to their
Plan.
Continuous
Quality Improvement
Improvement Plan.
Continuous Quality

at the
CAP
1: Physician
CAP -- 1:
Physician and
and Provider
Provider (PA
(PA and
and NP)
NP) Staffing
Staffng at
the
th
44th
Avenue
AvenueIntake
Intake Center

th Avenue Jail Intake Center, CHS will expand its
At
At the 44th
Avenue Jail Intake Center, CHS wil

professional
professional coverage
coveragetotoinclude
include24
24 hour
hour per
per day presence of
at least one
(PA) or
one licensed
licensed physician,
physician, physician assistant (PAl
nurse
practitioner (NP)
(NP) qualified
nurse practitioner
qualified by
by training,
training, experience,
experience,
assess, treat and,
licensure
licensure or
or certification
certification to identify, assess,
and, when
when
pretrial detainees
detainees who
all newly
necessary,
refer out,
out, all
newly received
received pretrial
necessar, refer
who
have
haveor
orare
areat
atrisk
risk for
for serious
serious acute
acuteor
or chronic
chronic illnesses,
ilnesses,
physical
physical handicaps,
handicaps,debilitation
debiltation or other
other vulnerabilities
vulnerabilities
All new
associated
associated with
with their
their physical
physical or
or mental
mental condition.
condition. All
new
physicians
physicians employed
employed to
to provide
provideexpanded
expanded coverage
coveragewill
wil be
be
34
34

Case 2:77-cv-00479-NVW Document 1966

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Board- certified
certified in
in Internal
InternalMedicine,
Medicine, Family
FamilyMedicine
Medicine or
or
BoardEmergency Medicine.
Physician Assistants
Assistantsor
orNurse
Nurse
Emergency
Medicine. Physician
Practitioners participating
participating in
in coverage
coverage will
be skiled
skilled in
in the
the
Practitioners
wil be
basic procedures
procedures and
andemergency
emergency care
care needed
needed to
to cover
cover the
the
basic
Department. They
They wil
will at
at all
Intake Department.
all times
times have
have either
either on-site
on-site or
or
Intake
telephonic back-up by
by a physician. During the 168
168 hours
hours
telephonic

comprising each
each week,
week, 80 hours will
willbe
be covered
covered by physician
physician
comprising
assistants and 88 hours by
by physicians.
physicians. Expanded
Expandedweekday
weekday
be in
night shift
shift coverage
coverage will
in place
place no later than
than June
June 1,
1,
night
wil be
2011. Weekend
Weekend and
and holiday
holiday coverage
coveragewill
wil start
start no
no later than
by shift on a
August 1, 2011.
CHS will
201 1. CHS
wil document staffing
staffng by
to secure
secure expanded
expanded
monthly
taken to
monthly basis
basis and report actions taken
physician
physician coverage
coverage

Treatment Plans
Plans at
at
CAP
and Treatment
CAP -- 2:
2: Timely
Timely Assessment
Assessment and
Medical Problems
Intake for Patients
Patients with
with Significant
SignificantMedical
Problems
Simultaneous
Simultaneous with
with expansion of physician and PA/NP
coverage
the Intake Center, CHS
CHS will
coverageof
ofthe
will steadily
steadily increase
increase its
capacity
capacity to
to complete
complete medical
medicalevaluations
evaluationsand
andinstitute
institute
treatment
plans promptly
promptly after
after initial
initial Reception
Reception Screening,
treatment plans

including
including prescribing
prescribing of
ofessential
essential medications,
medications, for
for all
allpatients
patients
with
with significant
significantacute
acute or
or chronic
chronic medical
medicalconditions.
conditions. The
The
objective
objectiveisisfor
for all
all such
such patients
patients to have
have aa "hands-on"
"hands-on"
assessment and
examination
examination and
and completion
completion of
of an
an initial
initial assessment
and plan
plan

to
to include
include the
the ordering
ordering of
of medications,
medieations,pertinent
pertinent labs
labs and
and aa

35
35

Case 2:77-cv-00479-NVW Document 1966

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foregoing
scheduled follow-up
follow-up specific
specific to
to their
theirneeds.
needs. The
Theforegoing
scheduled
completed
taskswil
willbe
becompleted
cOlnpleted no
no later
laterthan
than24
24hours
hoursafter
afterinitial
initialjail
jail
tasks
entry, and
and in
in most
most instances
instances much
much sooner.
sooner. The
Theexpanded
expanded
entry,
PAjNP
CHS
IntakeCenter
Centerphysician
physicianand
andPA/NP
coverage wil
willenable
enableCHS
PA/NPcoverage
Intake

to fulfill
fulfIll
fulfillrequirements
requirementsofofthe
theRECEIVING
RECEIVINGSCREENING
SCREENING
to
2008 Standards
HealthServices
Standard J-E-02
J -E-02
- E-02 of
ofthe
the 2008
Standardsfor
forHealth
Services in
in
Standard
on Correctional
Jails
J ails of
ofthe
theNational
National Commission
Commission on
Correctional Health
Health Care
Care
Jails
(NCCHC). Furthermore,
Furthermore, CHS
CHS will
be better
better prepared
prepared to
to
(NCCHC).
wil be
first
provide, no later than
than the
the first
frrst24
24hours
hoursafter
afterReceiving
Receiving
provide,
Screening, an
initial health
assessment for
for all
all persons
persons
Screening,
an initial
health assessment
identified with
with clinically
clinically significant
in compliance
compliance
identified
signifcant findings in
onINITIAL
withinNCCHC
NCCHC Standard
Standard J-E-04
J-E-04 on
INITIAL HEALTH
HEALTH
within
ASSESSMENT. The
ASSESSMENT.
The foregoing
foregoing services
services will
will be
be implemented
implemented
between April
practitioner staffing
staffing
As practitioner
between
April 11 and
and August
August 1,
1, 2011.
2011. As
CRS
increases
in the
the 4th
4 th Avenue
Avenue Intake
CHS will
increases in
Intake Center,
Center, CHS
wil steadily
steadily
proportion of
achieve
the proportion
of patients
with clinically
clinically
achieve increases
increases in
in the
patients with
significant findings who have
health assessment
assessment
have their
their initial
initial health
completed
after Receiving
Receiving Screening.
Screening.
completed within
within 24
24 hours
hours after
CAP
- 3:
CAP 3:Timely
Timely Referrals
Referralsand
and Transport
Transport of
of Intake
Intake Center
Center
Patients
Patients Needing
Needing Infirmary
Infirmary Care
Care

Expert's Report
In
20,
2010 Expert's
Report on
on Compliance,
Compliance, I
In my
myAugust
August20,2010
20,2010
th Avenue Jail Intake Center adapt its
proposed
proposed that
that the
the 44th
Avenue Jail Intake Center adapt its

facilities
facilities and
and add
addequipment
equipmentand
andstaff
staffsuitable
suitable for
for patients
patients
who
whoneed
needan
anInfirmary
Infirmar level
levelof
ofcare,
care,but
butwho
whocannot
cannot be
be
36
36

Case 2:77-cv-00479-NVW Document 1966

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transferredto
tothe
theLBJ
LBJbecause
because of
of pre-arraignment
pre-arraignment status
status or
or
transferred
other reasons.
reasons. I Iam
ammodifying
modifyingmy
myoriginal
originalrecommendation
recommendation in
in
other
thisregard
regardfor
forthe
thefollowing
followingreasons:
reasons:
this
Onbehalf
behalfof
of the
MCSO,
Defendants have
have responded
responded that
that
.• On
the MeSO,
MCSO, Defendants
pre-arraignment or
or classification
classification status
status does
does not
not pose
pose
pre-arraignment
significant obstacles
obstacles to transferring
transferring patients timely
timely to
to
significant
LBJ Infirmary.
the LBJ
Infirmar.
TheMCSO
Meso
MCSO has
hasagreed
agreed to
to expand
expand the
the proximate
proximate space
space
.• The
available to
This expansion
expansion of
of space
space
available
to the Intake Center. This
will be
be beneficial
beneficial in
in helping
helping CHS
CHS to better evaluate,
evaluate,
wil
observe and
more patients during the
the first
first 24
24
observe
and treat more
hours after
after reception
reception screening.
screening.
•. While
Whilebeneficial,
beneficial, additional
additional available
available space
space proximate-to
proximate to
the Intake Center is not suitable for
for conversion
conversion to an
infirmary
level of
of care.
infirmar level
Because
Becauseof
ofthe
theforegoing
foregoingconsiderations
considerationsititwill
willbe
benecessary
necessar for
for
CHS
received patients
CHS to
to ensure
ensure that
that all newly received
patients whose
whose clinical
clinical
condition
for an
infirmary level
condition indicates
indicates need
need for
an infirmary
level of
ofcare
care will
wil be
be
transferred
transferred to
to the
the LBJ
LBJInfirmary
Infirmar no
no later
later than
than 24
24 hours
hours after
after
booking.
booking. CHS
CHS will
wil also
also need
need to
to establish
establish aa formal,
formal, continuous
continuous
system
system of
of medical
medicalrecord
recordreview/monitoring
review/monitoringtotoconfirm
confirmthat
that
this
feasible for
this 24
24 hour
hour timeline
timeline is
is being
being met.
met. It is feasible
for the
the
objective
I,
objectiveof
ofCAP
CAP- -33totobe
beimplemented
implementedas
asof
ofApril
April 1,
1, 2011.
2011.
This
ongoing monthly
Thiscomponent
componentwill
wil be
be assessed
assessed through
through ongoing
monthly
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and quarterly
quarterlyreview
reviewby
byCHS
CHSand
andby
byme
meofofrepresentative
representative
and
medical records.
records. The
The overall
overall rate
rate of
of monthly
monthly transfers
transfers from
from
medical
the 4th
4 th Avenue
will also
also be
be
the
Avenue Intake
Intake Center
Center to
to the
the LBJ
LBJInfirmary
Infirmar wil
tracked, trended
trendedand
andreported.
reported.
tracked,

CAP -- 4:
Persons in Non-Acute
Non-Acute and
and
CAP
4: Health Assessments for Persons

Stable Condition
Condition
Stable
With implementation
implementation of
of CAP
CAP -- 11 and CAP
CAP -- 2,
be aa
With
2, there
there will
wil be
substantial decrease
decrease in
of persons
persons who
need
substantial
in the number of
who will
wil need
to have their Initial Health Assessments (also
(also known as Health
Health

Appraisals) completed between
between day
day 22 and
and day 14 following
Receiving Screening
their Receiving
Screening evaluations.
evaluations. The majority of such
such
persons
have no significant
significant acute
acute or chronic medical
medical
persons will
wil have
conditions
time of
of entry
entry to
to the
the 4th
4 th Avenue
Avenue Intake
conditions at the time
Intake Center.
A
will exhibit
A small
small number
number of
of such
such patients
patients will
exhibit onset
onset of acute
acute
medical
their initial
initial two
two weeks
medical problems
problems during
during their
weeks of
of
incarceration
incarceration and need to be promptly
promptly seen
seen and evaluated
with
with aa complete
complete Initial
Initial Health
Health Assessment
Assessment by
by aa physician
physician or
or
PAjNP.
PA/NP.
PAjNP. For
For the
the far greater number of newly
newly admitted
admitted persons
persons

who
who are
are in
in good
good condition,
condition, completion
completion of
ofthe
the Initial
Initial Health
Health
Assessment
Assessment can
can safely
safely be
be done
donewithin
within 14
14 days
days after
after arrival
arrival at
at
th Avenue Jail.
the
the 44th
Avenue JaiL.

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At this
this time,
time,Dr.
Dr.Alvarez
Alvarez is
is reviewing
reviewing several
several options
options with
with
At
respect to
to content
content and
andeffectiveness
effectiveness of
of the
the CHS
Initial Health
respect
CHS Initial
Health

Assessment form and
and process.
process. Among
Among the
the questions
questions he
he is
is
Assessment
considering are
are which
whichtypes
typesof
ofprofessional
professionalpersonnel
personnel(CMT's,
(CMT's,
considering
RN's, MD's,
MD's, PA's,
PA's, and NP's)
NP's) should be
be involved in
in completing
completing
RN's,
the Initial
Initial Health
Health Assessment
Assessment including the traditional
traditional
the
Physical Examination for persons
of acute or
or
Physical
persons with no history of
chronic medical
medical problems.
problems. Specific
Specific NCCHC
NCCHC standards
standards pertain
pertain
chronic
to these
these questions, especially
especially with
with respect
respect to
to scope
scope of
of practice,
practice,
to
training and
and oversight.
oversight. Another
Another important
consideration
training
important consideration
concerns what
what components
components of
of the
the traditional
traditional periodic
periodic physical
physical
concerns
examination are
are supported
examination
supported by
by evidence-based
evidence-based
recommendations of
of authoritative
professional organizations,
organizations,
recommendations
authoritative professional
such
as the
the U.S.
u.s.
U.S. Preventive
Preventive Services
During the
such as
Services Task
Task Force.
Force. During
the
next
next sixty days,
days, I will
will be
be having
having frequent
frequent detailed
detailed discussions
discussions
with Dr. Alvarez
Alvarez regarding
the physical
regarding the
the content
content of
ofthe
examination
CHS appraisal
examination within
within the
the CHS
appraisal and
and which professional
personnel
for completion of
personnel are appropriate for
of this
this clinical
clinical task.
task.
By
1,2011,
will provide
provide aa more
more specific
specific
ByJune
June 1,
2011, II wil
recommendation
recommendation in
in this
this regard.
regard.

CAP
CAP- -5:5:Nursing
NursingCare
CareStaffing
Staffing Expansion
Expansion
CHS
(FTE) complement
CHScurrently
currently has
has aa full-time
full-time equivalent (FTE)
complement of
of
88
(LPN),
88 Registered
Registered Nurses
Nurses (RN),
(RN),59
59 Licensed
Licensed Practical
Practical Nurses (LPN),
63
(CHT), and one
63 Correctional
Correctional Health Technicians (CHT),
one RN
RN

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Discharge Planner.
Planner. For
Fortheir
theirbudget
budgetyear
year2010,
2010,CHS
CHS
Discharge
leadership has
has proposed
proposed adding
adding 11
11 FTEs,
FTEs, including
including66RNs,
RNs, 22
leadership
LPNs and
CHTs.
They also
also anticipate
anticipate aa stand-alone
stand-alone
LPNs
and 33 CRTs.
CHTs. They
supplemental budget
request for
for 2012
2012 funding
funding wil
willbe
be
budget request
supplemental
submitted to
to address
address staffing
staffing needs not addressed
addressed in
in the
the
submitted
proposal.
original proposal.
original
In order
order to
to achieve
achieve compliance
compliance with
with SAJ
SAJ requirements,
requirements, II·
In
believe itit is
and supplemental
supplemental
believe
is essential
essential that
that the
the initial
initial and
requests noted
noted above
above be
be approved
approved by
by the
the Maricopa
Maricopa County
requests
soon as
as possible
possible by
by
Board of Supervisors
Supervisors and
and implemented as
as soon
CRS.
My most
most recent
recent reviews
reviews of
of medical records show that
CHS.
CHS. My
unacceptable frequency
gaps in
frequency of
there continues to be
be an unacceptable
of gaps

continuity of medical
medical care
care and
and medication
medication administration,
administration, as
of RN-generated
RN-generated
well
documentationof
well as
as lapses
lapses in quality and documentation
care between
between medical
assessments and coordination
coordination of
ofcare
patient
patient assessments
the planned
of
and
nursing personnel.
and nursing
personneL. With
With the
planned expansion
expansion of
th Avenue Infirmary and the
practitioner
practitioner staffing
staffing in
in the
the 44th
Avenue Infirmar and

resultant
in Day
Day 11 Initial Health Assessments,
resultant increase in
expanded
RN and
expanded RN
and LPN
LPN staffing
staffingwill
wil be
be critically needed.
CHS has
recognized the
In
In recent
recent discussions
discussions with me, CHS
has also recognized
the

need
need to
to have
have an
an RN
RNwho
whohas
has expertise
expertise in
in chronic
chronic wound
wound care
care
need for
some
evaluation
particular need
for some
evaluationand
and treatment.
treatment. This is a particular

patients
patients served
served within
within the
the LBJ
LBJ Infirmary
Infirmary but
but also
also for
for referrals
referrals
from
from the
the other
other eight
eight CHS
CHSoutpatient
outpatienthealth
healthfacilities.
facilties.
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is reasonable
reasonable to
to expect
expect that
thatthe
theinitially
initially proposed
proposed nursing
nursing
ItIt is
staffing for
forbudget
budgetyear
year2012
2012 can
canbe
be phased-in
phased-inbetween
between April
April11
staffing
and September
September 1,2012,
1,2012, including
includingrecruitment
recruitmentofofan
anRN
RN
and
wound care
care specialist.
specialist. Between
Between April
April 11 and
and July
July1,
1, 2011,
2011, II
wound
bein
incommunication
communicationwith
withCHS
CHS leadership
leadership to
to identify
identify any
any
willbe
wil
other additions
additions to
to nursing
nursingstaffing
staffing required
required after
after September
September 1,
1,
other
2011.
2011.
CAP - - 6:
CAP
6: Physician Staffing and Chart Documentation at
the LBJ
LBJ Infirmary
the
Infirmary
CHS has
that defines
defines the three
three levels
levels of
CHS
has aa well-written
well-written policy that
medical/
nursing services
services available
available to
the LBJ
LBJ
medical/nursing
to patients
patients in the

Infirmary.
Eachofofthese
thesethree
threeservice
servicelevels
levels is
is linked
linked with aa
Infirmar. Each
specified
assigned
specified frequency
frequencywith
withwhich
whichthe
theInfirmary's
Infirmar's assigned
physicians are expected
expected to
to evaluate
evaluate and
and document
document periodic
medical
medical evaluations
evaluations and
and updates
updates in
in each
each patient's
patient's plan of
care.
These frequencies
However,
care. These
frequencies are
are medically
medically appropriate.
appropriate. However,
my
my medical
medical record
record reviews
reviews have
have identified
identifiedaa serious
serious problem
problem
with
with the
the legibility
legibility of
ofmany
manyphysician
physician generated
generated Infirmary
Infirmary
admission
admission and
and progress notes. These types of illegible
ilegible medical
medical
record
record entries
entries truly
truly impede effective
effectivecommunication
communication and
and
coordination
coordination among
amongthe
the physicians,
physicians,nurses
nurses and
andother
other staff
staff
that
advance the
that need
need to
to understand
understand and advance
the plan
plan of care.
care.

Therefore,
Therefore,IIhave
haveasked
asked Dr.
Dr. Alvarez
Alvareztotoidentify
identifyand
andimplement
implement

41
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aneffective
effective corrective
an
corrective action
action to
to ensure
ensure legibility
legibilty of
of Infirmary
Infirmar
physician entries
entries as
as well
well as any
any other
other similar
similar situations
situations he
he
physician
becomes aware
aware of
of in CHS
CHS health
is reasonable
reasonable to
to
becomes
health facilities.
facilities. ItIt is
expect that
thatthis
thisobjective
objective be
be accomplished
accomplished by June
June 1,
1, 2011.
2011.
1,2011.
expect
In concert
concert with
withthe
thechanges
changes described
described in
inCAP-1
CAP-l
CAP-1 and
and CAP-2,
CAP-2, itit
In
is predictable
predictable that
that there
there wil
willbe
be aa significant
significant increase
increase in
in the
the
is
number and acuity of patients
patients referred
referred from
fromthe
the4th
4 th Avenue
Avenue

number and acuity of

.Intake
Intake Center
Center to
to the
the LBJ
LBJ Infirmary
onweekends
weekends and
andholidays.
holidays.
Intake
Infirmar on
For this
this reason
reason and
and also
also on
on the
the basis
basis of
of prior
priorexperience,
experience, there
there
compelling medical reasons
to have
have
are compellng
reasons for
for the
the LBJ
LBJ Infirmary
Infirmar to
part-time (four
(four hours
hours per
per day)
day) practitioner
practitioner coverage
coverage on
on-site part-time
weekends and
dutyof
of the
the practitioner
practitioner
weekends
and holidays.
holidays. The
The primary
primar duty
providing
providing this
this coverage
coveragewill
wil be
be to
to see
see and evaluate any new
patients
after 55 PM
the prior
patients admitted
admitted to
to the
the Infirmary
Infirmar after
PM the
prior day
day and
and
also
write progress
also to
to evaluate
evaluate and
and write
progress notes
notes for
for any
any other
other
patients whose
need for
whose clinical
clinical condition dictates the need
for such an
evaluation.
propose that
CHS phase-in
expanded
evaluation. II propose
that CHS
phase-in this
this expanded
physician
coverage of
physician coverage
of the
the LBJ
LBJ Infirmary
lnfirmary between
between April
April 11 and
and
August
August 1,2011.
1, 2011.
CAP
CAP- -7:7:Evaluation
Evaluationand
andTreatment
Treatmentof
ofPatients
Patientsat
at Risk
Risk for
for

Alcohol
Alcoholand
and Opiate
Opiate Withdrawal
Withdrawal Syndromes
Syndromes
CHS
CHSalready
alreadyhas
hasin
in place
place use
use of
of the
the CIWA
CIWA Scale
Scale(Clinical
(Clinical
Institute
for CIW
CIWAAscale
Institute for
scaleWithdrawal
Withdrawal Scale
Scale for Alcohol)
Alcohol) for
for
42
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evaluation of
of patients
patients at
at risk
riskfor
foralcohol
alcoholwithdrawal
withdrawalsyndrome.
syndrome.
evaluation
CHS also has in place
place a
a treatment protocol for usc
use of
of Librium,
Librium,
CHS
benzodiazepine
benwdiazepine medication)
medication) that
that is
is consistent
consistentwith
with
aa benzodiszepine
authoritative professional
professional recommendations
recommendations including
including
authoritative
Pharmacological Management
Management of
ofAlcohol
MetaPharmacological
Alcohol Withdrawal
Withdrawal-- AA Metaanalysis and
andEvidence
Evidence Based
Based Guideline
Guideline by M.F. Mayo-Smith,
Mayo-Smith,
analysis

JAMA 1997;
1997; 278(2):
278(2): 144-152:
144-152: From
Fromthe
theAmerican
American Society
Society of
of
JAMA
Addiction Medicine
Medicine Committee
on Practice
Practice Guidelines.
Guidelines.
Addiction
Committee on
With respect
respect to evaluation
evaluation of
of persons at risk
risk for
for opiate
opiate
With
CBS
CHS is
withdrawal syndromes, CHS
is not
not now
now using
using aa separate,
separate,
distinct scale and validated evaluation
evaluation scale
scale such
such as
as the
Clinical Opiate
Opiate Withdrawal
Withdrawal Scale
Scale (COWS)
(COWS) or
Clinical
Clinical
or the
the Clinical
Institute
Narcotic Assessment
Assessment (CINA)
I,
2011
Institute Narcotic
(CINA)Scale.
Scale.By
ByJuly
July 1,
i, 2011
CBS
COWS to
CHS will
wil utilize
utilize the
the COWS
to evaluate
evaluate incoming
incoming patients
patients with
with

aa prior
prior history
history of
of use
of opiates
of any
use of
opiates of
any type
type including
including heroin,
heroin,
methadone,
methadone, and
and analgesic
analgesic such
such as
as oxycodone,
oxvcodone,dilaudid
dilaudid and
codeine.
of both alcoholism
codeine. For patients
patients with
with aa prior history of
and
I addiction, both
CIWA-Ar and
and opiate
opiate dependence
dependence/addiction,
both the ClWA-Ar

COWS
COWSwill
wilbe
beutilized.
utilzed.
CHS
CHScurrently
currently relies
relies on
on use
use of
of c1onidine,
clonidine, hydroxyzine,
hydroxyzine, and
and

loperamide
loperamidefor
fortreatment
treatment of
ofpatients
patients at
at risk
risk for
for opiate
opiate
withdrawal
withdrawal syndrome,
syndrome,including
including those
those who
whoare
are being
beingtreated
treated
in
in community-based
community-basedmethadone
methadone treatment
treatment programs
programs prior
prior
th Avenue Intake Center. As has been stated
entry
entry into
into the 44th
Avenue Intake Center. As has been stated

43
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repeatedly in
in my
my prior
prior reports,
reports, patients
patientsparticipating
participatingin
inlegal
legal
repeatedly
methadone treatment
treatmentprograms
programs should
shouldcontinue
continuetotoreceive
receive
methadone
methadone maintenance
maintenance after
after during
duringtheir
theirpre-trial
pre-trialdetention.
detention.
methadone
In addition,
addition, since
since methadone
methadoneisismedically
medically preferable
preferable to
to
In
clonidine in
in most
most respects,
respects, methadone
methadone needs
needsto
tobe
beavailable
available
clonidine
within the
the MCJ
MCJ for
for use
in an
an opiate
opiate withdrawal
withdrawal treatment
treatment
within
use in
protocol for patients
patients who
who are
are heroin dependent.
dependent. Two
Two other
other
protocol
drugs -- Suboxone
Suboxone and
and Subutex
Subutex -- are
are also
also acceptable
acceptable
drugs
alternatives.
alternatives.
Alvarez and I are having ongoing discussions about his
Dr. Alvarez
approvals and
diligent efforts to secure the approvals
and community
necessarytotoprovide
providemethadone
methadone maintenance
maintenance
partnerships necessar
after
use of
of methadone
or other
other drugs
drugs for
for
after jail
jail entry
entry and
and use
methadone or
treatment of opiate
Multiple regulatory,
regulatory, legal,
legal,
opiate withdrawal.
withdrawal. Multiple
licensure
remain to
to be
be resolved.
resolved. There
There
licensure and
and training
training issues
issues remain
appear
be three
main options,
options, which
which are
appear to
to be
three main
are not
not necessarily
necessarily
lllutuallyexclusive.
nlutuallyexclusive.
These options are
are the following:
exclusive. These
following:
mutually

licensed and
drug addiction
addiction treatment
•. AA licensed
and community-base
community-base drug
treatment
network
COlne into MCJ facilities
network might
might be
be engaged to come
facilities to
to
evaluate,
evaluate, counsel
counsel and
and treat
treat patients
patients receiving methadone
methadone
maintenance
maintenanceor
orat
atrisk
risk for
for opiate
opiate withdrawal
withdrawal and
and
addiction
addiction counseling
eounselingand
andfollow-up
follow-up addiction
addiction treatment.
treatment.
•. CHS
CHS may
may be
be able
able to obtain Opiate
Opiate Treatment Program
Program
(OTP)
(OTP)certification
certificationby
bythe
the Substance
SubstanceAbuse
Abuseand
andMental
Mental
44
44