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

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Services Administration
Administration(SAMHSA)
Health Services
(SAMHSA) linked
linkedtotoOTP
OTP
Health
accreditation through
theNational
NationalCommission
Commission on
on
throughthe
accreditation
Correctional Health
Care. The
requisite standards
Health Care.
The requisite
standards for
for
Correctional
accreditation are
are available
available in
the2004
inthe
2004NCCHC
NCCHC
accreditation
publication, Standards
Standardsfor
forOpiod
OpiodTreatment
TreatmentPrograms
Programs in
in
publication,
Correctional Facilities.
Facilities.
Correctional
• Individual
Individual physicians
might complete
complete
.
physicians employed
employed by
by CHS
CHS might
the additional
additionaltraining
trainingneeded
neededtotoobtain
obtainaaSAMHSA
SAMHSA DATA
DATA
(Drug Addiction
Addiction Treatment
Treatment Act
Act of
of2000)
2000) Waiver
Waiver for
for use
use of
of
(Drug
Suboxone (buprenorphine)
(buprenorphine
Suboxone
(buprenorphine) and Subutex (buprenorphine
naloxone hydrochloride) in treatment
treatment of
of opiate
opiate
plus naloxone
addiction.
of these options involve approvals from state and federal
All of
federal
agencies including the US
US Drug Enforcement Administration.
1, 2011)
be
I estimate
estimate that
that another
another three
three months
months (July
(July 1,
2011) will
wil be
implementation of
of which
needed
feasible plan, implementation
needed to
to establish aa feasible
can hopefully
hopefully be
be completed
completed by
by December
December1,1,2011.
2011. This
projected
projected date
date reflects
reflectsthe
the substantial
substantial time required to
above.
complete
completeany
any of
ofthe
thethree
three options
options outlined
outlned above.

Procedures
CAP
CAP- -88- - Review
Reviewand
and Revisions
Revisions of
of Policies
Policies and Procedures
On
Onconcert
concertwith
withits
itsapplication
applicationand
and preparation
preparation for
for an
an
accreditation
by NCCHC,
NCCHC, CHS
accreditation survey by
CHShas
has reviewed
reviewedand
and
revised
revisednumerous
numerous policies,
policies, procedures,
procedures, clinical
clinical guidelines
guidelines and
and
45
45

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

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protocols. This
Thisongoing
ongoing work
work is
is consistent
consistent with
withthe
the following
following
protocols.
objectives as stated in my August 20,2010
20, 2010Expert's
Expert'sReport:
Report:
objectives
Clinical guidelines
guidelines that
that meet
nationally established
established
.• Clinical
meet nationally
professional recommendations
recommendations are
are in
in place
place for
for evaluation
evaluation
professional
and management
management of
of chronic
chronic diseases
diseases (including
(including asthma,
asthma,
and
chronic lung disease, epilepsy/seizure
epilepsy/seizure disorders,
disorders, cardiac
cardiac
chronic
disease; diabetes,
diabetes, lipid
lipid disorders,
disorders, hepatitis
hepatitiscc infection,
infection,
disease,
chronic liver
liver disease,
disease, chronic
chronic kidney
kidney disease,
disease, human
chronic
immunodeficiency virus
virus infection/
infection/AIDS);
AIDS);
immunodeficiency
Nursingpolicies
policies and
proceduresand
andprotocols
protocols for
for
• Nursing
.
and procedures
assessment are
and any
any changes
changes
are to be
be reviewed
reviewed in
in detail and
necessary have
have been
been made
made to
to assure
assure appropriate nursing
care in handling sick call
call requests
requests and encounters,
emergency
emergency encounters
encounters and appropriate referrals to
physicians,
physicians, physician assistants
assistants or nurse
nurse practitioners;
•. Nurses
Nurseshave
havebeen
beenproperly
properly trained, oriented,
oriented, and
evaluated
evaluated in
in their
their use of these policies,
policies, procedures
procedures and
and
protocols.
protocols.

CHS
CHSisis making
making progress
progress in
in accomplishing
accomplishing the foregoing
foregoing
objectives.
reviewing their
objectives. II will
wil be reviewing
their continued
continued efforts
efforts regularly
regularly
and
Alvarez, Thomas
and in detail with Dr. Alvarez,
Thomas Tegeler
Tegeler and
and Katie
Katie
Wingate.
reasonable to
Wingate. It is reasonable
to project
project that
that the foregoing
foregoing
objectives
2011.
objectivescan
can be
be completed
completed by
by August
August 1, 201
1.
46
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CAP -- 99 -- Continuous
QualityImprovement
Improvement(CQI)
(CQI)Program
Program
CAP
Continuous Quality
Through application
application of
of the
the methods
methods established
established in its current
current
Through
CBS
includethe
CHS will
CQI Annual Plan,
Plan, CHS
thefollowing
following actions:
actions:
CQI
wil include

• Systematic
Systematicreviews
reviewsofofpatient
patient records
records by
by senior
senior and
peer
.
and peer
medical staff to measure access, timeliness,
timeliness,
medical
appropriateness, coordination,
continuity of
ofmedical
appropriateness,
coordination, and continuity

Written findings
findings and
and
and nursing care.
care. Written
identification of
of any
recommendations wil
will accompany
accompany identification
or problems
problems in
lapses or
in care.
be suffcient
sufficient in
to be
•. Medical
Medicalrecord
record reviews
reviews wil
will be
in number
number to
be
of acute (for
(for example,
example,
representative of broad range
range of
syndrome) or
alcohol
alcohol withdrawal
withdrawal syndrome)
or chronic conditions and
of patients
patients residing
residing in
in all
all jail
jail facilities.
assess whether
record reviews
Medicalrecord
reviews will
•. Medical
wil assess
whether clinically

appropriate
appropriate care
care is
is documented,
documented, including
including patient
patient
assessments
assessmentswhenever
wheneverorders
ordersfor
for medication
medication or
diagnostic
diagnostic tests
tests are
are initiated.
initiated.
•. Under
Underthe
the direction
direction of
of the
the Medical
Medical Director,
CHS
Director, CBS
CHSwill
wil
conduct
clinical performance
performance reviews
reviews of the
conduct annual
annual clinical
the

employed
employedphysicians,
physicians,physician
physician assistants,
assistants, and
and nurse
nurse
practitioners.
These reviews
reviews will
practitioners. These
will be
be documented
documented and
and
include
include consideration
consideration of
of the
the results
results of medical
medical record
record

47
47

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reviews, professional
professional development
development and
and education,
education, and
and
reviews,
maintenance of
ofspecialty
specialty board
board certification.
certification.
maintenance
CHSclinical
clinicaland
andexecutive
executive leaders
leaders will
regularly identify
identify
.• CHS
wil regularly
and review
review all
all deaths
deaths or
or other
otheradverse
adverse patient
patientoutcomes
outcomes
and
and oecurrences.
occurrences. When
When indicated,
indicated,methods
methodsof
ofroot
rootcause
cause
and
analysis as
as recommended
recommended by the Joint
Joint Commission
Commission on
on
analysis
Accreditation of Health Care Organizations wil
will be
be
Accreditation
employed and
and documented.
documented.
leastquarterly,
quarterly,CHS
CHSutilization
utilizationmanagement
management activities
activities
.• AtAtleast
will be
be reviewed
reviewed and
wil
and evaluated to
to document that
practitioner requests
requests for specialist
specialist consultations, offsite
offsite
practitioner
diagnostic and treatment
treatment procedures
procedures are
are completed
completed in a
diagnostic
timely manner.
timely
•. CHS
CHSwil
willinstitute
institute and
tracking
and maintain
maintain comprehensive
comprehensive tracking
and
monitoring systems
systems for
for Patient
Patient Health
Health Care
Care
and monitoring
Requests.
be conducted to validate
Requests. Regular reviews
reviews will
wil be
that inmates are seen in a timely
timely manner
manner and
and that
that
written responses
responses to
requests are
to their
their requests
are informative
informative and
professional.
professionaL.
•. CHS
CHS wil
willtrack
trackand
andmonitor
monitorof
ofindividual
individual medication
medication
profiles
profilesand
and medication
medicationadministration
administration records
records to
to ensure
ensure
continuity
eontinuity of
ofadministration,
administration, prevention of
of adverse
adverse drug
drug
reactions,
reactions, and
and dosages
dosages consistent
consistent with
with individual
individual patient
patient
needs
adequate
needsand
andphysiological
physiologicalcharacteristics.
characteristics. Fully adequate
attent.ion
attention to
to this
this action
action remains
remains dependent
dependent on
on initiation
initiation
of
ofthe
theelectronic
electronicmedical
medicalorder
orderentry
entry and
and medication
medication
48
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administration record
record systems
systemscurrently
currently being
being developed
developed
administration
jointlyby
byCHS
CBS and
and Diamond
DiamondPharmacy
PharmacyServices.
Services.
jointly
Most of
of the
the foregoing
foregoing actions are
are either
either already
already in
in place
place or
or
Most
implemented by
by CHS.
CBS. For
For those
those actions
actions not
notalready
alreadyin
in place,
place,
implemented
reasonable to
to expect
expect completion
completion by
bySeptember
September 1,
1, 2011.
2011.
ititisisreasonable
CAP-- 10:
10: Electronic
CAP
Electronic Order
Order Entry,
Entry, Medication
Medication

Administration and
and Health
Health Record
Record Systems
Systems
Administration
There has
has been
been aa delay
delay in
in implementation
implementation of
of the
the electronic
electronic
pharmacy order entry project due to a
a recent Drug
Enforcement Administration
directive that
that each
each CHS
CHS clinic site
site
Administration directive
have
separate DEA
DEA license.
have aa separate
license. Another factor was
was the
the need to
add
The
add data lines
lines to
to the older Durango
Durango and
and Estrella Sites.
Sites. The
new
time1ine
new "go
"go live"
live" timeline
timeline for
for the
the electronic
electronic order entry and
medication administration
record systems
systems is
administration record
is June
June 1, 2011.
201 1. I
agree
with this
this timeline
agree with
timeline as
as part
part of
of the
the Corrective
Corrective Action
Action Plan.
Plan.
Regarding
Record
Regarding development
development of
ofthe
the Electronic
Electronic Health
Health Record
System,
System, aa Request
Request for
for Proposals
Proposals (RFP)
(RFP)document
document has
has been
been
approved
approved by
by the
the Maricopa
Maricopa County
County Materials
Materials Management
Management
Department.
Selection of aa Vendor/System
Department. Selection
Vendor/System and the
the HER
HER
Contract
Contract Award
Awardisisslated
slatedtotooccur
occurininJuly
July2011.
2011. This
This will
will be
be
followed
followedbybya aseries
seriesofofsteps
stepsincluding
includinghardware
hardwareinstallation;
installation;
Net
Netdeployment;
deployment;building
building work
work flow;
flow; content
content design;
design; testing;
testing;
49
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and training.
training. Full
Fullactivation
activationof
ofthe
the system
systemisisprojected
projectedfor
for
and
June 2013. As part of this
this Corrective
Action Plan,
Plan, the
the
Corrective Action

June 2013. As part of

foregoing milestones
be incorporated
incorporated and
andmonitored.
monitored.
foregoing
milestones will
wil be
CAP-- 10:
10: Internal
External Validation
Validation of
of Structure,
Structure,
CAP
Internal and
and External

Processes and
and Outcomes
Outcomes Pertinent
Pertinent to
to SAJ
SAJ Requirements
Requirements
Processes
leade~ship
settlt~d
The new CHS
leadership
sett}(~d
is now
now
CHS leadeI,'ship
leadership team
team is
is settled
settled in
in place.
place. ItIt is

appropriate and feasible
feasible to establish a more robust and
consistent framework to
to evaluate
evaluate compliance
compliance with
with SAJ
SAJ
are three
three components
components I
requirements. Going
Going forward,
forward, there
there are
requirements.

believe
believe are
are most important:
complete their preparations
•. CHS
CHSand
andthe
theMCSO
MCSO need
need to
to complete

for a
a NCCHC
NCCHC accreditation
accreditation survey and to achieve
achieve full
full
accreditation.
Many of
accreditation. Many
of the
the structure
structure and process
are essential for aa
NeCHC accreditation are
requirements for NCCHC
NCCHC
stable and effective
effective jail
Achievement
jailhealth
health care
care system.
system. Achievement
are also a
a positive
and
and maintenance of accreditation are

factor
factor in
in recruitment
recruitment of qualified practitioners and
nurses.
nurses.
its CQI
cQr
to
•. CHS
CHSwil
willcontinue
continue to
to enhance
enhance its
CQI program
program and
and to
CAP-8
accomplish
accomplish the
the tasks and objectives specified in CAP-8
and
and CAP
CAP-- 99 as
as previously
previously described.
described.

late May
May 201
1, rIIwill
wilbe
beconducting
conducting
•. Beginning
Beginningin
in late
2011,
quarterly
quarterly medical
medical record
record reviews
reviewsjointly
jointlywith
withCHS.
CHS. The
The
50
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Case 2:77-cv-00479-NVW Document 1966

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standardized methodology
methodology of
of these
these reviews will
allow for
for
standardized
will allow
comparison of
of results
sequential comparison
results from
from one
one quarter
quarter to
to the
the
sequential
next. Medical
Medicalrecords
recordsselected
selected for
for review
review will
be
next.
wil be
sufficient in
in number
numberto
characterize and
tocharacterize
andcompare
compare
suffcient
populations, including
outcomes for
for typical patient
including those
those
outcomes
patient populations,
with and
and without
without chronic
chronic ilnesses.
illnesses.
with
my Sixth
This concludes
concludes my
Sixth Report.
Report.

Respectfully
Respectfully submitted,

/s/
lsI
Lambert
N. King,
King, MD,
MD, PhD,
PhD, FACP
FACP
Lambert N.

51
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UNITEDSTATES
STATESDISTRICT
DISTRICTCOURT
COURT
UNITED
FORTHE
THEDISTRICT
DISTRICTOF
OFARIZONA
ARIZONA
FOR

No
No CV
CV 77-0479-PHX-NVW
77-0479-PHX-NVW

Arpaio.
Gravesv.
v. Arpaio
Graves

SIXTH REPORT
REPORT OF
OF KATHRYN
KATHRYN A.
A. BURNS,
BURNS, MD,
MD, MPH
MPH
SIXTH
ON CORRECTIONAL
CORRECTIONALHEALTH
HEALTHSERVICES
SERVICESCOMPLIANCE
COMPLIANCE
ON
WITH
SECOND
AMENDED
JUDGMENT
WITH SECOND AMENDED JUDGMENT
APRIL 2011
2011
APRIL

This report
report is
is being
being fied
filedfollowing
following aa February
February 2011
2011site
sitevisit
visitto
to the
theMaricopa
Maricopa County
County
This
Jails. II visited
February 14-17,2011.
touredthe
theMental
Mental Health
Health Unit
Unit(MHU)
(MHU) and
and
Jails.
visited the
the jails
jails February
14-17,2011. IItoured
other mental
mental health
health treatment
treatmentspace,
space, met
mental health
health supervisory
supervisory staff
staffand
and
other
met with
with mental
reviewed a
a number
The medical
medical
reviewed
number of
of documents
documents in
in addition
addition to
to reviewing
reviewing medical
medical records.
records. The
records
reviewed focused
focused almost
serious mental
records reviewed
almost exclusively
exclusively on
on records
records of
of inmates
inmates with
with serious
mental
illness.
ilness.
II toured
space and
and reviewed
reviewed medical
medical records
records at
at Lower
Lower
toured mental
mental health
health treatment
treatment space

in
Buckeye
Jail, 4th Avenue Jail, Estrella and Durango. Since the time of the last site visit in
Buckeye Jail, 4th Avenue Jail, Estrella and Durango. Since the time otthe last site visit
it is
2010,
2010, Towers
Towers Jail
Jailisisno
nolonger
longerbeing
beingused
usedtotohouse
housepre-trial
pre-trial detainees;
detainees; it
is housing
housing only
only
sentenced
Towers JaiL.
Jail. Fifty
sentencedinmates.
inmates. Ii did
did not
not visit
visit Towers
Fifty (50)
(50) medical
medical records
records were
were reviewed.
reviewed.
This
headings in
This report
report is
is organized
organized around
around the
the item headings
in my
my August
August 2010
2010 Compliance
Compliance
It is
Report
Reportand
andJanuary
January2011
2011site
sitevisit
visitreport
report and
and addendum.
addendum. It
is focused
focused on
on the
the activity
activity and
and
progress
progress of
of Correctional
Correctional Health
Health Services
Services (CHS)
(CHS) and
and the
the provision
provision of
of mental
mental health
health care
care to
to
pre-trial
Information from
pre-trial detainees.
detainees. Information
from the
the medical
medical record
record reviews
reviews isisincluded
includedunder
underthe
the
relevant
relevanttopic
topicareas
areasbut
but also
alsosummarized
summarizedatatthe
theend
endof
ofthe
thereport.
report.

11

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Intake/ReceivingScreening
Screening
Intake/Receiving
CHS continues
continues to
to conduct
conduct intake
intake screening
screening of
ofall
a}] inmates
inmatesas
as they
they are
are booked
booked into
intothe
the
all
CHS
jail. Timeframes for follow-up ofpositive
positive screenings
screeningshave
have been
been updated
updatedand
andare
arein
inthe
the

jaiL. Timeframes for follow-up of

process of
of implementation.
implementation. The
The screening
screening instrument
instrument has
has been
been updated
updated and
and wil
willbe
be
process
entirelyelectronic
electronicstarting
startingininearly
earlyApriL.
April.
entirely
the medical
medical records
records indicates
indicates the
the screenings
screenings are
are timely
timely and appropriately
appropriately
Review ofthe

Review of

identify persons
persons in
in need
need of
of immediate
immediate mental
mental health
health attention,
attention, medication
medication orders
orders and
and
identify
other types
types of
ofreferraL.
referral. The
The screening
screening instrument
and process
process appear
other
instrument and
appear to
to be
be appropriately
appropriately
were three
threeinstances
instancesin
inwhich
which follow-up
follow-up was
was not
not
sensitive and
and specific.
specific. However,
However, there
sensitive
there were
to aa positive
positive screen;
screen; two
two of
ofthe
the three
three involved
involvedfemale
femaleinmates.
inmates. CHS
CBS
CHS is
is
timelyininresponse
response to
timely
responsiveness to
necessity. A
aware that
aware
that responsiveness
to aa positive
positive screening
screening is
is aa critical
critical necessity.
A Quality
Quality
Improvement study
study is
is planned
to address
implementation of
of the
the electronic
electronic screening
Improvement
planned to
address implementation
screening
follow-up timeframes.
processand
and compliance with follow-up
process
Referrals
Health
Need Requests (Inmate Self-Referrals) and Staff Referrals
Health Need Requests (Inmate Self-Referrals) and Staff

The new Health Needs
Needs Request (HNR)
(HNR)system
system was
was put
put into
into place
place in
in November
November 2010
2010
and
It was
was too
and includes
includes aa mechanism
mechanismto
totrack
track referrals
referrals and
and responses.
responses. It
too soon
soon to
to have
have seen
seen
in the
HNR process
dramatic
dramatic improvement
improvement in
the HNR
process in
inFebruary,
February,though
thoughall
allmental
mentalhealth-related
health-related
requests
of the
requests were
were seen
seen face-to-face
face-to-facerather
rather than
than screened
screened on
on paper
paper only.
only. Three
Three of
the 50
50
HNR responses;
one case
case involved
involved HNRs
HNRs from
clinical
problematicHNR
clinicalfiles
fies reviewed
reviewed contained
contained problematic
responses; one
from
August
Augustand
andSeptember
September(before
(beforethe
thenew
newprocesses
processeswere
were implemented)
implemented) and
and in
in one
one case
casethe
the
HNR
HNRwas
wasincorrectly
incorrectlyrouted
routedto
to medical
medicalrather
rather than
than mental
mental health.
health.By
Bythe
thetime
timethe
theerror
error
was
wasdiscovered,
discovered,the
theinmate
inmatewas
wasreleased.
released. (The
(The HNR
HNRwas
wasincorrectly
incorrectlyrouted
routedthrough
through
medical
medicalbecause
becausethe
theinmate
inmatehad
hadidentified
identifiedititasasa amedical
medicalrather
ratherthan
thanmental
mentalhealth
healthrequest
request

22

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

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medicallTiage
thoughthe
thenarrative
narrativeclearly
clearlyidentified
identifiedititasasmental
mentalhealth;
health;a acareful
carefulread
readby
bymedical
medical
triage
though
triage
sentthe
the request
request to
to mental
mental health
health initially
initiallysaving
savingtime
timeand
and permitting
permittingaa
wouldhave
havesent
would
critical nature.)
nature.) In
HNRwas
was not
not of
of aa critical
In the
thethird
thirdinstance,
instance,the
the
responsethough
thoughthis
thisparticular
particularHNR
response
ofless
the larger
issue involving
involvingscreening
screeningand
and
HNR was
was ofless
of
lessconcern
concernthan
than the
largerissue
handlingofofthe
theHNR
handling
Health Unit
Unitfollow-up.
follow-up.
Mental Health
Mental
Mental Health
Unit(MHU)
Health Unit
(MHU)
Mental
Admission and
and discharge
discharge criteria
criteria have
have been
been formalized
formalized and
and implemented.
implemented. Length
Length of
of
Admission
stay data
data is
is being
being maintained.
maintained. Staff
Staff have
have been
about the
the availabilty
availabilityof
of the
the
stay
been educated
educated about
if hospitalization
is deemed
deemed
Maricopa County
County Health
Maricopa
Health System
System for
for psychiatric
psychiatric hospitalization
hospitalization if
hospitalization is
necessary though
though the
the transfer
transfer process
process had
had not
not yet
yet been
the site
site visit.
visit.
been utilzed
utilizedatatthe
thetime
timeof
ofthe
necessary
Inmate-patients returning
returning from
from outside
outside mental
mental health
emergency treatment
or
Inmate-patients
health emergency
treatment or
MHU upon
to the
jail. Much
Much progress
hospitalization
are automatically
automatically admitted
admitted to
to MHU
hospitalization are
upon return
return to
the jail.
progress
group treatment
treatmentin
inthe
theMHU.
MHU. Confidential
Confidential individual
has
been made
made in
in privacy
privacy of
of care
has been
care and
and group
individual
and
space has
modified as
as necessary
necessary and
and group
group treatment
treatment space
has been
been identified,
identified, physically
physically modified
and is
is in
in
use.
of seeing
is changing.
changing.
use. The
The culture
culture of
seeing patients
patients at
at the
the cell
cell front
front is
On
Onanother
anotherbright
bright note,
note,treatment
treatment and
and programming
programming for
for patients
patients that
that are
are
difficultto
historically
historically very
very difficult
difficulttototreat
treatare
arequite
quitegood:
good:treatment
treatment plans
plans are
are comprehensive
comprehensive and
and
MHU staff
push to
individualized
and MHU
individualized and
staff do
do not
not push
to have
have these
these patients
patients discharged
discharged back
backinto
into the
the
general
general population
population quickly.
quickly.These
Theseare
arethe
thetypes
typesof
ofpatients
patientsthat
thatother
other correctional
correctional systems
systems
and
andfacilities
facilties sometimes
sometimes view
viewas
asuntreatable
untreatable and
and manipulative
manipulativeand
andmental
mentalhealth
healthstaff
staff
CHS MHU
refuse
refuse to
to treat.
treat. CHS
MHUstaff
staffshould
shouldbebeapplauded
applaudedfor
fortheir
theirwork
workwith
withthis
thissubset
subsetof
of
patients.
patients. Further,
Further, there
there isis good
goodcoordination
coordinationwith
with the
the other
other jails
jails around
around discharge
discharge
planning
planningfor
forthis
thisgroup
groupof
ofinmates.
inmates.

33

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

Filed 04/06/11 Page 59 of 65

Unfortunately,there
thereare
areaasizable
sizable number
numberofofpatients
patientsthat
thatare
aregetting
gettingdischarged
discharged
Unfortunately,
oradequate
adequatefollow-up
follow-upupon
uponrelease
releasetotoone
one
prematurelyand
andmany
manyare
arenot
notreceiving
receivingtimely
timelyor
prematurely
the other
otherjails.
jails. Premature
Prematurerelease
releasecases
casesmost
mostoften
ofteninvolve
involveinmates
inmatesadmitted
admittedas
asaa
ofthe
of
underthe
the
precautiondirectly
directlyfrom
from the
the booking
booking process
process due
due to
to statements
statementsmade
madewhile
while under
precaution
or while withdrawing
withdrawing from
from drugs and/or
and/oralcohoL.
alcohol. Such
Such inmates
inmates are
are rapidly
rapidly
influence or
influence
MHU but
in short
order
assessedand
anddischarged
dischargedquickly
quickly from
from MHU
assessed
but some
some return
return for
for readmission
readmission in
short order
that perhaps
perhaps the
the assessment
assessment was
enough or
or occurred
occurred too
toosoon
soon
_- an
an indication
indication that
was not
not thorough
thorough enough
theabsence
absenceof
ofdrugs
drugs and
andalcohoL.
alcohol. This
This issue
issue is
is further
further
to accurately
accurately assess
assess mental
mental state
statein
in the
to
treatmentspace
space to
to manage
manage arriving
inmates that
that are
are
complicated by
by the
the lack
lack of
of medical
medical treatment
complicated
arriving inmates
or withdrawing
withdrawingand
andthe
theMHU
MHU staffs
concern to
to ensure
ensureadequate
adequateMHU
MHU
intoxicated or
intoxicated
staffs concern
admission bed space is available for emergency admissions both from booking and other
mustbe
be addressed
addressedjointly
jointlyby
byCHS
CHS medical
jails. ItIt is
is complicated
complicated but
but must
medical and mental health
leadership
and line
line staff.
staff.
leadership and
with respect
respect to the MHU was
The
The problem
problem that occurred most frequently
frequently with
was untimely
untimely
other jails
jails upon
CHS planned
to
and
outpatient follow-up
follow-up in
in the
and inadequate
inadequate outpatient
the other
upon discharge.
discharge. CHS
planned to
address
address the
thetimeliness
timeliness issue
issuethrough
through changing
changing the
the process
processfor
forscheduling
schedulingthe
thefollow-up
follow-up
by the
the receiving
receiving jail
jail but
but CHS
CHS changed
appointments.
The follow-up
follow-up had
had been
been scheduled
scheduledby
appointments. The
changed the
the
protocol
responsible"
protocol to
to make
make MHU
MHUstaff
staffresponsible
responsiblefor
forscheduling
schedulingthe
thefollow-up
follow-up appointments
appointments in
in the
the
Jail
Management System as a result of this
this finding.
finding. Future
Future audits
audits should
should find
find improvement
improvement
Jail Management System as a result of
in
inthis
this critical
criticalarea.
area. Adequacy of
of outpatient
outpatient follow-up
follow-up isisrelated
related to
tothe
the frequency
frequency (or
(or

aswell
wellasasthe
thetype(s)
type(s)
infrequency)
ofwith
contacts
and other mental health staff as
infrequency) of contacts
psychiatry with
and otherpsychiatry
mental health staff
of
oftreatment
treatment interventions
interventions provided.
provided. These findings
findings are
are discussed
discussed more
more fully
fullyunder
under
Outpatient
OutpatientTreatment.
Treatment.

44

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

Filed 04/06/11 Page 60 of 65

Atthe
thetime
timeofofthe
thesite
sitevisit,
visit,suicide
suicide prevention
preventionand
and clinical
clinical restraint
restraintpolicies
policieshad
had
At
reviewand
anddiscussion.
discussion.
been revised. The draft revisions are currently in the process ofreview

been revised. The draft revisions are currently in the process of

hadbeen
beenone
onesuicide
suicideprior
priortotothis
thissite
sitevisit,
visit, another
anothersuicide
suicideoccurred
occurredin
inlate
late
(Note: There
Therehad
(Note:
earlyMarch.
March. CHS
CHS isis in
in the
the process
processof
of
Februaryand
andaathird
thirdinmate
inmatedied
diedby
bysuicide
suicideininearly
February
critically reviewing
reviewing these
these incidents
incidentsand
andconducting
conductingpsychological
psychological autopsies.)
autopsies.)
critically
Outpatient Care
Care
Outpatient
Problems· with
outpatientcare
care were
identified in
infifteen
fifteenof
were identified
ofthe
the 50
50 records.
records. Problems
Problems
Problems
with outpatient
treatmentintervals;
intervals; treatment
treatmentofofcaseload
caseload inmates
inmates only
only in
in response
response to
to
included infrequent
infrequent treatment
included
HNR rather
than planned,
planned, regular
contact; and
and over-reliance
of psychotropic
psychotropic medication
medicationas
as
HNR
rather than
regular contact;
over-reliance of
intervention. Significant
Significant improvement
improvement in
in this
this area
area is
is not
not
essentially the
essentially
the sole
sole treatment
treatment intervention.
CHS develops
discharge criteria;
criteria;
expected until
until CHS
expected
developsand
andimplements
implements outpatient
outpatient admission
admission and
and discharge
treatmentteam
team meetings
meetings and
and
frequency
by discipline;
discipline; frequency
frequency of
frequem.y
oftreatment
frequency of
of intervention
intervention by
treatment
plan updates;
updates; and
and group
group and
and individual
individual interventions.
interventions. By
By mutual
mutual agreement,
agreement,
treatment plan
level of
revising
revising the
the outpatient
outpatient level
of care
care was
was postponed
postponed to
to permit
permit earlier
earlier and
and undivided
undivided
other critical
critical areas
areas and
and to
to encourage
encourage the
the use
use of
of line
line staff
staffto
attention
to other
attention to
to develop
develop the
the
outpatient
guidelines through
outpatient guidelines
through aa quality
quality improvement
improvement team
team process.
process.
Coordination
Coordination of
ofmedical
medicaland
andmental
mental health
health care
care
CHS
CHSundertook
undertookaanumber
numberofofinitiatives
initiativesto
toensure
ensurebetter
bettercoordination
coordination between
between
medical
medicaland
andmental
mentalhealth
health providers
providers for
for inmates
inmates with
with both
both types
types of
of problems.
problems. The
The medical
medical
policy
policyregarding
regardingtreatment
treatment of
ofpregnant
pregnant women
women was
wasrevised
revisedto
to reflect
reflectreferral
referral and
and
coordination
coordinationwith
withmental
mentalhealth;
health;psychiatric
psychiatricdisorders
disordersare
are now
nowdocumented
documented on
onthe
the
medical
medicalproblem
problemlist
listininfront
frontof
ofeach
eachchart
chartand
andthe
theproblem
problemlist
listdocument
documentitself
itselfwas
was

55

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

Filed 04/06/11 Page 61 of 65

redesigned to
to better
betterintegrate
integratemedical
medicaland
and mental
mental health
healthcare;
care; and
and psychiatric
psychiatric providers
providers
redesigned
chroniccare
have been
been instructed
to review
reviewmedical
medical chronic
care flow
flowsheets
sheets during
during psychiatric
psychiatricclinics
clinics
have
instructed to
theirlevel
levelof
ofawareness.
awareness. Four
Four fies
filesreviewed
reviewedcontained
raising their
containedproblems
problemsrelated
relatedto
tomedical
medical
raising
mentalhealth
healthpatients:
patients:one
onerelated
care follow-up
follow-upofofmental
relatedtotomedical
medicalhanding
handingofofaaHNR,
HNR,one
one
care
thatdoesn't
doesn'tappear
appeartotobe
related to
to seizure
seizure disorder
disorderthat
befollowed
followedby
bymedical,
medical,and
andone
one related
related
related
to not
not receiving
receiving prescription
prescriptionmedications
medications timely
timely following
MHU discharge.
discharge. The
The most
most
followingMHU
to
of coordination
with medical
in aa psychiatric
psychiatric patient
serious case
case involved
involved the
the lack
lack of
medical in
patient with
with
serious
coordination with
psychogenic polydipsia
polydipsia -- aa condition
causes metabolic
metabolic abnormalities that
that can
can lead
lead to
to
psychogenic
condition that
that causes
not treated for
for them or
death. (The
(The patient
patient had
had abnormal laboratory
laboratory results
but was
was not
or
results but
death.
Fortunately,an
medical for the
the problem.
problem. Fortunately,
an adverse
adverse incident
incident did
not result
result and
and
followed by
by medical
did not
patient was
statehospitaL.)
hospital.)
careatatthe
the patient
was discharged
discharged to
to inpatient
inpatientpsychiatric
psychiatriccare
thestate
for Incompetent
Treatment for
Incompetent Criminal
Criminal Defendants
Defendants
As noted
noted previously,
previously, use of the
There is
is nothing new to
to report on this topic.
topic. As
Maricopa
Maricopa County Health
Health System
Systemfor
forpsychiatric
psychiatric hospitalization
hospitalization had not yet started at the
time
time of the
the site visit.
Psychotropic medications
Thirteen
Thirteen cases
cases involved
involved issues
issues with
with respect
respect to
to psychotropic medication
medication
management.
management. They were divided
divided into
into problems of two
two types:
types: prescriptive
prescriptive issues
issues and
and
follow-up
follow-upissues.
issues. Prescriptive
Prescriptive issues
issuesincluded:
included: problems
problems with
with prescriber
prescriber medication
medication
choice(s);
choice(s); continued
continued problems
problems with
with medication
medication renewal
renewal or
or discontinuation
discontinuation without
without aa facefaceof Court
to-face
to-faceappointment;
appointment;delays
delaysininrecognition
recognition(and
(andsubsequent
subsequent utilization)
utilzation) of
Court Ordered
Ordered

receipt
medication in spite of receipt
(COT);
and
one afailure
to medication
provide
a non-formulary
Treatment
Treatment (COT); and
one failure
to provide
non-formulary
in spite
of

66

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

Filed 04/06/11 Page 62 of 65

ofverification.
verification. The
Theissues
issuesinvolving
involving
follow-upincluded
involVingfollow-up
includedcases
casesininwhich
whichthe
thefollow-up
follow-up

of

interval after
aft~rstarting
startingmedications
medicationswas
wastoo
toolong;
long; failure
failure to
to address
address noncompliance
noncompliance or
or
interval
reportsof
ofside
sideeffects
effects timely;
timely; and
and medication
or
medication continuity
continuity problems
problems with
with inmate
inmatehousing
housingor
reports
job assignment
assignment changes.
changes. Psychiatric
Psychiatricprovider
providerpeer
peerreview
reviewprocesses
processesshould
shouldbegin
begin to
to
job
address prescriptive
intervalissues
identify and
and address
prescriptive and
andinterval
issueswhile
while the
the more
more general
general medication
medication
identify
audits should
should find
find and
and correct
correctnoncompliance
noncomplianceand
andcontinuity
continuitywith
withhousing
housingmoves.
moves.
audits
Staffing
Staffing
There is no update with regard
regard to
to staffing other than to report
report that
thatlast
lastyear's
year'snewly
newly
created
positions have
have been
been filled
filled and
has been
notable improvement
been notable
improvement in
in the
the capacity
capacity
created positions
and there
there has
space.
and treatment
in privacy
privacy due
to provide
provide treatment
to
treatment in
due to
to the
the additional
additional escort
escort officers
offcers and
treatment space.
time have
have also
also yielded
yielded beneficial results.
Additional
Additional psychiatric and
and clerical/support
clerical/support time
(CQI)
Continuous
Continuous Quality
Quality Improvement
Improvement (CQ1)
the HNR
A number
HNR process
number of
of initiatives
initiatives are
are underway:
underway: the
process was
was revised,
revised, implemented
An audit
audit instrument
forMHU
MHU levels
levels of
ofcare
care is
is
and
instrumentfor
and monthly
monthly compliance audits
audits were
were started.
started. An
system to
under
A system
under development.
development. A
to track and analyze
analyze major
major mental health
health incidents
incidents is in
for mental
health staff,
staff, psychologists
mental health
place.
underway for
place. Peer review efforts are underway
psychologists and
and
psychiatric
A quarterly
medical-psychiatric committee
meeting has
psychiatric providers.
providers. A
quarterly medical-psychiatric
committee meeting
has begun.
begun.
SegregationjDiscip-line
Segregation
Segregation/DisciQline
Segregati 0 nI Discip-line
(Discipline
CHS
CHSisisnow
nownotified
notifiedof
ofall
allcaseload
caseloadinmates
inmateswith
withserious
seriousmental
mentalillness
ilness who receive aa
disciplinary
disciplinaryinfraction.
infraction. The
The relevant
relevant policies
policiesmust
must now
now be
bewritten
written or
or revised
revised to
to reflect
reflect the
the
practice
practiceand
andinform
inform CHS
CHSstaff
staffon
ondocumentation
documentationrequirements.
requirements. Mental
Mental health
health care
care to
to
inmates
inmatesininsegregation
segregationisisprovided
providedunder
under private
private conditions.
conditions. The
The place
placeand
and circumstances
circumstances

77

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

Filed 04/06/11 Page 63 of 65

the interaction
interactionisisdocumented
documentedininthe
thechart
an audit
ofthe
chartnote
noteand
andan
auditofufthe
theprivacy
privacyexpectation
expectation
of
as reflected
reflected in
in the
the charting
chartingisis planned.
planned.
as
Training
Training
provided the
lesson plans
was provided
the training
trainingcurriculum
curriculumlesson
plans used
used in
in providing
providing 16-hours
16-hours of
of
iI was
mental health-related
health~relatedtraining
trainingtotoall
allMaricopa
MaricopaCounty
County Sheriffs
SheriffsOffice
Office correctional
correctionalofficers.
officers.
mental
In general,
accurate and
relevant, accurate
and appropriate.
appropriate. Further,
Further,although
althoughII
In
general, the
the content
content appears
appears relevant,
relevant,
the actual
have
have~ not
not seen
seen the
actual training,
training, itit is
is clear
dear from
from the lesson plans that
that aa number
number of
of methods
methods
have
information such
such as
as lecture,
lecture, fim,
are used
used to
to convey
convey the
the information
film, discussion
disClission and
and role
role play;
play; different
different
are
arereinforced
inmultiple
multiple ways.
ways.
learning styles are addressed
addressed and
and important
importantpoints
pointsare
reinforcedin

However, for reasons
Report, II continue to believe that
reasons sited
sited in
in my
my Fifth Report,
that the modest quality
joint mental
health-custody staff
staff committee to review
improvement
for aa joint
mental health-custody
improvement recommendation for
it as
as necessary
for officers
assigned to
to
supplement it
the curriculum in order to revise or supplement
necessary for
offcers assigned

posts dealing with
with inmates
inmates most at risk and at highest risk of serious
serious mental health
problems (booking/receiving
(booking/receiving area,
area, MHU
MHU and
andall
allsegregation
segregationunit
unitposts)
posts) remains
remains relevant
relevant
and
and appropriate.
appropriate.
Medical
Medical records
records review
review
As
SO
sample
As noted
noted previously,
previously, Ii reviewed
reviewed 50
50 medical
medical records
records during
during the
the site
site visit.
visit. The sample
included
included nine
nine cases
casesthat
that were
were referred by plaintiffs'
plaintiffs' counsel;
counsel; other
other records
records were selected at
random
random from
from lists
listsof
ofseriously
seriouslymentally
mentallyillilcaseload
caseloadinmates.
inmates. Attention
Attention was
was focused
focused
primarily
primarily on
onthe
the last
last six
sixmonths
monthsof
ofcare
caretotodetermine
determinewhether
whether more
more recent
recent changes
changes have
have
focusing on
lead
leadto
to improvement
improvement rather
rather than
than focusing
on past
past problems
problems and
and deficiencies
deficiencies already
already
CHS.
identified
and acknowledged
acknowledged as
as problematic
by CHS.
identified and
problematic by

88

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

Filed 04/06/11 Page 64 of 65

Mostof
the
ofthe
the findings
findingshave
have been
been reported
reportedwhen
whendiscussing
discussingthe
the various
varioustopics
topicsininthe
Most
preceding sections
sections and
and won't
won'tbe
be repeated
repeatedhere
hereexcept
exceptin
insummary/table
summaryIta bleformat
formatatatthe
theend
end
preceding
ofthis
this section.
section. Items
Items not
notpreviously
previously mentioned
mentioned include:
include: 12/50
12/50 fies
filesreviewed
reviewedrevealed
revealedno
no

of

the level
level of
of mental
mental health
deficiencies with
with respect
health care
care provided:
provided: the
the inmate-patient
inmate-patient
respect to
to the
deficiencies
appeared to
to be
be receiving
receiving an
an appropriate
appropriatelevel
level of
of care,
care, was being seen at appropriate
appropriate
appeared
had been
been enrolled
enrolled into
into treatment
treatmentat
atscreening
orthereafter
thereafteras
intervals, had
screening or
asnecessary
necessaryin
in aa
intervals,
timely fashion, was receiving medications appropriate
appropriatefor
for condition,
condition, etc.
etc. (One
(One of
of the
the
twelve reviewed
reviewed was
was identified
identified as
as being
being on
on the mental health
health caseload
caseload according
according to the
the
twelve
inmate-patient was
caseload list but the inmate-patient
was not
not actually
actually on
on the caseload
caseload nor
nor did he appear
appear to
Thisisisaa database
database clean-up
require services
services based
based on
on his screening
screening and
and assessment
assessment results. This
require
issue,
Notably, there
these cases
cases identified
identified this visit
issue, not
not aa care
care issue.
issue. Notably,
there were many fewer of
ofthese
to clean-up inaccuracies
than in the past
past and CHS
CHS has
has dedicated
dedicated some
some support
support resources to
and update information in the database.)

Record Review
Review Issue
Issue or
or Problem
Problem
None
Intake/Receiving
IntakefReceiving
Intake/Receiving Screening
~~9.!!~st
Health
Re9!!.est
Health Needs
Needs Reguest
Request
MHU
Stay
MHU Stav
MHU
MHU Follow-up
Follow-un
Outpatient
Outoatient
Coordination
Coordination with
with Medical
Medical
Medication
Medication prescription
orescriotion
Medication
follow-up
Medication follow-uo
._._-~-

records'
## records*
12
3
33
7
12
12
19
19
44
66
66

such as
as premature
MHU discharge
discharge and
and missed
missed
more than
one problem
problemsuch
*· Some
reviews had
had more
than one
prematureMHU
Some file
fie reviews
timely
timelyoutpatient
outpatient follow-up
follow-upappointment,
appointment, so
sothe
the problems
problems total
total exceeds
exceeds 50.
50.

99

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

Filed 04/06/11 Page 65 of 65

Conclusion
Conclusion

There has
has been
been significant
significant progress
progressin
inphysical
physical plant
plantmodifications
modifications for
for confidential
confidential
There
care, policy
policy and procedure implementation
implementation and
and developing
developing processes
processes for
for self-monitoring
self-monitoring
care,
through continuous
continuous quality
quality improvement.
improvement. The
The revised
revised policies
policies and
and procedures
procedures for
for suicide
suicide
through
The MHU
MHU is
patients,
prevention and
and clinical restraint
restraint are in draft form. The
prevention
is treating
treating difficult
diffcult patients,
plans for them and
and coordinating
coordinating discharge
discharge planning
planning
developing comprehensive treatment
treatment plans
outpatientproviders.
providers. More
Moregroup
group interventions
interventionsare
arebeing
beingprovided
provided to
to all
all inmates
inmates in
in
with outpatient
MHU. Staffing has improved with psychiatric providers as well as some support staffto
staff to

MHU. Staffng has improved with psychiatric providers as well as some support staff

assist with scheduling,
scheduling, tracking
tracking and
and filing
fiing tasks
tasks and there are additional dedicated escort
officers which has
has helped
helped get
get inmate-patients
inmate-patients to
to mental
mental health
health appointments
appointments in
in treatment
treatment
spaces that
Pretrialdetainees
detaineesare
areno
nolonger
longerhoused
housedininTowers
TowersJaiL.
Jail.
spaces
that are
are private.
private. Pretrial
Areas
include premature
prematureMHU
MHU discharge,
discharge, MHU
MHU
Areas that continue to need improvement
improvement include
follow-up
follow-up after
after discharge,
discharge, integrating
integrating medical
medical and
and mental health care and psychotropic
medications.
Mental health outpatient
outpatient care
care too
too often consists of medication management
medications. Mental
other mental
mental health
health clinicians
clinicians though there is a plan
with infrequent supportive
supportive contacts by
by other
to more
more critical
critical areas of
of care such as
to address outpatient
outpatientlevel
level of
of care after improvements to
screening,
screening, health
health need
need requests
requests and
andMHU
MHUoperations
operations are
are more
more firmly
firmly established.

Respectfully
Respectfully submitted,
submitted,

~4.~l~4Plt

~(f.~,~~lt
~a,~/~~lf
~a·~,~~lf
Kathryn
MD, MPH
MPH
Kathryn A. Burns, MD,
AprilS,
2011
2011
AprilS,

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