2014
A REVIEW OF MENTAL HEALTH SERVICES
IN LOCAL AND REGIONAL JAILS

MMiicchhaaeell FF.. AA.. MMoorreehhaarrtt,, CCPPAA
State Inspector General
January 2014

COMMONWEALTH of VIRGINIA
Office of the State Inspector General
Michael F. A. Morehart
State Inspector General

James Monroe Building
101 North 14th Street, 7th Floor
Richmond, Virginia 23219

Telephone (804) 625-3255
Fax (804 786-2341

January 13, 2014
The Honorable Terence Richard “Terry” McAuliffe, Governor of Virginia
1111 East Broad Street
Richmond, Virginia 23219
Members of the Virginia General Assembly
General Assembly Building
Richmond, Virginia 23219
Re:

A Review of Mental Health Services in Local and Regional Jails

Dear Governor McAuliffe and Members of the General Assembly,
The attached Report contains the results of the Office of the State Inspector General’s (OSIG)
review of mental health services provided in the Commonwealth’s local and regional jails. This
review was conducted between July 17, 2013 and September 25, 2013, pursuant to the OSIG’s
authority as stated in the Code of Virginia § 2.2-309.1(B)(1)&(2), and included a site visit to 25 of the
state’s 62 local and regional jails.
According to the Compensation Board’s 2012 Mental Illness in Jails Report, one in four inmates in
local and regional jails was known, or suspected, to be mentally ill—making Virginia’s jails one of
the Commonwealth’s largest providers of mental health services for persons with mental illness.
In July 2013, Virginia’s local and regional jail systems reported 6,346 incarcerated persons with
mental illness, of which 56% qualified for a diagnosis of serious mental illness. In September 2013,
the Commonwealth’s state-operated behavioral health hospitals census consisted of 1,200
individuals with mental illness. Moreover, according to the Compensation Board’s Annual Reports,
since 2008 the number of individuals identified with mental illness in jails has increased by 30%.
The OSIG initiated this review in order to understand how Virginia’s jails are addressing the
challenge of serving individuals with mental illness. This examination focused on answering nine
questions relevant to the policies and practices developed and utilized by Virginia’s jails to supervise
incarcerated individuals with mental illness.

This Report has been circulated among the Department of Corrections (DOC), the Department of
Behavioral Health and Developmental Services (DBHDS), the Virginia Sherriff’s Association (VSA),
and the Virginia Association of Regional Jails (VARJ). Excerpts from the DOC and VSA comments are
below:
Virginia Department of Corrections: Thanks for providing me the opportunity to
review the document. I believe the report is comprehensive and I agree with the
assertions pertaining to the problems with the delivery of mental health services. I
also believe that the recommendations are sound and merit implementation. –
Harold Clarke, Director, Virginia Department of Corrections
Virginia Sheriffs’ Association: Mental health has appropriately become a priority for
the Governor and General Assembly. The sheriffs appreciate the opportunity to
participate in this study and commend the Inspector General for producing a quality
report in a short time frame. The sheriffs are particularly interested in addressing
the needs of the 3,000 plus individuals in jails that are in serious need of mental
health services that are there because they are sick, not because they have
committed serious crimes.
Virginia's jails have become the largest mental health providers in Virginia. The
current mental health system uses resources intended by policy makers to address
traditional public safety needs, and the transportation requirements relating to the
ECO and TDO processes use valuable law enforcement resources routinely to serve a
growing mental health population, placing significant burdens on local law
enforcement agencies…. – John W. Jones, Executive Director, Virginia Sheriffs'
Association
If you have any questions concerning this Report, please contact me at (804) 625-3248, or I am
always happy to meet with you at your convenience.
Respectfully,

Michael F. A. Morehart
State Inspector General

CC: Paul Reagan, Chief of Staff
Harold W. Clarke, Director, Department of Corrections
John Jones, Executive Director, Virginia Sheriffs’ Association
Walter Minton, Executive Director, Virginia Association of Regional Jails
John J. Pezzoli, Interim Commissioner, Department of Behavioral Health and Developmental Services

Table of Contents
EXECUTIVE SUMMARY ............................................................................................................................................ I
AUTHORITY, SCOPE, AND FOCUS OF REVIEW ........................................................................................................................ I
OSIG OBSERVATIONS ..................................................................................................................................................... II
OSIG RECOMMENDATIONS............................................................................................................................................. III
Funding for Mental Health Treatment in Jails ..................................................................................................... iii
Physical Environment ........................................................................................................................................... iii
Variation in Practice ............................................................................................................................................. iv
The Relationship between CSBs and Jails ............................................................................................................. iv
Mental Health Pods or Regional Mental Health Facilities ................................................................................... iv
Recidivism and Linkage with Community on Release .......................................................................................... iv
Training/Cross-Training ........................................................................................................................................ v
BACKGROUND ....................................................................................................................................................... 1
WHY REVIEW JAIL-BASED MENTAL HEALTH SERVICES? ............................................................................................................1
The Civil Rights of Institutionalized Persons Act....................................................................................................2
2013 COMPENSATION BOARD REPORT .................................................................................................................. 4
COMMONWEALTH LOCAL AND REGIONAL JAILS SYSTEM ...................................................................................... 5
THE BOARD OF CORRECTIONS ...........................................................................................................................................6
THE DEPARTMENT OF CORRECTIONS ..................................................................................................................................6
THE COMPENSATION BOARD ............................................................................................................................................6
LOCAL JAILS...................................................................................................................................................................6
REGIONAL JAILS .............................................................................................................................................................6
LINKAGE OF MENTAL HEALTH AND CRIMINAL JUSTICE ...........................................................................................................7
JAIL DIVERSION INITIATIVES ..............................................................................................................................................7
REVIEW RESULTS ................................................................................................................................................... 9
QUESTION 1: ARE JAIL POLICIES AND PRACTICES SUFFICIENT TO IDENTIFY AND MEET THE NEEDS OF INDIVIDUALS WITH MENTAL ILLNESS?
...................................................................................................................................................................................9
Recommendation No. 1-A ...................................................................................................................................15
Recommendation No. 1-B ...................................................................................................................................15
Recommendation No. 1-C ...................................................................................................................................16
Recommendation No. 1-D ...................................................................................................................................16
Recommendation No 1-E ....................................................................................................................................16
Recommendation No. 1-F ...................................................................................................................................16
QUESTION 2. DO INMATES WITH MENTAL ILLNESS RECEIVE THE MINIMUM TREATMENT REQUIRED BY STATE OR LOCAL STANDARDS OF
CARE FOR INCARCERATED PERSONS?................................................................................................................................. 16
Recommendation No. 2 ......................................................................................................................................17
QUESTION 3. IS APPROPRIATE AND PROVEN MEDICATION AVAILABLE DURING AN INDIVIDUAL’S INCARCERATION? ............................17
Recommendation No. 3-A ...................................................................................................................................18
Recommendation No. 3-B ...................................................................................................................................18

QUESTION 4. HOW ARE INDIVIDUALS WITH AN ACUTE EPISODE OF MENTAL ILLNESS, ACCOMPANIED WITH BEHAVIORAL PROBLEMS,
HOUSED AND TREATED? ................................................................................................................................................. 19
Recommendation No. 4-A ...................................................................................................................................21
Recommendation No. 4-B ...................................................................................................................................21
Recommendation No. 4-C ...................................................................................................................................21
Recommendation No. 4-D ...................................................................................................................................21
Recommendation No. 4-E ...................................................................................................................................21
QUESTION 5. DO SERVICES PROVIDED BY CSBS OR PRIVATE PROVIDERS OF JAIL-BASED SERVICES MEET THE NEEDS OF INCARCERATED
INDIVIDUALS WITH MENTAL ILLNESS?................................................................................................................................ 21
Recommendation No. 5-A ...................................................................................................................................22
QUESTION 6. ARE POLICIES AND PRACTICES IN PLACE TO EFFECTIVELY LINK INDIVIDUALS WITH MENTAL ILLNESS TO COMMUNITY-BASED
SERVICES WHEN THEY LEAVE JAIL? .................................................................................................................................... 23
Recommendation No. 6-A ...................................................................................................................................25
Recommendation No. 6-B ...................................................................................................................................25
Recommendation No. 6-C ...................................................................................................................................25
Recommendation No. 6-D ...................................................................................................................................25
Recommendation No. 6-E ...................................................................................................................................25
QUESTION 7. ARE THE TOTAL COSTS FOR PROVIDING MENTAL HEALTH CARE INCURRED BY LOCAL AND REGIONAL JAILS ACCURATELY
ACCOUNTED FOR? ........................................................................................................................................................ 25
Recommendation No. 7 ......................................................................................................................................26
QUESTION 8. HAS CIT TRAINING HAD AN IMPACT ON JAILS’ MENTAL HEALTH-SPECIFIC POLICIES, PROCEDURES, AND PRACTICES? .......26
Recommendation No. 8-A ...................................................................................................................................27
Recommendation No. 8-B ...................................................................................................................................27
Recommendation No. 8-C ...................................................................................................................................27
QUESTION 9. WHAT DO JAIL ADMINISTRATORS BELIEVE CONTRIBUTES TO THE INCARCERATION OF INDIVIDUALS WITH MENTAL ILLNESS,
AND WHAT ARE THE PRIORITIES FOR ADDRESSING THE NEEDS OF THIS POPULATION? .................................................................. 27
APPENDIX I—GLOSSARY OF TERMS ..................................................................................................................... 29
APPENDIX II—SUMMARY OF MEDICAL RECORDS REVIEW ................................................................................... 31
APPENDIX III—STUDY INSTRUMENTS .................................................................................................................. 33
APPENDIX IV—SEQUENTIAL INTERCEPT MODEL .................................................................................................. 34
APPENDIX V—BRIEF JAIL MENTAL HEALTH SCREEN/CORRECTIONAL MENTAL HEALTH SCREEN FOR WOMEN
(CMHS-W) ............................................................................................................................................................ 35
APPENDIX VI—SHERIFF AND SUPERINTENDENT RESPONSES TO OPEN-ENDED QUESTIONS ................................. 36
APPENDIX VII—REVIEW METHODOLOGY ............................................................................................................. 39
APPENDIX VIII—DEPARTMENT OF CORRECTIONS—STANDARDS COMPLIANCE FORM FOR JAILS ........................ 41

www.osig.virginia.gov
A Review of Mental Health Services in Local and Regional Jails

Acknowledgment
This review would not have been possible without the cooperation of the Commonwealth’s
Sheriffs, the regional jail Superintendents, the Virginia Department of Corrections, the Virginia
Sheriffs’ Association, and the Virginia Association of Regional Jails. Throughout the review
process, Virginia’s correctional professionals expressed genuine interest and concern for the
mentally ill individuals in their care.

www.osig.virginia.gov
A Review of Mental Health Services in Local and Regional Jails

Executive Summary
Authority, Scope, and Focus of Review
The Office of the State Inspector General (OSIG) conducted a review of the mental health
services provided in the Commonwealth of Virginia’s (Commonwealth) local and regional jails
pursuant to the Code of Virginia (Code) §2.2-309.1(B)[1][2]. The review’s scope included site
visits to a representative sample of the state’s local and regional jails (25 of 62 facilities)
between July 17, 2013 and September 25, 2013, the review of 172 medical records of
incarcerated individuals with mental illness, and interviews with leadership at all jails visited. 1
In July 2012, Virginia’s local and regional jail systems reported 6,322 incarcerated persons with
mental illness. Of this group, 48% (3,043 individuals) qualified for a diagnosis of serious mental
illness. 2 According to the Compensation Board’s 2012 Mental Illness in Jails Report, one in four
inmates in local and regional jails was known, or suspected, to be mentally ill—making Virginia’s
jails one of the Commonwealth’s largest provider of mental health services for persons with
mental illness.
The OSIG initiated this review in order to understand how Virginia’s jails are addressing the
challenge of serving individuals with mental illness. This examination focused on answering the
following questions concerning the policies and practices developed and utilized by Virginia’s
jails to supervise incarcerated individuals with mental illness. 3
1. Are jail policies and practices sufficient to identify and meet the needs of individuals
with mental illness?
2. Do inmates with mental illness receive the minimum treatment required by state or
local standards of care for incarcerated persons?
1

Throughout this Report the term “jail” or “jails” is used, and unless otherwise noted, “jails” includes the
Commonwealth’s 62 local and regional jails.

2

Compensation Board. 2012 Mental Illness in Jails Report. 2012. Available at:
http://www.scb.virginia.gov/docs/2012mentalhealthreport.pdf. Accessed December 5, 2013.
3

This review was limited to examining jail-based services for persons with mental illness in local and regional jails
and did not consider mentally ill individuals incarcerated in the Commonwealth’s prison facilities managed by the
state’s Department of Corrections.

Executive Summary

i

3. Is appropriate and proven medication available during an inmate’s incarceration?
4. How are individuals with an acute episode of mental illness, accompanied with
behavioral problems, housed and treated?
5. Do services provided by Community Service Boards (CSB) or private providers of jailbased services meet the needs of incarcerated individuals with mental illness? 4
6. Are policies and practices in place to effectively link incarcerated individuals with mental
illness to community-based services when they leave jail?
7. Are the total costs for providing mental health care incurred by local and regional jails
accurately accounted for?
8. Has Crisis Intervention Team (CIT) training had an impact on jails’ mental health-specific
policies, procedures, and practices?
9. What do jail administrators believe contributes to the incarceration of individuals with
mental illness, and what are the priorities for addressing the needs of this population?
OSIG Observations
The OSIG review of jail-based mental health services resulted in the following observations:
1. All sheriffs, regional jail superintendents, and facility staff voiced concern for the
mentally ill individuals in their care as well as the lack of options for addressing the
needs of these individuals.
2. Jails lack the capacity to satisfy the current demand for mental health services.
3. Inmates that had been receiving community mental health services prior to their
incarcerations were not always tracked or monitored by their previous community
provider(s).
4. Local and regional jails applied screening tools to identify individuals with mental illness;
however, there was no consistency in the screening tools utilized or the level of staff
training with the screening tools.
5. Jails were designed to control inmate movement in order to maximize safety as opposed
to creating an environment that promotes recovery from mental illness through active
treatment and interaction with others—common elements in psychiatric facilities.
6. Some jails established separate mental health units or pods in order to decrease the
isolation of individuals with mental illness. These units were likely to have staff with
additional mental health training.

4

According to the DBHDS’s Comprehensive State Plan 2012-2018, there are 39 CSBs and one BHA in the
Commonwealth. While there are some structural differences between a CSB and a BHA, for the purposes of this
Report, there is no material difference and we will use the term CSB to include the BHA.

Executive Summary

ii

7.

The lack of coordination between jails and community services providers, such as CSBs,
generally led to poor continuity of care for persons with mental illness.

8.

Treatment gains made while individuals with mental illness are incarcerated are at-risk
once the individuals are released. This is attributable, in part, to the following:
a.

The lack of any funding to support successful transition from jail to
community—including case management and housing.

b.

Delay in reactivation of Medicaid.

c.

A lack of planning for accessing Medicaid, or other available health coverage.

9. Jail administrators confirmed the value of CIT mental health training for jail staff.

OSIG Recommendations
Below are several recommendations that if implemented, will improve the services provided to
incarcerated individuals with mental illness.
FUNDING FOR MENTAL HEALTH TREATMENT IN JAILS
• In order to reduce the number of mentally ill individuals in jails, Virginia should continue
to prioritize funding for jail diversion alternatives defined in the Sequential Intercept
Model (SIM). 5
•

The state should develop a strategy for funding mental health treatment for individuals
in local and regional jails that is proportional with the Commonwealth’s investment in
support services for the same population in the community. The first phase of the
alignment process for the funding strategy recommendation should be guided by a
comparative analysis of the Department of Behavioral Health and Developmental
Services’ (DBHDS) FY 2013 Annual Report and the Compensation Board’s 2013 Report on
Mental Illness in Jails.

PHYSICAL ENVIRONMENT
• The Virginia State Board of Corrections (BOC), in concert with mental health
practitioners, should review BOC Standard 6VAC15-40-990 on the use of administrative
segregation in order to provide additional guidance on segregation of individuals with
serious mental illness.
•

Future jail construction and renovations should place greater focus on the safety and
treatment needs of mentally ill individuals.

5

An illustration of the Sequential Intercept Model is discussed below and appended to this Report.

Executive Summary

iii

VARIATION IN PRACTICE
• Jails should consider the use of brief and validated instruments at the initial booking
screening in order to standardize the process and minimize risks of under-identifying
individuals with mental illness. 6
•

Jails that are not certified by the American Correctional Association (ACA) or National
Commission on Correctional Health Care (NCCHC) should consider applying the
standards of these accrediting agencies to mental health services.

THE RELATIONSHIP BETWEEN CSBS AND JAILS
• CSBs and local jails should develop written and joint agreements among affected CSBs
when individuals with mental illness are in regional jails. At a minimum, these
agreements should address:
i.

The timely exchange of information at point of entry and release.

ii.

The capacity for CSBs to provide onsite engagement with individuals identified as
current consumers or likely to need CSB community follow-up on release.

iii.

Transition procedures for individuals who are actively receiving mental health
treatment at release.

iv.

Pre-admission screening roles and responsibilities, including time limits for
responding to jail requests.

•

The CSBs and local or regional jails should develop Business Associate Agreements to
facilitate the effective exchange of mental health treatment information.

•

The DBHDS should continue to seek funding for CSB clinicians to provide individualized
mental health treatment in jails.

MENTAL HEALTH PODS OR REGIONAL MENTAL HEALTH FACILITIES
• The BOC should work with the jails that operate mental health units to identify
standards for such units, including staff training and availability of treatment.
•

Consideration should be given to the creation of mental health pods in local and
regional jails. This would serve to expand active treatment for individuals with mental
illness.

RECIDIVISM AND LINKAGE WITH COMMUNITY ON RELEASE
• Jails should develop mechanisms for tracking recidivism of individuals with mental
illness that were engaged in treatment at release.
•

An initiative similar to the Discharge Assistance Program (DAP) should be created to
help individuals with mental illness successfully transition from jails to their
communities. 7

6

The Correctional Mental Health Screen for Women (CMHS-W) and the Brief Jail Mental Health Screen (BJMHS) are
in the appendices of this report.

Executive Summary

iv

•

The BOC should consider a new standard, distinct from Standard 6VAC15-40-1090, to
address transition planning for individuals with mental illness.

•

Jails, probation and parole offices, other providers, and CSBs should seek to help
individuals with mental illness being released from jail gain access to health care that
may be available to them through new health care exchanges and develop strategies to
facilitate timely enrollment or re-activation of Medicaid.

•

The DOC should continue to advance the Thinking for a Change: Integrated Cognitive
Behavior Change Program curriculum for use in jails, and the DBHDS should support
similar initiatives in the community for individuals who have been incarcerated in local
and regional jails.

TRAINING/CROSS-TRAINING
• Continue current efforts to provide CIT training to jail personnel.
•

The BOC should consider expanding its Standard 6VAC15-40-1040 to include a basic
level of mental health training for jail personnel who interact with individuals with
mental illness.

•

The BOC should consider establishing training standards for CSBs and private providers
furnishing jail services to ensure their understanding of the distinctions between mental
health care in a community and mental health care in a jail.

7

The Discharge Assistance Project (DAP) provides supplemental state general funding to assist individuals who
have been discharged from state behavioral health facilities with reintegrating into their communities.

Executive Summary

v

www.osig.virginia.gov
A Review of Mental Health Services in Local and Regional Jails

Background
Why review jail-based mental health services?
The Office of the State Inspector General’s (OSIG) review of mental health services provided in
local and regional jails was predicated on the following:
•

The Commonwealth has a financial interest in the operation of local and regional jails.
According to the Compensation Board FY 2011 Jail Cost Report, the state provided $291
million in state general fund dollars (SGF) to support the operation of jails and
underwrote 35.1% of the operating cost of this system. 8

•

Since 2008 the number of individuals identified with mental illness in jails has increased
by 30%, from 4,879 to 6,322. 9

•

Each year, several thousand people with mental illness move among CSBs, stateoperated behavioral health facilities, and local jails. Over 1,000 inmates in local jails are
transferred each year to state behavioral health facilities for treatment under the
forensic chapters of the Code of Virginia (Code). During FY 2011, adults with a forensic
status occupied 36% of state hospital beds.2

•

Jails have become an essential part of the Commonwealth’s mental health system and
the quality of the services provided in each venue impacts this interdependent system.

•

Individuals incarcerated in local and regional jails fall under the protection of the Civil
Rights of Institutionalized Persons Act (CRIPA) and are entitled, by law, to receive
medical treatment—including treatment for mental health issues.

•

During 2013 the U.S. Department of Justice (DOJ) investigated the treatment of
incarcerated individuals in Florida,10 Pennsylvania, 11 and Virginia 12 for CRIPA
compliance.

8

Compensation Board. FY 2011 Jail Cost Report.
Available at: http://www.scb.virginia.gov/docs/fy11jailcostreport.pdf. Accessed December 5, 2013.
9
Comparison of the 2008 and 2012 Compensation Board Report on Mental Illness in Jails.
10
U.S. Department of Justice, Civil Rights Division. Escambia County Jail Findings Letter. Escambia County, Florida.
2013. Available at: http://www.justice.gov/iso/opa/resources/7492013522113545964446.pdf. Accessed
December 5, 2013.
11
U.S. Department of Justice, Civil Rights Division. Investigation of State Correctional Institution at Cresson and
Notice of Expanded Investigation Findings Letter. Cambria County, Pennsylvania. 2013. Available at:
http://www.justice.gov/crt/about/spl/documents/cresson_findings_5-31-13.pdf. Accessed December 5, 2013.
12
This jail was not selected by the OSIG for an on-site review.

Background

1

THE CIVIL RIGHTS OF INSTITUTIONALIZED PERSONS ACT
The courts, as discussed in the JLARC Report cited below, no longer overlook the adequacy of
mental health standards for incarcerated individuals. Pursuant to the Civil Rights of
Institutionalized Persons Act (CRIPA) and Americans with Disabilities Act (ADA), the DOJ began
investigating a number of states to assess availability of quality mental health care, excessive
use of isolation and force, inadequacy of mental health training for jail personnel, and
inadequate housing of mentally ill inmates.
In the 1994 Evaluation of Inmate Mental Health Care report, the Joint Legislative Audit and
Review Commission (JLARC) noted:
The legal question about the rights of inmates to mental health care was
addressed in the late 1970s by the Supreme Court, when it held that inmates
have a Constitutional right to care. Broad standards have been developed for
mental health treatment by several associations as part of their overall medical
treatment standards. Generally, the adequacy of these standards has not been
addressed by the courts.13
In a hearing before the House Subcommittee on Human Rights and the Senate Law Committee,
the DOJ’s Deputy Assistant Attorney General, Samuel Bagenstos, summarized this issue:
Inadequate mental health care in the nation's jails and prisons poses a critical
problem for inmate safety, and can stand in the way of real rehabilitation for
those incarcerated without access to treatment…We have aggressively pursued
reforms to ensure that inmates are afforded their constitutional rights. 14
The two recent DOJ investigations in Florida and Pennsylvania cited above identified the
following as the most common deficiencies that led to findings and settlement agreements:10,11
•
•
•
•

Failure to commit sufficient resources to provide adequate mental health care.
Failure to provide adequate mental health training to jail personnel.
Prolonged isolation of individuals with mental illness.
Use of excessive force on individuals with mental illness.

The DOJ and a Virginia jail recently reached a settlement agreement arising out of a CRIPA
investigation requiring that prisoners suffering from mental illness receive treatment
appropriate to their conditions and adequate to prevent unnecessary suffering or risk of harm.
13

Joint Legislative Audit and Review Commission. Evaluation of Inmate Mental Health Care. Available at:
http://jlarc.virginia.gov/reports/Rpt153.pdf. Accessed December 5, 2013.
14
Bagenstos, S. Written statement for the Joint Hearing on Human Rights at Home: Mental Illness in U.S. Prisons
and Jails. September 15, 2009. Available at: http://www.judiciary.senate.gov/pdf/09-0915%20Bagenstos%20Testimony.pdf. Accessed January 9, 2014.

Background

2

Proper treatment will also assist prisoners in successfully reentering the community upon
release.

Background

3

www.osig.virginia.gov
A Review of Mental Health Services in Local and Regional Jails

2013 Compensation Board Report
In 2005 and annually since 2009, the Compensation Board has produced a report on mental
illness in Virginia’s local and regional jails. While the OSIG was conducting its review, the
Compensation Board conducted and published its 2013 survey of local and regional jails. The
2013 Mental Illness in Jails Report is available on the Compensation Board’s website.15
The results of the 2013 survey confirmed a continued presence of individuals with mental
illness in local and regional jails and further recognized that an increasing number of
incarcerated individuals have a serious mental illness (SMI). While the number of jails
submitting surveys (58 of 64 or 90.6%) was the lowest in four years, the total number of
individuals with mental illness increased slightly from 2012, growing from 6,322 to 6,346, and
the percentage of those individuals identified as having an SMI increased from 48% to 56%—
the highest rate of SMI in any Compensation Board survey to date.16
While there are response variables complicating a multi-year analysis, it is clear that Virginia’s
local and regional jails continue to be a primary setting for the identification and treatment of
individuals with mental illness and that this population is growing more acute.

15

Compensation Board. Mental Illness in Jails Report. 2013. Available at:
http://www.scb.virginia.gov/docs/2013mentalhealthreport.pdf. Accessed December 5, 2013.
16
The OSIG recommends caution when using the previous Compensation Board’s Reports for comparative trend
analysis because the response rate for the survey has varied in each of the past five years.

2013 Compensation Board Report

4

www.osig.virginia.gov
A Review of Mental Health Services in Local and Regional Jails

Commonwealth Local and Regional Jails System
The Virginia system is the most peculiar one in the nation. The grounds and
buildings are owned by the counties and cities, the jails are operated by the
sheriffs and city sergeants, authority is divided between these officials and the
county supervisors or town councils and the circuit or corporation courts, and the
state pays the cost of keeping the prisoners.
…The State, although paying the bills, has no actual authority over the jails other
than the power of inspection and recommendation by the Department of Public
Welfare, truly an anomalous situation. (Virginia Legislative Jail Commission,
1937)17
The Virginia system of local and regional jails has changed considerably since 1937, but the
system continues to be unique in that responsibilities (e.g., construction, operation,
certification, funding, etc.) are spread across multiple state and local agencies. The state still
provides substantial funding for jails, but other than certifying and inspecting the facilities, it
has little direct authority over their operation.
The key components of the Commonwealth jail system include the:
•
•
•
•
•

Board of Corrections
Department of Corrections
Compensation Board
Local jails
Regional jails

A brief description of the system’s components follows to provide context and clarity about the
operation of the Commonwealth’s jail system.

17

Virginia Department of Criminal Justice Services. Virginia’s Peculiar System of Local and Regional Jails. 2010.
Available at: http://www.dcjs.virginia.gov/research/documents/2010%20JailReport-2.pdf. Accessed December 5,
2013.

Commonwealth Local and Regional Jails System

5

The Board of Corrections
In addition to other responsibilities, the BOC develops and establishes operational and fiscal
standards governing the operation of local, regional, and community correctional facilities per
the Code § 53.1-5 and certifies that these facilities meet BOC standards.
The Department of Corrections
The DOC monitors jails’ compliance with BOC standards through monitored visits, annual
inspections, and accreditation and certification audits.
The Compensation Board
The Compensation Board establishes “a reasonable budget” for the state portion of operating
costs for jails, including salaries and benefits of correctional officers and support staff, costs for
certain programs and services, and office expenses. 18 According to the Compensation Board FY
2011 Jail Cost Report, the state provided 35.1% of the total cost of local and regional jail
operations, but no dedicated funds for mental health treatment.19
Local Jails
Local jails generally serve the single locality in which they are located (though they may hold
inmates for other localities). Locally elected sheriffs are constitutional officers and manage
these facilities. There are 37 local jails (city and county) in Virginia.
Regional Jails
Regional jails serve multiple localities that may or may not operate their own local jails. A
superintendent, who serves the regional jail board or jail authority, administers these facilities.
The superintendents have the same authority as sheriffs with respect to individuals committed
to their facilities. The jail boards consist of, at minimum, the sheriffs of participating localities
and one appointed representative of each municipality. According to the Compensation Board
there are 25 regional jails in Virginia.
This funding and compliance structure places great authority and responsibility on local and
regional jail administrators to determine how they address the needs of individuals with mental
illness within their jails using available resources.

18

Compensation Board’s website: http://www.scb.virginia.gov/.
Compensation Board. FY 2011 Jail Cost Report. 2011. Available at:
http://www.scb.virginia.gov/docs/fy11jailcostreport.pdf. Accessed December 5, 2013.
19

Commonwealth Local and Regional Jail Systems

6

Linkage of Mental Health and Criminal Justice
Mental health services within the jail setting represent only one element of a comprehensive
SIM approach to addressing the interface of mentally ill individuals with the criminal justice
system. 20 A graphic illustration of the SIM is attached hereto as Appendix IV.
The points of interception depicted in the SIM include law enforcement and emergency
services; initial detention and hearing; jails, courts, forensic evaluation and hospitalizations;
reentry from jails, prisons, and hospitalization; and community supervision and support
services. According to the SIM at each of these points, there are unique opportunities to assist a
person in getting appropriate services and preventing further involvement with the criminal
justice system.
Anecdotal reports provided by corrections professionals suggest that without support or
interventions during this process, many individuals will ultimately come back into contact with
law enforcement during another crisis and repeat the revolving door cycle.
Jail Diversion Initiatives
The Substance Abuse and Mental Health Services Administration (SAMHSA), primarily through
the work of its GAINS Center for Behavioral Health and Justice Transformation, has worked for
years to strengthen the linkages between the mental health and criminal justice systems. Much
of the work in Virginia can be traced directly to SIM initiatives that originated with the GAINS
Center.21
During the 2008 session of the Virginia General Assembly, budget provisions were adopted that
directed the DBHDS to coordinate the implementation of a jail diversion treatment program
with the Department of Criminal Justice Services (DCJS). This led to the DBHDS establishing the
position of Director, Office of Behavioral Health and Criminal Justice Services in 2009.
Since 2009 the DBHDS and the DCJS have collaborated to advance a range of initiatives
intended to divert individuals with SMI from the criminal justice system, including, but not
limited to: mental health training of community law enforcement officers, development of
“drop-off” assessment centers for law enforcement officers to use in place of arrest, and
intensive case management of individuals who are incarcerated in order to promote improved
coordination and follow-up on release from jail.
20

Patti Griffin, ATTC Grantee Meeting. A Tool For System Transformation: Sequential Intercept Mapping. 2013.
Available at: http://gainscenter.samhsa.gov/cms-assets/documents/103893-516686.sim.pdf. Accessed December
5, 2013.
21
SAMHSA’s Gains Center website. http://gainscenter.samhsa.gov. Accessed January 6, 2014.

Commonwealth Local and Regional Jail Systems

7

Approximately 5,712 individuals, including law enforcement officers, emergency dispatchers,
mental health treatment providers, and other first responder personnel, have participated in
Crisis Intervention Team (CIT) training. The CIT training programs have enabled the diversion of
many individuals with mental illness from the courts and criminal justice system. There are
currently 13 CIT assessment sites, including six sites developed in FY 2013/14 with $1.5 million
from SGF specifically allocated for these programs.
The DBHDS/DCJS partnership has also supported the cross-systems mapping process that brings
community stakeholders together to:
•
•
•
•

Improve the early identification of people with mental illness and/or co-occurring
substance abuse, who intersect with the criminal justice system.
Increase effective service linkage.
Reduce the likelihood of recycling through the criminal justice system.
Enhance community safety and improve quality of life for individuals with mental illness.

According to the DBHDS, 97 of Virginia’s 134 localities (72%) have participated in cross-systems
mapping. A current summary of these collaborative efforts and community initiatives may be
accessed through the “Resource – Behavioral Health and Criminal Justice” link found on the
DBHDS website at http://www.dbhds.virginia.gov/.

Commonwealth Local and Regional Jail Systems

8

www.osig.virginia.gov
A Review of Mental Health Services in Local and Regional Jails

Review Results
Question 1: Are jail policies and practices sufficient to identify and meet the needs of
individuals with mental illness?
Observations
This review found that local and regional jails lacked the resources to develop and implement
the policies and practices necessary to provide needed mental health services to incarcerated
individuals with mental illness. Inadequate resources increased the risk that individuals with
mental illness would deteriorate during their incarceration. Individuals in the Commonwealth’s
jails are denied access to the array of mental health services that are available to nonincarcerated mentally ill persons in the community.
The Role of the CSBs and Their Relationship with the Jails
Policies and practices governing the relationship between jails and CSBs are not always aligned
in a manner that serves the treatment needs of individuals with mental health issues.
Individuals with mental illness who enter jails frequently have a history of treatment in their
community, and many people with psychiatric disabilities are either covered by a public
program, such as Medicaid or Medicare, or have no health coverage at all. 22 The interface
between the jail and the local CSB is important for fashioning effective treatment for many
individuals entering jail because their treatment history is most often with the CSB and the
public provider is most likely to be the setting for post-release mental health services. 23
According to the 2012 Compensation Board Survey, 40% of jail-based mental health services
were delivered by private providers (non-CSBs); a rate that has grown from 14% in 2009. The
continuity of care for incarcerated individuals is threatened because the trend data supports a

22

Chris Koyanagi. How Will Health Reform Help People with Mental Illness. 2010. Available at:
http://www.bazelon.org/NewsPublications/Publications/List/1/CategoryID/8/Level/a/ProductID/54.aspx?SortField=ProductNumber,ProductNum
ber Accessed December 5, 2013.
23
A CSB was identified as the community mental health provider in 67% (113 of 168) of the records that had the
provider identified.

Review Results

9

conclusion that CSBs are increasingly unlikely to provide treatment for this cohort as they move
from community venues to jails and return to their communities when released.
In the jails visited by the OSIG, we observed that the relationship and interaction between jails
and local CSBs varied significantly. Jails with the most positive comments about CSBs cited the
responsiveness of the CSB in providing onsite visitation within 24 hours or less when called.
Moreover, in 11 jails, the CSB staff person worked regular hours within the jail. In two jails, the
CSB staff person worked a full-time schedule. The role of the CSB and the jail in these settings
was often documented in a Memorandum of Agreement.
The OSIG team reviewed agreements between jails and CSBs that stressed a commitment to
provide continuity of care for individuals that had been treated by the CSB. These jails and CSBs
also had a “Business Associate Agreement” in place to facilitate the exchange of mental health
information. In two jails, the CSB staff person had immediate access to the CSB electronic
health records of individuals, eliminating delay in accessing important treatment information.
Jails that complained about the relationship with their local CSB cited difficulty accessing
current or previous mental health treatment information and the reluctance of CSB staff to
provide onsite visits.
Regional administrators noted an additional challenge when an individual associated with a CSB
outside of their region was transferred to their jail. Distance from the CSB, variation in
resources devoted to jail follow-up, and lack of working relationships were the primary
challenges noted by administrators. Several jail administrators and medical staff noted
challenges in getting CSB staff to conduct pre-admission screenings at the jail. Jail staff also
cited an instance when an individual’s mental condition had to deteriorate to extreme levels in
order to meet the criteria for hospitalization.
Providing effective, cohesive, and timely mental health treatment is often challenging
regardless of the setting, but for jails this is particularly true. Limited professional resources,
legal considerations, and other environmental risks make the handling of both chronic and
acute mental health situations in jails complicated. The OSIG learned first-hand that
determining a path for treatment was often complicated because persons with SMI often had a
co-morbid physical illness that also placed them at risk. The case study that follows highlights
this challenge.

Review Results

10

Pre-admission Screening Challenges in Jail Setting
While the OSIG conducted this study, OSIG staff members assisted jail staff with securing
necessary services for an individual with a significant history of mental illness who was
experiencing acute medical problems along with acute symptoms of mental illness. The
individual had been in a state hospital, but was transferred to the jail after assaulting a hospital
staff member. While in the jail, the individual refused to take medication and developed lifethreatening medical complications. OSIG staff members questioned the treatment of this
individual who was subsequently transferred to a community hospital and admitted to its
intensive care unit.
Several issues were identified and resolved as a result of the incident:
•

•

•

•

A prior history of ineffective communication between the jail and the local CSB contributed
to a delay in securing the needed services for the individual. Even though the poor working
relationship between the jail and local CSB was well-known, outreach by either party geared
toward resolving the issue had not recently occurred until this case.
OSIG staff received anecdotal information that requests for prescreenings by jails in the
region were often unsuccessful because the “person was already in a secure setting under
observation” blocking legal pathways for securing services.
The professional mental health staff person onsite was relatively new to the position and
had not been faced with such a critical situation before. Efforts to secure treatment did not
include the local CSB charged with the responsibility for conducting the required
prescreening.
The interconnectedness of the individual’s medical and psychiatric problems raised
questions regarding competency, informed consent, and other legal and ethical issues.

Trying to address long-standing issues during an acute situation is not optimal. It is
recommended that CSBs in conjunction with DBHDS assure that open communications with
local and regional jails be re-established to identify and resolve any problems that exist,
reconfirm working relationships and identify best practices that can be modeled across the
state.
Jail Screening Practices for Identifying Mental Illness and Treatment Needs
Jail screening practices to identify individuals with mental illness and the training and
qualifications of the mental health screeners, varied throughout the Commonwealth. According
to a DOJ Report, effective mental health triage in the corrections setting can be viewed as a
three-stage process:

Review Results

11

1.

2.
3.

Routine, systematic, and universal mental health screening performed by
corrections staff during the intake or classification stage, to identify those
inmates who may need closer monitoring and mental health assessment for a
severe mental disorder.
A more in-depth assessment by trained mental health personnel conducted
within 24 hours of a positive screen.
A full-scale psychiatric evaluation when an inmate’s degree of acute
disturbances warrants it.24

The OSIG review revealed a consistent presence of screening for mental illness, but the
screening process lacked consistency or standardization. Of the 172 records we reviewed, 156
contained a documented screening for mental illness. Of these 156 records, 149 (96%) revealed
the individual’s mental illness had been identified during the jail entry (screening) process.
While not a focal point of the study, the OSIG noted that there were examples of the screening
for mental illness beginning with the arresting officer. This practice focused on the jails
receiving information from the arresting officer, family members, or through staff observation
or interaction with the individual during transport to the jail.
In the jails visited, the initial screening for mental illness was conducted during the booking
process by correctional staff as part of the overall first level screening for medical concerns. The
“receiving screenings” varied, ranging from “yes/no” check boxes to broader “comment”
formats. Questions related to mental health during the booking process focused on
medications, suicide history or ideation, past mental health treatment, and use of alcohol or
drugs. On several forms, there were rating systems that required referral for more detailed
mental health assessments or immediate action based on risk of suicide.
Qualifications of Staff Conducting Screenings and Providing Treatment
The individuals conducting initial screenings were not medical personnel and their mental
health-related training varied from two hours to 40 hours of CIT training. All individuals had
received annual training on suicide prevention. It was noted that in most jails these screenings
took place in open areas with little to no privacy.
Many of the mental health concerns noted during this initial process were based on the
correctional staffs’ observations of unusual behavior or the individual’s reported use of
medications associated with mental illness.

24

U.S. Department of Justice. Mental Health Screens for Corrections. 2007. Available at:
https://www.ncjrs.gov/pdffiles1/nij/216152.pdf. Accessed December 5, 2013.

Review Results

12

In all jails visited, a secondary screening was conducted in a private setting, and an LPN, an RN,
or a mental health staff person usually performed this screening. The secondary screening
repeated the questions asked during the booking process, but medical personnel frequently
observed that the more private interview often led to greater disclosure of current or past
mental health treatment histories.
Depending on the information provided during the booking and secondary screenings, the jails
arranged for a third screening by an individual they identified as their qualified mental health
provider. That individual was often a social worker or another qualified mental health provider.
In two jails, a full-time CSB staff person interviewed all individuals entering the jail, regardless
of whether the issue of mental illness had been raised during the booking or medical screening
process.
This multistep screening and evaluation process determined how the jail classified an inmate.
This, in turn, influenced decisions on housing, including placement in any special mental health
sections, medical units, or special observation areas due to risk of harm to self or others, or
high vulnerability, such as with an intellectual disability.
Mental Health Treatment in Jails
The qualifications of mental health providers included: psychiatrists, licensed professional
counselors (LPC), licensed clinical social workers (LCSW), counselors, nurse practitioners, and
case managers. The qualifications of the provider of mental health services was identified in
96% (165 of 172) of the records reviewed. 25
o Of the 165 records, 127 (77%) identified the provider as a psychiatrist.
o In 54% (69 of 127) of the records where the psychiatrist was providing treatment,
the individual was also being seen by another provider.
o In 89% (34 of 38) of the records that did not involve a psychiatrist, mental health
treatment was provided by an LPC, LCSW, general physician, counselor, case
manager, or nurse practitioner.
Of the 25 jails visited, private contract staff provided mental health services in 12 (48%), CSBs
provided services in 11 (44%), and full-time jail employees provided services in two (8%). CSB
jail services were often associated with pre-admission screenings to determine the need for
hospitalization.
Records indicated that LCSWs, LPCs, or a non-licensed counselor or case manager primarily
provided “supportive counseling.” Not including some individuals receiving substance abuse
25

Of the 172 medical records reviewed, 165 identified the individual as having mental illness.

Review Results

13

counseling, there were only limited instances of individuals with mental illness participating in
group counseling.
Community vs. Jail-based Behavioral Health Services
This review determined that incarcerated individuals with mental illness did not have access to
the level of mental health services that could be found in the community.
o In 55% (92 of 167) of the records documenting treatment, the only service
documented was medication management.25
o Of the 167 records reviewed, 35% (59) documented medication management with
“supportive counseling,” which focused primarily on medication adherence.
o Additional services, such as case management, group, or psychosocial services were
documented in 17% (28 of 167) of the records.

State Funding for Behavioral Health Services
The Commonwealth annually appropriates $762 million to support community-based mental
health treatment, but there are no comparable SGF appropriated to jails for the treatment of
individuals with the same behavioral health treatment needs.
In FY 2012, Virginia appropriated $184 million in SGF and $11.2 million of federal block grant
dollars for community-based mental health treatment, spent an additional $366 million as the
state share of Medicaid mental health payments for treatment in the community, and invested
$211.7 million in support of state hospital mental health treatment for individuals whose
treatment needs could not be met in the community. 26
Individuals with mental illness who are living in the community, especially those with serious
mental illness, are likely to have health coverage under Medicaid or Medicare. The Virginia
Department of Medical Assistance Services (DMAS) reported that 12% of the Medicaid-enrolled
population in Virginia received behavioral health services (109,908) in FY 2012. 27 The total
expenditure for those services was $733,749,350, with 50 cents of each dollar being SGF.28

26

DBHDS. Fiscal Year 2012 Annual Report. 2012. Available at:
http://www.dbhds.virginia.gov/documents/RD360.pdf. Accessed December 6, 2013.
27
Behavioral Health includes mental health and substance abuse services.
28
DMAS. Division of Behavioral Health Services Administrator Fact Sheet. Available at:
http://www.dmas.virginia.gov/Content_atchs/obh/bh-admin1.pdf. Accessed December 6, 2013.

Review Results

14

Considering the percentage of the total community mental health services CSBs provided to
adults (71%) and the number of adults with mental illness served by CSBs in FY 2012 (80,453),
the per person investment of SGF alone was $1,625 ($184,098,776 * .71/80,453 = $1,625).
Applied to the 2012 Compensation Board Survey census, an equivalent investment of SGF for
mental health services in jails would be approximately $10.3M (6,322 x $1,625). This amount
represents a portion of what the full state investment would be if there was parity in treatment
for individuals in the community and jails.29
Beyond SGF support for mental health services, the array of Medicaid-funded services and
supports that exist have been successful in supporting individuals in the community; however,
once an individual enters a jail, Medicaid eligibility is terminated and the funding for any
current services terminates. Since most community providers rely on Medicaid reimbursement
to underwrite mental health, CSBs and other providers frequently have no reimbursement
mechanism to serve individuals in jails. The cessation of Medicaid funding and the absence of
SGF lead to a breakdown in the continuity of care in the Commonwealth.
The loss of Medicaid combined with the lack of any proportionate dedicated state funding for
jails to provide mental health treatment, means individuals do not have access to the same
level of treatment they available to them in the community. Absent a comprehensive array of
psychiatric interventions, overreliance on medication develops as a means to address inmate
mental health treatment needs. When resources do not exist for an individualized treatment
response, control of symptoms through medication is often the only intervention available to
jails.
RECOMMENDATION NO. 1-A
Virginia should develop a strategy for funding mental health treatment for individuals in local
and regional jails that is proportional to the investment in support services for the same
population in the community. A comparative analysis of the DBHDS’s FY 2013 Annual Report
and the Compensation Board’s 2013 Report on Mental Illness in Jails would serve as a starting
point for implementing this recommendation.
RECOMMENDATION NO. 1-B
The Commonwealth should establish a process for suspending, rather than terminating,
Medicaid when individuals enter local and regional jails.

29

It is worth noting that $1,625 per capita represents only a portion of the Commonwealth’s FY 2012 funding for
community mental health. Moreover, the community mental health system is supported by an infrastructure that
has been created over decades at a cost of billions of dollars.

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15

RECOMMENDATION NO. 1-C
CSBs and local jails should develop written and joint agreements among effected CSBs when
individuals are in regional jails. The agreements should clearly address:
i.

The timely exchange of information at point of entry and release.

ii.

The capacity of CSBs to engage with incarcerated individuals identified as current
consumers or likely to need community follow-up on discharge.

iii.

Transition procedures for individuals who are actively receiving mental health
treatment at release.

iv.

Pre-admission screening roles and responsibilities, including time limits for responding
to jail requests.

RECOMMENDATION NO. 1-D
CSBs and local or regional jails should develop Business Associate Agreements to facilitate the
effective exchange of mental health treatment information.
RECOMMENDATION NO 1-E
DBHDS should continue to seek state funding for individualized mental health treatment in jails
by CSB clinicians.
RECOMMENDATION NO. 1-F
Jails should consider the use of brief and validated instruments at the initial booking screening
in order to standardize the process and minimize risks of under-identifying individuals with
mental illness. 30
Question 2. Do inmates with mental illness receive the minimum treatment required by state
or local standards of care for incarcerated persons?
Observations
Every jail visited by the OSIG met, or exceeded, the BOC standards and jail policies for the
identification, treatment, and housing of individuals with mental illness.
BOC standards for local jails define the expectations for the operation of Virginia’s jails,
including the manner in which jails are expected to address the health care needs of inmates—
including those with mental illness.
To ensure compliance with BOC’s standards, DOC’s Compliance & Accreditation Unit's Local
Facilities Section conducts annual unannounced Life, Health, and Safety Inspections, while the
30

The Correctional Mental Health Screen for Women (CMHS-W) and the Brief Jail Mental Health Screen (BJMHS)
are in the appendixes of this report and have been endorsed by SAMHSA.

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16

Certification Section conducts triennial Certification Audits. Each of the jails visited during this
review had met DOC standards and were certified.
The OSIG study relied primarily on 32 BOC standards selected because they included at least
one reference to mental health/mental illness, or the selected standards were judged by the
OSIG review team to address areas where the jail’s mental health policies or practices would be
evidenced (Appendix VIII).
The OSIG found that, in most instances, jail polices were written to meet the minimal
compliance indicators that DOC uses for their inspections or certification visits. However, in
every jail tested, the OSIG found that practices related to the identification, treatment, and
housing of mentally ill individuals exceeded the policies written in response to the BOC
standards.
The OSIG did observe that jails that had obtained accreditation from the American Correctional
Association (ACA) or the National Commission on Correctional Health Care (NCCHC) had more
comprehensive policies and practices specific to the identification and treatment of individuals
with mental illness.
RECOMMENDATION NO. 2
Jails that are not ACA or NCCHC accredited should consider applying ACA and NCCHC mental health
standards to individuals under their supervision.
Question 3. Is appropriate and proven medication available during an individual’s
incarceration?
Observations
Medication management is the primary form of mental health treatment in local and regional
jails. This was verified by the observation that in 55% (92 of 167) of the medical records
reviewed, medication management was the only treatment documented.26 While each jail has a
capacity to provide medications to individuals with mental illness, the variation in funding by
localities for local or regional jails, the emphasis on medication cost containment, variation in
jail formularies, and the differences between jail versus state-operated facility formularies
created a fragmented and inconsistent system of treatment. 31
Medical staff reported that the inability of jails to provide medication over objection sometimes
meant that individuals with mental illness deteriorated during incarceration—often to the point
31

Since it is impossible to stock every type of medicine for every disease, jails and hospitals create formularies
listing the drugs they keep in house. It is possible for a jail or a hospital to obtain non-formulary drugs by ordering
them from a neighboring hospital or pharmacy.

Review Results

17

where hospitalization in a state-operated behavioral health facility was required. The fact that
individuals with mental illness are in secure and supervised settings in jails may contribute to
delay in transferring these individuals to state hospitals because CSB emergency staff look for
imminent risk of harm to self or others and inability to care for self as key criteria for
involuntary hospital admission and people in jails are deemed to be “safe.”
In interviews of forensic staff at the DBHDS Central Office and one state facility in advance of
initiating this study, there were reported patterns of deterioration in mental conditions for
individuals that had medications discontinued or changed when returning to jails.
Access to general practitioners and psychiatrists varied significantly at the jails reviewed. Each
jail had a unique medication formulary, and cost considerations were most often cited by jail
staff as the only factor that would influence prescribing practices.32
•

OSIG reviewers noted formulary restrictions in eight (32%) of the jails; although medical
staff consistently noted that generic medications were a primary consideration.

•

Seven jails reported having a physician onsite between 30 and 40 hours a week. Nine jails
reported eight hours or less.

•

For the jails surveyed, the onsite time of a psychiatrist in the 30 days prior to the OSIG site
visit varied from zero hours to 80 hours. Eight jails reported less than 20 hours of onsite
psychiatric time in the 30-day period.

Jail medical staff noted that efforts would be made to use generic medications and formularybased medications, unless there was clear justification of an individual responding to a
particular non-formulary medication. Of the 25 jails surveyed, eight (32%) had policies
prioritizing the use of generic medications whenever possible.
Medical and mental health personnel reported that efforts were made to continue medications
that had been prescribed for individuals in active community treatment at the time of their
incarceration, or that had been initiated during a period of hospitalization. The OSIG observed
instances of the jails providing continuing “bridge” medications until a physician or psychiatrist
could make a full assessment.
RECOMMENDATION NO. 3-A
The BOC should work with the Virginia Sherriff’s Association (VSA) and Virginia Association of
Regional Jails (VARJ) to determine if creation of a single pharmacy contract would be more cost
effective and aligned with the formulary used by state behavioral health facilities.
RECOMMENDATION NO. 3-B
A workgroup consisting of jail medical staff, CSB emergency staff, and DBHDS facility medical
staff should develop protocols to guide the pre-admission screening process for individuals with

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18

mental illness who are in local and regional jails, focusing on reducing the risk of individuals
deteriorating solely as a result of their jail residency.
Question 4. How are individuals with an acute episode of mental illness, accompanied with
behavioral problems, housed and treated?
Observations
All jails reviewed were designed to house individuals in a manner that maximized safety and
ensured the greatest capacity to control inmate movement. The design was consistent with the
objectives of a correctional facility, but was not always conducive to addressing the treatment
needs of inmates with mental illness, especially the most severe forms of mental illness and
those individuals with active psychotic symptoms.
All jails reviewed had policies in place for the segregation of inmates based on suicide concerns,
but this review revealed that guidance on segregation of individuals with mental illness, or
acute mental illness, was lacking in 16 of the 25 (64%) jails visited. In each jail, the medical staff
emphasized that the focus during an acute episode was primarily on “control and safety,” not
the active treatment of mental illness.
Nine (36%) of the jails specifically referenced mental illness in their policy on segregation; while
13 (54%) had a procedure in place for segregation of individuals identified as having mental
illness during the screening process, or for an individual experiencing an acute episode.
As noted, the screening process on entering a jail was intended to identify concerns that would
influence a decision regarding where an individual with mental illness should be housed. During
this review, individuals with mental illness that were in an acute phase were observed in single
cells, located in the medical section of the jails, and in administrative segregation cells, or
rooms, where they could be monitored.
Monitoring was observed to be either in the form of cameras, regularly scheduled observation,
or a combination of both. At one large jail with a significant mental health population, the
facility Administrator reported that he frequently needed to have a corrections officer placed
outside an observation room 24 hours a day.
In each jail, the medical staff emphasized that the focus during an acute episode was primarily
on “control and safety,” not treatment. Medication management was cited as the primary tool
for intervention in an acute episode and inability to medicate over objection was cited as a
barrier to treatment.

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Suicide Prevention
Suicide is the number one cause of death for inmates in jails.32 Merely being in custody is one
of the top ten risk factors for suicide. Correctional staff are the frontline defense for suicide
prevention.
Individuals who had been placed on suicide watch were seen wearing safety vests in their cells,
and in one instance, an individual who was attempting to harm himself was in a restraint chair
with staff providing arms-length observation. The staff noted the need for more specialized
rooms for individuals who were suicidal or experiencing acute psychiatric episodes.
Serious mental illness affects an individual’s perceptions and judgment, adding to the risk that
they will be non-compliant with jail rules, which places them at increased risk for use of
segregation. Segregation cells or rooms offer safety for the individual or others, but studies
indicate isolation in a room with little space and limited contact through a small window or slot
could actually exacerbate the individual’s illness.33
While not a focal point of this study, the OSIG believes that the problem of suicide attempts
and death by suicide warrants a joint mental health and correctional study of suicides that have
occurred in jails and prisons across the Commonwealth in the last five years. To promote full
participation, this suicide study could be a simple paperwork review with anonymous results.
Six of the 25 (25%) jails visited had established mental health units or pods in order to decrease
the isolation of individuals with mental illness and expand opportunities for engagement. These
units were likely to have dedicated staff with additional mental health training and were able to
interact more readily, although much of that interaction lacked privacy. That said, there were
significant differences in mental health units or pods in the jails visited.
If there was a regional jail with a mental health unit or pod, the local jails reported that they
transferred individuals with mental illness to the regional facility. The movement of individuals
from local jails to regional jail settings can create additional barriers to effective linkages
between the regional jail and the CSB serving the locality of the individual’s residence.

32

L. Hayes. National Study of Jail Suicide: 20 Years Later. National Center on Institutions and Alternatives (NCIA)
(Mansfield, MA) National Institute of Corrections. Jails Division (Washington, DC). 2010. Available at:
http://static.nicic.gov/Library/006540.pdf.
33

J. Metzner, J. Fellner. Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics.
Journal of the American Academy of Psychiatry and the Law. 2010. Available at:
http://www.jaapl.org/content/38/1/104.full.pdf+html. Accessed December 6, 2013.

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RECOMMENDATION NO. 4-A
Virginia should continue to prioritize funding the array of jail diversion alternatives defined in
the Sequential Intercept Model (SIM) in order to reduce the number of mentally ill individuals
in local and regional jails.
RECOMMENDATION NO. 4-B
The BOC should involve current jail mental health practitioners in a review of BOC Standard
6VAC15-40-990 on the use of administrative segregation in order to provide greater guidance
on segregation of individuals with serious mental illness.
RECOMMENDATION NO. 4-C
Future jail construction and renovations should place greater focus on the safety and treatment
needs of mentally ill individuals.
RECOMMENDATION NO. 4-D
The BOC should work with jails that operate mental health units to create standards for such
units, including staff training and availability of treatment.
RECOMMENDATION NO. 4-E
Consideration should be given to the creation of mental health pods in local and regional jails.
This would serve to expand active treatment for individuals with mental illness.
Question 5. Do services provided by CSBs or private providers of jail-based services meet the
needs of incarcerated individuals with mental illness?
Observations
Life, health, and safety needs are the first priority, and the reality is that jails have been
designed primarily to be “management and control” settings—not treatment settings.
Interviews of jail administrators, corrections officers, medical staff, and mental health providers
point to thoughtful efforts to meet the needs of individuals with mental illness, but it was clear
that mental health services in jails did not rise to the level of what is available in the
community.
In the jails reviewed, private providers had good screening tools in place, and they offered
medication management via tele-psychiatry or scheduled hours, but there was limited
supportive counseling provided. While all local and regional jails used screening tools to identify
individuals with mental illness, there was no consistency among these tools, or in the level of
mental health training for the jail staff that conducted the initial screening.
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The Compensation Board’s Annual Reports of Mental Illness in Jails in recent years suggest that
jails rely more on contracted private providers for overall health care, including mental health
services, than on the CSBs. In 2009, 14% of the mental health services were delivered by private
(non-CSB) providers. The percentage of mental health treatment from private providers in 2012
was 40%. While CSBs still were identified as providing 42% of mental health services, that
percentage has dropped from 61% in 2009.34
The CSBs that were funded to provide targeted jail diversion/treatment were actively engaged
at five jail study sites, and there was significant engagement in five other jails that had purchase
of service agreements with the CSBs for onsite services. CSBs had good screening tools in place,
offered psychiatric coverage with their own staff, and provided supportive counseling, although
these services appeared to be limited to “check-in visits” of no more than three to four hours
weekly.
Cognitive behavior therapy or other forms of individualized therapy were almost non-existent
and direct engagement in even supportive counseling was brief. Psychiatric time in the study
jails was limited, with 32% (8 of 25) jails reporting 20 hours or less a month for the jail’s
mentally ill population.
In some jails, each person that entered was interviewed by a mental health clinician, while in
others that interview only took place based on information collected at the booking or during
medical screenings. The level of experience of the mental health staff conducing actual mental
health assessments ranged from bachelor level and associate degree personnel to licensed
social workers and licensed professionals.
Jails that were currently, or previously, accredited by the ACA or the NCCHC had policies and
practices with greater specificity on screening and treatment of individuals with mental illness.
RECOMMENDATION NO. 5-A
Jails that are not ACA or NCCHC accredited should consider applying ACA and NCCHC mental health
standards to individuals under their supervision (Recommendation No. 2).

34

Compensation Board. 2012 Mental Illness in Jails Report (and a comparison of Reports from prior years). 2012.
Available at: http://www.scb.virginia.gov/docs/2012mentalhealthreport.pdf. Accessed December 6, 2013.

Review Results

22

Question 6. Are policies and practices in place to effectively link individuals with mental illness
to community-based services when they leave jail?
Observations
Jails seek to identify if individuals entering jail were receiving, or had a history of receiving,
mental health treatment in the community, but efforts to follow-up on community linkage on
release were less productive. Jails in the review were not able to provide information about the
rate of recidivism for individuals with mental illness, but staff at each jail commented on
numerous “frequent flyers” in their facility. While jail administrators, medical staff, and mental
health staff frequently commented on the problem of recidivism, only 39% (9 of 25) of jails had
policies with a provision to link the individual with community mental health providers on
release.
Recidivism, and the incidence of community mental health treatment, is a meaningful
performance measure that could serve as the focus of future inquiry to better understand the
root cause(s) of recidivism.
The capacity of individuals to access treatment in the community was hindered by a lack of
funding to support successful transition from jail to community, delay in reactivation of
Medicaid, and a lack of planning for accessing Medicaid or other health care coverage that may
be available.
In every jail surveyed, administrative and treatment staff discussed the issue of recidivism—a
revolving door for some individuals, often times convicted of minor offenses. All jail staff
identified individuals that were at-risk for a felony conviction, due to habitual offender status,
where the underlying issue was the person’s mental illness and the lack of stability in the
community.
“Release” occurred when a jail relinquished responsibility and custody for the individual when
they exited the jail facility; however, the release of an individual with mental illness is only onestep in a “transition plan.” The lack of effective transition planning increased the risk of
recidivism, because without effective linkage with community mental health providers,
mentally ill individuals could deteriorate and resume the recidivism cycle. 35
The process of linkage between the jail and the community at the time of release varied greatly.
The OSIG observed that the coordination or linkage at release was best when there was active
engagement by the CSB at the point of entry into jail, when the CSB had staff onsite on an
35

F. Osher. Short-term Strategies to Improve Re-entry of Jail Population. 2007. Available at:
http://gainscenter.samhsa.gov/pdfs/reentry/APIC_Model.pdf. Accessed December 6, 2013.

Review Results

23

ongoing basis, and when there was a memorandum of agreement between the jail and the CSB
that addressed release planning.
Areas of concern for the release of individuals with mental illness included:
•

Medication: All jails reviewed provided mentally ill individuals with the medication they
had been receiving during their incarceration. The supply of medication provided
released individuals ranged from three to 30 days.

•

Appointments: Jails reported that follow-up appointments were often weeks after a
release date, and jails could not confirm if individuals had been seen by community
mental health providers following their release.

•

Recidivism: The jails noted that individuals often returned to jail after arrest for minor or
“nuisance” offenses like vagrancy, shoplifting, etc. During this review, jails did not have
a tracking mechanism to monitor rates of recidivism for individuals with mental illness.

•

Lack of Health Care Coverage: Individuals who had been receiving Medicaid prior to
their incarceration can face weeks or months of delay following release, while those
entitlements re-activated. Additionally, individuals who were eligible for Medicaid, or
other health insurance, may have experienced a delay in accessing coverage, or were
unable to initiate applications without direct assistance.

There were promising practices observed and reported during site visits that may emerge as
best practices, including:
•

Regular meetings among jail, CSB, and probation staff as part of a coordinated re-entry
program (these initiatives appeared to be a result of community cross-systems mapping
efforts that identified the release process as a gap in the continuity of care).

•

Onsite CSB “jail diversion” staff that developed transition plans.

•

A CSB-targeted case manager who met with the individual at release.

Based on the data contained in the Compensation Board’s 2013 Mental Illness in Jails Report,
the population served by jails and CSBs—mentally ill and seriously mentally ill persons—was
increasingly overlapping. However, this review revealed that all too often, there was no defined
relationship between the two entities (jails and CSBs), which led to poor continuity of care.
Part of the definition for serious mental illness in the CSBs’ Performance Contract stated, “The

person exhibits inappropriate behavior that often results in intervention by the mental health or
judicial system.” 36 Per their Performance Contract, CSBs were expected to provide services and
support specific to the needs of this population, for which they received funding or payments,
mostly from Medicaid.
36

FY 2013 and FY 2014 Community Services Performance Contract. Page 5. (Also see Core Services Taxonomy.
Available at: www.dbhds.virginia.gov/occ-default.htm. Accessed January 8, 2014.)

Review Results

24

Once an individual who had been receiving active treatment in the community entered jail, the
CSB had no obligation to continue the therapeutic relationship and funding for services and
supports terminated. As such, the CSB and jail relationship was either self-directed based on
the belief there was common interest in working together, there was a financial connection
because the jail contracted for behavioral health services, or the CSB was receiving targeted jail
diversion and treatment funds.
RECOMMENDATION NO. 6-A
Jails should develop mechanisms for tracking recidivism of individuals with mental illness that
were “engaged” in treatment at release.
RECOMMENDATION NO. 6-B
An initiative similar to the Discharge Assistance Program (DAP) should be created to support
successful jail-to-community transition.
RECOMMENDATION NO. 6-C
The BOC should consider a new standard, distinct from Standard 6VAC15-40-1090, to address
transition planning for individuals with mental illness.
RECOMMENDATION NO. 6-D
Jails and CSBs should seek to help individuals gain access to health care that may be available to
them through new health care exchanges and develop strategies to facilitate timely reactivation of Medicaid or enrollment therein for individuals being released from jail.
RECOMMENDATION NO. 6-E
The DOC should continue to advance the Thinking for a Change: Integrated Cognitive Behavior
Change Program curriculum for use in jails, and the DBHDS should support similar initiatives in
the community for individuals that have been incarcerated in local and regional jails.
Question 7. Are the total costs for providing mental health care incurred by local and regional
jails accurately accounted for?
According to the Compensation Board’s 2012 Mental Illness in Jails Report, the cost of serving
individuals with mental illness was $13.3 million. 37 Based on our review, the OSIG estimated
that the cost is likely higher because the jails visited lacked mechanisms to capture all costs
associated with supervising incarcerated individuals with mental illness.

37

Compensation Board. 2012 Mental Illness in Jails Report (and a comparison of Reports from prior years). 2012.
Available at: http://www.scb.virginia.gov/docs/2012mentalhealthreport.pdf. Accessed December 6, 2013.

Review Results

25

The review revealed that jails typically only tracked the following direct costs for providing
mental health care to incarcerated individuals:
i)

Annual contract costs.

ii)

The cost of psychiatric time plus the cost of medical staff with mental health
treatment responsibilities.

iii)

The cost of providing psychotropic medication purchased through their
pharmacies.

Thus, when the jails respond to the Compensation Board’s annual mental illness in jails survey
questions, they refer to these cost centers.
The review revealed that the 2012 Compensation Board survey of jails did not capture all direct
and indirect costs associated with supervising individuals with mental illness in their custody. To
cite a few omissions, the annual survey does not document:
i)

The staff cost for providing one-to-one supervision of mentally ill inmates
experiencing acute episodes.

ii)

The staff and equipment cost of transporting mentally ill individuals to
hospitals.

iii)

The cost (including medical care) of injuries resulting from inmate-on-staff
aggression arising from behaviors associated with mental illness.

RECOMMENDATION NO. 7
The Virginia Association of Regional Jails (VARJ) and the Virginia Sherriff’s Association (VSA)
should work with their members to account for all direct and indirect costs associated with
housing and treatment of individuals with mental illness.
Question 8. Has CIT training had an impact on jails’ mental health-specific policies,
procedures, and practices?
Crisis Intervention Team (CIT) training provides 40 hours of training to law enforcement
officers, emergency dispatchers, mental health treatment providers, and other first responders
in order to improve their ability to: respond safely and effectively to persons with mental
illness, reduce the use of force and restraint, divert arrest, and link individuals to mental health
supports whenever possible.
Jail Administrators consistently described positive impressions about the CIT training their staffs
received. Administrators reported a reduction in the use of force, inmate-on-inmate violence,
and inmate-on-staff aggression following this training.
Review Results

26

Since 2008, the number of CIT programs has increased from 22 to 33. This means that 85
percent of Virginia’s population now lives in areas served by CIT-trained personnel. As this
Report was being drafted, approximately 5,712 individuals consisting of law enforcement
officers, emergency dispatchers, mental health treatment providers, and other first responder
personnel have now participated in CIT training. 38
Jail Administrators confirmed the value of mental health training for jail staff and expressed a
preference for having all staff trained in CIT. Several Administrators indicated they had
established goals for 100% training of jail personnel that regularly interacted with inmates. Jail
Administrators, medical staff, and mental health staff also recommended that any mental
health provider who was going to work in a jail needed to be trained on the goals, objectives,
and philosophy of the jail.
RECOMMENDATION NO. 8-A
Continue current efforts to provide CIT training to jail personnel.
RECOMMENDATION NO. 8-B
The BOC should consider expanding BOC Standard 6VAC15-40-1040 to include a minimum level
of mental health training for jail personnel who work with individuals with mental illness.
RECOMMENDATION NO. 8-C
The BOC should consider a standard for training any CSB or private provider working in a jail to
ensure they have an understanding of the differences between mental health care in a
community-based program versus a jail setting.
Question 9. What do jail administrators believe contributes to the incarceration of individuals
with mental illness, and what are the priorities for addressing the needs of this population?
During the planning phase of this review, representatives of the VSA and the VARJ requested an
opportunity to provide comments related to the growth in the mentally ill population in their
jails, and to offer suggestions for addressing the challenges they face in housing this population.
In consideration of this request, Jail Administrators (or their designees) responded to four
open-ended questions. A full account of their comments is appended to this report. A summary
of the concerns we received from these corrections professionals during this review appears
below:
•

The number of incarcerated individuals with mental illness has increased due to the loss
of large numbers of public and private psychiatric beds, the limited community

38

A current summary of these collaborative efforts and community initiatives may be accessed through the DBHDS
website at http://www.dbhds.virginia.gov/.

Review Results

27

resources available to treat mentally ill persons, and the difficulty of placing forensic
individuals in community settings.
•

Changes that could decrease jail census included a diversion option for minor offenses,
creation of more drop-off centers, the establishment of regional mental health jails, and
additional mental health training for law enforcement officers.

•

What was most needed to support efforts to address the needs of incarcerated mentally
ill persons included Compensation Board reimbursement for mentally ill individuals, and
more resources, overall; access to inpatient (non-jail) psych beds; greater CSB
participation and community resources at release; and the creation of mental health
pods/areas.

•

The top priorities for responding to inmates with mental illness are psychiatric bed
access, creation of a regional mental health correctional center, onsite pre-admission
screening, establishing a structured “hand-off” at release, funding for mental health,
access to a state pharmacy to help control drug costs, and funding for additional mental
health staff.

Review Results

28

Appendix I—Glossary of Terms
ACA

American Correctional Association. A professional organization for
individuals working in criminal justice.

ADA

Americans with Disabilities Act of 1990. The ADA is a wide-ranging civil
rights law that prohibits, under certain circumstances, discrimination
based on disability.

BH

Behavioral Health. Refers to the collective field of mental health and
substance abuse.

BHA

Behavioral Health Authority. A public body and a body corporate and
politically organized in accordance with the provisions of Chapter 6 of
Title 37.2 of the Code of Virginia, that is appointed by and accountable
to the governing body of the city or county that established it for the
provision of mental health, developmental, and substance abuse
services.

CIT

Crisis Intervention Team. A model of intervention for law enforcement
officers that improves their ability to respond to individuals with mental
illness.

Community-based

Services provided in community settings and most often managed by a
community services board or behavioral health authority.

CSB

The public body established pursuant to § 37.2-501 that provides mental
health, developmental, and substance abuse services within each city
and county that established it.” Code § 37.2-100.

CRIPA

Civil Rights of Institutionalized Persons Act. A United States federal law
intended to protect the rights of people in state or local correctional
facilities, nursing homes, mental health facilities and institutions for
people with intellectual and developmental disabilities.

DAP

Discharge Assistance Program. A funding initiative that helps individuals
transition from state behavioral health facilities to the community.

DBHDS

Department of Behavioral Health and Developmental Services. Formally
known as the Department of Mental Health, Mental Retardation and

Appendix I—Glossary of Terms

29

Substance Abuse Services.
DOJ

U.S. Department of Justice.

FORENSIC STATUS

State hospitals provide forensic evaluation, emergency, continuing
treatment, and competency restoration services. These various pre-trial and
post-trial services are required by Code § 19.2-169.1, § 19.2-169.2, § 19.2169.5, and 19.2-169.6.

JLARC

Joint Legislative and Audit Review Commission. An oversight agency of the
Virginia General Assembly, established to evaluate the operations and
performance of state agencies and programs.

NCCHC

National Commission on Correctional Health Care. An accrediting body that
establishes standards for correctional settings.

Olmstead

Refers to a 1999 United States Supreme Court decision holding that,
under the Americans with Disabilities Act, individuals with mental
disabilities have the right to live in the community rather than in
institutions if, in the words of the opinion of the Court, "the State's
treatment professionals have determined that community placement is
appropriate, the transfer from institutional care to a less restrictive
setting is not opposed by the affected individual, and the placement can
be reasonably accommodated, taking into account the resources
available to the State and the needs of others with mental disabilities."

OSIG

Office of the State Inspector General

Performance Contract

A contract between DBHDS and the CSBs that defines the responsibilities
of the parties for the delivery of services, service quality and fiscal
accountability.

SAMHSA

Substance Abuse and Mental Health Services Administration

SGF

State General Fund Dollars

SMI

Serious Mental Illness

Appendix I—Glossary of Terms

30

Appendix II—Summary of Medical Records Review
A total of 172 medical records of individuals identified as having mental illness were reviewed
for this study. At each of the 25 jails visited, between five and ten records were reviewed,
unless the number of individuals in the jail indentified with mental illness on the day of the visit
was fewer than five.
Ability of the jail to identify the number of individual in the jail that had a mental illness:
All but one of the 25 jails visited was able to identify the number of individuals with mental
illness. This information was either accessible from a database, from records maintained by the
medical staff, or from tracking tools used by the mental health staff.
Screening Forms Had Identified Mental Illness:
Of the 172 records reviewed, 156 (91%) contained documentation of a formal screening. Of
those, 149 (96%) had the need for mental health services identified during the jail entry
process. The remaining 4%, who were receiving mental health services, were identified after
the screening and classification process.
Diagnosis of mental illness from jail medical staff or other provider of mental health services
present:
Of the 156 records that identified mental illness through a screening process, 146 (94%)
contained a formal mental health diagnosis. In the records where there was no formal
diagnosis, the individual was still receiving medication(s). A prior history of the person being
treated with medication appeared to be the basis for the treatment.
Record contains determination of the individual having been an active consumer/client at the
time of their admission to the jail:
In 113 (67%) of the records, the screening indicated that the individual was receiving or had
received mental health treatment in a community setting; however, only 93 (of 113) records
identified the source of those services.
A CSB was identified as the community provider in 58 (62%) of those records. A private provider
was identified in 31 (33%) of the records. The remaining records referenced the Veterans
Administration or another prison as the prior provider.
Record contains documentation of jail notifying the CSB or Private Provider of the individual
being admitted to the jail:
Appendix II—Summary of Medical Records Review

31

Of the 113 records with a reference to the individuals having received community treatment,
89 records (78%) included documentation of efforts to contact the provider. The contact was
most often tied to seeking treatment information.
Record Contains documentation of the individuals receiving mental health services in the jail:
Mental health treatment was documented in 165 (97%) of the 172 records we reviewed. Of the
165 records:
•
•
•

Medication management was the only service documented in 92 (55%) of the records.
Fifty (30%) of the records documented medication with “supportive” counseling that
focused primarily on medication adherence.
Twenty-seven (16%) of the records included documentation of additional services such
as case management, group or psychosocial services.

Record contains documentation of who prescribed medication:
A private contract physician/psychiatrist or full-time jail physician prescribed medications in
68% (17 of 25) of the study jails and a CSB psychiatrist was identified in eight (32%).
Record documents qualifications of the person providing mental health services:
Of the 165 (of 172) records wherein mental health treatment was documented, 127 (77%)
identified a psychiatrist as the provider.
Record documents efforts to encourage the individual to take an active role in managing their
illness:
Of the 158 (of 172) records that documented active mental health treatment, 102 (65%)
included documentation relating to efforts to actively engage the individuals managing their
illness. In most instances, this effort took place during medical visits or when “supportive
counseling” was provided. Wellness Recovery Action Plan (WRAP) groups were noted in one
jail.
Record documents efforts to encourage the individual to continue treatment in the
community upon release from jail:
Of the 172 records, we reviewed 168 for this criterion, and efforts to promote continuity of
mental health treatment on release from jail were noted in 29% (49 of 168) of the records
reviewed.

Appendix II—Summary of Medical Records Review

32

Appendix III—Study Instruments
Study Instrument 1: Review Instrument for Medical Records of Jail Inmates Identified as
Receiving Mental Health Treatment Services

Adobe Acrobat
Document

Study Instrument 2: Board of Corrections Minimum Standards Selected by OSIG Relevant to
Reviewing Policy and Practice Specific to Identifying/Treating/Releasing Individuals with Mental
Illness

Adobe Acrobat
Document

Appendix III—Study Instruments

33

Appendix IV—Sequential Intercept Model

For full details: http://www.dbhds.virginia.gov/documents/Adm/080513Griffin.pdf

Appendix IV—Sequential Intercept Model

34

Appendix V—Brief Jail Mental Health Screen/Correctional
Mental Health Screen for Women (CMHS-W)
Brief Jail Mental Health Screen

Adobe Acrobat
Document

Correctional Mental Health Screen for Women (CMHS-W)

Adobe Acrobat
Document

Appendix V—Brief Jail Mental Health Screen/Correctional Mental Health Screen for Women

35

Appendix VI—Sheriff and Superintendent Responses to OpenEnded Questions
What factors do you believe contribute to any increase of persons with mental illness in your
jail population?
• Societal issues…PTSD (post-traumatic stress disorder) issues
• Closure of state beds
• Inability to place forensic individuals in community settings
• Arrest for misdemeanor crimes and then sitting for months or even a year
• Lack of options for judges
• Lack of options on release that lead to recidivism
• Lack of community resources
• Restricted bed access at state and local hospitals
• Lack of hospital beds
• Better ability to identify mental illness
• Without intervention of community services, police bring all individuals to the jail
• Community outplacement without needed support for inmates with mental illness
• Societal issues
• Increased involvement with alcohol, drugs, etc.; Societal breakdown
• Undiagnosed in general population
• Better diagnosis of mental illness
• Loss of inpatient beds at local hospital
• Lack of understanding by arresting officer (jail becomes dumping ground for mentally ill)
• General increase in MH population reflects the society issues
• Reflection of the problems in society
• General population increase of individuals with mental illness; Lack of CSB support
• Overall increase in MH inmates from society
• Law enforcement has no other place to put individuals with mental illness
• Alcohol and drugs – Lack of skills and services – Lack of access to services
What changes do you believe are needed to decrease the growth of persons with mental
illness in the jails?
•
•
•
•

Better diagnostic efforts
Diversion options for minor offenses
Drop-off centers
Regional treatment setting for individuals that are arrested

Appendix VI—Sheriff and Superintendent Responses to Open-Ended Questions

36

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Drop-off center
More funding for community care
Inpatient beds
Better follow-up after discharge from jail may reduce repeat bookings
“I don’t really have an answer”
More psychiatric beds
More community resources
Greater access to hospital treatment
A release follow-up to ensure MH individuals receive continued treatment
Awareness, and staff onsite to help individuals
Better diagnosis of MH
Training of law enforcement officers on MH
Intervention at the earliest possible time in life
Greater support of MH ($) and diversion courts
Follow-through with MH services in the community upon inmate discharge
More cooperation from CSB
More Funding
Additional funding for specific MH needs
More state facility MH beds available
Additional funding for medications
Increase in availability of services

What would be needed to support your efforts at addressing the needs of persons with MI in
the jails?
•
•
•
•
•
•
•
•
•
•
•
•

Additional staffing
Capacity to provide more stimulation
Housing resources for transition
Pilot programs for MH probation
Specific funding for MH efforts
Active involvement of CSB during incarceration
Help with medication costs
Compensation Board payments adjusted for mental health inmates
Increased funding and physical facilities
Funding to support the MH needs
Dedicated capacity for housing mentally ill inmates
Additional mental health counseling resources

Appendix VI—Sheriff and Superintendent Responses to Open-Ended Questions

37

•
•
•
•
•
•
•
•
•
•

Funding
Education, funding
Additional funding for specific MH treatment
Funding for proper treatment
More hands-on time with deputies; In–house training for jail CSB would be helpful
Additional funding specific to MH
Increased funding
More cooperation from CSB. More Funding
Funding
Money – Personal responsibility and accountability – Discharge manager

What would be your top priority for responding to your MH inmates in your jail if you had the
capacity to address the priority?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Establish structured “hand-off” of the discharged MH inmate
Seamless transition; services in the jail/housing/monitoring
Better housing environment in jail “doors/more open/more interactive”
Access to emergency forensic beds
Drop-off center
Funding for MH psychiatric services and medication
A state pharmacy to help drive down costs
Funding to hire additional MH support staff
A mental health correctional center
Utilizing Western Regional
Increased staffing to cover MH inmates
Increased treatment in jail to allow for future community-based treatment
Training of personnel on MH
Life skills training for inmates
Developing steps to set-up and address all MH issues
Ensuring that the inmates really should be in jail and not in some treatment facility
Establish on-going treatment beyond discharge from jail
Out-sourcing of support needs, once discharged from the jail
Cost of medications
More psychiatric hours

Appendix VI—Sheriff and Superintendent Responses to Open-Ended Questions

38

Appendix VII—Review Methodology
Stakeholder Engagement: The OSIG worked with the VSA and the VARJ to conduct two
stakeholder conference calls before initiating the study in order to clarify the purpose of the
study and to answer questions from sheriffs, jail superintendents, and other interested parties.
Jail Selection Criteria: The 12 city or county jails and 13 regional jails were selected based on the
following criteria:
(1) Regional representation of the three regions identified in Appendix B of the
Compensation Board 2012 Mental Illness in Jails Report.
(2) Representation within regions of Regional/County/City Jails.
(3) Representation within region based on overall jail population and number of individuals
identified in the Compensation Board 2012 Mental Illness in Jails Report as having
mental illness. The 2012 data was assumed a reasonable projection of the mental health
population at the time of the study.
(4) Jails identified by the DBHDS as being “primary feeder” jails for state mental health
hospitals.
(5) Jails that serve areas or communities that have participated in DBHDS and Department
of Criminal Justice trainings for identification, diversion, or treatment of individuals with
mental illness. (Based on information provided by DBHDS)
(6) Jails that serve areas or communities where the CSBs are funded to provide jail-based
mental health treatment (based on DBHDS information).
Announced Visits/Entry and Exit Meetings: The State Inspector General provided a list of
selected jails to leadership of the VSA and the VARJ for dissemination to sheriffs and jail
superintendents. The announced visit clarified the purpose of the study for the jails beforehand
and identified individuals that ideally would be onsite during the OSIG team visit. The OSIG
conducted entry and exit meetings with jail personnel at each location.
Review Instruments: The OSIG used two instruments to conduct the study of each local or
regional jail. A copy of both instruments is included in at Appendix III of this report.
(1) Policy and Procedures—A 57-question instrument linked to 32 selected BOC Standards.
The standards were selected from the 124 standards that jails housing adults must meet
to be certified by the DOC.

Appendix VII—Review Methodology

39

The standards were selected based on whether they included specific references to
mental illness/mental health, or if it was an area of emphasis within the jail, the OSIG
behavioral health staff believed the standard could drive policies that focused on the
needs of individuals with mental illness.
a. Financial Management—The instrument included one question to identify how
the jail determined and documented their expenditures for mental health
services.
b. Jail Administrator Perspectives—The instrument included four open-ended
questions to gain input from jail administrators.
(2) Medical Records—A ten-question instrument focused on determining the type of
mental health treatment provided, qualifications of the mental health treatment
provider, linkages with a community mental health provider if the individual was active
in treatment at the time of jail entry, and release linkages with community mental
health providers.
Walk-Through: The OSIG toured each jail visited to understand where individuals were
screened for mental illness; where individuals with mental illness were housed, including
general population areas and any special housing areas identified by the jail; and where
individuals were housed in the event they required special observation due to their mental
illness or threats of suicide.
Record Reviews: At each jail, the OSIG team reviewed randomly selected medical records of
individuals identified as having a mental illness. The number reviewed was determined by the
number of individuals in the jail on the day of the visit that had been identified through the
screening process as having a mental illness. The maximum number of reviews at any jail was
10. A total of 172 medical records were reviewed.
Research on National Best Practice Models: The OSIG conducted research in advance and during
the study to identify resources that offered information on best or promising practices specific
to jail-based mental health services. Resources or materials are referenced directly in this
report or included in the appendices.

Appendix VII—Review Methodology

40

Appendix VIII—Department of Corrections—Standards
Compliance Form for Jails
DEPARTMENT OF CORRECTIONS
STANDARDS COMPLIANCE FORM
FOR JAILS
LHS: Refers to Life/Health/Safety Standards – reviewed annually by DOC
1. 6VAC15-40-30. Requirement for Written Statement – The facility shall have a written statement
and policy discussing its philosophy, goals and objectives. The written statement shall be
reviewed every 12 months by administrative staff.
2. 6VAC15-40-40. Policy and Procedures Manual – Written policy and procedures shall be
maintained and available 24 hours a day to all staff. The facility’s policies and procedures shall
be reviewed every 12 months by administrative staff and updated to keep current with changes.
3. 6VAC15-40-60. Annual Report – A written annual report of the availability of services and
programs to inmates shall be reviewed by the facility administrator and provided to the
sentencing courts and may be provided to relevant community agencies.
4. 6VAC15-40-90. Content of Personal Inmate Records – Personal records shall be maintained on
all inmates committed or assigned to the facility. Inmate records shall be kept confidential,
securely maintained, and in good order to facilitate timely access by staff. Inmate records shall
contain, but not be limited to:
Inmate data form;
Commitment form or court order, or both;
Records developed as a result of classification;
5. 6VAC15-40-100. Daily Logs – The facility shall maintain a daily log(s) that records the following
information:
Inmate count and location, to be verified with a minimum of one formal count per shift,
observing flesh and movement;
Intake and release of inmates;
Entries and exits of physicians, attorneys, ministers, and other nonfacility personnel; and
Any unusual incidents that result in physical harm to, or threaten the safety of, any person or
the security of the facility.
6. 6VAC15-40-110. Serious Incident Reports – A report setting forth in detail the pertinent facts of
deaths, discharging of firearms, erroneous releases, escapes, fires requiring evacuation of
inmates, hostage situations, and recapture of escapees shall be reported to the Local Facilities
Supervisor of the Compliance and Accreditation Unit, Department of Corrections (DOC), or
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designee. The initial report shall be made within 24 hours and a full report submitted at the end
of the investigation.
7. 6VAC15-40-120. Classification – Classification instruments enable objective evaluation and/or
scoring of:
Mental health or medical treatment history or needs.
Identified stability factors.
The classification system includes administrative review of decisions and periodic reclassification
and override procedures that are documented and maintained on file.
The classification system addresses both the potential security risks posed and treatment
needs of the inmate.
8. 6VAC15-40-140. Awareness of Programs – The facility administrator or designee shall make
each inmate aware of available programs.
9. 6VAC15-40-320. Licensed Physician – A licensed physician shall supervise the facility’s medical
and health care services. Facilities that contract with private medical facilities or vendors shall
maintain a current copy of the agreement, unless employed by the facility. LHS
10. 6VAC15-40-330. Restrictions on Physician – No restrictions shall be imposed by the facility in
the practice of medicine. However, administrative and security regulations applicable to facility
personnel shall apply to medical personnel as well.
11. 6VAC15-40-340. Health Care Provider and Licensing, Certification and Qualification of Health
Care Personnel – Each facility shall have a minimum of one licensed or qualified health care
provider who is accessible to inmates a minimum of one time per week. Health care personnel
shall meet appropriate and current licensing, certification, or qualification requirements. LHS
12. 6VAC15-40-350. Private Examination and Treatment of Inmates – Where in-house medical and
health care services are provided, there shall be space for the private examination and
treatment of inmates.
13. 6VAC15-40-360. Twenty-Four Hour Emergency Medical and Mental Health Care – Written
policy, procedure, and practice shall provide 24-hour emergency medical and mental health care
availability. LHS
14. 6VAC15-40-370. Receiving and Medical Screening of Inmates – Written policy, procedure, and
practice shall provide that receiving and medical screening be performed on all inmates upon
admission to the facility. The medical screening shall:
Specify screening for current illnesses, health problems and conditions, and past history of
communicable diseases;
Specify screening for current symptoms regarding the inmate’s mental health, dental problems,
allergies, present medications, special dietary requirements, and symptoms of venereal disease;
Include inquiry into past and present drug and alcohol abuse, mental health status, depression,
suicidal tendencies, and skin condition;

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15. 6VAC15-40-380. Inmate Access to Medical Services – Written policy, procedure, and practice
shall be developed whereby inmates shall be informed, at the time of admission to the facility,
of the procedures for gaining access to medical services. LHS
16. 6VAC15-40-400. Management of Pharmaceuticals – Written procedures for the management of
pharmaceuticals shall be established and approved by the medical authority or pharmacist, if
applicable. Written policy, procedure, and practice shall provide for the proper management of
pharmaceuticals, including receipt, storage, dispensing and distribution of drugs. These
procedures shall be reviewed every 12 months by the medical authority or pharmacist. Such
reviews shall be documented. LHS
17. 6VAC15-40-410. Inmate Medical Records – The medical record for each inmate shall be kept
separate from other facility records and shall include the following:
The completed screening form; and
All findings, diagnoses, treatments, dispositions, prescriptions, and administration of
medication.
18. 6VAC15-40-420. Transfer of Summaries of Medical Record – Medical record summaries shall be
transferred to the same facility to which the inmate is being transferred. Required information
shall include: vital signs, current medications, current medical/dental problems, mental health
screening, mental health problems, TB skin test date and results, special inmate
needs/accommodations, pending medical appointments, medical dispositions, overall
comments, health care provider/personnel signature and date, and any additional pertinent
medical information such as lab work, x-rays, etc. LHS
19. 6VAC15-40-440. Medical Care Provided by Personnel Other than Physician – Medical care
provided by personnel other than a physician shall be pursuant to a written protocol or order.
Protocols or orders shall be reviewed and signed by the supervising physician every 12 months.
LHS
20. 6VAC15-40-450. Suicide Prevention and Intervention Plan – There shall be a written suicide
prevention and intervention plan. These procedures shall be reviewed and documented by an
appropriate medical or mental health authority prior to implementation and every three years
thereafter. These procedures shall be reviewed every 12 months by staff having contact with
inmates. Such reviews shall be documented. LHS
21. 6VAC15-40-470. Medical Co-Payment – Jail medical treatment programs, wherein inmates pay
a portion of the costs for medical services, shall be governed by written policy and procedure.
22. 6VAC15-40-490. Policy and Procedure Information – Written policy and procedure shall specify,
at a minimum, the following information:
Medical services that are subject to fees;
Fee amounts;
Payment procedures;
Medical services that are provided at no cost;
Fee application to medical emergencies, chronic care and pre-existing conditions; and
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Written notification to inmates of proposed fee changes.
23. 6VAC15-40-970. Restrictions of Physical Force – Written policy, procedure, and practice shall
restrict the use of physical force to instances of justifiable self-defense, protection of others,
protection of property, orderly operation of the facility and prevention of escapes. In no event is
physical force justifiable as punishment. A written report shall be prepared following all such
incidents described above and shall be submitted to the facility administrator, or designee, for
review and justification. LHS
24. 6VAC15-40-980. Restraint Equipment – Written policy, procedure and practice shall govern the
use of restraint equipment. A written protocol pertaining to the monitoring of inmates in
restraint equipment shall be established and approved by the medical authority.
25. 6VAC15-40-990. Administrative Segregation – Written policy, procedure, and practice shall
provide for administrative segregation of inmates who pose a security threat to the facility or
other inmates, and for inmates requiring protective custody.
26. 6VAC15-40-1000. Physical Living Conditions for Disciplinary Detention and Administrative
Segregation – Written policy, procedure, and practice shall ensure that, inmate behavior
permitting, the disciplinary detention and administrative segregation units provide physical
living conditions that approximate those offered in the general population.
27. 6VAC15-40-1010. Mental Health Inmates – Written policy, procedure, and practice shall specify
the handling of mental health inmates, including a current agreement to utilize mental health
services from either a private contractor or the community services board. LHS
28. 6VAC15-40-1020. Record of Activities in Disciplinary Detention and Administrative Segregation
– Written policy, procedure, and practice shall ensure that a record is kept of scheduled
activities in disciplinary detention and administrative segregation units. Documented activities
shall include the following: admissions, visits, showers, exercise periods, meals, unusual
behavior, mail, and release.
29. 6VAC15-40-1030. Assessment of Inmates in Disciplinary Detention or Administrative
Segregation – Written policy, procedure, and practice shall require that a documented
assessment by medical personnel that shall include a personal interview and medical evaluation
of vital signs, is conducted when an inmate remains in disciplinary detention or administrative
segregation for 15 days and every 15 days thereafter. If an inmate refuses to be evaluated, such
refusal shall be documented. LHS
30. 6VAC15-40-1040. Staff Training – The facility shall provide for 24-hour supervision of all inmates
by trained personnel. LHS (Mental Health training)
31. 6VAC15-40-1090. Release of Inmates – Written policy, procedure, and practice shall require
that, prior to the release of an inmate, positive identification is made of the release, authority
for release is verified, and a check for holds in other jurisdictions is completed.
32. 6VAC-15-40-1180. Special Purpose Area – The facility shall have a special purpose area to
provide for the temporary detention and care of persons under the influence of alcohol or
narcotics, who are uncontrollably violent or self-destructive, or those requiring medical
supervision.

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