Graves v Arpaio Expert Report on Medical Compliance at Maricopa County Jail Apr 2011 Partd
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Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 49 of 65 Services Administration Administration(SAMHSA) Health Services (SAMHSA) linked linkedtotoOTP OTP Health accreditation through theNational NationalCommission Commission on on throughthe accreditation Correctional Health Care. The requisite standards Health Care. The requisite standards for for Correctional accreditation are are available available in the2004 inthe 2004NCCHC NCCHC accreditation publication, Standards Standardsfor forOpiod OpiodTreatment TreatmentPrograms Programs in in publication, Correctional Facilities. Facilities. Correctional • Individual Individual physicians might complete complete . physicians employed employed by by CHS CHS might the additional additionaltraining trainingneeded neededtotoobtain obtainaaSAMHSA SAMHSA DATA DATA (Drug Addiction Addiction Treatment Treatment Act Act of of2000) 2000) Waiver Waiver for for use use of of (Drug Suboxone (buprenorphine) (buprenorphine Suboxone (buprenorphine) and Subutex (buprenorphine naloxone hydrochloride) in treatment treatment of of opiate opiate plus naloxone addiction. of these options involve approvals from state and federal All of federal agencies including the US US Drug Enforcement Administration. 1, 2011) be I estimate estimate that that another another three three months months (July (July 1, 2011) will wil be implementation of of which needed feasible plan, implementation needed to to establish aa feasible can hopefully hopefully be be completed completed by by December December1,1,2011. 2011. This projected projected date date reflects reflectsthe the substantial substantial time required to above. complete completeany any of ofthe thethree three options options outlined outlned above. Procedures CAP CAP- -88- - Review Reviewand and Revisions Revisions of of Policies Policies and Procedures On Onconcert concertwith withits itsapplication applicationand and preparation preparation for for an an accreditation by NCCHC, NCCHC, CHS accreditation survey by CHShas has reviewed reviewedand and revised revisednumerous numerous policies, policies, procedures, procedures, clinical clinical guidelines guidelines and and 45 45 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 50 of 65 protocols. This Thisongoing ongoing work work is is consistent consistent with withthe the following following protocols. objectives as stated in my August 20,2010 20, 2010Expert's Expert'sReport: Report: objectives Clinical guidelines guidelines that that meet nationally established established .• Clinical meet nationally professional recommendations recommendations are are in in place place for for evaluation evaluation professional and management management of of chronic chronic diseases diseases (including (including asthma, asthma, and chronic lung disease, epilepsy/seizure epilepsy/seizure disorders, disorders, cardiac cardiac chronic disease; diabetes, diabetes, lipid lipid disorders, disorders, hepatitis hepatitiscc infection, infection, disease, chronic liver liver disease, disease, chronic chronic kidney kidney disease, disease, human chronic immunodeficiency virus virus infection/ infection/AIDS); AIDS); immunodeficiency Nursingpolicies policies and proceduresand andprotocols protocols for for • Nursing . and procedures assessment are and any any changes changes are to be be reviewed reviewed in in detail and necessary have have been been made made to to assure assure appropriate nursing care in handling sick call call requests requests and encounters, emergency emergency encounters encounters and appropriate referrals to physicians, physicians, physician assistants assistants or nurse nurse practitioners; •. Nurses Nurseshave havebeen beenproperly properly trained, oriented, oriented, and evaluated evaluated in in their their use of these policies, policies, procedures procedures and and protocols. protocols. CHS CHSisis making making progress progress in in accomplishing accomplishing the foregoing foregoing objectives. reviewing their objectives. II will wil be reviewing their continued continued efforts efforts regularly regularly and Alvarez, Thomas and in detail with Dr. Alvarez, Thomas Tegeler Tegeler and and Katie Katie Wingate. reasonable to Wingate. It is reasonable to project project that that the foregoing foregoing objectives 2011. objectivescan can be be completed completed by by August August 1, 201 1. 46 46 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 51 of 65 CAP -- 99 -- Continuous QualityImprovement Improvement(CQI) (CQI)Program Program CAP Continuous Quality Through application application of of the the methods methods established established in its current current Through CBS includethe CHS will CQI Annual Plan, Plan, CHS thefollowing following actions: actions: CQI wil include • Systematic Systematicreviews reviewsofofpatient patient records records by by senior senior and peer . and peer medical staff to measure access, timeliness, timeliness, medical appropriateness, coordination, continuity of ofmedical appropriateness, coordination, and continuity Written findings findings and and and nursing care. care. Written identification of of any recommendations wil will accompany accompany identification or problems problems in lapses or in care. be suffcient sufficient in to be •. Medical Medicalrecord record reviews reviews wil will be in number number to be of acute (for (for example, example, representative of broad range range of syndrome) or alcohol alcohol withdrawal withdrawal syndrome) or chronic conditions and of patients patients residing residing in in all all jail jail facilities. assess whether record reviews Medicalrecord reviews will •. Medical wil assess whether clinically appropriate appropriate care care is is documented, documented, including including patient patient assessments assessmentswhenever wheneverorders ordersfor for medication medication or diagnostic diagnostic tests tests are are initiated. initiated. •. Under Underthe the direction direction of of the the Medical Medical Director, CHS Director, CBS CHSwill wil conduct clinical performance performance reviews reviews of the conduct annual annual clinical the employed employedphysicians, physicians,physician physician assistants, assistants, and and nurse nurse practitioners. These reviews reviews will practitioners. These will be be documented documented and and include include consideration consideration of of the the results results of medical medical record record 47 47 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 52 of 65 reviews, professional professional development development and and education, education, and and reviews, maintenance of ofspecialty specialty board board certification. certification. maintenance CHSclinical clinicaland andexecutive executive leaders leaders will regularly identify identify .• CHS wil regularly and review review all all deaths deaths or or other otheradverse adverse patient patientoutcomes outcomes and and oecurrences. occurrences. When When indicated, indicated,methods methodsof ofroot rootcause cause and analysis as as recommended recommended by the Joint Joint Commission Commission on on analysis Accreditation of Health Care Organizations wil will be be Accreditation employed and and documented. documented. leastquarterly, quarterly,CHS CHSutilization utilizationmanagement management activities activities .• AtAtleast will be be reviewed reviewed and wil and evaluated to to document that practitioner requests requests for specialist specialist consultations, offsite offsite practitioner diagnostic and treatment treatment procedures procedures are are completed completed in a diagnostic timely manner. timely •. CHS CHSwil willinstitute institute and tracking and maintain maintain comprehensive comprehensive tracking and monitoring systems systems for for Patient Patient Health Health Care Care and monitoring Requests. be conducted to validate Requests. Regular reviews reviews will wil be that inmates are seen in a timely timely manner manner and and that that written responses responses to requests are to their their requests are informative informative and professional. professionaL. •. CHS CHS wil willtrack trackand andmonitor monitorof ofindividual individual medication medication profiles profilesand and medication medicationadministration administration records records to to ensure ensure continuity eontinuity of ofadministration, administration, prevention of of adverse adverse drug drug reactions, reactions, and and dosages dosages consistent consistent with with individual individual patient patient needs adequate needsand andphysiological physiologicalcharacteristics. characteristics. Fully adequate attent.ion attention to to this this action action remains remains dependent dependent on on initiation initiation of ofthe theelectronic electronicmedical medicalorder orderentry entry and and medication medication 48 48 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 53 of 65 administration record record systems systemscurrently currently being being developed developed administration jointlyby byCHS CBS and and Diamond DiamondPharmacy PharmacyServices. Services. jointly Most of of the the foregoing foregoing actions are are either either already already in in place place or or Most implemented by by CHS. CBS. For For those those actions actions not notalready alreadyin in place, place, implemented reasonable to to expect expect completion completion by bySeptember September 1, 1, 2011. 2011. ititisisreasonable CAP-- 10: 10: Electronic CAP Electronic Order Order Entry, Entry, Medication Medication Administration and and Health Health Record Record Systems Systems Administration There has has been been aa delay delay in in implementation implementation of of the the electronic electronic pharmacy order entry project due to a a recent Drug Enforcement Administration directive that that each each CHS CHS clinic site site Administration directive have separate DEA DEA license. have aa separate license. Another factor was was the the need to add The add data lines lines to to the older Durango Durango and and Estrella Sites. Sites. The new time1ine new "go "go live" live" timeline timeline for for the the electronic electronic order entry and medication administration record systems systems is administration record is June June 1, 2011. 201 1. I agree with this this timeline agree with timeline as as part part of of the the Corrective Corrective Action Action Plan. Plan. Regarding Record Regarding development development of ofthe the Electronic Electronic Health Health Record System, System, aa Request Request for for Proposals Proposals (RFP) (RFP)document document has has been been approved approved by by the the Maricopa Maricopa County County Materials Materials Management Management Department. Selection of aa Vendor/System Department. Selection Vendor/System and the the HER HER Contract Contract Award Awardisisslated slatedtotooccur occurininJuly July2011. 2011. This This will will be be followed followedbybya aseries seriesofofsteps stepsincluding includinghardware hardwareinstallation; installation; Net Netdeployment; deployment;building building work work flow; flow; content content design; design; testing; testing; 49 49 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 54 of 65 and training. training. Full Fullactivation activationof ofthe the system systemisisprojected projectedfor for and June 2013. As part of this this Corrective Action Plan, Plan, the the Corrective Action June 2013. As part of foregoing milestones be incorporated incorporated and andmonitored. monitored. foregoing milestones will wil be CAP-- 10: 10: Internal External Validation Validation of of Structure, Structure, CAP Internal and and External Processes and and Outcomes Outcomes Pertinent Pertinent to to SAJ SAJ Requirements Requirements Processes leade~ship settlt~d The new CHS leadership sett}(~d is now now CHS leadeI,'ship leadership team team is is settled settled in in place. place. ItIt is appropriate and feasible feasible to establish a more robust and consistent framework to to evaluate evaluate compliance compliance with with SAJ SAJ are three three components components I requirements. Going Going forward, forward, there there are requirements. believe believe are are most important: complete their preparations •. CHS CHSand andthe theMCSO MCSO need need to to complete for a a NCCHC NCCHC accreditation accreditation survey and to achieve achieve full full accreditation. Many of accreditation. Many of the the structure structure and process are essential for aa NeCHC accreditation are requirements for NCCHC NCCHC stable and effective effective jail Achievement jailhealth health care care system. system. Achievement are also a a positive and and maintenance of accreditation are factor factor in in recruitment recruitment of qualified practitioners and nurses. nurses. its CQI cQr to •. CHS CHSwil willcontinue continue to to enhance enhance its CQI program program and and to CAP-8 accomplish accomplish the the tasks and objectives specified in CAP-8 and and CAP CAP-- 99 as as previously previously described. described. late May May 201 1, rIIwill wilbe beconducting conducting •. Beginning Beginningin in late 2011, quarterly quarterly medical medical record record reviews reviewsjointly jointlywith withCHS. CHS. The The 50 50 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 55 of 65 standardized methodology methodology of of these these reviews will allow for for standardized will allow comparison of of results sequential comparison results from from one one quarter quarter to to the the sequential next. Medical Medicalrecords recordsselected selected for for review review will be next. wil be sufficient in in number numberto characterize and tocharacterize andcompare compare suffcient populations, including outcomes for for typical patient including those those outcomes patient populations, with and and without without chronic chronic ilnesses. illnesses. with my Sixth This concludes concludes my Sixth Report. Report. Respectfully Respectfully submitted, /s/ lsI Lambert N. King, King, MD, MD, PhD, PhD, FACP FACP Lambert N. 51 51 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 56 of 65 UNITEDSTATES STATESDISTRICT DISTRICTCOURT COURT UNITED FORTHE THEDISTRICT DISTRICTOF OFARIZONA ARIZONA FOR No No CV CV 77-0479-PHX-NVW 77-0479-PHX-NVW Arpaio. Gravesv. v. Arpaio Graves SIXTH REPORT REPORT OF OF KATHRYN KATHRYN A. A. BURNS, BURNS, MD, MD, MPH MPH SIXTH ON CORRECTIONAL CORRECTIONALHEALTH HEALTHSERVICES SERVICESCOMPLIANCE COMPLIANCE ON WITH SECOND AMENDED JUDGMENT WITH SECOND AMENDED JUDGMENT APRIL 2011 2011 APRIL This report report is is being being fied filedfollowing following aa February February 2011 2011site sitevisit visitto to the theMaricopa Maricopa County County This Jails. II visited February 14-17,2011. touredthe theMental Mental Health Health Unit Unit(MHU) (MHU) and and Jails. visited the the jails jails February 14-17,2011. IItoured other mental mental health health treatment treatmentspace, space, met mental health health supervisory supervisory staff staffand and other met with with mental reviewed a a number The medical medical reviewed number of of documents documents in in addition addition to to reviewing reviewing medical medical records. records. The records reviewed focused focused almost serious mental records reviewed almost exclusively exclusively on on records records of of inmates inmates with with serious mental illness. ilness. II toured space and and reviewed reviewed medical medical records records at at Lower Lower toured mental mental health health treatment treatment space in Buckeye Jail, 4th Avenue Jail, Estrella and Durango. Since the time of the last site visit in Buckeye Jail, 4th Avenue Jail, Estrella and Durango. Since the time otthe last site visit it is 2010, 2010, Towers Towers Jail Jailisisno nolonger longerbeing beingused usedtotohouse housepre-trial pre-trial detainees; detainees; it is housing housing only only sentenced Towers JaiL. Jail. Fifty sentencedinmates. inmates. Ii did did not not visit visit Towers Fifty (50) (50) medical medical records records were were reviewed. reviewed. This headings in This report report is is organized organized around around the the item headings in my my August August 2010 2010 Compliance Compliance It is Report Reportand andJanuary January2011 2011site sitevisit visitreport report and and addendum. addendum. It is focused focused on on the the activity activity and and progress progress of of Correctional Correctional Health Health Services Services (CHS) (CHS) and and the the provision provision of of mental mental health health care care to to pre-trial Information from pre-trial detainees. detainees. Information from the the medical medical record record reviews reviews isisincluded includedunder underthe the relevant relevanttopic topicareas areasbut but also alsosummarized summarizedatatthe theend endof ofthe thereport. report. 11 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 57 of 65 Intake/ReceivingScreening Screening Intake/Receiving CHS continues continues to to conduct conduct intake intake screening screening of ofall a}] inmates inmatesas as they they are are booked booked into intothe the all CHS jail. Timeframes for follow-up ofpositive positive screenings screeningshave have been been updated updatedand andare arein inthe the jaiL. Timeframes for follow-up of process of of implementation. implementation. The The screening screening instrument instrument has has been been updated updated and and wil willbe be process entirelyelectronic electronicstarting startingininearly earlyApriL. April. entirely the medical medical records records indicates indicates the the screenings screenings are are timely timely and appropriately appropriately Review ofthe Review of identify persons persons in in need need of of immediate immediate mental mental health health attention, attention, medication medication orders orders and and identify other types types of ofreferraL. referral. The The screening screening instrument and process process appear other instrument and appear to to be be appropriately appropriately were three threeinstances instancesin inwhich which follow-up follow-up was was not not sensitive and and specific. specific. However, However, there sensitive there were to aa positive positive screen; screen; two two of ofthe the three three involved involvedfemale femaleinmates. inmates. CHS CBS CHS is is timelyininresponse response to timely responsiveness to necessity. A aware that aware that responsiveness to aa positive positive screening screening is is aa critical critical necessity. A Quality Quality Improvement study study is is planned to address implementation of of the the electronic electronic screening Improvement planned to address implementation screening follow-up timeframes. processand and compliance with follow-up process Referrals Health Need Requests (Inmate Self-Referrals) and Staff Referrals Health Need Requests (Inmate Self-Referrals) and Staff The new Health Needs Needs Request (HNR) (HNR)system system was was put put into into place place in in November November 2010 2010 and It was was too and includes includes aa mechanism mechanismto totrack track referrals referrals and and responses. responses. It too soon soon to to have have seen seen in the HNR process dramatic dramatic improvement improvement in the HNR process in inFebruary, February,though thoughall allmental mentalhealth-related health-related requests of the requests were were seen seen face-to-face face-to-facerather rather than than screened screened on on paper paper only. only. Three Three of the 50 50 HNR responses; one case case involved involved HNRs HNRs from clinical problematicHNR clinicalfiles fies reviewed reviewed contained contained problematic responses; one from August Augustand andSeptember September(before (beforethe thenew newprocesses processeswere were implemented) implemented) and and in in one one case casethe the HNR HNRwas wasincorrectly incorrectlyrouted routedto to medical medicalrather rather than than mental mental health. health.By Bythe thetime timethe theerror error was wasdiscovered, discovered,the theinmate inmatewas wasreleased. released. (The (The HNR HNRwas wasincorrectly incorrectlyrouted routedthrough through medical medicalbecause becausethe theinmate inmatehad hadidentified identifiedititasasa amedical medicalrather ratherthan thanmental mentalhealth healthrequest request 22 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 58 of 65 medicallTiage thoughthe thenarrative narrativeclearly clearlyidentified identifiedititasasmental mentalhealth; health;a acareful carefulread readby bymedical medical triage though triage sentthe the request request to to mental mental health health initially initiallysaving savingtime timeand and permitting permittingaa wouldhave havesent would critical nature.) nature.) In HNRwas was not not of of aa critical In the thethird thirdinstance, instance,the the responsethough thoughthis thisparticular particularHNR response ofless the larger issue involving involvingscreening screeningand and HNR was was ofless of lessconcern concernthan than the largerissue handlingofofthe theHNR handling Health Unit Unitfollow-up. follow-up. Mental Health Mental Mental Health Unit(MHU) Health Unit (MHU) Mental Admission and and discharge discharge criteria criteria have have been been formalized formalized and and implemented. implemented. Length Length of of Admission stay data data is is being being maintained. maintained. Staff Staff have have been about the the availabilty availabilityof of the the stay been educated educated about if hospitalization is deemed deemed Maricopa County County Health Maricopa Health System System for for psychiatric psychiatric hospitalization hospitalization if hospitalization is necessary though though the the transfer transfer process process had had not not yet yet been the site site visit. visit. been utilzed utilizedatatthe thetime timeof ofthe necessary Inmate-patients returning returning from from outside outside mental mental health emergency treatment or Inmate-patients health emergency treatment or MHU upon to the jail. Much Much progress hospitalization are automatically automatically admitted admitted to to MHU hospitalization are upon return return to the jail. progress group treatment treatmentin inthe theMHU. MHU. Confidential Confidential individual has been made made in in privacy privacy of of care has been care and and group individual and space has modified as as necessary necessary and and group group treatment treatment space has been been identified, identified, physically physically modified and is is in in use. of seeing is changing. changing. use. The The culture culture of seeing patients patients at at the the cell cell front front is On Onanother anotherbright bright note, note,treatment treatment and and programming programming for for patients patients that that are are difficultto historically historically very very difficult difficulttototreat treatare arequite quitegood: good:treatment treatment plans plans are are comprehensive comprehensive and and MHU staff push to individualized and MHU individualized and staff do do not not push to have have these these patients patients discharged discharged back backinto into the the general general population population quickly. quickly.These Theseare arethe thetypes typesof ofpatients patientsthat thatother other correctional correctional systems systems and andfacilities facilties sometimes sometimes view viewas asuntreatable untreatable and and manipulative manipulativeand andmental mentalhealth healthstaff staff CHS MHU refuse refuse to to treat. treat. CHS MHUstaff staffshould shouldbebeapplauded applaudedfor fortheir theirwork workwith withthis thissubset subsetof of patients. patients. Further, Further, there there isis good goodcoordination coordinationwith with the the other other jails jails around around discharge discharge planning planningfor forthis thisgroup groupof ofinmates. inmates. 33 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 59 of 65 Unfortunately,there thereare areaasizable sizable number numberofofpatients patientsthat thatare aregetting gettingdischarged discharged Unfortunately, oradequate adequatefollow-up follow-upupon uponrelease releasetotoone one prematurelyand andmany manyare arenot notreceiving receivingtimely timelyor prematurely the other otherjails. jails. Premature Prematurerelease releasecases casesmost mostoften ofteninvolve involveinmates inmatesadmitted admittedas asaa ofthe of underthe the precautiondirectly directlyfrom from the the booking booking process process due due to to statements statementsmade madewhile while under precaution or while withdrawing withdrawing from from drugs and/or and/oralcohoL. alcohol. Such Such inmates inmates are are rapidly rapidly influence or influence MHU but in short order assessedand anddischarged dischargedquickly quickly from from MHU assessed but some some return return for for readmission readmission in short order that perhaps perhaps the the assessment assessment was enough or or occurred occurred too toosoon soon _- an an indication indication that was not not thorough thorough enough theabsence absenceof ofdrugs drugs and andalcohoL. alcohol. This This issue issue is is further further to accurately accurately assess assess mental mental state statein in the to treatmentspace space to to manage manage arriving inmates that that are are complicated by by the the lack lack of of medical medical treatment complicated arriving inmates or withdrawing withdrawingand andthe theMHU MHU staffs concern to to ensure ensureadequate adequateMHU MHU intoxicated or intoxicated staffs concern admission bed space is available for emergency admissions both from booking and other mustbe be addressed addressedjointly jointlyby byCHS CHS medical jails. ItIt is is complicated complicated but but must medical and mental health leadership and line line staff. staff. leadership and with respect respect to the MHU was The The problem problem that occurred most frequently frequently with was untimely untimely other jails jails upon CHS planned to and outpatient follow-up follow-up in in the and inadequate inadequate outpatient the other upon discharge. discharge. CHS planned to address address the thetimeliness timeliness issue issuethrough through changing changing the the process processfor forscheduling schedulingthe thefollow-up follow-up by the the receiving receiving jail jail but but CHS CHS changed appointments. The follow-up follow-up had had been been scheduled scheduledby appointments. The changed the the protocol responsible" protocol to to make make MHU MHUstaff staffresponsible responsiblefor forscheduling schedulingthe thefollow-up follow-up appointments appointments in in the the Jail Management System as a result of this this finding. finding. Future Future audits audits should should find find improvement improvement Jail Management System as a result of in inthis this critical criticalarea. area. Adequacy of of outpatient outpatient follow-up follow-up isisrelated related to tothe the frequency frequency (or (or aswell wellasasthe thetype(s) type(s) infrequency) ofwith contacts and other mental health staff as infrequency) of contacts psychiatry with and otherpsychiatry mental health staff of oftreatment treatment interventions interventions provided. provided. These findings findings are are discussed discussed more more fully fullyunder under Outpatient OutpatientTreatment. Treatment. 44 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 60 of 65 Atthe thetime timeofofthe thesite sitevisit, visit,suicide suicide prevention preventionand and clinical clinical restraint restraintpolicies policieshad had At reviewand anddiscussion. discussion. been revised. The draft revisions are currently in the process ofreview been revised. The draft revisions are currently in the process of hadbeen beenone onesuicide suicideprior priortotothis thissite sitevisit, visit, another anothersuicide suicideoccurred occurredin inlate late (Note: There Therehad (Note: earlyMarch. March. CHS CHS isis in in the the process processof of Februaryand andaathird thirdinmate inmatedied diedby bysuicide suicideininearly February critically reviewing reviewing these these incidents incidentsand andconducting conductingpsychological psychological autopsies.) autopsies.) critically Outpatient Care Care Outpatient Problems· with outpatientcare care were identified in infifteen fifteenof were identified ofthe the 50 50 records. records. Problems Problems Problems with outpatient treatmentintervals; intervals; treatment treatmentofofcaseload caseload inmates inmates only only in in response response to to included infrequent infrequent treatment included HNR rather than planned, planned, regular contact; and and over-reliance of psychotropic psychotropic medication medicationas as HNR rather than regular contact; over-reliance of intervention. Significant Significant improvement improvement in in this this area area is is not not essentially the essentially the sole sole treatment treatment intervention. CHS develops discharge criteria; criteria; expected until until CHS expected developsand andimplements implements outpatient outpatient admission admission and and discharge treatmentteam team meetings meetings and and frequency by discipline; discipline; frequency frequency of frequem.y oftreatment frequency of of intervention intervention by treatment plan updates; updates; and and group group and and individual individual interventions. interventions. By By mutual mutual agreement, agreement, treatment plan level of revising revising the the outpatient outpatient level of care care was was postponed postponed to to permit permit earlier earlier and and undivided undivided other critical critical areas areas and and to to encourage encourage the the use use of of line line staff staffto attention to other attention to to develop develop the the outpatient guidelines through outpatient guidelines through aa quality quality improvement improvement team team process. process. Coordination Coordination of ofmedical medicaland andmental mental health health care care CHS CHSundertook undertookaanumber numberofofinitiatives initiativesto toensure ensurebetter bettercoordination coordination between between medical medicaland andmental mentalhealth health providers providers for for inmates inmates with with both both types types of of problems. problems. The The medical medical policy policyregarding regardingtreatment treatment of ofpregnant pregnant women women was wasrevised revisedto to reflect reflectreferral referral and and coordination coordinationwith withmental mentalhealth; health;psychiatric psychiatricdisorders disordersare are now nowdocumented documented on onthe the medical medicalproblem problemlist listininfront frontof ofeach eachchart chartand andthe theproblem problemlist listdocument documentitself itselfwas was 55 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 61 of 65 redesigned to to better betterintegrate integratemedical medicaland and mental mental health healthcare; care; and and psychiatric psychiatric providers providers redesigned chroniccare have been been instructed to review reviewmedical medical chronic care flow flowsheets sheets during during psychiatric psychiatricclinics clinics have instructed to theirlevel levelof ofawareness. awareness. Four Four fies filesreviewed reviewedcontained raising their containedproblems problemsrelated relatedto tomedical medical raising mentalhealth healthpatients: patients:one onerelated care follow-up follow-upofofmental relatedtotomedical medicalhanding handingofofaaHNR, HNR,one one care thatdoesn't doesn'tappear appeartotobe related to to seizure seizure disorder disorderthat befollowed followedby bymedical, medical,and andone one related related related to not not receiving receiving prescription prescriptionmedications medications timely timely following MHU discharge. discharge. The The most most followingMHU to of coordination with medical in aa psychiatric psychiatric patient serious case case involved involved the the lack lack of medical in patient with with serious coordination with psychogenic polydipsia polydipsia -- aa condition causes metabolic metabolic abnormalities that that can can lead lead to to psychogenic condition that that causes not treated for for them or death. (The (The patient patient had had abnormal laboratory laboratory results but was was not or results but death. Fortunately,an medical for the the problem. problem. Fortunately, an adverse adverse incident incident did not result result and and followed by by medical did not patient was statehospitaL.) hospital.) careatatthe the patient was discharged discharged to to inpatient inpatientpsychiatric psychiatriccare thestate for Incompetent Treatment for Incompetent Criminal Criminal Defendants Defendants As noted noted previously, previously, use of the There is is nothing new to to report on this topic. topic. As Maricopa Maricopa County Health Health System Systemfor forpsychiatric psychiatric hospitalization hospitalization had not yet started at the time time of the the site visit. Psychotropic medications Thirteen Thirteen cases cases involved involved issues issues with with respect respect to to psychotropic medication medication management. management. They were divided divided into into problems of two two types: types: prescriptive prescriptive issues issues and and follow-up follow-upissues. issues. Prescriptive Prescriptive issues issuesincluded: included: problems problems with with prescriber prescriber medication medication choice(s); choice(s); continued continued problems problems with with medication medication renewal renewal or or discontinuation discontinuation without without aa facefaceof Court to-face to-faceappointment; appointment;delays delaysininrecognition recognition(and (andsubsequent subsequent utilization) utilzation) of Court Ordered Ordered receipt medication in spite of receipt (COT); and one afailure to medication provide a non-formulary Treatment Treatment (COT); and one failure to provide non-formulary in spite of 66 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 62 of 65 ofverification. verification. The Theissues issuesinvolving involving follow-upincluded involVingfollow-up includedcases casesininwhich whichthe thefollow-up follow-up of interval after aft~rstarting startingmedications medicationswas wastoo toolong; long; failure failure to to address address noncompliance noncompliance or or interval reportsof ofside sideeffects effects timely; timely; and and medication or medication continuity continuity problems problems with with inmate inmatehousing housingor reports job assignment assignment changes. changes. Psychiatric Psychiatricprovider providerpeer peerreview reviewprocesses processesshould shouldbegin begin to to job address prescriptive intervalissues identify and and address prescriptive and andinterval issueswhile while the the more more general general medication medication identify audits should should find find and and correct correctnoncompliance noncomplianceand andcontinuity continuitywith withhousing housingmoves. moves. audits Staffing Staffing There is no update with regard regard to to staffing other than to report report that thatlast lastyear's year'snewly newly created positions have have been been filled filled and has been notable improvement been notable improvement in in the the capacity capacity created positions and there there has space. and treatment in privacy privacy due to provide provide treatment to treatment in due to to the the additional additional escort escort officers offcers and treatment space. time have have also also yielded yielded beneficial results. Additional Additional psychiatric and and clerical/support clerical/support time (CQI) Continuous Continuous Quality Quality Improvement Improvement (CQ1) the HNR A number HNR process number of of initiatives initiatives are are underway: underway: the process was was revised, revised, implemented An audit audit instrument forMHU MHU levels levels of ofcare care is is and instrumentfor and monthly monthly compliance audits audits were were started. started. An system to under A system under development. development. A to track and analyze analyze major major mental health health incidents incidents is in for mental health staff, staff, psychologists mental health place. underway for place. Peer review efforts are underway psychologists and and psychiatric A quarterly medical-psychiatric committee meeting has psychiatric providers. providers. A quarterly medical-psychiatric committee meeting has begun. begun. SegregationjDiscip-line Segregation Segregation/DisciQline Segregati 0 nI Discip-line (Discipline CHS CHSisisnow nownotified notifiedof ofall allcaseload caseloadinmates inmateswith withserious seriousmental mentalillness ilness who receive aa disciplinary disciplinaryinfraction. infraction. The The relevant relevant policies policiesmust must now now be bewritten written or or revised revised to to reflect reflect the the practice practiceand andinform inform CHS CHSstaff staffon ondocumentation documentationrequirements. requirements. Mental Mental health health care care to to inmates inmatesininsegregation segregationisisprovided providedunder under private private conditions. conditions. The The place placeand and circumstances circumstances 77 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 63 of 65 the interaction interactionisisdocumented documentedininthe thechart an audit ofthe chartnote noteand andan auditofufthe theprivacy privacyexpectation expectation of as reflected reflected in in the the charting chartingisis planned. planned. as Training Training provided the lesson plans was provided the training trainingcurriculum curriculumlesson plans used used in in providing providing 16-hours 16-hours of of iI was mental health-related health~relatedtraining trainingtotoall allMaricopa MaricopaCounty County Sheriffs SheriffsOffice Office correctional correctionalofficers. officers. mental In general, accurate and relevant, accurate and appropriate. appropriate. Further, Further,although althoughII In general, the the content content appears appears relevant, relevant, the actual have have~ not not seen seen the actual training, training, itit is is clear dear from from the lesson plans that that aa number number of of methods methods have information such such as as lecture, lecture, fim, are used used to to convey convey the the information film, discussion disClission and and role role play; play; different different are arereinforced inmultiple multiple ways. ways. learning styles are addressed addressed and and important importantpoints pointsare reinforcedin However, for reasons Report, II continue to believe that reasons sited sited in in my my Fifth Report, that the modest quality joint mental health-custody staff staff committee to review improvement for aa joint mental health-custody improvement recommendation for it as as necessary for officers assigned to to supplement it the curriculum in order to revise or supplement necessary for offcers assigned posts dealing with with inmates inmates most at risk and at highest risk of serious serious mental health problems (booking/receiving (booking/receiving area, area, MHU MHU and andall allsegregation segregationunit unitposts) posts) remains remains relevant relevant and and appropriate. appropriate. Medical Medical records records review review As SO sample As noted noted previously, previously, Ii reviewed reviewed 50 50 medical medical records records during during the the site site visit. visit. The sample included included nine nine cases casesthat that were were referred by plaintiffs' plaintiffs' counsel; counsel; other other records records were selected at random random from from lists listsof ofseriously seriouslymentally mentallyillilcaseload caseloadinmates. inmates. Attention Attention was was focused focused primarily primarily on onthe the last last six sixmonths monthsof ofcare caretotodetermine determinewhether whether more more recent recent changes changes have have focusing on lead leadto to improvement improvement rather rather than than focusing on past past problems problems and and deficiencies deficiencies already already CHS. identified and acknowledged acknowledged as as problematic by CHS. identified and problematic by 88 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 64 of 65 Mostof the ofthe the findings findingshave have been been reported reportedwhen whendiscussing discussingthe the various varioustopics topicsininthe Most preceding sections sections and and won't won'tbe be repeated repeatedhere hereexcept exceptin insummary/table summaryIta bleformat formatatatthe theend end preceding ofthis this section. section. Items Items not notpreviously previously mentioned mentioned include: include: 12/50 12/50 fies filesreviewed reviewedrevealed revealedno no of the level level of of mental mental health deficiencies with with respect health care care provided: provided: the the inmate-patient inmate-patient respect to to the deficiencies appeared to to be be receiving receiving an an appropriate appropriatelevel level of of care, care, was being seen at appropriate appropriate appeared had been been enrolled enrolled into into treatment treatmentat atscreening orthereafter thereafteras intervals, had screening or asnecessary necessaryin in aa intervals, timely fashion, was receiving medications appropriate appropriatefor for condition, condition, etc. etc. (One (One of of the the twelve reviewed reviewed was was identified identified as as being being on on the mental health health caseload caseload according according to the the twelve inmate-patient was caseload list but the inmate-patient was not not actually actually on on the caseload caseload nor nor did he appear appear to Thisisisaa database database clean-up require services services based based on on his screening screening and and assessment assessment results. This require issue, Notably, there these cases cases identified identified this visit issue, not not aa care care issue. issue. Notably, there were many fewer of ofthese to clean-up inaccuracies than in the past past and CHS CHS has has dedicated dedicated some some support support resources to and update information in the database.) Record Review Review Issue Issue or or Problem Problem None Intake/Receiving IntakefReceiving Intake/Receiving Screening ~~9.!!~st Health Re9!!.est Health Needs Needs Reguest Request MHU Stay MHU Stav MHU MHU Follow-up Follow-un Outpatient Outoatient Coordination Coordination with with Medical Medical Medication Medication prescription orescriotion Medication follow-up Medication follow-uo ._._-~- records' ## records* 12 3 33 7 12 12 19 19 44 66 66 such as as premature MHU discharge discharge and and missed missed more than one problem problemsuch *· Some reviews had had more than one prematureMHU Some file fie reviews timely timelyoutpatient outpatient follow-up follow-upappointment, appointment, so sothe the problems problems total total exceeds exceeds 50. 50. 99 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 65 of 65 Conclusion Conclusion There has has been been significant significant progress progressin inphysical physical plant plantmodifications modifications for for confidential confidential There care, policy policy and procedure implementation implementation and and developing developing processes processes for for self-monitoring self-monitoring care, through continuous continuous quality quality improvement. improvement. The The revised revised policies policies and and procedures procedures for for suicide suicide through The MHU MHU is patients, prevention and and clinical restraint restraint are in draft form. The prevention is treating treating difficult diffcult patients, plans for them and and coordinating coordinating discharge discharge planning planning developing comprehensive treatment treatment plans outpatientproviders. providers. More Moregroup group interventions interventionsare arebeing beingprovided provided to to all all inmates inmates in in with outpatient MHU. Staffing has improved with psychiatric providers as well as some support staffto staff to MHU. Staffng has improved with psychiatric providers as well as some support staff assist with scheduling, scheduling, tracking tracking and and filing fiing tasks tasks and there are additional dedicated escort officers which has has helped helped get get inmate-patients inmate-patients to to mental mental health health appointments appointments in in treatment treatment spaces that Pretrialdetainees detaineesare areno nolonger longerhoused housedininTowers TowersJaiL. Jail. spaces that are are private. private. Pretrial Areas include premature prematureMHU MHU discharge, discharge, MHU MHU Areas that continue to need improvement improvement include follow-up follow-up after after discharge, discharge, integrating integrating medical medical and and mental health care and psychotropic medications. Mental health outpatient outpatient care care too too often consists of medication management medications. Mental other mental mental health health clinicians clinicians though there is a plan with infrequent supportive supportive contacts by by other to more more critical critical areas of of care such as to address outpatient outpatientlevel level of of care after improvements to screening, screening, health health need need requests requests and andMHU MHUoperations operations are are more more firmly firmly established. Respectfully Respectfully submitted, submitted, ~4.~l~4Plt ~(f.~,~~lt ~a,~/~~lf ~a·~,~~lf Kathryn MD, MPH MPH Kathryn A. Burns, MD, AprilS, 2011 2011 AprilS, 10 10