Snohomish County, WA Health Care Assessment DOJ 2013
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United States Department of Justice Snohomish County, WA Correctional Facility Washington, DC National Institute of Corrections Assessment of Correctional Health Care Policy & Practice Medical, Mental Health, Suicide Prevention Technical Assistance Report Number 13J1075 ASSESS Sept. 23-25, 2013 ANALYZE ACTUALIZE Kenneth A. Ray, M.Ed. DOJ / NIC Technical Consultant U.S. Department of Justice National Institute of Corrections Washington, DC 20534 DISCLAIMER RE: NIC Technical Assistance No. 13J1075 This technical assistance activity was funded by the Jails Division of the National Institute of Corrections. The Institute is a Federal agency established to provide assistance to strengthen State and local correctional agencies by creating more effective, humane, safe and just correctional services. The resource person who provided the onsite technical assistance did so through a cooperative agreement, at the request of the Snohomish County, WA Sheriff and through the coordination of the National Institute of Corrections. The direct onsite assistance and the subsequent report are intended to assist the agency in addressing issues outlined in the original request and in efforts to enhance the effectiveness of the agency. The contents of this document reflect the views of Mr. Kenneth Ray. The contents do not necessarily reflect the official views or policies of the National Institute of Corrections. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 1 of 100 CONSULTANT QUALIFICATIONS Kenneth A. Ray, M.Ed., LMHC, NCC The United States Department of Justice National Institute of Corrections assigned Kenneth A. Ray this short-term technical assistance project at the specific request of Snohomish County officials following a review of prospective qualified consultants. Ken is a national expert in correctional administration, policy, and operations with more than 35 years of experience in law enforcement, corrections, security, criminal justice administration, behavioral health and consulting. He retired from county government administration in 2005, following a very successful and productive 29-year career serving in many professional and community roles including deputy sheriff, police officer and supervisor, law enforcement administrator and director, criminal justice academy director, emergency management director, jail administrator and director of medium and large county jail systems, community leader and volunteer. His professional and community contributions earned several local, state, and national accolades in the areas of public safety, criminal justice, academic, community and youth wellness. Ken is also a licensed mental health primary care provider and Board Certified by the National Board for Certified Counselors. His expertise in jail mental health, suicide prevention practices, and facility design has provided pivotal assistance to numerous jails throughout the United States. Some include Yakima County, WA Department of Corrections (1200 beds), Dallas County, TX (8500 beds), Lake County, IN (1050 beds) St. Croix and Chippewa Counties, WI (500 beds combined) and Orange County, TX (350 beds). Ken has served as the lead compliance consultant to a Federal Jail Civil Rights Settlement Agreement at Lake County, IN since late 2010. As that County’s Liaison to the United States Department of Justice Civil Rights Division and compliance assurance coordinator, he leads an interdisciplinary team of national experts in the fields of correctional medicine, suicide prevention, life and fire safety, sanitation, and use of force. Ken also serves as the court appointed Federal Monitor for Golden Grove Correctional Facility, St. Croix, U.S. Virgin Islands. Ken holds a M.Ed. in Counseling and Human Development, Bachelors and Associates degrees in Criminal Justice and Law Enforcement, and is pursuing a Doctor in Behavioral Health degree at Arizona State University. His work in behavioral health spans the entire time of his professional career including developing and implementing school-based behavioral health services, forensic assessment and counseling, jail-based mental health services, residential and outpatient clinical primary care of individuals, families, children, and groups. He has in excess of 4000 hours professional development training, and has completed academic residencies and internships in metropolitan police administration, community policing, psychiatric prison inmate assessment and treatment, jail-based mental health services, pediatric health diagnosis and treatment, and community mental health. As an adjunct professor at public and private universities in Texas and Washington states, Ken taught graduate and undergraduate courses in criminal justice, business administration, and counseling. He has conducted over 300 professional presentations on various criminal justice, education, law enforcement, corrections, and mental health topics at the local, state, and national levels since 1986. Ken is married with six children and one grandson, and resides in Ashland, Kentucky. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 2 of 100 ONE PROFESSIONAL PERSPECTIVE “When you begin to use excuses to justify a bad outcome, whether it be low staffing levels, inadequate funding, physical plant concerns, etc. – issues we struggle with each day – you lack the philosophy...that even one death is not acceptable. If you are going to tolerate a few deaths in your jail system, then you’ve already lost the battle.” (Jail Commander, Orange County, California)1 1 http://www.ncianet.org/suicideprevention/publications/avoidingobstacles.asp SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 3 of 100 EXECUTIVE SUMMARY This short-term technical assistance assessed medical, mental health, and suicide prevention practices at the Snohomish County, WA Correctional Facility. This assessment compared current practices to over 50 important components for providing constitutional and effective correctional health care programming. This study should not be considered an in-depth or comprehensive evaluation. All recommendations herein are provided as pathways to best practices and to assist Snohomish County target and prioritize its plans for improving inmate care. By no means does the report intend to minimize the exceptionally high-level commitment, competence, and professionalism of any Snohomish County official or staff member. To the contrary, this report fully assumes that it is precisely those qualities and attributes that cause the Snohomish County Correctional Facility to be an excellent operation and fully capable of implementing relevant improvements proposed. Furthermore, considering its limited resources, all officials and staff should be commended for their commitment to maintaining a very professional local correctional facility. This document provides findings and recommendations for all of the health care components assessed. Three common themes became vivid among most areas of care and should be of significant concern. These include: 1) inadequate staffing levels, 2) jail crowding, and 3) lack of evidence-based health care policy and procedure manual. Health care staffing levels are simply undersized to ensure adequate assessment and care of inmate medical and mental health needs. The jail health care program (medical and mental health) is seriously understaffed for this size jail, its layout, annual admissions and average daily population. Additionally, authorized correctional staffing levels appear inadequate to ensure consistent and timely access to health care services for the same reasons. Jail crowding continues to exist and poses significant health and personal safety risks for the staff and inmates. Crowding increases environmental stressors that can increase jail violence and medical injuries. Inmates suffering from mental illness are more difficult to manage and care for in crowded conditions. The stress of crowding can also exacerbate mental health symptoms. Communicable disease prevention, management, and control are debilitated where housing units are overpopulated. Adding to these problems is the high level of stress experienced by jail staff and the adverse impact that stress has on their physical, emotional, social health. Relieving the crowded conditions should be considered a top priority. Current jail health care policies and procedures documents should be considered only as basic guidelines but require comprehensive reform. Policy and procedure development and implementation is a medium-range project (6-12 months) that can be streamlined efficiently by researching, developing, and moving individual or a few policies through the process rather than the entire policy manual. Kenneth A. Ray, M.Ed., DOJ/NIC Technical Assistance Consultant SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 4 of 100 TABLE OF CONTENTS SECTION: PAGE(S) COVER X DISCLAIMER 1 CONSULTANT QUALIFICATIONS 2 ONE PROFESSIONAL PERSPECTIVE 3 EXECUTIVE SUMMARY 4 TABLE OF CONTENTS 5 I. INTRODUCTION 6 II. PURPOSE OF ASSISTANCE 7 III. SCOPE OF WORK 7 IV. DOCUMENT REVIEW 16 V. METHODOLOGY 17 VI. LEGAL FRAMEWORK – INMATE RIGHTS TO HEALTHCARE 18 VII. DESCRIPTIONS OF THE SNOHOMISH COUNTY JAIL 25 VIII. MEDICAL CARE ASSESSMENT, FINDINGS, & RECOMMENDATIONS 34 IX. MENTAL HEALTH CARE ASSESSMENT, FINDINGS, & RECOMMENDATIONS 55 X. SUICIDE PREVENTION ASSESSMENT, FINDINGS, & RECOMMENDATIONS 67 XI. RELATED ISSUES, FINDINGS, & RECOMMENDATIONS 97 XII. CONCLUSION 100 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 5 of 100 Technical Assistance Report Inmate Medical, Mental Health & Suicide Prevention & Management Services and Practices Snohomish County Correctional Facility NIC Technical Assistance Request No. 13J1075 Kenneth A. Ray, M.Ed., DOJ/BOP/NIC Technical Service Provider I. INTRODUCTION This report is a summary of the observations, document reviews, interviews, discussions, findings and recommendations of Kenneth A. Ray, M.Ed., NIC Technical Services Provider, following the completion of professional technical assistance at Snohomish County Correctional Facility, herein referred to as SCCF. Short-term technical assistance to assess jail medical, mental health and suicide prevention practices and services was requested in writing to the Department of Justice National Institute of Corrections, herein referred to as NIC, by elected county Sheriff Ty Trenary. Sheriff Trenary selected this technical resource provider to provide this service. This assistance project was approved by Virginia Hutchinson, NIC Jails Division Chief, and coordinated by Panda Adkins, NIC Correctional Program Specialist, Washington, D.C.2. 2 NIC Technical Assistance Authorization Letter, 2013. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 6 of 100 PURPOSE OF ASSISTANCE Snohomish County Sheriff Ty Trenary requested assistance from NIC to assess and evaluate jail medical, mental health, and suicide prevention practices. Technical assistance was specifically requested to focus on the following objectives for medical and mental health services regarding standards of care and services: II. SCOPE OF WORK This technical assistance project includes activities performed prior to the onsite visit. On-site work was performed September 23-35, 2013. Project activities included pre on-site preparation, on-site assessment, post-visit follow-up, and report writing. A. Pre-On-Site Activities Included: 1. Contact with Sheriff Trenary, Chief Jeff Miller, Major Mark Baird to prepare for and coordinate on-site work. Collection and review of several jail documents including policies and procedures, census reports, and health care reports. 2. Prepare an agenda for the technical assistance event. 3. Review all requested and received documents and data. 4. Prepare a timeline of tasks to be completed while onsite. 5. Prepare any questions to be resolved prior to the technical assistance onsite visit. This consultant provided the following information to Snohomish County prior to the onsite visit to give them a general idea about information needed and scope of this assessment. Historical Information and Data Basic information about the existing facilities, construction dates, total bed capacity, basic housing and inmate management designs (direct supervision, linear, indirect podular, etc.). Administrative 1. Jail health care and related policies, procedures, protocols; 2. Intake health screening and classification documents and electronic screens/templates; 3. Health care assessment and care assessment, treatment, and discharge documents and forms 4. Health care budgets (5 years); 5. Health care charting practices; 6. Current staff credentialing notebook; 7. Continuous quality improvement meeting minutes and practices; 8. Health care provider contracts; 9. Health care provider contract monitoring reports (if any, 5 years); 10. Health care related grievances, claims, litigation (5 years); 11. Jail state inspection reports (5 years); SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 7 of 100 12. Major health care related incident reports (5 years); 13. Inmate deaths, suicides, suicide attempts (5 years); 14. Admission, release, ADP data (5 years); 15. Other information and documents deemed relevant to assessment. Health Care Service Delivery Components 1. Access to healthcare, responsible health authority, medical autonomy, administrative meetings and reports; 2. Healthcare policies and procedures; 3. Continuous quality improvement program; 4. Emergency response plan; 5. Communication on special needs patients; 6. Privacy of care; 7. Inmate death procedures; 8. Grievance mechanism for healthcare complaints; 9. Federal sexual assault reporting regulation compliance (PREA); 10. Infectious control program; 11. Environmental health and safety; 12. Ectoparasite control; 13. Healthcare staff credentialing, qualification; 14. Clinical performance enhancement program; 15. Continuing education program; 16. Correctional officer training; 17. Medication administration training; 18. Inmate worker training/health assessment; 19. Staffing plan (healthcare organizational structure); 20. Healthcare liaison (after hours support); 21. Corrections orientation for healthcare staff; 22. Pharmaceutical operations (access and administration); 23. Medical services control of medications and access; 24. Clinical space, equipment, and supplies (access, quantity, control and access); 25. Diagnostic services; 26. Hospital and specialty care; 27. Inmate information about healthcare services while incarcerated; 28. Intake healthcare screening (who, how, what, when); 29. Health assessments (who, how, what, when); 30. Mental health screening (who, how, what, when); 31. Oral care services; 32. Non-emergency healthcare requests and services; 33. Emergency services (include afterhours); 34. Health segregated inmates; 35. Patient escorts and movement; 36. Nursing assessment protocols; 37. Continuity of care during incarceration; 38. Discharge planning; SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 8 of 100 39. Inmate healthcare education and promotion; 40. Nutrition and medical diets; 41. Exercise; 42. Personal hygiene; 43. Use of tobacco; 44. Special needs treatment plans; 45. Management of chronic disease; 46. Infirmary care; 47. Mental health services; 48. Suicide prevention and intervention program; 49. Intoxication and withdrawal; 50. Care of pregnant inmates/counseling; 51. Inmates with substance abuse/addiction problems; 52. Sexual assault prevention and intervention program; 53. Orthoses, prostheses and other impairment aids 54. Hospice care; 55. Health record format and contents; 56. Record / information confidentiality; 57. Access to custody information; 58. Availability and use of health records; 59. Transfer of health records; 60. Retention of health records; 61. Use of restraints and seclusion; 62. Emergency psychotropic medications; 63. Forensic information; 64. End-of-life decision making; 65. Informed consent; 66. Right to refuse treatment; 67. Medical and other research. Jail Suicide Prevention Program Components 1. 2. 3. 4. 5. 6. 7. 8. 9. Critical Component #1: Staff Training Critical Component #2: Intake Screening/Assessment Critical Component #3: Communication Critical Component # 4: Housing Critical Component # 5: Levels of Supervision Critical Component #6: Intervention Critical Component #7: Reporting Critical Component #8: Follow-up Mortality Review Critical Incident Debriefing SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 9 of 100 Mental Health Services Components Minimum care program requirements: (Ruiz v. Estelle, 503 F. Supp. 1265 (S.D. Tex. 1980) 1. Constitutional Right #1: There must be a systematic program for screening and evaluating inmates in order to identify those needing mental health services. 2. Constitutional Requirement #2: There must be a mental health treatment program that involves more than segregation and close supervision. 3. Constitutional Requirement #3: There must be trained Mental Health Professionals in sufficient numbers to provide the identification and treatment services in an individualized manner to treatable inmates suffering a serious mental disorder. 4. Constitutional Requirement #4: There must be maintenance of accurate, complete, confidential records. 5. Constitutional Requirement #5: Treatment by prescription and administration of behavior- altering medications in dangerous amounts and by dangerous methods or without appropriate supervision and periodic evaluation is an unacceptable method of treatment and must not be present. 6. Constitutional Requirement #6: There must be a suicide identification, treatment and supervision program. There must be a basic program for identification, treatment and supervision of inmates who evidence suicidal tendencies (and mental health problems). Additional components of this assessment: 7. Diversion of selected defendants and offenders with mental illness: As a general rule, a person with serious mental illness is less likely to be dangerous, especially with community support, than a person without mental illness. There are some terrible exceptions. Studies continue to show that non-dangerous people with serious mental illness can and will comply with non-incarceration conditions of release. The costs for diverting a mentally ill defendant or offender from incarceration has also proven to be an effective option for reducing incarceration costs and recidivism among this population. 8. Identification of people with mental illness entering the criminal justice system: An effective system utilizes evidence-based mechanisms to identify and manage this population. In general, jails as a rule cannot meet the needs of seriously mentally ill inmates. Special judicial mechanisms and community involvement have been found to improve both criminal justice and treatment outcomes. 9. Jail-based treatment programs encompass co-occurring / co-morbid mental health conditions: It is likely that most mentally ill inmates have a substance abuse problem, history of severe psycho-emotional trauma (physical and sexual abuse, severe neglect, etc.). Jail-based treatment programs are most effective in affecting good custody and care when these issues are assessed and treated. 10. Training of staff on the signs and symptoms of mental disorders and inmates with specific needs: Pre and in-service training should include topics that help staff recognize, identify, and effectively manage this population from intake through to release. 11. Adequate number of qualified mental health jail staff: This includes licensed and unlicensed care providers, support staff, and custody staff. Staffing levels should be determined by levels of need and required care activities (intake, assessment and SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 10 of 100 diagnosis, treatment and discharge planning, medication management, and records keeping). 12. Adequate physical resources: There is adequate housing and treatment capacity for this population. Exercise and recreation are considered basic jail requirements and are required to be provided for this population. Areas for individual and group treatment should exist and allow for adequate levels of privacy and confidentiality. Housing options should allow for different levels of care and security based on needs and risk. 13. Access to care: This includes how and when inmates access mental health care services. Are services readily accessible? Is there enough custody staff needed to consistently move inmates to and from care services? Is there enough care staff on-site to meet the needs of the population? 14. Contents of health records: Good health records are the cornerstone to effective care and to the legal requirement of continuity of care. They are instrumental in evidencing care quality of assurance. Records must be complete, thorough, and accurately represent care activities. 15. Medication management: Psychotropic medications can be a first-line of care for treating severe mental illness and can be an extremely expensive treatment. Accurate diagnoses, individual and group therapy, and status monitoring combined have shown to produce the best care outcomes. However, jails tend to use older medications that can cause serious side effects resulting in “inmate zombies” and less-than-effective care. It is important that medications prescribed are indicated by the FDA for the diagnosis or symptoms presented, that there is ongoing monitoring of inmate progress, and medications are changed as indicated. As a rule, it is a very poor practice to change medications of a newly admitted mentally ill inmate simply because the jail does not want to pay for current medication regime. 16. Restorative opportunities: This simply refers to the options and services provided in a jail setting that affects restoration of mental health stability and activities of daily living – self-care. 17. Management information systems: A model MIS should be computerized and used for needs assessment, continuous quality improvement, and tracking. Jail-based electronic health systems should easily interface with the jail management system to ensure data reliability and utility efficiency. 18. Quality assurance program: An ongoing internal survey, evaluation, and feedback system accompanied by a statutory, evidentiary privilege to safeguard such studies from disruptive discovery demands should be part of any system. 19. Data/research on treatment outcomes: Treatment objectives are first determined for this population, then policies, procedures, programs, services, environments, etc. are developed to meet the objectives. The entire care delivery process is data driven. 20. Economy of scare: Administrative and organizational structures should be designed to provide the maximum care for the funds allocated. 21. Policies and procedures: Contemporary, comprehensive, and accessible policies and procedures are developed, implemented, and reviewed by a multidisciplinary team. 22. Discharge planning: Structures and processes should exist to prepare mentally ill inmates for release. This should include assisting them to reactivate financial and community resources to meet basic needs and their treatment needs. All inmates with a serious mental illness should be released with a completed and clear release plan. The release SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 11 of 100 plan should be coordinated with appropriate criminal justice components, community and personal supports. Staffing Levels: Staffing (health care, support, and custody) levels are generally assessed in terms of the facility’s ability to meet access to and delivery of required medical and mental health services. A general recommendation regarding whether or not additional staffing is necessary to meet required levels of care will be provided in the final report. Additional Information and Documents: A) Medical and Mental Health Information: 1. A mock or blank chart containing all forms used, filed in appropriate order. 2. The infection control policies. 3. The names of inmates who have died in the past year, and access to/or copy of both their records and mortality review. 4. The names of any inmates diagnosed with active TB in the past year and access to/or a copy of their records. 5. To the extent not provided above, the policies and procedures governing medical and mental health care. 6. A staffing roster with titles and status, part time or full time, and if part time, how many hours worked per week. 7. The staffing schedule for the past two (2) months for nursing and providers, including on-call schedules for the same time period. 8. Job descriptions for medical staff and copies of current contracts with all medical care providers, including hospitals, referral physicians, and mental health staff. 9. Inter-local professional services agreements with health care providers, companies, to include health care policies under which those persons and/or entities provide inmate health care. 10. Tracking Logs for consults and outside specialty care services provided, chronic illness, PPD testing, health assessments, and inmates sent to the emergency room or off-site for hospitalization listing where applicable name, date of service, diagnosis and service provided. 11. A list of all persons with chronic illness listing name, location, and name of chronic illness. 12. A schedule of all mental health groups offered. 13. Minutes of any meeting that has taken place between security and medical for the past year. 14. Quality assurance and Medical Administration Committee minutes and documents for the past year. 15. A list of all emergency equipment at the facility. 16. A list of current medical diets. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 12 of 100 17. Sick call logs (i.e., lists of all persons handing in requests for non-urgent medical care to include in the log presenting complaint, name, date of request, date triaged, and disposition) and chronic illness appointments for the past two (2) months. 18. A copy of the nursing protocols. 19. To the extent not provided above, a copy of any training documentation for security and medical staff on policies and procedures and emergency equipment. 20. A list of all the inmates housed at the facility by birthdate, entry date, and cell location. 21. To the extent not provided above, external and internal reviews or studies of medical or mental health services including needs assessments and any American Correctional Association and National Commission on Correctional Healthcare reports. 22. List of all inmates placed in restraints, and all inmates receiving mental health treatments, under suicide watch, or taking psychotropic drugs. Current mental health case list including inmate name, number, diagnosis, date of intake, last psychiatric appointment, next psychiatric appointment, and any case lists of inmates followed only by counseling staff with last appointment date and follow-up appointment. 23. Documentation reflecting any training that facility staff has received on suicide prevention, including certificates and training materials. 24. All documents related to the any suicide occurring within the past year. 25. List of all persons on warfarin, Plavix, digoxin. B) Suicide Prevention Information: 26. All policies and directives relevant to suicide prevention. 27. All intake screening, health evaluation, mental health assessment, and any other forms utilized for the identification of suicide risk and mental illness. 28. Any suicide prevention training curriculum regarding pre-service and in-service staff training, as well as any handouts. 29. Listing of all staff (officers, medical staff, and mental health personnel) trained in the following areas within the past year: first aid, CPR/AED, and suicide prevention. 30. The entire case files (institutional, medical and mental health), autopsy reports, and investigative reports of all inmate suicide victims within the past three years. 31. List of all serious suicide attempts (incidents resulting in medical treatment and/or hospitalization) within the past year. 32. List of names of all inmates on suicide precautions (watch) within the past year. 33. The suicide watch logs for the past year. 34. Clinical Seclusion logs for the past year. 35. Use of clinical restraint logs for the past three years. 36. Any descriptions of special mental health programs offered. 37. A list of all uses of emergency and forced psychotropic medications in the past year. 38. A list of any use of force associated with the administration of psychiatric medications for the past year. 39. A description of medical and mental health’s involvement/input into the disciplinary process and clearance for placement in segregation. 40. List of all inmates referred for off-site psychiatric hospitalization in the past three years. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 13 of 100 It is noted that these officials were exceptionally helpful and timely with the pre-visit process and coordination. Though much of the information and data requested was either not available or easily compiled prior to and during the site visit, staff were very knowledgeable about the topics and provided basic information and data needed to complete this assessment. B. On-Site Activities Included: 1. Meet with Major Mark Baird and other designated staff to discuss the purpose of the technical assistance scope of work. 2. Review the established agenda and discuss any modifications. 3. Review medical/mental health staffing and meet all key personnel 4. Tour the facility including intake and release, classification, initial housing, housing unit(s), segregation, and medical and mental health areas including cells and/or housing units. 5. Review any documentation and contracts not previously received. 6. Review medical care processes. 7. Continue interviews with facility staff, inmates, and other medical, behavioral health and social service administrators as designated by Major Baird. 8. Conduct an exit interview meeting with Sheriff Trenary, Chief Miller, Major Baird, and other designated staff, providing them with observations, preliminary findings and recommendations. While on-site, this consultant met with several SCCF staff, jail medical and mental health treatment providers, and inmates. Participants in this activity are listed below: 1. Sheriff Ty Trenary 2. Mark Ericks, Deputy County Executive 3. Brent Speyer, Undersheriff 4. Chief Jeff Miller 5. Chief Rob Beidler 6. Major Mark Baird 7. Captain Chris Bly 8. Captain Harry Parker 9. Hillary Graber, County Counsel 10. Keith Mitchell, Risk Manager 11. Michael Held, Deputy Prosecutor 12. Dan Oster, Classification 13. Stuart Andrews, MD, Medical Director 14. Sandra Needham, ARNP 15. Dan Miller, ARNP 16. Tim King, RN 17. Greg White, MS, Lead MHP 18. Elizabeth Bellmer, MHP 19. Edward Dapra, MHP 20. County and Agency Nursing Staff SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 14 of 100 It is important to note that ALL Snohomish County officials and service providers were exceptionally professional, helpful, motivated, and cooperative in participating in this process. This consultant observed positive, active, and deliberate efforts to develop, provide, and maintain effective inmate medical, mental health and suicide prevention services by all SCCF, County officials and services providers involved in this work. C. On-site Activity Agenda: PRE VISIT CONTACT Jeffrey Miller, Chief of Corrections PRE VISIT Mark Baird, Corrections Admin Panda Adkins, NIC ON-SITE VISIT 09/23/13 ACTIVITY Review TA request; clarify TA objectives, scheduled, activities, and involvement. CONTACT / ACTIVITY Ty Trenary, Sheriff 9:00am Jeffrey Miller, Chief of Corrections Collect & review pertinent information & documents, discuss data systems, performance tracking method. PROPOSED ACTIVITY DETAIL Meet & Greet with Sheriff and Jail administration and medical leadership; review proposed needs & objectives, special needs, review schedule, & involvement. 10:00am TBD HealthCorrections Care Leadership Mark=Baird, Admin (Medical, Behavioral Health, Social Services) Intros, overview of access to and delivery of care model, system, practices. Identify needed data and documents i.e., Policies, procedures, protocols, clinical guidelines, MAR, EMR, credentialing records, CQI and volume data, reports, studies. Concerns, needs, strengths, and challenges. 11:00am TBD =Facility Tour Overview tour from Sally Port, intake, classification, initial housing, housing assignment, segregation, medical and mental health areas and cells, etc. 12:00pm Lunch meeting TBD Review tour; clarify observations, verify data/information needed for assessment/report. 1:30pm TBD = Team Interviews Booking supervisor, Intake medical and mental health screeners, classification supervisor. 2:30pm TBD = Team Interviews Medical primary care team, charge nurse, HSA, infectious care program coordinator, chronic care program coordinator, sick call / clinic coordinator, infirmary coordinator, others. Review medical care processes, concerns and needs, clarify collect data, information and documents for review, meeting with jail and community healthcare providers and resources; clarify needs; concerns; challenges; barriers and opportunities, document examination. 4:00pm Debrief with Corrections Leadership Debrief: review, clarify, refocus as indicated 5:00pm Follow-Ups PRN 09/24/13 8:00am Check-in with Admin 8:30am TBD = Team Interviews SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY Behavioral Heath primary care team, Mental health director, selected primary care providers, DMHPs, other MH team members including correctional officers. Mental health services / suicide prevention services. Discuss and review mental health and suicide prevention care processes, concerns and needs, clarify collect data, information and documents for review, meeting with jail and community healthcare providers and resources; clarify needs; concerns; challenges; barriers and opportunities, document examination. NIC TA 13J1075 Page 15 of 100 11:00am Corporate Council Review medical-legal issues and concerns 12:00pm Lunch Meeting Discuss CRIPA and jail health care requirements, other. 1:00pm TBD = Inmate Interviews GP, segregation, intake holding, suicide/special needs, female/male, other. 3:00pm TBD = Team Interviews Training Discuss and review initial, pre-service, in-service training program and processes, examine relevant training topics, curricula, certification and credentialing, strengths, limitations, opportunities. 4:00pm Leave open for document reviews Focus area: Population health management data, epidemiology, volume, etc. 8:00am Check-In with Admin Verify information/data/document collection and clarification. 8:30am Follow-up Interviews, Tour, Etc. Overview provisional assessment and findings. 9:30am Pre-exit Sheriff/Admin Team General overview of assessment and findings, attendance per Sheriff. 09/25/13 TBD General Exit Meeting TBD Late Flight Departure to Chicago III. DOCUMENT REVIEW Numerous documents were provided and reviewed before, during, and following the on-site assessment visit: 1. Jail policies and procedures 2. Professional services agreement for health care services 3. Various general orders 4. Inmate census and charge reports 5. Jail organizational chart 6. Inmate treatment intervention referral procedure 7. Inmate mental health treatment services reports 8. Health care policies, procedures, and protocols 9. Inmate intake forms and related documents 10. Medication administration records (MAR) 11. Suicide risk screening 12. Special Watch Log Forms 13. Inmate Consent for Release of Information 14. One Month Medication Utilization Report 15. Inmate Classification Housing Lists 16. Mental Health Status Exam documents 17. Medical transport forms 18. Health screening and appraisal forms 19. Medical charts 20. Miscellaneous documents SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 16 of 100 IV. METHODOLOGY A. This short-term assessment was conducted according to NIC jail technical assistance protocols. This included pre-visit communication with client/agency officials, collection and review of relevant document, data and other information provided by the client/agency, coordination of site visit activities and a short-term site visit. B. The site visit included an initial meeting with key officials to discuss the assessment and to clarify expectations and outcomes. It also included several tours of the facility, meetings, and interviews with key jail and health care staff, interviews with inmates, review of health care charts and other medical records, reviews of agency health care policies, procedures, protocols, staff, training, and other information. An exit meeting with the Sheriff, Jail administrator and other key officials was conducted on the last day of the site visit. This meeting included a discussion of this consultant’s general impressions and opinions; issues of concern and risk, and a general discussion of the report and completion timelines. C. Report writing included a more in-depth review of documents and information provided before, during and following the site visit. Additional research was conducted on salient topics and issues involved in this assessment, consultation with other professionals as needed, follow-up contact with client-agency officials and contractors to clarify specific information and findings, and completion of the report with supporting documents and references. Special Note: Snohomish County officials and staff are to be commended for their involvement in this work. The value of this assessment is a direct result of their commitment to quality and constitutionally sound inmate healthcare at the Snohomish County, WA jail. The following section provides a brief discussion about the legal framework on which jail health care services are required and provided. This discussion does not assume any facts or findings about health care services at the Snohomish County jail unless specifically stated and explained. This discussion intends to serve as a backdrop of the legal foundation for providing appropriate and constitutional levels of health care services in the jail setting. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 17 of 100 V. LEGAL FRAMEWORK - INMATE RIGHTS TO ADEQUATE HEALTHCARE The following discussion lays out a general legal foundation regarding a jail’s obligation to provide adequate medical, dental and mental health care to inmates. A. The Civil Rights of Institutionalized Persons Act (CRIPA)3 In an effort to stem the tide of prisoner section 1983 litigation and strike a balance between deference to state officials and the rights of the institutionalized, Congress enacted the Civil Rights of Institutionalized Persons Act (“CRIPA”) in 1980. Prior to 1980, inmates who wanted to sue in court were not required to exhaust their administrative remedies. CRIPA applied only to section 1983 actions and contained the first exhaustion requirement for prisoner lawsuits. CRIPA did not require mandatory exhaustion, however, and gave judges the power to require plaintiffs to exhaust administrative remedies when "appropriate and in the interests of justice." A judge could continue a case for up to 180 days if he believed that the suit could be resolved using administrative remedies. This discretionary exhaustion requirement offered [jail] officials the ability to resolve violations in administrative proceedings without involving the courts. The exhaustion provision of CRIPA further limited its own application by mandating that exhaustion could only be required where the administrative remedies had been certified by the Attorney General as meeting certain minimum standards. These standards required that inmates be afforded an advisory role in creating and applying a grievance procedure. The Supreme Court created a balancing test for determining when to require exhaustion under CRIPA, "federal courts must balance the interest of the individual in retaining prompt access to a federal judicial forum against countervailing institutional interests favoring exhaustion." Beyond the exhaustion requirement, CRIPA also gave the Attorney General of the United States authority to sue state and local officials responsible for facilities exhibiting a pattern or practice of flagrant or egregious violations of constitutional rights. CRIPA also set forth guidelines for prison administrative procedures and required that states have their procedure certified by the Attorney General in order to require exhaustion of remedies. Even with this discretionary exhaustion requirement, CRIPA allowed inmates to participate in the formation of the grievance procedures and many states refrained from having their procedures certified because of this requirement. The states’ refusal to adopt these provisions and alter their grievance procedures to accommodate inmates’ civil rights had the opposite of the intended effect and actually increased the number of prisoner suits filed and contributed to the burden on federal dockets as well as increased costs to prisons caused by defending suits. In response, many legal scholars, politicians and judges supported a change in the system that would reduce the number of frivolous lawsuits. 3 Civil Rights of Prisoners: The Seventh Circuit and Exhaustion of Remedies Under the Prison Litigation Reform Act, Seventh Circuit Review, Volume 1, Issue 1, Spring 2006 (www.kentlaw.edu/7cr/v1-1/mccomb.pdf) SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 18 of 100 B. The Prison Litigation Reform Act of 1995 The civil rights of inmates were again the subject of Congressional legislation in 1996 with the passage of the aptly named amendment to CRIPA, the Prisoner Litigation Reform Act (“PLRA”). Though the legislative history is minimal, the PLRA was intended to stem the tide of purportedly frivolous prisoner lawsuits and reduce judicial oversight of correctional facilities. The PLRA represented a major change in prison litigation creating barriers such as requiring physical injury in tort claims, forcing even in forma pauperis prisoners to pay filing fees, and creating limits on attorney's fees. Most importantly, however, the PLRA drastically modified the CRIPA’s exhaustion of administrative remedies provision. Under the PLRA, inmates are required to exhaust all administrative remedies available, mandating, “No action shall be brought with respect to prison conditions under section 1983 of this title, or any other Federal Law, by a prisoner confined in any jail, prison, or other correctional facility until such administrative remedies as are available are exhausted.” The PLRA's exhaustion requirement was more restrictive and differed from CRIPA in five important ways: First, the PLRA applies to all state, local and federal prisoners in contrast to CRIPA, which did not apply to federal prisoners or juveniles. Second, the exhaustion requirement was broadened to include pretrial detainees as well as convicted prisoners. Third, the PLRA requires dismissal of cases in which administrative remedies were not exhausted. Before the PLRA, courts continued or stayed cases until prisoners had exhausted administrative remedies. The PLRA lacks the discretionary application of the exhaustion requirement and removes the ability of judges to determine when requiring exhaustion is appropriate. Finally, before a court could require a prisoner to use a prison's administrative grievance process, the process had to meet certain requirements. The PLRA removed the requirements that exhaustion of administrative remedies must be "appropriate and in the interests of justice" or that the administrative remedies be "plain, speedy and effective." The PLRA also removed the five statutory standards for administrative remedies and required only that the remedies be "available." The impact of the PLRA on prisoner lawsuits for constitutional violations was immediate and substantial. In the last year under CRIPA, inmates filed 41,679 civil rights petitions. In 2000, four years after the passage of the PLRA, the number of civil rights petitions dropped to 25,504 - a reduction of 39%. Specifically, the more comprehensive and automatic exhaustion requirement greatly increased the number of inmate lawsuits that were dismissed for failure to exhaust all available administrative remedies. The Supreme Court, in interpreting the new exhaustion requirement under the PLRA, held that inmates were required to exhaust all available administrative remedies regardless of whether the claims involved general circumstances of incarceration or particular incidents, thus ensuring that the PLRA will govern all prisoner lawsuits in every state. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 19 of 100 C. Inmate Healthcare4 Jail inmates have the right to receive adequate health care. The Eighth Amendment of the US Constitution guarantees the right to be free from cruel and unusual punishment, which the Supreme Court has determined to include the right of prisoners to have access to health care.5 The denial of necessary medical care is a Constitutional violation only if prison officials are "deliberately indifferent" to a “substantial risk of serious harm.” 6 Medical, dental and mental health care would fall within the scope of these legal expectations. In order for an inmate to successfully claim that inadequate medical care violated his constitutional rights, he must prove two things 7 : (1) that the poor treatment resulted in “sufficiently serious”8 harm (the objective standard), and (2) that the prison official responsible for the harm knew of an excessive risk to inmate health or safety and disregarded that risk by failing to attempt to minimize it9 (the subjective standard). The Objective Standard of Care: Generally speaking, for an injury to be considered "sufficiently serious," the harm must significantly change the prisoner's quality of life. For example, harm would be considered "sufficiently serious" if it causes degeneration or extreme pain. Some examples of medical needs that the courts have considered "sufficiently serious": degenerative, painful hip condition that hindered the inmate's ability to walk painful, obviously broken arm bleeding ulcer that caused abdominal pain inflamed appendix shoulder dislocation painful blisters in mouth and throat caused by cancer treatment pain, purulent draining infection, and 100 degrees or more fever, caused by an infected cyst cuts, severe muscular pain, and burning sensation in eyes and skin, caused by exposure to mace head injury caused by slip in shower substantial back pain painful fungal skin infection broken jaw requiring jaw to be wired shut for months severe chest pain caused by heart attacks 4 http://www.washlaw.org/projects/dcprisoners_rights/medical_care.htm#objectiveStandard Estelle v. Gamble, 429 U.S. 97, 97 S. Ct. 285, 50 L. Ed. 2d 251 (1976). 6 Farmer v. Brennan, 511 U.S. 825 (1994). 7 Criteria summarized in A Jailhouse Lawyer’s Manual (JLM), 5th edition. New York: Columbia Human Rights Law Review , 2000, p. 540. 8 Wilson v. Seiter, 501 U.S. 294, 298, 115 L. Ed. 2d 271, 111 S. Ct. 2321 (1991). 9 Martinez v. Mancusi 443 F.2d 921, 924 (1970). In: JLM, p. 542. 5 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 20 of 100 Some examples of medical needs that the courts have determined NOT to be "sufficiently serious": sliver of glass in palm that did not require stitches or painkillers pain experienced when doctor removed a partially torn-off toenail without using anesthetic nausea, shakes, headache, and depressed appetite caused by family situational stress "shaving bumps" The Subjective Standard of Care: A jail official cannot be “deliberately indifferent” to a medical need if he is not aware of the medical problem. Thus, an inmate must make sure that jail officials know about his medical needs. If an inmate wants to see medical personnel, he must inform the corrections officers on his block. He must fill out sick call slips and, if these are not honored, he must file grievances. Once an inmate gets in to see a nurse or doctor, he should tell him about his symptoms and any relevant medical history. While an inmate should do all he can to make sure that medical personnel are aware of his medical problems, medical personnel can also be held responsible for knowing information in addition to what the inmate tells them. Specifically, medical personnel are responsible for information gained by examining the inmate, reviewing the inmate’s medical records, and by talking to others familiar with the inmate (guards, other doctors, and family members, for example). If a jail official knows of an inmate’s medical problem, he must do what is in his power to address that problem. If a jail official knows of an inmate’s substantial medical need and disregards it, he can be held accountable for violating the inmate’s constitutional rights. Listed below are some common situations in which courts have held that officials were deliberately indifferent to inmates’ medical needs. Failure to Treat a Diagnosed Condition: If a jail doctor diagnoses an inmate with a certain medical condition and then fails to provide that inmate with treatment for this condition, courts are likely to find that that doctor has been deliberately indifferent to inmate’s medical needs. If an inmate suffers serious harm as a result of this lack of treatment, jail officials can be held liable for violating the inmate’s rights. For example, if an inmate who is diagnosed with HIV receives no drugs to inhibit the virus and as a result develops full-blown AIDS more quickly than he should have, jail medical staff can be held liable. Similarly, jail officials other than doctors can be held liable for infringing on an inmate’s rights if the official prevents an inmate from receiving treatment recommended by a doctor. For example, the 2nd Circuit Court of Appeals held that prison officials were deliberately indifferent to an inmate’s medical needs when they removed him from a hospital without permission from the SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 21 of 100 doctors. 10 Jail officials without medical training do not have the right to second-guess the recommendations of doctors. Delay in Treatment or Delay in Access to Medical Attention: Jail officials do not have to provide inmates with immediate access to non-emergent medical care. Generally speaking, jail officials can delay in providing medical care if they have a legitimate reason for doing so. For example, security concerns can justify delaying an inmate’s access to medical care, as long as this delay does not make the medical problem significantly worse. On the other hand, unreasonable delays do violate the Constitution. A delay is considered to be unreasonable if it is medically unjustified and it is likely to make the medical problem worse or to result in permanent harm. For example, the 7th and 8th Circuit Courts of Appeals have ruled that 10-15 minute delays in responding to heart attacks constitute deliberate indifference.11 Also, the 4th Circuit Court of Appeals held that prison officials were deliberately indifferent when they delayed 11 hours in examining an inmate’s painfully swollen and obviously broken arm.12 Denial of Access to Medical Personnel: Jail officials cannot deny inmates’ access to health care personnel. If an inmate requests health care attention, non-healthcare staff may not decide whether or not to allow the inmate to see health care personnel. For example, in Parrish v. Johnson, the 6th Circuit Court of Appeals ruled that a guard who failed to relay an inmate’s request for health care was deliberately indifferent to the inmate’s medical needs.13 Similarly, the 11th Circuit Court of Appeals found a physician’s assistant to be deliberately indifferent to an inmate’s medical needs when the assistant refused to x-ray an inmate with a broken hip or to send him to a doctor for examination.14 Grossly Inadequate Care: Negligent medical care does not generally violate the Constitution. In jails, health care malpractice, generally speaking, does not constitute a violation of prisoners’ rights. On the other hand, excessively bad medical care can violate a prisoner’s eight Amendment rights. For example, a jury could find that a jail official acted with deliberate indifference if he treats a patient with a serious risk of appendicitis by simply giving him aspirin and an enema.15 Inadequate staffing levels have been determined by the United States Department of Justice as a direct and indirect cause for Civil Rights violations. Insufficient staff levels create serious access to care barriers resulting in medical neglect. Additionally, assigning unqualified staff to perform 10 Martinez v. Mancusi, 443 F.2d 921, 924 (1970). In: JLM, p. 542. Lewis v. Wallenstein, 769 F.2d 1173, 1183 (7th Cir. 1985) and Tlamka v. Serrell, 244 F.3d 628, 633-34 (8th Cir. 2001). In: Toone, p. 81 12 Loe v. Armistead, 582 F.2d 1291, 1296 (4th Cir. 1978). In: Toone, p. 81 13 800 F.2d 600, 605 (1986). In: Toone, p. 80. 14 Mandel v. Doe, 888 f.2d 783, 789-90 (1989). In: Toone, p. 80 15 Sherrod v. Lingele, 223 F.3d 605, 611-12 (7th Cir. 2000). In: Toone, p. 84. 11 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 22 of 100 medical or mental health care functions outside their scope of licensure or practice can be cause for inadequate care violations as noted in a 2012 DOJ jail Investigation Findings Letter16: “Our investigation found reasonable cause to believe that the Jail is denying necessary medical and mental health care, and consequently places prisoners at an unreasonable risk of serious harm, in violation of the Constitution… Many of the lapses we identify below are directly related to [the jail’s) inadequate medical staffing. There is too little onsite coverage by properly licensed staff members, forcing certified nursing assistants (CNAs) to practice and provide medical care beyond their training and licensure. The lack of sufficiently trained and available medical staff for the management and evaluation of serious medical conditions places prisoners at risk of unnecessary harm and is deliberately indifferent to prisoners’ serious medical needs. Prison officials, including doctors, “violate the civil rights of inmates when they display ‘deliberate indifference to serious medical needs.’” Gordon v. Kidd, 971 F.2d 1087, 1094 (4th Cir. 1992) (citing Estelle v. Gamble, 429 U.S. 97, 104 (1976))... “Perhaps the most significant single concern we have with the provision of medical and mental health care at the Facility is that staff members routinely perform medical services beyond what they are trained and credentialed to do. A further concern involves “medical” security officers. We reviewed several incidents in which security staff were used to evaluate prisoner injuries, and cleared the prisoners without any medical input or consultation. Any clinical support by corrections officers must be limited, must be overseen by the medical department, and must be guided by clear protocols. Corrections officials may, and in fact, should, respond to medical emergencies in acute, life-threatening situations and be properly trained to do so. They should never, however, evaluate prisoners for medical reasons, perform sick call, or provide any type of nonemergency care. There are no protocols in place at [the jail] to guide corrections officers in the very limited medical tasks they may perform, and the current level of medical department oversight of officers is insufficient.” D. Inmate Psychiatric Treatment and Mental Health Care: It is important that jail officials and local government leaders clearly recognize and acknowledge that adequate inmate psychiatric treatment and mental health care is a fundamental constitutional obligation of the jail and, therefore, a constitutional duty of local government. Such care should be looked at no differently than medical care when it comes to providing constitutionally adequate care and custody of inmates. The courts have consistently applied the same constitutional standard for inmate medical care to psychiatric and mental health services. These standards generally consist of these six (6) elements: 16 http://www.justice.gov/crt/about/spl/documents/piedmont_findings_9-6-12.pdf SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 23 of 100 1) Timely and appropriate assessment, treatment and monitoring of inmate mental illness 2) Making appropriate provisions for an array of mental health services that is not limited to psychotropic medication only 3) Ensuring that administrative segregation and observation is used appropriately 4) Mental health records are accessible, complete and accurate 5) There is proper and adequate response to medical and laboratory orders in a timely manner 6) That adequate and ongoing quality assurance programs are in place The Fourteenth Amendment mandates that jails must provide pre-trial inmates “at least those constitutional rights . . . enjoyed by convicted prisoners,” including Eighth Amendment rights.17 Under the Eighth Amendment, prison officials have an affirmative duty to ensure that inmates receive adequate food, clothing, shelter, and medical care.18 The Constitution imposes a duty on jails to ensure an inmate’s safety and general well-being.19 This duty includes the duty to prevent the unreasonable risk of serious harm, even if such harm has not yet occurred. 20 Thus, jails must protect inmates not only from present and continuing harm, but also from future harm. This protection extends to the risk of suicide and self-harm.21 The Constitution also mandates that jails provide inmates adequate medical and mental health care, including psychological and psychiatric services. 22 Jail officials violate inmates’ constitutional rights when the officials exhibit deliberate indifference to inmates’ serious medical needs.23 17 Bell v. Wolfish, 441 U.S. 520, 545 (1979). Farmer v. Brennan, 511 U.S. 825, 832 (1994). 19 County of Sacramento v. Lewis, 523 U.S. 833, 851 (1998) (citing DeShaney v. Winnebago County Dep’t of Soc.Servs., 489 U.S. 189, 199-200 (1989)). 20 Helling v. McKinney, 509 U.S. 25, 33 (1993). 21 Matos v. O'Sullivan, 335 F.3d 553, 557 (7th Cir. 2003); Hall v. Ryan, 957 F.2d 402, 406 (7th Cir. 1992)(noting that prisoners have a constitutional right “to be protected from self-destructive tendencies,” including suicide) 22 See Farmer, 511 U.S. at 832 23 Estelle v. Gamble, 429 U.S. 97, 102 (1976). 18 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 24 of 100 VI. DESCRIPTION OF SNOHOMISH COUNTY CORRECTIONAL FACILITY The Snohomish County Correctional Facility is managed by the Elected Snohomish County Sheriff and is located in Everett, Washington. SCCF operates under the Revised Code of Washington (RCW) Title 70, Public Health and Safety, City and County Jail Act (Chapter 70.48). Additionally, the SCCF is a function under the oversight of the Sheriff’s Office pursuant to Snohomish County Code. SCCF The Facility SCCF consists of two adjoining structures, the Wall Street facility, and the Oakes Street facility. Wall Street facility, the oldest of the two structures, opened in 1986 as a direct supervision jail with a rated capacity of 477. By 2001, the average daily inmate population exceeded 1,000. Subsequently, construction of the Oakes Street facility, also direct supervision, began in 2003 and it opened in 2005, raising the combined bed capacity to 1196 beds excluding medical and intake beds. The combined facilities’ current total capacity is 1233 beds. Housing Capacities SCCF has 26 inmate housing units totaling 1233 beds, excluding the booking area. The table below shows unit designations and capacities: Location 2-N 2-S 3-N 3-S 4-NC 4-NC 4-ND 4-SA 4-SA 4-SB 5-N 5-S Unit Designation Male Intake Male Minimum Male Inmate Workers Male Minimum Segregation Male Max / Discipline Male Max / Discipline Segregation Male Max / Discipline Male Minimum Male Psychiatric Housing Male Special Custody Capacity 79 79 97 79 2 18 20 2 18 36 17 37 Location D-MHU D-MHO E-1 E-2 E-3 E-4 F-1 F-2 F-3 F-4 G-1 G-2 G-3 G-4 Unit Designation Medical Housing Mental Health Observation Female Special / Max Female Minimum Female Intake Male Psych Male High/Medium Male High/Medium Male Medium Male Medium Male Minimum Male Minimum Male Minimum Male Minimum Capacity 24 10 32 64 64 40 64 64 64 64 64 64 64 64 As a matter of practice, SCCF utilizes six (6) units for medical and mental health monitoring and care. In some cases, mentally ill inmates co-house with non-mentally ill inmates. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 25 of 100 Classification Capacity Standard The generally accepted standard for determining usable capacity is to determine what is known as “Classification Capacity.” Classification capacity is usually 85 percent of a jail’s maximum capacity. In this case, the maximum bed capacity is 1233. The classification capacity for the Snohomish County Jail, therefore, is 85 percent of 1233 beds or 1048 inmates. To rephrase, when the average daily population (ADP) reaches 1048 inmates, the jail is functionally full. Classification capacity is a common and necessary tool that jails use to ensure that adequate capacity exists to implement needed separation of various inmate classifications, to handle temporary surges in occupancy, and to provide temporary housing for large arrest events. Maintaining average daily jail population at classification capacity is vital to the safety and security of the facility. Jail data provided for this assessment clearly show that the facility has exceeded its maximum and authorized capacity for most of time it has been in operation. Crowded inmate conditions, combined with insufficient health care and custody staffing levels, present unique access to care concerns. The following are a few of these concerns: 1. Management of communicable disease; 2. Inmate injuries sustained in assaults and fights related to psychoemotional stress caused by crowding in housing units; 3. Successfully controlling chronic illness such as hypertension and diabetes; 4. Providing security during medication passes; 5. Moving inmates to and from sick call clinics; 6. Monitoring inmates on suicide watch and inmates recovering from illnesses; 7. Effective management of mentally ill inmates; 8. Temptation to authorize unqualified health care staff to provide assessment and care that exceeds their scope of practice/licensure. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 26 of 100 A. ADP, Classification Capacity, Population Management Average daily inmate population (ADP) and capacity data provided by SCCF officials clearly suggest chronic long-term crowding. Although severe overcrowding was alleviated in 2005 with the opening of the Oakes Street facility, that was the only year since 2001 that the facility operated below its designated classification capacity of 1048 inmates. The figure below illustrates these findings. Chronic crowding is further evidence by the fact that the maximum and classification capacity utilization averaged 95% and 112% respectively from 2005 – 2013. Simply stated, SCCF has daily operated well above its classification capacity, and at or near its maximum capacity, for almost 12 years as shown in the figure below. Max Capacity Utilization 2001 213% 2002 209% 2003 187% 2004 173% 2005 80% 2006 98% 2007 104% 2008 99% 2009 96% 2010 94% 2011 97% 2012 96% 2013 96% Avg (since 2005) 95% Year SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY Classification Capacity Utilization 251% 246% 220% 203% 94% 115% 123% 117% 113% 111% 114% 112% 112% 112% NIC TA 13J1075 Page 27 of 100 Jail crowding imposes many direct and indirect challenges and adverse impacts on inmate health care delivery and services. Meeting inmate health needs are especially challenged when the inmate census exceeds bed capacity and/or health care and custody staffing resources. Unfortunately, this assessment, combined with findings in a recent NIC Operational Assessment, finds that both of these conditions exist. Inmate crowding continues to exist, health care and custody staffing levels are insufficient to ensure consistent assessment of inmate health care needs and delivery of services care by qualified health care providers. Despite its best efforts, the SCCF is unable to provide adequate access to health care service to its inmates. RECOMMENDATION(S): Officials should take immediate steps to reduce jail crowding. County should implement planning activities that project future jail needs, identify opportunities to reduce future jail use (or at least reduce the rate of growth) and explore facility options to prevent crowding in the future. Serious consideration should be given to exploring alternative housing options for inmates with serious medical and mental health needs. B. SCCF Custody and Health Care Staffing Levels – The Critical Challenge Jail Staffing and the Federal Courts24 Court decisions define important parameters for jail operations by establishing minimum levels of service, performance objectives, prohibited practices, and specific required practices. We explore federal court decisions in this appendix, but we note that state and local courts also play an active role in evaluating and guiding jail operations. Decisions handed down by federal courts have required jails to: Protect inmates from themselves, other inmates, staff, and other threats Maintain communication with inmates and regularly visit occupied areas Respond to inmate calls for assistance Classify and separate inmates Ensure the safety of staff and inmates at all times Make special provisions for processing and supervising female inmates Deliver all required inmate activities, services, and programs (medical, exercise, visits, etc.) Provide properly trained staff Federal court involvement with jails goes back more than 40 years. State and federal prisons were the focus of many landmark cases in this era, and local jails soon became targets as well. 24 See: Excerpts from: Jail Staffing Analysis Third Edition, Jail Staffing and the Federal Courts Copyright 2009, Rod Miller, Dennis R. Liebert and John E. Wetzel. (An NIC project). SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 28 of 100 Early federal decisions tackled fundamental constitutional issues in jails. Many of these pioneering decisions are still cited in current litigation. Courts view staffing levels and practices as central to the constitutional duty to protect The United States Constitution imposes an extraordinary duty to protect on jails that has no counterpart in the public safety. While our duty is less visible to the public, and likely less appreciated, it rises above the constitutional responsibilities of our public safety colleagues. Even probation does not approach the duty to protect that is imposed on jails. Probation officials are not held responsible for the behavior of offenders under their supervision, nor for what happens to the offenders when they are not actually with a probation officer. Do citizens have a constitutional right to be protected from crime or to have a fire extinguished? No, these are services that government chooses to provide. Whether or not to provide these services, and the level of services that are delivered, are discretionary decisions, from a constitutional perspective. To be sure, it is politically expedient to provide fire and police protection. Because such services are discretionary, officials may vary staffing levels in response to temporary or long term staff shortages. But a jail’s duty to protect is constant, beginning when an inmate is admitted and continuing until release. Case law clearly establishes the responsibility of jail officials to protect inmates from a “risk of serious harm” at all times, and from all types of harm-- from others, from themselves, from the jail setting, from disease, and more. Because our duty to protect is constant and mandated, we do not have the option to lower our level of care just because we do not have enough staff. If a shift supervisor leaves a needed post vacant because there are not enough employees to staff all posts, he/she increases risk and exposes the agency and government to higher levels of liability. Duty to Protect In an early federal district court case in Pulaski County, Arkansas, the court described the fundamental expectations that detainees have while confined: …minimally, a detainee ought to have the reasonable expectation that he would survive his period of detainment with his life; that he would not be assaulted, abused or molested during his detainment; and that his physical and mental health would be reasonably protected during this period… Hamilton v. Love, 328 F.Supp. 1182 (D.Ark. 1971). In a Colorado case3, the federal appeals court held that a prisoner has a right to be reasonably protected from constant threats of violence and sexual assaults from other inmates, and that the failure to provide an adequate level of security staffing, which may significantly reduce the risk of such violence and assaults, constitutes deliberate indifference to the legitimate safety needs of prisoners. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 29 of 100 Staffing Levels The first Pulaski County case produced continuing federal court involvement with jail operations. When the county was brought back to court by inmates in 1973, the county asked the court to consider their plans to build a new jail. But the judge held that, while the plans are promising, current conditions must be addressed: This Court can only deal with present realities….The most serious and patent defects in the present operation result directly from inadequate staffing. Hamilton v. Love, 358 F.Supp. 338 (D.Ark. 1973). A federal district court judge linked Platte County (Missouri) Jail’s duty to protect to staffing levels: There shall be adequate correctional staff on duty to protect against assaults of all types by detainees upon other detainees. Ahrens v. Thomas, 434 F.Supp. 873 (D.Mo. 1977). In New Jersey, the federal district court required county officials to obtain an independent, professional staffing analysis addressing security staffing and training, classification, and inmate activities. The court set expectations for the plan and ordered the county to implement the plan: The staffing analysis shall review current authorized staffing, vacancies, position descriptions, salaries, classification, and workload…[The county] must implement the plan… Essex County Jail Annex Inmates v. Treffinger, 18 F.Supp.2d 445 (D.N.J. 1998). Liability Officials may be found to be “deliberately indifferent” if they fail to address a known risk of serious harm, or even if they should have known of the risk. Ignorance is not a defense. Failure to protect inmates may result in liability. Usually court intervention takes the form of orders that restrict or direct jail practices. Sometimes the courts award compensatory damages to make reparations to the plaintiffs. In more extreme situations, defendant agencies may be ordered to pay punitive damages. A U.S. Supreme Court decision held that punitive damages may even be assessed against individual defendants when indifference is demonstrated: A jury may be permitted to assess punitive damages in a § 1983 action when the defendant's conduct involves reckless or callous indifference to the plaintiff's federally protected rights. Smith v. Wade, 103 S.Ct. 1625 (1983) Court Intervention Most court decisions produce changes in jail conditions, including operations. Continuing court involvement might be prompted by a consent agreement between the parties, or by failure of the defendants to comply with court orders. The nature of court involvement may even include the review of facility plans. In a New Mexico case, the court renewed its involvement when plans to SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 30 of 100 reduce staffing were challenged by the plaintiffs. The court prevented the state from reducing staffing levels at several correctional facilities: ..defendants will be enjoined from…reducing the authorized or approved complement of security staff…unless the minimal staffing levels identified as being necessary to provide a constitutional level of safety and security for prisoners have been achieved.. The Court also will enjoin defendants to fill existing vacancies and thus to employ at least the number of medical and mental health staff as well as the number of security staff authorized to be employed during fiscal Year… Duran v. Anaya, 642 F.Supp. 510 (D.N.M. 1986). Connecting Staffing Practices to Other Conditions In the New Mexico case, the court went on to draw links between staffing levels and other aspects of facility operations, ranging from overtime to inmate idleness: Overtime “...security staff will be adversely affected by excessive overtime work as a result of the understaffing of the institutions subject to the Court's orders in this litigation” Out-of-Cell Opportunity “…In addition, prisoners will be required to remain in their housing units for longer periods of time, and inmate idleness will increase.” Idleness. “Prisoner idleness…will increase as a result of staff reductions...” Programs and Activities. “There is a direct, inverse correlation between the incidence of acts and threats of violence by and between inmates, on the one hand, and the types and amounts of educational, recreational, work and other programs available to inmates, on the other--i.e., acts and threats of violence tend to decrease as program availability and activity increase.” Training. “Reduction in security staff positions will prevent…complying with staff training requirements of the Court's order…” The court noted concerns by a security expert that the “security staff reductions that are contemplated will result in a ‘scenario at this time…very similar to the scenario that occurred prior to the 1980 disturbance’”, referring to the deadly inmate riot at the New Mexico Penitentiary that claimed 33 inmate lives and injured more than 100 inmates and 7 officers. Lack of funds is not an excuse Federal courts have made it clear that lack of funds does not excuse violation of inmates’ constitutional rights: Humane considerations and constitutional requirements are not, in this day, to be measured or limited by dollar considerations… Jackson v. Bishop, 404 F.2d 571 580 (8th Cir.1968) SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 31 of 100 Courts may even restrict a jurisdiction’s discretion with regard to where funds are found to make needed improvements. An appeals court held that it may restrict the sources from which monies are to be paid or transferred in order to protect the legal rights of those who have been victims of unconstitutional conduct.4 In a 1977 decision, Supreme Court Justice Powell observed: …a federal court's order that a State pay unappropriated funds to a locality would raise the gravest constitutional issues... But here, in a finding no longer subject to review, the State has been adjudged a participant in the constitutional violations, and the State therefore may be ordered to participate prospectively in a remedy otherwise appropriate. The case concluded: It is not the province of a federal court to instruct the legislature on how it should finance its obligations. The district court did not attempt to do so. The court did what was within its authority--order a wrongdoer to pay the cost of remedying its wrongdoing. Recent Federal Cases Although the basic tenets of federal court involvement with jail staffing and operations were forged many years ago, the practice has not ended, as suggested in these more recent cases: Cavalieri v. Shepard, 321 F.3d 616 (7th Cir. 2003). The court noted that the detainee's right to be free from deliberate indifference to the risk that he would attempt suicide was clearly established. Wever v. Lincoln County, Nebraska, 388 F.3d 601 (8th Cir. 2004). The court held that the arrestee had a clearly established Fourteenth Amendment right to be protected from the known risks of suicide. Estate of Adbollahi v. County of Sacramento, 405 F.Supp.2d 1194 (E.D.Cal.2005). The court held that summary judgment was precluded by material issues of fact as to whether the county knowingly established a policy of providing an inadequate number of cell inspections and of falsifying logs showing completion of cell inspections, creating a substantial risk of harm to suicide-prone cell occupants. Hearns v. Terhune, 413 F.3d 1036 (9th Cir. 2005). The court held that the inmate’s allegations stated a claim that prison officials failed to protect him from attacks by other inmates. The inmate alleged that an officer was not present when he was attacked even though inmates were not allowed in the chapel without supervision. Velez v. Johnson, 395 F.3d 732 (7th Cir. 2005). The court held that the detainee had a clearly established Fourteenth Amendment right to be free from the officer’s deliberate indifference to an assault by another inmate. Smith v. Brevard County, 461 F.Supp.2d 1243 (M.D.Fla. 2006). Violation of the detainee’s constitutional rights was the result of the sheriff’s failure to provide adequate staffing and safe SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 32 of 100 housing for suicidal inmates, and in light of the sheriff’s knowledge that inmate suicide was a problem, his failure to address any policies that were causing suicides constituted deliberate indifference to the constitutional rights of inmates. SCCF Custody Staffing Levels This assessment did not study in-depth SCCF custody staffing levels. However, based on the poor environmental conditions found during this and the previous assessment, chronic crowding, and a serious lack of adequate medical and mental health service levels (to be discussed further in this report), SCCF officials should complete a comprehensive custody staffing analysis as soon as possible. SCCF Health Care Staffing Levels Adequate jail health care staffing levels are considered by federal courts as equally important as officer levels for meeting constitutional levels of protection and care. Inadequate jail health staffing levels prevent reasonable access to necessary medical and mental health care. Inmates have a constitutional right to access to qualified health care services while incarcerated. SCCF medical staffing is approximately 19.4 FTEs and includes a mixture of nurses who are county employees and staffing agency employees. Health Care Position Physician Nurse Practitioner Registered Nurse Licensed Practical Nurse Total: FTE 0.6 2 15 1.8 19.4 SCCF mental health staffing consists primarily of three licensed mental health professionals (LMHC) who are county employees, and a psychiatric nurse practitioner (uncertain of hours per week). Health care staffing levels at SCCF are inadequate to provide consistent access to care to approximately 20,000 annual admissions and an average daily population almost 1200. Based on this consultants experience as a professional corrections administrator, corrections consultant, and as a primary health care provider, as well as national jail health care standards, it is unreasonable to expect current staffing levels to consistently provide timely or complete access to health care services. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 33 of 100 VII. MEDICAL CARE ASSESSMENT, FINDINGS & RECOMMENDATIONS The following jail health care assessment elements are based upon provisions found in previous and existing Federal Settlement Agreements, Consent Decrees, and national standards. These elements should not be considered health care standards per se, but used to compare assessment findings with what the U.S. Department of Justice has determined are adequate levels of services according to constitutional requirements and Federal case law. 25 A. Health Care Intake Assessment: 1. Qualified Medical Staff utilize an appropriate medical intake screening instrument to identify and record observable and non-observable medical needs, and seek the inmate's cooperation to provide information regarding: (1) (2) (3) (4) (5) (6) (7) medical, surgical, and mental health history, including current or recent medications; current injuries, illnesses, evidence of trauma, and vital signs, including recent alcohol and substance use; history of substance abuse and treatment; pregnancy; history and symptoms of communicable disease; suicide risk history; and history of mental illness and treatment, including medication and hospitalization. Inmates who screen positively for any of these items shall be referred for timely medical evaluation, as appropriate. 2. Adequate and reasonably private intake health screening is conducted by qualified staff to determine the serious medical and mental health needs of all inmates before admission in to the facility. FINDING(S): Trained correctional staff performs all intake health screenings, generally at the time of booking at the open booking desk. The health screening form appears generally adequate. However, nursing and custody staff interviewed noted that this process is seriously inadequate because custody staff is not trained to adequately assess inmate health needs, and inmates with serious medical problems have gone days without seeing qualified medical staff at booking. A review of three inmate medical charts confirmed this serious concern. In one of these cases, an inmate with a serious cardiac illness went several days without required medication because the information was not appropriately communicated from booking to the medical department. Fortunately, medical staff was ultimately alerted to this medical 25 http://www.justice.gov/crt/about/spl/findsettle.php SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 34 of 100 need days later when the inmate’s parent called inquiring whether the inmate had received needed medication. The booking desk is somewhat centrally located in the booking area. The intake health screening interview is within full view and hearing of other nearby staff, inmates, and arrestees in the booking area. The level of privacy for conducting an intake health screening interview is inadequate. RECOMMENDATION(S): The intake health screening process appears to collect adequate medical, mental health, and suicide risk prevention information. To ensure the reliability of intake health screens and timely access to qualified care, and to reduce liability, SCCF should completely remove custody staff from the intake health screening process. Appropriate levels of qualified nursing staff should conduct ALL intake health screens 24/7. The report booking volume suggests a minimum of 2-3 Registered Nurses. All intake health-screening interviews must be performed in a location that maximizes privacy. 3. Intake assessment and screening policies and procedures exist and are used to ensure that adequate medical and mental health intake screenings and health assessments are provided to all inmates within 14 days. A comprehensive assessment is performed for each inmate within 14 days of his or her arrival at SCCF and shall include a complete medical history, physical examination, mental health history, and current mental status examination. The physical examination shall be conducted by Qualified Medical Staff. FINDING(S): In general, SCCF operates with no approved health care policies and procedures. Interviews with nursing staff revealed that they “…just do what we are trained to do and look at what few protocols we have…” This is a serious concern of the overall health care program. Additionally, medical staff reported that 14-day health assessments are not performed on inmates due to the very high workload and inmate population having serious and co-morbid health problems. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 35 of 100 RECOMMENDATION(S): SCCF should immediately begin the process of promulgating an evidence-based jail health care policy and procedure manual. Because this deficiency is likely related to inadequate staffing levels, officials should complete a comprehensive staffing analysis to accurately define staffing levels required to adequately meet the health care needs of the inmate population. Immediately begin performing a formal comprehensive history and physical assessment by a qualified health care professional. Ensure that medical staff only work within their scope of license and practice. 4. Basic medical care policies, procedures, and practices to address and guide all medical care and services including, but not limited to the following: access to medical care; sick call; continuity of medication; infection control; medication administration; intoxication and detoxification; documentation and record-keeping; disease control and prevention; medical triage and physician review; intake screening; infection prevention and control; comprehensive health assessments; mental health; women's health; quality management; and urgent/emergent response. FINDING(S): As stated above, there is currently no written health care policy and procedure manual. RECOMMENDATION(S): SCCF should immediately begin developing health care policies, procedures, and protocols into a single, comprehensive, and unified policy manual using a multidisciplinary team consisting of custody, medical, and mental health staff and qualified professionals. Final drafts should be forwarded to the sheriff, jail leadership, and the Commissioner’s attorney for review and approval before implementation. The SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 36 of 100 manual should follow the outline and content recommended by the National Commission on Correctional Health Care (NCCHC). Below is a recommended table of contents to use to revise policies and procedures. GOVERNANCE & ADMINISTRATION Access to Care Responsible Healthcare Authority Healthcare Autonomy Administrative Meetings and Reports Policies and Procedures Continuous Quality Improvement Program Emergency Response Plan Communications on Patients’ Health Needs Privacy of Care Procedure in the Event of Inmate Death Grievance Mechanism for Health Complaints HEALTHCARE SERVICES SUPPORT Pharmaceutical Operations Medical Services Clinic Space, Equipment and Supplies Diagnostic Services Hospital and Specialty Care SPECIAL NEEDS AND SERVICES Chronic Disease Services Patients with Special Health Needs Infirmary Care Mental Health Services Suicide Prevention Program Intoxication and Withdrawal Care of Pregnant Inmates Pregnancy Counseling Inmates with Substance Abuse Problems Aids to Impairment Care for the Terminally Ill SAFETY Infection Control Program Patient Safety Staff Safety Federal Sexual Assault Reporting Regulations Procedure in the Event of Sexual Assault INMATE CARE & TREATMENT Information on Health Services Admissions/Receiving Screenings Transfer Screening Initial Health Assessment Mental Health Screening and Evaluation Oral/Dental Care Nonemergency Healthcare Requests and Services Emergency Services Segregated Inmates Patient Escort Nursing Assessment Protocols Continuity of Care During Incarceration Discharge Planning HEALTH RECORDS Health Record Formats and Contents Confidentiality of Health Information/HIPAA Access to Custody Information Management of Health Records Electronic Medical Records System SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY PERSONNEL & TRAINING Credentialing Clinical Performance Enhancement Professional Development Healthcare Training for Correctional Staff Medication Administration Training Inmate Workers Staffing Healthcare Liaison Orientation for Healthcare Staff HEALTH PROMOTION Healthy Lifestyle Promotion Medical Diets Use of Tobacco NIC TA 13J1075 MEDICAL LEGAL ISSUES Restraint and Seclusion Emergency Psychotropic Medication Forensic Evaluation End-of-life Decision Making Informed Consent and Right to Refuse Care Medical and Other Research Page 37 of 100 5. Records documenting the assessment and results shall become part of each inmate's medical record. FINDING(S): A review of several inmate health care charts found no 14-day assessments, very few intake health screens, and a plethora of various, disorganized health-care-related documents. The current health records system is inadequate to support an adequate health care delivery system. RECOMMENDATION(S): Ensure that all health-care-related records required for assessment and treatment of medical and/or mental health problems are filed in the inmate medical record/chart. Reorganize health care charts to provide a clear understanding about inmate health care needs, treatment regimens and outcomes, diagnostic assessment and testing, and medication information. 6. A readmitted inmate or an inmate transferred from another facility who has received a documented full health assessment within the previous three months, and whose receiving screening shows no change in the inmate's health status need not receive a new full physical health assessment. For such inmates, Qualified Medical Staff shall review prior records and update tests and examinations as needed. FINDING(S): As previously stated, a full health assessment is typically not completed on new or transferred inmates. RECOMMENDATION(S): A comprehensive health and physical examination must be completed on all inmates transferred from other facilities except as stated above. Full health care records must be obtained by SCCF within 72 hours of the inmate’s admission to verify health needs and to determine what level of assessment will be required. A release of medical information for these purposes can be completed and signed by the inmate during the intake screening process. 7. Qualified Medical Staff should attempt to elicit the amount, frequency and time of the last dosage of medication from every inmate reporting that he or she is currently or recently on medication, including psychotropic medication. A medication continuity system so that incoming inmates' medication for serious medical needs can be obtained in a timely manner, as medically appropriate when medically indicated. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 38 of 100 FINDING(S): Newly booked inmates self-report current medications during the intake screening process performed by a custody officer. However, it is unreasonable to expect that this information is always reliable because: 1) a uniformed officer is asking for the information, and 2) the information is expected to be given openly with no privacy. This is why only qualified medical staff should perform all intake health screens in a private setting. Interviews with custody and medical staff, and a review of charts support this finding. RECOMMENDATION(S): Only qualified medical staff should complete the intake health screening process. This will help to ensure that medications for serious medical needs are continued during incarceration. SCCF should ensure that substituted medications, especially for mentally ill inmates, possess equivalent efficacy and are indicated for the diagnosed illness and/or are indicated for reported or presenting symptomology. SCCF should develop a standard formulary for jail medical care that is both cost effective and provides for the necessary treatment. Such a formulary should include exceptions for professional discretion to ensure that cost never outweigh appropriate care. Within 24 hours of an inmate's arrival at SCCF, or sooner if medically necessary, Qualified Medical Staff decide whether to continue the same or comparable medication for serious medical needs. If the inmate's reported medication is discontinued or changed, a Qualified Medical Professional shall evaluate the inmate face-to-face as soon as medically appropriate and document the reason for the change. 8. Incoming inmates who present with current risk of suicide or other acute mental health needs will be immediately referred for a mental health evaluation by a Qualified Mental Health Professional. FINDING(S): All incoming inmates are screened for suicide risk using a standard suicide assessment screening tool as previously discussed. Inmates who are screened for possible suicide risk are either transferred to the hospital for acute cases or placed in a safety cell under suicide precautions and regular monitoring. In some cases, and when available, the community mental health agency counselors respond to the jail to assess inmate status. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 39 of 100 RECOMMENDATION(S): Continue to use the current electronic and paper screening tools for assessing risk of suicide. Review other assessment instruments periodically to ensure the screening process remains contemporary and accurate. Continue the practice of transferring inmates presenting acute symptoms of active suicidal ideation and behavior to a local hospital. Ensure that all required discharge and aftercare documents accompany the inmate when returned to the jail. Establish a quality assurance process that ensures completeness and accuracy of safety cell monitoring records. Revise the monitoring record so that it shows the actual date, time, status of the inmate, and staff conducting safety check. Require an RN to assess each inmate placed on suicide precautions at least once per shift. Ensure an adequate number of qualified mental health professionals and staff to be onsite and on call who can respond as needed in a timely manner. Other recommendations will be provided in the Suicide Prevention section of this report. 9. Qualified staff constantly observes such inmates until they are seen by a Qualified Mental Health Professional. Incoming inmates reporting these conditions will be housed in safe conditions unless and until a Mental Health Professional clears them for housing in a medical unit, segregation, or with the general population. FINDING(S): SCCF is unable to constantly observe inmates placed on suicide precautions due to insufficient health care and custody staffing levels. The lack of timely access to qualified mental health professionals exacerbates this situation. Current SCCF practice allows for monitoring by cameras but monitoring is also intermittent due to current staffing shortages. RECOMMENDATION(S): Same as above ASAP hire additional custody staff and/or health care staff to ensure constant monitoring of these inmates. Current practice approves the use of camera monitoring to supplement direct observation. The policy should be revised to specifically prohibit using camera monitoring as a primary means for monitoring inmates placed on suicide prevention precautions. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 40 of 100 10. All inmates at risk for, or demonstrating signs and symptoms of drug and alcohol withdrawal are timely identified and provided appropriate treatment, housing, and medical supervision. FINDING(S): There were several inmates being treated for active and suspected drug and/or alcohol withdrawal at the time of this assessment. However, because qualified medical staff do not conduct intake health screens at booking, there is a high risk that some inmates who require withdrawal care could be left untreated for hours or days. Additionally, due to a lack of adequate housing for these inmates, several inmates in active withdrawal were housed in the booking area. This is an inappropriate practice and should cease due to high mortality risks associated with alcohol and opioid withdrawal complications. RECOMMENDATION(S): Ensure early detection of inmates who are or suspected of alcohol or drug withdrawal. Develop and implement evidence-based withdrawal intervention and treatment policies, procedures, and protocols. Do not use the booking for inmate housing for any reason and ensure that all inmates suspected of, or being treated for, drug or alcohol withdrawal are housed in medically appropriate housing areas. 11. Incorporate the intake health screening information into the inmate's medical record in a timely manner. FINDING(S): As previously noted, health screens and other necessary medical documents are not maintained in the inmate’s official medical record. An inspection of the medical records room showed that files and records are stacked on cabinets and tables in various stages before being filed. Many charts required review and signature of the physician. Other charts were in a “pulled” or “put-back” status. Although seemingly organized according to a specific process logic, it was clear that inmate health records upkeep was a “get to it when you can” activity, due largely to a lack of staffing and the absence of an electronic health records system (EMR/EHR). RECOMMENDATION(S): Hire or contract health records staff as soon as possible to organize, file, and maintain inmate health records consistently. Implement jail electronic medical/health records system that is compatible with the current jail information management system. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 41 of 100 Establish a quality assurance process that includes random sampling of a specified number of inmate medical records for accuracy and completeness. B. Medical Chronic Care 12. A written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care. FINDING(S): The lack of an organized medical records system and the limited time allowed for this assessment made it impossible to determine the adequacy of chronic disease management. A review of several medical charts involving chronic disease cases found limited information and few formal treatment plans. Treatment appeared to be “medication-driven.” Additionally, the lack of an electronic records system made it impossible to estimate reliably the prevalence of chronic disease among the SCCF inmate population. RECOMMENDATION(S): Increase qualified medical staffing level to support the development and management of a formal chronic disease control program. This work should be assigned to a dedicated RN. Develop and implement a written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care. Adopt and implement appropriate written clinical practice guidelines for chronic diseases consistent with nationally accepted guidelines. Maintain an updated and accurate log to track all inmates with chronic illnesses to ensure that these inmates receive necessary diagnosis, monitoring, and treatment. Maintain records of all care provided to inmates diagnosed with chronic illnesses in the inmates' individual medical records. Ensure that inmates with chronic conditions are timely seen by a qualified medical provider according to levels of disease control to evaluate health status and the effectiveness of the medication administered for their chronic conditions. Ensure inmates with disabilities or who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care. Ensure that the jail medical budget is adequately funded for lab tests and other assessments required for monitoring chronic disease control levels. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 42 of 100 C. Communicable Disease 13. Adequate testing, monitoring, and treatment programs exist for the management of communicable diseases, including tuberculosis ("TB"), skin infections, and sexually transmitted infections ("STIs"). FINDING(S): Generally the same as chronic disease management findings. All admitting inmates are questioned about history and treatment of TB, as well as other infectious disease or current open wounds. PPD plants and/or chest x-rays are performed on all admissions reporting a history or treatment of TB or who otherwise report positive indicators. These inmates are isolated from other inmates until conclusive test results determine that no risk exists or the inmate is transferred to the hospital for further assessment and treatment. Data were not available at the time of this assessment to determine timeliness of testing and results from the time of admission or the time condition was suspected. SCCF medical officials also stated that there is virtually no testing for MRSA or STDs but that presumed and observed infections are treated with prophylactic medications and monitored. RECOMMENDATION(S): SCCF should develop and implement a formalized communicable disease prevention and control plan that is consistent with CDC guidelines for either Minimal or Non-Minimal Risk Jails. Officials should consult with local health department officials to determine the population’s risk level and develop the plan in collaboration with local public health officials. One FTE RN should be assigned to manage the infectious disease prevention program. Revise and/or develop and implement infection control policies and procedures that address contact, blood borne and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates. Maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identify, treat, and control infectious diseases. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 43 of 100 14. Infection control policies and procedures that address contact, blood-borne and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates. FINDING(S): Generally the same as chronic and infectious disease findings. RECOMMENDATION(S): Same recommendation as above and those related to section on policy and procedure. 15. Current CDC guidelines are followed for management of inmates with TB infection, including providing prophylactic medication when medically appropriate. If directed by a physician, inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and hospitalized or housed in an appropriate, respiratory isolation ("negative pressure") room on-site or off-site. SCCF provides for infection control and for the safe housing and transportation of such inmates. FINDING(S): Same as above. RECOMMENDATION(S): SCCF should be considered a “Non-Minimal Risk Facility” as defined by the CDC until otherwise verified by the local or state public health agency. D. General Access to Care 16. Inmates have timely and adequate access to appropriate health care. FINDING(S): Access to care begins at the point of admission at SCCF and throughout incarceration. There is no doubt that SCCF staff is doing their best to identify, treat, and monitor inmate health needs. However, high numbers of inmates with serious medical and mental health problems, inadequate health care staffing levels, and unqualified intake health screens, absence of clear and formal policies and procedures, and lack of a functional records system make timely and consistent access to appropriate health care virtually impossible. This is addressed in more detail in the next section. RECOMMENDATION(S): Refer to previous recommendations regarding: - Intake screening SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 44 of 100 - Staffing levels Records Housing of medically and/or mentally ill inmates Policies and procedures Facility sanitation Chronic and infectious disease management 17. A medical request ("sick call") process for inmates should be adequate and provides inmates with adequate access to medical care. The sick call process shall include: (1) (2) (3) (4) written medical and mental health care slips available in English, Spanish, and other languages, as needed; a confidential collection method in which the request slips are collected by Qualified Medical Staff seven days per week; opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and opportunity for all inmates, irrespective of primary language, to access medical and mental health care. FINDING(S): In general, SCCF inmates have reasonable access to a sick call process. Sick call forms (kites) are available to inmates upon request and there was no evidence found that indicated otherwise. However, examination of 84 recently submitted kites found several problems with the sick call process. SCCF’s standard practice is to collect these kites during medication pass, which is done by registered nurses, primarily. If time permits, the nurse will attempt to address the inmate’s medical request during the medication pass. However, this is seldom the case due to the high volume of requests and nurse staffing levels according to nurses interviewed. In most cases, the kites are returned to the medical office, date stamped, and placed into a wall pocket for triaging within 24hrs if possible. However, an examination of 84 kites found most reporting medical and mental health symptoms with some of those showing a collection date well beyond 24 hours. Several kites were actually multiple requests with different dates from the same inmates. Some were not date stamped at all. Despite the fact that registered nurses devote an enormous amount of time and energy this process, it is barely functional simply due to a lack of clear policies and procedures, and inadequate staffing levels. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 45 of 100 RECOMMENDATION(S): Written sick call requests from inmates should be collected daily and only by health care staff. Ensure that sick call slips are triaged within 24 hours of being received and prioritized according to acuity and need. Sick call slips involving current medical or mental health symptoms should trigger a same day face-to-face assessment by an RN. A written response to the inmate submitting a sick slip should be provided within 72 hours of receipt of the sick slip. A logging procedure should include documentation of the date and summary of each request for care, the date the inmate was seen, the name of the person who saw him or her, the disposition of the medical or mental health visit (e.g., referral; whether inmate scheduled for acute care visit), and if follow-up care is necessary, the date and time of the inmate's next appointment. Log information should be reviewed periodically for accuracy and completeness. Ensure that sick call assessment and treatment occurs in a reasonably private clinical setting. Continue scheduling inmates for physician clinic as indicated. Maximize RN scope of practice by hiring an adequate number of LPNs or Qualified Medication Assistants to perform the medical pass. This will free-up RNs for higher levels of assessment and care currently not being accomplished. 18. There are an adequate number of correctional officers to escort inmates to and from medical units to ensure that inmates requiring treatment have timely access to appropriate medical care. FINDING(S): SCCF custody and medical staff reported that custody staffing levels has not interfered with inmate movement. RECOMMENDATION(S): Review clinic appointment schedules to verify this finding. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 46 of 100 19. SCCF ensures that Qualified Medical Staff make daily rounds in the isolation areas to giving inmates opportunities discuss medical and mental health concerns with Qualified Medical Staff in a setting that affords as much privacy as reasonable security precautions will allow. During rounds, Qualified Medical Staff will assess inmates for new clinical findings, such as deterioration of the inmate's condition. FINDING(S): Health care staff stated that they are inadequately staffed to make daily rounds in all isolation and/or segregation areas and rely heavily on custody staff to provide, monitor and report inmate needs. Custody staff interviewed stated that they feel unqualified to provide this level of monitoring by “do the best [they] can…” SCCF maintains at least eight (8) special housing units where daily rounds should be conducted by qualified health care staff. Although all units are staffed with at least of custody officer under direct supervision model, this should not be considered an adequate substitute for daily monitoring by qualified health care staff, especially when those units are at maximum capacity as they were during the time of this visit. 4-NC 4-SA 5-N 5-S D-MHU D-MHO E-1 E-4 Unit Designation Segregation Segregation Male Psychiatric Housing Male Special Custody Medical Housing Mental Health Observation Female Special / Max Male Psych TOTAL Capacity % Capacity Location 9/23/2013 On September 23, 2013, these “special needs” units were at 99% combined average capacity; half of the units were at or exceeded their maximum capacity as shown in the figure below: 2 2 17 37 24 10 32 40 1 1 17 28 35 10 29 42 50% 50% 100% 76% 146% 100% 91% 105% 164 163 99% RECOMMENDATION(S): Increase staffing as previously recommended. Ensure qualified health care staff makes rounds a minimum of once per day to assess and document the health status of each inmate according to health care needs. Documentation should become a permanent entry in the inmate’s medical chart. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 47 of 100 Develop methods to correct sight and sound privacy limitations in the infirmary and booking segregation cells. Alleviate crowding in special needs/isolation/segregation units. E. Medical Follow-up Care 20. Adequate care and maintenance of completed records must be provided for inmates who return to SCCF following hospitalization or off-site medical services. FINDING(S): Health care officials stated that every attempt is made to obtain discharge records when an inmate returns from either a hospital or outside medical appointment but that the process is not consistent. Medical staff are often required to contact the outside provider for additional information. An examination of medical records for inmate recently discharged from a hospital to SCCF found that most possessed adequate discharge documentation. RECOMMENDATION(S): Meet with local hospital officials to develop a more consistent process of returning inmates to the jail with all necessary discharge records. Maintain a tracking log for each time these records are either not provided or are not completed. Meet with hospital officials as needed to improve compliance. Consider adopting a policy that prohibits reacceptance of an inmate until such records are provided. Ensure that inmates who receive specialty or hospital care are evaluated upon their return to SCCF and that, at a minimum, discharge instructions are obtained, appropriate Qualified Medical Staff reviews the information and documentation available from the visit. This review and the outside provider documentation are recorded in the inmate's medical record, and appropriate follow-up is provided. F. Emergency Medical Care 21. Qualified Medical and Mental Health Staff are trained to recognize and respond appropriately to medical and mental health emergencies. All inmates with emergency medical or mental health needs receive timely and appropriate care, including prompt referrals and transports for outside care when medically necessary. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 48 of 100 FINDING(S): Time did not permit a comprehensive review of health care staff credentialing files. RECOMMENDATION(S): Increase medical, mental health, and custody staffing levels as previous recommended. Ensure that emergency first aid supplies are located at each satellite area, the infirmary, and other locations to ensure timely assessment and care. Emergency supply kits should be audited regularly to ensure they are properly stocked with necessary supplies in sufficient quantities. Ensure that all CPR/AED/First Responder certification of all staff are kept current. Ensure AED devices are located at each satellite area, in the infirmary, and other needed locations, and that the devices are tested regularly for functionality. 22. Jail officers and other staffing having contract with inmates should be to recognize and respond appropriately to medical and mental health emergencies. FINDING(S): SCCF officials report staff are training prior to and during employment in recognizing and responding to medical and mental health emergencies. Time did not permit a review of training files. RECOMMENDATION(S): Continue current practice. Consider purchasing a subscription to an online training site, such as Essential Learning, to supplement current training program for all staff. 23. All jail officers are provided with the necessary protective gear, including masks and gloves, to provide first line emergency response. FINDING(S): Protective gear as indicated was found accessible to all first responder staff. RECOMMENDATION(S): Continue current practice. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 49 of 100 G. Medical Record Keeping 24. Medical and mental health records are adequate to assist in providing and managing the medical and mental health needs of inmate. FINDING(S): Refer to previous findings related to health care records issues and problems. RECOMMENDATION(S): Increase medical staff as previously recommended to ensure better maintenance of medical records. Invest in a jail electronic medical records system (EMR). Ensure that the system includes a medical records function and interfaces with the jail information management system. Develop a health record tracking system that documents who uses a health file, why, when, and for what reason. Any records added or removed from a health chart should be documented on the tracking log. Medical records should be periodically audited against the tracking log. I. Medication Administration 25. Inmates receive necessary medications in a timely manner. FINDING(S): Examination of inmate health records, medication administration records, kites, and interviews with nurses indicated that medications are administered as ordered with few exceptions. However, it was reported by one medical official that delays in obtaining medications from the contract pharmacy continues to cause problems in timely administration of ordered medications. RECOMMENDATION(S): Develop a tracking system to monitor compliance with medication orders by prescribers. Develop a tracking log to measure timeliness of medications received by the contract pharmacy, meet with contracting provider to correct deficiencies. Utilize LPNs instead of RNs for medication passes as previously recommended. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 50 of 100 26. Provide a systematic physician review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition. FINDING(S): No systematic review was found or reported to exist during this assessment. RECOMMENDATION(S): Develop and implement policies and procedures for a systematic review as described. 27. Medicine administration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distribution. FINDING(S): All medications appeared to be in proper containers, in a secured and clean location. RECOMMENDATION(S): Continue current practice. 28. Administration is performed by Qualified Nursing Staff who shall administer prescription medications on a directly-observed basis for each dose, (unless the physician's order notes that the inmate can self-administer the medication), shall not discontinue medications without a physician's order, and shall accurately document medication orders as being ordered via telephone. Qualified Nursing Staff shall practice within the scope of their licensures. FINDING(S): Med passes are performed primarily by Registered nurses who report direct observation of administration and only a licensed prescriber discontinues medications. Phone orders are documented in the inmate record as indicated and all nursing staff only practice within their scope of licensure. RECOMMENDATION(S): Implement an electronic medical records system that includes an electronic medication administration record interface. 29. Maintain a formal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelines for the prescription of certain types of medications. FINDING(S): There is currently no formal P&T or CQI program. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 51 of 100 RECOMMENDATION(S): Implement formal P&T and CQI programs. 30. SCCF ensures that Qualified Medical Staff counsel all patients who refuse medication. FINDING(S): Chart examination found no records indicating that qualified medical staff counsel inmates who refuse medications. However, nurse interviews found that nurses commonly counsel these inmates but do not always record that counseling. RECOMMENDATION(S): Ensure to counsel all inmates who refuse prescribed medication and document counseling in the medical record. Ensure inmates sign all refusal forms. Forms should include statement about possible health care problems resulting in refusal of medication. Refusal encounter should be charted. Seek assistance from qualified mental health staff where refusal involves psychotropic medications. 31. Medication is secured, allowing no food to be stored in the medication refrigerator. FINDING(S): The medication rooms were secured but medications seem to be somewhat disorganized. No food or food containers were observed in or near medication rooms. RECOMMENDATION(S): continue current practice. 32. Hand washing stations in medical areas are fully equipped, operational and accessible. FINDING(S): Hand washing stations were found in intake, medical, the kitchen. All were equipped and properly supplied; all were operational. RECOMMENDATION(S): Continue current practice. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 52 of 100 33. Appropriate containers are readily available to secure and dispose of medical waste (including syringes and sharp medical tools) and hazardous waste. FINDING(S): Medical waste and sharps containers were observed in the medical area. It appeared that waste was disposed of regularly; no overfilled containers were observed. RECOMMENDATION(S): Continue current practice. K. Specialty Care 35. Inmates whose serious medical or mental health needs extend beyond the services available at SCCF shall receive timely referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs. FINDING(S): No policies and procedures exist for providing specialty care described in this element. Special care is provided by local providers, hospital, and community mental health. Charts reviewed showed encounters and documents indicating that inmates receive specialty care as medically determined. RECOMMENDATION(S): Continue current practice. Review and update current list of providers annually. 36. Inmates who have been referred for outside specialty care by the medical staff or another specialty care provider are scheduled for timely outside care appointments and transported to their appointments. FINDING(S): Element not assessed. RECOMMENDATION(S): SCCF should review this element and determine compliance. Develop appropriate policy and procedure for this element. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 53 of 100 37. Inmates waiting on outside care shall be seen by Qualified Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate. FINDING(S): Element not assessed. . RECOMMENDATION(S): SCCF should review this element and determine compliance. Develop appropriate policy and procedure for this element. 38. Pregnant inmates are provided adequate pre-natal care. FINDING(S): Element not assessed. . RECOMMENDATION(S): SCCF should review this element and determine compliance. Develop appropriate policy and procedure for this element. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 54 of 100 X. MENTAL HEALTH CARE ASSESSMENT, FINDINGS & RECOMMENDATIONS Current National Perspective: Growing numbers of mentally ill offenders have strained jails’ fiscal and operational capacities, many to the point of costly federal intervention and judicial oversight involving the United States Department of Justice Civil Rights Division. 26 Thousands of people with mental illness are falling through the cracks of this country's social safety net and are landing in the criminal justice system at an alarming rate. Each year, more than ten million people are booked into U.S. jails. Studies indicate that rates of mental illness among these individuals are at least three to four times higher than the rates of serious mental illness in the general population. 27 The origins of the problem are complex and largely beyond the scope of this report. During the last 35 years, the mental health system has undergone tremendous change. Once based exclusively on institutional care and isolation, the system has shifted its emphasis almost entirely to the provision of community-based support for individuals with mental illness. This public policy shift has benefited millions of people, effecting the successful integration of many people with active or past diagnoses of mental illness into the community. Many clients of the mental health system, however, have difficulty obtaining access to mental health services. Overlooked, turned away, or intimidated by the mental health system, many individuals with mental illness end up disconnected from community supports. The absence of affordable housing and the crisis in public housing exacerbates the problem. Most studies estimate that at least 20 to 25 percent of single adult homeless population has a serious mental illness. Most troubling about the criminal justice system's response in many communities to people with mental illness is the toll it exacts on people's lives. Law enforcement officers' encounters with people with mental illness can sometimes end in violence, including the use of lethal force. Although rare, police shootings do more than end the life of one individual. Such incidents also have a profound impact on the consumer's family, the police officer, and the general community. When incarcerated, people with untreated mental illness are especially vulnerable to assault or other forms of intimidation by predatory inmates. In prisons and jails, which tend to be environments that exacerbate the symptoms of mental illness, inmates with mental illness are especially at risk of harming themselves or others. Once they return to the community, people with mental illness learn that providers already overwhelmed with clientele are sometimes reluctant to treat someone with a criminal record. 26 The United States Attorney is authorized by federal law to investigate and litigate violations of Constitutional Civil Rights under the Civil Rights for Institutionalized Persons Act (CRIPA). There are currently more than 30 correctional facilities under federal order to comply with Constitutional requirements for the care and protection of inmates. Most of these cases involved medical and mental health violations. See: http://www.justice.gov/crt/about/spl/findsettle.php 27 See: http://consensusproject.org/the_report/executive-summary SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 55 of 100 Given the dimensions and complexity of this issue, the demands upon the criminal justice system to respond to this problem are overwhelming. Police departments dedicate thousands of hours each year transporting people with mental illness to hospitals and community mental health centers where staff often have to turn away the individual or quickly return him or her to the streets. Jails and prisons are swollen with people suffering some form of mental illness. On any given day, the Los Angeles County Jail system and detention centers hold more people with mental illness than any state hospital or mental health institution in the United States. Not surprisingly, the Snohomish County criminal justice system has encountered people with mental illness with increasing frequency. Calls for crackdowns on quality-of-life crimes and offenses such as the possession of illegal substances have netted many people with mental illness, especially those with co-occurring substance abuse disorders. Ill-equipped to provide the comprehensive array of services that these individuals need, corrections administrators often watch the health of people with mental illness deteriorate further, prompting behavior and disciplinary infractions that only prolong their involvement in the criminal justice system. According to a study published in 2006, by the United States Bureau of Justice Statistics, at midyear 2005, more than half of all prison and jail inmates had a mental health problem, including 705,600 inmates in State prisons, 78,800 in Federal prisons, and 479,900 in local jails. These estimates represented 56% of State prisoners, 45% of Federal prisoners, and 64% of jail inmates. In addition, this research states that "people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four times the general population”. These findings serve as a clarion wake-up call to local officials for taking immediate action, and to provide guidance for developing cogent response plans, not only to avoid expensive federal intervention, but also to rally community leaders and partners to address psychosocial and criminogenic characteristics among this inmate population. 28 Overall, jail inmates reportedly have higher mental health problems than those inmates in state or federal prisons (64.2%, 56.2%, and 44.8% respectively). This makes perfect sense when considering the fact that all state and federal inmates typically begin incarceration in a local jail. Simply stated, not all jail inmates go to prison but all state prison inmates are initially booked into a local jail. A. Psychosocial and Criminogenic Characteristics of Mentally Ill Inmates Local government, criminal justice, and community leaders are best served by interpreting the needs of their mentally ill inmates as a reflection of the needs in the overall community. Mentally ill inmates are no less citizens or constituency than are the mentally well. Yet, the debilitating stigma of being labeled “mentally ill” worsens when the label “offender” or “inmate” is added. 28 See: http://www.bjs.gov/content/pub/pdf/mhppji.pdf SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 56 of 100 Staggering moral and financial issues, added to the high liability risks surrounding the incarceration of this community population drives a salient and unending obligation for community leaders to focus special attention and dedicate resources toward adequate care and management. A good first step for this attention can be to focus resources on establishing a datadriven and compassionate understanding of factors that place the mentally ill at risk of criminal justice involvement and incarceration. Understanding the relevant psychosocial and criminogenic risk factors specific to Snohomish County’s mentally ill population is a formative basis for good response planning. Compared to non-mentally ill jail inmates, mentally ill inmates are more likely to have a current or past violent offense and three or more prior incarcerations. They are much more likely to have substance dependence or abuse issues and are more likely to report drug use a month before their arrest. Mentally ill inmates are almost twice as likely to be homeless and three times more likely to have a history of being victims of physical or sexual abuse. They are more likely to have parents who abused drugs or alcohol. Regarding jail behavior, mentally ill inmates are twice as likely to violate jail rules, engage in physical or verbal assaults at a rate of four times more often, are three times more likely to be injured in a fight during incarceration than non-mentally ill inmates are. Some Criminal, Substance Abuse, and Familial Characteristics of Mentally Ill Jail Inmates Current or past violent offenses 44% 36% 3 or more prior incarcerations 20% 26% SUBSTANCE DEPENDANCE OR ABUSE Drug use in the month prior to arrest 42% Homeless in year before arrest 9% Past physical or sexual assault victim 8% Parents abused alcohol or drugs CHARGED WITH VIOLATING FACILITY… Physical or verbal assault 76% 53% 2% Injured in a fight since incarceration 3% 9% 8% 9% 62% 17% 24% 19% 19% 37% With Mental Problem Without Snohomish County leaders should drill even deeper into these factors in order to target jail-based and community interventions so that resources are focused strategically. Homeless, employment, and family background information can provide a better understanding for this process. As stated above, mentally ill jail inmates were found to be homeless at almost twice the rate of the non-mentally ill and less likely to be employed in the month of their arrest. They are four SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 57 of 100 times more likely to be victims of physical abuse and three times more likely to be victims of sexual abuse. While growing up, they are more likely to receive public assistance and twice as likely to live in foster care, an agency, or institution. Regarding family background, mentally ill inmates lived with both parents slightly less often than their counterparts but were more likely to live with one parent or someone else. Twice as many mentally ill inmates have parents who abused substances and less likely to have parents who do not. They are significantly more likely to have parents, siblings, and children who have been incarcerated. Homelessness, Employment, and Family Background Characteristics Homeless in the past year 8.8% 17.2% 68.7% 75.9% Employed in month before arrest ABUSED BEFORE ADMISSSION Physically abused Sexually abused 24.2% 7.6% 20.4% 5.7% 10.2% 3.2% Received public assistance Live in foster home, agency, institution 42.6% 30.3% 6.0% 14.5% 40.5% Most of the time live with both parents 49.1% 45.4% 40.4% With one parent 12.0% 9.4% Someone else PARENTS OR GUARDIANS ABUSED SUBSTANCES 18.7% Alcohol 14.1% Drugs 2.7% 1.1% Alcohol and drugs 3.4% 37.3% 23.2% 11.5% 62.7% Neither substances abused INCARCERATED FAMILY MEMBERS Mother With Mental Problem Without 36.2% 3.4% 12.6% Brother Child Spouse 52.1% 9.4% Father Sister 81.3% 22.1% 25.8% 5.1% 34.8% 11.3% 4.0% 2.6% 2.4% 0.9% Snohomish County continues to look very closely at the clinical mental health and substance abuse and dependence characteristics of its mentally ill offender population to determine its SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 58 of 100 capacity for treatment and programming before, during, and after incarceration. The BJS study provides further insight into these issues. Gender, race, and age are also important factors for targeting custody and community intervention services and program capacity to inmates with mental illness. This means that interventions must use evidence-based programming specific to the salient demographic characteristics. Programs should be qualified, culturally competent, gender sensitive, and age specific. Regarding these characteristics, the BJS study found several program development indicators. 39. Constitutional Right #1: There must be a systematic program for screening and evaluating inmates in order to identify those needing mental health services. FINDING(S): SCCF performs all initial intake and classification functions using adequate electronic and paper screening forms. The jail information management system appears to collect sufficient salient health care information for detecting mental health needs during the booking process. Additionally, all jails in the State of Washington are required to include a Transfer Medical Summary document for all inmates. This form includes mental health information about the inmate being transferred. Arrestees showing severely acute mental health problems at intake are transferred to the local hospital for assessment and treatment before being returned to the jail or local mental health crisis services respond to the jail when available. Following intake, inmates with, or suspected of having, mental illness are referred to SCCF mental health staff for further assessment and follow-up. However, comprehensive evaluations are not always possible due to inadequate mental health staffing levels. The figure below was provided by the SCCF Coordinator to show MHP Face-to-Face Contacts (Assessments and Evaluations with Inmates, 2001-2012). 3,000 2,500 2,000 1,500 1,000 I/Ms Seen # of MHPs 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1,920 2,160 1,860 2,532 2,700 2,795 2,672 2,570 1,647 2,623 2,613 2,790 3 3 3…2 3 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY 4…6 6…4 4…6 6…3 3…2 NIC TA 13J1075 3 3 3…4 Page 59 of 100 RECOMMENDATION(S): Increase mental health staffing levels as indicated by needs of the population. Ensure qualified medical and/or mental health professionals conduct intake health screens for mental health needs. Develop and implement a formal program for ongoing screening and evaluation for and of inmates with mental illness that is linked to the intake screening process as soon as possible. Ensure that all care is directly linked to screenings and evaluations and documented accordingly in the medical record. Ensure that inmates presenting mental health symptoms or report a history of mental illness and/or attempted suicide receive a comprehensive mental health evaluation by a licensed qualified mental health profession within 72 hours as indicated by acuity and risk. SCCF reclassification policy should specifically address mental health conditions for making initial and permanent housing assignment changes; and the release policy should include a process for connecting or reconnecting inmates with mental illness to mental health service providers after release. Develop and implement a quality assurance program that routinely reviews intake screening assessment and evaluations for completeness and accuracy. 40. Constitutional Requirement #2: There must be a mental health treatment program that involves more than segregation and close supervision. FINDING(S): As previously stated, SCCF’s very limited level of mental health services prevents full development and maintenance of adequate mental health treatment programming. In general, mental health treatment is limited to medications, segregation, close supervision, and monitoring by licensed mental health professionals. There are no standard formal treatment plans and only sparse formal discharge plans as shown in the figure provided by SCCG mental health staff. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 60 of 100 500 400 300 200 100 0 Release Plans # of MHPs 200 200 200 200 200 200 200 200 200 201 201 201 1 2 3 4 5 6 7 8 9 0 1 2 108 96 72 3 3 3…2 198 234 295 446 323 176 204 187 261 3 4…6 6…4 4…6 6…3 3…2 3 3 3…4 However, as stated, treatment for mental illness is very limited beyond medications, and treatment planning is inadequate for the number of inmates who have or who likely have a diagnosable mental illness. This should be reviewed. There is virtually no regular individual or group mental health treatment provided to the inmates. However, SCCF has as excellent team of qualified mental health professionals who have developed an active network of community mental health and criminal justice agencies, and family supports as shown in the figure provided below. SCCF Mental Health Agency Networking by MHPs: 2001-2012 350 300 250 200 150 100 50 0 200 200 200 200 200 200 200 200 200 201 201 201 1 2 3 4 5 6 7 8 9 0 1 2 MH Agencies 204 204 174 204 210 303 341 191 168 209 203 158 # of MHPs 3 3 3… SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY 3 4… 6… 4… 6… 3… 3 NIC TA 13J1075 3 3… Page 61 of 100 SCCF DMHP Networking by MHPs and total ITAs: 2001-2012 140 120 100 80 60 40 20 0 20 20 20 20 20 20 20 20 20 20 20 20 01 02 03 04 05 06 07 08 09 10 11 12 Consult N/ N/ N/ N/ 66 78 70 64 51 63 72 58 ITA Request 72 78 72 78 48 82 78 94 99 76 10 12 ITAs 15 12 # of MHPs 3 9 18 24 39 33 34 29 28 41 52 3 3… 3 4… 6… 4… 6… 3… 3 3 3… Criminal Justice Agency Networking by SCCF MHPs: 2001-2012 400 300 200 100 0 20 20 20 01 02 03 20 04 20 20 20 20 05 06 07 08 20 09 20 20 20 10 11 12 Crim Justice 312 324 252 264 204 296 311 345 279 313 286 300 # of MHPs 3 3 3… SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY 3 4… 6… 4… 6… 3… 3 NIC TA 13J1075 3 3… Page 62 of 100 Inmate Family/Friends Networking by MHPs: 2001-2012 350 300 250 200 150 100 50 0 Fam/Frds # of MHPs 200 200 200 200 200 200 200 200 200 201 201 201 1 2 3 4 5 6 7 8 9 0 1 2 348 318 246 204 282 300 299 319 203 331 310 355 3 3 3… 3 4… 6… 4… 6… 3… 3 3 3… RECOMMENDATION(S): Develop and implement an integrated behavioral health program that includes medical, mental health, custody staff, and community providers. Hire or contract licensed mental health staff as previously recommended to conduct mental health assessments, comprehensive evaluations, individualized treatment plans, individual and group counseling. Hire additional mental health staff as previously indicated to ensure access to, during, and from points of care in the jail and to increase monitoring and supervision of inmates with mental illness. Develop individualized mental health treatment plans that include DSM IV (or V) multiaxial diagnoses, primary problem statements, goals, objects, interventions, and progress. All treatment should be charted using a standard medical SOAP note or similar documentation that includes the following elements at minimum: Date and time of service Clinician/provider initials Subjective presentations Objective presentations Assessment of condition/presentation Intervention applied to resolve healthcare issue Plan to improve and maintain health care issue Treatment should involve an array of crisis and ongoing treatment utilizing evidencebased practices for jail settings and populations. Services should be delivered in reasonable privacy or in private settings involving other cohort groups. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 63 of 100 Develop and implement an ongoing process to identify mentally ill inmates within the SCCF. Conduct additional evaluations as needed to establish a diagnosis by history or provisional diagnosis and primary symptoms. Complete individual treatment plans that identify treatment goals, objectives and interventions. Medication should be included as an intervention on the plan if included in the treatment modality. Treatment services provided should be related to and charted according to plan elements. Develop a “step down” plan for all inmates placed in segregation/isolation using behavioral incentives and documented progress in an effort to remove these inmates to more social housing environments as soon as possible. Do not use isolation or segregation for permanent or primary housing for this population except when indicated by the needs of the inmate and safety of other inmates. Develop and implement a release plan that includes medical and mental health after-care connections, appointments, and services. Ensure sufficient amount of medication to maintain mental health stability until the inmate can connect with outside healthcare providers. Strengthen community linkages by working with community providers to design a method to track admissions of their clients into and release from jail. SCCF should involve community organization such as Washington NAMI, Washington Mental Health America, etc. in the development of a comprehensive jail mental health services program that includes wrap-around provisions. Collaborate closely with local community mental health agencies and providers to maintain continuity of care services and ongoing program support. 41. Constitutional Requirement #3: There must be trained Mental Health Professionals in sufficient numbers to provide the identification and treatment services in an individualized manner to treatable inmates suffering a serious mental disorder. FINDING(S): As previously stated, there are only three full-time licensed mental health professionals working at SCCF. There is no doubt that Snohomish County officials desire to provide the best possible care to inmates suffering with mental illness. Everyone involved in this assessment seemed both hopeful and very concerned about this issue. Snohomish County has developed and maintained exceptional intergovernmental and community collaborations that can provide assistance in meeting this standard. RECOMMENDATION(S): Hire additional mental health professionals as previously recommended. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 64 of 100 Continue to maintain and grow community connections. 42. Constitutional Requirement #4: There must be maintenance of accurate, complete and confidential records. FINDING(S): As previously stated, mental health records are minimal beyond the electronic and paper intake screening forms. Overall, the mental health aspects of inmate medical records included only very basic information and there appeared minimal mental health-related charting, if any. Mental health care information is essentially limited to the medical administration records, sick call requests and responses, and what is handwritten in the charts by the physician and other medical staff. These records, however, appear accurate and complete. RECOMMENDATION(S): See recommendations related to medical record keeping. 43. Constitutional Requirement #5: Treatment by prescription and administration of behavior-altering medications in dangerous amounts and by dangerous methods or without appropriate supervision and periodic evaluation is an unacceptable method of treatment and must not be present. FINDING(S): A review of the current medication administration record indicates that SCCF is frugal and cautious in prescribing psychotropic medication. Quantities and dosing documented in the record appeared consistent with this standard. However, inadequate medical and mental health staffing levels would seem to make regular monitoring sporadic at best. RECOMMENDATION(S): Increase medical and mental health staffing levels as previously recommended to ensure consistent, ongoing, and qualified administration and monitoring of mental health medications. Develop and implement comprehensive mental health evaluations and treatment plans as previously recommended. Ensure that medications prescribed are consistent with evaluation findings and indicated for the assessed diagnoses. Consultation and mental health records should be obtained from current and recent mental health providers as part of the mental health evaluation, diagnosing, treatment planning, and prescribing practices. Medications for newly admitted inmates should not be discontinued or changed except when substituted medications have equivalent treatment efficacy or to otherwise meet the care needs of the mentally ill inmate. SCCF is SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 65 of 100 discouraged from establishing any policy or practice that places medication cost above necessary treatment. Ensure that only qualified medical providers prescribe mental health medications. Develop and implement quality assurance metrics to conduct period performance compliance studies and revise practices and protocols as indicated. Ensure that medication management is included in the inmate mental health treatment plan and that inmates taking these medications are educated on the purpose and side effects. 44. Constitutional Requirement #6: There must be a suicide identification, treatment and supervision program. There must be a basic program for identification, treatment and supervision of inmates who evidence suicidal tendencies (and mental health problems). FINDING(S): SCCF has an adequate suicide risk identification intake screening process involving electronic and paper assessment forms. Inmates who screen positive for risk of suicide at intake, or who present suicidal ideation during incarceration are immediately placed on suicide precautions in an isolation cell near the booking area. Suicide precaution status typically involves removal of possessions, and clothing is routinely replaced with a suicide prevention smock. Policy requires staggered 15-minute observations by staff that is recorded on a paper monitoring log. The bulk monitoring is performed by custody staff that is trained in suicide prevention. RECOMMENDATION(S): Refer to the suicide prevention section below. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 66 of 100 XI. SUICIDE PREVENTION ASSESSMENT, FINDINGS, & RECOMMENDATIONS A. Current National Perspective: A recently published national study on jail suicide reports that “Suicide continues to be a leading cause of death in jails across the county; the rate of suicide in county jails is estimated to be several times greater than that in the general population.”29 This study goes on to describe many of the salient factors and influences associated with jail suicides. Although it appears that the base-rate for jail suicides is decreasing, certain factors found 20 years ago have changed. The significant findings in this study are in bold and italics below: Suicide Victims: 67% were white. 93% were male. The average age was 35. 42% were single. 43% were held on a personal and/or violent charge. 47% had a history of substance abuse. 28% had a history of medical problems. 38% had a history of mental illness. 20% had a history of taking psychotropic medication. 34% had a history of suicidal behavior. Characteristics of Suicides: Deaths were evenly distributed throughout the year; certain seasons and/or holidays did not account for more suicides. 32% occurred between 3:00pm and 9:00pm. 24% occurred within the first 24 hours, 27% between 2 and 14 days, and 20% between 1 and 4 months. 20% of the victims were intoxicated at the time of death. 93% of the victims used hanging as the method. 66% of the victims used bedding as the instrument. 30% of the victims used a bed or bunk as the anchoring device. 31% of the victims were found dead more than 1 hour after the last observation. CPR was not administered in 37% of incidents. 38% of the victims were held in isolation. 8% of the victims were on suicide watch at the time of death. 29 Lindsay Hayes, “National Study of Jail Suicide 20 Years Later”, DOJ/NIC AN 024308, April 2010. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 67 of 100 No-harm contracts were used in 13% of cases. 35% of deaths occurred close to the date of a court hearing, with 69% occurring in less than 2 days. 22% occurred close to the date of a telephone call or visit, with 67% occurring in less than 1 day. Characteristics of the Jail Facilities: 84% percent were administered by county, 13% by municipal, 2% by private, and less than 2% by state or regional agencies. 77% provided intake screening to identify suicide risk, but only 27% verified the victim’s suicide risk during prior confinement, and only 31% verified whether the arresting officer believed the victim was a suicide risk. 62% provided suicide prevention training, but 63% either did not provide training or did not provide it on an annual basis. 93% provided a protocol for suicide watch, but less than 2% had the option for constant observation; most (87%) used 15-minute observation periods. 32% maintained safe housing for suicidal inmates. 35% maintained a mortality review process. 85% maintained a written suicide prevention policy, but as shown above, suicide prevention programming was not comprehensive. Finally, the suicide rate in detention facilities during 2006 was calculated to be 38 deaths per 100,000 inmates, a rate approximately three times greater than that of the general population. This rate, however, represents a dramatic decrease in the rate of suicide in detention facilities during the past 20 years. The almost three-fold decrease from a previously reported 107 suicides in 1986 is extraordinary. Absent in-depth scientific inquiry, there may be several explanations for the reduced suicide rate. During the past several years, prior national studies of jail suicide have given a face to this longstanding and often ignored public health issue within our nation’s jails. Findings from the studies have been widely distributed throughout the country and eventually incorporated into suicide prevention training curricula. The increased awareness to inmate suicide is also reflected in national correctional standards that now require comprehensive suicide prevention programming, better training of jail staff, and more in-depth inquiry of suicide risk factors during the intake process. Finally, jail suicide litigation has persuaded (or forced) jurisdictions and facility administrators to take corrective actions in reducing the opportunity for future deaths. Therefore, the antiquated mindset that “inmate suicides cannot be prevented” should forever be put to rest.30 30 Lindsay Hayes, “National Study of Jail Suicide 20 Years Later”, DOJ/NIC AN 024308, April 2010. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 68 of 100 Twenty years later, this national study of jail suicides found substantial changes in the demographic characteristics of inmates who committed suicide during 2005–06. Table 1 shows that some of these changes are stark. For example, suicide victims once characterized as being confined on “minor other” offenses were most recently confined on “personal and/or violent” charges. Intoxication was previously viewed as a leading precipitant to inmate suicide, yet recent data indicate that it is now found in far fewer cases. Previously, more than half of all jail suicide victims were dead within the first 24 hours of confinement; current data suggest that less than one-quarter of all victims commit suicide during this time period, with an equal number of deaths occurring between 2 and 14 days of confinement. In addition, it appears that inmates who committed suicide were far less likely to be housed in isolation than previously reported, yet for unknown reasons it was less likely that they would be found within 15 minutes of the last observation by staff. Finally, more jail facilities that experienced inmate suicides had both written suicide-prevention policies and an intake screening process to identify suicide risk than in previous years, although as noted above, the comprehensiveness of programming remains questionable.31 Changing face of Jail Suicide Victims 1985-1986 70% Detention 72% White 94% Male 30 52% Single 29% Minor Other 89% Detained 60% 30% between 12:00am and 6:00am Length of Confinement 51% within 1st 24 hours Method 94% Hanging Instrument 48% Bedding Time Span (between last observation and 42% found within 15 finding victim) minutes Isolation 67% Known History of Suicidal Behavior 16% Known History of Mental Illness 19% Intake Screening of Suicide Risk 30% Written Suicide Prevention Policy 51% Variables Facility Type Race Sex Age Marital Status Most Serious Charge Jail Status Intoxication at Death Time of Suicide 2005-2006 88% Detention 67% White 93% Male 35 42% Single 43% Violent/Personal 91% Detained 20% 32% between 3:01pm and 9:00pm 23% within 1st 24 hours 93% Hanging 66% Bedding 21% found within 15 minutes 38% 34% 38% 77% 85% The study concluded that “findings… create a formidable challenge for both correctional and health care officials, as well as their respective staffs. While our knowledge base continues to increase, seemingly corresponding to a dramatic reduction in the rate of inmate suicide in detention facilities, much work lies ahead. The data indicates that inmate suicide is no longer centralized to the first 24 hours of confinement and can occur at any time during an inmate’s confinement. As such, because roughly the same number of deaths occurred within the first few 31 Hayes Study SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 69 of 100 hours of custody as in more than several months of confinement, information gathered regarding current suicide risk during intake screening should be viewed as time-limited. Instead, because inmates can be at risk at any point during confinement, the biggest challenge for those who work in the corrections system will be to conceptualize the issue as requiring a continuum of comprehensive suicide prevention services aimed at the collaborative identification, continued assessment, and safe management of inmates at risk for self-harm.”32 B. SCCF Suicide Prevention Program SCCF experienced three (3) successful inmate suicides and over 200 suicide attempts/self-harm events between 2001 and 2012 as shown in the figure provided below. Overview of Completed Suicides & Serious Suicide/Self Harm Attempts for 2001-2012: Monthly Totals 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Attempts JAN 12 FEB 11 MAR 21 APR 21 MAY 16 JUN 24 JUL 13 AUG 16 SEP 30 OCT 20 NOV 17 DEC 13 Suicides 0 0 0 0 0 0 1 0 0 1 0 1 The figure below compares suicide/self-harm events and ADP from 2001 – 2012. 32 Hayes Study SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 70 of 100 Detailed below is the assessment of suicide prevention, intervention, and management practices at the SCCF. The department’s suicide prevention-related policies and practices were reviewed and compared to eight critical components of a jail suicide prevention policy: staff training, intake screening/assessment, communication, housing, levels of supervision, intervention, reporting, and follow-up/mortality reviews.33 45. Critical Component #1: Staff Training The key to any successful suicide prevention program is properly trained jail staff. Trained corrections officers are often the staff most likely to recognize signs and symptoms of suicidal behavior. Often the focus of suicide prevention plans is the initial 48 to 72 hours of incarceration, but it is important to stress that suicides can and do occur at any time during incarceration. Staff and other inmates often recognize inmates who have destabilized or are reacting with hopelessness to recent losses, problems at home, or the reality of the disposition of their legal situation. Simply stated, because jail deputies are generally the only staff in the jail 24 hours per day they form the front line of defense in suicide prevention. Jail staff cannot effectively or consistently detect, make an assessment, or prevent a suicide for which they have no training. FINDING(S): All jail officers complete both orientation and in-service training on suicide prevention, as indicated above. However, not all staff who has contact with inmates receives this training. RECOMMENDATION(S): Develop comprehensive suicide prevention policies and procedures that include clear guidance and expectations about training. The following include essential elements of adequate training policies and procedures: o All staff (including correctional, medical, and mental health personnel) that have regular contact with inmates shall be initially trained in the identification and management of suicidal inmates, as well as in the eight components of a suicide prevention program. Initial training shall encompass eight (8) hours of instruction. New employees shall receive such instruction through the training academy. Current staff shall receive such instruction through scheduled training workshops. o The initial training should include inmate suicide research, why the environments of correctional facilities are conducive to suicidal behavior, staff attitudes about suicide, potential predisposing factors to suicide, high-risk suicide periods, warning signs and symptoms, identifying suicidal inmates despite their denial of risk, components of the 33 Lindsay B. Hayes, National Center on Institutions and Alternatives. Updated, Jail Suicide/Mental Health Update, Spring 2005, Volume 13, Number 4. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 71 of 100 suicide prevention policy, case studies of recent suicides and/or serious suicide attempts, and liability issues associated with inmate suicide. o All staff who have regular contact with inmates shall receive two (2) hours of annual suicide prevention training. The two-hour training workshop shall include a review of predisposing risk factors, warning signs and symptoms, identifying suicidal inmates despite their denial of risk, and review of any changes to the suicide prevention program. The annual training shall also include general discussion of any recent suicides and/or serious suicide attempts in the Jail. o All staff who have regular contact with inmates shall receive standard first aid and cardiopulmonary resuscitation (CPR) training. All staff shall be trained to use emergency equipment located in each for responding. In an effort to ensure an efficient emergency response to suicide attempts, “mock drills” shall be incorporated into both initial and refresher training for all staff. Consider a subscription to a web-based training program to supplement current training program, as previously recommended. Review orientation and in-service training lesson plans to ensure the training remains current and contemporary. It is also important to include information about mental health disorders and appropriate jail-based management interventions in both pre-service and refresher training for all who have regular contact with inmates.34 SCCF should access the online Jail Suicide/Mental Health Update newsletter, a quarterly publication available at no charge and devoted to suicide prevention and mental health services within detention and correctional facilities.35 Both medical and mental health staff should also consider subscribing to the newsletter mentioned above. In addition, they may seek further information from the NIC information center about providing suicide prevention practices in a jail facility. 46. Critical Component #2: Intake Screening/Assessment Identification is also critical to any effective jail suicide prevention program. Research in the area of jail suicides has identified a number of characteristics that are strongly related to suicide including: intoxication, emotional state, family history of suicide, recent significant loss, lack of social support, psychiatric history, and various “stressors of confinement”. Most importantly, 34 Instructors Materials, Behavioral Health Needs in Local Jails: A Cross Training Program, KY NAMI; Department of Mental Health and Retardation; Department of Corrections; and Commission on Services and Supports of Individuals with Mental Illness, Alcohol and other Drug Abuse Disorders and Dual Diagnosis. 35 Funded by National Institute of Corrections; published by Lindsay M. Hayes, National Center on Institutions and Alternatives. Access at http://www.ncianet.org/suicideprevention/publications/update/index.asp SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 72 of 100 prior research has consistently reported that at least two-thirds of all suicide victims communicate their intent sometime prior to death, and that any individual with a history of one or more suicide attempts is at a much greater risk for suicide than most of those who have never made an attempt. The key to identifying potentially suicidal behavior in inmates is to inquire not only during admission to SCCF, but at other key risk periods during incarceration. Screening should inquire about past suicidal ideation or attempts, current ideation, threat or plan, prior mental health treatment including hospitalizations, recent significant loss (job, relationship, death of family member/close other, suicide risk during prior confinement, and arresting/ transporting officer’s belief that inmate is currently at risk. Given the strong association between inmate suicide and special management (i.e., disciplinary and/or administrative segregation) housing unit placement, any inmate assigned to such a special housing unit should receive a written assessment for suicide risk by mental health staff upon admission to the special housing placement. In addition, the inmate’s healthcare records should be thoroughly reviewed to ensure that the placement is not contraindicated or requires special treatment. FINDING(S): The SCCF intake suicide screening process appears basically adequate but that process should be performed primarily by qualified health care professionals as previously discussed. Electronic and paper screening and assessment forms appear adequate, as previously stated and booking staff seem to understand the importance of this screening process. A review of screening documents indicates that were consistently completed. MHP suicide evaluation volume activity is shown in the figure provided below. SCCF MHP Suicide Evaluations: 2001-2012 1,800 1,500 1,200 900 600 300 0 Sui Evals # of MHPs 200 200 200 200 200 200 200 200 200 201 201 201 1 2 3 4 5 6 7 8 9 0 1 2 432 426 360 900 1,64 1,82 1,48 1,12 903 1,09 1,42 1,60 3 3 3…2 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY 3 4…6 6…4 4…6 6…3 3…2 NIC TA 13J1075 3 3 3…4 Page 73 of 100 MHP suicide evaluation volume seems quite high for a few MHP staff but unusually low compared to SCCF annual admissions, and considering the literature evidencing a much higher jail population at risk of suicide. The figure below compares SCCF admissions and MHP evaluations, 2001-2012. Year Admissions 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20,414 19,092 19,946 19,986 22,732 25,558 25,571 24,297 25,447 25,109 27,411 27,120 MHP Evaluation Suicide Rate Evaluations 432 2.1% 426 2.2% 360 1.8% 900 4.5% 1,644 7.2% 1,825 7.1% 1,488 5.8% 1,128 4.6% 903 3.5% 1,097 4.4% 1,422 5.2% 1,607 5.9% MHP Staffing 3 3 3…2 3 4…6 6…4 4…6 6…3 3…2 3 3 3…4 These presumed low evaluation rates could result from several factors. SCCF officials should review this process to ensure the validity and reliability of its intake screening tools, staff ability to detect and identify suicidal risk behavior, and ensure adequate levels of MHP staff to complete timely and comprehensive evaluations. RECOMMENDATION(S): As previously stated, SCCF should develop related policies and procedures so that all necessary elements are integrated into a single, comprehensive document. Policies and procedures should be integrated so that they specifically direct an interdisciplinary approach to assessment and screening that involves custody, medical, and mental health services. See previous recommendations for policy elements. Minimum policy elements for the identification, referral, and assessment of suicidal risk are listed below: o All inmates should be administered the Mental Health/Suicide Risk Intake Screening upon entry in the jail and prior to placement in any housing unit. The form shall be administered during the admission and booking process by a Registered Nurse (RN) or other qualified and designated medical/mental health staff in their absence. Every effort shall be made to ensure this screening is conducted in a reasonably private and confidential location within the booking area. o The Mental Health/Suicide Risk Intake Screening Form includes inquiry regarding: past suicidal ideation and/or attempts; current ideation, threat, plan; prior mental health SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 74 of 100 treatment/hospitalization; prior/current psychotropic medication; recent significant loss (job, relationship, death of family member/close friend, etc.); history of suicidal behavior by family member/close friend; suicide risk during prior confinement; arresting/transporting officer(s) belief that the detainee is currently at risk; and brief mental status examination. o A Registered Nurse (RN) or other qualified staff in their absence shall question the arresting and/or transporting officer(s) regarding their assessment of the inmate’s medical, mental health or suicide risk. Such information shall be documented on the Mental Health/Suicide Risk Intake Screening Form. o The a Registered Nurse (RN) or other designated staff in their absence shall determine through the review of the electronic medical record (i.e., “Past Medical History Screen”) whether the inmate was a medical, mental health or suicide risk during any prior confinement. Such information shall be documented on the Mental Health/Suicide Risk Intake Screening Form. o A Registered (RN) or other designated staff in their absence shall make all appropriate observations, and ask all questions and appropriate follow-up questions, as contained on the Mental Health/Suicide Risk Intake Screening Form. o Although an inmate’s verbal responses during the intake screening process are critically important to assessing the risk of suicide, staff should not exclusively rely on an inmate’s denial that they are suicidal and/or have a history of mental illness and suicidal behavior, particularly when their behavior and/or actions or even previous confinement suggest otherwise. o Following completion of the Mental Health/Suicide Risk Intake Screening Form, the Registered Nurse (RN) and only other qualified medical/mental health staff in their absence shall confer with the Corrections Shift Supervisor for appropriate disposition. o If identified as a risk for suicide, the inmate shall be immediately placed on “Suicide Precautions” and then referred to a qualified mental health professional for further assessment. o The assessment of suicide risk by mental health staff shall include, but not limited to the following: description of the antecedent events and precipitating factors; suicidal indicators; mental status examination; previous psychiatric and suicide risk history, level of lethality; current medication and diagnosis; and recommendations/treatment plan. Findings from the assessment shall be documented on the Suicide Risk Assessment of the electronic medical record. o Although any designated supervisory correctional, medical, or mental health staff may place an inmate on Suicide Precautions and/or upgrade those precautions, only licensed qualified mental health professional staff may downgrade and/or discontinue Suicide SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 75 of 100 Precautions following a comprehensive suicide risk assessment and following consultation jail medical and custody officials. o A completed Mental Health/Suicide Risk Intake Screening Form shall be performed on all inmates prior to assignment to a housing unit, except under the following circumstances: a) Inmate refuses to comply with process; b) Inmate is severely intoxicated or otherwise incapacitated; or c) Inmate is violent or otherwise belligerent. o For inmates listed in 11: a-c above, the a Registered Nurse (RN) or other designated staff in their absence shall still complete all non-questionnaire sections of the Mental Health/Suicide Risk Intake Screening Form and make a notation on the Form regarding why the inmate was unable to answer the questionnaire section. The Corrections Shift Supervisor shall then make the appropriate Disposition. A continuing, but reasonable effort shall be made to complete the entire Mental Health/Suicide Risk Intake Screening Form on inmates listed on 11: a-c above at least every two (2) hours. o The Mental Health Director or clinical supervisor shall review each completed Mental Health/Suicide Risk Intake Screening Form for accuracy and completeness within 24 business hours. o All inmates shall be asked to sign a release of information form authorizing the disclosure of health records from outside providers. Medical and mental health staff shall make a reasonable effort to obtain records of previous medical and mental health treatment, including both inpatient and outpatient treatment services. o Any inmate who screens positive for mental illness or suicidal ideation during the intake screening process, or who is otherwise referred for mental health services, shall receive a comprehensive Mental Health Evaluation in a timely manner from a licensed qualified mental health professional according to the following timetable: immediate for an Emergent issue; within 24 hours for an Urgent issue; and within 72 hours for a Routine issue. The comprehensive evaluation shall include a recorded diagnosis section, including a standard five-Axis diagnosis from DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If the QMHP finds a serious mental illness, they shall refer the inmate for appropriate treatment. Findings from the assessment shall be documented on either the Mental Health Evaluation or Psychiatric Evaluation forms in the inmate’s electronic medical record. o Given the strong association between inmate suicide and segregation, Qualified Mental Health medical, and custody Staff shall make regular rounds in segregation at least once per week. Documentation of the rounds shall be made in the segregation log, with any significant findings documented in the inmate’s electronic medical record. Inmates with serious mental illness who are placed in segregation shall be immediately and regularly evaluated by a QMHP to determine the inmate’s mental health status, which shall include an assessment of the potential effect of segregation on the inmate’s mental health. Following these regular assessments, qualified staff shall evaluate whether SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 76 of 100 continued segregation is appropriate for that inmate, considering the QMHP assessment, or whether the inmate would be appropriate for graduated alternatives. See previous recommendations on staffing increases. The assessment of suicide risk should not be viewed as a single event, but as an ongoing process. Because an inmate may become suicidal at any point during confinement, suicide prevention should begin at the point of arrest and continue until the inmate is released from SCCF. In addition, once an inmate has been successfully managed on and discharged from suicide precautions they should remain on a mental health caseload and assessed periodically until released from SCCF. Screening for suicide during the initial booking and intake process should be viewed as something similar to taking one’s temperature – it can identify a current fever but not a future cold. The shelf life of behavior that is observed and/or self-reported during intake screening is time-limited, and we often place far too much weight upon this initial data collection stage. Following an inmate suicide, it is not unusual for the mortality review process to focus exclusively upon whether the victim threatened suicide during the booking and intake stage, a time period that could be far removed from the date of suicide. If the victim had answered in the negative to suicide risk during the booking stage, there is often a sense of relief expressed by participants of the mortality review process, as well as a misguided conclusion that the death was not preventable. Although the intake screening form remains a valuable prevention tool, the more important determination of suicide risk is the current behavior expressed and/or displayed by the inmate. Prior risk of suicide is strongly related to future risk. At a minimum, if an inmate had been placed on suicide precautions during a previous confinement in SCCF or agency, such information should be accessible to both correctional and health care personnel when determining whether the inmate might be at risk during their current confinement. SCCF should not rely exclusively on the direct statements of an inmate who denies that they are suicidal and/or have a prior history of suicidal behavior, particularly when their behavior, actions, and/or history suggest otherwise. Often, despite an inmate’s denial of suicidal ideation, their behavior, actions, and/or history speak louder than their words.36 Additionally, suicide and mental health policies should be reviewed regularly by staff and provided annual training on these policies as previously recommended. 36 Lindsey Hayes, www.ncianet.org/suicideprevention/publications/guidingprinciples.asp SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 77 of 100 47. Critical Component #3: Communication The screening and assessment process, coupled with staff training, will only be successful if an effective method of communication is in place. It is not enough to identify inmates who are at risk for suicide. It is essential that this information be communicated. There are essentially three levels of communication in preventing inmate suicides: 1) communication between the arresting or transporting officer and the jail receiving staff; 2) communication between and among facility staff including medical and mental health personnel; and 3) communication between facility staff and the suicidal inmate. It is also critically important for jail staff to maintain open lines of communication with family members who often have pertinent information regarding the mental health status of inmates. Officers should recognize that they are an integral part of the mental health team and often the key factor in preventing suicide. Communication cannot stop at receiving or during the early hours and days of incarceration. There are a number of key risk periods/points including crisis precipitated by court services such as new/additional charges, separation, divorce, child removal or custody, or protection from abuse orders. Also sentencing, especially unexpected harsh or lengthy sentences can precipitate suicidal crises. A little explained but fairly common phenomenon is a suicide immediately prior to release. FINDING(S): SCCF seems to place exceptionally high value on open communication among staff at all levels. This was very noticeable and quite impressive. Leadership provides ongoing training materials and coaching to subordinate leaders that further encourage open communication with and between line staff and other jail employees. There appears to be good verbal and written communication at the intake process between intake officers and admitting law enforcement personnel. Overall communication between and among facility staff regarding this critical element seems equally appropriate and effective. RECOMMENDATION(S): Continue to grow current communication between all staff participating in inmate suicide detection, prevention, intervention, and aftercare services. Post information that explains the purpose for suicide watch placement, reasons for lengths of stay on suicide watch, and where and how to receive help following return to general population and before release from the jail. Updated training on effective communication with inmates, special needs offenders, and manipulative inmates should be provided at pre- and in-service intervals. Custody, medical SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 78 of 100 and mental health staff should train together on subjects of mutual interest and concern as a means to increase inter-function reliance, support and communication. The inmate handbook should clearly explain the signs and symptoms of suicide/mental health problems and how to access help while incarcerated. SCCF should post information in the visiting areas that encourage visitors to communicate any concerns about inmate suicide/ mental health to staff as soon as possible. Jail managers and supervisors should make regular rounds of all housing areas, and when so doing inquire about problems the inmates are experiencing, as well as invite suggestions for improving conditions of confinement. These rounds will demonstrate to both staff and inmates that jail administration is concerned about the well-being of the inmates and open improved dialogue between inmates and custody staff. Revise current policies and procedures to include comprehensive guidance and expectations for suicide prevention communication purposes. Minimum policy elements are listed below: o All staff shall maintain awareness, share information and make appropriate referrals regarding potentially suicidal inmates to mental health staff. o All staff shall use various communication skills with the suicidal inmate, including active listening, staying with the inmate if they suspect immediate danger, and maintaining contact through conversation, eye contact, and body language. o All incidents of suicidal behavior shall be documented on the Observation Sheet, which shall also be utilized to document all physical cell checks of suicidal inmates. o The Corrections Shift Supervisor shall maintain a suicide precaution monitoring log of all inmates on Suicide Precautions. The sheet shall be updated daily, designate each inmate’s level of observation, and be distributed to appropriate correctional, medical, and mental health personnel. o The Corrections Shift Supervisor shall ensure that appropriate staff is properly informed of the status of each inmate placed on Suicide Precautions. The Corrections Shift Supervisor shall also be responsible for briefing the incoming Corrections Shift Supervisor regarding the status of all inmates on Suicide Precautions. o Should an inmate be returned to the facility following temporary transfer to the hospital or other facility for suicide risk assessment and/or treatment, the Corrections Shift Supervisor shall inquire of medical and/or mental health officials what further prevention measures, if any, are recommended for the housing and supervising the returning inmate. o Authorization for Suicide Precautions, reassessment and any changes in Suicide Precautions shall be documented on the precautions log and distributed to appropriate staff. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 79 of 100 o Multidisciplinary case management team meetings (to include SCCF officials and available medical and mental health personnel) shall occur on a weekly basis to discuss the status of inmates on Suicide Precautions. 48. Critical Component # 4: Housing It is essential that the least restrictive housing commensurate with classification and risk for suicide be assigned for all inmates. It is important to maintain inmates in a safe and secure housing unit that is maximally designed to eliminate suicide attempts and behaviors as long as their risk level requires special housing. Regular assessment of inmates’ suicide risk and movement to the least restrictive housing when the inmate is stabilized must be provided. Housing assignments should be based on the ability to maximize staff interaction with the inmate, avoiding assignments that heighten the depersonalizing aspects of incarceration. All cells designated to house suicidal inmates should be suicide-resistant, free of all obvious protrusions, and provide full visibility. FINDING(S): SCCF staff currently makes intermittent direct physical observations of persons on suicide watch as part of their daily rounds. Camera monitoring is used only as a supplement to direct observation according to policy and practice. SCCF inmate housing practices prohibit the use of disciplinary segregation for inmates presenting a credible risk of self-harm. This practice clearly acknowledges the mental and emotional well-being of inmates placed in disciplinary segregation and specifies segregation time limits. SCCF administrative segregation practices are applied to inmates presenting symptoms of suicidal risk and/or mental illness. This practice further prohibits any punitive restrictions to food, correspondence, attorney or clergy visits. Cells used for this purpose appeared to be relatively free of protrusions but seemed unclean and somewhat ill kept. RECOMMENDATION(S): SCCF practice appears to embrace a least restrictive approach to managing such at-risk inmates. SCCF should develop policy to audit the written close supervision logs to the electronic logs to ensure compliance, accuracy, and consistency. This audit should be conducted no less than quarterly. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 80 of 100 Revise current policies and procedures to include comprehensive guidance and expectations for suicide prevention housing purposes. Minimum policy elements are listed below: o Any inmate placed on Suicide Precautions shall be housed in a designated suicideresistant cell. o The decision to remove the clothing and mattress from a suicidal inmate and issuance of a safety smock shall only be done with the approval of a QMHP or Qualified Medical Professional in their absence, and only following a face-to-face direct assessment of the inmate by the qualified health care provider in-person or by telephone contact with the inmate, when said qualified staff are not on duty. A reliable and secure telemedicine system may be used for a face-to-face assessment in cases where no QMHP is available on-site. In most instances, the removal of clothing of an inmate on Constant Observation status should not be necessary. Documentation of the decision shall be in both the Suicide Risk Assessment and the Observation Sheet. o Unless contraindicated in writing by a QMHP or Qualified Medical Professional in their absence, each inmate on Suicide Precautions shall continue to receive regular privileges (e.g., showers, telephone, visiting, recreation, etc.) commensurate with their security level. Documentation of the decision shall be in both the Suicide Risk Assessment and the Observation Sheet. It is understood that such loss of such privileges, unless necessary for security and the personal safety of the inmate, can be counterproductive to the goals of suicide prevention efforts and should, therefore be avoided unless otherwise necessary. o The use of any physical restraints (e.g., restraint chairs or bunks, leather straps, etc.) shall be avoided whenever possible, and used only as a last resort when the inmate is physically engaging in self-injurious behavior. A Qualified Medical Professional shall be immediately notified to monitor and assess the need for further restraint. Metal handcuffs shall never be utilized for restraint. o Regardless of whether restraints are initiated by custody or health care personnel, the use of any restraints shall include adherence to the following minimal guidelines: - Restraints shall not be used for punitive purposes; - Restraints require an order by a Qualified Medical Professional (physician, nurse practitioner, or physician’s assistant); - Only a Restraint Chair shall be authorized for restraints. The restrained inmate shall be immediately transported via the restraint chair to the 4th floor medical/mental health unit for further assessment and observation. - The restrained inmate shall be seen immediately by Qualified Medical Staff, as well as receive a face-to-face assessment by a physician or Licensed Independent Practitioner (LIP) within four (4) hours of initial restraint; - Inmates shall never be restrained in an unnatural position; - Restraint equipment must be medically appropriate; SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 81 of 100 - Inmates placed in restraints shall be under the constant observation of a Crisis Stabilization Technician or designated correctional staff in their absence; - Vital signs of inmates placed in restraints shall be assessed every 2 hours by nursing staff; - Each restrained limb shall be untied for at least 10 minutes every two hours to allow for proper circulation; - Restrained inmates shall be allowed bathroom privileges as soon as practical; - Restrained inmates shall be reassessed by a physician, LIP, or registered nurse every 2 hours after the initial assessment, and must be reduced as quickly as possible to the level of least restriction necessary to protect the inmate and others; and - Restraint orders shall be automatically terminated after 12 hours and, if the inmate remains in a highly agitated state after 12 hours that they cannot be released because of physical danger to self or others, they shall be transferred to the hospital. o Each Jail housing unit shall contain various emergency equipment, including a first aid kit; CPR pocket mask or Ambu-bag; and emergency rescue tool (to quickly cut through fibrous material). The Corrections Shift Supervisor staff should ensure that such equipment is in working order on a regular basis. 49. Critical Component # 5: Levels of Supervision: Inmates who are at risk of suicide require increased levels of observation, communication, and interaction with custody and healthcare staff. These staff must be available and unencumbered by other assignments that would interfere with a suicide prevention priority. The incarceration experience is a very dehumanizing experience for all inmates and the inmate’s primary contact with the outside world is through their access to correctional staff. Differing levels of suicide risk, mental illness, and vulnerability requires different levels of observation and management. Experience shows that prompt, effective emergency medical and other health care services can save lives and mitigate the adverse impact of incarceration on suicidal and mentally ill inmates. FINDING(S): There were three inmates on suicide watch at the time of this visit to observe the interaction between inmates placed on suicide watch and jail officers. However, these inmates were housed in a single cell near the booking, making it very difficult to maintain consistent monitoring due to inadequate staffing levels and the needs of several other inmates housed in that area. Although this may be an adequate location for temporary monitoring, staffing levels severely limit monitoring. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 82 of 100 RECOMMENDATION(S): SCCF staff is to be commended for their professional interactions with inmates and are encouraged to continue practicing such interactions. Increase custody, medical, and mental health staffing as previously recommended to ensure adequate supervision and monitoring of inmates placed on suicide precautions near the booking area. Develop a “step-down” housing unit that increases social interaction and privileges for inmates who have been as assessed as stable or stabilizing. Each inmate placed on suicide precautions should have an integrated treatment plan that involves a multi-disciplinary team in its development and implementation. The plan should specifically define “stabilized” in descriptive behavioral terms to help ensure that staff understands when an inmate may be eligible for the step-down environment. The plan should be behavior based with incentives, and it should be shared with the inmate. Revise current policies and procedures to include comprehensive guidance and expectations for suicide prevention levels of observation purposes. Minimum policy elements are listed below: o “Suicide Precautions,” defined as the level of observation and management of inmates identified as suicidal in the Jail, shall include two levels of observation: - Close Observation: Reserved for the inmate who is not actively suicidal, but expresses suicidal ideation (e.g., expressing a wish to die without a specific threat or plan) and/or has a recent prior history of self-injurious behavior. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, shall be placed under close observation. Staff shall observe the inmate at staggered intervals not to exceed every 15 minutes (e.g., 5, 15, 7 minutes). - Constant Observation: Reserved for the inmate who is actively suicidal, either threatening or engaging in self-injurious behavior. Staff shall observe such an inmate on a continuous, uninterrupted basis and have a clear non-obstructed view of the inmate at all times. o The observation of inmates on either Close Observation or Constant Observation status shall be the primary responsibility of trained mental health technicians or trained jail officers. o The use of closed-circuit television monitoring shall be utilized as a supplement to, but never a substitute for, the physical observation checks provided by staff. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 83 of 100 o For each inmate placed on Suicide Precautions, MHTs or designated correctional staff in their absence shall document the Close Observation check as it occurs (but no more than staggered 15-minute intervals), and the Constant Observation check every 10 minutes, on an Observation Sheet. The inmate’s observed activity will also be recorded on the form. o The Corrections Shift Supervisor shall make periodic visits to suicide prevention housing areas each shift to ensure that Observation Sheets are complete and accurate and those inmates are being observed as required. o All inmates on Suicide Precautions shall be assessed by a QMHP within 24 hours of placement utilizing a Suicide Risk Assessment. The assessment form includes a brief mental status examination, listing of chronic and acute risk factors, listing of any protective factors, level of suicide risk (e.g., low, medium, or high), current medication, diagnosis, and treatment plan. The Suicide Risk Assessment form shall be utilized during the initial assessment of risk that justifies an inmate’s placement on Suicide Precautions, as well as when the QMHP determines that the inmate’s behavior has stabilized and may be discharged from Suicide Precautions. o A QMHP or Qualified Mental Health Staff shall assess and interact with (not just observe) inmates on Suicide Precautions on a daily basis and enter quality progress note into the electronic medical record. Each progress note should be SOAP-formatted, include a brief mental status examination, and provide a sufficient description of the current behavior and justification for a particular level of observation. o Unless contraindicated by safety/security concerns, every effort shall be made to ensure that these assessments are conducted in a reasonably private and confidential location. (e.g., the visiting booths, counseling office or room, etc.). o An inmate placed on Constant Observation shall always be downgraded to Close Observation for a reasonable period of time prior to being discharged from Suicide Precautions. o An inmate can only be downgraded or discharged from Suicide Precautions by a QMHP, and only after the QMHP has conducted a thorough assessment, reviewed the electronic medical record, conferred with CSTs or designed correctional staff, and consulted with the Psychiatrist. o Whenever an inmate is discharged from Suicide Precautions, the designated QMHP shall enter the information into the “Past Medical History Screen” (i.e. “Suicide Precautions, Date”) of the electronic medical record. This information shall not be deleted when the inmate is removed from Suicide Precautions or released from the Jail. o Any inmate placed on Suicide Precautions for more than 24 hours shall have an individualized treatment plan developed by a QMHP. The treatment plan shall describe signs, symptoms, and the circumstances in which risk for suicide is likely to recur; how SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 84 of 100 recurrence of suicidal thoughts can be avoided, and the actions the inmate or staff can take if suicidal thoughts do occur. o In order to ensure the continuity of care for suicidal inmates, all inmates discharged from Suicide Precautions (following minimum placement of 24 hours) shall remain on the mental health caseload and receive regularly scheduled follow-up assessment by Qualified Mental Health Staff. Unless their individual treatment plan directs otherwise, the reassessment schedule shall be as follows: within 24 hours, then again within 72 hours, then again within 1 week, and then periodically, as needed. 50. Critical Component #6: Intervention Following a suicide attempt, the degree and promptness of intervention provided by staff often foretells whether the victim will survive. It is essential to balance the safety of officers and the inmates. It is also imperative that all officers understand that brain injury can occur within four minutes and that death can occur within five to six minutes from asphyxiation by hanging. Crime scene protection should not outweigh saving lives. Provided below is a listing of the applicable national correctional standards relating to emergency response within correctional facilities. Unless otherwise indicated, these standards apply to adult correctional facilities.37 American Correctional Association Performance-Based Standards for Adult Local Detention Facilities, 4th Edition, June 2004, Performance-Based Standards for Correctional Health Care in Adult Correctional Institutions, 1st Edition, January 2002 Emergency Response Correctional and health care personnel are trained to respond to health-related situations within a four-minute response time (emphasis added). The training program is conducted on an annual basis and is established by the responsible health authority in cooperation with SCCF or program administrator and includes instruction on the following: 37 recognition of signs and symptoms and knowledge of action that is required in potential emergency situations. administration of basic first aid certification in cardiopulmonary resuscitation (CPR) in accordance with the recommendations of the certifying health organization. methods of obtaining assistance signs and symptoms of mental illness, violent behavior, and acute chemical http://www.ncianet.org/suicideprevention/publications/update/Winter%202008.pdf SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 85 of 100 intoxication and withdrawal procedures for patient transfers to appropriate medical facilities or health care providers suicide intervention Comment: SCCF administrator and the health care authority may designate those correctional officers who have responsibility for responding to health care emergencies. Staff not physically able to perform CPR is exempt from the expected practice. National Commission on Correctional Health Care Standards for Health Services in Jails, 7th Edition, 2003, Standards for Health Services in Prisons, 5th Edition, 2003 Training for Correctional Officers A training program, established or approved by the responsible health authority in cooperation with SCCF administrator, guides the health-related training of all correctional officers who work with inmates. Compliance Indicators All aspects of the standard are addressed by written policy and defined procedures. Correctional officers who work with inmates receive health-related training at least every 2 years, which includes a minimum: administration of first aid; recognizing the need for emergency care and intervention in life-threatening situations (e.g., heart attack); recognizing acute manifestations of certain chronic illnesses (e.g., asthma, seizures), intoxication and withdrawal, and adverse reaction to medication); recognizing signs and symptoms of mental illness; procedures for suicide prevention; procedures for appropriate referral of inmates with health complaints to health staff; precautions and procedures with respect to infectious and communicable diseases; and cardiopulmonary resuscitation. The appropriateness of the health-related training is verified by an outline of the course content and the length of the course. A certificate or other evidence of attendance is kept on site for each employee. While it is expected that 100% of the correctional staff who work with inmates are trained in all of these areas, compliance with the standard requires that at least 75% of the staff present on each shift are current in their health related training. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 86 of 100 Discussion: This standard intends to promote the training of correctional officers to recognize when the need to refer an inmate to a qualified health care professional occurs and to provide emergency care until he/she arrives. Because correctional personnel are often the first to respond to problems, they must be aware of the potential for emergencies that may arise, know the proper response to life-threatening situations, and understand their part in the early detection of illness and injury. Emergency Services SCCF provides 24-hour emergency medical, mental health, and dental services. Compliance Indicators A written plan includes arrangements for the following, which are carried out when necessary: emergency transport of the patient from SCCF; use of an emergency medical vehicle; use of one or more designated hospital emergency departments or other appropriate facilities; emergency on-call physician, mental health, and dental services when the emergency healthcare facility is not located nearby; security procedures for the immediate transfer of patients for emergency medical care and notification to the person legally responsible for SCCF. Emergency drugs, supplies, and medical equipment are regularly maintained. Discussion: This standard intends that sufficient emergency health planning occurs and is put into effect when necessary. Planning ahead for emergencies can help minimize bad outcomes. Policy and procedures address, for example, of which facility on-call staff need to be notified, arranging for an ambulance, and alerting the community emergency room. The choice of basic emergency equipment depends on the size of SCCF, its distance from the nearest emergency department, and the level of staff training. FINDING(S): SCCF are provided training for intervening in suicidal ideation and attempts. Training is also provided in CPR and first response techniques. A review of all medical staff files indicated that all CPR/First Aid certifications are current. RECOMMENDATION(S): Ensure that all staff are provided ongoing and updated training on these policies. Also ensure that all CPR certifications are kept up-to-date. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 87 of 100 Increase custody, medical, and mental health staffing levels as previously recommended to help insure timely detection, intervention, monitoring, stabilization, and aftercare for inmates presenting suicidal ideation and who attempt suicide. Establish a multidisciplinary morbidity review process to review all serious suicide attempts. The review process should include officials from custody, medical, and mental health. Revise current policies and procedures to include comprehensive guidance and expectations for suicide prevention intervention purposes. Minimum policy elements are listed below: o All correctional and medical staff shall be trained (and maintain certification) in standard first aid and cardiopulmonary resuscitation (CPR). o All correctional and medical staff shall participate in annual “mock drill” training to ensure a prompt emergency response to all suicide attempts. o All housing units shall contain an emergency response bag that includes a first aid kit; CPR pocket mask or Ambu bag, latex gloves, and emergency rescue tool. All staff who come into regular contact with inmates shall know the location of this emergency response bag and be trained in its use. o Any staff member who discovers an inmate attempting suicide will immediately respond, survey the scene to ensure the emergency is genuine, alert other staff to call for the facility’s medical personnel, and bring the emergency response bag to the cell. If the suicide attempt is life-threatening, Central Control personnel will be instructed to immediately notify outside (“911”) Emergency Medical Services (EMS). The exact nature (e.g., “hanging attempt”) and location of the emergency will be communicated to both facility medical staff and EMS personnel. o Following appropriate notification of the emergency, the First Responding Officer shall use his/her professional discretion in regard to entering the cell without waiting for backup staff to arrive. With no exceptions, if cell entry is not immediate, it shall occur no later than four (4) minutes from initial notification of the emergency. Correctional staff will never wait for medical personnel to arrive before entering a cell or before initiating appropriate lifesaving measures (e.g., first aid and CPR). o Upon entering the cell, correctional staff shall never presume that the victim is dead, rather lifesaving measures shall be initiated immediately. In hanging attempts, the victim shall first be released from the ligature (using the emergency rescue tool, if necessary). Staff shall assume a neck/spinal cord injury and carefully place the victim on the floor. Should the victim lack vital signs, CPR will be initiated immediately. All lifesaving measures shall be continued by correctional staff until relieved by medical personnel. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 88 of 100 o The Corrections Shift Supervisor shall ensure that both arriving jail medical staff and EMS personnel have unimpeded access to the scene in order to provide prompt medical services to, and evacuation of, the victim. o Although the scene of the emergency shall be preserved as much as possible, the first priority shall always be to provide immediate lifesaving measures to the victim. Scene preservation shall receive secondary priority. o Automated External Defibrillators (AEDs) are positioned in various locations within the jail. All medical and correctional staff shall be trained in their use. The jail Medical Director or Designee shall provide direct oversight of AED use and maintenance. o The Medical Director or Designee shall ensure that all equipment utilized in the response to medical emergencies (e.g., emergency response bag, crash cart, oxygen tank, AED, etc.) is inspected and in proper working order on a regular basis. o All affected staff and inmates involved in the incident shall be offered critical incident stress debriefing (see Section H). o Although not all suicide attempts require emergency medical intervention, all suicide attempts shall result in the inmate receiving immediate intervention and assessment by a QMHP. 51. Critical Component #7: Reporting and Notification In the event of a suicide attempt or suicide, all appropriate correctional officials should be notified through the chain of command. Following the incident, the victim's family should be immediately notified, as well as appropriate outside authorities. All staff that came into contact with the victim prior to the incident should be required to submit a statement including their full knowledge of the inmate and incident. FINDING(S): The active suicide prevention policy does not include statements or procedures for reporting. That said, SCCF officials described their reporting practices as including all elements of an effective reporting system. RECOMMENDATION(S): Revise current policies and procedures to include comprehensive guidance and expectations for suicide prevention intervention purposes. Minimum policy elements are listed below: SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 89 of 100 o In the event of a suicide or serious suicide attempt (i.e., requiring medical treatment and/or hospitalization), all appropriate officials shall be notified through the chain of command. o Following the incident, the victim’s family shall be immediately notified, as well as appropriate outside authorities. o All staff that came into contact with the victim before the incident shall be required to submit a statement including their full knowledge of the inmate and incident 52. Critical Component #8: Follow-up/Mortality Review Experience has demonstrated that jail systems that carefully review suicides and serious suicide attempts will reduce the likelihood of future suicides. FINDING(S): SCCF conducts thorough investigations for inmate death incidents and involves outside law enforcement in those investigations. However, there are no active policies and procedures that provide guidance for mortality or morbidity reviews (for serious suicide attempts). RECOMMENDATION(S): A full mortality review should include key members of administration and department heads, and key medical and mental health staff. Additionally, regular (monthly) reviews of inmate self-harm and suicide attempts should be conducted to learn from this information how to improve prevention and management efforts. A review of policy and protocol is indicated. Revise current policies and procedures to include comprehensive guidance and expectations for suicide prevention intervention purposes. Minimum policy elements are listed below. An effective and complete mortality/morbidity review process should include the following elements: o Every completed suicide, as well as serious suicide attempt, shall be examined by a multidisciplinary Morbidity-Mortality Review Team that includes representatives of both line and management level staff from the corrections, medical and mental health divisions. The Mental Health Director shall chair the committee. o The Morbidity-Mortality Review process shall comprise a critical inquiry of: a) circumstances surrounding the incident; b) facility procedures relevant to the incident; c) all relevant training received by involved staff; d) pertinent medical and mental health services/reports involving the victim; e) possible precipitating factors leading to the SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 90 of 100 suicide; and f) recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures. The inquiry shall follow the outline described in the Morbidity-Mortality Review Checklist. o The mortality review report should include the following minimum components: - day, date and time of incarceration arrest reports intake and assessment documents date, time, and location of death inmate personal information and demographics apparent and actual cause of death death modality review of staff interactions previous to death inmate healthcare records current medications and administration activity inmate medical and mental status during incarceration and preceding death food service records relevant to inmate diet and eating habits autopsy report, if applicable interviews with cellmates review of any and all documentation associated with inmate’s incarceration visitation logs inmate mail photographs of inmate cell and location of death review of health care and suicide protocols other information needed to provide a clear understanding of the inmate’s activities while incarcerated 53. Critical Component #9: Critical Incident Debriefing A shift from rehabilitation to a more custodial approach, an increase in long-term sentences, overcrowding, and more violent and mentally ill offenders led Cheek and Miller (1979) to examine the effects of stress in staff and inmates in the New Jersey Department of Corrections. Cheek & Miller (1982) also investigated the strategies that the Department implemented to reduce those stressors. Brodsky (1982) conducted one of the earlier analyses of correctional stress from an organizational and cultural perspective. The evidence indicated that correctional employees experience a significant amount of stress in their work, which may lead to high job turnover, high rates of sick leave and troubled relationships with inmates, other staff, and family members. Lindquist and Whitehead (1986) investigated burnout, job stress and job satisfaction among southern correctional officers. They found that 20% to 39% experienced burnout and SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 91 of 100 stress but that only 16% expressed job dissatisfaction. It was suggested that correctional officers mask their dissatisfaction to prevent facing job changes. There was no analysis or implication regarding the effect this could have on families. Stohr (1994) and associates studied stress in contemporary jails by examining jails in five areas across the U.S. They found that stress in workers was a serious problem and approaching dangerous levels in some facilities. The contributing factors were primarily related to management and organizational methods. There was less stress when fair compensation, investment in employee development and participatory management practices were employed. Similarly, Wright, Saylor, Gilman and Camp (1997), in a study of U.S. Federal Bureau of Prisons' employees, found lower job-related stress a factor when workers were involved in decision making. Although not new to correctional employees on the front line, workplace violence was identified as having a negative impact on employees' wellness in the 1990s. The National Crime Victimization Survey (NCVS) report for 1992-1996 (U.S. Dept. of Justice, 1998) revealed that the field of Law Enforcement was the second largest group in the nation to experience workplace violence. Prison guards experienced non-fatal workplace violence at the rate of 117.3 per 1,000 workers. Additional investigations of staff victimization have been cited in the literature (Andring, 1993; Dowd, 1996; Seymour & English, 1996; VandenBlos & Bulatao, 1996). From November 21 through December 4, 1987, prisoners rioted and took hostages in Federal Prisons in Oakdale, Louisiana and Atlanta, Georgia (National Victim Center [NVC], 1997). Bales (1988) reported about the stressors and follow-up for the hostages including a family resource center. There was no indication of pre-incident stress inoculation or family support planning. Additional hostage situations that reached national media attention were Attica, New York, 1971, Wyoming State Penitentiary, 1988, and Pennsylvania State Correctional Institution, Camp Hill, 1989 (NVC, 1997). Throughout the 1980s and 1990s, the recognition of the need for crisis intervention after a critical incident became apparent. The earliest crisis intervention programs for correctional employees were conducted post-incident. Bergman and Queen (1987) credited the retention of employees after the riot at Kirkland Correctional Institution Columbia, South Carolina to the "critical incident debriefing" (Mitchell, 1983; Mitchell & Everly, 1993) conducted immediately after the incident. Van Fleet (1991) also referred to debriefing traumatized correctional staff to mitigate stress that could lead to posttraumatic stress disorder (PTSD). Training workshops and training guides/manuals became available (Concerns of Police Survivors [COPS], 1996; Finn & Tomz, 1997; NVC, 1997; U.S. Office of Personnel Management, 1998). Directly or indirectly, the resources referred to Critical Incident Stress Management (CISM) (Everly & Mitchell, 1997). Traditionally, in the correctional field any type of assistance offered to employees' and their SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 92 of 100 families was post-incident, usually at the employees or families' request and in the form of referrals to the agency’s Employees Assistance Program or private contractors. Little mention is made of preventive or stress inoculation programs for employees and families at the front end or when entering correctional employment. On the other hand, police (COPS, 1996; National Institute of Justice [NIJ], 1997) and firefighting agencies have initiated family awareness and educational programs, which range from a few hours to several weeks. An Introduction to Critical Incident Stress Management38 A critical incident is defined as "any event which has a stressful impact sufficient enough to overwhelm the usually effective coping skills of either an individual or a group are typically sudden, powerful events outside of the range of ordinary human experiences" (Mitchell & Everly, 1993). Most employees entering the criminal justice system recognize that verbal and minimal physical abuse from those in their care, custody, and control is a reality of the job. Critical incidents and stressors experienced by employees in correctional, prison, and forensic settings include: held hostage, riot, physical/sexual assault, death or serious injury in line of duty, suicide of inmate or employee, use of lethal force on inmate, participation in execution and witness to any of the above. Historically, the approaches to help staff deal with critical incidents and stressors fall into three broad categories including: (1) Employee Assistance Program (EAP), a contracted service with the state, agency or facility. Traditionally, the EAP provider is typically an individual mental health clinician (i.e., counselor, social worker, and psychologist). Since employees in these settings tend to be cautious and somewhat suspicious of mental health providers and outsiders, a few EAP programs include clinician-trained peer support personnel selected from the employees likely to be represented in an event. (2) Peer Support Program (PSP) which consists of non-clinician employees, who are representative of the workforce, and trained in crisis intervention. (3) Critical Incident Stress Management (CISM) Program, the International Critical Incident Stress Foundation (ICISF) model. The CISM Team is "described as a partnership between professional support personnel (mental health professionals and clergy) and peer support personnel (employees) who have received training to intervene in stress reactions" (Mitchell & Everly, 1993). Professional support personnel are required to have academic training at the master's degree or higher level and/or recognition of their training and skills through certification or licensure. They must also have education, training and experience in critical incident stress intervention. 38 http://www.aaets.org/article88.htm SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 93 of 100 Components of a Comprehensive CISM Program A comprehensive CISM program is multi-faceted (Mitchell & Everly, 1993; PDOC, 1992). Pre-incident prevention and stress inoculation are essential. All employees receive education and training in everyday and work-related stress awareness and stress management techniques as well as how to access the EAP program and CISM team when necessary, while attending Basic Training Academy. Employees whose job requires direct contact with inmates/patients attend biannual refresher stress management classes. Managers receive training in recognition of employee stress and referral procedures. Families and significant others are provided similar stress awareness and coping skills and how to access referral services at the Family Academy. CISM team development, member selection and training needs to be well-planned and foster a partnership between employees, management and labor relations. A CISM Program policy/standards and procedures manual, applicable to the agency, must be established. Best results are achieved if team membership is voluntary. A selection committee comprised of management and employees/ labor representatives should develop an application form and include an interview in the selection process. Team members, professional and peer, must be trusted and accepted by their fellow employees. Peer members must be representative of the employee population including custody, maintenance, counseling, education, medical, clerical, etc. It is recommended that each facility have a team available for rapid deployment. In order to respond to major events, in large systems, regional teams composed of members from various facilities are also suggested. Although there are similarities in the training programs available, this article and model adheres closely to the ICISF standards. All team members should be required to complete ICISF Basic Critical Incident Stress Debriefing Training. Peer Support/Crisis Intervention Strategies is also recommended. All members should also have an understanding of Incident Command system, if used in their setting, and specialized units such as Emergency Response, Hostage Recovery and Hostage Negotiation Teams. The CISM team and specialty teams should participate in joint training exercises at least once annually. The CISM Program services should include: 1. On-scene support (usually provided by peer support members during a major/prolonged event). 2. Demobilization or de-escalation (brief intervention to assist employees in making the transition from the traumatic event back to routine or stand-by duty, formal debriefing to follow in several days). SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 94 of 100 3. Defusing (a three-phase group crisis intervention provided immediately or within twelve hours after the event to mitigate the effects of the stressors and promote recovery, usually twenty to forty-five minutes in duration). 4. Debriefing (a seven-phase group crisis intervention process to help employees work through their thoughts, reactions, and symptoms followed by training in coping techniques, usually lasting one and one-half to two hours). 5. One-on-one support (individual intervention if a single or small event and a group intervention is not possible or additional individual assistance is deemed necessary after a group process). 6. Significant other/family defusing/debriefing (services may be provided separately from traumatized employees). 7. Line-of-duty death support (defusing provided immediately after event for staff, team assists family, and a debriefing provided for staff after the funeral). 8. Referrals (team member recommends and instructs employee to access additional support/treatment through EAP or other resources). 9. Follow-up (team leader or designated member contacts employee(s) and/or employee(s) supervisor a few days after team services). Records and Program Evaluation Client(s) confidentiality must be maintained. However, in order to maintain service continuity and program quality improvement minimal record keeping is necessary. A request for service form including time of event, nature of incident, number of personnel involved, contact person and contact number will assist the team leader in selecting team members and establishing meeting location and time. The service provided form should include information from the request form and a summary or themes of reactions, thoughts, and symptoms presented, educational material provided, and coping techniques recommended and if referrals were made. Individual(s) names and comments are not recorded. The team leader may, with the majority consensus and participants' permission, provide administrative staff with a report of recommendations to improve conditions or remedy situations that led to the critical event. In most situations consumer satisfaction will be determined informally through follow-up with the participants and from supervisory staff. However, after major events, a participant's satisfaction questionnaire is recommended. A combination of checklist, multiple choice and general comment format works best in this employment setting. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 95 of 100 Interagency and Community Support Traditionally correctional facilities are scattered through the state and many times located in rural areas. Correctional CISM Teams can be a resource for smaller counties and municipalities and provide services for jails, probation and parole agencies, police and community emergency responders. The Correctional CISM Team professionals may act as consultants or supplement communities volunteer peer teams. The CISM teams can, along with other correctional special response teams, assist communities affected by a disaster. The Correctional CISM Teams may also work very effectively with other State agencies such as state police and probation and parole. FINDING(S): There does not appear to be a formal policy or practice for CISM, in part due to very few jail deaths within the past five years. Additionally, there does not appear to be a coordinated policy with local community mental health services to provide CISM services. RECOMMENDATION(S): Develop and implement comprehensive CISM policies and procedures. This procedure is not the same as mortality review debriefing. Instead, this refers to a formalized opportunity for involved or affected staff members to talk about their thoughts and feelings about a possibly difficult critical incident, such as a death or suicide attempt, so as to try to deal more effectively with their difficult or troubling feelings. Policy should indicate that this opportunity is available and should indicate who has the responsibility for planning and implementing it. Policies and procedures should be developed to coordinate both internal and external CISM services. Traditionally, a critical incident debriefing focuses on the experiences and needs of staff involved in the stressful event. Inmates can also experience post-event trauma. It is important to recognize that inmates who are exposed to suicides or other serious trauma while incarcerated may suffer temporary and/or long term psycho-emotional harm. It is therefore important that a comprehensive critical incident debriefing policy and action plan includes providing similar services to appropriate inmates. Again, policies and procedures should be developed to coordinate both internal and external CISM services and include services for inmates. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 96 of 100 XII. RELATED ISSUES & RECOMMENDATIONS A. Data Collection and Information Management: Effective jail management requires accurate and easily accessible data39 In the past, managing jails was considered to be so basic that there was nothing to it. However, with increased court intervention in correctional matters, demands for better management of correctional facilities increased in the 1970s. The courts discovered that often the difference between a “constitutional jail” and an “unconstitutional jail” was the way in which they were managed. Since good management relies strongly on good information, sheriffs and jail administrators found that their organizational world had become a much more complex environments. As a result, “professional management” arrived in correctional facilities. Sheriffs and jail administrators were introduced to a number of techniques, such as cost benefit analysis, Total Quality Management, and organizational development that were designed to help them improve organizational performance. Sometimes these techniques were very helpful, and sometimes they were not. In analyzing their relative successes and failures, the ability of the organization to generate good, valid information about its problems emerged as a critical variable. So what is management? Management is mostly about mobilizing an organization’s resources, in this case the jail’s, to solve or avoid problems. In many cases, problems are not solved in the sense that they go away, but the organization finds a way to manage them more effectively. Regardless of the complexity of the problem, a basic management formula applies to analyzing a situation. It consists of five steps: 1. Facts are gathered. 2. Facts are interpreted in light of the organization’s mission and values. 3. Alternative solutions are developed. 4. A decision is made. 5. Action is taken. Easy and timely access to good jail data is pivotal to effective jail management. Valid data are absolutely needed to safely and effectively operate the jail at all levels and can significantly improve jail performance in all functional areas. FINDING(S): The current SCCF data management system appears to collect the necessary jail data elements to develop a useful set of jail operational reports. The system appears easy to extract data from and should afford SCCF the opportunity to become more “data driven”. In doing so, SCCF may find fiscal and operational decision making more efficient and effective. 39 Gail Elias, http://nicic.gov/Library/021826 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 97 of 100 Additionally, SCCF regularly collects and reviews population and healthcare related data relevant to jail services and management. RECOMMENDATION(S): Consider the creation of a jail information and reporting team to determine exactly what data are needed to better support decision making at all levels of the jail. The teams should decide specifically how the various functions of the jail can use better data and consult with those areas to clarify and document needs. Outside professional consultation should be considered. Once the data team determines what data elements are needed, they should consult with current jail management system provide for assistance. It is likely that much of the information desired already exists in the jail management system data base and accessing may be as simple as being trained by the provider on how to most efficiently query the data. The data may then be reformatted into workable spreadsheets for simple, clear and ongoing review and analysis. B. Cross-Discipline Staff Meetings : Regular meetings among staff who work with the inmates can greatly improve communication and build a team-based response to working with the inmates who require mental health services. FINDING(S): SCCF currently holds regular health care meetings involving only jail administration and health care staff. Although this is a great opportunity to discuss issues and resolve problems, the topics and discussions are limited to the scope of information brought to the meeting. RECOMMENDATION(S): SCCF leadership is to be commended for its open communication philosophy. SCCF is encouraged to continue this process. C. Involve Advocates40: Numerous advocacy groups throughout the greater Snohomish County area and region may be able to assist the jail in securing the mental health resources that are needed and for informing the public about the problems of inmates with mental illnesses in the jail. Many jails that have found little to no public or financial support for jail mental health services have discovered that advocates have the interest, mission and power to force changes and support that benefits the jail. 40 Op Cit: La Crosse County NIC TA # 06B5007 SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 98 of 100 Mental health advocacy groups and coalitions are interested in supporting appropriate mental health services in the jail. There is a view within the mental health community, the advocates, and the families, that the jail should be more treatment oriented. As in many communities, the public is often confused about the discrete role of the jail in the criminal justice system. The jailer is often "blamed" for much of the perceived "unfairness" of incarceration as well as other components of the criminal justice system. There are paradoxical perceptions that criminals "should be locked away in harsh punitive correctional environments" until that "criminal" is someone that you know or is related. When a friend of relative is incarcerated there is recognition that much of the jail population is pre-trial and not convicted criminals. The perception shifts to "he/she is still a human being and the jail environment should be humane." These conflicting perceptions can result in a confused correctional philosophy that impacts funding for jail design, staffing, and programming. Even among the advocates (both family and agency) there are mixed perceptions of the jail and a willingness to believe that "jailers do not care." Unfortunately, jailers are stigmatized by public perception based on media stereotypes. I would encourage Snohomish County advocates to consider whether their perceptions are based on reality or media-driven stereotypes that stigmatize the very difficult jobs of jail personnel. If they are based on stereotypes, what can be done to further understanding and advocacy for jail personnel and inmates? RECOMMENDATION(S): Engage or develop a mental health coalition to become a voice to advocate for an appropriate level of mental health services at the jail. Current services cannot meet basic mental health needs; however, more could be done particularly in the programming area which will be discussed next. The mental health coalition could become a strong force to ensure that programs are put into place in the jail. Build stronger relationships with the members of an existing mental health coalition, with NAMI of Snohomish County, and other consumer advocacy groups. Contact the advocacy groups that provide services in the Snohomish County area. These would include local/regional chapters of National Alliance for Mentally Ill (NAMI) and other consumer groups. Each of the advocacy groups, whether they advocate for families or consumers, has their own mission. Study their missions, and contact the appropriate advocacy group(s) for each problem to be solved. Using the expertise of advocates often goes far in educating the public, the mental health system, and county funders about the problems providing services to the vast and growing numbers of inmates who have mental illnesses who are arrested and incarcerated in county jails. While there is public acknowledgment that mental health has lost funding across the country, there is minimal understanding that those funds were not transferred to the criminal justice system to treat the growing numbers of people with mental illnesses in jails. Advocates, once informed, are often an active voice that educates the public and mental health service providers about the limitations of jails. Jails are not and were never intended to be a treatment facility for people who have mental illnesses. These advocacy groups can stress the importance of diversion and alternatives to incarceration for people who have serious mental illnesses. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 99 of 100 XIII. CONCLUSION Based on this assessment, this consultant is convinced that the Snohomish County jail is, overall, a well-managed and professional correctional facility. Despite several opportunities to improve jail health care services, jail officials and staff continue to focus on doing the very best they possibly can within limited fiscal realities and crowded conditions. It is hoped that this document will be of meaningful assistance to Snohomish County officials in their continuing efforts to ensure constitutional and quality inmate health care services. Special thanks are extended to Sheriff Trenary, Chief Miller and Major Baird, the jail staff, and County officials who participated in this short-term technical assistance study. In conclusion, I want to take this opportunity to thank the National Institute of Corrections for providing this professional assistance to the Snohomish County, Washington Sheriff’s Office. SNOHOMISH COUNTY, WA CORRECTIONAL FACILITY NIC TA 13J1075 Page 100 of 100