Inmate Healthcare recommendations

The Inmate Healthcare category includes 108 recommendations. 52 recommendations (48 percent) have been audited and completed, 51 recommendations (47 percent) are covered by consent decrees and monitored by experts under federal court oversight, and 5 recommendations (5 percent) are not covered by the consent decrees and are subject to audit by OCLEM. 
 

	Not covered by Consent Decree/subject to audit by OCLEM.
	Covered by Consent Decree and subject to monitoring by federal court appointed experts.
	Completed, audited, and presented to the Board.

Recommendation	Master List Number	Status (Updates are in progress)
Custody Health Services is to conduct a full-scope evaluation of the handling of medical and behavior health complaints.	30
Custody Health Services is to ensure that all medical and behavioral health complaints are properly routed for timely responses.	31
Assure that the present changes in custody mental health at the jail are not limited to the main jail. There should be no delay in providing mental health evaluations and if prescribed, medications, becomes at Elmwood as well as the main jail.	44
Improve timeliness, seamlessness, and continuity of “outpatient” behavioral health and medical care by, among other things, more timely response to requests for treatment, particularly emergencies; improved access to medications and other necessary care upon booking; and better follow-up care after inmates are treated at Valley Medical Center.	45
Upon release from jail, the Sheriff’s department should facilitate access to an appropriate supply of medication as ordered in the discharge plan, a prescription, and a list of pharmacies accepting the issued prescription that are easily accessible to the person, rather than faxing all prescriptions to the Enborg Pharmacy which is far from the jail. Also, the mentally ill indigent offender should be transported to pick up those medications.	46
Mental health staff should be available at jail-booking and  at all times thereafter. Most specifically, mental health staff should be a part of any response team relating to behavior of the mentally ill person while in custody.	47
Improve coordination of community- based and in-custody behavioral health services for people coming into, and being released from, the jail.	48
Offenders with mental illness who do not have federal and state benefits, or have lost them due to the length of their incarceration, should receive assistance from jail  staff or in-reach care managers in preparing and submitting the necessary forms and documentation to obtain benefits immediately upon reentry into the community.	50
Mentally ill inmates should be evaluated promptly. They should not have to wait at Elmwood Processing for hours to be transferred to the Main Jail for evaluation after 11:00 p.m.	52
Mental Health Treatment: There should be group therapy focused on substance abuse, Post Traumatic Stress Disorder and anger/stress management and predischarge planning/counseling for release to the community.	53
Apply the same rigorous analysis and establishment of performance measures for Custody Health Services that is comparable to audits and evaluations of other departments and programs.	54
Provide regular preventative care for detainees who are housed for a year or longer in the facilities, such as dental cleanings and x-rays, physicals, immunizations and other standard care that would be received outside. To reduce the loss of teeth and the cost of trips to the emergency room, institute more preventative care for detainees and improve response to requests for care. Consult medical professionals for typical standards of recommended care.	55
Need computerized Tracking System and Dashboards to produce statistical data as to mentally ill offenders.	56
The Women’s Facility needs to establish a mental health unit to provide adequate care for the female mentally ill inmates. Female mentally ill inmates should not be transferred to module 8A.	101
Ensure that medical care and behavioral health care delivery systems have adequate space for in- facility urgent care, and ensure that prescribed equipment is on hand to avoid delays in accommodating temporarily or permanently physically disabled inmates.	102
Ensure co-equal leadership and decision-making between the Sheriff’s Office and Custody Health around the needs of inmates with behavioral health disabilities. This should include increased collaboration around housing, classification, safety, and behavioral health treatment access for inmates with behavioral health needs; co- review of use of force incidents involving inmates with behavioral health disabilities; joint responsibility for correctional officer training on behavioral health needs; and joint problem solving with respect to individual inmate behavioral health needs.	103
Need a records and information system that ties custody health to County Mental Health and Community Mental health to allow for linkages and connections when mentally ill offenders are released. The system must allow input from all health programs involved in providing care to the individual.	111
Physical Health Treatment: Treatment should be a timely with a compulsory minimum wait time to be seen after a request has been made. Also, Optometry should be included in physical health treatment to examine inmates perhaps during “orientation” for possible eyeglasses.	112
Create inmate suicide awareness and prevention program and a post- venation program for surviving inmates. Designate specific staff to address these issues.	123
Create inmate suicide awareness and prevention program and a post- venation program for surviving inmates. Designate specific staff to address these issues.	129
Ensure that pregnant inmates are provided enough food as needed between regularly scheduled meals, whether or not she has money to pay for commissary items.	172
Ensure that medical & behavioral health care needs of inmates, as reported by inmates and in court orders are responded to timely fashion  based on medical and behavioral health  best practices.	329
Ensure that medical care and behavioral health care delivery systems have adequate space for in- facility urgent care, and ensure that prescribed equipment is on hand to avoid delays in accommodating temporarily or permanently physically disabled inmates.	330
Ensure that inmates’ access to and provision of preventative and urgent medical and behavioral health care are based on best practices for short- term and long-term needs.	331
Implement a plan to reduce the number of inmates in custody with mental health issues.	376
Increase the number of mental health treatment opportunities for those scheduled for release from custody.	377
Continue to work with County Behavioral Health on the concept of mobile crisis response teams to potentially reduce the numbers of arrests where treatment is more appropriate.	378
Conduct a comprehensive clinical review of our custody healthcare program to determine what gaps, if any, exist in our custody healthcare delivery system.	389
Upon completion of the clinical gap analysis, finish implementation of the recommended changes that will improve access to competent healthcare in a cost effective and efficient manner.	390
Add minimum performance standards for Custody Health clinical positions.	391
Accelerated the implementation of cutting edge electronic medical record technology.	392
Evaluate administrative oversight of Custody Health to achieve greater accountability and oversight.	393
Develop a mental health pilot program for seriously mentally ill inmates housed in our custodial facilities that increases clinical staffing, increases individual/group therapy, increases out of cell recreation opportunities, develops a resilient reentry process to ensure continuity of care in the community. This program will explore alternative structured and supervised environments in the community for the seriously mentally ill that reduces returns to custody for behaviors that are an affect of their mental illnesses without jeopardizing public safety.	394
Analyze clinical outcomes for pilot project quarterly and make appropriate adjustments, if any, in clinical treatment programs to improve outcomes in a cost effective manner.	395
Develop a plan for consistent and reliable transportation from jail to the designated treatment center.	397
The Jail should not subject inmates with psychiatric disabilities to prolonged placement in restrictive housing, ensure in policy and practice that inmates with psychiatric disabilities are not subjected to any period of restrictive housing as a disciplinary measure in response to behaviors associated with their disability, and ensure an appropriate balance of structured and unstructured out-of-cell time for such inmates. The Jail should review its restrictive housing practices regarding other inmates, expand step-down planning and opportunities, and abandon any use of highly subjective custody input forms as part of its classification procedures. The Jail should implement the DOJ’s recent guidance on jails’ use of restrictive housing and seek technical assistance from DOJ’s Bureau of Justice Assistance and/or the Vera Institute of Justice’s Segregation Reduction Project.	518
The Office of the Sheriff should assign personnel whose sole responsibility is to update and maintain all Custody Bureau policies and procedures with priority given to the Medical and Health Care Services chapter and the Security and Control Chapter.	529
The Office of the Sheriff should work closer with the Custody Health department to best address health- related issues.	545
The Office of the Sheriff should retain an experienced correctional health care administrator to monitor the provision of health services and coordinate the interaction between health care and custody.	547
The scope of services should be broadened for longer-term inmates and be based on the dental priority codes used by CDCR which categorize treatment needs as Urgent Care, Interceptive Care, Routine Rehabilitative Care, No Dental Care Needed, and Special Needs Care.	548
Urgent Care should be sub-divided based on a condition's acuity. Conditions characterized with sudden onset and severe pain should be treated within 24 hours. Urgent Care should be made available to all inmates.	549
Inmates requiring Interceptive Care should be treated within 120 days. Interceptive Care should be available to inmates who have six months or longer left in their sentences or inmates who are no adjudicated but who are likely to be in custody for at least six months.	550
Routine Care should be provided to inmates within 12 months. It should be available to inmates who have 12 months or longer left in their sentences or those who are not adjudicated but likely to be in custody for at least 12 months.	551
Dental policies and procedures should be rewritten to address a wider scope of services (e.g., oral self-care, periodontal diagnosis and non- surgical treatment, denture fabrication and repair, restorations, and routine care), and clinical administrative procedures (e.g., record keeping and workload reporting). The Policies and Procedures should be modeled on those used by CDCR, especially with respect to the DPC system.	553
The policy regarding prescribing inmates dental prosthesis should be rewritten.	554
The Refusal of Care Form should be rewritten to fit the educational level of the typical inmate and should describe the specific treatment that has been recommended and is being refused, as well as the specific consequences of declining the treatment.	555
A policy should be developed to address dental floss and other interdental cleaning devices. The policy should also address the circumstances when use of such devices will be denied for security reasons.	556
A policy should be developed to treat inmates who have fixed orthodontic appliances.	557
A policy should be developed to address when inmates who are expected to remain in custody for six months or more will be provided dentures. The policy should also address when sott diets will be prescribed to inmates who experience chewing difficulty due substantial tooth loss.	560
Dr. Shulman recommends that the principal evaluation metric for the dental program be changed from the number of patient encounters to the number of procedures (using CDT codes) that dentists do on a daily basis. Consequently, it is critical that any EDR be designed with the capability to produce management and productivity reports using CDT codes. In addition, the EDR should be sufficiently flexible to track DPC codes. Dr. Shulman notes that this can be done initially using a manual (paper) system that is completed after each appointment and totaled at the end of the day. This system can be migrated to Microsoft Excel, and later be produced by the EDR.	568
The County should choose one medical information system and insist that all information about health care reside in that singular system.	571
The EPIC target system implementation should be expedited as much as possible.	572
Nurses who perform the intake assessment should be adequately and specifically trained to do intake screenings and the training should be updated yearly.	574
Nurses should complete all five vital signs as well as height and weight measurements on every patient.	575
From an operational perspective, unifying the intake process for male and female prisoners would open up a significant amount of physical plant space to provide for these options and it would greatly reduce the duplication of staff necessary to run two separate parallel tracks.	577
The intake facility should redesign the alcohol, opiate, and benzodiazepine withdrawal assessment and treatment protocols to conform to contemporary standards.	578
The intake facility should change the management techniques for seriously mentally ill, acutely intoxicated, and behaviorally challenged patients to a methodology of separation and isolation during the booking process as opposed to restraints in the lobby area.	579
The DOC should create an operational process whereby white cards are readily available from officers and nurses.	583
The DOC should create a process so that completed white cards can be submitted at any time to a locked mailbox that is accessed only by health care staff.	584
The DOC should redesign the sick-call process to include a triage encounter with a brief face-to-face visit with a nurse including a full set of vital signs within 24 hours of submission of the health services request.	587
The DOC should assign a triage score at the time of face-to-face triage to schedule patients with providers according to priority.	588
The DOC should redesign the white card form to provide more information to prisoners.	589
The DOC should inform all prisoners submitting white cards what their triage grade is and what that means for when the prisoner will be seen.	590
The DOC should implement an aging report as part of the health services administrative dashboard to monitor backlogs and care for medical, mental health, and dental appointments.	591
The DOC should encourage officer involvement in ensuring that blank white cards are available in the housing units.	595
The DOC should require nursing staff to collect the health services requests from a request box.	596
The DOC should monitor the availability of blank white cards in all units as part of the unit daily management log.	597
The DOC should require that all health care staff who interact with patients wear a standardized uniform with respect to color and presentation.	598
The DOC should require that the health care staff uniforms be embroidered in a standardized location with the staff member’s first name, last initial and job title within the institution.	599
The DOC should implement additional techniques for managing patients who require insulin and create a comprehensive diabetic management protocol for the institution.	607
The DOC should devise a methodology whereby patients can be discharged from jail and receive a set number of days of their medication to ease their transition back into the community. This program should pertain to all prescription medications with the exception of controlled substances, injectables, and PRN (as needed) medications.	608
The DOC should devise a methodology whereby patients are given information about health care appointments at the hospital that are scheduled for them in the future.	609
The DOC should provide patients with a discharge summary of their care that details their current medications, their allergies, their current diagnoses, and important diagnostic information.	610
The County should investigate the possibility of deploying a KOP medication process within the Santa Clara County Jail System and possible nursing staff savings associated with this process.	611
The DOC should modify the facility schedules to serve meals at normal times of day that conform to normal circadian rhythms.	612
White cards should be readily available in the units, from officers, and from nurses; and there should be a methodology for submitting them into a locked mailbox in each unit for medical staff to access and then assess. In units where prisoners are not allowed out because of security or behavioral issues, some methodology for submitting white cards must be devised so that access to care is not impeded.	613
Dr. Gage recommended the creation of a position for a Director of Mental Health. This position would oversee all aspects of mental health services in the jail, including psychiatric prescribers and psychiatric nurses.	614
Dr. Gage recommended that the Director of Mental Health should have a doctoral degree in a mental health field with clinical experience, a robust clinical administration background, and correctional (or at least institutional) experience.	615
Dr. Gage recommended a complete redesign of the intake screening form for nurses. The content must identify the most acute and risk-laden mental health conditions to allow rapid identification of these conditions by the nurse and the mental health clinician reviewing the form. Inmates should then be prioritized for assessment based on their acuity  and risk. Inmates who have emergent needs should be seen within four hours, those with urgent needs within 72 hours, and those with routine needs within 10 working days. Medications for inmates identified as being on medications in the community should be ordered on the day of admission, but at least within 72 hours.	616
Dr. Gage recommends that DOC follow through with the plan to get expert consultation regarding the classification system.	617
Dr. Gage recommended requiring more uniform conditions that are policy driven throughout the jail for each security level. It is important to provide for regular, random cell searches of mental health Special Management Units (and perhaps for all units) at an established frequency that is not discretionary. This should specifically include attention to hoarding and potentially dangerous contraband.	618
Dr. Gage recommended that the County carefully review its options for involuntary medications under both emergent and non- emergent situations, which should include the jails as well as those committed under LPS.	619
Dr. Gage also recommended review of the limited use of temporary and permanent conservators, which he opined were likely underutilized. Related to this is a need for thorough examination of policies and practices related to the evaluation of competency and securing informed consent. This should include examination of the current practice of permitting incompetent patients to refuse any health treatment including medical, dental, and mental health treatment.	620
Dr. Gage recommended development of the Prison Rape Elimination Act policies and procedures for mental health clinicians.	621
Dr. Gage found that there was no unitary medical record system. The records were accordingly fragmented. Dr. Gage recommended that the medical records system be  completely revamped, and noted that there are plans to do so.	622
Dr. Gage recommended that inmates admitted to restrictive housing be promptly screened. It is reasonable for nursing staff to conduct the initial screening, but mental health staff should screen new arrivals by the next working day. Mental health staff should also do at least weekly rounds in restrictive settings.	623
Dr. Gage recommended adequate monitoring of prescribed antipsychotics. He stated that drug levels and laboratories for mood stabilizers, baseline studies before initiating treatment, and electrocardiograms for certain medications need to be done routinely.	624
Dr. Gage recommended that medication administration by nursing staff be standardized and include appropriate identification checks. Further, mouth checks for establishing adherence should be done by clinical staff, but custody can also perform mouth checks for safety and security reasons.	625
Dr. Gage recommended the following for reentry services for the seriously mentally ill:  • Assure medication continuity until community services take over (in all cases). This will  almost certainly require that medications be given to releasing inmates who do not have their own supply of medications in the community.  • Assure that a mental health appointment is in place within a period of time that will allow medications not to lapse (those incarcerated for more than two weeks). • Assist in applying for or restoring medical insurance and benefits (those incarcerated for more than one month). • Assist in securing housing (those incarcerated for more than two months).	626
Dr. Gage recommended that inmates in restraints, whether in the restraint chair for behavioral reasons or clinical restraints on 8A, should be on constant watch rather than periodic checks (or constant video monitoring with direct visualization every 15 minutes). Nurses must check inmates in restraints at least every two hours for vital signs (the current policy specifies hourly), neurovascular assessment (under current policy only vascular assessment is specified and the frequency is not specified), and limb range of motion and movement, including the legs (which custody can do).	627
Dr. Gage further recommended that the County modify its policy on prone restraint, which should be avoided absent clear evidence that prone restraint is indicated for certain medical conditions.	628
Dr. Gage also recommended that restraint chairs be utilized for no more than four hours. Additional restraint should involve mental health assessment and include consideration for placement in a mental health setting. Similarly, clinical restraint should be ordered every four hours for the first twelve hours. The current limitation of 24 hours is reasonable. Exceptions for longer restraint may be necessary in some cases but this should require special oversight and in-person evaluation by the ordering clinician and authorization by a supervisor.	629
Dr. Gage recommended that the type of clothing afforded inmates in restraint and seclusion be individualized and based on an assessment of risk. As those in restricted settings improve, it is important to restore items noted to be potentially risky to ascertain their readiness to manage themselves in less restrictive settings.	630
Dr. Gage recommended that confidentiality be provided in all settings to the maximum degree possible. All written documents, including personal health information should be processed by health care staff, including administrative staff (sealed or otherwise protected materials can be handled by any staff, e.g., for the purposes of transport) or custody staff who are bound by the same confidentiality strictures.	631
Dr. Gage recommended that staff on 8A, at a minimum, and preferably on all mental health Special Management Units, receive more detailed training about serious mental illness, providing relevant observations, special medico-legal considerations, and specialized management techniques.	632
Dr. Gage recommended that all custody staff receive more extensive training on the nature of mental illness, including identification of markers for potentially serious problems in addition to suicidality such as psychosis, depression, mania, delirium, catatonia, cognitive disorders, and serious adverse medication reactions.	633
Custody staff should also have specific training in the differences between personality disorders and mental illness with an emphasis on Cluster B personality disorders and psychopathy. Training in behavior management plans and the basic behavioral principles that underlie them is also critical.	634
Dr. Gage recommended the dedication of more resources to QA/QI, including staff resources, IT support, and analytic support. He further recommended that the QA/QI programs include formal provision for clinical supervision and/or peer review.	635
Dr. Gage also recommended a more robust review of sentinel events, including near miss events, serious self-harm, assaults involving injury in mental health Special Management Units and LPS-certified units, injuries during episodes of restraint, and emergent use of force involving the mentally ill (controlled use of force should be reviewed through standard processes for use of force review).	636
BHSD to develop and implement a standardized, validated screening tool and assessment process with public safety partners. The goal is to divert individuals from jail into community services when appropriate.	647
Expand post-custody mental health and/or co-occurring outpatient services by 40 slots to address a service gap for clients.  BHSD currently offers 180 outpatient slots for post-custody clients; however, there is an ongoing wait list for these services.	648
Increase the Criminal Justice (CJ) FSP capacity by 20 slots.  The JAC list demand is largely for FSP slots, which are currently full due to the limited number of outpatient slots.  Some of these individuals cannot be released from jail until stable housing is available, based on their charges.	649
Expand the 90-day Intensive Outpatient Service Team by 50 additional post-custody client slots. This service will support clients as they leave custody, linking them to housing, BHSD services, primary care services and benefit assistance, as well as addressing any other needs. In addition, the team will employ Peer Mentors in order to connect clients to the appropriate BHSD services upon release.	650
Develop one Behavioral Health  Urgent Care Center in East San Jose as a drop-in center for law enforcement. The JDBHS suggests that such a Center could be modelled after “Restoration Centers” that exist in Bexar County, Texas.  The goal is that the Urgent Care Center would offer voluntary services 24/7/365 and provide a community drop-off site for law enforcement that would divert individuals to treatment, rather than jail or Emergency Psychiatric Services (EPS).  Individuals served in an Urgent Care Center would be assessed for treatment needs and referred to the appropriate level of care in the community.	651
Add flex funds for CJ FSP to provide housing for 50 clients referred into treatment services.  Flex Fund expenditures will be utilized for individuals after it is established that there are insufficient funds available for the client’s housing subsidies. These funds will assist clients in successfully meeting their housing goals on their Personal Service Plans related to the Treatment plans listed above.	652
Establish a Permanent Supportive Housing (PSH) program.	653
Enhance an existing Pretrial Mental Health Supervision Program with Superior Court and integrate the program with future Behavioral Health Services Court and Transitions Team by adding a Pretrial Service Officer.	654
Add a Health Care Program Manager at Behavioral Health Services Department to assign Jail Diversion referrals to Clinical Social Worker/Marriage and Family Therapists for screening, referral, and treatment placements of clients.	655