exhibit b a. allen, md introduction i have been asked jointly by counsel representing the county of...
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Review of Medical Care – Santa Barbara County Jail, Executive Summary, September 2017 1
ReviewofSantaBarbaraCountyJailMedicalServicesExecutiveSummary
ScottA.Allen,MDIntroductionIhavebeenaskedjointlybycounselrepresentingtheCountyofSantaBarbaraandcounselrepresentinginmatestoprovideanindependentassessmentofthemedicalcareprovidedbytheCountyinitsjailsystemandtomakerecommendationsasindicatedaspartofanalternativeresolutionprocess.StandardsWhileitisunderstoodthattheSantaBarbaraCountyJailisnotcurrentlyaccreditedbytheNationalCommissiononCorrectionalHealthCare(NCCHC),theStandardsforServicesinJails(2014Ed.)providesausefulbenchmarkforminimumstandardsforjailhealthservicesintheUnitesStates,andIwillrefertothosestandardsinthisreport.1InadditiontotheNCCHCstandards,Iwillmakereferenceinthisreporttocommunitymedicalstandards.Whiletheacceptableclinicalpracticeofmedicineallowsforawidevarietyofapproachestopractice,communitymedicalstandardsarethepointinwhichthegreaterbodyofexpertsandpractitionersinthefieldhavefoundagreementandareestablishedbythestandardofcareacceptedbythecommunityatlarge.Thereisnoseparateorunequalstandardofcareforinmatesofcorrectionalinstitutions;therearemerelylogisticalchallengesandreasonableaccommodationsandmodificationsofstandardmedicalapproachesthatareadirectresultoftheconstraintsofconfinementsettings.Thoseexceptionsandaccommodationstosecurityneedsshouldbeminimalandrarelyinterruptandneverpreventessentialhealthcaredelivery.Totheextentthatprovidingmedicalcareinacorrectionalsettingraisessomeuniquechallenges,Idrawonmyknowledgeofstandardsandpracticesasaphysicianexperiencedincorrectionalhealthcareandfamiliarwithstandardsofthefield.Ingeneral,whenIrefertominimalcommunitystandards,IrefertoservicesapatientwithMedicaidorMedi-Calcoveragewouldlikelybeeligibletoreceiveinacommunityhealthcenterornon-correctionalcountyfacilityorsimilarsetting,1WhenIcitethe2014NCCHCStandardsforHealthServicesinJails,thestandardisinthefollowingformat:theletter“J”followedbyletter“A”through“I”andanumber.Forexample,thestandardforReceivingScreeningisJ-E-02.
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recognizingthatinmatesarenotconstitutionallyentitledtothemostsophisticatedcaremoneycanbuy,buttoadequatemedicalcare.Finally,whenIdomakereferencetoconstitutionalstandardstohealthcare(basedontheEighthAmendmentprohibitiononcruelandunusualpunishment)Idosonotasalawyer(whichIclearlyamnot)butasaphysicianwithextensiveexperienceinactuallyprovidingthatlevelofcareinjailsandprisonsandinhelpingthecourtstodefinethatstandardinpracticalterms.SpecificFindingsandRecommendationsThesectionthatfollowsoutlinesspecificdeficienciesnotedinmyreview.IfthereisarelevantNCCHCstandard,Inoteit.2Noadversefindingisbasedsolelyonaninmateclaimmadeduringaninterviewalthoughsomewereidentifiedfirstbyaninterview;allproblemsdescribedwereverifiedeitherbythemedicalrecordorbystafforinsomecases,byboth.
1. AccreditationstatusFinding:
•Currently,theSantaBarbaraCountyJailHealthServicesarenotaccreditedwiththeNationalCommissiononCorrectionalHealthCare(NCCHC)ortheAmericanCorrectionalAssociation(ACA).
Recommendation:•Thedepartmentshouldmoveforwardwiththeprocessofpreparingfor,applyingforandsecuringaccreditationwiththeNationalCommissiononCorrectionalCare.
2. PoliciesandProcedures:
Findings:•Inthecourseofthisinvestigation,Ihadsomedifficultyinobtainingacopyofthepoliciesandproceduresastheywerefelttobeproprietarybythemedicalcontractor.
2MyinclusionofthestandardsismerelyforreferenceandalthoughIdodescribedeficiencies,inclusionofthestandardinthissectiondoesnotmeanIhavenecessarilyconcludedthatthestandardisnotbeingmet.IdosummarizestandardsthatIfeelarenotbeingmetlaterinthisdocument.
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•ThepolicieswereeventuallyprovidedtomeandIfoundnomajorinconsistencieswithNCCHCminimumstandards.(J-A-05)
•ThepoliciesprovidedwereCFMGpolicies,andwerenotsitespecifictoSantaBarbara.
•Therewasnopolicyfordealingwithtransgenderpatients.•Thepolicyondrug/alcoholwithdrawaldidnotincludedetailedguidelinesandflowsheetsfornursestomakeclearthefrequencyofassessmentandspecificfindingstobenotedandrecordedduringthemonitoringperiod.
Recommendations:•ThepoliciesandproceduresgoverningthedeliveryofmedicalcareoftheSantaBarbaraCountyJailshouldbepromulgatedbytheCountyitself,andtheCountyshouldexerciseownershipandcontroloverthosepolicies.
•TheCountyshouldhaveapolicyfordealingwiththemedicalcareoftransgenderpatients.
•Thedrug/alcoholwithdrawalpolicyshouldbesupplementedbyclearclinicalguidelinesandflowsheetstoenhancecompliancewithstandardclinicalprotocolsreferencedbythepolicy(CIWAandCOWS).
3. Staffing:
Findings: •Currentlynursingstaffingremainsshortofthedepartment’sownstatedplanandisnotsufficienttodeliverappropriatemedicalcare.Areasonablestaffingrecruitmentplanisinplace(withonenotableexceptioninintakedescribedbelow),andeffortstorecruitnewphysiciansandnursesisunderway,butfouryearsafterthedepartmentwasmadeawarebyconsultantsofstaffingdeficiencies,thestaffinglevelsproposedbythedepartmenthavenotyetbeenmet.
•Theoneshortcomingofthecurrentstaffingplanistheabsenceofanursingpostforintake.Theintakenursingresponsibilityishandledbynursesbeingpulledfromotherposts.Whenthathappens,otherfunctionsshutdown.Intakeisacriticalpostinajailfacility,andassuch,itshouldhaveitsowndedicatednurse.
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•Thefacilityisunderstaffedformedicalprovidersandthescheduleisinadequatetocovertheneedsofa24/7facility.Jailsarehighturnoverinstitutionswithmanyadmissionsandreleases,andaninmatepopulationofteninpoorhealth.AccordingtotheSheriff’s2013-2015TriennialReport,themedicalprogramhandledover13,000sickcallsperyear,orroughly35sick-callsaday.
•Thecurrentphysiciancoverageforthejailisonlya0.4FTEposition,withphysicianpresenton-siteforonlythreedaysaweek,andthosedaysaregroupedtogethermid-week.Asaresult,thereisnophysicianpresentforfourcontinuousdayseveryweek.Thisistotallyinappropriateandcreatesunjustifiablerisksandliabilities.
•Currentphysiciansalariesmaynotbecompetitivewithothercorrectionalmedicineopportunitiesinthestate.(J-C-07)
Recommendations:•Thedepartmentshouldworkwiththecontractortoestablishappropriatemedicalprofessionalstaffinglevelsandthenworktomaintainthemandadjustthemtoaddresschangingneeds.
•Whentargetstaffinglevelsareachieved,ongoingreassessmentofchangingneedsandappropriateadjustmentstostaffinglevelsisessential.
•Themostcriticalshortcominginthecurrentnursingstaffingplanistheabsenceofanurseprimarilyassignedtointake.Theroleofintakenurseisacriticalfunctionatajailfacilityandshouldnotbestaffedbynursespulledfromotherposts.
•GiventhevolumeofintakesandreleasesattheSantaBarbara.ThestaffingplanshouldincludeatleastoneboardcertifiedFTEphysician,supplementedbyoneFTEphysicianextendersuchasanursepractitioner.
•Effortshouldbemadetomakesalariescompetitivewithcorrectionalhealthsalariesinthestate.
4. PhysicianQualifications
Findings:•Thereiscurrentlyonlyonephysicianmedicalprovideratthemainjail.
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•Areviewofmedicalrecordsrevealsthatthephysician’smedicaldocumentationofcareispoorandcareofchronicconditionsdoesnotmeetreasonablecommunitystandards.
•Theonlyphysicianisnotboardcertifiedininternalmedicine,familymedicinenoremergencymedicine(thethreeappropriatespecialtiesforaprimarycareproviderinanadultjail).
Recommendations:•Thedepartmentshouldworkwiththecontractortoestablishappropriatemedicalprofessionalproviderstaffinglevelsandthenworktomaintainthemandadjustthemtoaddresschangingneeds.
•Thephysician(s)providingoversiteandcareattheSantaBarbarajailsshouldbeboardcertifiedininternalmedicine,familymedicineoremergencymedicine.ThephysicianwhowouldalsoserveastheResponsiblePhysicianwithultimateauthorityonallclinicaldecisionsconsistentwithNCCHCpoliciesshouldbeafull-timeposition.
5. OvercrowdingandImpactonHealth
Findings:•Accordingtothe2016-2017SantaBarbaraCountyGrandJuryReport“Since1988,theCountyhasbeenunderacourtordertoreducethedailyjailpopulationtoan819approvedbedcapacity.However,theaveragepopulationfrequentlyexceeds1,100.”•From2017GrandJuryReport“TheMainJail,originallybuiltin1971,hasbeendescribedasold,antiquatedandovercrowded.Itisratedfor659inmates,andtheMediumSecurityFacilityisratedforanadditional160inmates.Theaveragepopulationatthejailtendstobeover1,100.”
•Overcrowdingcanimpactbothmentalhealthandphysicalhealth.Overcrowdingmatthreatenphysicalhealthbybringingpeopleintoclosecontactthatisconducivetothetransmissionofinfectiousdiseases,rangingfromcommonrespiratoryandgastrointestinalviruses,tobacteriaandeventuberculosis.•Whilethecurrentmedicalprogramdidnothavegoodsurveillancedata,Ihappeneduponahighnumberofinmateswhoactivelyhadorhadrecentlysufferedfromaseriousskininfectionduetoadrugresistantformofthebacteriastaphylococcusaureus,knownasMRSA.Althoughwithoutfulldataitisdifficulttomakeafirmconclusion,thisMRSAproblemislikelyareflectionofovercrowdingcombinedwithsanitationissues.
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•Bothovercrowdingandpoorhealthcarehavebeenfoundbythefederalcourts,includingtheU.S.SupremeCourt,aspotentialevidenceofunconstitutionalcare.Asaconstitutionalissue,theobligationoftheCountytoaddressovercrowdingandhealthcareimpactscannotbeexcusedsimplyduetofinancialpressuresfacingtheCounty.Recommendation:•Astheimpactofovercrowdingimpactsthehealthinthefacilities,theCountymustdevelopatimelyplantoaddressovercrowding.
6. Physicalspaceformedicalcare:Findings:
•Thereisnoadequatecentralizedclinicspaceintheoldjail.Clinicspaceandexamroomsisdispersedthroughoutthefacilityimpactingefficiencyofcareandrequiringthesupportofanadditionalsecurityofficerforeachclinicspaceinoperationatanygiventime.•Intakescreeningroomdoesnothaveadoorandthereforedoesnotprovideauditoryisolationforconfidentialityofsensitivemedicalinformation.Lackofauditoryprivacymightleadtoincompletedisclosureofcriticalhealthinfoandmissedopportunitiesforriskmitigation.Allclinicandscreeningspacesshouldhaveauditoryprivacyforhealthprofessional–patientinteractions.•Adequateclinicalspaceinthemainjail,aswellasdevelopmentofisolationcellsthatarenothiddenorremotelylocated,willrequiresubstantialarchitecturalmodifications.
•Thereisinadequateofficespacetosupportthemedicalworkforce,andinadequatespaceforstorageofsupplies.(J-D-03)
Recommendations:•Thedepartmentshouldexamineandconsideroptionstodevelopnewerandmoresuitableclinicspacetosupporthealthoperation;spaceshouldbelargeenoughtoaccommodateclinicaloperationswhilealsosecuringappropriateprivacyforpatients.Isolationcellsshouldhavedirectlineofsiteandbewithinhearingortwowayintercomorcallbutton.
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•ItwouldbeadvisabletoconsultcloselywithcountycorrectionalhealthstaffontheplansforclinicspacebeforebreakinggroundontheNorthernBranchproject.
7. SanitationandEnvironmentalHealthIssuesFindings:
•Thebuildingisoldandindisrepair.Overcrowdingcreatesadditionalchallengestosanitationandcleanliness.Duringmyvisit,floors,countersandotherserviceswereinpoorconditionandwerenotclean.Rubbishanddebriswerefoundonfloorsandhallways.Boxesandothernon-trashitemswereimproperlystoredinhallwaysandoffices.•Poorconditionofphysicalplantandpoorcleanlinesshavebeennotedinthisfacilityinthepast.•Ifoundissuesofsanitationtobeaproblemthroughoutthefacility,butworstintheoldestareasofthebuilding.(J-B-01)
Recommendation:
•ThecountyshouldformallyconsultanEnvironmentofCareexperttoevaluatethefacilitytomakerecommendationstoaddressissuesofcleanlinessandsanitation.
8. InfirmaryorIntermediateLevelofCare
Findings:
•Acrosstheentiresystem,theSantaBarbaraCountyJailhasnoabilitytoprovideinfirmarylevelorintermediatelevelofcare.Asaresult,inmatepatientsrequiringhigherlevelofmustbetransferredtooutsidefacilitieswiththeattendanthighermedicalandsecuritycosts.•Themainjaildoeshaveaso-called“medicalunit”butthereisnothingabouttheunitthataffordsahigherlevelofmedicalcare.Itissimplyadormitorywhereinmateswithmedicalconditionsarehoused.(J-G-03)Recommendation:•Thedepartmentshouldexploreoptionsfordevelopingatleastonefacilitythatcouldprovideahigherlevelofmedicalcaresuchasinfirmaryorsub-acutelevelsofcare.
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9. ScreeningonIntakeandInitialHealthAssessments:
Findings:•CurrentintakedoesnotmeetNCCHCstandards(J-E-02andJ-E-04)becausenotallincominginmatesarebeingscreened.Inrandommedicalrecordreviews,Iidentifiedrecordsofinmateshousedinthefacilityforovertwoweekswithnomedicalscreeningatall.Recommendations:•Thedepartmentshouldcontinuetoensurethatallnewlyarrivedinmatesarescreenedonarrivalbylicensednursingstaff.•Thestaffingplanshouldincludeanintakenursingpostcommensuratewiththehighvolumeofthefacilityandcriticalnatureofthisfunction.(J-E-04).
10. QualityManagement:
Findings:•QualityManagement(QM)forthemedicalunitdoesnotappeartoexistattheSantaBarbaraJail.•CFMGpolicyrequiresaQMprogramandthereareplanstostandupaQMprogramincomingmonths.(J-A-06)Recommendation:
•ThedepartmentshouldcontinuetodevelopacontinuousQualityManagementprogram.Informationgleanedfromwell-functioningQMprocesseshelpsadministratorsimprovebothqualityofcareaswellasefficiencyofcareandcanhelpidentifyopportunitiesforcostcontainment.
11. UtilizationManagement:
Findings:•Beyonddelegatingauthoritytothevendor(CFMG),thereisnoapparentprocessfortheCountytoreviewandapproveuseofoutsidecareforpatientsrequiringsub-specialtyandhospitalservices.Recommendation:
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•Thedepartmentshoulddevelopautilizationmanagementprocess.Managedcareapproachestoallocatingresourcesforhighcostcarehavebecomeanestablishedmechanismforstandardizingandcontrollingutilizationofhealthresources.•Thedepartmentcouldconsultwithotherdetaininginstitutionsbothinthestateandelsewheretolearnmoreabouttheutilizationmanagementprocessforincarceratedpopulations.Effectiveutilizationmanagement,whileaimingtoachievecostcontainment,mustnotadverselyimpactaccesstocare.
12. MedicalRecords:
Findings:•Medicalrecordsarecurrentlypaper-based.In2017,apaperbasedmedicalrecordsinajailsystemiswoefullyinefficientandinadequate.•Areviewofrecordsrevealsapatternofunsignedtelephoneordersbyphysicians–someasoldasoneweek–andkeylabresultsthathavebeenfiledwithoutnotationoracknowledgmentbyaphysicianornursepractitioner.Documentationofclinicalencountersisoftenbriefandincomplete.•Thereisalmostnodocumentationbyphysiciansofpatienteducationabouttheirillnesses,theirlabortestresultsorthetreatmentplan.•Documentationbythecurrentnursepractitioner,whiletypedandlegible,over-usedshortcutsandgeneral,non-specificwords.•Inothercharts,handwritingisfrequentlypoor,andsomeprovidersdonotuseasignaturestampsoitisuncleartoareviewerwhowrotethenoteandtheirprofessionalcapacity(doctorversusnurseorotherstaff).•Problemlistsareoftenincomplete.Labandradiologyresultsarefrequentlyfiledwithoutprovidersignoffandabnormalresultswereoftenfiledwithoutanydocumentedinterventiontoaddresstheabnormality.(J-H-01andJ-H-03)•ThedepartmenthasplansformovingtoanElectronicHealthRecord(EHR)inthefuture.Atthetimeofthisreport,thisnewsystemisnotyetdeployed.Recommendation:
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•ThedepartmentshouldfollowthroughwithitsplantodeployacorrectionalElectronicHealthRecord(EHR)andprovideongoingITsupporttoboththenetworkinfrastructureandITsupportforendusersofthesoftware
13. ChronicDiseaseManagement
Findings:•Chronicdiseasemanagementisinadequate.(J-G-01)Myreviewfoundmanagementofchronicillnessessuchasasthma,diabetes,HIVandhypertension,amongothers,tobeadhoc,incomplete,inconsistent,andreactiveasopposedtoproactive.Careofchronicdiseasesappearstobedrivenmorebyinmateself-advocacythanbywidelyacceptedclinicalguidelines(includingbutnotlimitedtothosereferencedbytheNCCHCandFederalBureauofPrisons).•Thereisnocomplete,accurateorreliablelistofpatientswithchroniccareconditions.•Therearenoprotocolsthatarefollowedforongoingcareofchronicillness,suchasregularlyscheduledfollowupvisits(thoseappeartobescheduledinconsistently–ifatall–byindividualphysiciansandnurseswithnoclearlydocumentedlogicorclinicalreasoning).•Inanumberofreviewedcases,careofchronicdiseasepatientsappearedtobenegligentandoverallcareofchronicdiseasescouldbecharacterizedasdeliberatelyindifferent.Recommendation:
•TheDepartmentshoulddevelopachronicdiseasemanagementprocessthatreferencesestablishedguidelines(bothcorrectionalandcommunity)forthemanagementofcommonchronicconditionssuchas,butnotlimitedto,diabetesmellitus,asthma,hypertension,HIVandhepatitisC.•Awell-functioningchronicdiseasemanagementprogramshouldinclude:- Documentedindividualtreatmentplans- Casetracking(thefacilitydoesnotcurrentlyknowwhohaschronic
disease)- Adherencetowidelyacceptedcommunitystandards- Routinescheduledfollowupwithqualifiedhealthprofessionalsincluding
specialistswhereindicated
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14. TimelyAccesstoCare:Findings:•TheSantaBarbaraCountyJailisnotconsistentlyprovidingtimelyaccesstocareforseriousmedicalconditions.
•Timelyaccesstonursing–Areviewofrecordsshouldinconsistentresponse
timestorequestsformedicalcare,rangingfromsamedaytofourorfivedays.
•Timelyaccesstofacilityphysicians-Acrossthesystem,Idocumentedunacceptablylongwaitstoseeaphysician,withtypicalwaitsrangingfromfivedaystotwomonthsormore.Forthemostpart,thisappearedtoberelatedtolimitedstaffingofphysicianproviders.Inothercaseswherephysicianavailabilityhasbeenimproved,itappearedtobesimplyanestablishedinformalstandardbasedonpastpractice.(J-A-01)
•Timelyaccesstospecialtycare-TheSantaBarbaraCountyJailisnotprovidingtimelyaccesstospecialtycareforpatientswithseriousmedicalconditions.(J-D-05)
Recommendation:•Timelyaccesstonursesandfacilityphysicians-TheDepartmentshouldadjuststaffinginordertoaccommodatetimelyaccesstocareconsistentwiththetimelyaccessbenchmarksestablishedbytheNCCHC.•Timelyaccesstospecialtycare–TheDepartmentshouldcontinuetoworkwiththecommunityproviderstoprovidemoretimelyaccesstospecialtycareforseriousmedicalproblems.(Thecommunitystandardfortimelinessisestablishedbytheentirecommunity,notbythestandardsetbydepartment’schosencommunitypartner).
15. LaboratoryandDiagnosticServices
Findings:•Labsnotbeingordered,orifordered,notdrawn,orinrareoccasionswhendrawnarenotfiled,notedandoractedupon,andalmostneversharedwiththepatient.Thiscreatesbothdelaysinaccesstocareanddiagnosis,butalsocreatesasubstantialrisktopatientsandliabilityforthecountywhenabnormallabresultsarenotactedon.(J-D-04)Recommendation:
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•Policiesandproceduresmustbedevelopedanddeployedtoensurelabsorderedbycliniciansaredrawninatimelymanner,andthattheresultsarereviewedbynursesandcliniciansinatimelymanner,andthattheresultsarecommunicatedtothepatientsinatimelymanner.
16. PhysicalDisabilityIssues
Findings:•TheSantaBarbaraCountyJailmakesminimalaccommodationsforinmateswithphysicaldisabilitiesandinmanycasestheaccommodationsareoverlyrestrictiveorinadequatetoaccommodatethedisability.(J-G-02andJ-G-10)•Theoldbuildingisnothandicapaccessible.Wheelchairsdon’tfitthroughsomecelldoorswherewheelchairdependentinmatesarehoused(requiringtheinmatetobecarriedortransferredinandthewheelchairmustbecollapsedfirst)andtherearemanyotherphysicalbarrierstodisabledinmates.Recommendation:
•Thedepartmentshouldfollowexpertconsultantadviceondevelopinglessrestrictiveapproachestodealingwithinmateswithdisabilities.
17. PharmacyServices
Findings:•Thereisarestrictiveformularywithalmostnomedicalnon-formularyrequests.Thereweremultiplerequestsbythepsychiatristfornon-formularymedications(mostapprovedinrecentweeks),butthemedicaldoctoralmostneverrequestedanon-formularymedication.Thissuggestsanoverlyrestrictiveapproachtotheformularybeyondwhatisreasonable.•Ifoundrestrictedofrescueinhalers(suchasalbuterol)andunder-diagnosisofasthma.•Ininmateinterviews,manyinmatescomplainedthatgabapentin,amedicationcommonlyusedforneuropathy,wasdiscontinuedwithoutanyconsultationbetweenthedoctorandthepatients.Reviewsofmultiplemedicalrecordsconfirmedthattherewasablanketdiscontinuationof
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gabapentinwithoutappropriateclinicalconsultationandindividualizedmedicaljustification.•ThefacilitymakeslittleuseofKeepOnPerson(KOP)medications.(J-D-01)Recommendations:
•Formularyadherenceshouldbelessrestrictiveandallowforthoughtfulindividualizedtreatmentplansbasedonsoundclinicalcriteria.
•Cliniciansshouldbeeducatedintheprocessofrequestingnon-formularymedicationswhenthereislegitimateandcompellingclinicaljustification.Thefailuretoeverrequestexceptionstoarestrictiveformularyisevidenceoflackofindividualizedcare.•ThedepartmentshouldliberalizetheuseofKeeponPersonmedications–especiallyforinhalersandmedicationsthatareavailableover-the-counterinthecommunity.
18. ContinuityofMedications
Findings:•Inmatesarrivingonprescriptionmedicationsoftenexperiencedelaysinthemedicationbeingorderedandadministered,sometimesthedelayisdaysorevenoveraweek.•AdraftCFMGpolicycallsforverifiedmedicationstobeorderedwhentheinmateisseen“atthenextavailablesickcall.”Thisisproblematic,especiallyconsideringthatprovidersickcalldoesnotoccureveryday.Recommendation:
•Thedepartmentshouldreviewprocedurestoremoveunnecessaryinterruptionsintimelyaccesstocare.•Inordertoavoidinterruptionsinnecessarymedicationsforserioushealthconditions,nursesshouldevaluatepatientswhoarrivewithprescribedmedications,acuteillnessandchronicconditionsandconsultwithaproviderinatimelymanner(includingovernightsandweekends)toordernecessarymedicationsasclinicallyindicated.
•Policiesmustbedevelopedandimplementedtoensurethatnecessaryandverifiedmedicationsfromthecommunityarecontinuedwithout
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interruption,andthatinmateswithunverifiedmedicationsforseriousconditionsareevaluatedbythenurseswiththesupportofon-callmedicalproviders.
19. Grievances
Findings:•Allfacilitiesexperienceahighlevelofgrievancesbyinmatesalleginginadequatecare.Alargenumberofthesegrievancesweresubstantiated.(J-A-11)
Recommendation:
•GrievancesshouldbecategorizedandanalyzedaspartofaContinuousQualityImprovementprocess.
20. Dental
Findings:•Dentalcarewhenprovidedappearstomeetminimalstandards,buttherearesignificantdelaysinaccesstosuchcare.(J-E-06andJ-E-12))Recommendation:
•DentalClinicsshouldbescheduledandstaffedtoallowfortimelyaccesstoappropriatedentalcare.
21. Segregation
Findings:•Standardsdictatethatinmatesheldinsegregationareevaluatedbybothmentalhealthandmedicalstaff.Nursingstaffreportedthattheydocheckoninmatesheldinsegregation,oftenwhentheyareonahousingunitdoingapillpass,butthedocumentationbothonlogsorinthemedicalrecordfailtodocumentthattheseimportantchecksarebeingperformedattherequiredintervals(adailycheckisrequiredforcompleteisolationinaone-mancell).ThisdoesnotmeettheNCCHCstandardforthemonitoringofinmatesinsegregation.(J-E-09)•Inaddition,thefacilityusesisolationcellsthatarehiddenaroundcornersandoutsideofanystafflineofsite.Thesecellsdonothavecamera
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monitoringoraincellcallbutton,placingtheoccupantathighriskshouldeitherself-harmoramedicalemergencyarise.Recommendation:
•Thedepartmentshouldestablishprocedurestoensurethatinmatesheldinisolationandsegregationhavedailyassessmentsbymedicalpersonnelandinstitutealoggingprocedureforthoseencounters.•Isolationcellsshouldhavelineofsiteobservationorincellmonitoredcamerasandanintercomorcallbutton.
22. Impactofahighsecurityenvironmentonhealthcare
Findings:•ItisimportanttonoteforcontextthattheSantaBarbaraCountyJailisarestrictivejailenvironment.Thereappearstobenomeaningfulstandardizedrisk-basedclassification.Whilethismayseemtoallowforsomeefficiencyforsecuritypurposes,suchrestrictiveconditionsofconfinementcreateunnecessarybarrierstocareandintroducesignificantinefficienciesandrisksinthedeliveryofhealthcare.Thisapproachseemsparticularlyharshandproblematicforinmateswhomaybedetainedinthesefacilitiesforlongerperiods,suchastheAB109population.•Manyinmatesareconfinedtotheircellsorcellblocksformostoftheirincarcerationperiod.(Theyareletoutfordailyshowersandtwiceaweekforrecreationtime.Thereappearstobeveryminimalprogrammingoreducationaltime).Theiraccesstohealthcarepersonnelislimitedbytheirlimitedmovementandreliesonapaperdriven“kite”systemforreportingahealthconcern.Theironlyotheralternativeistocalla“mandown”medicalemergency.•Conditionsthatareoverlyrestrictivecananddohaveimpactoninmatehealthandwell-beingandincreaserisksofadversehealthevents.Minimally,theycreatebarrierstoaccesstorequiredmedicalcare.Recommendation:•Thedepartmentshouldconsultwithotherjailfacilitiesinthestateandinthenationtolearnaboutlessrestrictivedetentionpracticesthatdonotcompromisefacilitysafetyandsecurity,particularlyforthoseinmatesexpectedtoremainincarceratedforlongerperiodsoftime.
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23. SecurityStaffinginSupportofMedicalServices
Findings:•Thereisinsufficientcustodystaffingtosupportthemedicalprogram.•Evenifmedicalservicesareadequatelystaffed,accesstothepatientsisentirelydependentonescortservicesprovidedbysecurity.Thisincludesbothinfacilityandoutoffacilityescortneeds.A2013consultantreportbyCroutandSidafoundinsufficientcustodialstaffingoverall,andinsufficientmedicalescortstaffinginparticular.•Insufficientcustodialstaffinginsupportofmedicalservicesremainsanissueatthetimeofmyvisitresultinginpreventablebarriersintimelyaccesstomedicalcareandveryinefficientuseofmedicalprofessionaltime.Doctorsandnurseareroutinelykeptwaitingforpatientstobetransportedortobeescortedtoareasofthefacilitythatrequirecustodialescortforstaff.Recommendation:
•Security/Custodialstaffingmustbeadjustedtofullysupportthemedicalprogram.
24. DischargePlanning
Findings:•PertheJFAReportandmyowninvestigation,thejaillacksafullydevelopedcomprehensiveprogramtoprepareinmateswithchronicmentalandmedicalconditionsfortheirreleaseandtransitionbackintothecommunity.
Recommendation:
•ConsistentwiththeJFAReportrecommendationstheCountyshouldimplementandexpandacomprehensivein-custodydischargeplanningprogramwithemphasisoninmateswhosufferfromchronicmentalhealthandmedicalconditionsincludingaddiction.
25. ReviewofInCustodyDeaths
Findings:
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•Iwasprovidedwithlimitedaccesstosomemedicalfilesofinmateswhohaddiedincustody.•Whiletheinformationprovidedwasnotcomplete(Iwasnotprovidedwithmedicalexaminerreportsinallcases,forexample)whatwasclearwasthatroutinereviewsofinmatedeaths(includinganadministrativereview,aclinicalmortalityreviewandapsychologicalautopsyifdeathwasbysuicide)arenotroutinelyandconsistentlybeingdone.Thisisamissedopportunitytoaddresscriticalproblemsandpreventfutureincidents.(J-A-10)
Recommendation:
•Routinedeathreviews(includingaquick,multi-disciplinaryadministrativedeathreview,aclinicalmortalityreviewandapsychologicalreviewifdeathwasbysuicide)shouldbedonewithin30daysofthedeath.
26. CountyMonitoringoftheMedicalContract
Findings:•SantaBarbaraCountyJailfailedtodeliveradequatemedicalcareinlargepartbecausethepreviousmedicalcontractorprovidedinadequatecare.•Whilereplacingthatproviderwithanewproviderwasanimportantcorrectivestep,theCountyisstilllargelyrelyingonthecontractortomeettheCounty’sconstitutionalobligationstoprovidecare.•Whiletheworkcanbecontractedout,theresponsibilityoftheCountyinprovidingminimallyacceptablemedicalcarecannot.•TheCountycurrentlydoesnotemployCountyresourcesnorexpertiseinprovidingoversighttothemedicalcontract.Inthe2016reportonrealignment,theconsultantsmadethefollowingrecommendation:
RequiretheDepartmentofPublicHealthandBehavioralWellnesstoAdministertheNewMedicalContractfortheSheriffRationale:TheSheriffisnottheproperagencytomonitoracontractthatdeliversmentalhealthservicesinthejail.TheCounty’sDepartmentsofPublicHealthandBehavioralWellnessshouldadministerthecontracttoensureinmatesarebeingproperlyassessedandtreatedinthejail,andtoensurethetransitionfromthejailtothecommunitydoesnotinterrupttheservicesthatwerebeingprovidedinthejail.
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Recommendation:•TheCountymustunderstanditsresponsibilityinmonitoringthemedicalcontractonaday-to-daybasis.ItshouldconsiderhiringconsultantorusingexistingCountyemployedexpertisetoaccomplishthiscriticaloversitefunction.Consistentwithpriorconsultantrecommendations,theCountyshouldexplorethepossibilityofrequiringtheDepartmentofPublicHealthandBehavioralWellnesstoadministerthenewmedicalcontractfortheSherifforalternatively,createanewpositionforaqualifiedindividualwithappropriateexpertiseandexperiencetoperformthatrole.•Medicalcare,acriticalcomponentofconstitutionallyguaranteedrightsoftheincarcerated,istoogreataresponsibilitytocontractoutentirely.ExpertandCountybasedoversiteofthiscomplexprogramisinthebestinterestsoftheCountyanditscitizens.
Summaryof2014NCCHCJailStandardsNotBeingMetorRequiringFurtherWorkThefollowingismysummaryofpriorityareasthatthedepartmentshouldcontinuefocusoninordertobereadyforNCCHCaccreditation:J-A-01AccesstoCareJ-A-05PoliciesandProceduresJ-A-06ContinuousQualityImprovementPlanJ-A-09PrivacyofCareJ-A-10ProcedureintheEventofanInmateDeathJ-A-11GrievanceMechanismforHealthComplaintsJ-B-01InfectionPreventionandControlProgramJ-C-01CredentialsJ-C-02 ClinicalPerformanceEnhancementJ-D-01PharmaceuticalOperationsJ-D-03ClinicSpace,Equipment,AndSuppliesJ-D-05HospitalandSpecialtyCareJ-E-02ReceivingScreeningJ-E-04 InitialHealthAssessmentJ-E-07Non-EmergencyHealthCareRequestsandServicesJ-E-09SegregatedInmatesJ-E-12ContinuityandCoordinationofCareDuringIncarcerationJ-G-01ChronicDiseaseServicesJ-G-02PatientswithSpecialHealthNeedsJ-I-01RestraintandSeclusion
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RespectfullysubmittedtoCounselfortheCountyofSantaBarbaraandtheCounselforthePlaintiffsonJuly3,2017.
ScottA.Allen,MD
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AppendixExamplesofinadequaciesinchronicdiseasemanagement:
Asthma-Asthmacareinthecasesrevieweddoesnotmeetnationallyacceptedstandards.ThefacilitymakesnouseofPeakflowmeters.Peakflowmetersareinexpensiveplasticdevicesthatallowforreliableobjectiveassessmentoftheseverityofapatient’sabilitytobreathandareconsideredastandardpartofasthmamanagement.Insomecasesreviewed,patientswithsignificantasthmahistorieswerenotevaluatedbyphysiciansunlesstheypresentedwithanacuteattack.Evenwiththenewmedicalcontractor,useofkeeponpersoninhalerswasbeingrestricted,withinmateswithdocumentedasthmahistoriesbeingdirectedtocontactnursingonlywhentheythoughttheyneededtouseaninhaler.Thisisariskyandunnecessarilyrestrictivepractice. Diabetes-Diabetescareatthejailfacilitiesisinconsistent.Knowndiabeticsdotypicallyreceiveadequatemonitoringbynurseswithassessmentofbloodsugarbyfingersticktestingasorderedbyaphysician.However,regularevaluationbyaphysicianisinconsistent.MeasurementofHemoglobinA1C(HgbA1C–astandardmeasureofdiabeticcontrol)onarrivalandatrecommendedintervals(typicallyevery90days)isinconsistent.Inaddition,patientsenteringthefacilitywithconfirmedtreatmentregimensdonothavetheircommunitytreatmentcontinued.Rather,theyareoftenautomaticallychangedovertoagenericslidingscaleinsulinprotocoluntiltheycanbeseenbyaprovider,oftennotuntildaysafterarrival.Slidingscaleinsulinisnottheoptimalprimarymethodofmanagingdiabetesparticularlywhenapatienthasaconfirmedmedicationregimenfromthecommunity. Hypertension-ManagementofhypertensionintheSantaBarbaraCountyJaildidnotmeetnationallyacceptedguidelinesforthecasesIreviewed(Ref:NCCHCOctober2014guidelinesforhypertension,JNC8).Specifically,patientswithhypertensiondidnottypicallyreceivecompleteinitialexamsandwork-ups,theydidnotconsistentlyreceiveappropriatelaboratoryorEKGtests.InseveralcasesIreviewed,theinmateswentthreetofourdayswithoutmedications.HIV-HIVcareintheSantaBarbaraCountyJaildoesnotmeetnationallyacceptedguidelinesincludingtimelyconsultationbyamedicalconsultantwithexpertiseinHIVmanagement.Otherchronicconditions-Inothercaseswhereinmateshadknownchroniccareneeds(includingconditionssuchascoronaryarterydisease,
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