Medical and Mental Health Care in the Main Jail
Source: Santa Barbara County Grand Jury
At the beginning of 2016, Disability Rights California (DRC) released a report finding fault with the Santa Barbara County Main Jail (Jail) concerning the treatment of inmates with mental illness and disabilities.1 The 2016-17 Santa Barbara County Grand Jury (Jury) found the DRC report serious enough to warrant an investigation. Dissatisfaction with the current mental and physical health services provider at the Jail, Corizon Health (Corizon), also became public. Lapses in service by the medical and mental health provider were noted not only by the DRC, but also by the Board of Supervisors (BOS) and community groups.
During the summer of 2016, the Santa Barbara County Sheriff’s Office (Sheriff) sought a new health service provider and hoped to remedy any shortcomings by addressing the faults found in the DRC report and establishing accountability and guidelines for its new health provider. In December 2016, a new company, California Forensic Medical Group (CFMG), was chosen to provide medical and mental health services at the Santa Barbara County Jail and Juvenile Services. The new contract with CFMG confronts the deficiencies that had existed for years with the outgoing service provider.
The new contract will need to be supported and maintained by jail staff as well as the new medical and mental health provider. The Sheriff’s custody deputies are equally responsible for its success. After several years of unsatisfactory care, the remedy should elicit a dedicated and vigorous team effort.
The current Jail facility was built in 1960. Constant overcrowding has led to building additions and conversions for more beds. In this constricted setting, the Sheriff’s Office must deal with gang members, pre-trial detainees, long-term inmates, substance abusers, disabled inmates, and the mentally ill. This mix of inmates in crowded quarters has no benefit for the mentally ill.
The Jury was told that the population of inmates with mental health issues is rising and is estimated to be 45 percent of the total population. Approximately 180 of these inmates are also administered psychotropic drugs. The new Santa Barbara County Northern Branch Jail will have only 386 beds, and includes space adapted for the handicapped and mentally ill, but it will not accommodate this entire population.
1 Disability Rights California “Report on Inspection of the Santa Barbara County Jail (Conducted on April 2, 2015),” released February 23, 2016.
Previously, mental health services had been provided by the Santa Barbara County Public Health Department. The Jury understands that due to budgetary concerns and the effects of the recession, this contract was terminated and the contract with Corizon for health services began in 2009. These circumstances led to a less-than-desirable contract, which eventually led to less-than- complete accountability in the realm of health care.
In addition to medical staff, Corizon brought in two social workers, one Marriage and Family Therapist and one psychiatric Registered Nurse. These mental health workers had an enormous caseload. After public demonstrations of disapproval of the lack of adequate health care came before the Board of Supervisors in 2016, Corizon added one more Marriage and Family Therapist, two more mental health workers, one mental health Registered Nurse and two Licensed Vocational Nurses. The psychiatrist’s workweek went up from 24 to 40 hours. However, Corizon had a high turnover and unfilled positions, which further interrupted assessment and treatment. Moreover, in the fall of 2016, the Health Services Administrator and the Director of Nurses both quit.
The DRC regularly checks facilities and “has the authority to inspect and monitor conditions in any facility that holds people with disabilities.” As a result of their April 2015 inspection, they found “probable cause to conclude that prisoners with disabilities are subjected to neglect in the Santa Barbara County Jail.”2 There were three principal areas of concern: inadequate mental health care, excessive solitary confinement, and denial of rights under the Americans with Disabilities Act (ADA). Furthermore, an attorney for the DRC cited problems with the health care provider: “The report details the inadequacies in Corizon’s mental health services, which subject prisoners to further abuse, neglect and isolation.” The level of medical care under Corizon also came under unfavorable scrutiny.3
In 2015, the Jail staff proposed renewing its two-year contract with Corizon. The BOS resisted because they had not seen a contract for Corizon, had no performance data and did not know the number of inmates seen in a timely manner, or if they were given appropriate medications.4 Decision-making was delayed and during this time, protests from members of the community became impossible for the BOS to ignore. While the Jail representative painted a scenario with few problems and no grievances, at a meeting that was described as a “contentious hearing,” the BOS openly questioned the wisdom of another contract with Corizon.5 To delay a decision on a contract renewal, the BOS agreed that Corizon receive a temporary contract and an open request for bids was issued. The BOS decided to hire a consulting firm to find other health care providers for correctional systems and propose alternatives to Corizon.
After several more BOS sessions, the California Forensic Medical Group (CFMG) was chosen as the new health care provider and a contract with more provisions for adequate and timely care was offered. According to information received by the Jury, CFMG has high ratings. They began service on April 1, 2017.
After the release of the Disability Rights California report, the Jury began to interview persons involved with the incarcerated mentally ill and handicapped. Those interviewed included the Santa Barbara County Sheriff, deputies in charge of medical services, directors of mental health services, lawyers in the Public Defender’s office, and a grievance coordinator. Custody staff at the Main Jail involved with health care invited Jurors to meet with them to discuss changes and new procedures. Members of the Jury also attended a community meeting on mental health issues in the Jail. The Jury also visited the Santa Barbara County Main Jail.
The Jury read the DRC report, as well as reports and publications concerning mentally ill and disabled inmates in the Jail. Previous Grand Jury reports were also studied.
As stated by the Santa Barbara County Sheriff, our jail has become the “de facto mental institution for the county.” A 2013 study undertaken by Clergy and Laity United for Economic Justice (CLUE) estimated that it cost $44,500 per year to incarcerate an inmate in the County Jail and it costs the County an additional $4,000 to house each inmate with mental health issues. In 2017, the Sheriff estimated a $46,000 cost per inmate per year and an additional “marginal” cost of $5,000 per year for the care of mentally ill inmates.
The new contract with California Forensic Medical Group (CFMG) pinpoints areas of improvement for better medical and mental health care, and steps to redress prior inadequate treatment. The BOS voted an additional $1 million in the new contract over the previous contract with Corizon. Most of the increased expenditures go to salaries, with the idea of guaranteeing continuity of care by attracting and retaining qualified staff. Another $35,000 was accorded for initiating electronic medical records, which the Jail had not had before.6
The Board’s decision to devote more money to medical and mental health care in the Jail at this time of budget shortfalls is a welcome first step to remediate past inadequate care at the Jail. Furthermore, the Jail staff began making administrative changes to correct issues before the April 2017 takeover of services by CFMG. However, as stated in an update to the procurement process to the BOS, “Where there is a health care vendor, strong contract management is essential. The County can delegate health care but still carries accountability.”
Disability Rights Act Report
The DRC Report finds that the Sheriff is directly responsible for the following issues:
Excessive Solitary Confinement
Inadequate Mental Health Care
Denial of Rights under the Americans with Disabilities Act
6 Santa Barbara County Board of Supervisors Meeting Minutes, 28 February 2017.
2016-17 Santa Barbara County Grand Jury 3
Excessive Solitary Confinement
The DRC Report first found fault with the excessive use of isolation and solitary confinement. Inmates administratively classified with a mental illness, according to the DRC report, appeared to be “routinely placed in prolonged isolation.” The DRC inspection team found that prisoners were locked in small cells for 22-24 hours a day, with little or no time out of the cell. The Board of State and Community Corrections (BSCC) also noted in its report that the Jail was out of compliance in placing inmates in safety cells because of medical or mental health concerns.7
Moreover, the DRC reported that inmates were held in safety cells for many days at a time on a repeated basis. A safety cell is often called a “rubber room,” and it has only a pit in the center for a toilet. In standard practice, a safety cell is meant as a temporary stay for violent or suicidal inmates. The DRC found that medical records indicated that inmates in the Main Jail were kept there even after the dangerous behavior subsided. Corizon would then stipulate that the inmate be released at “custody discretion,” as noted in the DRC report. With matters left in the hands of the Jail’s custody staff, they became the responsible party for the care of mentally ill inmates. The DRC report pointed out that this process was further hampered by the Corizon staff being on site only during normal business hours. This led to lengthy stays in the safety cells. However, the Jury learned that with the addition of two more “step down” cells in 2016, fewer inmates have had to be placed in safety cells. Step down cells have minimal amenities such as a bed, a sink and a toilet.
The DRC team observed custody staff going through the motions for observation of the inmates in safety cells, without really looking at or assessing their condition. Such actions did not represent true monitoring of inmates who were at risk to themselves. The Sheriff’s response to the DRC report noted that the Jail was in compliance with state laws in matters of the safety cells. The BSCC also noted that the Main Jail was in compliance with performing timely checks of the safety cells. Custody staff informed the Jury that they now perform sight observations.
In anticipation of a new medical and mental health care provider, and in response to the DRC and public complaints, the custody staff began to remedy these problems in 2016. In a meeting with the custody staff, the Jury learned about the changes in procedure. They reduced the time for inmates to be in a safety cell. Before inmates are put in one of these cells, they are seen by a mental health practitioner as a form of intervention. If the inmate is not out of the safety cell in 12 hours, a Crisis and Recovery Emergency Services (CARES) team is called in to do an assessment. Additionally, the increase in the psychiatrist’s hours from 24 to 40 hours a week allows more treatment before possible confinement in a safety cell. The Jury learned from custody staff that treating the inmates in a more humane fashion has dramatically reduced the number of inmates being placed in safety cells.
Inadequate Mental Health Care
Overall, the mental health care rendered by Corizon was deemed inadequate by the DRC team. The report pointed out that in the area designated for mentally ill inmates, each cell holds inmates individually, even though they were designed to hold two. The DRC report found this “as isolating as maximum security housing.” The design of this section of the Main Jail, described as linear, 7 State of California, Board of State and Community Corrections, 2014-2016 Biennial Inspection, Santa Barbara County’s Type II and Court Holding Facilities.
does not allow for many programs to be offered in an open area near the cells. The Jury was told that all programs that the Sheriff would like to offer for the rehabilitation of inmates require space and, under the current design, extra deputies to escort them to the available space. Recreation and restorative programming are currently not within reach for most inmates, and this situation can only be corrected when the Northern Branch Jail is finished in 2019.
According to the DRC report and several interviewees, inmates complained of not seeing a mental health practitioner and not receiving medications for weeks or even months. The DRC report cited Corizon’s method of treatment as “cell front,” that is, only speaking through a slot in the door. Essentially, there was inadequate treatment for the mentally ill. Custody staff revealed to the Jury that with the new mental health provider there are plans to initiate face-to-face consultation and group sessions. Moreover, each inmate is now case-managed. California Forensic Medical Group (CFMG) also plans to assure that patient-specific medications are available, especially at intake.
The DRC report attributed some of the problems with medication to poor initial screening. The 2015- 16 Santa Barbara County Grand Jury also criticized the inmate intake process, recommending that a nurse always be present. As a result, the Main Jail reassigned a full-time RN to be present at intake 24/7. This may have improved the designation of who had serious mental illness upon arrival – by proper identification in the Intake Medical Questionnaire – but the problem of medications remained unresolved. The Jury heard that bridge (interim) medications were sometimes not given, according to inmates, family members and the Public Defender’s office. Now, with the improved intake screening, starting protocol medications are more quickly available, as are withdrawal therapies. Moreover, one LVN was added to deliver the more than 600 medications daily in a more timely fashion.
The Jury learned from several sources that inmates had often complained about lack of care. But the complaint system with Corizon broke down. As the DRC wrote, “we are concerned that Corizon’s reporting system may not be capturing all the sick call slips and psych line requests submitted by prisoners, especially because these requests are apparently not logged in the medical records.” It was disclosed to the Jury that these slips, or “kites,” and grievances seemed to disappear. Boxes of unanswered grievances came to light before and after Corizon left. To remedy this lack of accountability, the Jail custody staff created a new grievance system, which included a new form. The inmate now gets a copy of his complaint. Rather than grievances not being recorded, they are date-stamped and responded to within 12 hours. To better follow up on medical grievances, a Health Insurance Portability and Accountability Act (HIPAA) release form is part of the grievance. In 2016, a retired deputy was called back to service to be the grievance coordinator, and he has formed a committee of County representatives and advocacy groups who oversee the implementation of the grievance process.
The 2015-16 Grand Jury reported that the Jail staff conducted no oversight of contract compliance in evaluating Corizon’s treatment of inmates. Whereas the Sheriff exercised no performance reviews with Corizon, oversight is one of the top priorities in the contract with the new provider, with “timely, accurate and actionable data to monitor vendor.” The Jury learned that audits and compliance reviews are being performed by the Public Health Department to monitor appropriate medical care and by the Department of Behavioral Wellness for mental health. This County collaboration should revitalize care in the Santa Barbara County Main Jail.
After a decade of frustrated efforts to solve the problem of the mentally ill in the Jail, the Sheriff’s Office has begun to partner with community and national projects such as the Stepping Up Initiative, a program designed to divert nonviolent mentally ill from Jail to treatment programs. The Initiative hopes that individual treatment plans for each inmate and even alternative housing will reduce recidivism. As declared in the Stepping Up resolution: “Now, therefore, be it resolved, that the Santa Barbara County Board of Supervisors actively support the work of Stepping Up...to make more effective use of strained budgets and safely reduce the number of adults with mental illness in jails by connecting them to community-based treatment and services when possible.” Jail staff has also piloted its own program, Project BRACE (Breaking Recidivism and Creating Empowerment). Putting low-level offenders in treatment rather than in jail would incur lower costs and offer long-term savings for the County. With budget limitations again at the forefront of all funding, the opportunity for community and countywide involvement is most timely. These counseling programs, along with residential treatment housing, are necessary to unburden the Jail from the weight of its mental health services and to create a better path to wellness.
In the fall of 2016, the BOS formed an interdepartmental working group (the Sheriff’s Office, the Probation Department and the Department of Behavioral Wellness) to form an Assertive Community Treatment (ACT) team. Its purpose was to provide housing as “an alternative to incarceration at County Jail.”
Denial of Rights under the Americans with Disabilities Act
The DRC report found fault with the physical facilities, including bathrooms and proper housing for inmates with disabilities. Many deficiencies exist in the Jail, which was built before disability accommodations were required. However, the DRC report notes that the Department of Justice, in line with the ADA, “makes clear that it concerns the program access obligations of a correctional facility, which do not depend on... the date of construction or modification.” In the dormitory where inmates with mobility impairments are housed, “the toilet and shower areas do not meet architectural standards for wheelchair use, and lack properly placed grab bars, shower heads, etc.” The Jury was told that there have been some modifications and repairs but obstacles prevent remodeling. The Sheriff needs to wait for legal and architectural advice as well as the opening of the Northern Branch Jail before proceeding with reconstruction. (See the 2016-17 Santa Barbara County Grand Jury report “Santa Barbara Main Jail: An Outdated and Inefficient Facility.”)
Floor sleeping has long been noted in the Main Jail. It has too many inmates for the number of beds. This situation becomes more of a problem for inmates with disabilities, who should be assigned lower bunks. According to the DRC report, “The Jail apparently has no policy or practice to ensure that lower bunk orders are issued, honored and enforced.”
In addition, the DRC report stated that in 2015 there was no ADA coordinator on-site nor was there an ADA complaint system. According to the report, the “staff were unaware of such a position and could not identify any individual responsible....” The report also referred to untrained staff involving the handling of an inmate in a wheelchair facing accessibility barriers. There is now an ADA coordinator at the Jail.
Lack of oversight over Corizon’s practices at the Main Jail led to failure to ensure National Commission on Correctional Health Care accreditation of the medical services. The Sheriff’s Office did not oversee the accreditation process, and Corizon’s inefficiency led to its lapse. Corizon provided no justification for this, nor did the Sheriff. The paperwork just was not completed. Upon realization of this, the Sheriff’s Office tried to delay the application, knowing that it would take time for the medical and mental services to reach compliance with state or national standards. As a result, “compliance with health care accreditation standards” within nine months is one of the first priorities of the management team that selected the California Forensic Medical Group. 8
The Santa Barbara County Sheriff’s Office has been struggling with treatment of physically handicapped and mentally ill inmates for many years. Treatment did not improve when Corizon Health took over the care of these inmates at the Santa Barbara County Main Jail. New programs, new partnerships, and a new medical and mental health care provider, California Forensic Medical Group, offer possibilities for the change that the Sheriff’s Office has sought for many years. The Sheriff stated, “The alternative is to not do anything meaningful that will help the mentally ill. The result is people will get worse, not better.”9
The 2016-17 Santa Barbara County Grand Jury concludes that an effective working relationship between the Santa Barbara County Sheriff’s Office and the California Forensic Medical Group is essential at the Main Jail. With the Sheriff’s Office maintaining a robust role and full responsibility for implementing the reforms, the promises of new mental health and handicapped treatment can be fulfilled.