Wide-Ranging Safety and Health Care Issues at Santa Rita Jail

Recommendations 31

• R1

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  Standard grievances, used to report problems in detainment conditions.
• R2

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  Emergency grievances, used to report harassment or sexual assault in accordance with the Prison Rape Elimination Act of 2003 (PREA). Standard grievances may be submitted either on paper or electronically via jail-issued tablet. When filing on paper, detainees must request an official grievance form and a grievance tracking number from a deputy. While there is no limit on the number of paper grievances a detainee may file, electronic grievances are limited to four per detainee per month. In an effort to streamline the grievance process and provide detainees with a way to submit grievances without needing to engage with a deputy who may be the subject of a grievance, Santa Rita introduced the electronic submission option in 2019. Although many detainees successfully submit electronic grievances, others reported that filing electronically is confusing and does not work as intended. Staff appeared unaware of the problems detainees were experiencing with tablet-based submissions. 96 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Overview of the Grievance Filing and Investigation Process Submission Intake Review Investigation Appeal Excess Manager force? review Conclusion only, no details Internal Yes Affairs Tablet Gri U ev n a it nce No Yes: misconduct External Yes : other Wellpath In r s e p v e ie c w tor investigation? No t R o e G su ri l e ts v a p n ro ce v i U de n d it Obtain Tracking # and Submit to GSA Grievance Referred for Unit Investigation No Locally Resolved? Paper Review Yes Grievance Unit Decision after with Conducts Investigation deputy Investigation Appeal CLOSED Inmate review (Per policy should Notification be submitted to (if in custody) Grievance Unit for filing) Yes Appealed? No CLOSED One critical issue highlighted by detainees involves the continued need to engage with a deputy to obtain a grievance tracking number for electronic submissions. While staff had informed the Grand Jury that this was not a required step for tablet submissions, detainees demonstrated to the Grand Jury that the tablet submission form shows the tracking number field as “required,” warns users about consequences for submissions with inaccurate information and displays an error message on attempts to submit grievances with the field unfilled. The Grievance Unit’s response to these observations was that the requirement for including an accurate grievance tracking number had previously been eliminated and detainees could insert any number into that field to enable a submission. The detainees with whom the Grand Jury spoke were unaware of this authorized bypass and, given the limited number of submissions permitted per month and the warnings about consequences for inaccurate submissions, were understandably reluctant to follow the suggested work-around. 97 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Further complicating the use of placeholder tracking numbers is that detainees who used this approach reported inconsistency in receiving confirmation that their grievance was successfully submitted and delays in being notified of the actual tracking number once assigned. The Grand Jury believes that the implementation of a tablet-based option for grievance submissions improved the mechanism through which detainees can draw attention to concerns about detainment conditions. However, the flawed software implementation and inconsistent communication with detainees significantly reduce the value of this tool. A blank electronic grievance form. The field labeled “Enter the grievance number provided by the deputy” is marked as mandatory by a red asterisk. The default text states: “If the grievance number does not match our records, the grievance will be denied.” Emergency Grievances Emergency grievances are intended primarily for reporting sexual assault or harassment, in accordance with PREA requirements. Given the nature of these issues, the jail provides each housing unit with a lockbox to allow confidential and third-party submissions. By policy, lockboxes are checked daily, and the Grievance Unit assigns emergency grievances a high priority. The Grand Jury observed the presence of a lockbox in each housing unit visited and confirmed that, consistent with policy, the on-duty deputy did not have the ability to unlock the box. 98 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ An emergency grievance box in a minimum/medium-security housing unit. Grievance Investigations The first attempt to resolve a standard grievance occurs before it is formally submitted. By policy, when a detainee approaches a deputy to request a tracking number, the deputy attempts to resolve the issue directly. If the complaint is not resolved on the spot, the deputy obtains a tracking number from Grievance Unit staff, adds that information to the detainee’s completed form, gives the detainee a copy, and submits the original to the Grievance Unit through internal mail. The Grievance Unit is staffed by three deputies and three non-sworn technicians who are responsible for the initial investigation of all grievances. On receipt, paper grievances are scanned and converted into an electronic record, as all the Grievance Unit’s work is managed through an online case management system. Each day, a technician reviews that day’s newly filed grievances and assigns them to the investigators. Investigations typically involve interviewing staff members named in the grievance, reviewing jail policies, and viewing bodycam footage as appropriate. The Grand Jury learned that detainees are not routinely contacted as part of the investigation of their grievance, and several reported receiving no update on the status for weeks after submission. 99 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ The Grievance Unit refers and transfers investigation responsibility for several categories of grievances to other departments or contracted service providers. These include medical grievances, which are forwarded to Wellpath; facility issues, which are forwarded to GSA; and investigations of certain excessive use of force claims, which are forwarded to Internal Affairs (IA). These referrals are deemed necessary because the Grievance Unit has no access to detainee medical records, does not have the expertise required to address facility issues, and is prohibited from investigating the conduct of jail staff. Grievances alleging excessive use of force by a deputy are initially reviewed by the Grievance Unit manager to determine whether a full investigation is warranted by IA. If the manager does not believe the grievance warrants IA review, it is typically concluded with a finding of “Denied.” When a grievance has been referred to another department within the jail for investigation, the Grievance Unit suspends its tracking of investigation activities, as these steps are now being performed by a different department. As a result, some investigation steps conducted by other departments are not routinely captured in the case management system, and the Grievance Unit effectively cedes responsibility for the timely investigation of the grievance to the other department. The Grand Jury learned that once a grievance is referred to another department, the Grievance Unit awaits direction from that department before taking further action. There does not appear to be a consistent process within the Grievance Unit for checking the status of referred grievances that remain open for an extended period of time, nor is there regular reporting on open grievance investigations that have exceeded target turnaround times. The Grand Jury noted that many detainee complaints about the grievance process involved extended timelines for investigations and that referred investigations take, on average, longer to reach determination that those handled entirely within the Grievance Unit.
• R3

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  COVID-19 management, and
• R4

  Page 100
  the grievance process. The Grand Jury concludes that many of these findings present continuing risks to the health and safety of the staff and detainees who occupy the facility as well as a financial risk to Alameda County, which is ultimately responsible for the damages that may arise from conditions at the jail. The Grand Jury gratefully acknowledges the support and assistance of the many Santa Rita staff members who accompanied jurors on their inspections, located documents and data, and explained processes and procedures. While not all personnel interactions were positive, the few instances in which staff engaged in a manner that the Grand Jury experienced as adversarial or unprofessional were addressed during the investigation and did not impair the completeness or accuracy of this report. 103 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
• R28

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  The Alameda County Sheriff’s Office must remediate the following issues and verify full compliance with applicable codes: • Electrical connection to ovens and tablet-charging stations within housing units. • Provide permanent floor marking to demarcate area that must be kept clear around eyewash station in kitchen. 106 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ • Bring current the testing and maintenance for eyewash station in kitchen and incorporate the necessary periodic reviews into preventive maintenance scheduling system. • Ensure presence and readability of all emergency-stop controls in kitchen. • Attach signage for PPE/hazardous waste disposal to disposal containers.
• R29

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  The Alameda County Sheriff’s Office must conduct a facility-wide audit for health and safety code issues to be led by a subject matter expert and review results with the jail commander and the Alameda County General Services Agency (GSA) manager on completion.
• R30

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  The Alameda County Sheriff’s Office must incorporate into the Santa Rita Jail facility operation procedures a requirement for a semiannual facility-wide safety inspection to include the jail commander, the GSA facility manager, and a facility health and safety code expert. Document these results in a written report and add any issues identified to the facility’s maintenance issue tracking system.
• R31

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  The Alameda County Sheriff’s Office must inform GSA of all Santa Rita Jail inspections by the Board of State and Community Corrections or any other third-party entities.
• R32

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  The Alameda County General Services Agency must require a GSA facility manager be present during all Board of State and Community Corrections and other Santa Rita Jail facility inspections.
• R33

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  The Alameda County Sheriff’s Office must ensure that all entrants into the secure portion of the Santa Rita Jail facility are positively identified via government-issued identification in advance of entry.
• R34

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  The Alameda County Sheriff’s Office must implement access control procedures to reduce the risk of contraband being introduced into Santa Rita Jail by staff and administrative visitors. Controls should, at a minimum, place limits on the nature and number of personal effects that may be brought into the secure perimeter and establish protocols for screening those permitted personal effects for contraband. 107 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Detainment Conditions
• R35

  Page 108
  The Alameda County Sheriff’s Office must establish policies and procedures to ensure that each Santa Rita Jail detainee is provided an opportunity for access to outdoor space on at least three days per week for at least one hour per opportunity.
• R36

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  The Alameda County Sheriff’s Office must establish policies and procedures to ensure that each temporary access cell at Santa Rita Jail is removed from service until it is cleaned and sanitized.
• R37

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  The Alameda County Sheriff’s Office must establish policies and procedures that codify both the minimum acceptable levels of cleanliness at Santa Rita Jail in areas designated as being the cleaning responsibility of detainees and the responsibility of jail staff when those minimum levels are not maintained.
• R38

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  The Alameda County Sheriff’s Office must augment existing quality reviews to incorporate assessment of the timeliness of health care delivery at Santa Rita Jail.
• R39

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  The Alameda County Sheriff’s Office must institute monthly senior-level meetings of Santa Rita leadership, the on-site medical director, and Wellpath’s service delivery leadership to review quality assessment reporting and any emerging operational issues related to health care delivery at Santa Rita Jail.
• R40

  Page 108
  During the next amendment to the Wellpath contract, the Alameda County Sheriff’s Office must negotiate for the addition of jail-specific provisions requiring that the Sheriff’s Office be allowed to explicitly consent to personnel changes in key roles proposed by Wellpath. COVID-19 Management
• R41

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  The Alameda County sheriff’s Office must implement a visitor screening procedure for Santa Rita Jail that is consistent with current Alameda County Public Health Department and the Centers for Disease Control (CDC) guidance for congregate settings. 108 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
• R42

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  The Alameda County Sheriff’s Office must adopt a requirement that all Santa Rita employees be fully up to date with state and CDC-recommended COVID-19 vaccinations within congregate settings.
• R43

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  The Alameda County Sheriff’s Office must implement a procedure for discipline, up to and including removal, for employees who do not fully comply with Alameda County’s COVID-19 protocols for county employees.
• R44

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  The Alameda County Sheriff’s Office must provide and maintain accurate weekly reporting of staff COVID-19 vaccination statistics on the Sheriff’s Office website.
• R45

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  The Alameda County Sheriff’s Office must direct all Santa Rita staff (both Sheriff’s Office employees and contractors) to fully comply with Alameda County’s indoor masking recommendations.
• R46

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  The Alameda County Sheriff’s Office must develop a program that supplements COVID-19 education with targeted and compelling incentives for Santa Rita Jail detainees to become vaccinated. Grievance Process
• R47

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  The Alameda County Sheriff’s Office must inform Santa Rita Jail detainees, in writing, that electronic grievances may be submitted by using a placeholder tracking number.
• R48

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  The Alameda County Sheriff’s Office must update the electronic grievance submission system at Santa Rita Jail to make clear to all users that there is no requirement for deputy involvement in a grievance submission.
• R49

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  The Alameda County Sheriff’s Office must modify procedures for the review, referral, and management of medical-related grievances at Santa Rita Jail to achieve a target of 100% engagement with medical grievance submitters within 72 hours, and resolution of 95% of medical-related grievance within seven days of submission. 109 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
• R50

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  The Alameda County Sheriff’s Office must implement policy and procedure changes necessary to ensure that the Santa Rita Jail Grievance Unit actively tracks the status of grievances referred to all external departments and contracted service providers, and that these changes include a mechanism for follow-up and escalation should a grievance not be resolved within a predefined period of time. Recommendations 51: The Alameda County Sheriff’s Office must complete an analytical review of grievances received over the preceding 12 months that name individual Santa Rita Jail deputies.
• R52

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  The Alameda County Sheriff’s Office must adopt procedures that result in the delivery of a holistic analysis of grievance submission data on a quarterly schedule to the Santa Rita Jail commander.
• R53

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  The Alameda County Sheriff’s Office must adopt a mechanism for Santa Rita Jail detainees to alert jail administration to building safety and maintenance issues in a manner that is distinct from the filing of personal grievances.
• R54

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  The Alameda County Sheriff’s Office must adopt policies to acknowledge that the observation or knowledge of abuse or mistreatment of other detainees at Santa Rita Jail represents a potential grievance-qualifying harm requiring investigation.
• R55

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  The Alameda County Sheriff’s Office must modify Grievance Unit policies at Santa Rita Jail to acknowledge the value of seeking clarifications and direct testimony from submitters as an integral step in the investigative process. 110 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________