Riverside County Sheriti Stanley Sniff, Sheriff*

The Riverside County Sheriff is responsible for providing basic medical services to inmates in custody at all jails and detention centers in the County (The Eighth Amendment to the U.S. Constitution, California Penal Code §6030, and CCR Title 15, §3350 et seq). The Sheriff has the ultimate responsibility under CCR Title 15, Article 11, §1200 to provide medical services to inmates in accordance with the following guidelines: "...1. all health care will be provided outside the facility by transporting inmates to doctors' offices and/or hospitals; 2. only emergency health care will be provided by transporting inmates to doctors' offices and hospitals and basic health care will be provided in the facility; 3. all health care will be provided in the facility; or, 4. only first aid will be provided in the facility, with all other health care requiring transport to community medical services. Personnel considerations will help determine if it works best to: 1. hire medical personnel to work in the jail as employees of the police, sheriff's or corrections department; contract with a local hospital, private doctor, private psychiatrist, medical group, correctional health care company, or medical center; develop a written agreement with the county health department to provide jail health care; ... " In the mid-1990s, the Board of Supervisors transferred the medical services function from the Sheriff and funded RCRMC to provide these services. This resulted in the Sheriff having the legal responsibility for detention health care without practical authority for its provision. Response: Respondent Agrees. The respondent acknowledges it is the Sheriff's legal responsibility to provide emergency and basic medical services to inmates in Riverside County jails and detention centers. The respondent also acknowledges that while the legal responsibility for the delivery of medical services rests with the Sheriff, the practical authority of fulfilling the responsibility belongs to the Riverside County Regional Medical Center (RCRMC), Detention Health Services (DHS). The respondent believes it is important to note that beginning fiscal year 2008/2009, the conflict between legal responsibility and practical authority resulted in deep cuts to medical personnel staffing levels, without consideration for how those cuts affected the respondent's ability to fulfill the legal responsibility. It is important to note that since the practical authority for delivery of medical services was transferred to RCRMC, the respondent has attempted to reconcile the conflict through the creation of a Memorandum of Understanding (MOU) with RCRMC/DHS that would identify staffing levels necessary for the adequate and continuous delivery of medical services. The respondent observed that the budget and medical personnel staffing cuts beginning fiscal year 2008/2009 unacceptably impacted the delivery of medical services, and unacceptably impacted other jail operations as well. To confirm and accurately assess the extent of this impact, the respondent requested evaluations from the Corrections Standards Authority (CSA) and the Institute for Medical Quality (IMQ). Both the CSA and the IMQ found that emergency and basic medical services were not being delivered within the intent of the CCR Title 15 Minimum Standards for Local Detention Facilities. The respondent also obtained a legal opinion from Attorney, Martin J. Mayer of Jones & Mayer. Mr. Mayer confirmed the legal responsibility for the delivery of emergency and basic medical services for jailed inmates rests with the Sheriff. Mr. Mayer also confirmed the liability for failure to provide medical services within the intent of the provisions of CCR Title 15 rests with the Sheriff. The respondent has noticed the County Executive Officer as recently as March 9, 2011, of both the CSA and IMQ findings, and Mr. Mayer's legal opinion. Grand Jury Recommendation: Board of Supervisors transfer health care administration authority at all jails and 1. detention centers in the county back to the Riverside County Sheriff. Response to Recommendation: The Grand Jury's recommendation falls outside the scope of the respondent's authority. However, the respondent notes that whether health care administration authority is transferred to the respondent or remains with RCRMC, the continuous and effective delivery of medical services to inmates in County adult detention facilities is directly related to development and implementation of a binding Memorandum of Understanding (MOU) between the Sheriff and RCRMC that clearly identifies expectations, management measuring tools, and minimum staffing levels and classifications. The respondent's position is that such a MOU and related Board of Supervisors' funding should be specific to the Sheriff's operations. Because the Sheriff's scope of authority does not extend to the Probation Department, respondent believes the Probation Department should establish a separate MOU with RCRMC with its own separate funding. The respondent is and has been prepared to work cooperatively with the relevant county departments to establish a MOU for the delivery of medical services in all adult detention facilities in Riverside County. The respondent will continue to urge the Board of Supervisors to support this direction and resolve this matter through both funding and a formal memorandum of understanding.

The Riverside County Probation Department has responsibility for administering health care services to all minors in their facilities. (The Eighth Amendment to the U.S. Constitution, California Welfare and Institutions Code sections 201 and 885 and CCR Title 15, \S1400 et seq). The Riverside County Board of Supervisors has responsibility to provide funding for inmate medical services. (Brandt v. Board of Supervisors 840 Cal App 3rd 598, 601-602 (Cal App 5th Dist. 1978)). Probation Department Facilities Administrators have ultimate statutory responsibility under CCR Title 15, Article 8, §1400 to provide medical services to minor detainees: "The facility administrator shall ensure that health care services are provided to all minors. The facility shall have a designated health administrator who, in cooperation with the mental health director and facility administrator, and pursuant to a written agreement, contract, or job descriptions, is administratively responsible to: (a) develop policy for health care administration; (b) identify health care providers for the scope of services; (c) establish written agreements as necessary to provide access to health care; (d) develop mechanisms to assure that those agreements are properly monitored; and (e) establish systems for coordination among health care services providers. When the health administrator is not a physician, there shall be a designated responsible physician who shall develop policy in health care matters involving clinical judgments. ..." In the mid-1990s the Board of Supervisors transferred the medical services function from the Probation Department and funded RCRMC and Detention Health Services (DHS) to provide these services. This forced the Probation Department to modify its policies and procedures to conform to the budget considerations of DHS rather than having practical authority to administer the program. Response: The respondent defers official response to this finding to the appropriate County Departments. The respondent is not charged with providing healthcare services in juvenile detention centers and for this reason is not the appropriate authority to respond to the Grand Jury's finding. Grand Jury Recommendation: 2. Board of Supervisors transfer health care administration authority at all juvenile detention centers to the Riverside County Probation Department. Response to Recommendation: The respondent defers official response to this finding to the appropriate County Departments.

Documentation available to the Grand Jury reveals that beginning in FY 2011-2012, RPDC will be the only adult detention facility in Riverside County that is in compliance with Title 15 in the provision of 24-hour medical personnel on premises. Of the remaining facilities, Larry D. Smith will have medical staff 12-hours a day. Southwest, Indio, and Blythe will have no medical personnel at all. As a result of the current reduction of the Health Care Services budget, the method of adult inmate health care in four of the five detention facilities increased safety costs to the Sheriff's Department. The Grand Jury's investigation revealed that this cost increase is due to the additional transportation and security of inmates requiring medical care. Inmates requiring daily medical attention who are appearing in court in another area of the county impose additional transportation and security expenses. Response: The respondent agrees. The respondent agrees the lowered medical personnel staffing levels in County adult detention facilities, requires that inmates receive basic medical services outside the secure jail setting. Additionally, due to the absence of sufficient medical clerical staff the respondent has been unable to provide timely CSA Jail Profile Survey Reports consistent with CCR Title 15 regulation, as identified in our recent CSA technical assistance report. The respondent agrees that providing basic medical services outside the secure jail setting has increased the respondent's transportation and security expenses, while decreasing public safety. Furthermore, consistent with Mr. Mayer's legal opinion the practice has exposed the respondent to increased civil liability. Grand Jury Recommendation: Board of Supervisors provide funding for medical services as mandated by CCR Title 15 to inmates at all adult detention facilities in Riverside County. Response to Recommendation: The Grand Jury's recommendation falls outside the scope of the respondent's authority. However, the respondent will make every effort to work cooperatively with the Board of Supervisors and relevant County departments to identify costs for the delivery of medical services at all adult detention facilities in Riverside County. Consistent with the response to finding and recommendation #1, and in an effort to ensure adequate and continuous delivery of medical services, the respondent will work to establish a MOU for the delivery of medical services in all adult detention facilities in Riverside County. The respondent will continue to urge the Board of Supervisors to fund the delivery of basic and emergency medical services to inmates in Riverside County jails and detention centers, in accordance with a formal MOU.

The Grand Jury has learned that beginning in FY 2011-2012, Riverside JH will be the only juvenile facility providing medical services to minors. It will provide services 12- hours a day. Minors requiring medical attention at Indio JH, Southwest JH, Van Horn, and Twin Pines will require transport to either Riverside JH or the nearest hospital. Currently Southwest JH must transport any minor needing any medical attention either to Riverside JH, where medical services are available, or to RCRMC. These movements require two custodial staff members to accompany the minor and to remain with the minor, causing staff shortages at the detention facility for several hours at a time. Therefore, reduction of funding to DHS translates into higher expenditures for the Probation Department. As a result of DHS budget reduction the Probation Department is not in compliance with CCR Title 15. At the time of this writing, Southwest JH has the following backlogs: 22 physical examinations, dating back six weeks, which are mandated to be • completed by a doctor within the first 96-hours of incarceration. 17 minors waiting to see a doctor. The assigned doctor is currently available only one day per week for four hours at a time at Riverside JH, over 40 miles away. The elimination of medical services has resulted in violations of CCR Title 15 in the following areas: §1357 prescribes medical considerations in the use of force. §1358 requires medical assessment within two hours of placement in physical restraint, and every three hours thereafter. §1359 describes medical assessment and evaluation associated with the use of Safety Rooms. Response: The respondent defers official response to this finding to the appropriate County Departments. The respondent is not charged with providing healthcare services in juvenile detention centers . and for this reason is not the appropriate authority to respond to the Grand Jury's finding. Grand Jury Recommendation: 4. Board of Supervisors provide funding for medical services as mandated by CCR Title 15 to minor detainees at all juvenile probation facilities in Riverside County. Response to Recommendation: The respondent defers official response to this finding to the appropriate County Departments.