Sublease Agreement In addition to allowing Rcrmc to lease the Riverside County Inpatient

Since the opening of the ITF/ETS facility in the 1980s, an in- depth audit has never been performed by the Riverside County Auditor-Controller or by the Internal Audit Unit, a division of the Auditor-Controller’s Office. Resolution No. 83-338, establishing authority and declaring policy for Internal Audits, “be it resolved by the Board of Supervisors of the County of Riverside in regular session – pursuant to Government Code §26883 the Auditor- Controller is authorized to audit the accounts and records of any department, office, board or institution under control of the Board of Supervisors and any district funds that are kept in the County Treasury.” “Ordinance 442.3 Government Administration items 4(f) and 4(g) authorize the County Executive Officer to conduct comprehensive management reviews and investigations of programs, projects and departments.” The BOS Resolution No. 83-338 establishes authority and declares policy for bi- annual departmental internal audits. The funding and staffing levels are controlled by the BOS and limit the ability of the Office of the Auditor-Controller to comply with this Resolution.

The documents supporting the transfer of costs, licensing, equipment, building leases, and the Memorandum of Understanding written in 1999/2000 are not up to date, lack authorizing signatures, and are contrary to existing practices and operating agreements.

The CEO of RCRMC has not provided a budget to the RCDMH and the Assistant Hospital Administrator of the AC since the 1999 re- alignment. 3

The high utilization of registry personnel leads to a lack of continuum of care, poor documentation and an increased burden to the regular staff, therefore, a greater cost to the facility. The daily cost of a registry staff person is almost double the cost of a county staff person. The majority 70 percent of skilled and professional patient care attendants at the AC, are from Staff Registries, which account for 63 percent of the total salaries for daily staffing needs. 2005-2006 NON-ADMINISTRATIVE PROFESSIONAL STAFF SALARIES AND BENEFITS ITF ETS TOTALS % County Staff $2,728,543 $749,158 $3,477,701 37% Registry Staff $4,413,419 $1,407,431 $5,820,850 63% Totals $7,141,962 $2,156,589 $9,298,551 100%

Supervisors and managers at ITF/ETS have not submitted Registry Evaluations (Attachment #1), as requested. Professional Employment Registries request that each employer or supervisor submit a summarized Registry Evaluation of Registry Staff be sent to the site. This enables Registry Agencies to better evaluate their employees.

There is an absence of continuity of patient care. Due to the extensive use of Per Diem psychiatrist/physicians who do not work a daily schedule, one physician may perform the assessment and develop the treatment plan. Later, another psychiatrist monitors and evaluates the patient and may subsequently make the discharge determination.

ITF/ETS Administration has been unresponsive to complaints by staff psychiatrists regarding: • Nursing Supervisors overturning Doctors’ orders • substandard health and safety conditions adversely affecting patient care, such as patient on patient violence, and patients sleeping on the floor 4

The ITF/ETS is violating the RCRMC Department of Psychiatry Policy P.1.18 regarding incident reporting, as well as JCAHO standards PI.1.10, PI.2.20, PI.2.30, and PI.3.10 for sentinel events. “A sentinel event is an occurrence involving death or serious physical or psychological injury, or risk thereof.” “These events are called sentinel because they signal the need for immediate investigation and response.”

The Quality Improvement Department (QID) at RCRMC, which is responsible for creating a timely log of all reported incidents, has not maintained this log accurately to reflect the actual dates of reportable incidents. A review of the Incident Report Log reveals entry dates prior to the occurrence of the incidents, evidence of multiple entries with dates out of sequence, and missing data.

All AC incident reports were not submitted to QID and Risk Management. After January 7, 2007, the volume of incidents reported by ITF/ETS changed from 9 percent of total reported incidents in 2006, to 38 percent of the total during the first three months of 2007.

Some medical records contained incomplete documentation, including missing signatures on orders, telephone orders, and record of verbal orders.

The August 2004 Behavioral Assault Management (BAM) Training Manual presently in use does not reflect the current policies and procedures of the RCRMC Department of Psychiatry.

Assembly Bill (AB) 508 passed in 1993 mandates that psychiatric hospital employees receive training and education relating to general safety measures, aggression and violence, verbal and physical maneuvers to diffuse or avoid violent behavior. Based on the training record(s) provided by ITF/ETS Administration in August 2006, it could not be determined that all the staff are in compliance.

Within the last five (5) years, staff at ITF/ETS have not been given training and drills on Medical Emergency “CODE BLUE” policy and procedure P 1.16 Rev. 4/21/03 and Automated External Defibrillator (AED) policy and procedure P 1.16a Rev. 4/30/03. 5

Training records covering 234 Riverside County employees at ITF/ETS were found incomplete, disorganized, and not useful with regard to tracking the training of the majority of employees.

Insufficient staff coverage on the night shift violates the 4 to 1 and 5 to 1 patient/nurse ratios and has created an unsafe environment at the ITF/ETS facility for patient/clients and staff.

The AC facility is being run without adequate general medical staffing. RCRMC provides a primary care physician with an additional duty to attend patients at the AC after working scheduled shift at RCRMC in Moreno Valley.

Employees who want to work overtime must apply to management. It was found that overtime was often assigned selectively to a small number of employees. Such a practice lends itself to allegations of discrimination based on factors other than competence.

Senior Administration at RCRMC and RCDMH has shown inadequate leadership in making appropriate personnel changes: • leaving funded staff positions unfilled • not reducing the high turnover of professional services of doctors, nurses, and staff • not providing trained professional security staff

Items such as furniture, are not adequately secured to insure patient and staff safety. At the ITF/ETS facility we observed an agitated patient in a crowded dayroom pick-up a fiberglass chair and throw it across the room, narrowly missing other patients.

The indifference displayed by AC Administration has adversely affected employee morale. The mental and physical well-being of employees who have complained of abusive and violent behavior by patients are not supported by AC Administration with a program of follow-up care.

The AC administration has not been responsive for ensuring that a system of improved communications is maintained so that no one person can create an environment of fear and intimidation among the staff. 6

The current Security Guard Service Contract, “Professional Service Agreement #PUARC690B”, does not meet the unique needs including guard service coverage, emergency codes, and training for that type of facility. 24. “Panic Buttons” are not installed at each reception desk, nurses’ station, and activity room.

Install “Panic Buttons” at all reception desks, nurses’ stations, activity rooms, and any other critical areas at ITF/ETS.

The planned expansion by RCRMC of the ITF/ETS facility is contingent on the building meeting 1994 seismic standards. The building currently meets the 1973 standards, however, the modifications may reveal needed upgrades to bring the building up to the 1994 Northridge Earthquake Standards.

The average daily intake of 27 patients per day at ETS, makes the only existing interview room inadequate to manage the volume of patient interviews and comply with the Welfare and Institutions Code §5325.1(b), related to patient privacy.

Interviews with professional staff and psychiatrists indicate a constant return rate of patients. Some patients have been placed outside of the medical jurisdiction of Riverside County that does not match the level of care needed. The determination of severity of patient’s diagnosis does not match discharge process and placement.

Nurses are engaging in unlawful practice by administering medicines to patients without proper documentation on the Medical Administration Record, and requesting other staff members to sign for the administration of the medication.

During our inquiry we found a clear case where symptoms, and medical description of condition clearly described “schizophrenia with paranoid indications”, in the chart. When describing attempts at outplacement, these symptoms were clearly understated to potential residential placement, such as a board and care, instead of institutional placement, as indicated by a senior administrator.

After hours discharge of patients takes place without appropriate placement planning. Many patients discharged during this timeframe are unable to find shelter or residence of any kind. 7

ITF does not have qualified professional discharge planners dedicated to discharge placement of patients in California State Mental Hospitals when long-term care is indicated.

Annual Performance Reviews of County Employees at the AC are done on irregular basis, if at all. Therefore, opportunities for constructive criticism and team building are lost.

The Administration at the AC have relinquished their management operational responsibility to lower level managers.