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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

San Benito County Grand Jury • 2015-2016

San Benito County Public Mental Healthcare Management

124 pages
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Note: Missing finding numbers detected: F2, F10, F12, F24

Findings 33 findings

F1 Page 111
The San Benito County Board of Supervisors is out of compliance with California State Law; specifically the CA Welfare and Institution Code. F2. No written directive is in place from the County Administration Officer for designation of the county health care professional as required by California State Law (CA WIC paragraph (1) of subdivision (a) of Section 5150), and which also mandates the BOS certify whom the CAO designates as the county health professional.
F3 Page 111
A written policy is needed from the BOS to specifically designate the treatment facility to receive WIC 5150 holds in SBC.
F4 Page 111
San Benito County needs a clearly defined program to care for persons that need to be held involuntarily for mental care assessment (5150), through to evaluation and treatment (5151, 5250, and so on.)
F5 Page 111
Agencies and departments such as the ED, BH, SB County Jail, LE; all that come into contact with individuals who may need mental health assessment or treatment do not have updated, and consistently relevant to one another's, policies and procedures on file.
F6 Page 111
Conflicting policies and procedures exist with particular reference to 5150 holds among agencies, districts, and SBC departments.
F7 Page 111
General communication between departments, agencies and districts are lacking.
F8 Page 111
Negotiated Memorandums of Understanding (MOUs) do not exist for providing mental health care in SBC and between agencies under different boards, county, or state authority.
F9 Page 111
The time between initial custodial hold and admission as an inpatient for a person in an involuntary hold under WIC often exceeds 72 hours in SBC, and not infrequently goes beyond a week. Reports indicate that patients are being held waiting in the HHH ED for as long as 14 days for further mental health evaluation and treatment. F10. The SBC Behavioral Health Department is writing consecutive WIC 5150s.
F11 Page 111
Patients on a temporary involuntary hold in SBC hold may not know their legal rights under the CA WIC laws of civil commitment. F12. There is a possible violation of Patient's Rights when under a temporary involuntary hold in SBC being violated, under the CA WIC laws of civil commitment. 109
F13 Page 112
The HHH ED staff is using a pamphlet derived from Santa Cruz County to distribute to patients on WIC 5150 holds about their civil rights.
F14 Page 112
The HHH ED staff may be releasing WIC 5150 hold patients that exceed 72 hours due to concerns about violations of patient's rights.
F15 Page 112
BH does not have official authorization or paperwork from any authority to support the claim that they may stack 5150s. F 16. There is a lack of adequate county psychiatric health facilities, crisis centers, and/or inpatient psychiatric beds based upon the previous, current, and the rapidly growing SBC population. F 17. Mental health patients may have to wait a long time to be medically cleared. F 18. Mental health patients who come in, or are brought in, consecutively to the HHH ED may 'backup' in the ED while waiting for medical clearance and assessment. F 19. Healthcare and security manpower requirements at HHH increase when monitoring and holding an individual on a WIC 5150 involuntary hold, and increase at a more rapid rate when exceeding the allowed 72 hours. F 20. A backlog of individuals on a WIC 5150 involuntary hold results in mental health patients in the ED with no place to wait creates general HHH ED crowding, financial, and security risks. F 21. The ED can be holding multiple psychiatric patients in ED beds, creating a longer wait time for medical treatment for other types of ED patients. F 22. HHH or the HHH Emergency Department or does not have a psychiatrist on staff. F 23. The San Benito Health Care District, Board of Directors, is not involved enough in the oversight and disposition of HHH ED individuals in a WIC 5150 temporary involuntary hold and persons needing mental health care assessment, evaluation, and treatment or transfer. F 24. The Mayor of Hollister and City Council of Hollister are not systematically involved in the impact Hollister residents experience from alimited mental health program and dysfunction of the communications and protocols among the agencies. F 25. Jail psychiatric support is lacking. F 26. Correctly updated written SBC Jail policies and procedures in Section 609 are not possible in the current climate of a broken mental health care program in SBC. F 27. BH providing one-way directives to the Jail or other agencies such as LE or HHH ED that significantly impact the other's resources is not appropriate nor in the best interest of the SBC mental health care system. F 28. The current BH policy incurring significant limits to the Jail staff in making calls to clinicians AND the expanded timeframe the Jail staff endures while waiting for clinicians to arrive at the Jail for assessment has had a substantially negative impact on the Jail. F 29. Our local government is not considering the strain placed on County Jail Correctional Officers at the SBC Jail due to BH policies, and HHH limitations or as part of a comprehensive SBC mental health care program. F 30. Inmates are waiting in a safety cell for a mental health assessment for too long. F 31. Requiring Jail Corrections Officers to conduct 15-minute checks to the Jail's Safety Cell on an extended basis while waiting for mental health clinicians to perform a mental health assessment is unacceptable. F 32. Transportation logistics are inadequate. Obtaining and funding the appropriate type of transportation for mental health patients to other facilities with an available bed is problematic. F 34. Inmates are not provided with an adequate facility per Title 15 to accommodate psychiatric evaluation and treatment. F 33. There is no established, dedicated, and collaborative committee to confer and effect solutions under BOS oversight to remedy current mental health care problems and to explore the future mental healthcare needs of the county.
F16 Page 112
There is a lack of adequate county psychiatric health facilities, crisis centers, and/or inpatient psychiatric beds based upon the previous, current, and the rapidly growing SBC population.
F17 Page 112
Mental health patients may have to wait a long time to be medically cleared.
F18 Page 112
Mental health patients who come in, or are brought in, consecutively to the HHH ED may 'backup' in the ED while waiting for medical clearance and assessment.
F19 Page 112
Healthcare and security manpower requirements at HHH increase when monitoring and holding an individual on a WIC 5150 involuntary hold, and increase at a more rapid rate when exceeding the allowed 72 hours.
F20 Page 112
A backlog of individuals on a WIC 5150 involuntary hold results in mental health patients in the ED with no place to wait creates general HHH ED crowding, financial, and security risks.
F21 Page 112
The ED can be holding multiple psychiatric patients in ED beds, creating a longer wait time for medical treatment for other types of ED patients.
F22 Page 112
HHH or the HHH Emergency Department or does not have a psychiatrist on staff.
F23 Page 112
The San Benito Health Care District, Board of Directors, is not involved enough in the oversight and disposition of HHH ED individuals in a WIC 5150 temporary involuntary hold and persons needing mental health care assessment, evaluation, and treatment or transfer. F 24. The Mayor of Hollister and City Council of Hollister are not systematically involved in the impact Hollister residents experience from alimited mental health program and dysfunction of the communications and protocols among the agencies.
F25 Page 112
Jail psychiatric support is lacking.
F26 Page 112
Correctly updated written SBC Jail policies and procedures in Section 609 are not possible in the current climate of a broken mental health care program in SBC. 110
F27 Page 113
BH providing one-way directives to the Jail or other agencies such as LE or HHH ED that significantly impact the other's resources is not appropriate nor in the best interest of the SBC mental health care system.
F28 Page 113
The current BH policy incurring significant limits to the Jail staff in making calls to clinicians AND the expanded timeframe the Jail staff endures while waiting for clinicians to arrive at the Jail for assessment has had a substantially negative impact on the Jail.
F29 Page 113
Our local government is not considering the strain placed on County Jail Correctional Officers at the SBC Jail due to BH policies, and HHH limitations or as part of a comprehensive SBC mental health care program.
F30 Page 113
Inmates are waiting in a safety cell for a mental health assessment for too long.
F31 Page 113
Requiring Jail Corrections Officers to conduct 15-minute checks to the Jail's Safety Cell on an extended basis while waiting for mental health clinicians to perform a mental health assessment is unacceptable.
F32 Page 113
Transportation logistics are inadequate. Obtaining and funding the appropriate type of transportation for mental health patients to other facilities with an available bed is problematic.
F33 Page 113
There is no established, dedicated, and collaborative committee to confer and effect solutions under BOS oversight to remedy current mental health care problems and to explore the future mental healthcare needs of the county. F35. SBC Law Enforcement and HPD LE are out of compliance with WIC 5150 by not transporting persons placed under involuntary hold to a facility where the person may receive a mental health evaluation. F36. SBC government does not have an area set aside to construct the augmented infrastructure needed for a psychiatric treatment facility. F37. COG has not considered SBC LTA as an option for transportation in a comprehensive mental health care program nor a temporary solution in the shortfall of transportation logistics in SBC for mental health care patients. RECOMMENDATIONS R1. F1, F2, F3, F4. The BOS should review Division 5 of the CA Welfare and Institutions Code (CA W&I). R2. F1, F2, F3, F10-12, F14, F23, F35. The BOS should make the appropriate designations for both the SBC Mental Health Director and the treatment facility to receive SBC 5150 holds made by LE. Each designation should be official and produced by the BOS in writing. If the facility designated by the BOS is under San Benito Health Care District, Board of Directors (i.e. HHH) management, then both Boards should take note that HHH is not a licensed facility for evaluation or treatment of patients placed in a temporary involuntary hold for mental health reasons. The BOS should be aware that the result of designating HHH as the treatment facility may be to direct LE out of CA WIC compliance, and may result in patient's rights infringement by exceeding 72-hour limits while attempting to deliver patient care. R3. F1, F4. The BOS should provide a detailed plan of action indicating steps and initiatives taken in the public interest that put SBC in compliance with Division 5 of the California Welfare and Institutions Code and augments mental health care in SBC. This plan of action should be made in response to this investigation and submitted to the public in time for a review for continuity by the SBC Civil Grand Jury 2016-17. R4. F1, F4. The BOS should research and confer with BH to effectively get the attention of the State of CA to provide immediate resources to SBC for psychiatric mental health care assistance. R5. F5, F23, F24. LE and HHH ED should begin regularly providing data available to the BOS to track the number of WIC 5150 cases brought to the ED, and the disposition of each one, including total length of stay. R6. F5, F23, F24. HHH and BH ensure that LE receives information about all WIC 5150 individuals that released without further evaluation. R7. F4, F5, F6, F23, F24. As a result of collaboration, ALL agencies, and departments that come into contact with those whom may need mental health assessment or treatment should have relevant policies and procedures updated and relevant to one another's on file and shared with other agencies to minimize procedural conflict. R8. F4, F6, F7, F23. The LE, ED and BH Departments and the Jail are key relationships to one another. Policies and procedures between these agencies should be made with particular attention and supported with a close oversight of the BOS that reflects these dependencies to ensure mental health care program efficiency and success. R9. F1, F4, F5, F6, F7, F23. Collaborative effort should begin immediately from all parties for the health and welfare of SBC. R10. F4, F7, F8, F23. SBC BOS establish clear Memorandums of Understanding (MOUs) written by and for the involved agencies, districts that have a separate board, and counties, (i.e. those not operating under the SBC BOS direct authority) to determine and establish agreement upon, and compliance with, local protocol. Also, that the BOS effect policy to maintain these MOUs until superseded by subsequently negotiated agreements. R11. F1, F4, F10, F11, F12, F14, F23. "Stacking" 5150 holds is bad practice, and may be in violation of CA law. SBC should cease taking liberties with CA legislation concerning persons placed on 5150 holds. All methods available to agencies and departments should be implemented to attempt not to exceed the 72-hour maximum elapsed time from when the hold is initiated by LE, or otherwise, until the point of completed disposition of the patient. R12. F1, F4, F10, F11, F12, F14. F15. BH should not look for, or be compelled to find, creative ways to circumvent the law to extend the 5150 72-hour hold due to SBC's lack of psychiatric treatment resources. BH should not "fudge the start time of the 5150 hold" nor argue that the start time or "hold lift time" is ambiguous. BH's good intention is clear, but working with the BOS to gain the facilities for an outstanding mental health program is optimal. Anything else may be counterproductive to achieving a long-term viable and quality program in SBC. If SBC BH does obtain written official temporary authorization to stack 5150s from the state, SBC should still employ a more strict 5150 72 hold time, and county agencies work together to increase our quality of mental health care under this time constraint. If BH obtains formal approval to stack 5150s given our dire lack of resources, BH's use of the temporary waiver should be done so understanding that it to be used in parallel to a dedicated lobby for establishment and implementation of permanent solutions for SBC. R13. F9, F10. Recommended that SBC adopt a model such as Monterey County to consider weekends and holidays as part of the 72-hour period of a 5150 hold regardless of SEIU bargaining demands. R14. F1, F4, F10, F12, F23, F32. Both the ED and BH should be responsible for researching and locate bed availability to transfer 5150 persons who cannot receive needed care in SBC. Both departments should be held equally accountable for delays or wait time in the 72 hours to research and find a bed. This policy should be written in a formalized protocol and enforced by the BOS in oversight of the county mental health care program. R15. F1, F10, F11, F12, F14, F15, F23. If individuals object to being involuntarily held during or beyond the 72 hours on a 5150 hold, then the use of the patient's legal rights to judicial review (filing a writ of habeas corpus) process should be brought (again) to the patient's attention by the ED staff. In particular, when medical clearance has 113 processed but a BH assessment is not complete. That is, according to WIC the patient may be reminded that: "If held longer than 72 hours, you have the right to a lawyer and a qualified interpreter and a hearing before a judge. If you are unable to pay for the lawyer, then one will be provided to you free of charge." Notification by the individual to the County Public Defenders office or any other attorney should not be interfered with or discouraged. The individual may also be reminded that if demanding a writ of habeas corpus, the decision whether to file it lies solely with the SBC Public Defender. R16. F1, F4, F11, F12, F13, F23. The San Benito Health Care District in conjunction with BH and the BOS should develop its own, customized, patient's rights pamphlet to distribute to individuals on a WIC 5150 hold in the ED instead of using what was prepared specifically for Santa Cruz County. R17. F1, F14, F18, F23, F24. The HHH ED should cease developing plans to release individuals in need of psychiatric care by "lifting the hold" on WIC 5150s. Any authorization for the ED to use this type of protocol should be made as a result of the SBHCD Board of Directors and the SBC BOS joint approval following multi- departmental, agency, and district collaborations held with The Director, Behavioral Health. When any release is made, LE is to be notified immediately. R18. F1, F4, F9, F10, F11, F12, F13, F14, F15. Request immediate assistance from the State of CA, Department of Health and Human Services, before SBC has legal issues regarding patients' civil rights for involuntary detainment beyond the 5150 72- hour holds; and failing to admit a patient for evaluation and treatment because SBC does not have a necessary psychiatric treatment facility. R19. F1, F4, F5, F6, F7, F8, F14, F23, F24. Recommend preparation of negotiated agreements among the agencies that share the responsibility of WIC Division 5 management and agreement should include confidentiality in ARTICLE 7. Legal and Civil Rights of Persons Involuntarily Detained [WIC 5325 - 5337] especially Section 5328. This agreement should be established within the meaning of California Civil Code so that one agency may not unilaterally change established procedures which affect any other agency without a new negotiated agreement among the agencies. R20. F17, F19, F23. As the designated treatment facility HHH should provide resources to medically clear 5150 hold patients as soon as possible. R21. F16, F18, F23, F35. HHH should consider setting up a licensed inpatient area and move 5150s to 5151s for an added 72 hours of evaluation for treatment - then, if necessary, transfer the patient. R22. F17, F18 F19 F20, F21, F22, F23, F35. HHH should consider becoming a licensed psychiatric facility with 7 to 10 beds to help alleviate problematic county mental health issues. R23. F1, F17, F18 F19 F20, F21, F22, F23. It is recommended to take pressure off of the ED and BH clinicians by SBC finding at least ten beds for psychiatric care. The SBC 114 BOS and SBHCD Board of Directors should understand that SBC needs to augment mental health care now. El Dorado County has a 10-bed PHF, and Sacramento has a 12-bed PHF; this is a basis to understand CA counties can get the state's support for county mental health care needs. R24. F1, F16, F17, F18, F19, F20, F21. Recommended that BOS capture the attention of the state on the basis of the CA Law WIC 5770 which reads: "Notwithstanding any other provision of law, the State Department of Health Care Services may directly, or by contract, with any public or private agency, provide any of the services under this division [WIC Division 5] when the state determines that the services are necessary to protect the public health, safety, or welfare." R25. F1, F17-24, F35. SBC leadership and elected officials undergoing the impact of this lacking psychiatric mental health care system together implement an immediate and temporary solution. They should establish locations for a psychiatric crisis center for LE to bring 5150 holds needing assessment and a place to admit patients who require mental health evaluation and treatment as a result of the information provided in this report until effecting permanent solutions.
F34 Page 113
Inmates are not provided with an adequate facility per Title 15 to accommodate psychiatric evaluation and treatment.
F35 Page 113
SBC Law Enforcement and HPD LE are out of compliance with WIC 5150 by not transporting persons placed under involuntary hold to a facility where the person may receive a mental health evaluation.
F36 Page 113
SBC government does not have an area set aside to construct the augmented infrastructure needed for a psychiatric treatment facility.
F37 Page 113
COG has not considered SBC LTA as an option for transportation in a comprehensive mental health care program nor a temporary solution in the shortfall of transportation logistics in SBC for mental health care patients. 111

Recommendations 33