Riverside County Sheritt Stanley Sniff, Sheriff*

Initial Booking Screening When a person is arrested and brought to a Riverside County jail, it is necessary to determine the arrestee's medical/mental health needs. At the time of initial booking into county jails detainees are screened by correctional officers. Due to budget cuts to Mental Health Detention Services (MHDS), there are no mental health personnel at intake for screening in the five Riverside County jails. The screening checklist relies primarily on the detainee's self-reporting of his/her medical/mental history and current mental conditions including the use of prescription drugs. The checklist further records the booking officer's observations of detainee's behavior. Investigation revealed mental illness screening also makes use of records of prior hospitalization, prior or current use of psychotropic medications, exhibition of bizarre behavior and requests for care. Testimony revealed correctional officers may not recognize hidden medical and/or mental health problems that could be best observed by a medical/mental health expert. This could result in delaying needed treatment. Response: Respondent Agrees. The respondent acknowledges the absence of mental health professionals at jail intake could result in delayed mental health treatment. The respondent has made every effort within the existing environment to ensure that people who enter the Corrections Division are evaluated for real and immediate mental health care needs. The respondent has not been presented with real or empirical data that indicate a practice of less humane treatment of mentally ill persons in the respondent's custody. Grand Jury Recommendation: Mental health personnel should be assigned at each jail and used I. at the time of initial booking to screen for possible mental illness. The mental health personnel assigned to each jail should use a validated mental health-screening tool to increase the early identification of mental health and any co-occurring substance abuse problems of incarcerated individuals. A systematic program for screening and evaluating inmates by mental health personnel is needed to identify those in need of mental health care. Response to Recommendation: The respondent is working cooperatively with the relevant County departments to ensure the delivery of humane care for persons who suffer from mental illness. The implementation of the recommendation will help establish an appropriate treatment plan at the onset, as well as assist in the proper classification of the inmate. The Sheriff's Department will continue to urge the Board of Supervisors to support this need.

Delays in Accessing Care – Mental Health Evaluation Once an inmate has been determined to be in need of a mental health evaluation and treatment, there may be delays in access to necessary care in the mental health system. Investigation revealed inmates sometimes have to wait two or more weeks after booking to receive an initial mental health assessment and evaluation by a mental health specialist. Inmates with assessed moderate mental health problems such as neuroses, phobias, panic disorders, etc., are not always offered appropriate medication and counseling by qualified staff to get and maintain them in a stable condition. Investigation revealed MHDS has no confidential self-referral system by which inmates can request mental health care without revealing the nature of their request to correctional officers. Response: Respondent agrees in part and disagrees in part. The respondent agrees there are currently delays in mental illness treatment and such delays may impact an inmate's mental stability. However, the respondent makes every effort within the existing environment and available skill sets of Sheriff's Department employees to evaluate and make referrals for needed mental health treatment. The respondent disagrees that there is no confidential self-referral system to mental health services, or that inmates must reveal the nature of their mental health condition to a correctional officer to obtain a referral to mental health services. Existing policy and practice requires only that the inmate request the referral. The inmate is not required to disclose the nature of their illness. Grand Jury Recommendation: MHDS should provide an adequate mental health care evaluation 2. of inmates who screen positive for possible mental illness. This should be done within 24-hours of booking into a county jail (excluding weekends and legal holidays as long as an urgent evaluation is not indicated). Within 72-hours of booking into the jail MHDS should provide a mental health care evaluation of inmates admitted on weekends or holidays. If the evaluation identifies a serious mental illness, e.g. depression, bipolar disorder or schizophrenia, a brief initial treatment plan should be prepared. A qualified and appropriately trained mental health professional should, within 14-days of booking, complete and properly document an adequate mental health evaluation for each inmate who screened positive for possible mental illness. MHDS should develop and maintain a confidential self-referral system by which inmates can request mental health care without revealing the nature of their request to correctional officers. Response to Recommendation: The respondent will make every effort to work cooperatively with the Board of Supervisors and relevant County departments to ensure and facilitate the delivery of humane mental health care for inmates who suffer from mental illness. The respondent also supports the further development of a mental health services referral system through which inmates may access mental health services without unwarranted invasions into their medical health privacy.

Medication Administration Some inmates, due to the nature of their mental illness, should receive prescribed medications from medical staff several times during the day and at bedtime. However, medications are distributed only once or twice in a 24-hour period. Response: The respondent agrees with the finding. The respondent agrees that continuity in delivery of mental health medications may affect the stability of an inmate's mental health and is critical to inmate care. The reduction to health services in the Corrections setting has directly impacted the medication distribution to the inmates. Grand Jury Recommendation: 3. Medications, once properly prescribed, should be distributed, and administered to meet the needs of the patients. In many cases this will require distribution 2-3 times a day. . . Response to Recommendation: The respondent will make every effort to work cooperatively with the Board of Supervisors and relevant County departments to ensure and facilitate the humanely adequate delivery of mental health medications for inmates who suffer from mental illness.

Inmate Transfers to ETS and DCU The Department of Mental Health Section VI, Policy / Procedure 604, Subject: Transfers to the Emergency Treatment Services (ETS) and Detention Care Unit (DCU) outlines the procedure used to assess and to transfer certain mentally disordered inmates to ETS at the Arlington Campus and DCU at RCRMC. Interviews revealed that when inmates are transferred to ETS, some non-inmate patients are unduly disturbed to see inmates in shackles accompanied by armed correctional officers. There are no secure cells where the inmates can be housed while undergoing evaluation and treatment at ETS. Welfare and Institutions Code Section 4011 requires county correctional officials to maintain the necessary guards at all times when the inmate is out of jail for hospitalization. Response: The respondent defers official response to this finding to the appropriate Department of Mental Health and/or RCRMC. The respondent is not charged with the operation of ETS and for this reason is not the appropriate authority to respond to the Grand Jury's finding related to ETS operations. Additionally, the respondent is not the appropriate authority to respond to the Grand Jury's finding that non-inmate mental health patients were "unduly disturbed" by the sight of a shackled inmate in the company of a duly sworn and armed peace officer. It is important to note that existing practices are dictated by the location and availability of the mental health care resource. Grand Jury Recommendation: 4. Mentally disordered inmates should only be transferred to RCRMC / DCU for evaluation, treatment and possible admission. Inmates in county jails who can't be safely housed in the jail due to being a danger to self, danger to others or to being gravely disabled should not be transferred to ETS for evaluation and treatment. . . Response to Recommendation: The respondent will make every effort to work cooperatively with the Board of Supervisors and relevant County departments concerning the Grand Jury's

Medication Orders for Inmates RCRMC Policy P4.43, Medication Orders for Inmates (Revised Date 01/13/07) outlines the process to be followed when an ETS psychiatrist prescribes psychotropic medications over the phone for an inmate. The policy requires that a jail psychiatrist re-evaluate the inmate on a timely basis (e.g. next scheduled work day of the jail psychiatrist). The Blythe jail has no psychiatrists available. Inmates with mental health problems are transferred to jails with mental health personnel. At the other four jails a psychiatrist is assigned, but not on a full-time basis. Response: The respondent agrees with the finding. The reduction to health services in the Corrections setting has directly impacted the availability of psychiatric services within Corrections. Grand Jury Recommendation: 5. Medical/mental health staff should be employed in sufficient numbers to identify and treat, in an individualized manner, those treatable inmates suffering from serious mental disorders. In the interim, Policy P4.43 (Medication Orders for Inmates) should be reviewed and modified to reflect the capabilities of current staffing levels. Trained health care personnel should administer medications to ensure medication is in fact taken, to guarantee that the correct inmate takes it, and to observe any effects, especially adverse reactions of the medication. Response to Recommendation: The respondent will make every effort to work cooperatively with the relevant County departments to implement the Grand Jury's recommendation and urge the Board of Supervisors to support this need. 6|Page

Treatment Facility No Riverside County jail facility has been designated a 'treatment facility' for the sole purpose of administering court ordered antipsychotic medication to inmates identified as incompetent to stand trial, and who are unable to provide informed consent to medication due to a mental disorder. Testimony revealed that mentally incompetent inmates awaiting transfer to a state hospital are the most costly and difficult to manage. Typically these inmates will not voluntarily take prescribed medication when in the standard jail setting. Testimony revealed inmates usually get worse (decompensate) the longer they wait for admission to a state mental hospital or other approved 'treatment facility'. Once an inmate is restored to competency and returned to jail from a state hospital they may again refuse to voluntarily take medication, could decompensate, and repeat the cycle. Response: The respondent agrees in part with the finding. The respondent agrees that a delay in transferring an inmate to a state mental hospital and the absence of forced medicating may affect the stability of an inmate's mental health. However, the respondent has no empirical data from which to conclude that inmates in the custody of the Riverside County Sheriff's Department have inhumanely suffered due to a delay or refusal to take their medications. Grand Jury Recommendation: The County Board of Supervisors, the County Mental Health 6. Director and the Riverside County Sheriff should designate the 96-bed psychiatric unit at the Smith Correctional Facility in Banning as a 'treatment facility', for the sole purpose of administering antipsychotic medication pursuant to a court order as authorized in Penal Code Section 1369.1. The Board of Supervisors should authorize the District Attorney, Public Defender and Department of Mental Health to make arrangements with the neighboring county's jails to utilize their jail treatment facilities to treat Riverside County mentally incompetent inmates on an interim basis while awaiting transfer to a state mental hospital. The Department of Mental Health (DMH) should determine and designate appropriate public and private mental health facilities as other 'treatment facilities' within the meaning allowed by the Penal Code Section 1370.01(a)(1)(A). Response to Recommendation: The respondent is willing to designate a 32 bed unit at the Smith Correctional Facility as a section designed for inmate mental health housing. The implementation of a non-voluntary anti-psychotic medication program will be solely related to the adequate staffing of DMH and DHS personnel. The respondent will partnership with relevant County departments to determine if this is a viable option of treatment and petition the Board of Supervisors to support this need.

Transfers to State Hospitals Jail detainees adjudicated incompetent to stand trial and judicially ordered to be transferred to a state hospital or other suitable treatment facility for examination and treatment to promote their speedy restoration to mental competence, are not transferred in a timely manner, but can sometimes spend up to 60 or more days in county jail awaiting transfer. During this time detainees do not receive the necessary broad spectrum of care otherwise available in state hospitals or in other fully accredited public and private psychiatric treatment facilities. Penal Code Section 1370 (b)(1) requires, in part, "within 90 days of a commitment made pursuant to subdivision (a) the medical director of the state hospital or other treatment facility to which the defendant is confined shall make a written report to the court... concerning the defendant's progress toward recovery of mental competence." When Patton State Hospital reaches its legislated bed capacity, this necessitates placing Riverside County on a one-for-one exchange status until the inmate population decreases. During a one-for-one exchange status, Patton must release a Riverside County patient in order to bring in a new Riverside County patient. Patton State Hospital notifies the Sheriff's Transportation Unit in Riverside County on the availability of beds. Response: The respondent agrees with the finding. The respondent agrees that a delay in transfer of inmates to Patton State Hospital delays the delivery of the broad spectrum of mental health care they would receive while incarcerated at a fully accredited psychiatric facility. Grand Jury Recommendation: 7. When the court orders a detainee committed to a state mental hospital or other approved treatment facilities, MHDS and the Public Defender should ensure that the detainee is actually transferred within an appropriate period of time. This would allow the state hospital to properly assess and report back to the court within 90-days of the date of the commitment order as required by Penal Code Section 1370(b)(1). When there is a shortage of beds at state mental hospitals, MHDS should recommend to the court that inmates adjudicated incompetent to stand trial be placed in a community program in lieu of a period of state hospitalization. Programs are available through the Forensic Conditional Release Program, which is state financed and state directed, whereby patient mental health services are provided by local vendors. Examples of these vendors could be county mental health programs or private service providers that contract with the state. Response to Recommendation: The majority of the Grand Jury's recommendation falls outside the scope of the respondent's authority. However, to the extent appropriate and to the extent that the

Information Packets The court orders the inmate's information packets to be sent to Patton State Hospital. Once Patton staff receives the information packet, it is reviewed for compliance with the documentation requirements. Our investigation revealed many packets are missing critical documents. Patton will notify the County Sheriff's business office to gather and submit This delay complicates the process for an the missing documents. inmate's stabilization and adds to the county's problem in dealing with inmates from both custody and mental health perspectives. (See Exhibit #2 for listing of required documents.) Exhibit #2 provided by Patton State Hospital. Response: The respondent agrees in part with the finding. The respondent agrees that incomplete information packets may delay the administrative processing of inmate information. The respondent is aware of what information is required, and to the extent that the respondent is the custodian for the required information, it is routinely and consistently provided to Patton State Hospital in a timely manner. The respondent is not aware of any empirical data that indicates any consistent failure in this area or that such a failure has directly compromised the timely delivery of a humane level of care. Grand Jury Recommendation: 8. Court ordered packets sent to Patton State Hospital should have all required documents. (See Exhibit #2.) A checklist should be developed and followed by the Riverside County Sheriff's business office to insure each packet is complete before sending to Patton. Response to Recommendation: The respondent currently uses a checklist to ensure a complete package is sent to Patton. Respondent will continue long standing policy and practice designed to promote the efficient delivery of complete information packets. The respondent will also critically examine the practices to ensure critical documents are not being omitted.

Mental Health Staffing Levels Mental health staff is not available in any county jail facility in sufficient numbers to identify and treat in an individualized manner those treatable inmates suffering from serious mental disorders. (See Exhibit #3.) For example, there are no Behavioral Health Specialists assigned to any of the five jail locations to screen incoming inmates for mental illness and to respond to inmates mental health concerns at the time of admission. Exhibit #3 provided by RCDMH. The jail in Blythe has no medical or mental health personnel assigned. With the exception of the 24-hour coverage at RPDC, medical and mental health services at the other three (3) jails are only available approximately 12-hours a day. Occasionally, because of staff illness, vacation, unforeseen events, etc., even RPDC does not have full staff coverage during some 24-hour periods. The new 2010 expansion at the Smith Correctional Facility in Banning has the physical plant for a mental health housing unit, however the use of the unit is on hold due to lack of qualified mental health personnel, and budget constraints. Response: The respondent agrees with the finding. The respondent agrees inadequate staffing of both mental and medical health professionals may limit the ability to assess and treat an inmate's mental health. The respondent agrees that an increase in staffing levels of mental health personnel is needed to attain compliance with Title 15. Grand Jury Recommendation: 9. Department of Mental Health should provide mental health staffing at each jail on a 24-hour basis to ensure timely access to adequate mental health treatment. The Larry D. Smith Correctional Facility should be staffed to be used as a designated 'treatment center'. DMH should review the ratio of number of psychiatrists per 100 inmates who require medication to make sure ratios are within mental health industry standards. Response to Recommendation: The majority of the Grand Jury's recommendation falls outside the scope of the respondent's authority. However, to the extent appropriate, the respondent will make every effort to work cooperatively with the relevant County departments to implement the Grand Jury's recommendation and continue to petition the Board of Supervisors to support this need.

Mental Health Records Whenever inmates are transferred, mental health records are usually hand-carried between jail facilities. This procedure is labor intensive and creates an environment in which some records are misplaced, lost or not transferred in a timely fashion. Response: The respondent agrees with the finding. The respondent agrees digital information management systems would increase both the security and efficiency of records management. Grand Jury Recommendation: RCRMC and DMH should create and implement a computer 10. system that allows prompt up-to-date access to every inmate's medical / mental health records. This system should be available to all jail locations. Response to Recommendation: The majority of the Grand Jury's recommendation falls outside the scope of the respondent's authority. However, to the extent appropriate, the respondent will make every effort to work cooperatively with the relevant County departments to implement the Grand Jury's recommendation. The respondent has already implemented a digital information management system designed to manage requests for inmate medical care.

Policies RCRMC's Department of Psychiatry Policy / Procedure #P4.43, Medication Orders for Inmates, effective: June 12, 1990, authorizes ETS psychiatrists to prescribe psychotropic medications (via a telephone order) for jail inmates for up to 72-hours of treatment. The justification for this is the fact that the inmates will be re-evaluated by a jail psychiatrist on a timely basis (e.g. next scheduled work day of jail psychiatrist). This policy further authorizes the involuntary medication of inmates for up to 72-hours. Such involuntary medication should not be authorized since county jails have not been designated as 72-hour treatment and evaluation facilities according to Welfare and Institution Code Section 5150. Most of the policies and procedures provided to the Grand Jury by RCRMC required review and approval by the Assistant Hospital Administrator, Chief of Psychiatry and the Assistant Chief Nursing However, documents revealed only the Assistant Hospital Officer. Administrator signed the "approved by:" box. Response: The respondent agrees with the finding. The respondent is not the appointing authority for the referenced policy and defers to the appropriate County departments to conduct their reviews. . . . . . . . . . . . . . . . . . . . . . . Grand Jury Recommendation: 11. RCRMC / Department of Psychiatry should review and modify Policy / Procedure #P4.43 to reflect the actual mental health personnel assigned or available at each detention facility, and insure policies are consistent with current law. The Assistant Hospital Administrator, Chief of Psychiatry and the Assistant Chief Nursing Officer should review all detention mental health policies and procedures and update annually and as required. Response to Recommendation: The majority of the Grand Jury's recommendation falls outside the scope of the respondent's authority. However, to the extent appropriate, the respondent will make every effort to work cooperatively with the relevant County departments regarding policy review.

Mental Health Discharge Planning Testimony revealed that discharge planning for mentally ill inmates is not conducted in a comprehensive manner. Stabilized mentally ill inmates in jail are often released into society without making adequate provisions for continued care and other services. For example, inmates with mental illness are often released from county jail without housing arrangements, making it difficult for released inmates to succeed in managing their mental illness. Upon release an individual may receive information on how to get two weeks of needed psychotropic medications, with limited follow-up arrangements made for inpatient and outpatient individual and group therapy. Response: The respondent agrees with the finding. The respondent acknowledges the value of mental health maintenance beyond the period of incarceration. Grand Jury Recommendation: 12. DMH discharge plans should increase the possibility of successful community re-entry and reduce the rate of recidivism for offenders with mental illness, by identifying and arranging services needed to live successfully in the community. In addition to medications and therapy, the discharge plans should also include housing arrangements, government benefits assistance, veteran's benefits (if applicable), employment opportunities, and other services. Response to Recommendation: The majority of the Grand Jury's recommendation falls outside the scope of the respondent's authority. However, to the extent appropriate, the respondent will make every effort to work cooperatively with the relevant County departments to help establish appropriate re-entry programs.