Submittal to the Board of Supervisors County of Riverside, State of California From: Executive Office Submittal Date:

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 (MHOS), 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 with the finding Detainees brought to county jails for booking all receive an initial screening to determine their immediate medical/mental health condition(s) and to identify any history of medical/mental health problems. The initial booking screening, performed by correctional personnel, is simply used as an indicator of the need for immediate evaluation by medical personnel however; the screening is not a comprehensive review of the medical/mental health status. During the screening process, any positive responses by the detainee, relative to medical or mental health issues, mandate a follow up review by medical/mental health personnel. When medical personnel are on duty at the jail, this process is initiated and medical services follow. However, when medical professional are not available, correctional staff must seek the medical evaluation from outside medical resources. In these cases, detainees are taken to local medical facilities where they are evaluated by medical professionals prior to the acceptance for housing into the jail setting. This process is known as a Medical Clearance or OK-To Book. As correctional staff performs the initial medical/mental health screening, it is understood that they are not medical or mental health professionals who may recognize conditions warranting immediate attention. The acute booking phase is not the best point in time for correctional staff to obtain information from the "self reporting" detainee about their medical conditions and/or concerns since the inmates are often reluctant to provide accurate responses due to issues associated with their arrest. "Hidden medical or mental health" problems cannot usually be observed at this point. Additionally, medical/mental health professionals have additional training and expertise to identify issues through vital signs and general observation even if the inmate does not disclose pertinent medical information or medical history. Oftentimes this expertise allows the professional to identify critical information (physical symptoms, mental status or behaviors, and side effects to medications) that can be used in the overall evaluation process that may result in the need for immediate medical care and treatment. 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 MHOS has no confidential self-referral system by which inmate can request mental health care without revealing the nature of their request to correctional officers. Response: Respondent agrees with the finding The state and county economic recession has mental health programs. In the past three years, the detention program has established priorities which include psychiatric crisis intervention and medication for severe mental illness. All other moderate or mild complaints are second in priority. The jail system is operated and controlled by corrections staff of the Sheriff's Department. There cannot be a self-referral system or communications system that excludes the corrections staff. The inmates are the ward of the county and the responsibility of their security and maintenance rest fully with Correctional Deputies. 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: Respondent disagrees partially with the finding Medications that are ordered in the jails are routinely administered twice daily by Detention Health Services nursing staff. The twice daily medication administration process works well in the jail setting as inmates are often taken to court proceedings during the course of the day making it difficult give afternoon medications. Jail physicians & psychiatrists have indicated that there is no detrimental impact to the patient in two-a-day medication administration. However, if and when the physician or psychiatrist medication order specifically requires a three time per day administration regimen to maintain the efficacy of the drugs, it is ordered and administered in that manner. On rare occasions, due to staffing shortages, medication passes cannot be performed on all cell blocks. When this occurs, nurses prioritize their workload and determine, on a rotational basis, the cell block that will not receive medication passes for that particular shift. At Robert Presley Detention Center (RPDC), inmates housed on the 5th Floor (Mental health Unit), yth Floor (Sheltered Housing Unit) and Diabetics are listed as priority and always are provided medication passes. Inmate Transfers to ETS and DCU

The Department of Mental Health Section VI, Policy I 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 distributed 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: Respondent disagrees partially with the finding Mental Health Detention Services adheres to a protocol (Transfers of Correctional Inmates for Mental Health Treatment) that significantly reduces the probability of inmates requiring transfer to ETS. It allows for direct admission of inmates to the DCU, bypassing the ETS evaluation. The Department has provided a Psychiatric Consultation and Liaison Team at the RCRMC Moreno Valley Campus from 7:00am to 11 :OOpm, 7 days per week. The Department of Mental Health has an agreement with the Emergency Department and the Riverside County Sheriff's Department to bring inmates to RCRMC Emergency Department between 11 :OOpm and 7:00am. On rare occasions, inmates are brought to ETS for immediate or urgent psychiatric evaluation. Inmates are evaluated in separate ~ooms and are under constant supervision by the Riverside County Sheriff's Officers. Sheriff's Officers are required to remove weapons prior to entering the facility. Medication Orders for Inmates

RCRMC Policy #P4.4.3, 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: Respondent agrees with the finding RCRMC Policy P4.4.3 does not reflect current practice at RCRMC. Upon review it was determined that Policy #4.4.3 will be discontinued effective 5/23/2011. Policy #4.4.3 was a stand alone policy and will not be replaced. The jail psychiatrist will be writing their psychotropic medication orders. Psychotropic medication cannot be administered unless patient has been evaluated by prescribing psychiatrist who is familiar with the patient. If there is an emergency, the patient can be transferred to RCRMC Emergency Department for evaluation. 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: Respondent agrees with the finding These inmates are under the jurisdiction of the court not the County Department of Mental Health. Inmates who consent may be provided services. They are waiting for transfer to the State System to restore competency for standing trial. 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 Sheriffs Transportation Unit in Riverside County on the availability of beds. Response: Respondents cannot agree or disagree as both departments - Mental Health and RCRMC- find this outside their jurisdiction. 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 the missing documents. This delay complicates the process for an 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: Respondents cannot agree or disagree with this statement as it is outside their jurisdiction. Mental Health Staffing Levels

Mental health staff is not available in any county jail facility in sufficient numbers to identify and treat an individualized manner those treatable inmates suffering from serious mental disorders. (See Exhibit #3.) For example, there are not 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 Blyth 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 (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 period. 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: Respondent disagrees partially with the finding 6 There have been reductions in general fund support for staffing over the past three years due to the economic downturn. The initial screening process is adequate to establish when an inmate needs to be evaluated by mental health clinicians. The mental health staff prioritizes those in a psychiatric emergency and those who need medication for a severe mental illness. Mental Health Records

Whenever inmates are transferred, mental health records are usually hand carried between jail facilities. This procedure is in labor intensive and creates an environment in which some records are misplaced, lost or not transferred in a timely fashion. Response: Respondent disagrees wholly with the finding Mental Health Department staff does not hand-carry the original records between jail facilities. Records are faxed confidentially to mental health staff. Policies

RCRMC's Department of Psychiatry Policy I 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 Officer. However, documents revealed only the Assistant Hospital Administrator signed the "approved by:" box. Response: Respondent disagrees partially with the finding Policy #4.4.3 was reviewed and discontinued effective 5/23/2011. Policy #4.4.3 was a stand alone policy and will not be replaced. The jail psychiatrist will be writing their own psychotropic medication orders. Psychotropic medication cannot be administered unless patient has been evaluated by prescribing psychiatrist who is familiar with the patient. If there is an emergency, the patient can be transferred to RCRMC Emergency Department for evaluation. In a psychiatric emergency, current protocol is telephone orders from a psychiatrist with a follow-up in person, interview by a psychiatrist within 72 hours. This applies to inmates who voluntarily consent to medication. If treatment is refused, the inmate must be transferred to RCRMC's Detention Care Unit (DCU) or the ETS. 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: Respondent agrees with the finding 8