Submittal to the Board of Supervisors County of Riverside, State of California Submittal Date:*

In July, 2011, DMH was advised in a 2010-2011 Grand Jury report and was notified by the Institute of Medical Quality that the medical/mental health staffing levels in county jails needed to be restored to 2007 levels, in order to be in compliance with Title 15, Chapter 4, Article 9. As of this writing, the Grand Jury learned through sworn testimony that during the eight months following the 2010- 2011 Grand Jury report, DMH staffing levels were allowed to decrease even further. This was a result of transferring experienced, mental-health, registered nurses out of the jails before licensed clinician replacements were available. The 2012 RCDMH organizational chart reflects currently there are 21 vacant positions out of 40 positions funded with adult detention facilities and three vacant positions out of nine funded in the juvenile facilities. The same chart shows staffing in adult non-detention mental health facilities as having only one vacant position. The Grand Jury learned from sworn testimony that all have the same credentials, but non- detention clinicians have not completed the required background investigation as required by Title 15. The same issues exist in juvenile facilities, which also experienced staff reductions in 2009. The current 2011-2012 budget has not restored the juvenile facilities staffing of 2007. The Grand Jury learned from sworn testimony that filling vacant positions in DMH has been made even more difficult due to the non-competitive salary structure. Response: Respondent disagrees partially with the finding. In May 2011, Mental Health Adult Detention Services was surveyed by The Institute for Medical Quality (IMQ). During the survey, the IMQ Surveyors recommended various staffing suggestions which included converting the registered nurse positions to clinical therapist positions. The new model called for Mental Health Detention to provide evidence based practices that combine research based information, clinical expertise and the inmates own needs and values to work towards recovery. Recruitment has been ongoing and to date, over 91% of Detention positions have been filled. In the interim, additional staffing support such as the use of Per Diem Clinical Therapists and overtime for current Department of Mental Health employees has been utilized. Since 1993, Detention Services has adhered to a pay differential for clinical support staff in both adult and juvenile detention facilities. Riverside County Department of Mental Health (RCDMH) currently does have vacancies in Juvenile Facilities. The Department makes every effort to fill any vacant positions in Juvenile Detention facilities as quickly as possible. Unfortunately, the hiring process for people working in these facilities is very lengthy. The Respondent agrees with the statement: The current 2011-2012 budget has not restored the juvenile facilities staffing of 2007. Annual Performance Evaluations: Through sworn testimony, the Grand Jury learned that up to 60 percent of DMH

staff working in detention facilities have not received annual performance evaluations as required by Riverside County Board of Supervisors Policy C-21. Response: Respondent disagrees partially with the finding. Detention staff within the Department of Mental Health are to receive performance evaluations, but in some cases in juvenile facilities these have not been done in the timely manner consistent with Riverside County Policy C-21. This is most commonly due to changes in supervisory staff assigned to do the evaluations. Communication within Detention Mental Health: The Grand Jury learned that some detention mental health workers are fearful of

communicating with supervisors and/or managers about urgent work-related issues for fear of retaliation. Testimony also revealed that a number of Juvenile DMH clinicians have had onsite visits by their supervisors as few as three times a year. Response: Respondent disagrees partially with the finding. RCDMH staff are required to take Harassment Prevention training every three years. They are trained in BOS Policy C-25 in which they are encouraged to communicate relevant issues, including the option to report these directly to Human Resources. They also receive oral briefing and the county Harassment Prevention pamphlet on their rights annually by their supervisor. In this training, staff are empowered to report negative behavior outside of the chain of command. So, there has been a mechanism in place for staff to be trained on and report fears of retaliation. The Department acknowledges that the flow of information to and from the Probation staff and RCDMH staff could be better. Respondent agrees with the statement "a number of Juvenile DMH clinicians have had onsite visits by their supervisors as few as three times a year." Supervisors have been instructed to meet with staff from the juvenile facilities at least monthly and have at least one meeting with them at the detention site quarterly. Temporary Replacement of Mental Health Workers: There is an insufficient number of qualified RCDMH personnel to fill vacancies

that may arise in DMH. The requirement for level-one security in the jails makes a temporary assignment impossible when the appropriate level-one background investigation required is not completed. (Currently, juvenile facilities do not require a level-one security background check.) The requirements for a background check are the responsibility of the employing departments (i.e., RCDMH, Riverside County Regional Medical Center, and Riverside County Office of Education.) The background check consists of a fingerprint check for possible criminal background, physical exam, drug/alcohol screening, and education and licensure verification. Probation has the authority, through Title 15, Section 1400, to deny any person permission to work with juveniles; however, Probation is not provided with any background or security information obtained in the investigation. Response: Respondent disagrees wholly with the finding. Human Resources is carefully monitoring the recruitment of Detention Services staff and the current level is 91%. Since February 2012 Mental Health Detention Services has added staffing support such as the use of Per Diem Clinical Therapists and has provided overtime for current Department of Mental Health employees, all of which have received the appropriate security clearances. This proactive measure has afforded us the opportunity to provide quality mental health services and to respond to request for services in a timely fashion. Juvenile Detention Administration Consolidation:

Current organizational charts of RCDMH show that the administration of the five juvenile detention facilities in Riverside County are under three administrators based on their geographical location. The staffing of DMH workers under these three administrators represents approximately two to five percent of their staffing, as they are also responsible for over 100 other employees. This situation does not allow effective personnel management among facilities as needed or free communication with Probation or within DMH. Response: Respondent agrees with the finding. Effective August 1, 2012, the Department of Mental Health has consolidated the management and supervision of the mental health services in the juvenile facilities. Organizationally, the management of these programs and staff will be under the Western Children's Mental Health Services Administrator whose scope of authority will now include Indio Juvenile Hall, Southwest Juvenile Hall, Riverside Juvenile Hall, the Youthful Offenders Program and Twin Pines Ranch (Van Horn Youth Center has closed). The Department is in the process of hiring a Supervisor to oversee the staff at these programs. Memorandum of Agreement for Juvenile Facilities:

Sworn testimony from various sources in the RCDMH, DMH and Probation revealed mental-health-care services for in-custody juveniles lacks an adequate number of therapists and clerical assistants. This prevents provide mental-health services from being effective, as required by Title 15. The Probation director is responsible for the security of everyone in a juvenile facility per Title 15, but is not authorized access to the results of the findings of pre-employment investigation conducted by another agency for their employees. Pre-employment background checks for RCDMH, Riverside County Regional Medical Center, and Riverside County Department of Education employees that work in juvenile custody areas are being conducted by the person's employing department without the Probation's involvement. In addition, it was brought to the attention of the Grand Jury, through sworn testimony, that in some juvenile facilities mental-health records are not being completed in a timely manner as directed by Title 15, Section 1406, which states that the examination and paper work must be completed in 96 hours. Response: Respondent disagrees partially with the finding. When fully staffed, all Juvenile Detention facilities have 50 juveniles per 1 clinician ratio. This staffing ratio has been agreed upon by RCDMH and the Department of Probation and more recently signed into Memorandum of Agreement. Clerical staff in each facility has been adequate to meet the needs of the programs. Mental Health follows uniform procedures for hiring per requirements of our Human Resources department and Ordinance 440. If a Mental Health candidate for work at a Juvenile Facility passes the HR process then the recommendation is to move on to the Probation background check. Sharing the results of this process with another department would be considered a breach of confidential personnel information and outside of the policies/procedures of the department. The Probation Department will conduct its own background check of potential Mental Health Department candidates to work in juvenile detention. Examination of the children referred to mental health occurs within 48 hours or less of the mental health staff receiving the referral. If there is an urgent or emergent psychiatric issue, then the child can be assessed more quickly. Specifically, the minor can be assessed by the RCDMH Emergency Treatment Services in Riverside/Southwest and the Oasis Center in the Desert 24 hours per day for 7 days per week, if he or she displays acute psychiatric symptoms. The current standard for documentation of all services for the Department is same-day as service, and not later than one day in critical circumstances. The Department's electronic health record system provides supervisors with reports on paperwork completion. Referral Process in Adult Detention:

Sworn testimony by mental health workers and correctional staff indicate procedures for generating and tracking mental health referrals in the adult detention facilities as being insufficient in their compliance with Title 15, Division 1, Chapter 1, Subchapter 4. Current problems are: delays in notifying DMH of problems, concerns and requests for service, significant backlogs of adult referrals, particularly with the new AB109 transfers, no visual tracking or status reporting of referrals, and collected data does not separate critical requests from routine, thereby making the severity of a problem difficult to ascertain Response: Respondent disagrees wholly with the finding. Pursuant to the requirements in the Sheriff Detention Services Memo of Agreement, which was signed December of 2011, there is a reporting process and tracking system to determine the following information: Number of mental health cases open on the last day of the month • Number of new mental health cases open for the month • Number of inmates receiving psychotropic medications • Average response time to inmate mental health requests Gaps in Coverage:

The Grand Jury learned, through sworn testimony, that mental-health Crisis management has been reported by DMH to have gaps in its mental-health coverage. Outlying juvenile detention facilities often do not have mental-health coverage in the after-hours. Transportation of an individual requires by law, at least two officers. This takes the officers away from the facility for up to six hours. This may require outside assistance such as, but not limited to, fire department paramedics and ambulance services. Response: Respondent disagrees partially with the finding. Every child in juvenile detention facilities experiencing an acute psychiatric episode has 24 hour 7 days per week access to mental health services through Emergency Treatment Services or the Oasis Crisis Services. There are no gaps in coverage due to this access provided transportation services are available. Mental Health staff are available to provide crisis services at the juvenile detention facilities Monday through Friday during regular department business hours.