Roy Lee First District Laura Capps Board of Supervisors Second District, Chair County Administration Building Joan*

R1a

The Grand Jury recommends that the Sheriff's Office will not place an inmate deemed by mental health staff to have been recently suicidal in an observation cell that contains a telephone cord. To be implemented no later than January 1, 2026. This recommendation has been implemented. The County supports the utilization of cells that are adequately free of ligature risks for patients who are currently or recently under suicide precautions. As of November 2024, telephone cords have been removed from all holding cells that may be used for individuals on mental health observation.

R1b

The Grand Jury recommends to the Sheriff's Office that if no cordless mental health observation cells are available when stepping down a potentially suicidal inmate from a safety cell, a Jail mental health provider should seek to transfer that inmate to the closest facility that can offer adequate protection. To be implemented no later than January 1, 2026. This recommendation has been implemented. As stated above, telephone cords have been removed from all holding cells that may be used for individuals on mental health observation. The County emphasizes that any intervention taken for patients in a safety cell should be patient-specific and include consideration of all appropriate and available options for treatment, placement, and monitoring. This includes appropriate interventions for stepping-down from a safety cell, as well as escalation to a higher level of care when indicated. If no appropriate placement option exists within the facility to meet a patient's specific needs, the patient is to be transferred as indicated.

R1c

The Grand Jury recommends to the Sheriff's Office that if no cordless mental health observation cells are available when stepping down a potentially suicidal inmate from a safety cell in the Main Jail, a Jail mental health provider must contact the County's psychiatric holding facility, the Crisis Stabilization Unit, a local hospital, and the Northern Branch Jail to determine if a bed offering an appropriate level of care is available. To be implemented no later than January 1, 2026. This recommendation has been implemented. As stated above, telephone cords have been removed from all holding cells that may be used for individuals on mental health observation. The Sheriff's Office works in conjunction with Wellpath and when appropriate BWell's Mobile Crisis Unit to facilitate patient-specific evaluation and consult to determine appropriate placement. If no appropriate placement option exists within the facility to meet a patient's specific needs, the patient is to be transferred as indicated.

R1d

The Grand Jury recommends that the Board of Supervisors negotiate a memorandum of understanding with San Luis Obispo County, Ventura County, Los Angeles County, and other neighboring counties in California setting procedures for transferring and accepting inmates with severe mental health disease when no other safe housing options are available. To be implemented no later than January 1, 2026. This recommendation has been implemented. The County maintains a full continuum of care for the placement of persons with severe mental health issues with acute and subacute needs, including the utilization of available treatment beds in surrounding counties, when necessary and appropriate. The Sheriff's Office works in conjunction with Wellpath and BWell's Mobile Crisis Unit to facilitate evaluation and consult to determine appropriate placement. The County is in the process of contacting neighboring counties to determine feasibility of entering into MOUs related to transferring and accepting inmates with severe mental health conditions at out-of-county inpatient facilities if in-county beds at the appropriate level of care are unavailable.

R2

The Grand Jury recommends that while an inmate is housed in a safety cell, the Sheriff's Office require a Wellpath psychiatrist conduct an evaluation of that inmate. Given that the recommendation is to follow existing policy, to be implemented immediately. This recommendation will not be implemented. Although the intent of the recommendation is supported, psychiatric referrals should be based on clinical factors. Existing Wellpath policy does not require a psychiatric assessment for all patients housed in a safety cell; however, psychiatric referral is required when clinically indicated. Policy and protocol should reflect individualized and patient- specific interventions. Existing Wellpath policy requires a mental health assessment prior to placement in a safety cell. As part of that assessment, referral to psychiatry is to occur when clinically indicated. Additionally, BWell Mobile Crisis is available for assessment and placement to a higher level of care as appropriate. The SLAs in the current Wellpath agreement include these provisions and are monitored for compliance by BWell.

R3a

The Grand Jury recommends that if the on-duty psychiatrist is not available to conduct what Jail medical and mental health staff deem to be an urgent evaluation of an inmate, the Sheriff's Office require Wellpath to designate another backup on-call psychiatrist to conduct such an evaluation. To be implemented no later than January 1, 2026. This recommendation has been implemented. There are clear and detailed protocols and policies guiding the identification, assessment, evaluation, and care of persons with current and past mental health conditions who are placed at the jails, beginning at booking/intake and ongoing as appropriate, including policies related to psychiatric referral and evaluation. Wellpath's staffing includes an on- duty psychiatrist as well as an on-call psychiatrist. Additionally, BWell Mobile Crisis is available for assessment and placement to a higher level of care as appropriate. The SLAs within the current Wellpath contract include ensuring that patient needs are addressed within established timeframes based on triaged acuity of need. The SLAs for mental health needs are currently assessed by BWell, and under the new contract effective April 1, 2025, SLAs include medical needs reviewed by County Health.

R3b

The Grand Jury recommends to the Sheriff's Office that if a stepdown inmate refuses to participate in a psychiatric evaluation, the on-duty Jail psychiatrist be required to obtain and review the inmate's mental health history. To be implemented no later than January 1, 2026. This recommendation will be implemented. Wellpath's existing policy regarding Receiving Screening requires the Qualified Health Professional (QHP) to review the patient's health record from prior incarcerations (if available) to ascertain a history of medical or mental health conditions. Wellpath can now also access patients' mental health history through BWell's electronic health record. While Wellpath is currently requesting medical and mental health records from outside providers when clinically indicated, by January 2026, Wellpath intends to implement a policy revision to reflect this existing practice.

R4

The Grand Jury recommends that after an inmate spends more than 12 hours in a safety cell, the Sheriff's Office require that Wellpath staff always call the Mobile Crisis Unit to conduct an evaluation and document the call and its outcome in the Jail electronic health record. Given that the recommendation is to follow existing policy, to be implemented immediately. This recommendation has been implemented. Current protocol requires Wellpath to contact Mobile Crisis for evaluation if a patient has been in a safety cell for 8 hours and is decompensating or showing no signs of clinical improvement, and to request an evaluation within 12 hours for all patients unless they are stepped down from a safety cell before that time. As of July 1, 2025, the Wellpath agreement contains an SLA requirement to refer individuals in a safety cell to a higher level of psychiatric care after 8 hours of no improvement or deterioration, with associated liquidated damages if non-compliance is assessed. This protocol supports individualized and patient-specific intervention for patients placed in a safety cell, and it is more stringent than the 12-hour timeframe stated within the Murray v. County of Santa Barbara Remedial Plan for individuals who are not improving.

R5a

The Grand Jury recommends that the Sheriff's Office require additional training for Wellpath mental health providers regarding HIPAA regulations concerning inmates, including defining under what circumstances a mental health provider may legally contact outside mental health providers about an inmate's mental health history. To be implemented no later than January 1, 2026. This recommendation will not be implemented. Protected Health Information (PHI) may be shared for the treatment of inmates in a correctional institution under certain circumstances authorized by law. Therefore, obtaining a Release of Information (ROI) is unnecessary in some situations. However, pursuant to current protocol when seeking records from outside providers, Wellpath staff do request patients to sign an ROI, for purposes of promoting consent and transparency, facilitating seamless information sharing, and given that outside providers have historically not recognized permitted disclosures. The County agrees that greater awareness regarding the application of HIPAA in a correctional setting would benefit the incarcerated population and may allow for increased information sharing. However, the County believes that the above-recommended additional training would not address the Grand Jury's intent. The County will work with all stakeholders, including local hospitals and providers, to expand awareness and understanding regarding the permissible disclosure of PHI in correctional care settings.

R5b

The Grand Jury recommends that the Sheriff's Office require the on-duty registered nurses at the County's jails to request every newly arriving inmate at the time of intake to sign a written authorization to release their medical and mental health records and information. To be implemented no later than January 1, 2026. This recommendation will be implemented. HIPAA permits sharing of PHI with a correctional institution when necessary for the provision of healthcare and for health and safety purposes; thus, obtaining an ROI for every patient is unnecessary. However, ROIs are still requested from patients for the reasons described above. As stated in the Sheriff's response to the Grand Jury, patients are currently requested at intake to sign a universal ROI that would allow Wellpath staff to communicate about and receive the patient's records from other medical and mental health providers. The Sheriff further indicates that areas for improvement to this process have been identified and additional training is being provided to refine the process, with completion expected

R6a

The Grand Jury recommends that the Sheriff's Office require Wellpath staff to contact outside healthcare providers, such as hospitals, physicians, and clinics, to obtain inmates' health records in a timely manner following intake. This recommendation will be implemented. The County supports reinforcing the expectation to obtain relevant medical and behavioral health records when clinically indicated, particularly for patients recently hospitalized or assessed in an emergency department. By January 2026, Wellpath intends to implement a policy revision to request medical and mental health records from outside providers when clinically indicated. As stated above, CFMG/Wellpath clinical staff have since been provided access to BWell's EHR to improve information sharing. Wellpath is in the process of mandating staff access for all registered nurses and mental health staff, including psychiatry.

R6b

The Grand Jury recommends that the Sheriff's Office upgrade its electronic health record system to allow it to receive patient health information from outside providers via an industry-standard means of internet transmission. This recommendation will be implemented. Wellpath is working to ensure the current EHR (CorEMR) is CalAIM-compliant, which will require interoperability to share patient health information with outside providers, as required for the County's implementation of the California Advancing and Innovating Medi-Cal (CalAIM) Justice-Involved Initiative by October 2026. Additionally, the County is evaluating implementing a new EHR, which would be able to share information amongst various County departments and community providers. Through the upgraded EHR and participation in the Health Information Exchange, for patients served by outside providers the information from those visits could be incorporated into their health record.

R7a

The Grand Jury recommends that the Sheriff's Office provide and maintain safety and observation cells sufficient in number to meet ongoing demands. This recommendation has been implemented. As stated above, the County maintains sufficient cells, including safety and observation cells, to meet census and acuity needs. Additionally, the Sheriff's Office has removed telephone cords from all cells that may be used as observation cells.

R7b

The Grand Jury recommends that the Sheriff Office require custody staff to consider mental health staff's clinical input when determining placement upon discharge from a safety cell and document the reasons when clinical input is not followed. This recommendation has been implemented. According to the Sheriff's response to the Grand Jury dated August 25, 2025, the Sheriff's Office formalized and implemented a specific suicide watch step-down procedure in December 2024 and subsequently further refined this process. They anticipated completing staff training and implementing the refined procedure