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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.

Sutter County Grand Jury • 2021-2022

Sutter-Yuba Behavioral Health: Behind the Times

52 pages

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⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Findings 15 findings

F1. The patient rooms at the Sutter-Yuba Behavioral Health (SYBH) Psychiatric Health Facility (PHF)contain multiple Ligature Points. Among staff and administrative personnel interviewed, there was a general awareness of these issues but no apparent sense of urgency to address them.

F2. Based on site observations of the SYBH PHF Unit, various doors did not appear secure, leaving certain areas potentially vulnerable to unauthorized patient access.

F3. The perimeter fencing at the SYBH PHF Unit’s outdoor recreation area is vulnerable to the exchange of contraband, due to easy public access. It creates a sense of being “locked” in, which is not welcoming or comforting for the patients.

F4. The perimeter fencing at the SYBH PHF Unit’s outdoor recreation area is an AWOL risk.

F5. Based on site observations and interviews with staff, the Video Monitoring System at the PHF Unit is an old and antiquated system. Components of the system are non-operational including many of the cameras. Repairs of the current system are either cost prohibitive or not possible due to the age of the system.

F6. SYBH use of private security is inefficient and lacks good use of the services.

F7. SYBH Policy and Procedure of recording an AWOL and Hazard/Incident Report is antiquated. It lacks sufficient information and structure to monitor and record AWOL incidents in a concise and professional manner.

F8. Based on SCGJ observations, the signage at the County’s PHF Unit is inadequate, outdated, and in very poor shape.

F9. The beds in the Isolation Rooms at the PHF Unit are an old version that leave the patient in an uncomfortable position if restraint is required.

F10

F10 The parking lot at the SYBH facility is in disrepair and a hazard to the public.

F11

F11. The building and grounds at the County’s PHF Unit show lack of regular maintenance. The vegetation is overgrown. Weeds growing up in sidewalks as well as in large unplanted areas. The exterior walls, concrete walkways, garbage receptacles are dingy or outright dirty. The window information signage is unprofessional in appearance.

F12

F12. Based on those interviewed and a review of budgetary documents, it appears some SYBH and Health and Human Services (HHS) management and key fiscal staff lack sufficient knowledge/understanding of the budget practices. This includes MHSA and Realignment funding.

F13

F13. Based on Sutter County Grand Jury research and those interviewed, there is no regular meeting of key fiscal staff, department heads, and directors to address changing budgetary issues. Currently, this is done once a year or on an “as needed” basis. This has created some issues with timely budgetary reporting.

F14

F14. Based on Grand Jury research and those interviewed, the existing SYBH Electronic Health Care Record System is inadequate.

F15

F15. Based on site observations, review of county plans for the Gray Ave Building, and SYBH administration interviews, the 1965 Live Oak Blvd Building is no longer adequate to house the Psychiatric Health Facility (PHF) and other SYBH offices/programs. 97

Recommendations 10

R8
Page 107

SYBH and the County need to add to and or replace the facilities exterior building, site and street signage that has appropriate names and lighting. 98 •
R9
Page 108

SYBH and the County need to address the importance of ensuring the comfort of patients in need of isolation and possible restraint. SYBH needs to identify and submit a replacement request to the County. The County in turn needs to recognize the importance by prioritizing funding by July 31st, 2022. •
R10
Page 108

SYBH and the County need to prioritize the performance of the work needed to complete the parking lot by September 30st, 2022. If funding is still not available, an allocation of funds needs to take priority to ensure this work gets completed. •
R11
Page 108

SYBH and the County need to take the initiative to clean up, enhance, and consistently maintain the overall appearance of the SYBH facility. •
R12
Page 108

SYBH and HHS need to reevaluate the scope and value of their training program, as well as their outside 3rd party consultant contract(s) to make sure it is being used effectively. •
R13
Page 108

SYBH needs to provide proper training and education to ensure sufficient knowledge / understanding of MHSA and Realignment funding in order to maximize the necessary funding required in order to support the county programs dependent upon this funding. •
R14
Page 108

SYBH and HHS need to assess its current staff, training and processes related to its budget. They then need to develop standardized processes/procedures to facilitate necessary communication between department heads and key fiscal personnel as it relates to internal reporting, discussion, and evaluation of ongoing budgetary goals and or issues, etc. •
R15
Page 108

There should be regularly scheduled meetings between Department Heads, Branch Directors, Administrators, and key fiscal staff. For transparency purposes, these meeting updates should be presented to the Sutter Yuba Behavioral Health Advisory Committee as well as Sutter County Board of Supervisor Meetings. •
R16
Page 108

Based on the grand jury’s research, a new Electronic Health Care Record System has been defined and budgeted by SYBH. SYBH needs an implementation plan. The County needs to prioritize and approve funding for a complete EHR for outpatient, inpatient, and PES. •
R17
Page 108

The County needs to work with HHS to perform a needs assessment and begin developing a long-term strategy to address the clear need for a new facility for SYBH which includes housing the PHF Unit. 99